EXERCISE

EXERCISE & NUTRITION AS THERAPY ASSIGNMENTSPECIAL POPULATION CASE STUDY
BACKGROUND AND RISK STRATIFICATION
CLIENT INFORMATION: (Background)
Name Mrs Mrudula Joshi.

Health & fitness goal:1. Feel good every day and stay healthy.2. Improve strength in arms and legs.

Personal information:Age: 81 years & 2 months.Gender: Female.Birth Date: 8/6/1938.Occupation: Teacher.Height: 147 cm.Weight: 51 Kg.

Medical history:1. Present:2. Past:Hypertension (1998)Right leg femur bone multiple fracture Osteoporosis (2004)(2007)Left hand wrist fracture (2013)
Family history:
The reason behind the father’s death was heart problems: died because of cardiac arrest.The reason behind the mother’s death was old age. Few members in the family had blood pressure/hypertension issues. No one used to smoke but neither they did any sort of physical exercises but the lifestyle was not sedentary.

Other readings:1. RHR: 782. Blood pressure: 145/95 mmHg.3. Total cholesterol: 151 | HDL: 76 | LDL: 63 | VLDL: 12 | Triglycerides: 614. MHR: 220-age = 220-81 = 139 bpm CITATION Cal l 16393 (Calculate Your Maximum Heart Rate, 2018)5. BMI: Weight in kg/ (Height in m)2 = 51/ (1.47)2 = 23.6 CITATION Cal14 l 16393 (Calculating BMI Using the Metric System, 2014)Any restrictions or suggestions: (by the GP)1. Nutritional suggestions: Reduce sugar, sodium, oils, spicy food intake.2. Physical suggestions: No heavy object lifting, walk with a stick in hand, no jerks to joints, Strengthening of muscles necessary.3. Lifestyle suggestions: Socializing important, be as active as possible.

Observations: (by the client)1. Can’t bend down fully (both forward and backward bend)2. Can’t sit on the floor. (only on a chair or a bed but can’t with legs crossed)3. Slower actions, the speed of movements has been reduced drastically.4. Reduced strength and breathing capacity.5. Can’t turn to a side if sleeping on the back easily.

Note:
The client is 81 years old, short but more in weight. We need to consider a few factors which can affect a person’s physical as well as psychological health ; fitness. Those can be stated as Age, Gender, Body composition, past and present medical conditions, lifestyle etc. Her BMI is under 30 but resting heart rate is high could affect her performance.

The client does not smoke nor does consume any sort of alcoholic drinks. The lifestyle of the client is sedentary. Because of old age, cannot climb up or downstairs. According to medical history, the client has high blood pressure since 1998 (145/95 mmHg) and osteoporosis since 2004 which resulted in bone fractures in 2007 and 2013. The client was bedridden for 6 months because of Femur bone multiple injuries and later client’s hand was in plaster for 4 months because of wrist fracture injury. Rehabilitation and physiotherapy had been taken by the client for a year after the injuries. Till now the client has not been hospitalized post these accidents.

According to nutritional records, full meals consumed 4 times per day with a less quantity of proteins, a larger quantity of carbs and a negligible quantity of fats.

The client has filled the SIT Private Health Risk Questionnaire form in which she has answered all the fundamental questions regarding her health and lifestyle so as to help trainer understand, assess and plan an exercise program for a particular period.

Sport & Exercise
Private Health Risk Questionnaire
According to CITATION Sou18 l 16393 (SIT, 2018) following private questionnaire will help us to decide whether or not it is safe for you to participate in an exercise test. If you answer yes to any of the following questions (except #26), you may increase your risk of experiencing some unpleasant side effects or even evoking a heart attack during the test.

Part 1 – Known Diseases (Medical Conditions)
1.

List the medications/drugs you have taken within the last 72 hours or take on a regular basis.

Hyperlipidemia: Clopivas 75
Heart problem: Cardace & Aztor 5
BP: Nebicard 2.5 2.

Please list any drug allergies you have.

Rablet Yes
3. Do you have diabetes? No a) If yes, please indicate if it is insulin-dependent diabetes mellitus (IDDM) or non-insulin-dependent diabetes mellitus (NIDDM). IDDM NIDDM
b) If IDDM, for how many years, have you had IDDM? N/A Years
4. Have you had a stroke? No 5. Has your doctor ever said you have heart trouble? Yes
6. Do you have asthma? No a) Do you get exercise-induced asthma? No b) Do you use an inhaler? No 7. Are you or do you have reason to believe you may be pregnant? No 8. Is there any other physical reason that may prevent you from participating in an exercise test?
Osteoporosis Yes
9. Has your doctor ever advised you not to do strenuous exercise? Yes
Part 2 – Signs and Symptoms
10. Do you often have pains in your heart, chest, or surrounding areas, especially during exercise? No 11.

Do you suffer from bone or joint problems, or any other complaint that may be made worse by strenuous exercise? No 12. Do you often feel faint or have spells of severe dizziness during exercise? No 13. Do you experience unusual fatigue or shortness of breath at rest or with mild exercise? No 14.

Have you had an attack of shortness of breath that came on after you stopped exercising? No 15. Have you been awakened at night by an attack of shortness of breath? No 16.

Do you experience swelling or accumulation of fluid in or around your ankles? No 17. Do you often get the feeling that your heart is beating unusually faster, racing, or skipping beats, either at rest or during exercise? Yes
18.

Do you regularly get pains in your calves and lower legs during exercise which are not due to soreness or stiffness? No 19. Has your doctor ever told you that you have a heart murmur? No Part 3 – Cardiac Risk Factors
20. Do you smoke cigarettes daily, or have you quit smoking within the past two years? No If yes, how many cigarettes per day do you smoke (or did you smoke in the past two years)? N/A per day
21. Has your doctor ever told you that you have high blood pressure? Yes
22. Has your father, mother, brother, sister had a heart attack or suffered from cardiovascular disease before the age of 40? Yes
If yes, a) Was the relative male or female? __Male b) At what age did he or she have the stroke or heart attack? __40 c) Did this person die suddenly as a result of the stroke or heart attack? Yes
23. Have you experienced menopause before the age of 45? Yes
If yes, do you take hormone replacement medication? No Page 4 – Lifestyle
24. Does your job involve you sitting for a large part of the day? Yes
25. What activity pattern best describes your lifestyle? Sedentary
26. Do you exercise/train regularly No If yes, a) Frequency (number of sessions): ___N/A per wk
b) Duration (per session): ___N/A minutes
c) Intensity: Low Moderate High
d) History: <3 months 3-12 months >12 months
e) What types of exercise/training do you do? N/A
27. Do you feel that you may be unaccustomed to strenuous exercise? Yes
Part 5 – Injury
28. Have you a current/recent/long-term injury? Yes
If yes, please explain (history, treatment details, clearance to exercise)1. Right leg femur bone multiple fractures (2007)2. Left-hand wrist fracture (2013) 29.

Please list any illness, hospitalization or surgical procedure within the last two years?No Part 6 – General
30. Are you feeling unwell, or suffering from a viral infection, or cold? No 31. Do you suffer from any blood-borne infectious disease e.g. hepatitis, HIV etc.? No 32. Do you have any allergies and/or intolerances?
Please specify if answered Yes:Lactose intolerance Yes
33. Did you have any difficulty in understanding any of the above questions? No This form is totally confidential to the individual concerned, and the information will not be made available to the Southern Institute of Technology. (Adapted from “Pre-Exercise Health Screening Guide”, Olds & Norton, 1999)

CURRENT SCENARIO FOR HYPERTENSION AND OSTEOPOROSIS:
Globalization, urbanization, an upgrading information technology and artificial intelligence, quick access to the world using just 3 letters; www.; all these improvements and achievements are replacing human activity and integrating, changing human being’s life and lifestyle rapidly now-a-days. Even if these things are improving our so-called hectic life reducing down the physical activity, these are actually shattering our physical, psychological, intellectual health. The results are in front of us. Chronic illnesses, unnecessary injuries, depression, nutritional frauds etc. are some of the examples of how our enhanced lifestyle is actually downgrading our life.

Hypertension also called as high blood pressure (abbr. HT or HBP) and osteoporosis are one of the main diseases or physical conditions which affect human beings. According to World Health Organization, hypertension or heart related disease are increasing day by day and they are nothing but the world’s largest killer till nowCITATION WHO16 l 16393 (Q&As on hypertension, 2015). Men as well as women now-a-days suffer from such chronic conditions because of their poor lifestyle.
According to the National Institute of Health (NIH) “osteoporosis is nothing but a skeletal disorder. It is considered as compromised osteo power inducing the risk of bone cracking or simply fracture.” CITATION Smi09 p 270 l 16393 (Smith S., 2009, p. 270) Here osteo power is nothing but bone strength and bone density and bone quality which can be found reduced over a period of time in case of osteoporotic patients.

However, these conditions can be treated and prevented if we learn about them by opening our eyes. Let us see how these conditions are affecting humans and how can they be handled so as to improve human performance.

INTRODUCTION TO HYPERTENSION & OSTEOPOROSIS:
HYPERTENSION:
Hypertension or high blood pressure is nothing but a chronic heart condition or long-term medical condition which nothing but increases the pressure of blood in human being’s arteries, as the name suggests. High blood pressure would not cause any damage to a person but what damages human’s physiology is if high pressure remains in the body for longer duration. It affects arterial health, heart health, vision, kidney and vascularity problems etc.CITATION WHO16 l 16393 (Q&As on hypertension, 2015). HT is known as ‘the silent killer’ because it shows no symptoms. Such asymptomatic nature results in delaying in actions to get it checked by the doctor and disease remains undiagnosed & untreated CITATION Moo05 l 16393 (Moore, 2005).

Difference between systolic and diastolic blood pressure:
Unit for BP is mmHg which stands for millimeters of mercury and usually first value is nothing but a systolic pressure and second value can be read as diastolic pressure. Its value can be written as 120/80 mmHg. Let’s compare these BPs.

Fig. 1: Difference between systolic and diastolic BP CITATION Kat l 16393 (Systolic vs. Diastolic Blood Pressure)Clinical diagnostic norms for HT:
There are specified norms to diagnose if one has high blood pressure. According to American Heart Association, CITATION AHA14 l 16393 (AHA, 2014):
Normal BP: Systolic – ; less than; 120 mm Hg, Diastolic – ; less than; 80 mm Hg
Prehypertension BP: Systolic – 120-139 mm Hg, Diastolic – 80-89 mm Hg
Hypertension Stage 1: Systolic – 140-159 mm Hg, Diastolic: 90-99 mm Hg
Hypertension Stage 2: Systolic – ? 160 mm Hg, Diastolic – ? 100 mm Hg
Hypertensive Crisis: Systolic – ; greater than; 180 mm Hg, Diastolic – ; greater than; 110 mm Hg.

These norms are based on blood pressure measurements calculated using sphygmomanometer or blood pressure gauge, inflatable cuff and stethoscope.

Types of HT:
As per Chris Iliades, MD, stated in one of his articles, ‘different types of hypertension’, there are 2 main types but further can be added more based on specific diagnostic criteria as follows:
Primary high blood pressure (can be called as essential)
Secondary high blood pressure
Isolated systolic
Malignant
Resistant
According to Chris, CITATION wik l 16393 (Iliades, 2009), most individuals diagnosed are primary and remaining people are of secondary HBP type. Essential HBP is asymptomatic in nature therefore GP will suggest 3 or more tests so as to get to know if individual has HBP. Primary or essential is nothing but hypertension occurred because of lifestyle and genes or heredity. Whereas, secondary HBP is caused due to abnormality of arteries, hormones as well as thyroid problems, past or present diseases etc.
Signs and symptoms of HT:
In any case, an individual should not diagnose himself or herself. Being a silent killer, hypertension will show some or other signs but those would not be severe for the patient to know what is happening and why. As per stated in article published on Heart.org CITATION Wha16 l 16393 (What are the Symptoms of High Blood Pressure?, 2016), facial flushing, dizziness, blood spots in the eye are the direct signs but nose bleed or headaches are not the signs for most of the people who suffer from HT.

OSTEOPOROSIS:
Definition: It is nothing but a skeletal disease which is systematic in nature, which later results in reduced bone mass and microarchitectural deterioration of bone tissues. CITATION LiG17 l 16393 (Li G., 2017). As the name suggests, ‘osteo’ stands for bone or bone structure and ‘osis’ can be defined as deformity in that particular region. Osteoporosis generally diagnosed by measuring BMD which stands for Bone Mass Density.

Types of osteoporosis:
Susan S. Smith, PhD, and Susan A. Bloomfield, PhD states mainly 2 types of osteoporosis as follows CITATION Smi09 p 271 l 16393 (Smith S., 2009, p. 271):
Primary: This type can occur in all the sexes as well as in any age but most probably it occurs post menopause in women and one of the reasons could be deficiency of estrogen. (typically, between 50 to 80 for women and 70 and older for men) CITATION Smi09 p 271 l 16393 (Smith S., 2009, p. 271)Secondary: secondary osteoporosis is nothing but a result of various drugs or medications, if a person has had any disease earlier or in present then late complication could be osteoporosis, also other conditions like athletic amenorrhea etc. CITATION Smi09 p 271 l 16393 (Smith S., 2009, p. 271)Risk factors for Osteoporosis:
Gender or sex, certain races, family history, improper body composition, less estrogen levels in women, smoking, amenorrhea, history of fracture, alcohol consumption, reduced calcium and vitamin D intake, overdose of protein and caffeine as well as salt and vitamin A, inadequate exercises, some specific illness or diseases and mainly age CITATION Smi09 p 271 l 16393 (Smith S., 2009, p. 271).

Sign and symptoms of osteoporosis:
As the name suggests, signs of osteoporosis are to be diagnosed in any individual using his or her bone mass density. Common signs for osteoporosis are nothing but weak bones, low bone mass in skeletal system that means it increases bone fragility and fracture risk CITATION LiG17 l 16393 (Li G., 2017).

HEALTH RISK ASSESSMENT: (Risk Stratification)
Any person planning to start any kind of physical activity should go through a health risk screening and risk stratification process. This screening is important and the reasons according to Niemann CITATION Nie11 p 23 l 16393 (Nieman, 2011, p. 23) are:
To identify individuals needing a referral to a health care provider for an extensive medical evaluation.

Ensuring the safety of exercise testing and participation.

Determining appropriate exercise programs and tests for the individuals.

The following are the risk stratification categories, according to ACSM risk levels CITATION Gre10 p 22-28 l 16393 (Green, 2010, pp. 22-28), considered for this study:
“1. Low Risk: A young person (less than 45 years old men, less than 55-year-old women), with no more than one coronary disease risk factor and without symptoms or known disease. Tests: Sub-maximal and Maximal.

2. Moderate Risk: An older person (more than or equal to 45 years of age in men, more than or equal to 55 years of age in women), or with two or more coronary disease risk factors. Tests: Sub-Maximal
3. High Risk: A person with one or more symptoms of the cardiopulmonary disease, or with cardiovascular, pulmonary and/or metabolic disease. (Franklan2000) Test: No tests without a doctor present, no exercise without a doctor’s clearance.”
According to the Private Health Risk Questionnaire filled by the client, she currently comes under the category of high risk. According to the ACSM guidelines for risk stratification mentioned above, the client is ‘HIGH RISK’ as stated above. Therefore, no tests and exercises should be done without any clearance from GP.

Considering all the above factors, a trainer should take safety under consideration first. The client needs to be under supervision continuously while exercising or doing any physical activity.

LITERATURE REVIEW
Prevention ; treatment for HT:
According to World Health Organization, CITATION QAs15 l 16393 (Q;As on hypertension, 2015), any individual can prevent initially HBP problem by implementing these four steps as follows:
Positive lifestyle changes such as healthy diet, consistent physical activity, mindfulness so as to reduce anxiety and tension level.

If considered perfect diet: avoid extra sodium, reduce saturated and other fat intake as well as opt for more fruits and vegetables.

Say no to tobacco and same like items.

Reduce your alcohol consumption or take it down to zero percent if possible.

Prevention ; treatment for Osteoporosis:
Exercises as therapy for HT:
Exercises as therapy for Osteoporosis:
FITNESS ASSESSMENT ; STRATEGIES AND GOALS
Fitness assessment and testing:
A continuous requirement for drugs or medication without any physical activity or exercises to balance health problems may prove fatal and complicated in the long run CITATION Ily09 p 3-6 l 16393 (Ilyas, 2009, pp. 3-6).

Assessment strategies:
Considering client’s background, family history and body composition, the trainer should consider some basic things before starting with the exercise regime. Fitness assessment should be done on basis of medical reports, interview of the client and a Health Risk Questionnaire. The client lives in India currently. So physical testing/assessment and analysis are impractical. Notwithstanding, few guidelines for fitness testing & assessment in line with the ACSM’s guidelines could be given.

The most important thing is, be sure to assess the client in the presence of a cardiologist, a GP and a trainer. All the required equipment, such as a heart rate monitor, blood pressure digital machine (for faster measurements) or sphygmomanometer, in this particular case, should be kept handy in an emergency. Pre, during and post-exercise health checkup, constant monitoring and feedback are necessary so as to keep an eye on the above-listed risk factors. A trainer should ask questions, communicate with the client, motivate the client to do activities and help achieve their goal/goals.

SMART goal:
Client’s goal should be S: specific | M: measurable | A: achievable/attainable | R: realistic/relevant | T: timely/time bound. That is what SMART stands for.

Main fitness goals to focus on for the client:
Improve muscle strength (specifically, in arms and thighs).

Improve breathing technique (belly or full thoracic breathing technique).

Weight management (reduce weight by 3-4 kgs) with help of proper nutritional plans.

Improve joint health (mainly shoulder, wrist and fingers, knee).

Flexibility and mobility around joints (hip or waist, shoulder and knee).

PROGRAMME
Exercise Program:
Warm up session: 5-10min walk around the house + dynamic warm-up drills for main joints + belly breathing technique practice (sitting).

Strength focused exercise program:
no. Exercise name/description Sets Reps Load
1 Seated neck presses(4 side static press holds) 2-3 1-3(5 sec hold) Trainer’s help needed
2 Seated shoulder shrugs hold 2-3 3-5(10 sec hold) –
3 Standing/seated scapular retractions(against the wall if possible) 1-2 5(5 sec hold) –
4 Pec-dec last position press hold 2-3 5(5 sec hold) Self-squeezes
5 Seated overhead press 1-2 6-8 Squeeze ball in hand
6 Seated bicep curls(hands to the side) 1-2 6-8 Squeeze ball in hand
7 Seated wrist curls and extensions and rotations 1-2 8-10 Squeeze ball in hand
8 Seated waist twisting 2-3 8-10 Stick on back
9 Seated side and forward bending 2-3 8-10 Stick on back
10 Seated leg extensions with toe raise 2-3 8-10 –
11 Seated adductor/groin press/squeezes with leg extension hold 1-2 5(5 sec holds) Towel folds between knees
12 Seated calf raises 2-3 6-8 –
13 Standing leg curls 2-3 8-10 –
Flexibility focused exercises program:
no. Exercise name/description Sets Reps Time hold (sec)
1 Trapezius stretch both ways 1-2 1 5-15
2 Forearm stretch (up ; down) 1-2 1 5-15
3 Sitting forward bend (for lower back) 1-2 1 5-15
4 Sitting hamstring stretch 1-2 1 5-15
5 Sitting calf ; shin stretch 1-2 1 5-15
6 Overhead long hands stretch 1-2 1 5-15
7 Belly breathing practice and mindfulness 1 1 As per client
Cooldown session: 5 min walk around house + belly breathing technique practice (lying on back)
Comment: (for the trainer)Don’t:1. Heavyweight training2. High impact exercises (HIIT, any type of aerobic activity)3. High-intensity training4. Sudden movements or jerky movements5. Head low position exercises6. Long duration exercise program7. High set or high repetition program
Do’s:1. Preferably sitting exercises2. Without weight movements3. Breathing focus more and no breath holding (no Valsalva maneuver breathing method)4. Low repetitions and low sets exercise program5. Easy static or passive (if the client allows) stretching exercises6. Meditation and mindfulness techniques7. Posture correction exercises8. Isometric exercises as per capacity9. Keep heart rate monitors handy every time10. Pre and post exercise nutrition important11. Pre, during and post exercises feedbacks are important12. Exercises in front of mirror and trainer compulsory
REFERENCES
Literature review20%
An accurate, comprehensive and inclusive literature review, including associated benefits of specified exercise regimes (with citation from at least eight journals, eight books, plus other sources).

Fitness assessment strategies and goals20%
There are realistic goals for the client and suitable fitness assessment strategies
Programme 30%
The programme builds from evidence from the literature review and presents an appropriate, easy to follow eight week start up programme to meet client needs.