chapter 16: foundations of strength training for special...

Chapter 16: Foundations of strength training for

special populations Rachel Davis, Britt Chandler, and Jeff Chandler

Chandler, T.J., & Brown, L.E. (2008). Conditioning for strength and human performance. Baltimore, MD: Lippincott Williams and Wilkins

Chapter 16: Foundations of strength training for special populationsRachel Davis, Britt Chandler, and Jeff Chandler


Thought Questions

What is the relationship between resistance training and sarcopenia?

Can resistance training have an effect on childhood obesity?

How is resistance training beneficial in Post-Polio Syndrome? Arthritis? Muscular dystrophy? AIDS? Fibromyalgia?

Should a pregnant female do resistance training exercises? Give examples.



Strength Training for Special Populations

• The health fitness instructor needs to design an individualized program in close consultation with the client

• They must understand the client's needs and precautions, where to get more information, be alert to problems and know when to take action or call for medical help

• Resistance training has become an important component of exercise programs for athletes and for overall health and fitness in the general population

Bird, S.P., & Cannon, J. (2006). The role of resistance exercise in chronic disease:Prescription guidelines and application in clinical practice. [Review]. Critical Reviews inPhysical and Rehabilitation Medicine, 18(4), 317-342.



Geriatrics• People reaching age 65 have an average life expectancy of an

additional 18.2 years, but many will have to deal with at least one chronic condition that will impact their quality of life

• 65-74 yrs olds: 20% have difficulties with activities of daily living (ADLs); only 26% engage in regular physical activity

– 85 yrs old or above: over half have difficulties with ADLs

– 75 yrs old or above: only 16% engage in regular physical activity

Galvao, D. A., Newton, R. U., & Taaffe, D. R. (2005). Anabolic responses to resistance training inolder men and women: a brief review. Journal of Aging and Physical Activity, 13(3), 343-358.



Normal Aging and Sarcopenia

• Typical aging process: deleterious effects on human skeletal muscle; associated with loss of muscle mass, muscle strength and power, and even ADLs

• Sarcopenia: progressive loss of muscle mass with advancing age; accompanied by loss of motor units

• Overall effects of sarcopenia contribute to decline in basal metabolic rate and progressive increase in percent body fat

• Resistance exercise: a powerful stimulus to lessen the effects of sarcopenia in the elderly

• Progressive resistance training (PRT): preserves both muscle mass and strength in older adults

• Increasing muscular strength and mass in the elderly improves functional status, independence, and overall quality of life



Osteoporosis

• Osteoporosis: a systemic process of diminishing bone mass and deterioration of internal bone structure that results in an increased risk of fracture; known as a “silent disease” because the first sign of disease may be a fracture

• More than 1.5 million fractures annually are attributed to osteoporosis

• Osteopenia: death of bone cells

• Exercise has become a primary treatment recommendation for osteoporosis

– Evidence suggests that resistance training and weight-bearing exercise are essential for a client with osteoporosis

– Bone mass attained early in life and maintained with exercise, diet, and lifestyle choices is the best way to prevent osteoporosis



Arthritis• Arthritis: one of the most prevalent chronic conditions worldwide;

projected to affect 60 million individuals by the year 2020 in the U.S. alone

• Two common types

– Rheumatoid arthritis (RA)

– Osteoarthritis



Rheumatoid Arthritis• Chronic, systemic, multijoint disease

• Affects the joints of the hands, wrists, elbows, shoulders, knees, feet, and cervical spine in a symmetrical pattern

• No known cure for RA, but it can be controlled with a combination of medications

• Range-of-motion exercises and/or non-weight bearing workouts have been the predominant modes of exercises prescribed by health care professionals

• However, a study has shown that dynamic exercise therapy is effective in increasing muscle strength with no negative effects or increase in pain



Osteoarthritis• Also called degenerative joint disease

• Affects more than 20 million individuals in the U.S.

• Predicted to affect 70 million by 2030

• Characterized by the degeneration of cartilage, which covers the ends of bones in a joint

• Although a number of treatment approaches such as pain relief techniques, surgery, and/or pharmaceutical interventions exist, recent research has found that exercise is one of the better treatments for osteoarthritis



Pediatrics• Approximately 30% of children and adolescents are overweight; about

15% are obese

• This increases risk factors for conditions like asthma, diabetes, and hypertension.

• Some children are born with a disability, such as cerebral palsy, Down’s syndrome, or muscular dystrophy

• All of these conditions and disabilities can significantly affect physical functioning during childhood

• Health fitness professionals can play a key role in getting the pediatricpopulation started on a lifelong path of physical fitness



Healthy Children and Adolescents

• The process of growth and development in children (prepuberty) and adolescents (postpuberty) results in increases in muscle size and strength.

• There is an “age effect” which means older children and adolescents will be stronger, pound for pound, than younger individuals.

• Many studies have shown that resistance training in children and adolescents effectively increases muscle strength

– Prior to puberty, anabolic hormone concentrations are low; this limits the potential for resistance training to cause significant hypertrophy

– After puberty, both males and females are capable of changes in both muscle size and strength with properly implemented resistance training programs

• Major concern with youth resistance training is safety



• Improper resistance training can cause damage to epiphyseal plates which leads to improper growth of the long bones

• Key to safe resistance training in youth is to ensure that there is proper supervision for training and that lighter weights and higher repetitions are used

• A properly designed and supervised resistance training program should incorporate periodization principles to vary volume and intensity throughout the year

• Progression should emphasize increases in repetitions relative to increases in resistance, very light loads should be used when new movements are being learned to ensure learning proper technique

Wilson, G., Bird, S.P., O’Connor, D., Baker, D., & Jones, J. (2007). Resistance training for children and youth: A position stand from the Australian Strength and Conditioning Association (ASCA). Beenleigh, QLD: Australian Strength and Conditioning Association

2007 ASCA National Conference Presentation

http://www.strengthandconditioning.org/dimages/PositionStand%5B1%5D Powerpoint template October 2007.pdf



Cerebral Palsy• Cerebral palsy: term used to describe a group of non-progressive

infant-onset motor disorders typically caused by various sources of cerebral ischemia during the prenatal, perinatal, or postnatal period

• Common motor problems include spasticity, hyperreflexia, difficulties with fine motor control, and gait dysfunction

• Most common cause of childhood physical disability and occurs at a rate of between 2.0 and 2.5 cases per 1,000 live births

• Muscle weakness is often present in one (hemiplegia) or both limbs (diplegia)

– Resistance training shown to increase muscle strength in CP patients

– These increases in strength do not exacerbate symptoms of CP such as spasticity

– They may, however, help improve the performance of ADLs



Mental Retardation and Down’s Syndrome• One of the major causes of mental retardation is Down’s syndrome.

• Down’s syndrome: genetic disorder that affects approximately 1 in 600 to 1,000 live births

• Characterized by cognitive delay, distinct facial features such as epicanthal folds of the eyelids and a relatively flat occiput and nasal bridge, and short limbs

• People with Down’s syndrome also often have poor muscle tone (hypotonia) and joint laxity, which can lead to increased risk of musculoskeletal and orthopedic problems

• Individuals with Down’s syndrome have been shown to be significantly weaker than both age- and sex-matched controls

– This weakness is correlated with low bone mineral density; therefore the risk of osteoporosis is elevated in those with Down’s syndrome

– Resistance training greatly benefits individuals with Down’s syndrome by increasing muscle tone and motor activity



Muscular Dystrophy• Muscular dystrophy: describes a family of genetic muscular diseases

that involve dysfunction of the dystrophin glycoprotein complex in skeletal muscle; this leads to progressive muscle wasting, weakness, and disability

• The most common form is Duchenne muscular dystrophy (DMD)

• DMD: most common fatal childhood genetic disease (1 in 3,500 births); only found in boys

• Over time, repeated cycles of muscle degeneration and regeneration lead to a net degeneration of the muscle tissue, weakness, loss of mobility, and eventually death

• Alternative forms of progressive resistance training program can build muscle and maintain a healthy body in individuals with DMD



Neuromuscular Disease• Can be due to damage or dysfunction in the CNS, the peripheral

nerves, or the muscle tissue

• Complex multiple-system conditions can occur, like stroke and fibromyalgia

• Common symptoms: spasticity, rigidity, weakness, and sensory loss

• Resistance exercise can help in the rehabilitation of neuromuscular conditions where weakness is the main cause of loss of motor function

Lindeman, E., Spaans, F., Reulen, J., Leffers, P., & Drukker, J. (1999). Progressive resistancetraining in neuromuscular patients. Effects on force and surface EMG. J Electromyogr Kinesiol, 9(6),379-384.



Stroke• Stroke: death of brain cells as a result of impaired blood flow to the

brain

• About 750,000 people experience a stroke each year in the U.S.

• Third leading cause of death in the U.S. and the leading cause of disability in adults.

• Two general categories of strokes: ischemic strokes and hemorrhagic strokes

• Ischemic stroke: similar to a heart attack in that occlusion of a cerebral artery occurs due to plaque formation

• Hemorrhagic stroke: results from the loss of structural integrity of a cerebral blood vessel and subsequent bleeding

• Both types can lead to muscle weakness and spasticity



• Motor symptoms are typically most severe on one side of the body

• Several studies have shown that strength training has the potential to improve function

• Structured resistance training programs may improve a stroke patient’s cardiovascular and respiratory efficiency, thus improving quality of life

Harris, J. E., & Eng, J. J. (2010). Strength training improves upper-limb function in individuals with stroke: a meta-analysis. Stroke, 41(1), 136-140.



Fibromyalgia• Not a disease but rather a chronic pain syndrome

• Has a variety of symptoms; the main symptom is the presence of tender points at sites throughout the body (mainly muscle tissue)

• About 2% of the population has FMS; it is predominant in women and increases with age

• Diagnosis requires pain to be present in at least 11 of 18 common sites throughout the body

• Other symptoms include fatigue, sleep disturbances, and vision problems

• A deconditioning/ pain cycle is often seen in FMS, because those with this condition often avoid physical activity due to pain

• A resistance training program for FMS patients may help reduce pain and maintain muscle tone



Post-Polio Syndrome• Poliomyelitis: viral disease in which the polio virus attacks alpha motor

neuron cell bodies in the spinal cord and brainstem

• Individuals with post-polio syndrome are those who have recovered function after the initial poliomyelitis but develop symptoms of weakness and fatigue 30 or more years later

• Studies have found that exercise is safe and effective for individuals with PPS as long as individual tolerance is used to monitor exercise intensity



Multiple Sclerosis• Chronic inflammatory autoimmune disease of unknown etiology that

affects the central nervous system

• Causes a loss of myelin resulting in disruption of nerve conduction

• Symptoms may include weakness, tremors, spasticity, fatigue, sensory disturbance, heat sensitivity, and impairment of balance, coordination, vision, speech, swallowing, cognition, and bowel and bladder function

• MS affects about 400,000 people in the U.S.

• Studies show that people with MS can improve strength, fitness, and quality of life through aerobic and resistance training

• Exercise programs should be tailored to the individual

de Souza-Teixeira, F., Costilla, S., Ayan, C., Garcia-Lopez, D., Gonzalez-Gallego, J., & de Paz, J. A. (2009). Effects of resistance training in multiple sclerosis. Int J Sports Med, 30(4), 245-250..



Spinal Cord Injury• Most often results from motor vehicle accidents (50.4%) and falls

(23.8%), followed by violence (11.2%) and sports injuries (9%)

• Approximately 247,000 people live with SCI in the U.S.

• Categorization depends on the level of injury and whether it is complete or incomplete

– C1 to T1 injuries result in tetraplegia

– T2 to T12 injuries result in paraplegia

– These two groups are upper motor-neuron injuries

– T12 and below result in paraplegia and are considered lower motor-neuron injuries



• Research on resistance training with SCI has focused on those with paraplegia

• Circuit resistance training has been shown to be the most effective method of improving strength and decreasing pain

• Several precautions must be taken due to the motor and sensory deficits that result from an SCI

Willoughby, D. S., Priest, J. W., & Nelson, M. (2002). Expression of the stress proteins, ubiquitin, heat shock protein 72, and myofibrillar protein content after 12 weeks of leg cycling in persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 83(5), 649-654.



AIDS/HIV• Human immunodeficiency virus (HIV): a pandemic disease that

currently has no cure; may lead to acquired immunodeficiency syndrome (AIDS)

• Approximately 40,000 new cases of HIV/AIDS occur each year

• Along with its effects on the immune system, the disease is also associated with weight loss (muscle wasting)

• Wasting affects the musculoskeletal system resulting in weakness

• Incorporation of resistance training may increase muscle mass and facilitate health benefits

Bhasin, S., et al. (2000). Testosterone replacement and resistance exercise in HIV-infected men with weight loss and low testosterone levels. JAMA, 283(6), 763-770.



Chronic Obstructive Pulmonary Disease• COPD: a progressive respiratory illness that is not completely

reversible

• Primary pathology is expiratory airflow limitation

• Encompasses a number of pulmonary conditions such as asthma, emphysema, and chronic bronchitis

• Biopsies from the quadriceps muscles of COPD patients have revealed a loss of type I muscle fibers and a reduction in oxidative enzymes

• Traditional treatments have included pharmacological intervention, oxygen therapy, lung transplantation, or lung volume reduction surgery

• Pulmonary rehabilitation clinics have also begun to incorporate exercise training as a standard part of treating COPD patients

• A beneficial effect of resistance training for COPD patients is reduced anxiety and fatigue as well as independence in performing ADLs



Cardiovascular Disease• Includes coronary heart disease and stroke

• Is the leading cause of death among Americans

• Major risk factors include hypertension, elevated serum total cholesterol, cigarette smoking, and diabetes mellitus

• Higher levels of physical activity were associated with a lower risk of developing cardiovascular disease

• Effects of resistance exercise may also reduce cardiovascular risk factors

• A combination of aerobic exercise and circuit resistance training improves skeletal muscle function and vascular function

Braith, R. W., & Stewart, K. J. (2006). Resistance exercise training: its role in the prevention of cardiovascular disease. Circulation, 113(22), 2642-2650.



Obesity• Defined as a BMI greater than 30

• Is associated with cancer, type II diabetes, hypertension, hyperinsulinemia, and coronary heart disease

• A combination of resistance training , aerobic exercise, and caloric restriction is the optimal method of reducing body fat safely and effectively in obese individuals

Tresierras, M. A., & Balady, G. J. (2009). Resistance training in the treatment of diabetes andobesity: mechanisms and outcomes. J Cardiopulm Rehabil Prev, 29(2), 67-75..



Diabetes Mellitus

• Two general categories of diabetes:

– Type I diabetes: characterized by pancreatic damage, resulting in diminished insulin secretion from the pancreas; often referred to as juvenile-onset diabetes

– Type II diabetes: characterized by insulin resistance; a given glucose challenge requires a greater insulin response

• Aerobic exercise can both decrease the risk of developing type II diabetes and aid in glycemic control

• Studies have shown that resistance exercise improves insulin sensitivity and glucose tolerance and improves glycemic control

Zacker, R. J. (2005). Strength training in diabetes management. Diabetes Spectrum, 18(2), 71-75..



Cancer• In 2000, cancer was the second leading cause of death in the U.S.

• Treatment involves radiation, chemotherapy, surgery, or a combination of these

• Many of these treatments are intensive and affect physiologic function; this can cause fatigue, muscle wasting, and energy loss

• Resistance training and aerobic exercise can help counteract these effects

Galvao, D. A., Newton, R. U., & Taaffe, D. R. (2005). Anabolic responses to resistance training inolder men and women: a brief review. Journal of Aging and Physical Activity, 13(3), 343-358.



Pregnancy

• Concerns about exercise during pregnancy: increased body temperature, impaired uterine blood flow and nutrient supply, and the risk of preterm labor

• Moderate, regular exercise during pregnancy has many benefits for the mother, including decreased weight gain, more rapid weight loss after pregnancy, improved sense of well-being and decreased risk of musculoskeletal pain and gestational diabetes

• A pregnant woman should always seek guidance from her physician prior to proceeding with an exercise program

• If a woman has been exercising prior to pregnancy, she can continue with minor modifications

• If a woman has not exercised previously, she may cautiously begin a gentle exercise program and must be alert to overexertion and complications



Summary• It is increasingly apparent that resistance exercise provides significant

benefits to chronic disease patients. – Nonetheless, caution should be applied in introducing progression into a

program. Using a team approach with appropriate health care providers can enhance the safety and effectiveness of a program

• Future research needs to further delineate the program design variables (intensity, frequency, volume, etc.) that maximize benefits (including functional outcomes) while minimizing deleterious effects for different diseases and syndromes.

• In addition, longer-term studies need to be performed to assess the benefits and risks of prolonged resistance exercise for these special populations

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