Clinical Exercise Physiology Final Exam

autonomic nervous system disruption

Affects sympathetic and parasympathetic function controlling HR, SV, BP, blood flow, ventilation, thermoregulation, and metabolism.

Respiratory management issues with SPIs

Assisted ventilation often required for high cervical injuries Secretion management essential because of impaired cough and increased parasympathetic nervous system influence on pulmonary secretions Assisted cough required for SCI above T6 attributable to intercostal and abdominal muscle paralysis

special considerations for exercise in pregnant women

Avoid strenuous exercise during hot, humid weather Encourage plenty of water Avoid exercise when severely fatigued Avoid exercising at altitudes above 6,000 feet Be aware that pregnancy increases energy needs only slightly, but exercise increases needs as well Free weights can be hazardous due to joint instability

second trimester

Body adjusts to hormone levels Enlarging fetus promotes back pain Center of balance changes Joints become less stable Reflux develops as uterus and fetus are displaced Edema develops Blood Volume, Stroke Volume, Heart Rate, and Cardiac Output all increase to support growing fetus

third trimester

Fetus enlarges and crowds out maternal organs Urge to urinate increases Cardiac Output decreases (10-30%) Heart rate approximately elevated by 10-15 bpm Fatigue ensues Braxton-Hicks contractions might develop Irregular uterine contractions - usually increase with activity

Review medical history and medications Current symptoms Assess Balance Flexibility Strength Endurance Gait abnormalities

History and physical exam—assess for indicators that will affect the exercise prescription for people with MS include:

first trimester

Hormone levels fluctuate dramatically and promote nausea Perspiration increases Fetus enlarges and puts pressure on urinary bladder Fetal organ systems develop Each system has a "critical period"

men

Is the rate of SPI higher in men or women

Progesterone

Maintains endometrial lining during pregnancy Limits the natural movements of the uterus to prevent contractions early in pregnancy

Standard testing typically OK 1RM can be used, but modify if significant weakness

Musculoskeletal testing for people with MS?

somatic nervous system disruption

Neural pathways connect the brain to the body by the spinal cord. Complete SCI interrupts transmission of these signals, and voluntary movement and sensory perception are absent below the lesion.

exercise in children

Pediatrics is the branch of medicine concerned with children and their diseases. Children are the population between infancy and adolescence.

resistance training in pregnant women

Perform on at least 2 days per week Complete 8-10 exercises targeting major muscle groups Work at an intensity that permits 12-15 repetitions/set Avoid isometric exercises and the Valsalva maneuver Avoid full sit-ups throughout pregnancy Avoid the supine position after the 3rd month

cardiovascular training during pregnancy

Perform on at least 3 (preferably all) days of the week Exercise for a duration of 15 to 30 minutes Work at a moderate intensity 12 to 14 on the 6 to 20 Borg RPE scale Avoid contact sports and high-impact sports Low impact exercise

exercise testing in pregnant women

Pregnant women without contraindications may continue exercise throughout pregnancy Maximal exercise testing should be done only if medically necessary and only under physician supervision. Submaximal testing to predict maximum oxygen uptake for better program design is fine for most women

exercise prescription in pregnant women

Previously sedentary women should seek medical clearance before exercise initiation All pregnant women should be screened using the Physical Activity Readiness Medical Examination Begin all exercise with at least a 5- to 10-minute warm-up Include limbering movements Perform mild stretching

patho of spinal cord injury

Primary injury can damage neural tracts, cell bodies, and vascular structures that supply the cord. Secondary injury occurs because of hemorrhage and local edema within the cord. Can compromise vascular supply, resulting in local ischemia Infarction of the gray matter occurs within 4 to 8 h after injury if blood flow cessation persists.

Patho of MS

Process likely initiated by autoreactive T cells Cross blood-brain barrier and begin myelin damage Four major courses of clinical progression (table 26.1 slide 5 MS)

prolactin

Produced after delivery Stimulates milk production in mammary glands

Human chorionic gonadotropin (HGC)

Produced by day 12 after fertilization Maintains corpus luteum until placenta develops Detected by pregnancy tests

Progressive-relapsing (MS)

Progressive from onset with short, definite relapses with or without full recovery

Estrogen

Rebuilds the endometrial lining after menstruation Helps regulate progesterone levels during pregnancy

Cardiovascular management issues with SPI

Relative bradycardia attributable to impaired sympathetic nervous system in SCI above T6; occasionally requires pacemaker placement Hypotension attributable to systemic vasodilation resulting from impaired sympathetic drive Venous stasis can result in deep venous thrombosis or pulmonary embolism

relaxin

Released early in pregnancy to limit uterine contractions Softens cervix in preparation for child birth Makes joints in the body flexible (increases laxity of ligaments, nearly undetectable in not pregnant women)

oxytocin

Stimulates uterine contractions at end of pregnancy Stimulates milk ejection or letdown after birth

Functional mobility issues with SPI

Upper extremity range of motion, strengthening, and endurance within limitations of orthotics and medical management Bed mobility (including side to side, supine to prone to supine, supine to sit) Wheelchair mobility (including forward and backward propulsion, turning, uneven terrain, curbs, ramps, hills) Transfers (including bed to wheelchair to bed, wheelchair to toilet to wheelchair, wheelchair to bath to wheelchair, wheelchair to floor to wheelchair, wheelchair to car to wheelchair) Activities of daily living including feeding, grooming, dressing, bathing, toileting Bladder management training, typically with intermittent catheterization or alternative Bowel management training, typically with suppositories and digital stimulation or alternative Skin management training with monitoring and pressure relief techniques Equipment evaluation for personal care, mobility, and public accessibility Home and vehicle evaluation for accessibility Psychological and social adjustment to SCI Introduction to vocational and recreational opportunities for persons with SCI

healthy weight gain during pregnancy

Weight gain should be about 25-35 pounds Birth weight is the greatest predictor of health Exercise can prevent unwanted weight gain by increasing energy expended Exercise preserves muscle and bone mass and minimizes fat mass

contact sports activities with a high risk of falling scuba diving sky diving hot yoga

What are activities that should be avoided during pregnancy?

Intermittent BP and ECG determination Low/moderate work rate progressions each 2 to 3 min (~25 W per) Functional versus diagnostic testing (ECG, echo, or radionuclide)

What are assessments of lab testing that can be used with SPI?

Consider cycle ergometer if ambulatory impairment exists Treadmill if safe walking is not an issue Watch for indications of overheating and fatigue; electric fans, fluid replacement, and cooler room temperatures help Low-level protocols for most due to deconditioning Watch for attenuated BP response, especially if autonomic dysfunction has been diagnosed

What are cardiovascular testing considerations for people with MS?

Autonomic dysreflexia (sudden high BP) resulting from recent fracture—may precipitate spasms or increase the risk of fatty emboli or cerebrovascular events Orthostatic hypotension (sudden drop in BP while standing), with the risk of syncope Recent deep vein thrombosis or pulmonary embolism Pressure ulcers, which increase the risk of autonomic dysreflexia during exercise

What are common absolute contraindications for SPI?

Visual impairments Optic neuritis Nystagmus Motor function difficulties Paresthesia Spasticity—can affect range of motion and movement during high-speed flexion/extension Difficulties with walking and balance/coordination—may lead to falls Psychological effects Impaired cognition Memory loss Depression

What are common early indicators for MS?

To evaluate specific signs that are induced or aggravated by exercise To assess or identify abnormal responses to exercise in children with cardiac, pulmonary, or other organ disorders, including the presence of myocardial ischemia and arrhythmias To assess efficacy of specific medical or surgical treatments To assess functional capacity for recreational, athletic, and vocational activities To evaluate prognosis, including both baseline and serial testing measurements To establish baseline data for institution of cardiac, pulmonary, or musculoskeletal rehabilitation

What are common reasons for pediatric stress testing?

Active tendinitis (e.g., rotator cuff, elbow flexors, wrist flexors/extensors) Chronic heterotopic ossification Peripheral neuropathy Pressure ulcers of grade 2 or less Spasticity

What are common relative contraindications for SPI?

muscle weakness symptomatic fatigue numbness visual disturbances walking, balance, and coordination problems bladder dysfunction bowel dysfunction cognitive dysfunction dizziness and vertigo depression emotional changes sexual dysfunction pain optic neuritis nystagmus paresthesia spasticity

What are common signs and symptoms of MS?

walking swimming stationary cycling low-impact aerobics yoga, modified pilates, modified running or jogging racquet sports strength training

What are examples of exercises that are safe to do during pregnancy?

Use goniometer Can be quite inflexible due to disease progression and level of spasticity

What are flexibility testing that can be used for people with MS?

Wheelchair Upper body ergometry Functional electrical stimulation (FES)

What are modes of lab testing that can be used with SPI?

Hypotensive response (lack of sympathetic drive)

What are risks of exercise testing for SPI?

Kurtzke function systems MS Functional composite (MSFC) Modified Fatigue impact scale (MFIS) Health Status Questionaire (SF-36)

What are some functional assessments used to assess MS patients?

Alcohol Toxins in cigarettes and cigarette smoke Prescription and over-the-counter drugs Listeria spp. (Lunch meat and fresh vegetables) Caffeine (<200mg per day does not appear to be a risk factor for spontaneous abortion or preterm birth)

What are some hazardous substances during pregnancy?

Thermoregulation is poor. Good hydration and fluid replacement during and/or after exercise is essential Controlled temperature in room Consider electric fan for more convective cooling Consider precooling Fatigue may occur earlier than in healthy population. Watch for balance and coordination issues for safety.

What are some important issues that people with MS can have during exercise?

Physical therapy Occupational therapy Speech pathology Cognitive specialists Complementary treatments (e.g., Chinese medicine, relaxation, yoga), although the research on these is very limited Assistive devices—canes, crutches, orthoses, and the like

What are some options to consider for the treatment of patients with MS?

Special considerations Adapted or adaptable equipment necessary for appropriate and safe exercise training: Velcro straps Cuffed weights FES systems

What are some special considerations for exercise prescription for patients with SPI

relapsing-remitting primary progressive secondary progressive progressive-relapsing

What are the 4 clinical courses of MS?

Balance is negatively altered by MS due to longer double-support phase, loss of strength, and gait alteration. Resistance training and specific balance training (Bosu ball, large balls, and so on) can improve balance.

What are the benefits of balance training for people with MS?

Endurance training positively improves functional capacity Minimizes illness due to sedentary living

What are the benefits of cardiovascular exercise for people with MS?

Both isometric and dynamic strength can be improved; reduced strength due to reduced central NS activation, lower motor unit discharge rate Improvements noted for isometric and dynamic strength and power, Timed Up and Go test, walking speed, muscle endurance, and balance

What are the benefits of resistance exercise for people with MS?

Children have many conditions that may elicit a referral for exercise testing, including but not limited to: Asthma Cystic fibrosis Diabetes Obesity Various forms of heart disease

What are the exercise test referrals for children?

Easiest and least expensive to perform Low relationship to peak VO2, possibly due to variability in testing conditions

What are the field testing that is used for exercise testing for SPI?

Maintain ability to perform ADLs Provide general health benefits to reduce risk of diseases related to deconditioning Reduce symptoms Improve QOL

What are the goals of exercise prescriptions for people with MS?

attain physical ability to perform ADLs including: Feeding Grooming Hygiene Dressing Bathing All transfers Toileting Mobility

What are the goals of exercise training for patients with SPI?

increased submaximal oxygen consumption during treadmill walking same or decreased submaximal and maximal arterial BP same or increased temperature earlier skeletal muscle fatigue

What are the physiological response for people with MS during exercise?

Medical history Neurological exam MRI Evoked potential response Cerebrospinal fluid analysis Blood tests

What are the typical tests done to diagnose MS?

vaginal bleeding regular painful contractions amniotic fluid leakage dyspnea before exertion dizziness headache chest pain muscle weakness affecting balance calf pain or swelling

What are warning signs to discontinue exercise while pregnant? *very important

Preeclampsia is characterized by high blood pressure and protein in the urine It detrimentally affects mother and fetus

What are ways that exercise decreases risk for preeclampsia?

Exercise alleviates back pain, stiff joints, constipation, bloating, and insomnia Exercise maintains joint range of motion Exercise preserves muscle mass and strength Exercise improves mood and decreases the incidences of depression in pregnant women

What are ways that exercise reduces overall discomfort and improves mood?

The first step, as with adults, is to obtain a complete medical history and physical exam, along with any pertinent laboratory findings. The information gleaned from this will help the clinician evaluate the child for risk of exercise, through stratification for level of risk, and to determine contraindications to exercise testing and exercise participation. The goal is to make sure that, in the case of exercise testing, the benefit of the testing outweighs information to be gained by having the child attempt to complete the exercise test.

What do you need for children relating to health history and physical examinations?

Intimate connection between mother and fetus Exchanges nutrients, gases, and waste products Can be breached by hazardous substance

What does the placenta do during pregnancy?

Best if developed by multidisciplinary team: Clinical exercise physiologist Physical therapist Physician Those with complete SCI should begin exercise training under supervision.

What is exercise prescription for SPI?

Perform daily (multiple times a day if possible) Focus on all major joints Particular focus on joints with contracture or spasticity Consider care for those with osteopenia

What is the ROM exercise prescription for patients with SPI?

16 to 30 year olds

What is the age range that SPI most commonly occur?

Intensity: method of intensity monitoring controversial HR responses are variable depending on level of injury; in many, 30% to 80% HRR correlates to 50% to 85% peak VO2. RPE is often used and preferred; RPE of 11 to 14 is likely best. Duration: goal to follow guidelines for general population and work up to 60 min per session Frequency: 3 to 5 d/wk Consider multiple daily bouts for those with very low functional status

What is the cardiovascular exercise prescription for patients with SPI?

corticosteroids

What is the only medication available for the treatment of MS?

Establish relationship between fitness and return to work Determine how fitness level changes over time Diagnostic for CHD

What is the rationale behind the exercise testing for SPI?

Scapular stabilization and rotator cuff exercise in all patients Initially: two sets of 10 reps for all exercises Isometric contractions for shoulder Protractors Retractors Elevators Depressors Internal and external rotators Bands are useful Free weights only for those able to use safely Avoid overload of wheelchairs and always set brakes

What is the resistance exercise prescription for patients with SPI?

Although children do not, in and of themselves, constitute a clinical population, it is important for clinicians to know about the exercise responses of children and how they may influence exercise testing, exercise training, and exercise prescription. Children can present with many different clinically relevant signs and symptoms, diseases, and disorders. In recent years the number of children who are overweight or obese has increased dramatically. Children are now being diagnosed with chronic diseases that we often see in adult clinical populations, such as type 2 diabetes, hypertension, dyslipidemia, and metabolic syndrome.

What makes children unique?

6-12 weeks (possible as early as 4 weeks)

When do most women find our they are pregnant?

critical period

a limited period of time during which an organ system is growing rapidly

Spinal cord injury

affects conduction of neural signals across the site of the injury or lesion

women

are men or women more likely to suffer from MS?

secondary progressive (MS)

begins as relapsing-remitting but progresses either with or without infrequent relapses, plateaus, and remissions

Moderate intensity 5 d/wk >30 min/d May be accumulated in shorter bouts of 10 or 15 min Stationary cycling (legs, arms, or both), walking, water activities (swimming, aerobics) most common modes Progress based on individual heart rate response Train at 50% to 60% of peak VO2 or 65% to 70% of peak HR)

cardiovascular exercise prescription for people with MS

relapsing-remitting (MS)

characterized by disease relapses with either a full recovery or a deficit after recovery; no progression of disease symptoms in recovery stage

SPI degree of impairment A

complete, no motor or sensory function is preserved in the sacral segments S4-S5

primary progressive (MS)

disease progression from onset with infrequent plateaus and only temporary, small improvements; clinical status continuously worsens with no distinctive remissions

between 2 and 6 weeks

during what time of pregnancy does the central nervous system and heart develop?

Useful for baseline measures for future comparisons of effectiveness of exercise training Provides information on individual responses and exercise tolerance Cardiovascular testing

exercise testing for MS

SPI degree of impairment D

incomplete: motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of > 3

SPI degree of impairment C

incomplete: motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade of < 3

SPI degree of impairment B

incomplete: sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-S5

multiple sclerosis

inflammatory autoimmune disease of central nervous system

characteristics of MS

nerve demyelination Plaques (sclerosis) in brain and spinal cord Develop into permanent scars Impaired nerve transmission Symptoms of weakness, fatigue, and impaired motor function

SPI degree of impairment E

normal: motor and sensory function is normal

incomplete (SPI)

partial preservation of sensory or motor function below the neurological level

Important for mobility and independent living Perform >2 d/wk, never 2 consecutive days Weightlifting, stair climbing, and elastic bands are common modes. Aquatic resistance exercise may be useful. 8 to 12 repetitions per set; should go to volitional fatigue Range of motion and ability to perform certain exercises may be limited

resistance exercise prescription for people with MS

table 25.3

slide 8 of SPI

Devices for improved grip and reduction in risk of various injuries Devices to improve venous return and pulmonary function Other

what accommodations need to be made for patients with SPI during exercise testing?

hemodynamically significant heart disease restrictive lung disease incompetent cervix or cerclage multiple gestation at risk of premature labor persistent second or third-trimester bleeding placenta previa (placenta between cervix and baby) after 26 weeks of gestation premature labor during current pregnancy ruptured membranes preeclampsia or PIH severe anemia

what are absolute contraindications for aerobic exercise during pregnancy?

Improve or maintain fitness level Promotes a healthy weight gain Reduction in the incidence of cesarean delivery Shortened post-partum recovery time Reduces overall discomfort and improves mood Decreases risk of pregnancy induced hypertension Decreases risk for preeclampsia Decreases risk of gestational diabetes

what are benefits of exercise during pregnancy?

Tidal Volume increases during pregnancy. Alveoli become more "efficient" - oxygen travels easily from alveoli to blood due to reduced thickness of alveoli wall.

what are some respiratory changes during pregnancy?

First Trimester = 0 - 12 weeks gestation (0 starts at the beginning of the menstrual period before fertilization) Second Trimester = 13 - 26 weeks gestation Third Trimester = 29 to 40 weeks gestation

what are the 3 trimesters of pregnancy?

HCG increases in months 1-2 progesterone and estrogen both gradually increase over the 9 months of pregnancy

what are the hormone responses during pregnancy

anemia unevaluated maternal cardiac arrhythmia chronic bronchitis poorly controlled type 1 diabetes extreme morbid obesity extreme underweight history of extremely sedentary lifestyle intrauterine growth restriction in current pregnancy poorly controlled hypertension orthopedic limitations poorly controlled seizure disorders poorly controlled hyperthyroidism heavy smoker

what are the relative contraindications during pregnancy?

General flexibility improvement suggested May reduce spasticity, improve posture and balance Follow general guidelines for slow, static stretching of major muscle groups and joints Some with severe MS may require passive stretching

what is the exercise prescription for range of motion for people with MS?

to categorize into definite, possible, and not MS categories.

what is the goal of diagnostic testing for MS?

reduce or slow effects of MS and treat symptoms

what is the goal of treatment for MS

20 to 50 year

when is the initial diagnosis for MS typically?

Clinical exercise testing of children may be difficult. Children's body size in relation to testing equipment may be problematic (equipment designed for adults). Their peak performance may be poor. Their attention span tends to be short and they may have poor motivation during exercise testing, most often with longer exercise protocols.

why can exercise testing for children be difficult?

complete impairment (SPI)

without sensory function in the lowest sacral segment