Special Populations 2024 Exercise Programming PDF

SS4073: Exercise Programming SPECIAL POPULATIONS Dr. Karl Fleming 21/11/2024 Module 8 1  Aim To provide students with the knowledge and competencies required to...

SS4073: Exercise Programming SPECIAL POPULATIONS Dr. Karl Fleming 21/11/2024 Module 8 1  Aim To provide students with the knowledge and competencies required to plan safe, effective and enjoyable programmes for individuals with special programming needs Module 8 2  Learning Outcomes At the end of this session, you will be able to: Describe the considerations which need to be taken into account when designing exercise programmes for individuals with a variety of special conditions/circumstances including: Stroke Epilepsy Fibromyalgia Multiple Sclerosis Module 8 3  Learning Outcomes Parkinson’s Disease Anxiety Depression Feelings of Energy and Fatigue Multiple Chronic Diseases  Learning Outcomes Describe circumstances under which referral to a GP or health/medical professional may be appropriate Describe the guidelines relating to Warm-ups/Cool downs/exercise intensities for resistance/aerobic training for each of the conditions referred to above Design safe, effective and enjoyable exercise programs for individuals with any of the conditions and circumstances referred to above Module 8 5  Assessment 2 hour in-class written paper, divided into two sections: Section (A) (40%) will contain 4 questions relating to general programming and programming for special populations from which 3 must be answered. Section (B) (40%) will contain 2 Case Studies relating to programming and each case study will be followed by 4 questions. All 4 questions must be attempted Assessment date: Thursday 5th December 2024  Sample Questions 1. Describe 5 considerations/modifications a PT would consider when training a post-stroke client? 2. What safety guidelines would a PT give to a client with epilepsy who wishes to begin an exercise programme? 3. Outline 5 considerations a PT would consider when dealing with a client diagnosed with fibromyalgia 4. Summarize the available literature to support that engaging in exercise has emerged as a cornerstone of management among people with multiple sclerosis  Sample Questions 5. Summarize the available population-based and experimental literature that physical activity and acute and chronic exercise improve feelings of energy and fatigue. Provide citations of relevant literature to support your response 6. Describe in detail the guidelines that a PT would use when prescribing an exercise programme for a client who has being diagnosed with Parkinson’s Disease  Sample Questions Eileen is 50 years old and has a ten-year history of MS-like symptoms. Because of increased symptomatology (fatigue, mobility, frequent urinary incontinence) she has been reluctant to engage in exercise for over a year. However, following advice from her interdisciplinary rehabilitation team, Eileen has decided to engage in a regular exercise programme to help fatigue management, and overall fitness. She used to enjoy going to the swimming pool and walking in the local park but is less comfortable going owing to her increased symptoms. She lives with her spouse in their own accessible home. She performed resistance training exercises when she was younger, but not since developing her symptoms. She has hired you as her personal trainer to help get started on an exercise programme.  Sample Questions 1. What components of fitness would you include in Eileen’s exercise programme and describe in detail your reasons for including these components (10 marks) 2. What advice would you give to Eileen to avoid symptom exacerbation during exercise? (10 marks) 3. How would you propose to improve her functionality and ability to carry out everyday tasks? (10 marks) 4. Describe the structure of a typical exercise session for Eileen (20 marks)  Sample Questions Mary is a 42-year-old female, who lives alone in her apartment. She works as a receptionist and following a traffic accident over six months ago she has been experiencing ongoing pain. Her symptoms are indicative of fibromyalgia and include widespread pain on both sides of the body, that affects activities of daily living, fatigue and sleep. Following a recent visit to her physical therapist, Mary has been advised that starting an exercise programme could benefit her overall health. She was a member of a local leisure centre several years ago, but lost interest mainly due to a lack of direction and support.  Sample Questions 1. Before beginning any exercise programme, the Doctor has suggested that Mary talk to you about the benefits of different types of exercise for fibromyalgia. Provide an outline of what you will include in your talk to Mary. (10 marks) 2. What training considerations will you consider in the development of Mary’s exercise programme? (10 marks) 3. Design weeks 1-4 of Mary’s initial programme. (25marks) 4. Given that Mary sticks to the programme and progresses as expected, show how you think the programme will look at week 12. (5 marks)  REVISION HRR – heart rate reserve Heart rate reserve is the difference between maximum (peak) heart rate and resting heart rate MET – metabolic equivalents One MET = amount of oxygen consumed while sitting at rest and = 3.5 ml O 2 per kg body weight x min MET concept represents a simple, practical, and easily understood procedure for expressing the energy cost of PA as a multiple of the resting metabolic rate Energy cost of an activity can be determined by dividing the relative oxygen cost of the activity (ml O2/kg/min) by 3.5 Convenient method to describe the functional capacity or exercise tolerance of an individual as determined from progressive exercise testing and to define a repertoire of physical activities in which a person may participate safely, without exceeding a prescribed intensity level  REVISION VO2R – percentage of oxygen uptake reserve Once you have determined a client's VO2max, calculate VO2R by subtracting resting VO2 (3.5 ml/kg/min) from VO2max When calculating VO2R, as when calculating heart rate reserve, best to determine an intensity range that includes a low end and a high end VO2 – volume of oxygen consumed per minute 1-RM – one repetition maximum  REVISION Symptom of exertion is unique to an individual Subjective estimate of work intensity undertaken across various populations Risk of musculoskeletal injuries/disorders arising from mismatch between worker’s capability & physical demands Measure of how hard it feels that the body is working based on the physical sensations that the subject experiences, including ↑ HR, ↑ respiration/breathing rate/sweating/muscle fatigue  REVISION Participants asked to rate exertion on the scale during activity, combining all sensations and feelings of physical stress and fatigue Told to disregard any one factor such as leg pain or shortness of breath but to try to focus on the whole feeling of exertion Number gives an indication of the intensity of activity allowing the participant to speed up or slow down movements  REVISION Borg also developed the Borg CR10, a Category-Ratio (CR) scale anchored at number 10 Represents an extreme intensity of activity A general intensity scale with special anchors to measure exertion and pain Individual is asked to circle or tick the number that best describes breathlessness, on average, over the last 24 hr  REVISION METS are an index of energy expenditure (EE). “A MET is the ratio of the rate of energy expended during an activity to the rate of energy expended at rest.... [One] MET is the rate of EE while sitting at rest... by convention... [1 MET is equal to] an oxygen uptake of 3.5 [mL · kg-1 ∙ min-1]” MET-min: an index of EE that quantifies the total amount of PA performed in a standardized manner across individuals/types of activities Kilocalorie (kcal): energy needed to increase the temperature of 1 kg of water by 1° C. To convert METs to kcal ∙ min-1, necessary to know individual’s body weight, kcal ∙ min-1 = [(METs × 3.5 mL ∙ kg-1 ∙ min-1 × body weight in kg) / 1,000)] × 5. Module 8 18  REVISION Example: Jogging (at ~7 METs) for 30 min on 3 d ∙ wk-1 for a 70-kg male: 7 METs × 30 min × 3 times per week = 630 MET-min ∙ wk-1 [(7 METs × 3.5 mL ∙ kg-1 · min-1 × 70 kg) / 1,000)] × 5 = 8.575 kcal ∙ min-1 8.575 kcal ∙ min-1 × 30 min × 3 times per week = 771.75 kcal ∙ min-1 Module 8 19  Stroke When blood flow to a region of the brain is obstructed, brain function deteriorates quickly and leads to neuronal cell death Results in motor (functional), sensory, emotional, and cognitive impairments, the extent of which are greatly influenced by the size, location of the affected area and presence or absence of collateral blood flow Etiology of a stroke is most often ischemic (87%, due to either thrombosis or embolism) or haemorrhagic Annually, nearly 800,000 U.S. residents suffer a stroke, with women having a higher lifetime risk of stroke than men Module 8 20  Stroke in Ireland Second leading cause of death in the developed world, the leading cause of acquired adult physical neurological disability in Ireland and a major cause of dementia, depression, falls, loss of independent living and institutionalisation in later life (Irish National Audit of Stroke 2020) ~7,500 people in Ireland suffer from a stroke each year, estimated that over 30,000 are living with some form of disability post stroke in Ireland Almost certainly a gross underestimate considering The National Institute of Clinical Excellence estimates the UK figure as being over 1.2 million. An identical rate here would suggest over 90,000 people living with stroke or stroke survivors Module 8 21  Stroke Physical/occupational therapy are typically utilized for up to 3–6 months following stroke to improve/restore functional mobility, balance, and return to ADL ASA recommend PA/Ex for stroke survivors across all stages of recovery ↓physical stamina, mood disturbance, and adoption of sedentary behaviours are common in stroke survivors, which may result in several complications including ↑frequency of falls and balance issues Although the Ex Rx is often adapted to the functional abilities of the individuals, exercise training improves exercise capacity (10%–20%, as measured by V̇O2peak) and may improve overall quality of life and help manage risk for a secondary event Module 8 22  Stroke (Exercise Training Considerations) Avoid Valsalva manoeuvre during RT to avoid excessive elevations in BP Treadmill should begin at a slow speed (0.8 mph) and provide harness apparatus for individual safety or, if needed, partially unloaded walking Careful use of the HR for intensity monitoring is recommended, as age predicted maximal HR is rarely achieved by the stroke individual during a maximal exercise test All components of exercise training (aerobic, muscle strengthening, and balance training) are important to stroke exercise therapy Exercise therapy should be initiated only after the individual is medically stable Early-onset local muscle and general fatigue are common and should be considered when setting work rates and rate of progression Module 8 23  Stroke (Exercise Testing Considerations) Stoke survivors O2 uptake/functional capacity significantly ↓ Ex testing mode to accommodate client’s physical impairment Cycle ergometry (work rate increase of 5–10 W ∙ min-1 or 20 W per stage) and dual action semi-recumbent seated steppers may be preferred to mitigate any balance deficiencies Device modifications (e.g., pedal type, swivel seated, seated back, flip up arm rest) may be needed to facilitate safety and ease of use Treadmill testing protocols should ↑work rate by 0.5 to 1–2 METs ∙ 2–3 min-1 stage and only if client can stand, sufficient balance, ambulate with minimal or no assist Balance impairments demand caution, including dual sided handrails on treadmills and/or a body-weight support system Module 8 24  Stroke (Exercise Prescription) Strong evidence supports exercise therapy for individuals with history of stroke (Canadian Public Health 2013) Majority are elderly and many have multiple comorbidities including other CVDs, arthritis, and metabolic disorders All comorbidities and their associated medications should be considered when performing exercise testing and prescribing exercise Following stroke, main objective is to restore ability to return to ADL. Exercise therapy should occur in each of the three phases of recovery; acute (in-hospital), subacute (rehab facility/home), and maintenance (home) Module 8 25  Aerobic Guidelines for Persons suffering a Stroke Incident (ACSM 2021) F: Min 3 d ∙ wk-1, preferably up to 5 d ∙ wk-1 I: If HR data are available from a recent Graded Exercise Text (GXT)(evaluates blood supply to heart during Ex), use 40%–70% of HRR. In the absence of a GXT or if atrial fibrillation is present, use RPE of 11–14 on a 6–20 scale T: Progressively increase from 20 to 60 min ∙ d-1. Consider multiple 10-min sessions T: Cycle ergometry and semi-recumbent seated steppers; may need modification based on functional and cognitive deficiencies. Treadmill walking can be considered if individual has sufficient balance and ambulation with very minimal or no assist Module 8 26  Resistance Guidelines for Persons suffering a Stroke Incident (ACSM 2021) F: At least 2 d ∙ wk-1 performed on non-consecutive days I: 50%–70% of 1-RM T: 1–3 sets of 8–15 repetitions T: Use equipment and exercises that improve safety in those with deficits (e.g., strength, endurance, movement, balance): machine vs. free-weight, bar vs. hand weights; seated vs. standing as indicated  Flexibility Guidelines for Persons suffering a Stroke Incident (ACSM 2021) F: ≥2–3 d ∙ wk-1 with daily being most effective I: Stretch to the point of feeling tightness or slight discomfort T: 10–30 s hold for static stretching; 2–4 repetitions of each exercise T: Static, dynamic, and/or PNF stretching  Stroke (Other Considerations) Care involves being attentive to affective issues such as mood, motivation, frustration, and confusion Correct management can influence how clients conduct, adhere to, responds to a prescribed exercise regimen Strategies minimizing negative influences, i.e. close supervision, individualized instruction until independence is established, family member involvement, instruction repetition, alternate teaching methods. In addition, CVD risk factor reduction is essential (Billinger et al. 2014) Exercise therapy should be initiated only after client is medically stable (Billinger et al. 2014) Early-onset local muscle and general fatigue common and should be considered when setting work rates and rate of progression Module 8 29  Exercise and Epilepsy Approximately 37,000 men, women, and children over age 5 (1 in every 115) with epilepsy in this country and this number may be increasing (Epilepsy Ireland 2009) Seizures Regular aerobic exercise may contribute to improved seizure control Vigorous exercise may be a precipitant (Earle and Baechle 2004) Module 8 30  Epilepsy PT needs to be aware of the type of seizure disorder a client has and be alert to signs and symptoms suggestive of a seizure Same exercise principles as are recommended for apparently healthy populations may be applied Module 8 31  Safety Guidelines (Epilepsy Foundation) Use a buddy system - especially when using equipment such as treadmills, weights, or bike riding Cycling - avoid busy streets, and always wear a helmet Begin with short duration activity Take frequent breaks and drink plenty of fluids Module 8 32  Safety Guidelines (Epilepsy Foundation) Always wear a medic alert bracelet or necklace, and carry medic alert card! Consider using a seizure alert systems with GPS locator A cell phone with GPS locator can also help people find you. Program emergency numbers and key family members or contacts into phone People with uncontrolled seizures should avoid dangerous activities (scuba diving, rock climbing, skydiving, hang gliding, mountain climbing) as any episode of loss of consciousness may lead to injury and possible death Module 8 33  Fibromyalgia Syndrome characterized by chronic widespread non-articular pain, generalized sensory hypersensitivity, diffuse multiple tender points, fatigue, poor sleep, memory impairment, psychological distress To date, no definitive etiology, or clinical/laboratory test available to confirm fibromyalgia diagnosis Result of central pain and sensory processing (pain can intensity/subside and present in different body areas at different times) Affects 1-4% of population in Canada, Europe, United States, with 1 in 50 Irish people affected Women more affected than men, prevalence increases with age, peaking between the fifth and eight decade of life (ACSM 2021) Module 8 34  Exercise and Fibromyalgia Individuals with the condition have reduced aerobic capacity and muscle function (strength & endurance) Overall reductions in PA and functional performance (walking, stair climbing), and physical fitness (Jones et al. 2015) Reductions caused by chronic widespread pain, limiting ability to complete everyday activities, resulting in deconditioning and loss of physiologic reserve (ACSM 2021) In general, Ex improves flexibility, neuromuscular function, cardiorespiratory function, functional performance Based on potential for pain and symptom exacerbation, med history/health status must be reviewed prior to exercise testing and prescription (ACSM 2021) Module 8 35  Fibromyalgia (Exercise Testing Considerations) Clients can safely participate in ex testing, but PT should be aware of each client’s symptoms and how they are feeling at all times (ACSM 2021) Use submaximal aerobic tests as moderate intensity is more tolerable than vigorous Astrand, submaximal bicycle ergometer test, shuttle walk test Strength and flexibility tests similar to general population Module 8 36  Exercise Training Considerations Positive changes with frequency of 1-2 d ∙ wk-1 / ↑symptom reduction in response to 3 d ∙ wk-1 (Bidonde et al. 2014) Adequate recovery time between exercises and sessions Alternate different body parts and different systems (musculoskeletal v. cardiorespiratory) If single bout of 30 mins of continuous exercise is not initially tolerated, use smaller 10 min bouts Rate of progression as per FITT guidelines will depend on individual symptoms – educate on how to reduce intensity/duration accordingly Minimize resistance eccentric phases during flare-ups ↓ex vol if symptoms increase during/after exercise (Jones et al. 2002) Module 8 37  Aerobic Guidelines for Individuals with Fibromyalgia (ACSM 2021) F: 1-2 d ∙ wk-1, gradually progressing to 2-3 d ∙ wk-1 I: Begin at very light intensity (9,000 in Ireland) Disease manifests as symptoms of balance, mobility, spasticity and fatigue Psychological symptoms of depression (46.9%), anxiety (54.1%) and fatigue (58.1%) are highly prevalent among persons with Multiple Sclerosis (PwMS) (Jones et al. 2012; Nagaraj et al. 2013) Module 8 42  Multiple Sclerosis Onset usually occurs between ages of 20 and 50 yr and affects women at a rate two to three times more than men Disease course highly variable from individual to individual and within a given individual over time PwMS are described as having relapsing remitting MS (most common type) if they experience at least two relapses Of these, 15%–30% develop progressive disability with or without relapses (i.e., secondary progressive MS) Approximately 15% of PwMS experience progressive disability from the onset of MS, which is described as primary progressive MS Module 8 43  Multiple Sclerosis Symptoms limit ability to complete ADL and impact quality of life Fatigue as well as mobility impairment, may lead PwMS to avoid participation in PA Fatigue can be both primary (i.e., directly related to disease pathology) and secondary to reduced physical fitness PwMS also experience heat sensitivity and impaired temperature regulation, which can result in worsening symptoms including fatigue and physical and cognitive function during PA Module 8 44  Multiple Sclerosis PA avoidance due to fatigue and impaired thermoregulation may lead to reduced aerobic capacity, which is known to decrease with increasing levels of disability Upper and lower limb isometric muscle strength, lower limb muscle power, and lower limb rate of force development is reduced in people with MS compared to those without MS Decreased muscle flexibility may also be apparent in PwMS, particularly among those with spasticity Physical inactivity may also contribute to reductions in muscle size and muscle strength and therefore feed into a negative cycle of deconditioning and physical inactivity Module 8 45  Exercise and Multiple Sclerosis In recent years, a complementary approach of engaging in exercise has emerged as a cornerstone of symptom management among PwMS Exercise, a subset of physical activity, comprising bodily movements, planned, structured and repetitive, aimed at maintaining or improving health and fitness factors (Caspersen et al. 1985) can be safely engaged in by PwMS (Pilutti et al. 2014) Disease-modifying treatments providing decreased disease severity and progression among PwMS are warranted (Dalgas et al. 2019) Module 8 46  Exercise and Multiple Sclerosis Research supports small to moderate improvements in physical fitness following resistance (Kjolhede et al. 2012) and aerobic exercise training (Platta et al. 2016), including improved health and physical activity parameters of walking, balance, cognition, depression, fatigue and overall quality of life among PwMS (Paltamaa et al. 2012; Motl and Sandroff 2015; Learmonth et al. 2016) Meta-analytic evidence highlighted exercise induced improvements in symptoms of fatigue (Pilutti et al. 2013; Moss- Morris et al. 2021), depression (Ensari et al. 2014; Dalgas et al. 2015), and anxiety (Herring et al. 2010; Herring et al. 2012) among PwMS Module 8 47  Exercise and Multiple Sclerosis Evidence suggests that flexibility and stretching exercises are among the preferred exercise options for PwMS (Asano et al. 2013) PwMS are less physically active (Motl et al. 2005; Klaren et al. 2013), including less daily step output and minutes of moderate-to- vigorous physical activity (Casey et al. 2018), and spend twice as long sitting (Sasaki et al. 2018) than their healthy counterparts, with inactivity levels increasing throughout disease progression (Hallal et al. 2012) Module 8 48  Exercise Training Considerations for PwMS With individuals who have significant paresis, consider assessing RPE of the extremities separately using the 0–10 OMNI scale to evaluate effects of local muscle fatigue on exercise tolerance (Latimer-Cheung et al. 2013) Module 8 49  Exercise Training Considerations for PwMS During an acute exacerbation of MS symptoms, decrease the FITT of the Ex Rx to the level of tolerance. If the exacerbation is severe, focus on maintaining functional mobility and/or focus on aerobic exercise and flexibility. Recognize that in times of severe relapse, any exercise may be too difficult to perform When strengthening weaker muscle groups or working with easily fatigued individuals, increase rest time (e.g., 2–5 min) between sets and exercises as needed to allow for full muscle recovery. Focus on large muscle groups and minimize total number of exercises performed Module 8 50  Exercise Training Considerations for PwMS To eliminate balance concerns during flexibility exercises, slow and gentle passive ROM exercise should be performed while seated or lying down Muscles and joints with significant tightness or contracture may require longer duration (several minutes to several hours) and lower load positional stretching to achieve increases in joint ROM Very low intensity, low-speed, or no-load cycling may be beneficial in those with frequent spasticity Module 8 51  Exercise Prescription for PwMS PwMS not able to meet guidelines for PA of 150 min of moderate intensity per week should engage in regular PA according to their abilities with support from health care providers For individuals with minimal disability (EDSS 0–2.5), the FITT principles are generally consistent with those for healthy adults Module 8 52  Aerobic Guidelines for PwMS (ACSM 2021) F: 2-5 d ∙ wk-1 I: 40%-70% V̇O2R or HRR, RPE 12-15 T: Increase time initially to a minimum of 10 min before increasing intensity. Progress to 30–60 min as tolerated T: Prolonged, rhythmic activities using large muscle groups (e.g., walking, cycling, swimming) Module 8 53  Resistance Guidelines for PwMS (ACSM 2021) F: 2 d ∙ wk-1 I: 60%–80% 1-RM T: Begin with 1 and gradually work up to 2 sets of 10–15 repetitions T: Multi-joint and single-joint exercises using machines, free weights, resistance bands, or body weight Module 8 54  Flexibility Guidelines for PwMS (ACSM 2021) F: 5-7 d ∙ wk-1, one to two times ∙ d-1 I: Stretch to the point of feeling tightness or mild discomfort T: Hold stretch for 30-60 sec., 2-4 repetitions T: Static stretching Module 8 55  Special Considerations for PwMS Commonly used disease-modifying medications such as interferon β-1a and glatiramer acetate have common side effects including altered mood, flu-like symptoms, liver failure, and localized irritation at the injection site PT should take medication side effects into consideration with exercise testing and scheduling Some individuals may restrict their daily fluid intake because of bladder control problems They should be advised to increase fluid intake with increased PA levels to prevent dehydration and hyperthermia, secondary to impaired thermoregulation Module 8 56  Special Considerations for PwMS Many individuals with MS have some level of cognitive deficit that may affect their understanding of testing and training instructions May also have short-term memory loss that requires written instructions and frequent verbal cueing and reinforcement Watch for transient worsening of sensory and motor symptoms, most commonly, visual impairment, associated with exercise and elevation of body temperature Symptoms can be minimized by using cooling strategies and adjusting exercise time and intensity Module 8 57  Parkinson’s Disease (PD) Second most common neurodegenerative disease after Alzheimer’s disease – cause unknown, aging, genetic susceptibility, and environmental factors likely all play a role Estimated ~700,000 individuals in the US age ≥45 yr are living with PD, this projected to double by 2030 (Marras et al. 2018) (~18,000 in Ireland) Uncommon for PD to be diagnosed before 50 yr of age, but the incidence increases 5- to 10-fold from ages 60 to 90 yr (Poewe et al. 2017) Global estimate prevalence = currently 6.1 million (Dorsey et al. 2018) Chronic, progressive neurological disorder characterized by signs of bradykinesia (reduced movement/speed), resting tremor, rigidity, postural instability, and gait abnormalities (ACSM 2021) Module 8 58  Parkinson’s Disease (PD) People may have had PD for several years before they are given the diagnosis of the disease Referred to as the prodromal stage of the disease and is characterized by rapid eye movement sleep disorder, constipation, depression, loss of smell (hyposmia), anxiety, and excessive daytime sleepiness (Poewe et al. 2017) Exercise can help all of these symptoms, which can precede the disease by many years (ACSM 2021) Module 8 59  Parkinson’s Disease (PD) Treatment is complex due to progressive nature of the disease, vast range of motor and nonmotor symptoms, and different side effects associated with therapeutic interventions Disease is relentlessly progressive Different signs/symptoms progress at different rates, and progression is often fastest early on in the disease (Rascol et al. 2002) Treatments include drug therapy, surgery, physical rehabilitation, and exercise programming (ACSM 2021) Module 8 60  Parkinson’s Disease (PD) Regular exercise decreases or delays secondary sequelae affecting musculoskeletal and cardiorespiratory systems that occur as a result of reduced PA Because PD is a chronic progressive disease, sustained exercise necessary to maintain benefits Evidence suggests that exercise can reduce disease severity, slow down the progression of the signs of the disease, improves strength, aerobic capacity, gait performance, and quality of life in individuals with PD (ACSM 2021) Module 8 61  PD and Exercise Testing Ex testing can determine current fitness levels, physiological response to an exercise bout, and any functional limitations prior to prescribing exercise so that the program can be specified to the client’s particular needs Clients with PD have impaired mobility and problems with gait, balance, and functional ability, vary from individual to individual Clients with PD experience fluctuations of their motor symptoms from day to day, even from moment to moment. These fluctuations are sometimes attributed to the timing and dosage of their medication and can vary within the same individual and among different individuals Take into account during ex testing and programming, as variability of motor fluctuations may influence testing outcomes, daily exercise performance Module 8 62  PD and Exercise Testing Assessment of cardiovascular risk (older, reduced PA levels) warranted prior to beginning an exercise test ANS dysfunction can occur with these clients, thereby increasing the risk of developing BP abnormalities, which can be further affected by medications Tests of balance, gait, general mobility, ROM, flexibility, muscular strength, core stability, and aerobic capacity are recommended before exercise testing is performed Static and dynamic balance evaluation and physical limitations of the individual should be used in making decisions regarding testing modes for test validity and safety Module 8 63  PD and Exercise Testing Clinical balance tests include the functional reach test, Berg Balance Scale Functional mobility can be assessed with the Timed Up and Go test and chair sit-to-stand test Gait observation can be done during the 10-m walk test at a comfortable walking speed Strength can be evaluated by manual muscle testing, arm curl tests, RM assessment using weight machines, dynamometers, and chair rise tests just as it is in older adults Flexibility can be assessed with goniometry, the sit-and-reach test, and the back-scratch test Aerobic capacity can be assessed submaximally with the 6-MWT Module 8 64  PD and Exercise Testing Standard procedures, contraindications to exercise testing, recommended monitoring intervals, and standard termination criteria are used to exercise test individuals with PD No known serious adverse effects exacerbated by the interaction of PD medications and exercise Few episodes of SBP drops of >20 mm Hg during treadmill training sessions have been reported, no association between medication usage and drop in SBP during exercise was found Cognitive impairment frequently observed in individuals with PD, although not all experience cognitive deficits Feeling distracted, forgetful, slower thinking and information processing, difficulty concentrating/managing complex tasks Recommended all testing instructions be explained slowly, concisely, and repeated as necessary Module 8 65  PD and Exercise Programming The main goal of Ex for clients with PD should be to slow down the rate at which the signs of the disease progress, reduce the signs of the disease, reduce comorbidities, prevent secondary complications from muscle disuse, and improve functional ability, independence, and quality of life FITT principles should address CRF, muscular strength and endurance, flexibility, neuromotor training, and motor control Module 8 66  PD and Exercise Programming The ability to rigorously quantify, measure, and prescribe aerobic, resistance, and flexibility exercises has resulted in FITT principles of exercise design that focus predominantly on these three domains (ACSM 2021) Accumulating evidence suggests that long-term aerobic exercise may attenuate PD progression (Ahlskog 2018) General aerobic training at a moderate intensity may improve aerobic fitness, fatigue, mood, executive function, and quality of life in those with mild-to-moderate PD (Uc Ey et al. 2014) High intensity endurance exercise (80%–85% HRmax) can be safely prescribed to individuals with early-stage PD and has been shown to attenuate the worsening of motor signs (Schenkman et al. 2018) Module 8 67  PD and Exercise Programming Importance of identifying exercise modalities that a client enjoys should not be underestimated because adherence is key ingredient to gaining maximal benefit from exercise As PD is a chronic and progressive disorder, an exercise program should be prescribed early when the individual is first diagnosed and continue on a regular, lifetime basis The program should be reviewed and revised as PD progresses because different physical problems occur at different stages of the disease Because the FITT principle recommendations for clients with PD is based on a smaller literature, the Ex Rx for healthy adults generally applies to those with PD however, the limitations imposed by the disease process should be assessed, and the Ex Rx should be individually tailored accordingly Module 8 68  Aerobic Guidelines for Individuals with PD (ACSM 2021) F: 3-4 d ∙ wk-1 I: High intensity (80%-85% [HRmax] for mild-to-moderate PD; Moderate intensity (60%–65% HRmax) for deconditioned individuals or those with more advanced PD; progress to 80%–85% HRmax if possible T: 30 min of continuous or accumulated exercise T: Prolonged, rhythmic activities using large muscle groups (e.g., walking, running, cycling, swimming, dancing) Module 8 69  PD and Resistance Training Recommendations for resistance training in individuals with PD is based on literature with variable objectives with respect to study design and outcomes (Ramazzina et al. 2017) RT is well tolerated in individuals with mild-to-moderate PD and should be progressive (Corcos et al. 2013) Muscle strength, power, movement speed, dynamic balance, QoL life parameters such as fatigue, are improved with resistance training in individuals with PD Strength improvements similar compared to neurologically normal controls Therefore, recommendations for RT in neurologically healthy older adults may be applied to individuals with PD (Scandalis et al. 2001) Module 8 70  PD and Resistance Training A recent modification to progressive resistance training that has proven beneficial for individuals with PD is the incorporation of unstable devices into the resistance exercises Results from this type of training have shown improved mobility, motor signs, neuromuscular outcomes, balance, reduced cognitive impairment, reduced fear of falling, and improved quality of life, which may be attributed to the progression of exercise motor complexity (i.e., degree of instability) and quantitative training parameters (i.e., frequency, intensity, and time) (Silva-Batista et al. 2016) Module 8 71  Resistance Guidelines for Individuals with PD (ACSM 2021) F: 2-3 d ∙ wk-1 I: 30%–60% of one repetition maximum (1-RM) for individuals beginning to improve strength; 60%–80% 1-RM for more advanced exercisers T: 1–3 sets of 8–12 repetitions, beginning with 1 set and working up to 3 sets T: For safety, avoid free weights for individuals in more advanced stages of the disease; focus on weight machines and other resistance devices (e.g., bands, body weight) Module 8 72  Flexibility Guidelines for Individuals with PD (ACSM 2021) F: ≥2-3 d ∙ wk-1, with daily being most effective I: For safety, avoid free weights for individuals in more advanced stages of the disease; focus on weight machines and other resistance devices (e.g., bands, body weight) T: Hold static stretch for 10–30 s; 2–4 repetitions of each exercise T: Slow static stretches for all major muscle groups Module 8 73  PD and Neuromotor Exercise Importance of incorporating neuromotor training and exercises that enhance motor control should not be overlooked or undervalued, regardless of the difficulty associated with determining a precise prescription for these types of exercises As a general rule, neuromotor training should progress exercise motor complexity and quantitative training parameters (i.e., FITT principles) Exercise motor complexity refers to the coordinative and control requirements of the motor activity Thus, exercise motor complexity and quantitative training parameters should not be prescribed simultaneously, as the former impairs the progression of the latter, but instead should be done sequentially (ACSM 2021) Module 8 74  PD and Neuromotor Exercise Balance impairment and falls are major problems in individuals with PD, with approximately 61% of people with PD experiencing at least one fall and 39% of people suffering from recurring falls (Allen et al. 2013) Balance training is a crucial exercise in all individuals with PD Postural instability and balance performance in individuals with mild-to-moderate PD can be improved with PA and exercise (Dibble et al. 2009) Static, dynamic, and balance training during functional activities should be included Clinicians should take steps to ensure the individual’s safety (e.g., using a gait belt and nearby rails or parallel bars and removing clutter on the floor) when using PAs that challenge balance Module 8 75  PD and Neuromotor Exercise Training programs may include a variety of challenging PAs (e.g., multidirectional step training, step up and down, reaching forward and sideways, obstacles, turning around, walking with suitable step length, standing up and sitting down) (Morris 2000) When external cueing in the form of rhythmic auditory stimulation is utilized during multidirectional step training, individuals with PD show improvements in functional gait parameters, including balance, and maintain these improvements longer than when external cueing is not utilized (Morris 2000) Tai chi, Tango, and Waltz are other activities to improve balance in PD (Earhart 2010; Li et al. 2012) Incorporating unstable devices, such as balance pads, dyna discs, balance discs, BOSU balls, or Swiss balls, into a resistance training regimen has also been shown to improve balance in PD (Silva-Batista et al. 2016) Module 8 76  Neuromotor Guidelines for Individuals with PD (ACSM 2021) F: 2-3 d ∙ wk-1 I: N/A T: 30–60 min T: Exercises involving motor skills (e.g., balance, agility, coordination, gait, dual tasks) such as tai chi, yoga, multidirectional step training and instability Module 8 77  PD – Exercise training and modalities Exercise type is dependent on the individual’s clinical presentation of PD severity and personal preference Treadmill exercise, stationary cycles, recumbent cycles, ellipticals, rowers, and arm ergometers are safe and effective modalities for aerobic training Water exercises and robotic gait training are effective for some people living with PD (Da Rocha et al. 2015) Virtual reality training, mental practice, boxing, and Nordic walking have a small amount of evidence supporting their use in PD (Da Rocha et al. 2015) Dance programs, especially ones that include visual and auditory cues and rhythmic tasks, have been shown to improve some of the motor characteristics of the disease and improve functional mobility (Dos Santos Delabary et al. 2018) Module 8 78  PD – Exercise training and modalities Tai chi has been shown to be effective in improving motor function, balance, and quality of life in individuals with PD, with limited evidence also showing improvements in fall risk and depression (Song et al. 2017) Research behind the optimal dose and specific protocols for the varying PD subtypes and symptom burdens is limited (Song et al. 2017) Module 8 79  PD – Exercise training and modalities Free weights may be utilized for individuals with mild-to-moderate PD Free weights may become unsafe at more advanced stages and in those with increased severity of tremor, especially during exercises that involve overhead lifting (Bollinger et al. 2012) Weight machines and other resistive devices such as resistance bands or body weight are safe alternatives to free weights It may be necessary to modify certain exercises due to decreased ROM associated with PD (Bollinger et al. 2012) During resistance training, emphasize extensor muscles of the trunk and hip to prevent faulty posture. Train all major muscles of the lower extremities to maintain mobility Module 8 80  PD – Exercise training and modalities Flexibility and ROM exercises should include slow static stretches and passive ROM exercises for all major muscle groups and joints, with an emphasis on the upper extremities and trunk (Bollinger et al. 2012) Spinal mobility and axial rotation exercises are recommended for all severity stages (Schenkman et al. 1998) Neck flexibility exercises should be emphasized because neck rigidity is correlated with posture, gait, balance, and functional mobility (Franzen et al. 2009) In addition, functional exercises such as the sit-to-stand, step-ups, turning over, and getting out of bed as tolerated should be incorporated in an exercise program to improve neuromotor control, balance, and maintenance of ADL Module 8 81  PD – Exercise training and modalities The Lee Silverman Voice Training (LSVT) BIG program is an exercise-based behavioural treatment conducted by a certified therapist consisting of specific exercises involving large amplitude, exaggerated movement patterns (Farley et al. 2005) Exercises are performed with high intensity and effort that become progressively more difficult and complex, with the overall goal of restoring normal movement amplitude in real life situations and ADL (McDonnell et al. 2018) LSVT BIG has been effective at improving motor function in people with PD (Chandhuri et al. 2007) Incorporating the concepts of this program into functional exercise may be beneficial Module 8 82  PD – Special Considerations Some medications used to treat PD further impair autonomic nervous system functions (Haapaniemi et al. 2000) Training an individual who has had a recent change in medications because the response may be unpredictable (Protas et al. 2010) Cognitive decline and dementia are common nonmotor symptoms in PD and may burden the training and progression (Stacy 2009) It is recommended that instructions be explained slowly, clearly, concisely, and repeated as necessary Exercises should be demonstrated and broken down into a series of short, simple steps Utilize verbal, visual, and tactile cues while instructing the individual Module 8 83  PD – Special Considerations Fall history should be recorded Individuals with PD with more than one fall in the previous year are likely to fall again within the next 3 mo (Morris 2010) Precautions should be taken to prevent falls whenever possible, such as avoiding narrow and/or uneven walkways, avoiding sharp turns and pivots, and removing any obstacles on the floor Incorporate and emphasize fall prevention/reduction and education into the exercise program. Instruction on how to break falls should be given and practiced to prevent serious injuries. Most falls in PD occur during multiple tasks or long and complex movement (Morris 2010) If the exercise professional has any concerns, suggest the individual should seek a referral for fall prevention training from a physical therapist Module 8 84  PD – Special Considerations Balance training should be emphasized in all individuals with PD (Goodwin et al. 2011) Use dual tasking or multitasking with novice exercisers with great care Individuals with PD have difficulty paying full attention to multiple tasks Dual task performance during gait has been correlated with increased risk of falling and diminished quality of life (Kelly et al. 2012) Dual task training has been shown to significantly increase stride length and cadence in individuals with PD (Geroin et al. 2018) and may also better prepare an individual with PD for responding to a balance perturbation (Silsupadol et al. 2009) Module 8 85  PD – Special Considerations Visual and auditory cueing can be used to improve gait in persons with PD during exercise (Suteerawattanonon et al. 2004) Some individuals with PD experience freezing of gait (FOG), which is an intermittent feeling that their feet are “frozen” or stuck to the floor when trying to walk. While resistance and balance training do not seem to improve FOG in individuals with PD (Schelstedt et al. 2004), utilizing both visual and auditory cues will help during, but will not necessarily alleviate freezing episodes (Nieuwboer 2008) Utilizing exercise regimens that limit the opportunity for freezing episodes (stationary cycling/resistance exercises) alongside auditory cues are additional ways to handle FOG Although no reports exist suggesting resistive exercise may exacerbate symptoms of PD, considerable attention must be paid to the development and management of fatigue (Garber and Friedman 2003) Module 8 86  What is Anxiety? Unpleasant feelings of apprehension, tension, or thoughts of worry – Often in the absence of real or obvious danger – Often accompanied by activation of the ANS – An adaptive response to an objective or perceived threat – Longer lasting and more abstract than fear (brief emotional reaction to a threatening stimulus) – Can become maladaptive if anxiety becomes severe or chronic (Barlow 2002) Module 8 87  What is Depression? A severe condition with persistent emotional, physiological and cognitive components (American Psychiatric Assoc 2022) Defining it can be difficult, because there are several different types of mood disorders that have variable, and often opposite symptoms Feeling depressed is only a part of clinical depression. Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-V) places mood disorders into four categories: Depression – Major Depressive Disorder, Dysthymia (Persistent depressive disorder) Bipolar, or manic-depressive disorder Mood disorders due to a medical condition Substance-induced mood disorders Module 8 88  Depressive Symptoms & Disorder As too much and violent Primarily characterized by: exercise offends on the one ↑ sad mood side, so doth an idle life on the other... Opposite to Exercise ↓ concentration is Idleness or want of exercise, ↑ self-criticism the bane of body and ↑ Suicidal ideation mind,...the chief author of all mischief, one of the seven ↑ loss of interest deadly sinnes, and a sole ↑ fatigue ↓ energy cause of Melancholy Hypersomnia/Insomnia (Robert Burton 1632) Psychomotor agitation/retardation (DSM-V 2014) Module 8 89  Anxiety and Depression Disorders that interfere with social, occupational, or other important aspects of daily functioning Often comorbid, meaning that individuals with one disorder frequently experience symptoms of the other (sometimes enough to qualify for a dual diagnosis) Estimated 300 million people suffer from depression and over 250 million suffer from anxiety disorders worldwide Lifetime prevalence is such that over 33% of the U.S. adult population will experience an anxiety disorder and 21% will experience a mood disorder 45%–80% of people with anxiety or depressive disorders do not receive treatment and, many do not respond to first-line treatments Module 8 90  Anxiety In general, meeting the 2018 Physical Activity Guidelines for Americans recommendations is appropriate for reducing anxiety Adults accumulate at least 150 min ∙ wk-1 of moderate intensity PA (e.g., walking) or 75 min ∙ wk-1 of vigorous intensity PA (e.g., running, fast cycling, or the equivalent combination thereof) Muscle- strengthening exercise (e.g., push-ups, yoga, weight training) for all major muscle groups at least two times per week Module 8 91  Anxiety Beyond those general guidelines, systematic reviews of exercise effects on anxiety symptoms provide specific guidance to inform Ex Rx Frequency: In the general population, the effects of exercise appear to be greatest when sessions occur three to four times per week. In individuals with anxiety disorders, weekly exercise frequency was not associated with anxiety reduction, nor was an optimal frequency identified In individuals with primary diagnoses of other medical conditions (e.g., cardiovascular disease, fibromyalgia, multiple sclerosis, cancer), effects were greatest for programs held three or five times per week Module 8 92  Anxiety Intensity: In the general population, moderate and vigorous intensity PA (i.e., exercise) reduce anxiety Comparative effectiveness trials in individuals with anxiety disorders are limited, but based on the available trials, moderate-to- vigorous intensity physical activity (MVPA) may be effective for reducing anxiety symptoms In individuals with primary diagnoses of other medical conditions, light, moderate, and vigorous intensity exercise were all associated with reduced anxiety Some evidence that higher intensity aerobic exercise programs (e.g., treadmill running at 60%–90% maximum heart rate [HRmax] or 60% V̇O2max or greater) had greater effects for decreasing anxiety than lower intensity ones (e.g., walking below 60% HRmax or V̇O2max) Module 8 93  Anxiety Time: In the general population, exercise has acute effects that reduce state anxiety following exercise sessions, and there does not appear to be a minimum bout length for these effects Anxiety reductions are evident following bouts lasting 1–30 min and may increase for bouts lasting 61–90 min Effects are evident in programs lasting from 4 to 15+ wk; however, effects may taper over time In individuals with anxiety disorders, longer exercise programs are associated with greater reductions in anxiety symptoms but little is known about bout duration requirements In individuals with other medical conditions, program length and session duration both appear to influence the size of treatment responses. Largest responses have been found from sessions lasting 30+ min and programs lasting 3–12 wk Module 8 94  Anxiety Type: Both aerobic and resistance exercise training appear to be effective for reducing symptoms of anxiety in healthy and clinical populations Resistance training may reduce anxiety more in healthy populations than in populations with physical or mental illness It is not clear whether combining different types of activity leads to greater reductions in anxiety Module 8 95  Depression Exercise is effective for both reducing depressive symptoms in people with and without clinical depression and for reducing the odds of a clinical diagnosis in those who started with a clinical diagnosis of depression The effects of aerobic exercise are more profound among individuals who are clinically depressed In individuals with depression, aerobic exercise has proven to be as effective as psychotherapy or pharmacotherapy for reducing depressive symptoms Exercise is also more effective for reducing depression than bright light therapy and other controls Module 8 96  Depression Frequency: The cumulative frequency of exercise matters more for individuals with depressive disorders than those without Programs with 12 or fewer days of exercise have inconsistent effects However, programs lasting 13 or more days consistently reduce depressive symptoms in individual samples Module 8 97  Depression Intensity: There is not enough evidence to indicate that one particular intensity is more effective than another for reducing depressive symptoms PA at any intensity level appears to be effective for reducing depressive symptoms Even though more evidence has been collected on moderate-to- vigorous than light PA, it appears that exercise at all intensities is beneficial for reducing depressive symptoms Module 8 98  Depression Time: Exercise has acute or immediate effects on core affective states that can be useful for temporarily alleviating depressive symptoms after exercise Bouts as brief as 20 min appear to be sufficient to reducing depressive symptoms in individuals without depressive disorders For individuals with depressive disorders, 45 min is the recommended bout length Module 8 99  Depression Type: The effects of aerobic exercise on depressive symptoms have been characterized better than the effects of flexibility exercises In general, both aerobic and resistance training reduce depressive symptoms Mixed programs including both aerobic and resistance training components appear to be more effective than programs with only one form of training; however, this conclusion is based on limited evidence For individuals with depressive disorders, both aerobic and resistance exercises reduce depressive symptoms Exercise produces similar effects on depressive mood to stretching, meditation, and relaxation Module 8 100  Exercise Considerations Exercise can induce physiological changes similar to a panic attack (e.g., increased HR, shortness of breath); therefore, individuals with known panic disorders should be advised to expect these symptoms as a normal result of exercise Some exercise appears to be better than none for reducing anxiety and depression, although meeting recommended levels of PA has had the best results For depressed individuals, it is important to find PAs that will be maintained, and they should include a mix of aerobic and resistance training activities Module 8 101  Best Practices – Applied and Practical Be familiar with the symptoms and basic treatment of mental disorders and have referral sources on hand ▪ Recognize and respond: if express emotional distress, be prepared to refer to available resources ▪ Familiarize with common meds – may be more comfortable reporting meds than psychiatric conditions – side effects Avoid minimizing the person’s feelings or concerns ▪ Avoid making your regard for patient/participant dependent on the person’s meeting your standards for EX participation Establish boundaries in relationships with patients based on professional ethics and what is comfortable for you ▪ Supportive and encouraging without fostering dependence Module 8 102  Best Practices – Applied and Practical Assess current PA habits and fitness ▪ Could be significantly lower than typical sedentary person ▪ Individualize EX prescription Determine person’s motivation for EX ▪ Motivation is key determinant ▪ Important to consider – goals, EX prescription, promoting adherence EX should be enjoyable and non-threatening ▪ Identify and minimize features of EX that person finds intimidating ▪ Balance – too hard/too easy; social vs. isolated Module 8 103  Best Practices – Applied and Practical EX Accessibility is critical ▪ Plans to overcome perceived barriers Encourage personal responsibility by including the person in the planning of the EX program ▪ Control ▪ Encourage pride in his/her accomplishments no matter how small Be prepared for non-adherence and excuses ▪ Important to be non-judgmental ▪ Disallow magnifying lapse into catastrophe ▪ Facilitate identification of modifiable causes for lapse, strategies to overcome Module 8 104  Best Practices – Applied and Practical Encourage increased PA outside of established EX sessions Watch for sabotage ▪ May be subtle attempts by patient or others to discourage change ▪ Deterrents to change should be identified and addressed directly Be aware of what behaviour is being reinforced ▪ Negative attention is better than none for some ▪ If you always express concern for missed sessions, anxious/depressed disposition – may increase ▪ Positively reinforce desired behaviour in meaningful way for each individual Module 8 105  Take Home for Anxiety Available evidence indicates that acute aerobic exercise can attenuate state anxiety Weight of the available evidence indicates that exercise training reduces symptoms of anxiety among healthy adults, chronically-ill patients, and patients with panic disorder Preliminary data suggest that exercise training can serve as an alternative therapy for patients with social anxiety disorder, generalized anxiety disorder, and obsessive-compulsive disorder Anxiety reductions appear to be comparable to other empirically- supported treatments for panic and generalized anxiety Module 8 106  Take Home for Depression Substantial evidence from population-based studies suggest that physical activity reduces the risk for depression and depressive symptoms Experimental evidence supports the efficacy of EX to reduce depressive symptoms among healthy adults, depressed patients, and patients with a myriad of chronic illnesses Myriad of psychological and neurobiological mechanisms have been considered Module 8 107  Feelings of Energy and Fatigue Module 8 108  What is Fatigue? Conceptualized numerous ways Decrement in force production Reduced motor unit recruitment Mood state – transient feeling that people report experiencing ranging in duration from minutes to weeks Subjective feelings of having a reduced capacity to complete mental and/or physical activities no fatigue - - - - - - - - - - - - - - - - - - - - - - - - - highest fatigue feelings feelings possible no energy - - - - - - - - - - - - - - - - - - - - - - - - - highest energy feelings feelings possible  Fatigue is prevalent and burdensome Significant Economic Burden: Total yearly cost of fatigue globally ~$500 billion Moore-Ede, 1993, The 24-hour society, Addison-Wesley Publishing, Reading, MA McCrone et al., 2003, Psychological Med., 33(2): 253-261. Kohl et al., 2012, Lancet, 380(9838): 294-305; global yearly cost of physical inactivity ~1-3 trillion Meng et al., 2010, J Am Geriatrics, 58(10): 2033-34; past week - national sample of 17,084 adults over 50 Lewis & Wessely, 1992, J Epidemiology & Community Health, 46: 92–97; 1- month Fukuda et al., 1997, J Psychiatric Research, 31: 19-29; 6-months - rural communities, n = 1698  Correlates/Determinants Active engagement in cognitive tasks that requires sustained attention increases feelings of fatigue over time Even more fatigue provoking is sustaining this attention/cognitive vigilance over many hours either while engaging in a single complex task or switching among several complex tasks Physical or social situations perceived as interesting or threatening results in a reduction of fatigue symptoms People with neurotic personality types are characterized by elevated fatigue symptoms Some environmental conditions, such as exposure to bright or varying light, are energizing, whereas others, such as poor lighting or total darkness, promote fatigue Some sounds like your favourite updated music might be energizing while monotonous loud industrial noises might be fatiguing  Correlates/Determinants Decreased feelings of fatigue often results from the ingestion of stimulants, such as caffeine, nicotine, amphetamines (Adderall) Antihypertensives (blood pressure medication) can produce fatigue Alcohol, can increase and then later decrease feelings of energy Acute and chronic food restriction produces increased feelings of fatigue Eating, depending on what is being consumed and when, can generate feelings of either energy or fatigue Numerous illnesses and treatments cause or are associated with fatigue Allergies Depressive disorders Anemia Fibromyalgia Anorexia Heart failure Anxiety disorders Infections (e.g., flu) Asthma Multiple sclerosis Cancers Obesity Coronary heart disease Parkinson’s disease Chronic fatigue syndrome Sleep disorders COPD Stroke Chronic pain Substance abuse Diabetes Thyroid disease Other key determinants of fatigue include chronic sleep loss… Reduced mental energy can be inferred from increased errors on a boring task requiring sustained attention Baseline Experimental sleep nights Recovery Belenky et al., 2003, J Sleep Research, 12 (1): 1-12.  Chronic Physical Inactivity is Associated with Fatigue 16.4 – 18.8% 19.0 – 19.4% Fatigue 17.7 – 20.6% From the Centers for Disease Control, 2008, 21.1 – 22.6% prevalence Percentage of adults who are physically inactive in 23.1 – 25.2% (%) each county 25.4 – 30.0% Grandner et al., 2012, J. Clin. Sleep Med. 8(1): 77-86 N=157,319, 2006 Behavioral Risk Factor Surveillance System Single item, 2-week time frame, sextiles Feelings of fatigue can 19 Physical inactivity can result in physical inactivity 17 result in feelings of fatigue 15 POMS Vigor 13 11 9 7 5 Monday Tuesday Wednesday Thursday Fr No time Too tired Days of Physical Inactivity Brownson et al, 2001, Am J Public Health, 91(12): 1995-2003; random sample of 1,818 US adults Adapted from Mondin, Morgan, et al., 1996, MSSE, 28(9): 1199-203; M-W vigor ES d=1.3, fatigue ES d=.45 Similar findings by others: Glass et al., 2004, J. Psychosomatic Res., 57(4): 391-398 Berlin et al., 2006, Psychosomatic Med., 68(2): 224-230 Kop et al., 2008, Brain, Behavior & Immunity, 22(8): 1190- 1196 16 studies included in a quantitative analysis: 58 effect sizes 678 participants adults 18 – 55 years old 65% of samples were students Mean energy effect size =.47; 95% CI =.39 to.56 Increased energy compared to control condition  * * * * * denotes a significant finding p ≤.05  EX significantly improved: Feelings of energy (p