the joint pain. Exercise should elicit only mild pain in the joint (less than 3 on a scale of 10) or be modified to decrease pain (Vincent & Vincent, 2012). While ideally exercise should not cause any joint pain, many individuals with OA experience joint pain with daily physical activity and may experience some joint pain with exercise. When a joint is acutely inflamed, making weight-bearing exercises difficult, isometric strength training may be a beneficial form of resistance exercise. Performing isometric strength training will minimize the impact of movement but still allow for resistance training during times of acute inflammation. Isometric exercises are valuable because they produce low intra-articular pressures and can be done without increasing joint pain (Folland, Hawker, Leach, Little, & Jones, 2005). However, strength is only improved at the angle at which the muscle is trained. Therefore isometrics will need to be performed at multiple joint angles. It is generally recommended that the isometric strengthening exercise be performed every 10 to 30 degrees to cover the entire range of motion of a joint (Folland et al., 2005). The isometric contraction should be held for 4 to 6 seconds, and 8 to 10 repetitions in each joint angle should be performed (Folland et al., 2005). Reduced weight- bearing exercises, such as pool walking, swimming, and biking, may provide beneficial aerobic exercise during times of acute exacerbation. Tai chi has also been shown to decrease knee pain and to improve physical function and stiffness and may be a good resistance exercise option for those who are suffering from symptoms associated with OA (Brismee et al., 2007). Joint pain associated with exercise should decrease within 24 hours. If joint pain is significantly worse 24 hours after the exercise session, the activity may need to be modified in the following sessions to allow pain to decrease, and the program should be carefully modified to reduce joint pain. Reductions in the weight, duration, or types of exercise may be necessary to alleviate joint pain. The exercise session should also not induce changes in the patient’s gait (Vincent & Vincent, 2012). If the exercise increases joint pain to the point that the patient is limping or altering his or her gait pattern, then the exercise should be modified or reduced to avoid the alterations in gait. All patients suffering from symptoms associated with OA should be educated about the need for both aerobic and resistive exercise and encouraged to participate in both types of training. Short bouts of frequent aerobic activity may also help individuals in this population meet the target goal of 150 minutes of activity per week. With some minor modifications, older adults with OA should be able to get the exercise they need through participation in both aerobic and resistive exercise. Dementia As age increases, so does the prevalence of dementia. Up to 30% of adults over the age of 85 have dementia (Pitkala, Savikko, Poysti, Strandberg, & Laakkonen, 2013). Individuals with dementia suffer decreases in functional abilities, walking speed, and muscle loss (Cotter, 2007; Gillette Guyonnet et al., 2007). However, even adults with dementia benefit from exercise. It appears that exercise may result in decreased depression in those with dementia. Several systematic reviews have also found that aerobic exercise results in improved physical function in older adults with dementia (Forbes, Forbes, Blake, Thiessen, & Forbes, 2015; Forbes, Thiessen, Blake, Forbes, & Forbes, 2013; Heyn, Abreu, & Ottenbacher, 2004). Research into the effects of exercise on mobility and function in those with dementia is sparse, but recent systematic reviews concluded that studies consistently demonstrate that physical exercise (both aerobic and resistive) lead to improvements in mobility, functional limitations, and physical functioning in older adults with dementia (Forbes et al., 2013, 2015; Pitkala et al., 2013). However, older adults with dementia present several unique challenges for prescribing exercise. Those with advanced dementia traditionally have low compliance with an exercise program and will require additional motivation or supervision. Individuals with dementia may have increased difficulty adhering to an exercise program. One study found that those with Alzheimer’s disease completed on
When developing an exercise prescription for a person with type 2 diabetes, the PT must know the individual’s current medications. Individuals on some oral blood glucose-lowering drugs or individuals on insulin should monitor blood sugar before and after each exercise session to ensure that they do not become hyper- or hypoglycemic after exercise (American Diabetes Association, 2016). Adjustments may also need to be made to eating habits before or after exercise to avoid these swings in blood glucose levels. Older adults with blood glucose below 100 mg/dL should not start an exercise session unless they have had a small snack to prevent hypoglycemia (American Diabetes Association, 2016). Generally, for most older adults with type 2 diabetes, hyperglycemia is less concerning. Individuals with blood glucose above 300 mg/dL do not generally need to postpone exercise if they feel well and do not have ketones in their blood or urine (Colberg et al., 2010). Ketones are organic compounds that are produced when fat is broken down for energy in the body. If an individual is insulin resistant or if there is no insulin available to move glucose into the cells, the body begins to use fat as an alternative fuel source. When this happens, ketones are produced. If not treated, diabetic ketoacidosis may occur, leading to nausea, vomiting, abdominal pain, and, in serious cases, coma or death. If patients’ blood sugar is consistently above 250 mg/dL, they may require referral back to their physician to discuss other control options (American Diabetes Association, 2016). Older adults with diabetes should also be screened for peripheral neuropathy and educated about the need for appropriate footwear to avoid foot ulcers. Peripheral neuropathy is nerve damage that may occur with prolonged exposure to high blood glucose levels. Individuals with peripheral neuropathy may complain of numbness, tingling, or pain in their hands and feet, but they may also have no symptoms. Peripheral neuropathy puts individuals at an increased risk for developing foot ulcers and infections in the feet (American Diabetes Association, 2016), but it does not preclude them from participating in weight-bearing exercise. Weight-bearing activity does not appear to increase the rate of foot ulcer development in those with peripheral neuropathy (American Diabetes Association, 2016). However, if an individual already has a foot ulcer, exercises may need to be adjusted in order to be partial- or non-weight-bearing (Waryasz & McDermott, 2010). With the proper precautions, older adults with diabetes should be encouraged to participate in both aerobic and resistive exercise. Osteoarthritis OA is characterized by pain and joint space narrowing (Vincent & Vincent, 2012). More than 60 million Americans currently suffer from OA (Vincent & Vincent, 2012). Patients with OA in weight-bearing joints, such as the knees and the hips, may have previously self-limited their exercise due to pain, but exercise is critical for older adults with OA. Quadriceps weakness contributes to an increase in symptoms, including pain and impaired proprioception in patients with hip and knee OA, making resistive exercise an important but sometimes difficult undertaking for this population (Alnahdi, Zeni, & Snyder-Mackler, 2012; Nguyen, Lefevre-Colau, Poiraudeau, & Rannou, 2016). Both aerobic and resistive exercise are known to decrease pain and increase function and mobility in older adults with OA and have been adopted as a core recommendation for adults with OA (Bennell, Hall, & Hinman, 2016; McAlindon et al., 2014). This means that exercise is generally recommended for all individuals with OA, but modifications may be needed in an exercise program for those who are experiencing pain associated with OA (Vincent & Vincent, 2012). A slower progression of exercise may be necessary for these older adults, and only one variable at a time should be changed for resistance exercise (i.e., the frequency, resistance, or duration.) For example, when progressing a leg press for someone with OA, the PT should either increase the weight or the repetitions, but not both, in the same training session. If joint pain is elicited as a result of the progression, the PT can determine which variable increased
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