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Any
of these early warning signs may signal his presence. This guide
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Note:
Readers should always consult
their physicians before taking any action (or inaction) which
may affect their health or involve decision making.
The article
was written by William F. Brechue, Ph.D. (Assistant Scientist
at the University of Florida, Department of Medicine and the Center
for Exercise Science in Gainesville). It is reprinted below with
his permission:
When I talk
about exercise for health and rehabilitation, I talk about a changing
paradigm for exercise. We are all fmiliar with the use of exercise
training to improve athletic performance. In fact, the mention
of exercise gongers a vision of athletic training. However, in
the early 60s we heard about the need for exercise to improve
fitness. President Kenedy was concerned about the declining fitness
of American children and instituted the President’s Council
on Physical Fitness. In the 70s and 80s aerobic dance was popularized
as exercise to improve fitness. Today, the new paradigm for exercise
training relates to exercise for improving health. While it is
easy to see the differences between exercising for performance
and fitness, the differences between fitness and health are subtle
but distinct.
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Aging, Disease,
and Dysfunction: I would like to begin this discussion by talking about
phyiologic changes with aging and how they relate to our structure
and function. As we age, our bodies go through a series of
changes which ultimately result in a reduced ability to perform
work. This is associated with a reduction in maximal oxygen
consumption (a measure of how well our heart, lungs, nad muscles
function to do work) and muscular strength. Additionally,
there is a decline in fat free mass and an increase in fat
mass. The decline in fat free mass is determined by a decrease
in bone density and muscle mass. These changes in maximal
oxygen consumption, strength, and body composition are defined
as decreases in fitness with age. In addition, aging apparently
causes our bodies’ basal metobolic rate to decrease.
Basal metabolic rate can be defined as the amount of energy
our bodies need just to stay alive. Age-related changes in
blood vessels lead to increases in blood pressure. The increase
in fat mass described above is associated with increased blood
cholesterol: increases in low density cholesterol (bad cholesterol)
and decreases in high density cholesterol (good cholsesterol).
Aging leads to a reduced ability to metabolize glucose (sugar)
because of changes in the way insulin works, and thus, we
become diabetic-like. These changes would define one’s
decline in health with age.
M uch
research has been done on the changing with aging and the
impact of physical activity on those changes. It is now known
that many of the age-related changes can be minimized by exercise
and activity. That is, much of the decline seen with age is
related to physical activity. This was summarized and amplified
in 1992 when the American Heart Association accepted physical
inactivity as one of the major risk factors for heart disease.
Several major longitudinal studies have shown that there was
decreased mortality and sickness in individuals who remained
physically active through life. Consequently, there is a relationship
between aging, fitness and health, and physical activity.
As one ages, there is a decline in fitness and health which
reduces physical function. The decline in physical function
leads to physical function leads to inactivity. Inactivity
reduces physical function, and so on. The individual rapidly
gets into what can be termed a deconditioning cycle. The cycle
continues significantly reducing physical function and quality
of life. Thus, physiologic aspects of the deconditioning cycle
can be slowed, stopped, or reversed by physical activity and
exercise.
This same model of deconditioning can be applied to cases
of disease, sickness, or injury. Disease, sickness, or injury
can lead to pain, discomfort, and/or a limited ability to
move which leads to physical inactivity. If the timing or
debilitation is long enough or great enough, i.e. lung disease,
heart failure, etc., an individual’s decline in health
may be exacerbated by the deconditioning cycle. Ultimately,
quality of life is reduced. For example, Alpha-1 Antitrypsin
Deficiency causes a decrease in lung function and a decrease
in physical activity. A major problem becomes the loss of
fitness and health due to inactivity and deconditioning secondary
to the disease. In many instances the effects of deconditioning
become the greater problem.
The
consequences of deconditioning secondary to disease can be
and usually are similar to aging and inactivity: reduced maximum
oxygen uptake, muscular strength, and unfavorable body composition
and reduced musculoskeletal integrity (decreased bone density
and muscle mass and increased body fat), reduced glucose tolerance,
etc.
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The
Importance of Musculoskeletal Integrity: Anything that
reduces musculoskeletal integrity will reduce physical function.
Bones provide our framework, our structure, and are the mechanical
levers that allow motion. Skelatal muscle is a motor that is
connected to the bones. It functions by converting chemical
energy to mechanical energy which by generating force and changes
in length, allow for the movement of our bony levers. Research
shows us that muscoloskeletal integrity has a great impact on
physical function. A decrease in bone density, i.e. weak bones,
leads to risk of fracture (with or without impact), skeletal
deformity, and risk and fear of falling. Decreases in muscle
mass and strength are significant as strength defines our ability
to move. For example, leg strength is directly related to walking
speed, ability to climb stairs and stand-up. In addition, reduced
leg strength is associated with the risk and fear of falling.
Inactivity
leads to a reduction in maximal oxygen consumption and muscular
strength. Although some of the change in maximal oxygen uptake
is due to intrinsic changes in cardiovascular function, a good
deal of the reduction can be explainedby decreased muscle mass.
Likewise most, if not all, of the strength changes can be explained
by a decreased muscle mass caused by physical inactivity. Oxygen
uptake determines our ability to perform repetitive or long
duration tasks or work, while strength determines our ability
to move. So, maintaining or improving muscle mass is important.
Also, there is a relationship between muscle mass, strength,
and bone density. Muscular strength is directly related to the
amount of muscular mass. The more muscle you have the stronger
you are. Additionally, bone density has been shown to be related
to muscular strength. Individuals with osteoporosis have been
shown to have significantly less strength and muscle mass than
healthy individuals of the same age.
An
additional factor which will impact musculoskelatal integrity
and health is not related to inactivity but drug side-effects.
Alpha-1 Antitrypsin Deficiency, and many other diseases, involve
the use of the drug prednisone, a steroid, to depress the immune
system. In addition, prednisone is one of several drugs used
post-transplant to limit organ rejection. The side-effects of
this drug include loss of bone density and muscle mass. Thus,
prednisone can exacerbate the loss of bone and muscle due to
inactivity, and vise versa. Our research shows that there is
a 20% reduction in bone density between pre-transplantation
and 8 weeks post transplantation: presumably due to a combination
of anti-rejection medication and inactivity.
-
Rationale
for Resistance Exercise: Inactivity, deconditioning,
and/or prednisone treatment appears to have its greatest impact
on physical function and quality of life through decrements
in musculosketal system: bones and muscles. Thus, reducing the
loss of musculoskeletal integrity is an important goal of any
program. The use of exercise training for rehabilitation requires
the appropriate application of exercise principles to attain
the expected outcome. Maintenance or restoration of the musculoskeletal
system requires increasing bone density and muscle mass throughout
the entire body.
The
appropriate exercises for this purpose is resistance training
or weight lifting.
To
meet these goals, our resistance exercise program entails
13 different exercises which incorporate all of the major
muscle groups of the body. These exercises are performed
3 days per week with a minumum of 48 hours rest between
workouts. Each exercise is performed one time using a weight
that can be lifted throughout a weight that can be lifted
throughout a full range of motion 10-12 times. When 12 repetitions
can be completed, 5 pounds are added to the load for the
next workout. Each exercise session is preceded and followed
by 15 minute stretching program which is used as a warm-up
and cool-down. The stretching is a very important part
of the program. Every patient in our program receives a
full explanation of the exercises. In addition, there are
many forms of resistance exercise machines, including free
weights, so the program can be adapted to the type of equipment
that the patient has access to.
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Adaptions
to Resistance Exercise: Resistance exercise programs
have been shown to increase muscle mass, strength, and maximal
oxygen uptake in the young, the elderly, and various patient
populations including transplant patients. In the elderly, these
changes have resulted in an increase in walking speed and stair
climbing ability. Significant reductions in back pain have been
seen in many cases where specific resistance exercise of the
low back muscles was used. Bone density is greater in individuals
who are stronger and has been shown to increase with resistance
exercise. Patients with osteoporosis have less strength than
healthy people the same age, but resistance exercise can increase
both strength and bone density. We have shown that bone density
can be increased in post-transplant patients when resistance
exercise is prescribed. While aerobic training will increase
bone density of the legs, aerobic plus resistance exercise generally
leads to greater increases in whole body bone density because
of the whole body nature of resistance exercise. Resistance
exercise has also been shown to improve gluclose tolerance and
insulin function, thus reversing age-related changes. Resistance
exercise is not believed to have direct effects on body fat,
but, the addition of muscle mass and body weight results in
a relative, indirect reduction in body fat percentage. The effect
of resistance exercise on blood lipids and cholesterol remains
controversial and incompletely understood. Resistance exercise
has no apparent effects on blood pressure and thus, would not
be helpful in reducing pressure in hypertension. However, the
significance of this statement lies in the fact that many people
believed that resistance exercise would cause hypertention.
It doesn’t appear to.
-
Rationale
for Resistance Exercise in Lung Disease: Resistance
exercise would not be expected to have a positive or direct
influence on lung disease, but as described the benefits of
resistance exercise would be to limit or negate musculoskeletal
decline until lung function can be improved through other means
(drugs, lung reduction, or transplant). In addition, resistance
exercise may be ideal for lung patients as demand on the lungs
can be minimized by longer rest periods between exercises without
compromising the training effects of expected adaptions. Performing
12 repetitions of an exercise requires about 72 seconds. About
the time that the lung patient would begin to feel discomfort
(breathlessness and/or desaturation) the exercise would cease.
Recovery time before the next exercise could be as long as necessary.
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Other
Considerations: Balanced Program of Resistance and
Aerobic (Endurance) Exercise - the focus of this paper has been
the benefits of resistance exercise on musculoskeletal integrity
and physical function. However, this is not to be interpreted
as suggestion that this form of exercise should be performed
to the exclusion of endurance type exercise. Most research and
the guidlines for exercise prescription of the American College
of Sports Medicine and the American Heart Association state
that a program involving both endurance and resistance type
exercise is preferential and ideal. Part of the reason would
be that endurance exercise training has a direct impact on body,
lipid and cholesterol profile, and blood pressure control not
accomplished with resistance exercise. Thus it is very important
to include regular endurance type exercise such as walking,
swimming, skating (roller or ice), cycling, etc.
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Safety:
With the advent of exercise machine safety has improved significantly.
Most machines have adjustable seats with restraint systems to
limit falling. Since the weights are contained and are away
from the patient the possibility of dropping the weights on
yourself is negated. Resistance exercise has also been shown
to be safe from a physiologic standpoint. Heart rate and blood
pressure responses have been shown to be similar or less than
seen during treadmill exercises. In addtion, there are few,
if any, reports of negative impact on heart function during
lifting. Many resistance exercise studies have been performed
in heart patients. In fact many rehabilitation programs include
a resistance exercise component.
In
conclusion, the effects of physical inactivity secondary to disease
are devastating on the body and specifically on the musculoskeletal
(bone and muscle) system. The ultimate impact is reduced physical
function and quality of life. Resistance exercise can maintain
or improve musculoskeletal integrity and lead to improved physical
function. Resistance exercise is safe and may be well suited for
a lung patient because of the low demand on the lungs and the
possibility of long rest periods between sets.
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