communication should be maintained between the PT and the physician in case new signs or symptoms develop during the exercise program. If older adults are currently participating in an exercise program and are asymptomatic, medical clearance is not necessary to alter or continue the program so long as it is done at a light to moderate intensity. All exercise participants should be educated as to the importance of chest, arm, or jaw discomfort, abnormal shortness of breath, or heart palpitations as symptoms of cardiac dysfunction (Riebe et al., 2015). If any cardiac symptoms become apparent with exercise, exercise should be stopped and the individual should be referred to his or her physician for further follow-up and testing. An exercise stress test is recommended prior to the start of any vigorous exercise program for anyone with a known metabolic (such as type 2 diabetes), cardiovascular, or renal disease (Riebe et al., 2015). It is important that all patients be educated on the difference between moderate and vigorous exercise so that appropriate screening and testing can be completed as needed for the safety of the patient.
during the initial stages of participating in an exercise program (Fletcher et al., 2013; Williams et al., 2007). For individuals with relative contraindications, the advice of their physician should be sought prior to initiating an exercise program. A list of both absolute and relative contraindications to exercise can be found in Table 5. An exercise stress test is not a necessary screening tool for everyone prior to the start of exercise (Riebe et al., 2015). In general, healthy older adults with no comorbid conditions and no signs of symptoms suggestive of comorbid conditions do not require medical clearance prior to initiating a light to moderate exercise program (Riebe et al., 2015). Further, these participants may progress to vigorous exercise if desired following the above discussed guidelines. Older adults with known cardiovascular, metabolic, or renal disease should seek medical clearance from their physician prior to starting a new exercise program (Riebe et al., 2015). Medical clearance is left up to the discretion of the physician and may include a resting electrocardiogram, an exercise stress test, or even an angiography if warranted. Close T able 5: Absolute and Relative Contraindications to Exercise Absolute Contraindications • Unstable chronic heart disease. • Unstable angina (chest pain). • Uncontrolled heart arrhythmias such as ventricular tachycardia. • Worsening congestive heart failure. • Acute myocardial infarction. • Severe pulmonary hypertension. • Severe aortic stenosis. • Acute infection of the heart. • Aortic dissection. • Unstable eye disease such as advanced diabetic retinopathy. • Acute severe infection. • Pulmonary embolus. Note . Adapted from (Fletcher et al., 2013; Williams et al., 2007). Special populations Safety should always be the PT’s primary concern when establishing an exercise program for an older adult. To ensure safety, vitals should be taken for all older adults before and after all exercise sessions. Many older adults have comorbid conditions – such as diabetes, osteoarthritis (OA), and dementia – that warrant specific recommendations or adjustments for exercise. While most individuals with comorbid conditions will still be able to fully participate in an exercise program, some adjustments to the exercise prescription may be necessary to ensure safety. Such adjustments will ensure that older adults with these conditions are able to safely complete both aerobic and resistance training. In general, any progressive, degenerative neurological disorder, such as multiple sclerosis, amyotrophic lateral sclerosis, or Parkinson’s disease, will require adjustments to the exercise plan. Such adjustments may include a slower progression or a decrease in the intensity of exercise. Acute musculoskeletal conditions or extreme deconditioning will also require adjustments to the exercise plan. Any individual who has recently undergone surgery should also be carefully evaluated prior to starting an exercise program due to the potential of stress on healing tissues. While a full review of all comorbid conditions likely to be seen in PT practice is beyond the scope of this course, a brief discussion of diabetes, OA, and dementia follows. Diabetes Diabetes is a systemic metabolic disorder that currently affects 300 million individuals worldwide (Waryasz & McDermott, 2010). Older adults with diabetes are at an increased risk for
Relative Contraindications
• Moderate aortic stenosis. • Hypertrophic cardiomyopathy (enlarged heart). • Coronary artery disease. • Diabetes. • Uncontrolled hypertension with systolic above 200 mm Hg or diastolic above 110 mm Hg. • Stable congestive heart failure. • Recurrent or chronic infection. • Uncontrolled metabolic disorders such as uncontrolled thyroid disorders. • Implanted pacemakers or defibrillators. • Very low functional capacity. • Recent blood clot. • Acute illness. • Recent fracture. • Metastatic cancer. heart disease and stroke as a result of vascular changes that occur with increased blood glucose levels. As discussed earlier, both aerobic and resistive exercise have numerous benefits for insulin sensitivity and glucose control. However, because type 2 diabetes is characterized by abnormal glycemic control, exercise may cause swings in blood glucose levels, resulting in either hyperglycemia (high blood glucose) or hypoglycemia (low blood glucose). While there are many symptoms common to hyper- and hypoglycemia, in general hypoglycemia develops more quickly than hyperglycemia and is considered to be more immediately dangerous. Symptoms of both hyper- and hypoglycemia can be found in Table 6. Table 6: Signs of Hyperglycemia and Hypoglycemia Hyperglycemia Hypoglycemia • Confusion. • Increased thirst. • Headaches. • Blurred vision. • Frequent urination. • Fatigue. • Confusion. • Irritability. • Headache. • Sweating. • Increased heart rate. • Weakness. • Poor coordination. • Poor concentration. • Coma. • Nausea and vomiting. • Shortness of breath. • Coma.
Note . Adapted from (Ahren, 2013).
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