Exercise

ADA compliance and the accessibility of physical activity facilities in western Oregon.

Cardinal BJ, Spaziani MD.
Department of Exercise and Sport Science, 220 Langton Hall, Oregon State University, Corvallis, OR 97331-3303, USA. Am J Health Promot. 2003 Jan-Feb;17(3):197-201.

Objective: One of the mandates of Title III of the Americans With Disabilities Act (ADA) is to address the accessibility of public facilities for all people. The aim of this study was to determine how compliant physical activity facilities in western Oregon were with regard to Title III of the ADA. Comparisons were also made with the findings of a study conducted 5 years prior in a different geographic region.

Methods: On the basis of direct observations and physical measurements taken during on-site visits to 50 physical activity facilities located in western Oregon during 2000-2001, facility compliance with Title III of the ADA was characterized in terms of 10 structural domains.

Results: No facility was found to be 100% ADA-compliant. Exterior entrance/doors (90%) and telephone accessibility (88%) were the areas where compliance was highest, whereas accessibility to and around exercise equipment (8%) and customer service desk (37%) were areas lowest in compliance. Relative to a previously published study, the facilities in western Oregon showed greater rates of ADA compliance in six of the 10 structural domains evaluated.

Conclusion: There is an on-going need and legal mandate for increasing the accessibility of physical activity facilities. Furthermore, from a social-ecological perspective, the environmental constraints identified in this study might be limiting factors in efforts aimed at increasing individuals with disabilities’ physical activity involvement.

 

Effectiveness of a group exercise program in a long-term care facility: a randomized pilot trial.

Baum EE, Jarjoura D, Polen AE, Faur D, Rutecki G.
Northeastern Ohio Universities College of Medicine, Affiliated Hospitals at Canton, Canton, Ohio, USA. J Am Med Dir Assoc. 2003 Mar-Apr;4(2):74-80.

Objective: The purpose of this pilot was to determine whether a strength and flexibility program in frail long-term care facility (LTC) residents would result in improved function. p. Design: A prospective, randomized, controlled, semicrossover trial was designed with participants assigned either to group exercise (EX) or recreational therapy ©. In the EX group, the intervention continued for 1 year. In the C group, recreation continued for 6 months; these controls were then crossed over to the same exercise intervention as the EX group and followed for an additional 6 months. Functional outcomes were measured at baseline and 3, 6, 9, and 12 months for both groups.

Setting: A LTC facility, which included both assisted living (AL) and nursing home (NH) residents.

Participants: Twenty frail residents (5 from NH, 15 from AL) aged 75 to 99 years at one LTC facility.

Interventions: After random group assignment, the EX group met 1 hour three times per week. An exercise physiologist and LTC staff conducted sessions which included seated range of motion (ROM) exercises and strength training using simple equipment such as elastic resistance bands (therabands) and soft weights. The C group met three times per week and participated in activities such as painting during the first 6 months, before crossing over to exercise.

Methods: Objective measures of physical and cognitive function were obtained at baseline and 3, 6, 9, and 12 months using the timed get-up-and-go test (TUG), Berg balance scale, physical performance test (PPT), and mini-mental status exam (MMSE). Because we were interested in the impact of exercise on multiple endpoints and to protect the type I error rate, a global hypothesis test was used.

Results: There was a significant overall impact across the four measures of the exercise intervention (P = 0.013). Exercise benefit as indicated by the difference between exercise and control conditions showed exercise decreased TUG by 18 seconds, which represents an effect size (in standard deviation units) of 0.50, increased PPT scores by 1.3, with effect size = 0.40, increased Berg scores by 4.8, with effect size of 0.32, and increased MMSE by 3.1, with effect size = 0.54. Except for the Berg, 90% confidence intervals on these exercise effects excluded 0.

Conclusion: Frail elderly in a LTC facility were able to participate and benefit from a strength training program. The program was delivered with low-cost equipment by an exercise physiologist and LTC staff. The advantage of such a program is that it provides recreational and therapeutic benefits.

 

Obese, older adults with knee osteoarthritis: weight loss, exercise, and quality of life.

Rejeski WJ, Focht BC, Messier SP, Morgan T, Pahor M, Penninx B.
Department of Health and Exercise Science, Wake Forest University,
Winston-Salem, North Carolina 27109, USA. rejeski@wfu.edu
Health Psychol 2002 Sep;21(5):419-26

This study examined the effects of dietary weight loss and exercise on the health-related quality of life (HRQL) of overweight and obese, older adults with knee osteoarthritis. A total of 316 older men and women with documented evidence of knee osteoarthritis were randomly assigned to 1 of 4 18-month interventions: dietary weight loss, exercise, dietary weight loss and exercise, or healthy lifestyle control. Measures included the SF-36 Health Survey and satisfaction with body function and appearance. Results revealed that the combined diet and exercise intervention had the most consistent, positive effect on HRQL compared with the control group; however, findings were restricted to measures of physical health or psychological outcomes that are related to the physical self.

 

Oxygen-uptake (VO2) kinetics and functional mobility performance in impaired older adults.

Alexander NB, Dengel DR, Olson RJ, Krajewski KM.
The Geriatric Research, Education and Clinical Center, Veterans Affairs Ann Arbor Health Care System, and Division of Geriatric Medicine, Department of Internal Medicine, The University of Michigan, Ann Arbor, 48109-0926, USA. nalexand@med.umich.edu J Gerontol A Biol Sci Med Sci. 2003 Aug;58(8):734-9.

Background: Measures of maximal oxygen uptake (VO(2max)) are limited in disabled older adults, and measures of submaximal oxygen uptake (VO(2)) may better predict functional mobility limitations. These measures may include oxygen-uptake kinetics at the onset of submaximal exercise or during recovery. We sought to determine whether the lag in oxygen uptake at the beginning of exercise (oxygen deficit) and excess oxygen uptake above rest following exercise (excess postexercise oxygen consumption) (a) predict physical performance in impaired older adults with decreased aerobic function, and (b) predict physical performance better than peak VO(2).

Methods: Two groups of community-dwelling volunteers aged 65 or older were recruited according to their performance on a maximal graded exercise test. Using the Social Security Administration criterion of disability of a peak VO(2) 18 (Unimpaired, n = 21, mean +/- SEM age 76 +/- 1 years).

Results: The mean +/- SEM peak VO(2) was 58% lower in the Impaired (14 +/- 1 ml/kg/min) than the Unimpaired (24 +/- 1 ml/kg/min) adults. The time constant for oxygen deficit, tc(deficit), was more than twice as high in the Impaired than the Unimpaired (p <.05), and the time constant for excess postexercise oxygen consumption, tc(EPOC), tended to be higher in the Impaired than the Unimpaired (by 43%, p =.09). Measures of submaximal oxygen-uptake kinetics were as strong or more strongly predictive of functional mobility performance than peak VO(2) in both Unimpaired and Impaired older adults. The major predictor of functional performance for the Unimpaired was a measure of oxygen deficit accruing during exercise (tc(deficit)), and for the Impaired, it was a measure of oxygen debt during recovery, tc(EPOC).

Conclusion: Measurement of submaximal oxygen-uptake kinetics may provide a more practical and relevant assessment of deconditioning in frail older adults, and may eventually supplant maximal (peak) oxygen uptake as a predictor of functional disability in older adults.

 

The 6-minute walk test in mobility-limited elders: what is being measured?

Bean JF, Kiely DK, Leveille SG, Herman S, Huynh C, Fielding R, Frontera W.
Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA. bean@mail.hrca.harvard.edu J Gerontol A Biol Sci Med Sci. 2002 Nov;57(11):M751-6.

Background: The 6-minute walk (6mw) is a well-established measure of aerobic capacity in elders with cardiorespiratory and peripheral vascular disease and may be an accurate measure of functional performance in healthy elders. In mobility-limited elders, a population at risk for disability, impairments in strength and power are predictive of performance-based measures of function. Though commonly utilized as an outcome measure among otherwise healthy mobility-limited elders, it is not clear whether the 6mw best represents a measure of functional limitation, aerobic capacity, or both.

Methods: We hypothesized that the 6mw would be strongly representative of performance-based measures of function being determined by impairments in muscle strength and power. We performed a cross-sectional analysis of 45 community-dwelling elders with mild to moderate mobility limitations.

Results: The 6mw was strongly associated with established functional measures (r =.61-.83; p <.001), but was poorly associated with indirect measures of aerobic capacity (r <.25; p >.05). Multivariate linear regression models demonstrated that impairments in leg strength and power, especially those at the knee and ankle, were predictive of 6mw performance.

Conclusion: These findings emphasize the 6mw as a measure of functional limitation among mobility-limited elders without cardiorespiratory or peripheral vascular disease.

 

A comparison of various therapeutic exercises on the functional status of patients with knee osteoarthritis.

Huang MH, Lin YS, Yang RC, Lee CL.
Department of Physical Medicine, Kaohsiung Medical University Hospital, Taiwan. maohuang@ms24.hinet.net Semin Arthritis Rheum. 2003 Jun;32(6):398-406.

Objective: To investigate the therapeutic effects of different muscle-strengthening exercises on the functional status of patients with knee osteoarthritis (OA).

Methods: One hundred thirty-two patients with bilateral knee OA (Altman Grade II) were sequentially divided into 4 random groups (GI to GIV). The patients in group I received isokinetic muscle-strengthening exercise, group II received isotonic muscle-strengthening exercise, group III received isometric muscle-strengthening exercise, and group IV acted as controls. The changes of muscle power of leg flexion and extension were measured with a Kinetic Communicator dynamometer, and patients’ functional status was evaluated by visual analogue scale, ambulation speed, and Lequesne index before and after treatment, and at the follow-up 1 year later.

Results: The results showed that the patients with OA in each treated group had significant improvement in pain reduction, disability reduction, and in walking speed after treatment and at follow-up when compared with their initial status. Isotonic exercise had the greatest effect on pain reduction after treatment, and fewer participants discontinued the treatment because of exercise knee pain. Isokinetic exercise caused the greatest increase of walking speed and decrease of disability after treatment and at follow-up. The greatest muscle-strength gain in 60 degrees /second angular velocity peak torques was found in the isokinetic and isotonic exercise groups. A significant muscle-strength gain in 180 degrees /second angular velocity peak torques was found only in the isokinetic group after treatment.

Conclusion and Relevance: Isotonic exercise is suggested for initial strengthening in patients with OA with exercise knee pain, and isokinetic exercise is suggested for improving joint stability or walking endurance at a later time.

 

Impact of an exercise and walking protocol on quality of life for elderly people with OA of the knee.

Dias RC, Dias JM, Ramos LR.
Physical Therapy Department, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil. rosandi@metalink.com.br Physiother Res Int. 2003;8(3):121-30.

Purpose: The knee is the weight-bearing joint most commonly affected by osteoarthritis (OA). The symptoms of pain, morning stiffness of short duration and physical dysfunction in the activities of daily living (ADL) can have an effect on many aspects of health, affecting quality of life. Regular and moderate physical activity adapted to individuals’ life-styles and education, and joint protection strategies have been advocated as conservative management. The purpose of the present study was to assess the impact of an exercise and walking protocol on the quality of life of elderly people with knee OA.

Methods: The study design was a randomized controlled clinical trial. The subjects comprised 50 elderly people, aged 65 or more, with knee OA who had been referred to the geriatric outpatient unit for rehabilitation. Changes in severity of pain and quality of life were compared between a control group (CG) and an experimental group (EG). Both groups participated in an educational session and the EG also received a 12-week exercise and walking protocol. Both groups were assessed at baseline and after three and six months by an independent observer. The Lequesne Index of Knee OA Severity (LI), the Health Assessment Questionnaire (HAQ) and the Medical Outcomes Short-Form Health Survey (SF-36) were used as measurement instruments.

Results: In the CG, the measures of quality of life (SF-36), the HAQ and the LI between subjects did not yield statistically significant differences over the three measurement points. For the EG, there was a significant improvement in function, measured by HAQ, and decreasing OA symptom severity, measured by LI. For the SF-36 there were significant improvements in physical function, functional role limitation and pain. Comparisons between the groups showed statistically significant differences after three and six months for all measures, except for the SF-36 emotional domains.

Conclusion: The exercise protocol and walking programme had a positive effect on the quality of life of elderly individuals with knee OA.

 

Intervention programs for arthritis and other rheumatic diseases.

Brady TJ, Kruger J, Helmick CG, Callahan LF, Boutaugh ML. Health Educ Behav. 2003 Feb;30(1):44-63 Division of Adult and Community Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30341-3724, USA. tob9@cdc.gov

Disability reduction or prevention programs for people with arthritis and other rheumatic conditions reduce long-term pain and disability but reach only a fraction of their target audience. Few public health professionals are aware of these programs or their benefits. The objective of this study is to review and describe packaged (ready-to-use) arthritis self-management education and exerciselphysical activity programs that have had at least preliminary evaluation. Nine intervention programs (five self-management education programs, and four exercise/physical activity programs) met study criteria. Several of the packaged arthritis interventions reviewed help people with arthritis and other rheumatic conditions maximize their abilities and reduce pain, functional limitations, and other arthritis-related problems. Other packaged interventions show promise in reducing pain, disability, and depression and in increasing self-care behaviors, but they need to be evaluated more extensively.

 

Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial.

de Jong Z, Munneke M, Zwinderman AH, Kroon HM, Jansen A, Ronday KH, van Schaardenburg D, Dijkmans BA, Van den Ende CH, Breedveld FC, Vliet Vlieland TP, Hazes JM.

Comment in: • Arthritis Rheum. 2003 Sep;48(9):2393-5.
Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands. z.de_jong@lumc.nl Arthritis Rheum. 2003 Sep;48(9):2415-24.

Objective: There are insufficient data on the effects of long-term intensive exercise in patients with rheumatoid arthritis (RA). We undertook this randomized, controlled, multicenter trial to compare the effectiveness and safety of a 2-year intensive exercise program (Rheumatoid Arthritis Patients In Training [RAPIT]) with those of physical therapy (termed usual care [UC]).

Methods: Three hundred nine RA patients were assigned to either the RAPIT program or UC. The primary end points were functional ability (assessed by the McMaster Toronto Arthritis [MACTAR] Patient Preference Disability Questionnaire and the Health Assessment Questionnaire [HAQ]) and the effects on radiographic progression in large joints. Secondary end points concerned emotional status and disease activity.

Results: After 2 years, participants in the RAPIT program showed greater improvement in functional ability than participants in UC. The mean difference in change of the MACTAR Questionnaire score was 2.6 (95% confidence interval [95% CI] 0.1, 5.2) over the first year and 3.1 (95% CI 0.7, 5.5) over the second year. After 2 years, the mean difference in change of the HAQ score was -0.09 (95% CI -0.18, -0.01). The median radiographic damage of the large joints did not increase in either group. In both groups, participants with considerable baseline damage showed slightly more progression in damage, and this was more obvious in the RAPIT group. The RAPIT program proved to be effective in improving emotional status. No detrimental effects on disease activity were found.

Conclusion: A long-term high-intensity exercise program is more effective than UC in improving functional ability of RA patients. Intensive exercise does not increase radiographic damage of the large joints, except possibly in patients with considerable baseline damage of the large joints.

 

Obesity and physical inactivity among Wisconsin adults with arthritis.

Mehrotra C, Chudy N, Thomas V.
Bureau of Chronic Disease Prevention and Health Promotion, Division of Public Health, Wisconsin Department of Health and Family Services, USA. mehroc@dhfs.state.wi.us WMJ. 2003;102(7):24-8.

Background: Arthritis is the leading cause of disability in Wisconsin, and affects approximately 34% of Wisconsin adults. Obesity is an established risk factor for arthritis; however, the relationship between arthritis and obesity has not been well characterized at the population level in Wisconsin.

Objective: Describe the relationship between arthritis, obesity, physical inactivity, and efforts to lose weight among Wisconsin adults.

Methods: Wisconsin Behavioral Risk Factor Surveillance System 2000-2001. Arthritis was defined by either doctor diagnosis or self-reported chronic joint symptoms.

Results: Overall, 36% of respondents had arthritis. Among adults with arthritis, 28% were obese (BMI>30) compared to 16% without arthritis. The prevalence of leisure time physical inactivity was substantially higher among those with arthritis compared to those without arthritis (27.8% vs. 19.2%). Although prevalence of obesity was higher among those with arthritis, only 46% of adults with arthritis made an effort to lose weight.

Conclusion: A high proportion of adults with arthritis are obese and are physically inactive, even though studies have shown that weight loss and regular physical activity relieve arthritis symptoms. Efforts should be made to promote weight loss and physical activities among adults with arthritis.

 

The Arthritis, Diet and Activity Promotion Trial (ADAPT): design, rationale, and baseline results.

Miller GD, Rejeski WJ, Williamson JD, Morgan T, Sevick MA, Loeser RF, Ettinger WH, Messier SP; ADAPT Investigators.
Department of Health and Exercise Science Wake Forest University, Winston-Salem, North Carolina 27109, USA. millergd@wfu.edu Control Clin Trials. 2003 Aug;24(4):462-80.

Osteoarthritis (OA) of the knee leads to restrictions of physical activity and ability to perform activities of daily living. Obesity is a risk factor for knee OA and it appears to exacerbate knee pain and disability. The Arthritis, Diet, and Activity Promotion Trial (ADAPT) was developed to test the efficacy of lifestyle behavioral changes on physical function, pain, and disability in obese, sedentary older adults with knee OA. This controlled trial randomized 316 sedentary overweight and obese older adults in a two-by-two factorial design into one of four 18-month duration intervention groups: Healthy Lifestyle Control; Dietary Weight Loss; Structured Exercise; or Combined Exercise and Dietary Weight Loss. The weight-loss goal for the diet groups was a 5% loss at 18 months. The intervention was modeled from principles derived from the group dynamics literature and social cognitive theory. Exercise training consisted of aerobic and strength training for 60 minutes, three times per week in a group and home-based setting. The primary outcome measure was self-report of physical function using the Western Ontario and McMaster University Osteoarthritis Index. Other measurements included timed stair climb, distance walked in 6 minutes, strength, gait, knee pain, health-related quality of life, knee radiographs, body weight, dietary intake, and cost-effectiveness of the interventions. We report baseline data stratified by level of overweight and obesity focusing on self-reported physical function and physical performance tasks. The results from ADAPT will provide approaches clinicians should recommend for behavioral therapies that effectively reduce the incidence of disability associated with knee OA.

 

Assisted workouts: starting my own workout program.

Cousminer D.
University of Central Florida, Orlando 32816, USA. frozen100@hotmail.com J Am Coll Health. 2003 Jul-Aug;52(1):47-8.

As an undergraduate student with cerebral palsy, I found it difficult to achieve my goal of starting a regular exercise program at my school, the University of Central Florida. However, when I started a program called Assisted Workouts in spring 2003. the struggle proved to be well worth it. The program is not only beneficial to me, but it has also opened the door for other students who, because of disability or injury, need assistance in using gym equipment.

 

Involvement in Special Olympics and its relations to self-concept and actual competency in participants with developmental disabilities.

Weiss J, Diamond T, Demark J, Lovald B.
Department of Psychology, York University, Ont. M3J 1P3, Toronto, Canada. jweiss1@yorku.ca Res Dev Disabil. 2003 Jul-Aug;24(4):281-305.

The current study examined the relations among components of a physical activity program, Special Olympics (SO), and the self-concepts (i.e., perceived physical competence, social acceptance, and general self-worth) and adaptive behaviors of individuals with developmental disabilities. This research can assist in the development of theoretical models of how physical activity programs can be implemented to effect psychological change. Participants consisted of a randomly selected group of 97 individuals with developmental disabilities, between 9 and 43 years of age, and their parents. Participants’ self-concepts and adaptive behaviors were measured both by direct interview and parental report. Examined program components consisted of the length of time affiliated to the organization, number of competitions attended, of hours spent in training, of sports, and of medals obtained. Multiple regression analyses suggest relations between specific components of SO and participants’ self-concepts and adaptive behaviors. These relations highlight the importance of competition and sport for individuals with developmental disabilities.

 

American College of Sports Medicine position stand. Exercise and type 2 diabetes.

Albright A, Franz M, Hornsby G, Kriska A, Marrero D, Ullrich I, Verity LS.
Med Sci Sports Exerc 2000 Jul;32(7):1345-60

Physical activity, including appropriate endurance and resistance training, is a major therapeutic modality for type 2 diabetes. Unfortunately, too often physical activity is an underutilized therapy. Favorable changes in glucose tolerance and insulin sensitivity usually deteriorate within 72 h of the last exercise session: consequently, regular physical activity is imperative to sustain glucose-lowering effects and improved insulin sensitivity. Individuals with type 2 diabetes should strive to achieve a minimum cumulative total of 1,000 kcal x wk(-1) from physical activities. Those with type 2 diabetes generally have a lower level of fitness (VO2max) than nondiabetic individuals. and therefore exercise intensity should be at a comfortable level (RPE 10-12) in the initial periods of training and should progress cautiously as tolerance for activity improves. Resistance training has the potential to improve muscle strength and endurance, enhance flexibility and body composition, decrease risk factors for cardiovascular disease, and result in improved glucose tolerance and insulin sensitivity. Modifications to exercise type and/or intensity may be necessary for those who have complications of diabetes. Individuals with type 2 diabetes may develop autonomic neuropathy, which affects the heart rate response to exercise, and as a result, ratings of perceived exertion rather than heart rate may need to be used for moderating intensity of physical activity. Although walking may be the most convenient low-impact mode, some persons, because of peripheral neuropathy and/or foot problems, may need to do non-weight-bearing activities. Outcome expectations may contribute significantly to motivation to begin and maintain an exercise program. Interventions designed to encourage adoption of an exercise regimen must be responsive to the individual’s current stage of readiness and focus efforts on moving the individual through the various “stages of change.”

 

The challenge of diet, exercise and lifestyle modification in the management of the obese diabetic patient.

Foreyt JP, Poston WS 2nd.
Department of Medicine, Baylor College of Medicine, Houston, TX 77096, USA.
Int J Obes Relat Metab Disord 1999 Jun;23 Suppl 7:S5-11

Type 2 diabetes is associated with many comorbid medical conditions including obesity, neuropathy, microvascular pathology and atherosclerotic arterial disease. Due to its complications and chronicity, reducing risk factors such as obesity and sedentary lifestyle through lifestyle modification is crucial to the long-term health of patients with type 2 diabetes. Patients must learn how to adopt lifelong, low-fat eating habits and regular activity patterns, with formal treatments focusing on weight loss, increased physical activity and low-fat, low-saturated fat diets. In this article we review the efficacy of lifestyle modification programmes for obese diabetic patients. In addition, we discuss barriers to lifestyle changes and methods for improving long-term adherence. Finally, we present information on how this approach has been adapted to a group of Mexican Americans in the USA, a population at high risk for type 2 diabetes, obesity and sedentary lifestyle.

 

Physical activity interventions in low-income, ethnic minority, and populations with disability.

Taylor WC, Baranowski T, Young DR.
School of Public Health, Center for Health Promotion Research and Development, University of Texas-Houston Health Science Center 77030-9960, USA. Am J Prev Med 1998 Nov;15(4):334-43

Background: Low-income, racial and ethnic minority, and populations with disabilities are more likely to be sedentary than the general population. Increasing physical activity in these groups is an important public health challenge. This report summarizes interventions that have targeted populations at risk for inactivity.

Methods: Computer and manual searches were performed to identify manuscripts published from 1983 to 1997. Interventions conducted in these populations in which physical activity was part of the intervention, and activity or cardiorespiratory fitness were outcome measures, were included in the review.

Results: Fourteen studies were identified. Most studies used pre-post or quasi-experimental designs. Common intervention features for the ten studies that included ethnic minority groups were community advisory panels, community needs assessments, and community members delivering the intervention. Eight studies reported a theoretical framework that guided the intervention. Increased physical activity was documented in two studies. Post-intervention follow-up was conducted in two studies; both reported no significant findings. Only four studies for people with disabilities were found; all four reported post-intervention physical activity change.

Conclusion: Much work remains to develop effective interventions for these populations. Research that involves the community at all steps in the design and implementation of the intervention shows greatest promise for promoting behavior change. Future intervention studies should include: (1) rigorous experimental designs; (2) theoretically based interventions; and (3) validated assessment instruments to detect physical activity change.

 

Exercise for patients with chronic disease: physician responsibility.

Painter P.
Department of Physiological Nursing, University of California at San Francisco, Box 0610 UCSF, 2 Koret Way, Room 605C, San Francisco, CA 94143-0610, USA. painter@itsa.ucsf.edu Curr Sports Med Rep. 2003 Jun;2(3):173-80.

Patients with chronic disease typically become severely deconditioned, which often leads to physical disability. Every effort should be made to recommend and encourage patients to adopt and maintain a program of physical activity. Although there are no specific exercise guidelines for many chronic conditions, patients should be instructed to start a routine of physical activity that is gradual for most (if not all) days of the week, working up to 30 minutes per session at an exertion level that is easily tolerated. It is critical that assessment of physical functioning and recommendations for physical activity be included as a part of routine medical care. In doing so, we change the expectations of patients and family members, and work toward optimizing physical functioning and quality of life.

 

Physical activity for the chronically ill and disabled.

Durstine JL, Painter P, Franklin BA, Morgan D, Pitetti KH, Roberts SO.
Department of Exercise Science, University of South Carolina, Columbia 29208,
USA. ldurstine@sophe.sph.sc.edu
Sports Med 2000 Sep;30(3):207-19
Erratum in: Sports Med 2001;31(8):627

Exercise prescription principles for persons without chronic disease and/or disability are based on well developed scientific information. While there are varied objectives for being physically active, including enhancing physical fitness, promoting health by reducing the risk for chronic disease and ensuring safety during exercise participation, the essence of the exercise prescription is based on individual interests, health needs and clinical status, and therefore the aforementioned goals do not always carry equal weight. In the same manner, the principles of exercise prescription for persons with chronic disease and/or disability should place more emphasis on the patient’s clinical status and, as a result, the exercise mode, intensity, frequency and duration are usually modified according to their clinical condition. Presently, these exercise prescription principles have been scientifically defined for clients with coronary heart disease. However, other diseases and/or disabilities have been studied less (e.g. renal failure, cancer, chronic fatigue syndrome, cerebral palsy). This article reviews these issues with specific reference to persons with chronic diseases and disabilities.

 

Physical activity, metabolic issues, and assessment.

Fernhall B, Unnithan VB.
Exercise Science Department, Syracuse University, 820 Comstock Avenue, Room 201, Syracuse, NY 13244, USA. Bfernhal@syr.edu Phys Med Rehabil Clin N Am. 2002 Nov;13(4):925-47.

Considering the important health consequences of physical activity and aerobic capacity, current guidelines recommend that all individuals should be physically active all or most days of the week. Relatively little is known about physical activity patterns or aerobic capacity of individuals who have disabilities, but existing data clearly show a disturbing pattern of low levels of physical activity and aerobic capacity in most, if not all, populations who have disabilities. More research is needed on all populations who have disabilities, not only documenting current levels of physical activity and aerobic capacity but also investigating potential strategies for improvement. Unfortunately, the techniques available for measuring physical activity have significant shortcomings. DLW shows considerable promise, but it is expensive and not appropriate for population studies. All other techniques have significant shortcomings in regard to tracking individual physical activity patterns, but they might provide valuable insight regarding group behavior. Although maximal exercise testing is the gold standard for measuring aerobic capacity, this technique is difficult to use in many populations that have disabilities. Few protocols have been validated for use with individuals who have disabilities, and indiscriminant use of protocols developed for nondisabled populations is inappropriate when testing individuals who have disabilities. Submaximal testing could be of considerable utility, but few protocols have been validated. For most populations that have disabilities, submaximal tests designed to predict VO2peak are not valid, given the altered disability-specific physiological responses, which usually result in gross overpredictions. Submaximal tests designed to compare (either intra or inter individual comparisons) physiological responses at predetermined submaximal work rates show considerable promise. Both populations of children who have disabilities that are discussed herein exhibit low levels of physical activity and aerobic capacity, which is consistent with most of the literature for any group that has disabilities. Although the mechanisms for producing lower levels of activity and aerobic capacity differ among children who have mental retardation and children who have CP, the outcome is similar in both populations. Appropriate testing methodology differs between these populations, and the different mechanisms involved demonstrate the disability-specific nature of research in children who have disabilities, which also illustrates the difficulty of producing general guidelines for exercise and physical activity interventions. Current data clearly show the need for improving both physical activity patterns and aerobic capacity in most children who have disabilities. Failure to accomplish this goal will ultimately have considerable negative health outcomes for individuals who have disabilities.

 

The effects of exercise and education, individually or combined, in women with fibromyalgia.

King SJ, Wessel J, Bhambhani Y, Sholter D, Maksymowych W.
Health Science Council Office, University of Alberta, Edmonton, Canada. J Rheumatol. 2002 Dec;29(12):2620-7.

Objective: To examine the effectiveness of a supervised aerobic exercise program, a self-management education program, and the combination of exercise and education for women with fibromyalgia (FM).

Methods: One hundred fifty-two women were randomized into one of 4 groups: exercise-only, education-only, exercise and education, or control. The duration of the study was 12 weeks. All subjects were analyzed at 3 times: before study, immediately upon completion, and 3 months after completion of the intervention program on measures of disability, self-efficacy, fitness, tender point count, and tender point tenderness. Of the 152 women, complete data were available for 95 and 69 who complied with the protocol. In order to determine the group time interaction, a 2 way analysis of variance with repeated measures was used for each measure.

Results: The only significant group time interaction was reported with the compliance analysis for the Self-Efficacy Coping with Other Symptoms subscale and the Six Minute Walk. If the program was followed, the combination of a supervised exercise program and group education provided persons with FM with a better sense of control over their symptoms. Fitness improved in the 2 groups undergoing supervised aerobic exercise programs. However, the improvement in fitness was maintained at followup in the exercise-only group and not the combined group.

Conclusion: Subjects receiving the combination of exercise and education and who complied with the treatment protocol improved their perceived ability to cope with other symptoms. In addition, a supervised exercise program increased walking distance at post-test, an increase that was maintained at followup in the exercise-only group. Results demonstrate the challenges with conducting exercise and education studies in persons with FM.

 

Treatment of fatigue in fibromyalgia.

Guymer EK, Clauw DJ.
Division of Rheumatology/Allergy/Immunology, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007, USA.
Rheum Dis Clin North Am 2002 May;28(2):367-78

Clearly, fatigue is a large and challenging problem for those suffering from fibromyalgia. It adds greatly to the morbidity and disability associated with the disease. In the management of this specific symptom in fibromyalgia, attention should first be focused on identifying comorbidities that may be present and contribute to fatigue. As with other symptoms of fibromyalgia, education is a critical component of management. This can be done by the practitioner, with available free resources, or with specialized cognitive behavioral programs. This education process can be augmented with a variety of other nonpharmacologic therapies, especially very gradually increasing, low-impact, aerobic exercise programs. Numerous pharmacologic therapies may also be helpful as an adjunct to treatment. Classes of compounds that raise central levels of norepinephrine or dopamine appear to be the most specific for management of fatigue. There are also many medications used to combat fatigue in other disorders that have not yet been adequately explored as to the possible benefits in alleviating the fatigue of fibromyalgia. Advances in the management of fatigue in fibromyalgia are likely to come from a variety of directions. Easier access to well designed nonpharmacologic therapies is essential, because these treatments are underutilized in clinical practice at present. Improvements in pharmacologic therapies will come from new insights into mechanisms, especially those that might only be present in subsets of patients and would respond to more targeted therapies.

 

Exercise training for African Americans with disabilities residing in difficult social environments.

Rimmer JH, Nicola T, Riley B, Creviston T.
Department of Disability and Human Development (Rimmer), University of Illinois at Chicago, Chicago, Illinois 60612, USA. jrimmer@uic.edu Am J Prev Med. 2002 Nov;23(4):290-5.

Objective: To examine the feasibility, efficacy, and safety of a structured 12-week exercise training program for a predominantly African-American group of adults with multiple health conditions who reside in difficult social environments.

Methods: A total of 37 females and 7 males (mean age, 54.1 years) participated in an exercise training regimen 3 days per week for 60 minutes per day (cardiovascular, 30 minutes; strength, 20 minutes; and flexibility, 10 minutes). Outcome measures included peak VO(2) (mL min(-1), mL kg(-1) min(-1)); upper and lower body strength (strength); hand-grip strength (GS); body weight (BW); total skin folds (TS); waist-to-hip ratio (WHR); hamstring/low-back flexibility (HLBF); and shoulder flexibility (SF).

Results: Compared to the control group, the exercise group showed significant gains in peak VO(2) (p < 0.01); strength (p < 0.01); and body composition (TS, p < 0.01). There was no significant difference between the exercise and control groups on BW, WHR, HLBF, and GS. Of a total 1116 exercise sessions (31 experimental participants x 36 sessions), 87% of the sessions were attended.

Conclusion: A structured exercise-training program can provide substantial improvement in strength and cardiovascular fitness in low-income, sedentary adults with multiple chronic conditions and/or risk factors for chronic conditions. Future research should explore simple home-based and community-based physical activity interventions that provide ongoing support for increasing and maintaining physical activity participation in this cohort.

 

Recommendations for physical activity in patients with multiple sclerosis.

Petajan JH, White AT.
Department of Neurology, University of Utah, Salt Lake City, USA.
jack.h.petajan@hsc.utah.edu
Sports Med 1999 Mar;27(3):179-91

For many years, patients with multiple sclerosis (MS), an inflammatory demyelinating disease of the central nervous system, have been advised to avoid exercise. MS is believed to be autoimmune in origin, mediated by activated T cells which penetrate the blood-brain barrier and attack myelin. The pathophysiology, with respect to function is an impairment of salutatory conduction, specifically, slowing of conduction speed and/or conduction block. Symptoms can temporarily worsen on exposure to heat or during physical exercise. Exercise programmes must be designed to activate working muscles but avoid overload that results in conduction block. Fatigue, often severe, affects about 85% of MS patients and, along with motor and sensory symptoms, results in decreased mobility and reduced quality of life. Physical activity and recreation are reduced in patients with MS. Before developing recommendations, physical activity patterns and the physical effects of MS should be assessed in individual patients. Patients may then be functionally classified. Physical activity can also be classified in a pyramid structure, with the most basic functions forming the base and the most integrated functions on top. The muscular fitness pyramid progresses through passive range of motion, active esistive, specific strengthening and integrated strength exercises Overall physical activity may be increased according to functional level by performing activities of daily living, incorporating inefficiencies into daily living, pursuing more active recreation and eventually developing a structured exercise programme. The importance of the proper exercise environment, balance and coordination issues and factors related to adherence are discussed.

 

Response to resistive strengthening exercise training in humans with neuromuscular disease.

Kilmer DD. Department of Physical Medicine and Rehabilitation, University of California-Davis School of Medicine, Sacramento, California, USA. Am J Phys Med Rehabil. 2002 Nov;81(11 Suppl): S121-6

The role of strengthening exercise to potentially improve weakness and the functional abilities of persons with neuromuscular diseases is controversial. There are questions about the ability of diseased skeletal muscle to respond to resistance exercise, particularly in light of concerns about weakness induced by exercise. Numerous studies show promising results of strength training, although methodologic issues limit conclusions. This article reviews current knowledge in this area and provides recommendations for future investigations.

 

Energy expenditure during walking with weight-bearing control (WBC) orthosis in thoracic level of paraplegic patients.

Kawashima N, Sone Y, Nakazawa K, Akai M, Yano H. Motor Dysfunction Division, Research Institute, National Rehabilitation Center for the Disabled, 4-1 Namiki, Tokorozawa City, Saitama Pref., Japan. Spinal Cord. 2003 Sep;41(9):506-10.

Design: Comparative study of the effectiveness of walking exercise with a newly developed gait orthosis, the weight-bearing control (WBC) orthosis, for thoracic level of paraplegic patients.

Objective: To test its feasibility as a rehabilitation alternative for paraplegic patients, the energy consumption and cost during walking with WBC were calculated and compared with the values of conventional orthoses given in previous reports.

Setting: National Rehabilitation Center for the Disabled, Japan.

Methods: Four paraplegic patients with traumatic spinal cord injuries ranging from T8 to T12 participated. Experiments were conducted after 3 months of the orthotic gait training with WBC. The cardiorespiratory parameters were continuously measured at rest and during walking with a telemetric device. The steady-state value of the oxygen uptake (V(O2)), heart rate (HR), the energy consumption (J/kg/s) and energy cost (J/kg/m) were calculated. p. Results: The average walking speed was 19.0 +/- 2.58 m/min. The steady-state value of the V(O2) and HR were 16.08 +/- 1.93 ml/kg and 147.3 +/- 10.94 b/min, respectively. The energy cost during orthotic walking tended to be better than the values of conventional orthoses, whereas the energy consumption was almost similar.

Conclusion: WBC enables thoracic level of paraplegic patients to walk at relatively higher speed than conventional orthoses under similar energy expenditure. The special devices equipped with WBC are therefore considered to lead to improvement of the energy cost of walking. The physical intensity presumed by cardiorespiratory responses during walking with WBC is suited to promote their aerobic capacity. Therefore, it is concluded that the WBC orthosis could be an effective alternative in rehabilitation for thoracic level of paraplegic patients.

 

Disability motivates patients with ankylosing spondylitis for more frequent physical exercise.

Falkenbach A. Gasteiner Heilstollen Hospital, Bad Gastein-Bockstein, Bad Gastein, Austria. falke@gasteiner-heilstollen.com Arch Phys Med Rehabil. 2003 Mar;84(3):382-3.

Objective: To evaluate whether patients with ankylosing spondylitis who perform disease-specific exercises more frequently have fewer functional limitations and disability than those who exercise more often.

Design: Cross-sectional; retrospective chart review.

Setting: Rehabilitation center in Austria.

Participants: A sample of 1,500 patients with ankylosing spondylitis (1,163 men, 337 women; mean age +/- standard deviation, 50+/-12 y; disease duration, 21+/-11 y) grouped by how many times per week they performed disease-specific exercises for at least 5 minutes: group A (n=542), less than 1 time; group B (n=691), 1 to 3 times; and group C (n=267), more than 3 times.

Interventions: Not applicable.

Main Outcome Measures: Self-report of exercise frequency and a German version of the Health Assessment Questionnaire for the spondyloarthropathies (HAQ-S).

Results: The HAQ-S showed significant differences among the groups (analysis of variance on ranks, P<.001). In pairwise multiple comparison, group A showed significantly less disability (median, 0.5; interquartile range [IQR], 0.2-0.8) than group B (median, 0.6; IQR, 0.3-0.9) or group C (median, 0.7; IQR, 0.3-1.0).

Conclusion: Patients with less disability exercised less than their more disabled counterparts. The reasons for this difference, particularly the issue of motivation, deserve more attention.

 

Physical activity, health impairments, and disability in neuromuscular disease.

McDonald CM.
Department of Physical Medicine and Rehabilitation, University of California-Davis School of Medicine, Sacramento, California, USA.
Am J Phys Med Rehabil 2002 Nov;81(11 Suppl):S108-20

Reduced physical activity is a consequence of progressive neuromuscular diseases, which negatively impacts quality of life and health outcomes. Reduced functional muscle mass is common to all neuromuscular diseases and results from both atrophy of disuse secondary to a sedentary lifestyle and muscle degeneration secondary to the disease itself. This review summarizes current concepts relating to the impact of reduced physical activity on health and fitness, potential determinants of physical activity levels in neuromuscular diseases, and new approaches to the quantitative measurement of physical activity in neuromuscular disease populations. The interrelationship of disease pathophysiology, impairment, functional limitation, disability, and societal limitation in the determination of physical activity in the community in neuromuscular diseases is discussed using Duchenne muscular dystrophy as an example. Future research pertaining to physical activity in neuromuscular disease will need to focus on the development of scientifically based recommendations concerning optimal exercise approaches with both disease-specific and general guidelines.

 

Changes in function and disability after resistance training: does velocity matter?: a pilot study.

Sayers SP, Bean J, Cuoco A, LeBrasseur NK, Jette A, Fielding RA. Human Physilogy Laboratory, Department of Health Science, Boston University, Boston, MA 02215, USA. Am J Phys Med Rehabil. 2003 Aug;82(8):605-13.

Objective: To compare the effects of high- and low-velocity resistance training on functional performance and disability outcomes in physically limited older women.

Design: A total of 16 wk of high-velocity resistance training or traditional low-velocity resistance training consisting of knee extension and leg press exercises was performed three times per week by 30 women with self-reported disability to compare their effect on functional performance and disability. Tests of dynamic balance, stair-climb time, chair-rise time, and gait velocity were used to assess changes in functional performance. Changes in disability were assessed using the Medical Outcomes Study Short Form.

Results: Dynamic balance and stair-climb time improved 8% and 10%, respectively, with training. Self-reported disability, physical functioning, role physical, and mental health improved 11, 9, and 5% with training, respectively. There were no significant differences between high- and low-velocity training groups.

Conclusion: High- and low-velocity training achieved similar improvements in functional performance and disability. Improvements in functional performance and disability were modest compared with robust increases in strength and power. Specific modes of training or behavioral strategies may be necessary to optimize improvements in these outcomes.

 

Coronary heart disease risk between active and inactive women with multiple sclerosis.

Slawta JN, McCubbin JA, Wilcox AR, Fox SD, Nalle DJ, Anderson G.
Department of Exercise and Sport Science, Oregon State University, Corvallis, USA. slawta@sou.edu
Med Sci Sports Exerc 2002 Jun;34(6):905-12

Purpose: Physical activity is strongly recommended as a principal component of coronary heart disease (CHD) risk factor management aimed at favorably lowering abdominal fat accumulation, lowering levels of triglyceride (TG), raising levels of high-density lipoprotein-cholesterol (HDL-C), and improving insulin sensitivity. Although physical activity practices are reported to be low in women with multiple sclerosis (MS), some women with MS remain physically active despite their disability. Thus, the primary aim of the study was to determine whether abdominal fat accumulation and levels of TG, HDL-C, and glucose differ between active and inactive women with MS.

Methods: The study sample consisted of 123 women with MS, aged 23-72 yr. Venous blood was collected for measurement of lipids, lipoprotein-cholesterol, and glucose. Skin-fold thicknesses and girth circumferences were obtained for estimation of total and abdominal body fat. Leisure-time physical activity (LTPA) during the last 12 months was assessed by the physical activity questionnaire used in the Postmenopausal Estrogens/Progestins Intervention (PEPI) Study. Eating habits were assessed by the Block Food Frequency Questionnaire.

Results: LTPA was significantly associated with lower waist circumference (P = 0.0001), lower TG levels (P =0.0005), and lower glucose levels (0.002). After adjusting for several covariates, women participating in low- to moderate-intensity LTPA had significantly lower waist circumferences, TG levels, and glucose levels relative to inactive women.

Conclusion: Low- to moderate-intensity LTPA was significantly associated with less abdominal fat accumulation, lower levels of TG, and lower levels of glucose in the present sample of women with MS. These findings suggest that exercise levels attainable by women with MS may improve CHD risk and contribute to important health-related benefits.

 

Obesity as a confounding health factor among women with mobility impairment.

Sharts-Hopko NC, Sullivan MP. College of Nursing, Villanova University, USA. nancy.sharts-hopko@villanova.edu J Am Acad Nurse Pract. 2003 Oct;15(10):438-43.

Purpose: To examine the relationships between self-reported height and weight and factors associated with disabilities that impair mobility among adult women.

Data Sources: Survey data were gathered from a convenience sample of 83 women with disabilities at community events targeting the disabled population. Height, weight, and factors associated with their disabilities were reported on a demographic questionnaire. Body mass index (BMI) was estimated using a conversion table and the self-reported height and weight of each participant.

Conclusion: The average self-reported weight was 168.3 lb. Only 38% of the women fell into the normal range on estimated BMI, but 62% of the women fell into the categories of overweight or obese. The incidence of overweight and obesity exceeded that reported for the general population of women in a national sample X2 = 6.48, p = 03, 2 df). Self-reported weight was positively correlated with the number of comorbidities reported by the women (r = .419, p < .0001).

_Implications: The issue of obesity is an important problem facing women with disabilities. Women who have mobility limitations need to be weighed periodically, and strategies should be devised for weight management, including both dietary plans and appropriate exercise regimens given their limitations.

 

Resistance training on physical performance in disabled older female cardiac patients.

Ades PA, Savage PD, Cress ME, Brochu M, Lee NM, Poehlman ET.
Division of Cardiology, University of Vermont College of Medicine, Burlington, VT, USA. Philip.Ades@vtmednet.org Med Sci Sports Exerc. 2003 Aug;35(8):1265-70.

Purpose: We evaluated the value of resistance training on measures of physical performance in disabled older women with coronary heart disease (CHD).

Methods: The study intervention consisted of a 6-month program of resistance training in a randomized controlled trial format. Training intensity was at 80% of the single-repetition maximal lift. Control patients performed light yoga and breathing exercises. Study participants included 42 women with CHD, all >or= 65 yr of age and community dwelling. Subjects were screened by questionnaire to have low self-reported physical function. The primary study measurements related to the performance of 16 household activities of the Continuous Scale Physical Functional Performance test (CSPFP). These ranged from dressing, to kitchen and cleaning activities, to carrying groceries and walking onto a bus with luggage, and a 6-min walk. Activities were measured in time to complete a task, weight carried during a task, or distance walked. Other measures included body composition, measures of aerobic fitness and strength, and questionnaire-based measures of physical function and depression score.

Results: Study groups were similar at baseline by age, aerobic capacity, strength, body composition, and in performing the CSPFP. After conditioning, 13 of 16 measured activities were performed more rapidly, or with increased weight carried, compared with the control group (all P < 0.05). Maximal power for activities that involved weight-bearing over a distance, increased by 40% (P < 0.05).

Conclusion: Disabled older women with CHD who participate in an intense resistance-training program improve physical capacity over a wide range of household physical activities. Benefits extend beyond strength-related activities, as endurance, balance, coordination, and flexibility all improved. Strength training should be considered an important component in the rehabilitation of older women with CHD.

 

Exercise and sports for children who have disabilities.

Wilson PE.
Department of Physical Medicine and Rehabilitation, Box 285, Children’s Hospital, 1056 E. 19th Avenue, Denver, CO 80218, USA. wilson.pamela@tchden.orgwilson.pamela@tchden.org
Phys Med Rehabil Clin N Am 2002 Nov;13(4):907-23, ix

This article focuses on the exercise needs of children who have disabilities, how these needs differ from able-bodied children, and what medical concerns are relevant for a given disability. The information presented also discusses some preventative options related to individual sports and a discussion of various organized recreational and competitive opportunities available both nationally and internationally. In addition, a listing of major disabled sports organizations is provided for reference.

 

Osteoporosis in children who have disabilities.

Apkon SD.
Department of Rehabilitation Medicine, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, A040, Denver, CO, USA. apkon.susan@tchden.org
Phys Med Rehabil Clin N Am 2002 Nov;13(4):839-55

Children who have disabilities are at increased risk for osteoporosis during childhood. This not only puts them at risk for fractures during childhood but also during adulthood. Peak bone mass, which helps predict osteoporosis in adulthood, is never attained in children who have a disability. Care providers of this group of children must be aggressive in the prevention and treatment of osteoporosis. A thorough laboratory evaluation and DXA studies may be undertaken on all disabled children who are at risk for osteoporosis. Although medications have shown promise in the treatment of decreased bone mass, their efficacy in children who have disabilities must be evaluated in larger, controlled studies. Nonpharmocologic treatments also necessitate further exploration.

 

Relationship between functional ability and physical fitness in juvenile idiopathic arthritis patients.

Takken T, van der Net J, Helders PJ. Department of Pediatric Physical Therapy, University Hospital for Children and Youth ‘Hat Wilhelmina Kinderziekenhuis’, University Medical Center Utrecht, The Netherlands. t.takken@wkz.azu.nl Scand J Rheumatol. 2003;32(3):174-8.

Objective: To determine the relationship between aerobic and anaerobic physical fitness and functional ability in children with juvenile idiopathic arthritis (JIA).

Methods: Eighteen children with JIA (age 7 to 14 yr., 3 male/15 female) performed a maximal aerobic exercise test and a Wingate anaerobic exercise test. Functional ability was concurrently assessed using the Childhood Health Assessment Questionnaire (CHAQ).

Results: A low relationship between aerobic fitness and functional ability was found (r = 0.0 to 0.4, p > 0.05, except for eating r = 0.46, p < 0.05). The correlations between anaerobic physical fitness and functional ability in JIA patients were strong (r = 0.5 to 0.75, p < 0.05). This indicated a good relationship between anaerobic fitness and functional ability.

Conclusion: The strong association between anaerobic physical fitness and functional ability showed the importance of anaerobic physical fitness for children with JIA.