Prescription Module 3 Quiz
psychosocial factors for long-term disability and work loss associated with low back pain
-a negative attitude that back pain is harmful or potentially severely disabling -fear avoidance behavior and reduced activity levels -an expectation that passive, rather than active, treatment will be beneficial -a tendency to depression, low morale, and social withdrawal -social or financial problems
absolute contraindications for exercising during pregnancy
-hemodynamically significant heart disease -restrictive lung disease -incompetent cervix/cerclage -multiple gestation at risk for premature labor -persistent 2nd or 3rd trimester bleeding
benefits of exercise during pregnancy
-prevention of excessive gestational weight gain -prevention of gestational diabetes mellitus -decreased risk of preeclampsia -decreased incidence/symptoms of low back pain -decreased risk of urinary incontinence -prevention/improvement of depressive symptoms -maintenance of fitness -prevention of postpartum weight retention
commonly used physical performance tests for older adults
-senior fitness test -short physical performance battery -usual gait speed -6 min walk test -continuous scale physical performance test
relative contraindications for exercising during pregnancy
-severe anemia -unevaluated maternal cardiac dysrhythmia -chronic bronchitis -poorly controlled type 1 diabetes mellitus -extreme morbid obesity -extreme underweight -heavy smoker
Children and Adolescents
Children and adolescents (defined as individuals 6-17 years) are more physically active than their adult counterparts. Only the youngest children (6-7 years) are as physically active as recommended by experts, and most young individuals older than the age of 10 years do not meet prevailing physical activity guidelines
low back pain special considerations
Abdominal bracing should be used with extreme caution, as the increases in spinal compression that occur with abdominal bracing may cause further harm to the individual. Certain exercises or positions may aggravate symptoms of LBP. Walking, especially downhill, may aggravate symptoms in individuals with spinal stenosis. Limit any activity that causes a peripheralization of symptoms (spread of pain into lower limbs) Repeated movements and exercises such as prone pushups that promote centralization (i.e., a reduction of pain in the lower limb from distal to proximal), are encouraged to reduce symptoms in patients with acute LBP with related lower extremity pain Flexibility exercises are generally encouraged as part of an overall exercise program. Hip and lower limb flexibility should be promoted, although no stretching intervention studies have shown efficacy in treating or preventing LBP. Consider progressive, low-intensity aerobic exercise for individuals with chronic LBP with generalized pain (pain in more than one body area); and moderate- to high-intensity aerobic exercise for individuals with chronic LBP without generalized pain.
For prognosis and outcome purposes, LBP can be described as:
Acute (< 6 wk) Subacute (6-12 wk) Chronic (> 12 wk)
Older Adults - Exercise Prescription
Age should not be a barrier to PA because positive improvements are attainable at any age. The relative adaptations to exercise and the percentage of improvement in the components of physical fitness among older adults are comparable with those reported in younger adults and are important for maintaining health and functional ability and attenuating many of the physiologic changes that are associated with aging. Low aerobic capacity, muscle weakness, and deconditioning are more common in older adults than in any other age group and contribute to loss of independence, and therefore an appropriate Ex Rx should include aerobic, muscle strengthening/endurance, and flexibility exercises. Individuals who are frequent fallers or have mobility limitations may also benefit from specific neuromotor exercises to improve balance, agility, and proprioceptive training (e.g., Tai Chi), in addition to the other components of health-related physical fitness. An important distinction between older and younger adults should be made relative to intensity. Apparently healthy younger adults - moderate and vigorous intensity PA defined relative to METs (moderate intensity, 3-5.9 METs; vigorous intensity ≥6 METs) For older adults, activities should be defined relative to an individual's physical fitness within the context of a perceived 10-point physical exertion scale which ranges from 0 (an effort equivalent to sitting) to 10 (an all out effort), with moderate intensity defined as 5 or 6, and vigorous intensity as ≥7.
adult population experience LBP at any given point in time
Anywhere between 4% and 33% recurrent episodes of LBP can occur in over 70% of cases Approximately 20% of cases become chronic and about 10% of the cases progress to a disability
____ are often better indicators of ability to engage in PA than chronological age.
Health and functional status
pregnancy
Healthy, pregnant women without exercise contraindications are encouraged to exercise throughout pregnancy. Regular exercise during pregnancy provides health benefits and reduces the risks associates with sedentary behavior. ACOG and USDHH guidelines provide evidence-based guidance on exercise prescription for the minimization of risk and promotion of health benefits.
Pregnancy - Exercise Prescription
In the absence of obstetric or medical complications, the exercise recommendations during pregnancy are consistent with recommendations for healthy adults The recommended Ex Rx for women who are pregnant should be modified according to the woman's symptoms, discomforts, and abilities during pregnancy. The Physical Activity Readiness Medical Examination for Pregnancy (PARmed-X for Pregnancy) or the electronic Physical Activity Readiness Medical Examination (ePARmed-X+) should be used for the health screening of pregnant women before their participation in exercise programs
Older Adults - Exercise Testing
Most older adults do not require an exercise test prior to initiating a moderate intensity PA program If exercise testing is recommended, the associated ECG has higher sensitivity (i.e., ~84%) and lower specificity (i.e., ~70%) than in younger age groups (i.e., <50% sensitivity and >80% specificity), producing a higher rate of false positive outcomes. The increased prevalence of cardiovascular, metabolic, and orthopedic problems among older adults increases the overall likelihood of an early test termination. The initial workload should be light (<3 metabolic equivalents [METs]) and workload increments should be small (i.e., 0.5-1.0 MET) for those with low work capacities. The Naughton treadmill protocol is a good example of such a protocol. A cycle ergometer may be preferable to a treadmill for those with poor balance, poor neuromotor coordination, impaired vision, impaired gait patterns, weight-bearing limitations, and/or foot problems. However, local muscle fatigue may be a factor for premature test termination when using a cycle ergometer. Adding a treadmill handrail support may be required because of reduced balance, decreased muscular strength, poor neuromotor coordination, and fear. However, handrail support for gait abnormalities will reduce the accuracy of estimating peak MET capacity based on the exercise duration or peak workload achieved. Treadmill workload may need to be adapted according to walking ability by increasing grade rather than speed. Many older adults exceed the age-predicted HRmax during a maximal exercise test, which should be taken into account when considering test termination. The influence of prescribed medications on the electrocardiographic (ECG) and hemodynamic responses to exercise may differ from usual expectations.
Older adults are the least physically active of all age groups.
Only 11% of individuals aged ≥65 yr engage in regular aerobic and muscle strengthening activities. Less than 5% of individuals aged >85 yr engaging in regular aerobic and muscle strengthening activities.
what tests are considered reliable and valid for individuals with LBP.
Submaximal exercise tests
Pregnancy - Exercise Testing
The acute physiologic responses to exercise are generally increased during pregnancy compared with nonpregnancy. Because of the physiological changes that accompany pregnancy, assumptions of submaximal protocols in predicting maximal aerobic capacity may be compromised and are therefore most appropriately used in determining the effectiveness of training rather than accurately estimating maximal aerobic power.
Exercise Testing for the Oldest Segment of the Population
The oldest segment of the population (≥75 yr and individuals with mobility limitations) most likely has one or more chronic medical conditions. The likelihood of physical limitations also increases with age. Currently, there is a paucity of evidence demonstrating increased mortality or cardiovascular event risk during exercise or exercise testing in this segment of the population, therefore eliminating the need for exercise testing unless medically indicated (e.g., symptomatic CVD, uncontrolled diabetes). Individuals free from CVD symptoms should be able to initiate a light intensity (<3 METs) exercise program without undue risk.
Children and adolescents are physiologically adaptive to
endurance exercise training, resistance training, and bone loading exercise. Exercise training produces improvements in cardiometabolic risk factors, weight control, bone strength, and psychosocial well-being, and may help prevent sports-related injuries; thus, the benefits of exercise are much greater than the risks
When LBP is a symptom of another serious pathology (e.g., cancer),
exercise testing and Ex Rx should be guided by considerations related to the primary condition.
In addition to the PA guidelines, an expert panel from the National Heart, Lung, and Blood Institute and the American Academy of Pediatrics also recommend that children
limit total entertainment screen time to <2 hours per day
Children have a much lower anaerobic capacity than adults
limiting their ability to perform sustained vigorous intensity exercise
Current guidelines place a heavy emphasis on preventive measures and early interventions to
minimize the risk of an acute LBP episode from becoming chronic and/or disabling.
Most young individuals are healthy and able to start
moderate intensity exercise training without medical screening. Vigorous exercise can be initiated after safely participating in moderate exercise.
Low back pain (LBP) is defined as
pain, muscle tension, or stiffness localized below the rib margin and above the inferior gluteal folds, with or without leg pain.
Current literature does not support a definitive cause for initial bouts of LBP, however,
previous LBP is one of the strongest predictors for future back pain episodes.
Trunk coordination, strengthening, and endurance exercises can be used to
reduce LBP and disability in individuals with subacute and chronic LBP with movement coordination impairments. However, there is insufficient evidence for any benefit of emphasizing single-dimension therapies such as abdominal strengthening.
For all other causes, and in the absence of a comorbid condition (e.g., CVD with its associated risk factors), recommendations for exercise testing and Ex Rx are
similar as for healthy individuals.
older adults: Overwhelming evidence exists that supports the benefits of physical activity in
slowing physiologic changes of aging that impair exercise capacity, optimizing age-related changes in body composition, promoting psychological and cognitive well-being, managing chronic diseases, reducing the risks of physical disability, and increasing longevity.
To reduce the probability of disability, individuals with LBP should
stay active, continue ordinary activity within pain limits, avoid bed rest, and return to work as soon as possible.
Clinical practice guidelines for the management of LBP consistently recommend
staying physically active and avoiding bed rest.
Tests of the ______ are commonly assessed in individuals with LBP.
strength and endurance of the trunk musculature (e.g., isokinetic dynamometers with back attachments, selectorized machines, and back hyperextension benches)
Individuals with subacute and chronic LBP as well as recurrent LBP are encouraged to be physically active.
When recommendations are provided, they should follow very closely the recommendations for the general population combining resistance, aerobic, and flexibility exercise.
Physiologic responses to acute ex in children compared to adults
absolute oxygen uptake: lower relative oxygen uptake: higher heart rate: higher cardiac output: lower stroke volume: lower systolic blood pressure: lower diastolic blood pressure: lower respiratory rate: higher tidal volume: lower minute ventilation: lower respiratory exchange ratio: lower
Performance of muscular strength and endurance assessments is often limited by
actual or anticipated fear of reinjury in individuals with LBP.
children and adolescents physiologic responses to
acute, graded exercise are qualitatively similar to those seen in adults. There are important quantitative differences, many of which are related to the effects of body mass, muscle mass, and height.
The 2008 Physical Activity Guidelines for Americans call for children and adolescents to engage in
at least 60 min ∙ day−1 of moderate-to-vigorous intensity PA and to include vigorous intensity PA, resistance exercise, and bone loading activity on at least 3 d ∙ wk−1
Neuromotor exercise training, which combines
balance, agility, and proprioceptive training, is effective in reducing and preventing falls if performed 2-3 d ∙ wk−1. General recommendations include using the following: Progressively difficult postures that gradually reduce the base of support (two-legged stand, semitandem stand, tandem stand, and one-legged stand) Dynamic movements that perturb the center of gravity (tandem walk and circle turns) General recommendations include using the following: Stressing postural muscle groups (heel and toe stands) Reducing sensory input (standing with eyes closed) Tai chi
Approximately __ of acute low back episodes resolve within 6 weeks, regardless of treatment.
90%
Many individuals with LBP have fear, anxiety, or misinformation regarding their LBP, exacerbating a persistent pain state.
A combination of therapeutic and aerobic exercise, and pain education, improves individual attitudes, outcomes, perceptions, and pain thresholds.
Children and Adolescents Special Considerations
Children and adolescents may safely participate in strength training activities provided they receive proper instruction and supervision. Generally, adult guidelines for resistance training may be applied. Because of immature thermoregulatory systems, youth should avoid exercise in hot humid environments, be properly hydrated, and appropriately modify activities. Efforts should be made to decrease sedentary activities (i.e., television watching, surfing the Internet, and playing video games) and increase activities that promote lifelong activity and fitness (i.e., walking and cycling).
Children and Adolescents Exercise Prescription
Children and adolescents should be encouraged to participate in various physical activities that are enjoyable and age appropriate. PA in young children should include unstructured active play, which typically consists of sporadic bursts of moderate- and vigorous-intensity PA alternating with brief periods of rest. These small bouts of PA, however brief, count toward FITT recommendations.
Children and Adolescents Exercise Testing
Exercise testing for clinical purposes is generally not indicated for children or adolescents unless there is a health concern. The exercise testing protocol should be based on the reason the test is being performed and the functional capability of the child or adolescent. Children and adolescents should be familiarized with the test protocol and procedure before testing to minimize stress and maximize the potential for a successful test. Treadmill and cycle ergometers should be available for testing. Treadmills tend to elicit a higher peak oxygen uptake (VO2peak) and maximum HR (HRmax). Cycle ergometers provide less risk for injury but need to be correctly sized for the child or adolescent. Children and adolescents may require extra motivation and support during the exercise test compared to adults. Health/fitness testing may be performed outside of the clinical setting. The components of the Fitnessgram test battery include body composition (BMI or skinfold thicknesses), cardiorespiratory fitness (1-min walk/run, PACER), muscular fitness (curl-up test, pull-up/push-up tests), and flexibility (sit-and-reach test).
Older Adults Special Considerations
Intensity and duration of PA should be light at the beginning in particular for older adults who are highly deconditioned, functionally limited, or have chronic conditions that affect their ability to perform physical tasks. Progression of PA should be individualized and tailored to tolerance and preference; a conservative approach may be necessary for the most deconditioned and physically limited older adults. Muscular strength decreases rapidly with age, especially for those >50 yr. Although resistance training is important across the lifespan, it becomes more rather than less important with increasing age. For strength training involving use of selectorized machines or free weights, initial training sessions should be supervised and monitored by personnel who are sensitive to the special needs of older adults. Older adults may particularly benefit from power training because this element of muscle fitness declines most rapidly with aging, and insufficient power has been associated with a greater risk of accidental falls. Increasing muscle power in healthy older adults should include both single- and multiple-joint exercises (1-3 sets) using light to moderate loading (30-60% of 1RM) for 6-10 repetitions with high velocity. Individuals with sarcopenia, a marker of frailty, need to increase muscular strength before they are physiologically capable of engaging in aerobic training. If chronic conditions preclude activity at the recommended minimum amount, older adults should perform PA as tolerated to avoid being sedentary. Older adults should gradually exceed the recommended minimum amounts of PA and attempt continued progression if they desire to improve and/or maintain their physical fitness. Older adults should consider exceeding the recommended minimum amounts of PA to improve management of chronic diseases and health conditions for which a higher level of PA is known to confer a therapeutic benefit. Moderate intensity PA should be encouraged for individuals with cognitive decline given the known benefits of PA activity on cognition. Individuals with significant cognitive impairment can engage in physical activity but may require individualized assistance. Structured physical activity sessions should end with an appropriate cool-down, particularly among individuals with CVD. The cool-down should include a gradual reduction of effort and intensity and optimally, flexibility exercises. Incorporation of behavioral strategies such as social support, self-efficacy, the ability to make healthy choices, and perceived safety all may enhance participation in a regular exercise program. The exercise professional should also provide regular feedback, positive reinforcement, and other behavioral/programmatic strategies to enhance adherence
Individuals with LBP can be classified into one of three broad categories:
LBP associated with another specific spinal cause (e.g., cancer or fracture) LBP associated with radiculopathy or spinal stenosis Nonspecific LBP, which encompass over 85% of cases
Pregnancy - Exercise Testing
Maximal exercise testing should not be performed on women who are pregnant unless medically necessary. If a maximal exercise test is warranted, the test should be performed with physician supervision after the woman has been medically evaluated for contraindications to exercise.
Current best evidence guidelines for treating LBP indicate
PA as a key component in managing the condition
Pregnancy - Special Considerations
PA in the supine position should be avoided or modified after 16 wk of pregnancy. Women who are pregnant should avoid exercising in a hot humid environment, be well hydrated, and dressed appropriately to avoid heat stress. During pregnancy, the metabolic demand increases by ~300 kcal∙d−1. Women should increase caloric intake to meet the caloric costs of pregnancy and exercise. PA may help regulate weight gain during pregnancy Women who are pregnant and severely obese and/or have gestational diabetes mellitus or hypertension should consult their physician before beginning an exercise program and have their Ex Rx adjusted to their medical condition, symptoms, and physical fitness level. Women who are pregnant should avoid contact sports and sports/activities that may cause loss of balance or trauma to the mother or fetus. In any activity, avoid using the Valsalva maneuver, prolonged isometric contraction, and motionless standing. PA can be resumed after pregnancy, but should be done so gradually because of normal deconditioning in the initial postpartum period. Generally, gradual exercise may begin ~4-6 wk after a normal vaginal delivery or about 8-10 wk (with medical clearance) after a cesarean section delivery Women with higher CRF levels and more rigorous exercise routines prior to and during pregnancy may be able to resume exercise sooner. Light to moderate intensity exercise in the postpartum period is important for return to prepregnancy body mass index and does not interfere with breastfeeding.
Older Adults Physical Performance Testing
Physical performance testing has largely replaced exercise stress testing for the assessment of functional status of older. Most physical performance tests require little space, equipment, and cost; can be administered by lay or health/fitness personnel with minimal training; and are considered extremely safe in healthy and clinical populations
flexibility
There is no clear relationship between gross spinal flexibility and LBP or associated disability. A range of studies have shown associations between measures of spine flexibility, hip flexibility, and LBP but further study needed.
Pregnancy - Exercise Training Considerations
While there is no ideal number of days, exercise frequency during pregnancy should be regular, occurring throughout the week, and adjusted based on total exercise. Heart rate ranges corresponding to moderate intensity exercise have been developed, however due to heart rate variability, RPE may also be used to monitor exercise intensity during pregnancy. Exercise may be accumulated in shorter bouts (e.g., 15 minutes) or performed continuously. A 10-15 min warm-up and a 10-15 min cool-down of light-intensity PA are suggested before and after each exercise session. Previously inactive women should progress from 15 min∙d−1 (~3 d∙wk−1) at the appropriate RPE or target HR to approximately 30 min∙d−1 on most days of the week Women who habitually participate in resistance training should continue during pregnancy and should discuss how to adjust their routine with their health care provider. Kegel exercises and those that strengthen the pelvic floor are recommended to decrease the risk of incontinence during and after pregnancy.
FITT recommendations for women who are pregnant
frequency: -aerobic: greater than or equal to 3-5 days a week -resistance: 2-3 nonconsecutive days a week -flexibility: greater than or equal to 2-3 days a week with daily being most effective intensity: -aerobic: moderate intensity (3-5.9 METs; RPE of 12-13 on the 6-20 scale); vigorous intensity exercise (greater than or equal to 6 mets; RPE 14-17 on the 6-20 scale) for women who were highly active prior to pregnancy or for women who progress to higher fitness levels during pregnancy -resistance: intensity that permits multiple submaximal reps to be performed to a point of moderate fatigue -flexibility: stretch to the point of feeling tightness or slight discomfort time: -aerobic: ~30 mins a day of accumulated moderate intensity exercise to total at least 150 mins a week or 75 mins a week of vigorous intensity aerobic exercise -resistance: one set for beginners; two to three sets for intermediate and advanced; target major muscle groups -flexibility: hold static stretch for 10-30 seconds type: -aerobic: a variety of weight and non-weight bearing activities are well tolerated during pregnancy -resistance: a variety of machines, free weights, and body weight exercises are well tolerated during pregnancy -flexibility: a series of static and dynamic flexibility exercises for each muscle-tendon unit
FITT recommendations for older adults
frequency: -aerobic: greater than or equal to five days a week for moderate intensity; greater than or equal to 3 days a week for vigorous intensity; 3-5 days a week for a combination of moderate and vigorous intensity -resistance: greater than or equal to 2 days a week -flexibility: greater than or equal to 2 days a week intensity: -aerobic: on a scale of 0-10 for level of physical exertion, 5-6 for moderate intensity and 7-8 for vigorous intensity -resistance: light intensity (40%-50% 1 RM) for beginners; progress to moderate-to-vigorous intensity (60%-80% 1 RM); alternatively, moderate (5-6) to vigorous (7-8) intensity on a 0-10 scale -flexibility: stretch to the point of feeling tightness or slight discomfort time: -aerobic: 30-60 minutes a day of moderate intensity exercise; 20-30 minutes a day of vigorous intensity exercise; or an equivalent combination of moderate and vigorous intensity exercise; may be accumulated in bouts of at least 10 min each -resistance: 8-10 exercises involving the major muscle groups; 1-3 sets of 8-12 repetitions each -flexibility: hold stretch for 30-60 s type: -aerobic: any modality that does not impose excessive orthopedic stress such as walking. aquatic exercise and stationary cycle exercise may be advantageous for those with limited tolerance for weight-bearing activity -resistance: progressive weight-training programs or weight-bearing calisthenics, stair climbing, and other strengthening activities that use the major muscle groups -flexibility: any physical activities that maintain or increase flexibility using slow movements that terminate in static stretches for each muscle group rather than rapid ballistic movements
FITT recommendations for children and adolescents
frequency: -aerobic: daily -resistance: greater than or equal to 3 days a week -bone strengthening: greater than or equal to 3 days a week intensity: -aerobic: most should be moderate (noticeable increase in HR and breathing) to vigorous intensity (substantial increases in HR and breathing). Include vigorous intensity at least 3 days a week. -resistance: use of body weight as resistance or 8-15 submaximal repetitions of an exercise to the point of moderate fatigue with good mechanical form -bone strengthening: N/A time: -aerobic: as part of greater than or equal to 60 minutes a day of exercise -resistance: as part of greater than or equal to 60 min a day of exercise -bone strengthening: as part of greater than or equal to 60 minutes a day of exercise type: -aerobic: enjoyable and developmentally appropriate activities, including running, brisk walking, swimming, dancing, bicycling, and sports such as soccer, basketball, or tennis -resistance: muscle strengthening physical activities can be unstructured (playing on playground equipment, climbing trees, tugg-of-war) or structured (lifting weights, working with resistance bands) -bone strengthening: bone strengthening activities include running, jumprope, basketball, tennis, resistance training, and hopscotch
General testing of muscular strength and endurance in individuals with LBP should be
guided by the same considerations as for the general population.
Flexibility testing in individuals with LBP should be
guided by the same considerations as for the general population. It is essential to identify whether the assessment is limited by stretch tolerance of the target structures or exacerbation of LBP symptoms.
Research on the effects of resistance exercise during pregnancy is limited, but show that compared to sedentary controls, resistance training either:
has no effect (e.g., no difference in gestational age, preterm labor, or caesarian delivery; delivery of normal birth weight infants at term) or produces better outcomes (e.g., lower incidence of low back pain; shorter labor duration; shorter recovery time/faster return to activity in postpartum)
In chronic LBP, exercise programs that incorporate
individual tailoring, supervision, stretching, and strengthening are associated with the best outcomes. For the most favorable outcomes, use an individualized approach that addresses psychological distress, fear avoidance beliefs, self-efficacy in controlling pain, and coping strategies.
The term older adult (defined as
individuals ≥65 yr and individuals 50-64 yr with clinically significant conditions or physical limitations that affect movement, physical fitness, or physical activity) represents a diverse spectrum of ages and physiologic capabilities.
Actual or anticipated pain may limit submaximal testing as often as maximal testing. Therefore,
the choice of maximal versus submaximal testing in individuals with LBP should be guided by the same considerations as for the general population.
Individuals with LBP frequently have deficits in
trunk muscle strength and endurance and neuromuscular imbalance.
Because prepubescent children have immature skeletons,
younger children should not participate in excessive amounts of vigorous intensity exercise.
