The Role of Aerobic Exercise in the Management of Obstructive Sleep Apnea

THE ROLE OF AEROBIC EXERCISE IN THE MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA

Obstructive Sleep Apnea (OSA) is a common condition involving an obstructed airway and impaired breathing. Frequent side effects include snoring, pauses in breathing during the night, and sleepiness during the day. There is also a significant increase in hypertension, atrial fibrillation, stroke, and coronary artery disease. The consequences can be huge, and life-threatening.

Many patients with OSA are treated with a Continuous Positive Airway Pressure machine (CPAP), with good results. But exercise has an important role to play in the management of this condition.

Aerobic exercise and its benefits on OSA have been examined through many studies, and the results are clear. Aerobic exercise can strengthen the upper airway dilator muscles, decrease the severity of OSA, lessen daytime sleepiness and improve sleep efficiency, and may keep the condition from worsening.

While CPAP therapy is considered to be the best choice of treatment for OSA, not all patients can tolerate it. Consistent and frequent aerobic exercise is an effective tool in the management of OSA, whether or not a CPAP machine is part of the solution

Lower Back Pain

Lower back pain, or LBP, is an extremely common problem. It has a  wide variety of causes, and may come on suddenly, or gradually. The pain can stem from muscles, joints, or discs. It may be as a result of sudden trauma, or be a repetitive motion injury.

 It may seem trivial to say that someone has LBP, but this common complaint can cause loss of work, a spike in use of health care services, depression, family strain, and lack of self-esteem. Imagine being in pain all the time - it's very draining.

 By itself, LBP doesn't affect how your body responds to exercise - you can reach your cardio goals, strength markers, and agility and flexibility needs. However, the constant presence of LBP might elevate the level of pain experienced, and you may give up short of your goals because of the increased pain.

 Usually most episodes of LBP don't need any specific treatment, but sufferers are advised to modify activities, and to include icing, OTC analgesics, and daily flexibility work - stretching. If you need to stop activity for a while, keep it as short a time as possible, as inactivity can be as negative a factor as the cause of the flare-up itself.

 If you have chronic LBP - more than three months - consult a physician to rule out or confirm any injury and discuss pain management. Next, consult a qualified post-rehab trainer for exercises that will strengthen you without causing more distress and pain.

 Ideally, your program will include abdominal strengthening, such as back extensions, planks (modified to knees if needed), walking, and reinforcement of basic functional movements. The best thing to remember day-to-day is to keep moving - a little or a lot, depending on how your LBP is doing, will do wonders to help you.

Exercising With Asthma

 

Exercising With Asthma

Asthma is a chronic respiratory disorder, which creates variable obstruction to airflow, chronic inflammation of the airway, and elevated bronchial reaction to various triggers. These triggers can be allergens, stress environmental factors, genetic factors, or exercise. Asthma can be an almost constant presence for some; others may experience an episode only in the face of one or more of these triggers.

Although aerobic exercise, or cardio, can itself bring on an asthmatic episode, called exercise-induced asthma (EIA), generally exercise can help control how often and how harsh the attacks are. Asthmatics who engage in cardio activity two or three times a week, for around half an hour each time, will likely show improvements in their oxygen consumption, heart rate, and ventilation. There seems to be little proof that exercise makes asthma worse, or that sufferers should avoid exercise.

EIA usually occurs within around 15 minutes after the workout is finished, and the indicators include chest pain, shortness of breath, wheezing, coughing, or a combination of any of these. Almost all asthmatics will experience EIA at one time or another. If the EIA is well controlled, the asthmatic will usually see good improvement in his fitness level.

If you have asthma, it’s important to recognize that you will have episodes from time to time that will affect your capacity to work out. You also need to monitor your exercise intensity to establish the level of breathlessness and at what intensity it comes on. The Borg CR-10 scale can help you to understand this .

Rotator Cuff Injuries

Rotator Cuff Injuries

There are four muscles in the shoulder complex, which together make up the “rotator cuff”. They act together as dynamic stabilizers and movers in the shoulder. The four muscles involved are the supraspinatus, infraspinatus, teres minor, and supscapularis.

The supraspinatus, located on top of the shoulder, and the infraspinatus, which lies on top of the shoulder blade, are the two most likely to be injured. The main function of the supraspinatus is to lift the arm out to the side of the body, or abduct it. The infraspinatus externally rotates the arm, as if turning your palm facing forward.

Athletes often experience sudden rotator cuff injuries following a powerful effort. We frequently hear of baseball pitchers, golfers and tennis players who are in rehab for a rotator cuff injury. Any type of sport or activity that involves abduction and external rotation, combined with speed and force, increases the possible of such an injury. This is considered an acute tear. This type of injury can also happen from falling onto the shoulder or lifting a heavy weight. The person will feel sudden tearing in the shoulder, severe pain and tenderness, and limited movement in the joint.

However, we can develop a rotator cuff injury over time – this is a chronic tear. The same athlete may develop a chronic tear over time, with overuse of the shoulder. Long-term repetitive movement can cause a chronic tear at or around the tendon for anyone. Over time, range of motion becomes affected. The pain may become worse, especially at night. Eventually the person may experience weakness in the joint, and be unable to lift the arm out to the side. People whose jobs involve repetitive motion are also prone to chronic tears.

If you have been diagnosed with a rotator cuff injury by a doctor, you may require surgery. If the doctor feels that isn’t needed, you will likely be referred for physiotherapy. A physiotherapist may use a variety of techniques in the rehab stages, including mobilization, deep friction massage, and use of ice and ultrasound.

In the post-rehab stage, people often get impatient and jump right back into the activities that caused the problem in the first place, or start using too much weight or inappropriate exercises in their workout routine. A personal trainer versed in post-rehab training can provide education on how to avoid re-injury, and also exercises to strengthen the affected muscles. There is a safe path to take in post-rehab, and it takes time to go through the process. Exercises may include isometric contraction, range of motion work, light bands, tubing, and eventually light weights. Correct stretching techniques are also important to avoid further injury.

Exercising After a Stroke or Brain Injury

 Exercising After a Stroke or Brain Injury

A stroke takes place when blood flow to the brain is blocked, resulting in a loss of brain function for 24 hours or more. Most strokes are a result of a thrombosis or embolism, with a small percentage stemming from a blood vessel hemorrhaging and leaking into the brain. Stroke is more common in men than women, and is the third greatest cause of death in North America. Common effects of stroke include aphasia (problems using and comprehending language), loss of sensory input ,a  very short attention span, poor short-term memory, and struggles with emotional control.

Acquired traumatic brain injury (TBI) may result from a hit or strong bump to the head, or from being furiously shaken, such as Shaken  Baby Syndrome.  Falls and motor vehicle accidents make up the majority of incidences of TBI. TBI causes permanent injury to brain,  resulting in deficits in memory, language, reasoning, judgement, sensory and motor abilities, and information processing, to name just a few.

People who have experienced stroke or  TBI tend to have a much lower ability to take in enough oxygen for cardiovascular exercise. This means that these people need to work with lower maximal  workloads. After a stroke or TBI, aerobic capacities tend to be 67-74% lower than average levels. The end result is that these survivors breathe harder with exercise, grow very tired much more quickly, and have diminished motor skills and activities of daily living (ADL). There can be a cascade of events flowing from this situation. They may drift towards a sedentary lifestyle, with the negative health issues that go along with that. Such a lifestyle may also decrease even more their ability to perform at work or to engage in social activities.

Survivors typically take several medications, including blood thinners, vasodilators, anti-seizure agents, or medications to combat hypertonia, or an abnormal increase in muscle tension. Also, some medications may be used to contend with cognitive deficits.  As with all medications, there are side effects that speak to the person's ability to exercise, and should be taken into consideration when designing an exercise program for such survivors.  For instance, someone taking a  vasodilator may need a longer cool-down period in order to avoid low blood pressure after exercise. A person taking a medication to limit cardiac output may not be able to achieve as high a heart rate during exercise as an average person.  Also, dysrhythmias may occur if the survivor is taking a diuretic, because the fluid volume in the body is decreased, and the electrolyte balance is compromised.

It's true that coronary heart disease and subsequent strokes are the leading causes of death after stroke. But we know that exercise alone can reduce this mortality rate by at least 20% - that is a very significant influence from only one therapy. Also, people with TBI who are physically more active tend to be less depressed and have fewer cognitive problems. Exercise in both groups leads to improvements in blood pressure, resting heart rate, cholesterol levels, and peak  oxygen uptake. There are typically also improvements in walking speed and functional mobility. Often the person relies less on mobility assistive devices, such as a cane or walker.

So how does a survivor of stroke or TBI become more fit?  The first step is to enter exercise testing, keeping in mind that many in this population either have, or are at significant risk for, cardiovascular disease. This testing can be modified to work around the limbs and capacities affected. For instance, if the person has minimal motor skill deficits, a treadmill can be used to determine cardiovascular limits. However, a seated stepper machine, such as a NuStep, or a combined arm and leg ergometer can be used instead, depending on the level of motor skill impairment. Flexibility, or range of motion at any particular joint, should be assessed and monitored regularly to deal with the increase in muscle tension.

 

Aerobic guidelines for this group are to work to 40-70% of VO2 peak (the maximum amount of oxygen the body can use during intense exercise). The person can get to this goal using ergometers, treadmill, seated stepper, or recumbent bicycle. Aerobic exercise should be done 3-5 days per week, with a duration of 20-60 minutes per session.

 

Strength training, using a mix of weight machine, dumbbells, and isometric exercise (such as a plank), should be done 2 days per week, with a goal of 3 sets of 8-12 reps per exercise. Flexibility, or stretching, will increase the range of motion of the affected limbs, and prevent contractures. Stretching should be done every day, after exercise, or at the end of the day.

 

Doing coordination and balance exercises will help with the neuromuscular deficits and ideally should be done in conjunction with the strength training exercises, or 2 days per week.

These exercises should be modified by the trainer to suit the needs of the particular person, such as using dumbbells for the upper body while seated, to compensate for balance problems or lower limb mobility. Many core strength exercises can be performed lying on a treatment table, if getting down and back up from the floor poses a challenge or risk. The trainer also must create an exercise environment free of obstacles, and with equipment the survivor can easily access. Equipment may need to be modified, such as adding a harness to the upper body, or a waist belt to help stabilize the person exercising.

Aerobic exercise is a vital part of any training program, and yet many of us aren’t sure of what type to do, for how long, or how often. As a personal trainer, I apply the FITT principles to any kind of physical activity – Frequency, Intensity, Time and Type.

 

Most of us should aim to do aerobic activity between three and five times per week, for 30-45 minutes per session. This means getting your heart rate elevated for a sustained period of time, and you should feel tired, but not flat-out exhausted, at the end of it.  This brings us to the intensity of your cardio workout.

 

People new to exercise may want to stick to a moderate pace, still getting to fatigue, until these workouts become easy, and they notice that their results – cardiovascular endurance, weight lost – are plateauing.  At this point I encourage clients to vary their cardio workouts both in intensity and duration, or time.  First, I get the client’s resting heart rate, and determine the range of elevated heart rate we’re going for.  Then I set them up into different types of cardio challenge, varying the type within the week.  The client may be doing up to four types of cardiovascular challenge: Long Slow Distance, Continuous Interval, and Supramaximal Training. Here’s what such a program might look like (the bpm – heart rate – is a suggestion and will change for each person).

 

Exercising with Angina and Silent Ischemia

 Exercising with Angina and Silent Ischemia

The heart requires an uninterrupted, stable supply of oxygen to survive, since oxygen is virtually its only fuel. During our daily activities and exercise, the demand for myocardial oxygen varies. The heart  adjusts the coronary blood flow to meet the changing demand for oxygen. However when there is an obstruction in the coronary arteries, due to atherosclerosis, myocardial ischemia, or restriction in the blood flow, develops. When this condition causes pain in the chest, it is called angina.

Stable angina is usually associated with crossing the threshold of a certain level of physical exertion, or other stresses, such as emotional distress or cold temperatures. And is usually treated with rest and/or nitroglycerin.

Unstable angina is much riskier to deal with than the stable variety. There are three main hallmarks of UA:

  1. Angina experienced while at rest, or upon wakening, which lasts 20 minutes or more
  2. The first occurrence of anginal pain
  3. Increase in severity, frequency, length or change in the level of activity that brings on the pain, with already documented angina 

UA is often a warning sign of myocardial infarction – “heart attack”, and should be treated immediately with appropriate medical intervention. The severity of the coronary artery obstruction largely determines how much exercise a person can tolerate.

Exercise is generally helpful for people with stable angina. Exercise and changes in lifestyle choice, such as an improved diet, will help reduce cardiac risk.  The goal of exercise and angina sufferers is to raise their ischemic threshold, or the point during exercise at which the symptoms of angina occur. Proper medication will also help exercise performance. Most people with stable angina who exercise will realize most, if not all, of the same benefits as seemingly healthy people.  These benefits include improvements in blood pressure and heart rate, and better flow of oxygenated blood to the heart both at rest and during exertion.

Before starting on an exercise program, the person needs to determine the ischemic threshold, or the heart rate above which the symptoms of angina appear. The recommendations for exercise include:

  1. Aerobic: large muscle activities, such as walking briskly. Increase daily activities such as gardening, housework, errands, etc. Aerobic work should be done 3-7 days per week, around 20-60 minutes per session, with 5-10 minutes of a warm-up and also a cool-down. It’s important to keep the heart rate 10-15 contractions/ minute below the ischemic threshold.
  2. Circuit training is recommended for strength, to improve functional capacity. Do this 2-3 days/week, for 15-20 minutes per session, and your effort should be light resistance.
  3. Flexibility: stretching. Do upper and lower Range of Motion (ROM) activities, 2-3 days per week. This will improve your flexibility and reduce the chance of injury during exercise and activities of daily life.

Exercising with Osteoporosis

 Exercising with Osteoporosis

 Osteoporosis has become a part of our normal vocabulary these days; it seems we all know someone who has this significant loss of bone mass, or its precursor, osteopenia (low bone mass).

All of us experience some small degree of bone loss every year, after we’re thirty-five, but it is very common amongst older adults in industrialized countries. Once the bone begins to lose mass, it takes on a “honeycomb” appearance, and it loses its ability to withstand fracture. Seniors are much more likely than, say, a young adult, to sustain a fracture through a minor fall or even a sneeze.

More women seem to develop primary osteoporosis in their post-menopausal years, about 50-75 years old, due to the normal estrogen deficiency, and the rate of bone loss exceeds the rate of bone formation. This disease tends to show up in men in their 70’s. Secondary osteoporosis can develop because of various medications, such as ongoing prednisone (glucocorticoid) therapy.

But menopause and medication are not the only risk factors for this disease; some others are:

Low body mass index (BMI), being too thin

Not enough exercise, being sedentary

Smoking

More than 3 alcoholic drinks per day

Not enough Vitamin D (helps to absorb calcium into the bones)

Taking in too much protein, caffeine, sodium and Vitamin A

Diseases such as anorexia, bulimia, celiac disease and rheumatoid arthritis (RA)

 

People with this disease are likely to be quite deconditioned, due to their physical limitations and fear of injury and falling. However, regular physical activity, such as walking, aerobic activity and resistance training can improve the bone mineral density (BMD) in this population. Exercise also provides significant improvements in cardiovascular health, stronger muscles, and better balance. Stronger muscles also help safeguard bone mass.

 

Ideally, someone with osteoporosis should consult with both a physician and a personal trainer certified in dealing with exercise as treatment for this disease. An exercise program should include:

Exercises to improve balance

Exercises for the upper and lower body, and the core muscles – adaptations in bone are site specific, so all areas of the body must be worked

Core exercises that do NOT include forward flexion or twisting of the spine, such as crunches, sit-ups, and bicycle crunches. Exercises that flex the spine forward increase the risk of fractures in the vertebrae

Exercises that limit weight bearing – doing water-based exercise, swimming, or chair exercises may be better choices than traditional exercise programs

Start with light weights and more reps; as bone mass and muscle strength improve, you may be able to progress to heavier weights and fewer reps

 

Your workout environment should be evaluated for tripping hazards, such as mats or obstacles on the floor. Wall railings and side rails on cardio equipment are useful in protecting you from falls. Regular physical activity, modified correctly, is crucial to dealing effectively with osteoporosis, as it is a long-term and ongoing condition.

Diabetes and Exercise

 DIABETES AND EXERCISE

Health Canada reports that approximately 6.6% of Canada’s population, age 20 and older, have been diagnosed with diabetes, and researchers expect an increase to 2.4 million Canadian diabetics by 2016. Also, 6% of Canadian women 46-64 years old, have this disease, and that increases to 10% in the 65 and older group. A woman with type 2 diabetes has an 8 times greater chances of developing heart disease than a women without diabetes. These are sobering numbers, especially in view of the fact that much of that is preventable by making some lifestyle changes.

Some of the changes that will lower your risk of diabetes include: 

 1. stop smoking

 2. limit use of alcohol

 3. monitor blood pressure and cholesterol levels

 4. lose weight through a healthy diet – check out Health Canada for tips on healthy eating

 5. get active – physical activity plays a strong role in preventing type 2 diabetes.

Training with Diabetes

Exercise is a very important tool in diabetic care. The benefits of a diabetic person adding exercise to medical treatment include:

1. possible improvement in the blood glucose levels of type 2 diabetics

2. exercise can create an improved insulin sensitivity, which means that the type 2 diabetic might be able to reduce the amount of medications taken (always under advice of your doctor).

3. cardiovascular health improves, reducing the risk of cardiovascular diseases, not just for diabetics, but for everyone. About 80% of diabetics will die of heart disease or stroke.

People living with diabetes may be taking insulin or oral hypoglycaemic medications. Exercise often increases the absorption of injected insulin and so it’s very important to monitor blood glucose levels before, during, and after an exercise session. The most significant effect of both these kinds of medications is that they may cause hypoglycaemia during exercise testing and exercise training. So it is vital to keep a close eye on the timing of medication, food intake, and blood glucose levels.

Physical activity for diabetics without significant complications should include suitable endurance and resistance work. This can increase cardiovascular conditioning, muscle strength and endurance, and improve body composition, i.e., decreasing stored body fat and increasing lean muscle mass. Physical activity should include large muscle activities, such as walking, swimming and cycling. Strength training could include free weights, machines, or tubing. Consult Deb for programming specific to your individual needs.

 

A diabetic should not exercise if:

 

1. s/he has any active retinal haemorrhage, or has recently had treatment for retinopathy, such as laser treatment

2. is sick, or is suffering with an infection

3. blood glucose is above 14 mmol/L (250 mg/dl) and ketones are detected (blood glucose must be reduced before you engage in exercise)

4. blood glucose is lower than 4 mmol/L (70 ml/dl), because of the increased risk of hypoglycaemia. You may be able to eat some carbs to increase the blood glucose levels before exercise

A diabetic should also make sure that there are some carbs on hand during exercise. Drinking enough fluids before, during and post-exercise is important. Diabetics also need to exercise good foot care, checking the feet carefully after exercise, especially if there is damage to the nerves in the feet, or peripheral neuropathy.

 

Exercising with Osteoarthritis

Exercising with Osteoarthritis (OA)

People who struggle with OA often find themselves unable to do the kinds of exercise they have done for many years. The consequences of not exercising because OA may include weight gain, osteoporosis, muscle atrophy, and loss of flexibility.

There are a number of things  that you can do to introduce exercise into a daily routine again. The first thing to do is to consult with your doctor about limits for exercise, and pain/inflammation management particular to you. Once that is set out, you should check back with your practitioner at regular intervals to review these concerns, or sooner if your condition worsens.

Braces that limit the range of motion (ROM) are available for knee, ankle and thumb, which may help support movement during exercise. It would be wise to consult with a physiotherapist, preferably one well versed in sports injuries and/or OA specifically, before buying a brace. He may guide you to an informed choice of brace. Some physios also do taping to reposition and support a joint before exercise.

As with any exercise program, it's important to warm up. A longer warm up period, say, 10-15 minutes of low intensity cardio, will be beneficial. After that, move on to a selection of low- or no-impact activities. Having several choices available, such as water exercise, elliptical, recumbent bicycle, yoga, and low-impact group exercise will give you options on days when the OA flares up, so you're not stuck feeling as if you can't do any exercise at all that day.

Other prep work should include getting a new pair of shoes that will absorb shock well and give arch support, to minimize the impact on knees and hips. Keep an eye on your shoes' condition and replace them as soon as they show signs of wear, or are less supportive.

 

Exercise and Parkinson’s Disease

 Exercise and Parkinson’s Disease

Parkinson's Disease (PD) is a chronic progressive neurologic disease that affects the part of the nervous system that controls muscle reflexes. It is believed that PD is caused by a reduction in dopamine, which is a neurotransmitter, and so the muscle reflexes are adversely affected. Over time, the person will likely experience slow movements (bradykinesia), a resting tremor, rigidity, and negative changes in his gait and posture.

PD is classified as early, moderate or advanced.  Someone newly diagnosed with early PD will experience only minor symptoms.  In the moderate stage, the person will start to show limitations in his movements, and have a mild to moderate tremor. Substantial limitations in activity, in spite of treatment, mark the advanced stage of PD. Exercise is not a solution to PD, but it will be helpful with balance and rigidity problems.

Some of the concerns with exercising with PD include the fact that rigidity affects a person's ability to move freely, including fingers and toes. He may also be unable to stand easily from a seated position, or to walk without shuffling. Freezing is also a challenge to carrying out exercise. Communication can also be quite affected, and the person with PD may not be able to speak clearly verbally, nor be able to use facial expressions to help communication, due to a loss of motor skills.

Since each person with PD has a unique set of symptoms and challenges, it's not really possible to list a universal set of rules for exercise. Sometime a person with PD has trouble with thermoregulation, because the autonomic nervous system is malfunctioning; and so becoming overheated during exercise is a common concern.  Freezing can make certain activities more challenging than others, as can the stooped-over posture (kyphosis) that is prevalent in persons with PD.

In spite of these challenges, there are several documented benefits to bringing exercise to someone with PD.  They may experience positive changes in motor performance, ability to rotate their trunks, hand-eye coordination, muscle size and strength, and better balance and stability.

Exercise may not have a significant impact on the specific symptoms of the disease, but appropriate exercise may help combat the effects of PD on the patient's muscle structure and cardiovascular health. Some of the recommendations include aerobic work three times a week, short supervised walks, as the person is able, 4-6 times per day. Strength training with light weights, 8-12 reps, three times a week, will help maintain the strength in the upper and lower body. Stretching up to three times a week will help maintain their ROM (range of motion), and help cope with the spasticity. Exercise can play an important part in retaining as much physical ability as possible. The trainer must be able to adapt exercises to the ability of the PD client on any given day. For instance, exercise in the pool is a good choice on a day when balance is less stable.

As with any condition, it is important to take medications into consideration when investigating exercise. Most medications have significant to minor side effects, such as confusion, poor sleep and gastrointestinal problems. Also, medications tend to lose their effectiveness over time, and each person will respond differently to different medications, thus changing the exercise response.  Some medications are metabolized in peripheral muscle, such as legs and arms, and that decreases the amount of medication going to the target, the brain. Therefore it is crucial to discuss with the medical staff the optimal time and level of exercise appropriate for that person.

Some people with PD have widely varied response to aerobic exercise, and this makes it hard to achieve their target heart rates. These people should also be monitored for any changes in symptoms that occur during exercise, as this may be a sign that there are changes in drug absorption. Choose a trainer experienced in this type of population, and ensure that there is frequent communication between the trainer and the medical staff.

 

Deb Bailey Personal Trainer - in Home (Now On-line!)
Phone: 519-572-0986
debbailey@rogers.com
Kitchener, Ontario


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