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Effects of Common Medical Conditions

This is an excerpt from FallProof! 3rd Edition With HKPropel Access by Debra Rose.

A large proportion of the older adults who enroll in your balance and mobility program will already have been diagnosed with one or more chronic medical conditions that influence their ability to perform certain balance and mobility activities. Although the degree to which performance is affected will depend on both the type and the severity of an individual’s medical condition, you should become familiar with the signs and symptoms associated with the more common medical conditions so that you can eliminate or adapt any balance and mobility activities that might be contraindicated for or harmful to your participants. This section therefore discusses selected medical conditions you are likely to observe among older adults in your program, including stroke, cardiovascular disease, arthritis, joint replacement surgery, osteopenia and osteoporosis, Parkinson’s disease, diabetes, and vestibular disorders. Program considerations related to each medical condition are also discussed.

Stroke

When a person experiences a stroke, also known as a cerebrovascular accident (CVA), one of two things happens: A blood vessel in the brain either becomes occluded (blocked) or hemorrhages (a wall bursts). The loss of blood supply that accompanies either of these events causes an infarction in the area that was supplied by the blood vessel, causing brain cell death. A less serious medical event in which the blood supply is reduced (ischemia) but not cut off is a transient ischemic attack (TIA). A person experiencing a TIA may exhibit symptoms such as weakness, temporary paralysis or loss of speech, and confusion.

Given the prevalence of stroke among the older adult population (approximately three-quarters of all strokes occur in adults older than 65 years; Yousufuddin & Young, 2019), you are likely to encounter many older adults in a community-based class who have experienced a stroke or TIA. Older adults who have experienced a stroke often demonstrate weakness or even paralysis that affects one or both limbs on one side of the body. Depending on the location of the stroke, speech, cognition, or memory may also be affected. Individuals with impaired cognition are often impulsive or lack good judgment regarding their abilities. Others experiencing memory loss may find it difficult to complete the Health and Activity Questionnaire (HAQ) without assistance or to follow verbal directions during class. You can expect their progress to be much slower than that of clients without cognitive or memory impairments.

Knowing the exact nature of the deficits each client experiences after a stroke will help you decide which exercise progressions are most appropriate and, more important, which exercises should be eliminated. Having this knowledge can help you provide a safe practice environment for these clients. To learn more about important exercise considerations you need to consider as a balance and mobility instructor for older adults who have experienced a stroke or have other medical conditions, please review the ACSM’s Exercise Management for Persons With Chronic Diseases and Disabilities textbook (Moore et al., 2016) and a chapter by Peterson (2019), who specifically addresses how to provide safe exercise programming for older adults with many of the chronic medical conditions described in this chapter.

Cardiovascular Disease

Because of the high prevalence of cardiovascular disease among older adults (approximately 15.3 percent of adults aged 65 years or older have been diagnosed with coronary heart disease [CHD]; Statistica Research Department, 2024), many of the clients in your balance and mobility program will check one or more of the boxes related to heart disease when they complete their HAQ at the outset of the program. Clients with heart disease may become fatigued or short of breath when exercising, particularly if they have congestive heart failure (CHF). If your participants have hypertension (HTN), their blood pressure must be medically managed so that they can participate in the program. HTN is diagnosed when systolic blood pressure is greater than 140 mmHg and diastolic pressure is greater than 90 mmHg. Check the medications section of the HAQ to determine the type of medications prescribed to clients to control their blood pressure. At the same time, look to see if any clients have been prescribed anticoagulant medications, which are designed to prevent blood clots. These clients will be susceptible to excessive bleeding if they sustain a cut, so extra precaution will be needed to ensure their safety during class.

Although the FallProof program does not involve high-intensity exercise, you will need to closely monitor clients who have a history of heart disease. Be sure to check with them regularly to find out whether there has been any change in either the type or the dose of medications they have been prescribed.

Arthritis

More than 30 million adults in the United States have been diagnosed with osteoarthritis (OA; Cisternas et al., 2016). This form of arthritis typically affects the weight-bearing joints, thereby reducing the joints’ ability to transmit or absorb the forces associated with impact. Predisposing factors for osteoarthritis include obesity, abnormal joint shape and alignment, joint injury, and genetic predisposition. However, according to Loeser (2017), age has the greatest influence on the incidence and prevalence of OA. The joint pain that accompanies osteoarthritis invariably leads to inactivity and loss of strength, range of motion, and cardiovascular endurance. Although exercise has been shown to be an effective intervention, it does not cure the disease.

Land-based programming consisting of aerobic conditioning, resistance training, and flexibility exercises can moderately improve function, and aquatics exercise programs have also produced moderate improvements in strength and flexibility, particularly among older adults with moderate to severe joint damage (Deyle et al., 2000; Ettinger et al., 1999). With respect to aerobic exercise interventions, Messier and colleagues (2021) have demonstrated that low-intensity aerobic exercise is therapeutically more effective in patients with severe OA, whereas higher-intensity aerobic exercise produces better therapeutic effects in patients with mild OA (Multanen et al., 2017). Significant improvements in joint pain and overall physical function have also been documented following aquatics programs (Foley et al., 2003; Fransen et al., 2007). In particular, aquatic interventions during the early stages of OA have been shown to alleviate stiffness in the knee joint better than land-based interventions (Lund et al., 2008; Munukka et al., 2016). A review of the literature by Kong and colleagues (2022) provides a more in-depth review of the role of exercise in the treatment of osteoarthritis.

In contrast to osteoarthritis, rheumatoid arthritis (RA) causes joint deformities that are often more severe and affect the entire joint. Because RA is a systemic inflammatory disease process, it usually affects multiple joints throughout the body. This systemic disease also produces symptoms that include increased fatigue, sleep disorders, and anemia. As with osteoarthritis, exercise is fundamentally beneficial for persons diagnosed with RA (Cooney et al., 2011). Unfortunately, persons with RA tend to exercise considerably less than their counterparts without RA. As a result of the extreme physical inactivity observed in people with RA, overall health declines and the disease progresses at a faster rate (Sokka et al., 2008). Several randomized controlled trials investigating different exercise and physical activity promotion interventions have demonstrated moderate gains in aerobic endurance and muscle strength with no adverse effect on progression of the disease (Brady et al., 2003; Cooney et al., 2011; Rausch Osthoff et al., 2018).

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KEY POINT

Encourage your participants with arthritis to stop performing any exercise that increases their pain. Reiterate the mantra “where there is pain there is no gain.”

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The main goal of any exercise program for older adults with arthritis is to minimize the progression of the existing damage in the affected joints. With that in mind, you as an instructor should focus on selecting activities that promote awareness of postural alignment, good body mechanics when performing dynamic activities, and improved strength and flexibility. When conducting any of the strength activities associated with the program, encourage participants with arthritis to perform a higher number of repetitions (to fatigue) with resistance bands or hand weights that offer a low level of resistance. This is particularly important when using resistance bands because resistance increases as the band is stretched. The greatest resistance is therefore encountered at the end range of the joint’s movement, when the exercising muscle has exceeded its range of mechanical advantage.

You should also encourage participants with arthritis to stop performing any exercise that increases their pain. In some cases, you may be able to adapt an exercise, whereas in others, you may have to eliminate an exercise altogether because the required plane of motion irritates the joint. Watch these clients carefully when they perform exercise progressions you suspect might cause pain and ask them regularly during the class whether certain exercises are causing them unnecessary pain. Many older adults may be reluctant to tell you they are experiencing pain during a certain exercise, because they want to please you or do not want to be labeled as a complainer. Continually reiterate the mantra “where there is pain there is no gain” to these clients.

More Excerpts From FallProof! 3rd Edition With HKPropel Access

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