Introduction
I have spent many years counseling
patients on the merits of dietary modifications in
diabetes, hypercholesterolaemia, and obesity, the
avoidance of salt and caffeine for hypertensives,
adequate calcium and vitamin D intake for the prevention
of osteoporosis, cessation of smoking for the improvement
of cardiac and pulmonary risk factors, and cognitive
therapy for depression and anxiety disorders. However,
I have never found a more profound impact on all of
the above medical conditions as well as a patient’s
general well-being than a properly prescribed and
facilitated exercise regimen. This article will briefly
review the epidemiology of sedentarianism, the general
benefits and risks of exercise, a short primer on
the types of exercise, and then a step-by-step approach
to exercise prescription. The intent of this article
is to increase the level of activity in your geriatric
population safely, and to work through the basics
of exercise prescription. The medical approach to
dealing with more advanced levels of physical activity
falls beyond the scope of this article.
Epidemology
There has been a reduction
in the level of physical activity and a converse increase
in obesity and weight gain in the general population
over the last decade(1-3,10). This raises concerns
about the prospect of obese, sedentary, seniors with
multiple medical concerns.
Benefits
The benefits of exercise are
multiple and there is an abundance of clinical research
devoted to this topic. Interestingly enough, this
field of medical research was essentially nonexistent
prior to 1980(4). My intention is to briefly review
the literature. Firstly, increasing fitness levels
has had the empiric effect of reducing the effects
of aging associated with declining health and function(5,6).
Secondly, increasing fitness levels have been associated
with longer lives and decrease
in all types of mortality including certain cancers
and cardiovascular deaths(4-9). Thirdly, exercise
has shown to improve both physical and mental well-being
through the following mechanisms: improved body physique
(including increased muscle mass, strength, flexibility,
bone density, and reduction in body fat)(4,6,11,12,18),
reduced disability associated with arthritis(13,14),
improved balance and reduced falls(6,15), and improved
psychological health(16,17). Fourthly, in more specific
terms, exercise has been shown to improve glucose
tolerance and reduce insulin resistance, improve abnormal
lipoprotein profiles, reduce hypertension and left
ventricular hypertrophy, improve resting metabolic
rate, and reduce abdominal obesity(4).
Risks
This section is to be further
subdivided into risks associated with physical activity
and risks associated with exercise testing. The risks
associated with light to moderate intensity physical
activity are highest for those individuals with established
cardiac disease or poorly managed condition(s) like
“brittle” diabetes or high ventolin-use asthma, less
so for those individuals with coronary artery disease
(CAD) risk factors of undetermined significance like
smoking or hypercholesterolemia, and the lowest for
those in the healthy non-smoking category upto and
including stable well-managed medical conditions like
controlled atrial fibrillation or stable chronic obstructive
pulmonary disease(19). A history and physical examination
can be used to diferentiate between these categories.
There is, however, a more objective evaluation of
exercise-associated risk. The Canadian Society for
Exercise Physiology (CSEP)* through Health Canada
has developed the Physical Activity Readiness Questionnaire
(PAR-Q)(Figure 1) which can easily identify those
adults for whom physical activity might be inappropriate
or those who should have a more thorough medical work-up
prior to starting an exercise programme(20- 21). The
PAR-Q is specifically designed for use in those individuals
aged 15 to 69, but may serve as a good guideline for
those older. These individuals can be further evaluated
using a (sub)maximal graded exercise testing(GXT).
The risk factors of exercise testing by maximal GXT
is a risk of death<0.01% and a risk of myocardial
infarction(MI)<0.04%(19). The risks for submaximal
GXT are lower. Finally, there are contraindications
for exercise testing that must be noted (Figure 2)(19).
Types of Exercise
Most physicians are aware
of the two most common types of exercise training;
aerobic/cardiovascular endurance training and muscular
strength/resistance training. Other types of exercise
training include flexibility, balance and coordination.
In summary, cardiovascular endurance training deals
with the improvement in the body’s ability to utilize
oxygen efficiently while the body moves. Examples
include walking, cycling, swimming, skating, dancing,
skipping, etc. It will be important to define the
intensity, duration, and frequency as one moves from
the conditioning to improvement to maintenance stages
(see constituents of the exercise regimen). This type
of exercise training is an excellent starting point
for increasing the level of activity and would be
the singular focus for the frail elderly (see preliminary
programme). Resistance training or weight training
is the use of a gradually increasing resistance over
time to develop muscle strength. Flexibility is an
area of exercise training that is often neglected.
However, stretching and flexibility are tantamount
to maintaining and improving joint range of motion.
Lack of flexibility is rampant in the elderly and
integral to the reduced ability to perform activities
of daily living(ADL). Accordingly, any exercise prescription
for the elderly should include a stretching programme
focusing on the upper and lower trunk, neck, and hip/posterior
thigh(5,19). Balance and coordination are best incorporated
into sport, because certain skill development intuitively
incorporate these faculties. Examples of these sports
include tennis, golf, Tai Chi and lawn-bowling.
Approach to Exercise Prescription
During a patient’s annual
physical examination, it has become my routine to
ask about their level of physical fitness. If a patient
is active on a regular basis, I usually review their
activities, investigating the intensity, duration,
and frequency (to be desribed fully in constituents
of the exercise regimen) and then develop the next
goal. If a patient is minimally active, an assessment
must be done to determine if there are any contraindications
to exercising and if investigations should be done
prior to starting an exercise programme. For those
who are minimally active and have no contraindications
to exercise, I use my step-by-step approach. It is
based on years of clinical experience integrating
exercise science methodologies from various sources
with behavioral techniques. Christmas and Andersen
have developed an approach to exercise prescription
which also has some merits(22). It is a review article
that focuses more on the approach to motivating the
sedentary older patient than writing the exercise
prescription, which is my focus. Neither approach
has been validated in clinical trials.
Questioning
Typically, I inquire about
the patient’s knowledge of the benefits of exercise.
More often these days patients are very well-educated
and have some interest in exercising but are not exercising
for several reasons. These reasons usually fall into
the following categories: unsure of the programme
to follow, concern about personal safety or health
concerns, laziness, tiredness, aggravation of a present
condition (like an arthritic knee), and finally lack
of time(22). It is best to review their previous physical
activity level to ensure that you challenge them appropriately.
This often lets you assess the appropriate starting
point, the pace of progress, and the expectations.
Thereafter I usually say “wouldn’t you like to improve
so-and-so?” and that I would be willing to assist
them in this endeavour. Sometimes patients literally
jump at this opportunity, others are a bit hesitant.
For the hesitant ones, you have started a new dialogue.
For those who are willing, your job has just begun.
Preliminary Programme
To create long-term compliance
and attain the individual patient’s goals requires
a fine balance between the following principles of
exercise prescription and human motivational techniques(19).
All attempts are commended, any indiscretions are
calmly redirected to the goals without guilt. I ask
the patient to choose an aerobic activity and to commit
to a frequency of three to four times a week on non-consecutive
days. This is recorded in the chart as a tacit contract.
There are no limits to the minimum duration at this
stage because our interest is to increase physical
activity. This type of programme is acceptable as
the only exercise prescription for the frail elderly.
I usually include a stretching programme after the
aerobic activity at this stage as a matter of habit
and prevention. A series of easy-to-understand stretches
are published in the American College of Sports Medicine’s
Fitness Book. I include a calf stretch, a hamstring
stretch, a quadricep stretch, a few back stretches,
and if motivated, a groin stretch, a shoulder stretch
and neck stretches. Each stretch should last about
15 seconds up to a position of mild discomfort, three
times for each, in a slow, controlled motion (non-ballistic)
with a gradual progression to greater ranges of motion(ROM)(19,23,24).
I always include the proviso that if anything hurts
to take the next time off or to not progress the next
time in duration of programme or extent of stretch.
Finally, I ask each patient to record their heart
rate upon waking and their post-exercise heart rate.
This is the beginning of their exercise log, which
will include the type of exercise, duration, intensity,
and frequency. Patient’s should be encouraged to bring
it to each appointment. This serves two purposes;
one it helps to familiarize the patient with his or
her level of exertion and progress and two it helps
in the true exercise regimen for target intensity
levels. The appropriate juncture for promotion to
the next stage is based on dialogue between the patient
and his/her physician-coach. Typically, this preliminary
programme entices the patient into the first stage
of the true exercise regimen.
Constituents of the Exercise
Regimen
Stage One - Initial Conditioning
This stage often extends almost
imperceptively from the preliminary programme. Each
of these stages will include a warm-up, a stretching
programme, resistance training, and a cardiovascular
endurance component. This stage can last four to eight
weeks based on the individual’s interest and their
adaptation to the progression of challenge. The expectation
is to follow the exercise prescription three to four
days per week on non-consecutive days. The exercise
programme’s duration should begin at about 12 minutes
and progress to 20-30 minutes (it is possible to divide
this into ten minute aliquots). This stage should
start with a five minute walk, a five minute stretching
programme, and light resistance exercises using whatever
appliances are available (e.g. various sizes of canned
goods, condominium facilities). As the regimen progresses
the walk can be lengthened, or exchanged for another
low level aerobic activity (like stationary bike,
swimming, walking stairs), or split before and after
the resistance training. In detail, the aerobic component
involves a target heart rate of between 40 to 60%
of maximum heart rate(MHR), which is compatible with
mildly laboured ability to talk during exercise. The
formula for determining MHR is MHR = (220-age)(simplified
calculation)(19). This is probably the simplest method
to calculate MHR, however there are considerable limitations
to this calculation(19). In detail, the resistance
training involves 6 to 8 repetitions of each exercise,
with proper form, through a full ROM, and with a normal
breathing pattern. The latest research confirms that
only one set per exercise is required to have the
same benefit as multiple sets (27). Individual goals
should guide progression. Patients should be realistic
and generously praise their own efforts(19,25,26).
Stage Two - Improvement
This stage has the same pattern
of warm-up, stretching, resistance and aerobic training.
This stage typically lasts four to six months. The
exercise regimen continues at the same frequency of
three to four times per week, but can alternate exercise
days between an aerobic and a weight training focus.
The resistance training should attempt to train all
major muscle groups and to increase the number of
repetitions upto 10. The goals for the end of this
stage is to reach 70 to 75% of maximal heart rate
for aerobic training, a regular resistance training
programme with stable weights causing minimal muscle
soreness, discomfort, or injury, and a duration of
the total programme upto 40-45 minutes. The rate of
progression is, as always, commensurate with the individual’s
adaptation response. Commonly, progression in duration
of exercise then intensity of both resistance and
cardiovascular endurance occurs every 2-3 weeks(19,25,26).
The most important caveat is to not progress if pain,
discomfort, or interposing illness is encountered.
Sometimes a hold pattern or regression is required
and that is why the preliminary stages of education
and training were so important.
Stage Three - Maintenance
This stage is usually achieved after six months of
training. The key for this stage is to provide alternatives
to ensure that exercise is enjoyable, find a comfortable
intensity, duration, and frequency (at least three
timesand not more than five times a week), and set
new goals based on the patient’s new awareness and
health(19,25,26). Patients at this stage are very
proactive because they feel the impact of their training
and tend to want to exercise even during illness or
disability. It is important to maintain realistic
goals for each individual. One of my post angioplasty
patients went on to complete a marathon, but he was
an exceptional individual. This is not common.
Conclusion
Exercise prescription has
been the cornerstone of my medical practice because
of its pluripotential health improvements. Elderly
patients require a proper assessment to determine
the need for pre-exercise prescription investigations
and to set the right starting point. I have used it
as an adjunct to quitting cigarette smoking to reversing
frank type 2 diabetes into milder glucose intolerance
that is diet controlled to minimizing the destabilizing
mood disorders of a patient suffering from a somatiform
disorder. The properly prescribed exercise regimen
will incorporate the patient’s interests, needs, goals,
and overcome their perceived barriers. The properly
prescribed exercise regimen will motivate a patient’s
innate sensibilies to facilitate lifelong compliance.
The properly prescribed exercise regimen will really
improve all types of medical conditions.
*The CSEP can be reached @
613-234-3755 or www.csep.ca
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