ACSM’s

CertifiedNewsAPRIL/MAY/JUNE 2009 VOLUME 19, ISSUE 2

News You Need

Since I joined ACSM as the nationaldirector of certification, I have writtenabout our value as fitness professionalsmore than anything else. While I didn’tintend a variation on the same theme inthis column, the economic climate con-tributes to a new perspective.

Once again, it is truly a question of valuewhen it comes to decisions related to thepublic expenditure of hard-earned dollarson health and fitness services. We all knowthat the majority of people who start anexercise program do so primarily becausethey want to lose weight and subsequently“look better.” The younger someone is, thestronger the incentive to exercise forappearance reasons.

I am all for anything that will (literally)move someone to get started and stick withan exercise program or perform consistentphysical activity. The challenge: we cannothang our hats too much on the “look bet-ter” value of exercise. According to theAmerican Society of Plastic Surgeons, lipo-suction, tummy tucks and breast augmen-tation were down 19 percent, 18 percentand 12 percent, respectively, for 2008 ascompared to 2007. This comes as no sur-prise — any business that relies on extrane-ous consumer spending may continue tohave a very hard time over the next year ormore. An industry built on supporting itsconsumers in looking better will likely losecustomers when money gets tight.

Please don’t get me wrong; I have noth-ing against cosmetic surgery. It is likely thatmy own plastic surgery will always be lim-

IN THIS ISSUENews You Need: The Opportunity in Challenge . . . . . 1Exercise and HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Osteoporosis and Osteopenia: A Guide

to Proactive Bone Health . . . . . . . . . . . . . . . . . . . . 4Coaching News — Exercise is Medicine:

Doctors, Coaches, & Clubs . . . . . . . . . . . . . . . . . . . 5Peripheral Arterial Disease . . . . . . . . . . . . . . . . . . . . . 7Parkinson’s Disease: Etiology, Clinical

Characteristics and the role of Exercise . . . . . . . . . 9CEC Self-Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Exercise and HIVBy Nicole Cassato and James R. Churilla, Ph.D., M.P.H., M.S., RCEP, CSCS

Brooks College of HealthUniversity of North Florida Jacksonville, FL

INTRODUCTIONHuman immunodeficiency virus (HIV) is a

retrovirus that progressively lowers the body’sCD4+ cell counts and impairs the immune sys-tem.2 Acquired immunodeficiency syndrome(AIDS), a chronic, life-threatening conditionthat is caused by HIV, is the final stage of theHIV infection (see Table 1). At the end of2003, an estimated 1,039,000 to 1,185,000persons in the United States were living withHIV/AIDS, with 24% - 27% undiagnosed andunaware of their HIV infection.3 Many unfa-vorable metabolic and morphological abnor-malities are associated with HIV, particularlybody composition and muscle wasting.6

The standard treatment for HIV is a combi-nation of medicines called highly active anti-retroviral therapy (HAART). Antiretroviralmedicines slow the rate at which the virus mul-tiplies and promotes favorable virological con-trol, which significantly decreases themorbidity and mortality associated with HIV.6

Although the introduction of HAART hasimproved longevity among HIV patients, HIVand its therapy have been associated with thedevelopment of several metabolic complica-tions and may put patients at an increased risk

of metabolic and cardiovascular diseases.6

Examples of metabolic complicationsrelated to HIV and HAART include dyslipi-demia, lipodystrophy (swollen abdominalregion with loss of fat tissue in the face andextremities), insulin resistance, and diabetesmellitus.6 In regards to cardiovascular disease(CVD) and HIV-infected patients, one studyreported a 32% increase in the relative risk ofCVD over five years following the initiation ofHAART.7 Metabolic syndrome, the clusteringof specific cardiovascular risk factors1, isanother metabolic complication of HIV andHAART. The prevalence of metabolic syn-drome in HIV-infected patients ranges from17% - 45.5%4 and is associated with greaterinsulin resistance.7 In patients who developmetabolic syndrome while on HAART, therisk of developing diabetes increased four tofive-fold while CVD risk increased three-fold.7

Lipodystrophy is another notable complica-tion associated with HAART and is the mostdifficult to reverse.7 It is characterized by lossof fat in the face, arms, and legs and the accu-mulation of fat in the abdomen.

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by: Richard Cotton

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ited to monthly haircuts, but I certainly don’tfault others for their choices. Yet, whenmoney gets tight, people naturally gravitate toexpenditures based on needs rather thanwants. It follows that if we are unable todemonstrate the tremendously high value andneed for regular exercise, we are at the mercyof becoming a nonessential budget cut.

So far, the impact of the recession on thehealth-club industry is unclear. An informalsurvey recently conducted by the InternationalHealth, Racquet and Sportsclub Association(IHRSA), a trade group, found that two-thirdsof the 200 respondents said business in Janu-ary 2009 met or surpassed their expectations.

However, the remainder reported that lowusage among existing members and poor salesfor new memberships led to monthly resultsthat were dismal compared with the previousJanuary. IHRSA expects to release industry-wide performance results for the fourth quar-ter in the near future.

This naturally circles back to increasing thevalue of the services that we provide, whichmight mean pointing out the benefits of exer-cise beyond improving appearance. RobertSallis, M.D., FACSM, the immediate past-president of ACSM and the founder and chairof the Exercise is Medicine™ (EIM) task forceoften starts his EIM-related presentationswith this statement: “If there was a pill that

could provide both the preventive and reha-bilitative benefits that exercise offers, it wouldbe the most widely prescribed drug in theworld.” Exercise is truly medicine and there isno better time to promote the contributionsthat we as health and fitness professionals canmake than now!

The ExerciseIsMedicine.org Web site hasslides for health and fitness professionals touse or modify for various audiences that pres-ent the value of exercise as medicine. Thisthen could be used as a platform to promoteyour own services.

You might also consider modifying yourservices to include packages for moderate-income or financially challenged populations.How about a one-visit offering with monthlyoptional follow-ups? Or, consider selling 10-visit packages that are spread over three to sixmonths? I know this is counter to the currentmodel for personal training, but it is centeredaround working toward supporting yourclients and/or patients in becoming independ-ent exercisers.

These are challenging times for many peo-ple and now more than ever our support asfitness professionals is needed and a valuablecontribution to quality of life. Let’s think cre-atively in a manner that will contribute to thehealth and well-being of others and continueto move our profession to a status of a valuedhealth care service provider.

ACSM’S CERTIFIED NEWSCO-EDITORS

Paul Sorace, M.S., James R. Churilla, Ph.D., MPHCOMMITTEE ON CERTIFICATION AND

REGISTRY BOARDS CHAIRMadeline Bayles, Ph.D., FACSM

CCRB PUBLICATIONS SUBCOMMITTEE CHAIRJan Wallace, Ph.D., FACSM

NATIONAL CENTER NEWSLETTER STAFF

NATIONAL DIRECTOR OF CERTIFICATIONAND REGISTRY PROGRAMS

Richard CottonASSISTANT DIRECTOR OF CERTIFICATION

Hope WoodPROFESSIONAL EDUCATION COORDINATOR

Shaina LovelessPUBLICATIONS MANAGER

David Brewer

ACSM CERTIFICATION RESOURCE CENTER:1-800-486-5643

EDITORIAL BOARD

Chris Berger, Ph.D.

Brian Coyne, M.Ed.

Yuri Feito, M.S., M.P.H.

Tom LaFontaine, Ph.D., FACSM

Peter Magyari, Ph.D.

Jacalyn McComb, Ph.D., FACSM

Peter Ronai, M.S.

Larry Verity, Ph.D., FACSM

Stella Volpe, Ph.D., FACSM

Jan Wallace, Ph.D., FACSM

INFORMATION FOR SUBSCRIBERS

CORRESPONDENCE REGARDING EDITORIAL CONTENTSHOULD BE ADDRESSED TO:

Certification & Registry DepartmentE-mail: certification@acsm.orgTel.: (317) 637-9200, ext. 151

FOR BACK ISSUES AND AUTHOR GUIDELINES VISIT:www.acsm.org/certifiednews

CHANGE OF ADDRESS OR MEMBERSHIP INQUIRIESMEMBERSHIP AND CHAPTER SERVICES

TEL.: (317) 637-9200, EXT. 139 OR EXT. 136.

ACSM’s Certified News (ISSN# 1056-9677) is publishedquarterly by the American College of Sports MedicineCommittee on Certification and Registry Boards (CCRB). Allissues are published electronically and in print.The articles published in ACSM’s Certified News have beencarefully reviewed, but have not been submitted forconsideration as, and therefore are not, officialpronouncements, policies, statements, or opinions of ACSM.Information published in ACSM’s Certified News is notnecessarily the position of the American College of SportsMedicine or the Committee on Certification and RegistryBoards. The purpose of this newsletter is to inform certifiedindividuals about activities of ACSM and their profession andabout new information relative to exercise and health.Information presented here is not intended to be informationsupplemental to the ACSM’s Guidelines for Exercise Testingand Prescription or the established positions of ACSM.ACSM’s Certified News is copyrighted by the American Collegeof Sports Medicine. No portion(s) of the work(s) may bereproduced without written consent from the Publisher.Permission to reproduce copies of articles for noncommercialuse may be obtained from the Rights and Permissions editor.

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© 2009 American College of Sports Medicine.ISSN # 1056-9677

2 APRACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

Table 1. Stages of Human Immunodeficiency VirusStage 1 – Primary HIV infection and seroconversion (HIV negative to HIV positive).Stage 2 – Stabilization of the viral load (early disease stage). CD4+ count >500

cells·mm-3.Stage 3 – CD+4 cell count falls to 200 – 400 cells·mm-3. Skin disorders become

evident. Increased risk of advancing to stage 4 if disease left untreated.Stage 4 – CD4+ cell count drops below 200 cells·mm-3. This stage meets the Centers

for Disease Control and Prevention definition for AIDS. Risk increases ofdeveloping opportunistic infections.

Stage 5 – HIV infection is uncontrolled and CD4+ cell counts drop below 50cells·mm-3. Risk of death from opportunistic infection is highly probable.

Smith et al.7

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life expectancy for HIV-infected patients onHAART is severe metabolic complications.These individuals are now living longer, butwith more chronic diseases. Participation in anexercise program may be an important non-pharmacological alternative to improve themetabolic and morphological features ofHIV/AIDS.

BENEFITS OF EXERCISE/PHYSICAL ACTIVITYON HIV/AIDS

Physical activity has long been establishedas a supplemental therapy for treating chronicillnesses. Aerobic, resistance, and combinedresistance and aerobic training programs may

help alleviate the unfavorable metabolic com-plications associated with HIV and HAARTby altering body composition and body fatdistribution, as well as normalizing lipid pro-files.6

Aerobic training is important in HIV-infected patients on HAART because of itspotential to increase cardiovascular fitness andreduce body fat. One study examining theeffects of aerobic training on body weight,body composition, and fatigue noted adecrease in body weight, sum of skinfolds,waist circumference, and fatigue, while report-ing improvements in aerobic fitness.9 In

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another study examining aerobic training inadults with lipodystrophy and dyslipidemia, amean reduction of 12 cm in visceral fat wasnoted, as well as a reduction in total choles-terol and fasting triglycerides and in increase inHDL cholesterol.10 Both of these studies sug-gest that aerobic training may reduce centralbody fat, which is an important factor inreducing cardiovascular risk factors.

Metabolic complications arising from HIVand HAART and AIDS related wasting havebeen found to be associated with a decline inphysical functioning and quality of life. Resist-ance training (RT) has the ability to increaselean body mass and reduce fat mass in individ-uals who have HIV. However, many studiesare inconsistent in their findings.6 One notablestudy showed that participants in an eight-week RT program significantly increased theirfat free mass while decreasing their fat mass.Another study examining the effects of RT onbody composition showed a whole-body leanmass increase of 2.5% and a 2.6% increase intrunk adipose mass.11 This same study alsonoted a decrease in fasting triglycerides. Thesestudies suggest that a progressive RT programmay be effective intervention for patients suf-fering from AIDS-related wasting.

Combined aerobic and RT may be a moreeffective adjunct therapy for patients withlipodystrophy than either type of trainingalone. Jones et al.5 reported that aerobic andRT combined has the potential to reduce cen-tral body fat redistribution and results in posi-tive changes in body composition. Combinedaerobic and progressive RT also has beenfound to significantly improve muscle size andquality.2 These changes in muscle includeddecreases in muscle fat, which may contributeto improved metabolic profiles in HIV-infectedindividuals. Furthermore, improvement instrength and muscle mass may help amelioratethe metabolic complications of HIV/AIDS andthe negative metabolic side effects of HAART.

EXERCISE TESTING AND PRESCRIPTIONIndividuals with HIV can undergo exercise

testing similar to that of someone without theinfection. However, their exercise tolerancemay be limited due to a number of factors.Often, depending on the stage of the disease,individuals taking antiretroviral medications(i.e., HAART) suffer from nausea, vomiting,

and become easily fatigued.8 Thus, the type ofexercise test (or the decision not to test) thatis to be conducted will be based on the clini-cal judgment of the exercise professional(e.g., RCEP, CES). If the individual has led arelatively active lifestyle and maintained ahigher level of fitness, they may tolerate atreadmill test, conversely, if the individual tobe tested leads a sedentary lifestyle, or theyare in a later stage of the HIV (i.e., stage 3 or4) (see Table 1) they may not be candidatesfor exercise testing.

Regular physical activity and/or exercise canfavorably impact the devitalized state of manyindividuals suffering from HIV. Varying, butmeasurable improvements of the five compo-nents of fitness (cardiovascular fitness, muscu-lar strength and endurance, body composition,and flexibility) can be seen following exercisetraining in individuals with HIV.8 These indi-viduals do not need any special supervisionbeyond that of teaching the appropriate exer-cise techniques, progression, and safety. Theprimary concerns of the exercise professionalwhen designing physical activity/exercise pro-grams in this population is to be aware of thecurrent fitness/activity level of the individual,stage of the disease, medication regimen andside-effects, and fatigability (see Table 2). Theexercise professionals understanding of HIV,the medications prescribed and their numerousside-effects, and their compassion to want tohelp those with this infection improve theirquality of life are essential.

SUMMARYToday, due to medical advances and an

increased focus by the individual on their ownwell being, many individuals who are HIV+are living relatively normal lives. Beginning anexercise program or maintaining a physicallyactive lifestyle is one way to help improve the

quality of life of not only the apparentlyhealthy population, but also those diagnosedwith chronic conditions like HIV. The exerciseprofessional has a role in helping these individ-uals meet their fitness goals, while understand-ing the limitations involved with working withthis special population.

REFERENCES1. Churilla, J.R. Metabolic Syndrome: The Crucial Role of Exercise

Prescription and Diet. ACSM's Health & Fitness Journal. 13:20-26, 2009.

2. Dolan, S.E., W. Frontera, J. Librizzi, K. Ljungquist, S. Juan, R.Dorman, M.E. Cole, J.R. Kanter, and S. Grinspoon. Effects of asupervised home-based aerobic and progressive resistance trainingregimen in women infected with human immunodeficiency virus:a randomized trial. Archives of Internal Medicine. 166:1225-1231, 2006.

3. Erbelding, E.J. Highlights from the 2005 National HIVPrevention Conference. Hopkins HIV Rep. 17:4-5, 11, 2005.

4. Fitch, K.V., E.J. Anderson, J.L. Hubbard, S.J. Carpenter, W.R.Waddell, A.M. Caliendo, and S.K. Grinspoon. Effects of a lifestylemodification program in HIV-infected patients with the metabolicsyndrome. AIDS. 20:1843-1850, 2006.

5. Jones, S.P., D.A. Doran, P.B. Leatt, B. Maher, and M.Pirmohamed. Short-term exercise training improves bodycomposition and hyperlipidaemia in HIV-positive individuals withlipodystrophy. AIDS. 15:2049-2051, 2001.

6. Malita, F.M., A.D. Karelis, E. Toma, and R. Rabasa-Lhoret.Effects of different types of exercise on body composition and fatdistribution in HIV-infected patients: a brief review. CanadianJournal of Applied Physiology. 30:233-245, 2005.

7. Samaras, K. Metabolic consequences and therapeutic options inhighly active antiretroviral therapy in human immunodeficiencyvirus-1 infection. The Journal of Antimicrobial Chemotherapy.61:238-245, 2008.

8. Smith, B., Raper, J, and Saag, M. Human ImmunodeficiencyVirus. In: Clinical Exercise Physiology. J. Ehrman, Gordon, PM,Visich, PS, and Keteyian, SJ. (Ed.): Human Kinetics, 2003, pp.423-441.

9. Smith, B.A., J.L. Neidig, J.T. Nickel, G.L. Mitchell, M.F. Para,and R.J. Fass. Aerobic exercise: effects on parameters related tofatigue, dyspnea, weight and body composition in HIV-infectedadults. AIDS. 15:693-701, 2001.

10. Thoni, G.J., C. Fedou, J.F. Brun, J. Fabre, E. Renard, J. Reynes,A. Varray, and J. Mercier. Reduction of fat accumulation and lipiddisorders by individualized light aerobic training in humanimmunodeficiency virus infected patients with lipodystrophyand/or dyslipidemia. Diabetes Metabolism. 28:397-404, 2002.

11. Yarasheski, K.E., P. Tebas, B. Stanerson, S. Claxton, D. Marin, K.Bae, M. Kennedy, W. Tantisiriwat, and W.G. Powderly. Resistanceexercise training reduces hypertriglyceridemia in HIV-infected mentreated with antiviral therapy. Journal of Applied Physiology.90:133-138, 2001.

About the AuthorsNicole Cassato is a community healthmajor at the University of North Florida inJacksonville, Florida. Nicole is completingher internship at Shands Hospital in Jack-sonville, which is affiliated with the Uni-versity of Florida. Nicole is trained inhuman subject research and serves as aresearch assistant and volunteer in theEmergency Department. She is currently assisting in the datacollection for a metabolic syndrome research study.

James R. Churilla, Ph.D., M.P.H., M.S.,RCEP, CSCS is an assistant professor ofExercise Physiology and Physical ActivityEpidemiology in the Brooks College ofHealth at the University of North Floridain Jacksonville, FL. His research focuses onphysical activity, the metabolic syndrome,and population health. James is ACSMProgram Director Certified, an At-Large Member of theSEACSM Executive Board, and a current member of theACSM Publications Subcommittee. James is a member of theACSM, the American Heart Associations Council on Nutri-tion, Physical Activity and Metabolism, the American Physi-ological Society, and the National Strength and ConditioningAssociation.

Table 2. Primary Concerns ofthe Exercise Professional

Working with HIV+ Clients• Stage of Disease (See Table 1)• Current fitness and/or physical activity

level of their client• Medication regimen and side-effects• Fatigability

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APR4ACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

Co

EExercise isMMedicine™:DDoctors,CCoaches,&& Clubs

At long last, the ACSM/AMA Exercise isMedicine™ initiative acknowledges that exer-cise is a breakthrough medicine which is safeand effective to prevent or ameliorate mostcommon medical conditions. This initiativeoffers health clubs a new opportunity toreach out to the medical community, andopen up markets for new members and pro-grams. What will it take for success?

Deploy the cutting edge toolbox of the fit-ness or wellness coach. The combination ofthe professional coach’s toolbox with clinicalexercise physiology has unleashed a newgeneration of certified fitness and wellnesscoaches. Not only are they skilled at helpingpeople build and sustain healthy lifestyles,they impress physicians with their commandof exercise science along with their ability tohelp people make lasting change. While per-sonal training is valuable to many, trainingsessions alone often do not provide the skilland support to move people to take chargeand sustain regular exercise. Coaches prom-ise to be an important bridge between theclub and physician to implement Exercise isMedicine™.

Help physicians spark patient motivationto adopt fit lifestyles. Medical schools spendlittle time teaching students about exerciseprescription or how to help patients pursuehealthy lifestyles Clubs and coaches have aunique opportunity to assist doctors with theexercise prescription of their patients andprovide them with a resource to use shortphysician visits to spark patient motivationto get fit. Further, offering trial club member-ships and coaching programs to physiciansand their staff will help them learn whatcoaches do and why it is important to walkthe walk.

Build trust and collaborative relationshipswith physicians. To build trusting relation-ships, physicians appreciate open communi-cation and detailed background informationfrom clubs on the credentials of theiremployed fitness professionals and coaches,on equipment and programs available forpeople who are sedentary and have healthrisks, and a communication method toreceive concise feedback on the progress oftheir patients. Being honest about what your

facility offers and communicating aboutpatient progress is essential to a lasting col-laboration with physicians. A short sum-mary of a patient’s fitness or wellness planand goals, including motivators, strengths,and challenges is valuable. Detailed feedback(data) to physicians should be tailored toaddress the reason the physician advised thereferral, such as BMI, waist circumference,blood pressure, and heart rate measurementsfor someone who is overweight and hyper-tensive.

Cultivate your market. Cast a wide net. Inaddition to working directly with physicians,including alternative medicine, may also bean option. Examples may include chiroprac-tors, acupuncturists, and rehabilitation facil-ities. To facilitate the relationship, set up factfinding meetings with these providers touncover unmet needs of their patients, thenoffer your memberships and programs thatmeet the needs of their patients. Examplescould include a club membership plus a well-ness coaching program, short-term member-ship for first time exercisers, preventionprograms or lecture series for patients withrisk factors and rehabilitation programs.

Learn from success stories. The ThoreauClub partnered with a local hospital todeliver the Prelude program first to itsemployees, and later to patients via physi-cian referrals The Prelude program was an8-week introductory membership thatincluded weekly sessions with a wellnesscoach, personal trainer, and nutrition consul-tations. On-site fitness programs are offeredat the hospital to reduce the intimidation fac-tor of joining the club and reinforce theclub’s brand. To reciprocate, hospital clini-cians present educational sessions for clubmembers on prevention and health care. Awin-win for the club and hospital!

Adapted from The IHRSA Report/ClubAdvisor: The Exercise is Medicine™ Advan-tage with permission at www.ihrsa.org/cbi

Laura Klein, Wellness Director, Thoreau Club, Concord,MA; www.thoreau.com

Beth Frates, MD, Clinical Instructor, Harvard MedicalSchool, Director of Education, Institute of Lifestyle Medi-cine; www.institutelifestylemedicine.org

Margaret Moore, CEO, Wellcoaches Corporation,www.coachmeg.com

Lifestyle... Continued from Page 3

INTRODUCTION

Many exercise professionals mistakenlycategorize bone health as an aging issue.Bone health is an issue that should beaddressed with clients of all ages, and bothsexes. The manner in which exercise profes-sionals address bone health, with exerciseprescription, will be somewhat age depend-ent. A thorough understanding of the etiol-ogy and terminology involved with bonehealth as well as an awareness of the defini-tions of disease criteria are essential tools anexercise professional (e.g., RCEP, CES, HFS,CPT) should possess.

Throughout ones life, bone undergoes adynamic process of breakdown (resorption)and formation known as remodeling. Boneremodeling is a natural process that involvescells that act on degrading older bone (osteo-clasts) and cells that stimulate the building ofnew bone (osteoblasts). During childhood,adolescence, and early adulthood the bal-ance between these processes favors boneformation with peak bone mass beingattained sometime during the second or thirddecade of life. After the third decade, thereare a combination of lifestyle choices andnatural physiologic processes that eventuallyshift the balance of bone remodeling in favorof resorption.5 If specific steps are not takento optimize bone formation (build up bonemineral reserves) early in ones life and mini-mize the resorptive process that follows asone ages, bone loss may progress to the levelof osteopenia or osteoporosis (See Table 1).

Osteoporosis and osteopenia are skeletaldisorders characterized by a compromise inbone strength. Bone strength is reflective ofbone mineral content (grams of mineral perarea of bone), most commonly referred to asbone mineral density (BMD). A person canbe classified as having normal bone strengthwith a BMD that is either above the mean or

does not exceed one standard deviationbelow the mean of peak values for youngnormal adults. Osteoporosis is defined as aBMD of ! 2.5 standard deviations belowmean peak values for young normal adultsand represents an increased susceptibility tofracture. Osteopenia (low bone mass) isdefined as a BMD that is between 1.0 and2.5 standard deviations below mean peakvalues for young normal adults. It has beenestimated that 44 million Americans haveosteoporosis or osteopenia and that one halfof all women and one quarter of all men overthe age of 50 will suffer a fracture related tothese disorders during their lifetime.5

There are a host of nutritional, pharmaco-logical, and exercise interventions which canbe employed in the prevention and treatmentof osteoporosis and osteopenia. The remain-der of this paper will focus primarily onexercise interventions for individuals of vari-ous ages and stages of bone health. As withother chronic health issues, bone health ismost effectively addressed with preventativemeasures that begin early in life.

EXERCISE PRESCRIPTION FOR THE YOUNGCLIENT: OPTIMIZING PEAK BMD

With prevention in mind, clients less than30 years of age should concentrate on anexercise program that optimizes peak BMD.The level of BMD that is achieved duringearly adulthood is an important predictor ofsubsequent bone mineral status later in life.While all types of physical activity should beencouraged in children and adolescents,there are specific activities that will enhancethe osteogenic (bone formation) impact.Children and adolescents should be encour-aged to participate in sports (e.g., soccer,basketball, gymnastics, track and field, etc.)or other activities that generate relativelyhigh ground reactive forces such as running,skipping, and jumping. Active children who

participate in activities that generate highimpact forces have higher bone mass thanchildren who engage in low impact activities(e.g., walking) or non-weight bearing activi-ties (e.g., swimming).3

Young adults can add other physical activ-ities that generate relatively high intensityloading forces such as plyometrics and high-intensity resistance training. It is importantto remember the exercise principle of speci-ficity in that only the bones that are stressedby a specific activity receive an osteogenicstimulus. Therefore, including resistanceexercises that focus contraction on the hip(e.g., leg press, squat) and spine musculature(e.g., back extensions) will help optimizepeak BMD values in regions that are proneto resorptive bone loss in later years.

Exercises intended to stimulate anosteogenic effect should be included in theexercise programs of children, adolescents,and young adults at a minimum frequency ofthree-days per week and duration of 10-20minutes.3

EXERCISE PRESCRIPTION FOR THE MIDDLEAGE CLIENT: MAINTAINING PEAK BMD

With clients between the ages of 30 and50, exercise programming should focus onactivities that will maintain BMD’s at or nearpeak levels. Exercise professionals shouldpay particular attention to the principle ofreversibility in middle-age clients. Too fewmiddle-aged adults have kept up with thelevel of physical activity that they performedat younger ages. Therefore, bone loss mayexceed 0.5% per year after the age of 40,independent of sex or ethnicity.5

With the focus on maintaining BMD, thehigh intensity activities needed to build ahealthy bone base during youth can be scaledback to moderate to high intensity boneloading forces during middle age. While the

Osteoporosis and Osteopenia:

A Guide to Proactive Bone HealthBy Peter M. Magyari, Ph.D., HFS, CSCS,

Brooks College of Health at the University of North Florida in Jacksonville, FL

Table 1. Bone HealthClassification Diagnostic Criteria

Normal BMD that does not exceed onestandard deviation below themean

Osteopenia BMD that is between 1 and 2.5standard deviations below themean

Osteoporosis BMD of ! 2.5 standard deviationsbelow the mean

BMD: BONE MINERAL DENSITY

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5APRIL/MAY/JUNE 2009 | VOLUME 19; ISSUE 2 ACSM’s Certified NewsACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

Coaching News

EExxeerrcciissee iissMMeeddiicciinnee™™::DDooccttoorrss,,CCooaacchheess,,&& CClluubbss

At long last, the ACSM/AMA Exercise isMedicine™ initiative acknowledges that exer-cise is a breakthrough medicine which is safeand effective to prevent or ameliorate mostcommon medical conditions. This initiativeoffers health clubs a new opportunity toreach out to the medical community, andopen up markets for new members and pro-grams. What will it take for success?

Deploy the cutting edge toolbox of the fit-ness or wellness coach. The combination ofthe professional coach’s toolbox with clinicalexercise physiology has unleashed a newgeneration of certified fitness and wellnesscoaches. Not only are they skilled at helpingpeople build and sustain healthy lifestyles,they impress physicians with their commandof exercise science along with their ability tohelp people make lasting change. While per-sonal training is valuable to many, trainingsessions alone often do not provide the skilland support to move people to take chargeand sustain regular exercise. Coaches prom-ise to be an important bridge between theclub and physician to implement Exercise isMedicine™.

Help physicians spark patient motivationto adopt fit lifestyles. Medical schools spendlittle time teaching students about exerciseprescription or how to help patients pursuehealthy lifestyles Clubs and coaches have aunique opportunity to assist doctors with theexercise prescription of their patients andprovide them with a resource to use shortphysician visits to spark patient motivationto get fit. Further, offering trial club member-ships and coaching programs to physiciansand their staff will help them learn whatcoaches do and why it is important to walkthe walk.

Build trust and collaborative relationshipswith physicians. To build trusting relation-ships, physicians appreciate open communi-cation and detailed background informationfrom clubs on the credentials of theiremployed fitness professionals and coaches,on equipment and programs available forpeople who are sedentary and have healthrisks, and a communication method toreceive concise feedback on the progress oftheir patients. Being honest about what your

facility offers and communicating aboutpatient progress is essential to a lasting col-laboration with physicians. A short sum-mary of a patient’s fitness or wellness planand goals, including motivators, strengths,and challenges is valuable. Detailed feedback(data) to physicians should be tailored toaddress the reason the physician advised thereferral, such as BMI, waist circumference,blood pressure, and heart rate measurementsfor someone who is overweight and hyper-tensive.

Cultivate your market. Cast a wide net. Inaddition to working directly with physicians,including alternative medicine, may also bean option. Examples may include chiroprac-tors, acupuncturists, and rehabilitation facil-ities. To facilitate the relationship, set up factfinding meetings with these providers touncover unmet needs of their patients, thenoffer your memberships and programs thatmeet the needs of their patients. Examplescould include a club membership plus a well-ness coaching program, short-term member-ship for first time exercisers, preventionprograms or lecture series for patients withrisk factors and rehabilitation programs.

Learn from success stories. The ThoreauClub partnered with a local hospital todeliver the Prelude program first to itsemployees, and later to patients via physi-cian referrals The Prelude program was an8-week introductory membership thatincluded weekly sessions with a wellnesscoach, personal trainer, and nutrition consul-tations. On-site fitness programs are offeredat the hospital to reduce the intimidation fac-tor of joining the club and reinforce theclub’s brand. To reciprocate, hospital clini-cians present educational sessions for clubmembers on prevention and health care. Awin-win for the club and hospital!

Adapted from The IHRSA Report/ClubAdvisor: The Exercise is Medicine™ Advan-tage with permission at www.ihrsa.org/cbi

Laura Klein, Wellness Director, Thoreau Club, Concord,MA; www.thoreau.com

Beth Frates, MD, Clinical Instructor, Harvard MedicalSchool, Director of Education, Institute of Lifestyle Medi-cine; www.institutelifestylemedicine.org

Margaret Moore, CEO, Wellcoaches Corporation,www.coachmeg.com

INTRODUCTION

Many exercise professionals mistakenlycategorize bone health as an aging issue.Bone health is an issue that should beaddressed with clients of all ages, and bothsexes. The manner in which exercise profes-sionals address bone health, with exerciseprescription, will be somewhat age depend-ent. A thorough understanding of the etiol-ogy and terminology involved with bonehealth as well as an awareness of the defini-tions of disease criteria are essential tools anexercise professional (e.g., RCEP, CES, HFS,CPT) should possess.

Throughout ones life, bone undergoes adynamic process of breakdown (resorption)and formation known as remodeling. Boneremodeling is a natural process that involvescells that act on degrading older bone (osteo-clasts) and cells that stimulate the building ofnew bone (osteoblasts). During childhood,adolescence, and early adulthood the bal-ance between these processes favors boneformation with peak bone mass beingattained sometime during the second or thirddecade of life. After the third decade, thereare a combination of lifestyle choices andnatural physiologic processes that eventuallyshift the balance of bone remodeling in favorof resorption.5 If specific steps are not takento optimize bone formation (build up bonemineral reserves) early in ones life and mini-mize the resorptive process that follows asone ages, bone loss may progress to the levelof osteopenia or osteoporosis (See Table 1).

Osteoporosis and osteopenia are skeletaldisorders characterized by a compromise inbone strength. Bone strength is reflective ofbone mineral content (grams of mineral perarea of bone), most commonly referred to asbone mineral density (BMD). A person canbe classified as having normal bone strengthwith a BMD that is either above the mean or

does not exceed one standard deviationbelow the mean of peak values for youngnormal adults. Osteoporosis is defined as aBMD of ! 2.5 standard deviations belowmean peak values for young normal adultsand represents an increased susceptibility tofracture. Osteopenia (low bone mass) isdefined as a BMD that is between 1.0 and2.5 standard deviations below mean peakvalues for young normal adults. It has beenestimated that 44 million Americans haveosteoporosis or osteopenia and that one halfof all women and one quarter of all men overthe age of 50 will suffer a fracture related tothese disorders during their lifetime.5

There are a host of nutritional, pharmaco-logical, and exercise interventions which canbe employed in the prevention and treatmentof osteoporosis and osteopenia. The remain-der of this paper will focus primarily onexercise interventions for individuals of vari-ous ages and stages of bone health. As withother chronic health issues, bone health ismost effectively addressed with preventativemeasures that begin early in life.

EXERCISE PRESCRIPTION FOR THE YOUNGCLIENT: OPTIMIZING PEAK BMD

With prevention in mind, clients less than30 years of age should concentrate on anexercise program that optimizes peak BMD.The level of BMD that is achieved duringearly adulthood is an important predictor ofsubsequent bone mineral status later in life.While all types of physical activity should beencouraged in children and adolescents,there are specific activities that will enhancethe osteogenic (bone formation) impact.Children and adolescents should be encour-aged to participate in sports (e.g., soccer,basketball, gymnastics, track and field, etc.)or other activities that generate relativelyhigh ground reactive forces such as running,skipping, and jumping. Active children who

participate in activities that generate highimpact forces have higher bone mass thanchildren who engage in low impact activities(e.g., walking) or non-weight bearing activi-ties (e.g., swimming).3

Young adults can add other physical activ-ities that generate relatively high intensityloading forces such as plyometrics and high-intensity resistance training. It is importantto remember the exercise principle of speci-ficity in that only the bones that are stressedby a specific activity receive an osteogenicstimulus. Therefore, including resistanceexercises that focus contraction on the hip(e.g., leg press, squat) and spine musculature(e.g., back extensions) will help optimizepeak BMD values in regions that are proneto resorptive bone loss in later years.

Exercises intended to stimulate anosteogenic effect should be included in theexercise programs of children, adolescents,and young adults at a minimum frequency ofthree-days per week and duration of 10-20minutes.3

EXERCISE PRESCRIPTION FOR THE MIDDLEAGE CLIENT: MAINTAINING PEAK BMD

With clients between the ages of 30 and50, exercise programming should focus onactivities that will maintain BMD’s at or nearpeak levels. Exercise professionals shouldpay particular attention to the principle ofreversibility in middle-age clients. Too fewmiddle-aged adults have kept up with thelevel of physical activity that they performedat younger ages. Therefore, bone loss mayexceed 0.5% per year after the age of 40,independent of sex or ethnicity.5

With the focus on maintaining BMD, thehigh intensity activities needed to build ahealthy bone base during youth can be scaledback to moderate to high intensity boneloading forces during middle age. While the

Osteoporosis and Osteopenia:

A Guide to Proactive Bone HealthBy Peter M. Magyari, Ph.D., HFS, CSCS,

Brooks College of Health at the University of North Florida in Jacksonville, FL

Osteoporosis... Continued on Page 6

REFERENCES

1. ACSM's Guidelines for Exercise Testing and Prescription. 7thPhiladelphia: Lippincott Williams & Wilkins; 2005. p 133-73.

2. Bergen JL, Toole T, Elliott RG, 3rd, Wallace B, Robinson K,Maitland CG. Aerobic exercise intervention improves aerobiccapacity and movement initiation in Parkinson's disease patients.NeuroRehabilitation. 2002; 17 (2): 161-8.

3. Brigewater KJ, Sharpe MH. Aerobic Exercise and EarlyParkinson's Disease. J Neuro Rehab. 1996; 10: 233-41.

4. Dauer W, Przedborski S. Parkinson's disease: mechanisms andmodels. Neuron. 2003; 39 (6): 889-909.

5. De Lau LM, Breteler MM. Epidemiology of Parkinson's disease.Lancet neurology. 2006; 5 (6): 525-35.

6. Diamond SG, Markham CH, Hoehn MM, McDowell FH,Muenter MD. An examination of male-female differences inprogression and mortality of Parkinson's disease. Neurology.1990; 40 (5): 763-6.

7. Dibble LE, Hale TF, Marcus RL, Droge J, Gerber JP, LaStayo PC.High-intensity resistance training amplifies muscle hypertrophyand functional gains in persons with Parkinson's disease. MovDisord. 2006; 21 (9): 1444-52.

8. Fahn S. Description of Parkinson's disease as a clinical syndrome.Ann N Y Acad Sci. 2003; 991: 1-14.

9. Haas BM, Trew M, Castle PC. Effects of respiratory muscleweakness on daily living function, quality of life, activity levels,and exercise capacity in mild to moderate Parkinson's disease.Am J Phys Med Rehabil. 2004; 83 (8): 601-7.

10. Hooker S, Foudray C, McKay L, et al. Heart Rate and PerceivedExertion Measures During Exercise in People with Parkinson'sDisease. J Neuro Rehab. 1996; 10 (2): 101-5.

11. Keus SH, Bloem BR, Hendriks EJ, Bredero-Cohen AB, MunnekeM. Evidence-based analysis of physical therapy in Parkinson'sdisease with recommendations for practice and research. MovDisord. 2007; 22 (4): 451-60; quiz 600.

12. Lieberman A, Williams F. Parkinson's disease; The completeguide for patients and caregivers. New York: Fireside; 1993. p

13. Macaluso A, De Vito G. Muscle strength, power and adaptationsto resistance training in older people. Eur J Appl Physiol. 2004;91 (4): 450-72.

14. NCPAD. Parkinson's Disease and Exercise. [accessed March19th]. Available from: http://www.ncpad.org/disability/fact_sheet.php?sheet=59&section=444.

15. NINDS. Parkinson's Disease: Challenges, Progress, and Promise.[accessed March 19th]. Available from:http://www.ninds.nih.gov/disorders/parkinsons_disease/parkinsons_research.htm#basics;%20.

For a complete list of references e-mail: certification@acsm.org.

Parkinsons... from Page 12

JJooiinn WWeellllccooaacchheessCCoorrppoorraattiioonn...... a strategicpartner of the ACSM and Medical FitnessAssociation, for a one-day workshop on well-ness and health coaching core competencies.

This workshop is appropriate for bothexperienced coaches and for those new tocoaching. Learn current evidence basedpositive coaching psychology and skills,and how to work with your clients in away that gives them the power and confi-dence to make lasting lifestyle changes.

Location Sites for 2009Dallas, TX

Boston, MAPortland, OR

Cincinnati, OHMinneapolis, MN

Orlando, FL

Register at www.wellcoach.com

CNews19.2Final.JR:Layout 1 5/6/09 2:11 PM Page 5

APRIL/MAY/JUNE 2009 | VOLUME 19; ISSUE 2 ACSM’s Certified News6ACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

Osteoporosis... Continued from Page 5

Peripheral arterial disease (PAD), also knownas peripheral artery occlusive disease, is the mostcommon form of peripheral vascular disease(PVD), with an estimated 8-12 million Americanadults who are affected.7 Health and fitness pro-fessionals may see a rise in the number of exercis-ers with PAD as the benefits of exercise in thispopulation become better known. Therefore, fit-ness professionals must be aware of the possibleexercise limitations of this population, as well astheir health goals and the benefits that can beachieved through physical activity (PA) andpatient education.

Peripheral arterial disease is characterized byocclusion of arteries in the limbs due toendothelial dysfunction and atherosclerosis inthe vascular beds of the lower extremities.7

Inadequate circulation to the legs, or limbischemia, especially during PA can cause painfuland physically limiting leg pain, known as inter-mittent claudication. Consequently, individualswith intermittent claudication have ambulatorydysfunction that affects their ability to carry outactivities of daily living and can inhibit theirability and desire to exercise, which negativelyaffects their health risk profile for other cardio-vascular diseases.1 Exercise may improve theclinical outcome of patients with PAD by

continued involvement in sports such as ten-nis, basketball, volleyball, and soccer shouldbe encouraged, the inclusion of weight bear-ing (e.g., stair climbing, elliptical exerciser,moderate to high impact group exercises,jogging) and resistance training exerciseshelp fill the exercise gap. Weight bearingendurance activities should be performedthree to five days per week and resistancetraining exercises encompassing all majormuscle groups, in the 8-10 rep maximumrange, should be performed two to threedays per week.3

EXERCISE PRESCRIPTION FOR THE OLDERCLIENT: DEPENDENT ON CURRENT BONESTATUS

Exercise programming for clients over theage of 50 will be heavily dependent upon thelevel of attention placed on proactive bonehealth (earlier in life) and current bone statusif preventative exercises were either ignoredor underutilized in optimizing or maintain-ing peak BMD. For older clientele who havea BMD within the normal range, the exerciseprescription should concentrate on maintain-ing BMD and/or minimizing bone loss as thebody adjusts to a changing hormonal milieuthat favors bone resorption. In this popula-tion, the exercise prescription would notvary greatly from that recommended for thehealthy middle-aged persons mentionedabove. The primary difference would be thatas age increases, attention paid to safetyissues such as balance and exercise intensitymust increase as well.

In older adults who have been diagnosedwith osteopenia, exercise prescription shouldfocus on preventing further bone loss. Theexercise prescription should include moder-ate resistance training loads of 12-15 rep-maximums (attention should be placed onpreventing compressive forces on the verte-bral column), two to three days per week,and weight bearing endurance activities.Additionally, attention to nutrition (calcium,vitamin D) and pharmacologic intervention(bisphosphonates, calcitonin, estrogens) maybe needed to realize improvement in BMD.Those who were taking either bisphospho-nates or calcitonin realized significantimprovements in BMD when resistance train-ing was added to the pharmacologic interven-tion, while subjects on pharmacology alonewere unable to realize improvements.1, 2

The exercise prescription for older adultsdiagnosed with osteoporosis presents addi-tional challenges for the exercise profes-sional. Many of the activities with high boneloading forces (recommended to increaseBMD in non-osteoporotic patients) are con-traindicated for patients with osteoporosis.Contraindicated exercises include running,

jumping, jogging, rowing, plyometrics, high-intensity resistance training, and any type ofspinal flexion, especially when combinedwith a resistive or twisting movement.3, 5

Prior to prescribing exercise for an individ-ual with osteoporosis the exercise profes-sional should consult with the clients’physician.

Exercise programs most suited for osteo-porotic patients focus on fall prevention.These include conservative muscle strength-ening, aerobic/endurance, balance, andagility exercises. Recommendations includewalking or stationary cycling, conservativeresistance training with 8-10 exercises of 15repetitions, performed one to two days perweek, and range of motion exercises thatavoid spinal flexion.4 Unfortunately, morespecific resistance training guidelines, withregard to intensity, are not available at thistime. Treatment may also rely heavily onpharmacologic and nutritional interventions.

SUMMARYBone health is an issue that should be

addressed with clients of all ages. The exer-cise prescription varies throughout the lifes-pan beginning with building a strongfoundation of bone prior to the age of 30,preserving as much bone as possible throughthe aging process, and understanding theexercise limitations of patients diagnosedwith low BMD. As with all exercise prescrip-tion in special populations, it would be pru-dent to obtain medical clearance (prior toexercise testing and training) of individualsdiagnosed with either osteoporosis orosteopenia.

References1. Braith, RW, Magyari, PM, Fulton, MN, et al. (2006)

Comparison of Calcitonin versus Calcitonin and ResistanceExercise as Prophylaxis for Osteoporosis in Heart TransplantRecipients" Transplantation, 27;81(8):1191-5.

2. Braith RW, Magyari, PM, Fulton MN, et al. (2003). ResistanceExercise Training and Alendronate Reverse Glucocorticoid-Induced Osteoporosis in Heart Transplant Recipients. TheJournal of Heart and Lung Transplant; 22(10):1082-90.

3. Kohrt WM, Bloomfield SA, Little KD, et al. American Collegeof Sports Medicine Position Stand: Physical Activity and BoneHealth. Medicine and Science in Sports and Exercise.2004;36:1985–96.

4. Nichols, D.L., E. Trudelle-Jackson, and L. Fleisher.Osteoporosis. IN: ACSM’s Resources for Clinical ExercisePhysiology. (2nd Ed.) Lippincott Williams and Wilkins, 2010,pp. 162-174.

5. Petit, M.A., J.M. Hughes, and J.M. Warpeha. ExercisePrescription for People with Osteoporosis. IIIN:ACSM’sResource Manual for Guidelines for Exercise Testing andPrescription. (6th Ed.) Lippincott Williams and Wilkins, 2010,pp. 635-650.

About the AuthorPeter M. Magyari, Ph.D., HFS, CSCS isan assistant professor of exercise physiol-ogy in the Brooks College of Health atthe University of North Florida in Jack-sonville, FL. He has collaborated on sev-eral studies designed to investigate theimpact of resistance exercise training on bone health.

Peripheral Arterial DiseaseBy Nina Markil, B.S.

Exercise Science and Health Promotion at Florida Atlantic University.

ACSM Approved Providers forContinuing Education• Athletes’ Performance

www.athletesperformance.com

• CEPAww.acsm-cepa.org

• Club Industrywww.clubindustryshow.com

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• Desert Southwest Fitnesswww.dswfitness.com

• Diabetes Training Campwww.diabetestrainingcamp.com

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• IDEAwww.ideafit.com

• International Council on Active Agingwww.icaa.cc/

• Japan Fitness Associationhttp://www.jafanet.jp

• Medical Fitness Associationwww.medicalfitness.org

• National Intramural-Recreational SportsAssociationwww.nirsa.org

• National Society of Physical ActivityPractitioners in Public Healthwww.nspapph.org

• New England Health, Racquet & SportsClub Associationwww.nehrsa.org

• NYU Medical Centerwww.med.nyu.edu/cme

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SELF-TEST ANSWER KEY FOR PAGE 11————— QUESTION ——————12345

TEST #1:ACDAATEST #2:BDBABTEST #3:DCDABTEST #4:DBABC

CNews19.2Final.JR:Layout 1 5/6/09 2:11 PM Page 6

7APRIL/MAY/JUNE 2009 | VOLUME 19; ISSUE 2 ACSM’s Certified NewsACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

Peripheral arterial disease (PAD), also knownas peripheral artery occlusive disease, is the mostcommon form of peripheral vascular disease(PVD), with an estimated 8-12 million Americanadults who are affected.7 Health and fitness pro-fessionals may see a rise in the number of exercis-ers with PAD as the benefits of exercise in thispopulation become better known. Therefore, fit-ness professionals must be aware of the possibleexercise limitations of this population, as well astheir health goals and the benefits that can beachieved through physical activity (PA) andpatient education.

Peripheral arterial disease is characterized byocclusion of arteries in the limbs due toendothelial dysfunction and atherosclerosis inthe vascular beds of the lower extremities.7

Inadequate circulation to the legs, or limbischemia, especially during PA can cause painfuland physically limiting leg pain, known as inter-mittent claudication. Consequently, individualswith intermittent claudication have ambulatorydysfunction that affects their ability to carry outactivities of daily living and can inhibit theirability and desire to exercise, which negativelyaffects their health risk profile for other cardio-vascular diseases.1 Exercise may improve theclinical outcome of patients with PAD by

improving their risk profile. Therefore, it is crit-ical that PA not only be encouraged, but thatexercise be supervised to ensure proper safetyand program maintenance.

RISK FACTORSBecause atherosclerosis has already affected

the vasculature of the lower limbs in those withPAD, it is likely that these individuals may alsodevelop atherosclerosis in coronary and/or cere-brovascular arteries as well. Lifestyle modifica-tion including regular PA can help manage riskfactors and may help slow progression of suchdiseases. The health fitness professional can helpby encouraging regular physician visits, motivatethe patient to stay committed to PA /risk modifi-cation goals, and raise patient awareness througheducation.

DIABETESDiabetes is the number one risk factor for

peripheral vascular disease and puts individualsat a 1.5 to 2.0 times greater risk of developingPAD than those without diabetes.2 Tight glucosecontrol (maintaining healthy blood sugar levels)in those with diabetes with PAD may be amethod to deter the progression or severity ofthe disease. Therefore, the American Diabetes

Association recommends that HbA1c levels be<7.0 in the population.2

SMOKINGIn persons >45 years of age, the estimated risk

of developing intermittent claudication is up to16-fold higher among smokers than among non-smokers, making this the number one modifiablerisk factor.7 Smoking cessation programs, whereappropriate, can be an important component toa patient education plan.

BLOOD PRESSUREIn a Framingham Heart Study follow up, a

positive association between hypertension andclaudication pain was reported11 and may beimportant to manage claudication pain.2 TheJoint National Committee on Prevention, Detec-tion, and Treatment of High Blood Pressure rec-ommends that blood pressure be maintained lessthan 130/80 mmHg for those with cardiovascu-lar disease.5

HIGH CHOLESTEROLAccording to the National Cholesterol Educa-

tion Program Adult Treatment Panel (NCEPATP-III), LDL should be no higher than 100mg/dL and HDL ! 60mg/dL for individuals withcardiovascular disease.6 For individuals with hightriglycerides (! 200mg/dL), ATP III advises thatnon-HDL cholesterol be 30 mg/dL higher thanthe LDL goal.6

CLAUDICATION PAINThe severity of PAD is many times classified by

level of claudication pain experienced by thepatient. The Fontaine classification system is usedto organize the intensity of claudication to a stageof the disease progressing from mild to severe.9 Instage 1, patients are asymptomatic, stage 2patients experience intermittent claudication,stage 3 is characterized by claudication pain atrest, and stage 4 patients experience gangreneleading to possible amputations. Exercise special-ists most commonly work with Stage I and IIpatients. Stage III and IV patients require moreaggressive treatment such as revascularization.However, exercise may play an important role intheir rehabilitation and risk factor modification.

The risk of cardiovascular death increases withthe severity of claudication.11 Therefore, individ-uals who are beyond stage II are at the highestrisk for cardiovascular disease related deaths.This is incentive for patients in Stage I or II andtheir exercise professionals to aggressively help

continued involvement in sports such as ten-nis, basketball, volleyball, and soccer shouldbe encouraged, the inclusion of weight bear-ing (e.g., stair climbing, elliptical exerciser,moderate to high impact group exercises,jogging) and resistance training exerciseshelp fill the exercise gap. Weight bearingendurance activities should be performedthree to five days per week and resistancetraining exercises encompassing all majormuscle groups, in the 8-10 rep maximumrange, should be performed two to threedays per week.3

EXERCISE PRESCRIPTION FOR THE OLDERCLIENT: DEPENDENT ON CURRENT BONESTATUS

Exercise programming for clients over theage of 50 will be heavily dependent upon thelevel of attention placed on proactive bonehealth (earlier in life) and current bone statusif preventative exercises were either ignoredor underutilized in optimizing or maintain-ing peak BMD. For older clientele who havea BMD within the normal range, the exerciseprescription should concentrate on maintain-ing BMD and/or minimizing bone loss as thebody adjusts to a changing hormonal milieuthat favors bone resorption. In this popula-tion, the exercise prescription would notvary greatly from that recommended for thehealthy middle-aged persons mentionedabove. The primary difference would be thatas age increases, attention paid to safetyissues such as balance and exercise intensitymust increase as well.

In older adults who have been diagnosedwith osteopenia, exercise prescription shouldfocus on preventing further bone loss. Theexercise prescription should include moder-ate resistance training loads of 12-15 rep-maximums (attention should be placed onpreventing compressive forces on the verte-bral column), two to three days per week,and weight bearing endurance activities.Additionally, attention to nutrition (calcium,vitamin D) and pharmacologic intervention(bisphosphonates, calcitonin, estrogens) maybe needed to realize improvement in BMD.Those who were taking either bisphospho-nates or calcitonin realized significantimprovements in BMD when resistance train-ing was added to the pharmacologic interven-tion, while subjects on pharmacology alonewere unable to realize improvements.1, 2

The exercise prescription for older adultsdiagnosed with osteoporosis presents addi-tional challenges for the exercise profes-sional. Many of the activities with high boneloading forces (recommended to increaseBMD in non-osteoporotic patients) are con-traindicated for patients with osteoporosis.Contraindicated exercises include running,

jumping, jogging, rowing, plyometrics, high-intensity resistance training, and any type ofspinal flexion, especially when combinedwith a resistive or twisting movement.3, 5

Prior to prescribing exercise for an individ-ual with osteoporosis the exercise profes-sional should consult with the clients’physician.

Exercise programs most suited for osteo-porotic patients focus on fall prevention.These include conservative muscle strength-ening, aerobic/endurance, balance, andagility exercises. Recommendations includewalking or stationary cycling, conservativeresistance training with 8-10 exercises of 15repetitions, performed one to two days perweek, and range of motion exercises thatavoid spinal flexion.4 Unfortunately, morespecific resistance training guidelines, withregard to intensity, are not available at thistime. Treatment may also rely heavily onpharmacologic and nutritional interventions.

SUMMARYBone health is an issue that should be

addressed with clients of all ages. The exer-cise prescription varies throughout the lifes-pan beginning with building a strongfoundation of bone prior to the age of 30,preserving as much bone as possible throughthe aging process, and understanding theexercise limitations of patients diagnosedwith low BMD. As with all exercise prescrip-tion in special populations, it would be pru-dent to obtain medical clearance (prior toexercise testing and training) of individualsdiagnosed with either osteoporosis orosteopenia.

References1. Braith, RW, Magyari, PM, Fulton, MN, et al. (2006)

Comparison of Calcitonin versus Calcitonin and ResistanceExercise as Prophylaxis for Osteoporosis in Heart TransplantRecipients" Transplantation, 27;81(8):1191-5.

2. Braith RW, Magyari, PM, Fulton MN, et al. (2003). ResistanceExercise Training and Alendronate Reverse Glucocorticoid-Induced Osteoporosis in Heart Transplant Recipients. TheJournal of Heart and Lung Transplant; 22(10):1082-90.

3. Kohrt WM, Bloomfield SA, Little KD, et al. American Collegeof Sports Medicine Position Stand: Physical Activity and BoneHealth. Medicine and Science in Sports and Exercise.2004;36:1985–96.

4. Nichols, D.L., E. Trudelle-Jackson, and L. Fleisher.Osteoporosis. IN: ACSM’s Resources for Clinical ExercisePhysiology. (2nd Ed.) Lippincott Williams and Wilkins, 2010,pp. 162-174.

5. Petit, M.A., J.M. Hughes, and J.M. Warpeha. ExercisePrescription for People with Osteoporosis. IIIN:ACSM’sResource Manual for Guidelines for Exercise Testing andPrescription. (6th Ed.) Lippincott Williams and Wilkins, 2010,pp. 635-650.

About the AuthorPeter M. Magyari, Ph.D., HFS, CSCS isan assistant professor of exercise physiol-ogy in the Brooks College of Health atthe University of North Florida in Jack-sonville, FL. He has collaborated on sev-eral studies designed to investigate theimpact of resistance exercise training on bone health.

Peripheral Arterial DiseaseBy Nina Markil, B.S.

Exercise Science and Health Promotion at Florida Atlantic University.

PAD... Continued on Page 8

CNews19.2Final.JR:Layout 1 5/6/09 2:11 PM Page 7

manage risk and improve claudication. Unfortu-nately, many people with diabetes are atincreased risk for PVD and may unknowinglyalready have asymptomatic Stage I PAD. This isanother reason why it is crucial for those withdiabetes to remain or become physically activeand be screened regularly to prevent progressionof the disease.

EXERCISE/PHYSICAL ACTIVITYAn exercise prescription for patients with PAD

should focus on management of risk factors3, 8

similar to a patient with CHD1 and aim atimproving functional mobility to help the indi-vidual accomplish activities of daily living whileimproving intermittent claudication. Aerobicexercise, such as walking, has been utilized as ameans to increase VO2 PEAK, as well as pain freewalking distance in patients with PVD withimprovements seen in the onset of claudicationtime and time to maximal claudication pain.12

Time to onset is the moment during exercisewhen the patient begins to experience discom-forting leg pain. Time to maximal claudicationpain is the amount of time it takes the patient toexperience severe enough leg pain that they areunable to continue exercise.

Exercise interventions have also shown prom-ise in increasing peripheral adaptations, such asincreased capillary density, oxidative enzymes10

and central adaptations (e.g., stroke volume).12, 10

It also has been suggested that another possibleresponse to exercise training is an increase in paintolerance.12 As participants become acclimated tothe pain, they may be able to work through itmore effectively. When considering the level ofpain that must be tolerated during exertion, plusthe fact that the participants are usually unaccus-tomed to exercise, encouragement to persist withthe exercise rehabilitation can become an impor-tant factor for exercise adherence and long-termsuccess.

EXERCISE PRESCRIPTIONTypically, patients with PAD are considered

high risk and require medical clearance beforestaring an exercise program. Most will alsorequire monitoring during exercise (i.e., bloodpressure and heart rate). Consistent with theAmerican College of Sports Medicine (ACSM)guidelines, PAD patients should engage in car-diorespiratory exercise three to five days/week.Patients should walk at a speed and incline that

elicits claudication symptoms within three to fiveminutes and then continue to walk until theyreach symptoms of moderate claudication.1 TheACSM claudication pain rating scale (Table 1)may be a useful tool during training, keeping theclaudication pain at a moderate level (2 on theACSM scale).1

The initial duration should include 35 minutesof walking time; however, duration may start at15 minutes for more severely affected patientsand may include intervals if claudication pain issevere (!3 on ACSM scale). Duration shouldincrease five minutes each session until 30-50minutes (preferably continuous) of walking timecan be accomplished. The exercise interventionshould last for at least six months in order to seeimprovements in walking distance. Intensityshould be in the range of 50% – 80% VO2 PEAK orVO2 MAX (if max known) or 55% – 90%HRR.

Cycling can be used as a warm up or cooldown; however, it should not be used as the mainmode of exercise because it does not elicit claudi-cation pain and subsequent stimulus for claudica-tion improvements.10 Similarly, the Upper BodyErgometer can be a useful exercise modality formanaging risk factors and increasing cardiorespi-ratory fitness without the burden of claudicationpain. Claudication pain may not improve, butwalking ability may improve due to increases instroke volume.12

Resistance training (RT) programs consistingof exercises in the lower extremities may not beeffective at improving claudication pain. Onestudy found that RT was less effective than tread-mill training in improving peak treadmill walkingtime and did not result in increased VO2PEAK oronset to claudication pain.4 However, since RTdoes help maintain lean muscle mass andincrease bone density to prevent osteoporosis, itshould be included as part of a well designed fit-ness program for PAD patients and should fol-low ACSM Guidelines for general population.1

PAD AND SUCCESSFUL OUTCOMESCollectively, regular exercise would result in an

improved quality of life.3 It is necessary toimprove functional capacity (VO2 PEAK/MAX) in thesepatients because while performing everydayactivities, they may be working at their maximalwork capacity, become fatigued and stop morereadily, which would only perpetuate the pro-gression of the disease and complications.10

Exercise programs should focus on risk factorreduction and improvement of walking distanceto claudication. By reducing risk factors and clau-dication pain, patients may experience greaterindependence in their ability to perform activitiesof daily living, as well as a decreased risk ofcomorbidities. With appropriate supervised exer-cise and educational programs, exercise special-ists and PAD patients or those at risk for PAD,can work together to achieve health and fitness

goals that enable patients to live an independentlife with successful clinical outcomes.

References1. American College of Sports Medicine. Guidelines for Exercise

Testing and Prescription, 7th ed. Philadelphia, PA: LippincottWilliams & Wilkins, 2005.

2. American Diabetes Association. Peripheral Arterial Disease in Peoplewith Diabetes. Clinical Diabetes. 22; 4, 2004.

3. Gardner, A., Montgomery, P., & Parker, D. Metabolic syndromeimpairs physical function, health related quality of life, andperipheral circulation in patients with intermittent claudication.Journal of Vascular Surgery. 43:1191-1197, 2006.

4. Hiatt WR, Wolfel EE, Meier RH, Regensteiner JG. Superiority oftreadmill walking exercise versus strength training for patients withperipheral arterial disease. Implications for the mechanism of thetraining response. Circulation. 90:1866-1874, 1994.

5. National Heart, Lung, and Blood Institute, National Institute ofHealth, US Department of Health and Human Services. The seventhreport of the National Joint Committee on Prevention Detection,and Treatment of High Blood Pressure Express. 7, 2003.

6. National Heart, Lung, and Blood Institute, National Institute ofHealth, US department of Health and Human Services. ExectutiveSummary. Third Report of the National Cholesterol EducationProgram Expert Panel on Prevention Detection, and Treatment ofHigh Cholesterol, Adult Treatment Panel III, 2001.

7. Peripheral Arterial Disease. Retrived October 1, 2007, fromAmerican Heart Association. Website:http://www.americanheart.org/presenter.jhtml?identifier=3020242

8. Regensteiner, J. and Hiatt W. Current Medical therapies for patientswith peripheral arterial disease: a critical review. American Journalof Medicine. 112:49-57, 2002.

9. Rutherford, R.B. Standards for evaluating results of interventionaltherapy for peripheral vascular disease. Circulation. 83(suppl I):6-11,1991.

10. Skinner, J. Exercise Testing and Exercise Prescription for SpecialCases. Third Ed. Philadelphia, PA: Lippincott Williams & Wilkins,2005.

11. Tierney, S., Fennessy, F., & Hayes, D., ABC of arterial and vasculardisease. Secondary prevention of peripheral arterial disease. BritishMedical Journal. 320:1262-1265, 2000.

12. Zwierska, I., Walker, A., Choksy, S., Male, J., Pockly, A., Saxton,J.Relative tolerance to upper-limb and lower-limb aerobic exercise inpatients with peripheral arterial disease. Journal of Vascular Surgery.42:1122-1130, 2005.

About the AuthorNina Markil, B.S., is an exercise physiolo-gist currently completing a Master’s degreein Exercise Science and Health Promotionat Florida Atlantic University. As a gradu-ate assistant, she is currently teaching the undergraduate exer-cise physiology and exercise testing labs. Nina holds herACSM Clinical Exercise Specialist certification, and is a certi-fied Yoga and Spinning instructor. She has worked as an exer-

cise physiologist andfitness instructor inboth clinical and cor-porate settings.

APRIL/MAY/JUNE 2009 | VOLUME 19; ISSUE 2 ACSM’s Certified News8ACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

PAD... Continued from Page 7

Parkinson’s disease (PD) is a neurodegener-ative disease affecting the basal ganglia of thebrain, resulting in a deficiency of the neuro-transmitter dopamine.8 It is the second mostcommon neurodegenerative disease afterAlzheimer’s disease, and affects approxi-mately one million Americans.5 The overallnumber of individuals afflicted by this diseaseis difficult to obtain due to its slow develop-ment; however, it is estimated that 0.3% ofthe entire population and 1% of those overthe age of 60 years suffer from PD.5 Caucasianmales have been reported to be at higher riskcompared to their female counter parts, aswell as African American and Asians.6, 19

These differences, however, may be related tounder-sampling and lower response ratesfrom these ethnic groups in research studiesnot actual racial differences.

ETIOLOGY & PATHOGENESISAlthough the specific etiology of PD

remains unknown, genetic and environmentalfactors have been thought to influence the dis-ease; hence, two hypotheses have been devel-oped to further understand its development;the genetic hypothesis and the environmentaltoxin hypothesis.

The genetic hypothesis is based on the dis-

Care... Continued on Page 9

Table 1: ACSM Claudication Pain Rating Scale

1. Minimal Discomfort2. Moderate Pain (patient can be distracted)3. Intense Pain4. Unbearable Pain

Adapted from ACSM’s Guidelines for Exercise Testing andPrescription, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins,2005.

Parkinson’s Disease

Etiology, Clinical Characteristicsand the role of Exercise.

By Yuri Feito, M.S., M.P.H., RCEPDepartment of Exercise, Sport and Leisure Studies at The University of Tennessee

Table 1: Clinical features of Parkinson’s disease• Tremors at rest• Rigidity• Bradykinesia/hypokinesia/akinesia• Flexed posture of neck, trunk, and limbs• Loss of postural reflexes• Freezing phenomenon

Table 2: Nonmotor features of Parkinson’s Disease

Reference: Protas EJ, Stanley RK. Parkinson's Disease. In:Myers J, Nieman D, editors. ACSM's Resources for ClinicalExercise Physiology: Musculoskeletal, Neuromuscular,Neoplastic, Immunulogic, and Hematologic Conditions.Baltimore, MD: LWW; 2009. p. 44-57.

NEUROPSYCHIATRIC• depression• dementia• anxiety• cognitive decline• psychotic hallucinations• loss of motivation,

apathy

AUTONOMIC• hypotension• urinary problems• gastrointestinal

problems• sexual dysfunction• sweating

SENSORY• pain• paresthesia (pins and

needles)• numbness• akathisia (inability to sit

still)• Fatigue

SLEEP PROBLEMS• difficulty falling asleep• hypersomnolencerestless leg syndrome• sleep fragmentation

PARTICIPATE INA WEBINAR & EARN CECS!

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Inclusive Fitness TrainerJuly 13 - August 17;

Mondays at 7:00-8:30PM Eastern

Health Fitness SpecialistJuly 14 – August 18;

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manage risk and improve claudication. Unfortu-nately, many people with diabetes are atincreased risk for PVD and may unknowinglyalready have asymptomatic Stage I PAD. This isanother reason why it is crucial for those withdiabetes to remain or become physically activeand be screened regularly to prevent progressionof the disease.

EXERCISE/PHYSICAL ACTIVITYAn exercise prescription for patients with PAD

should focus on management of risk factors3, 8

similar to a patient with CHD1 and aim atimproving functional mobility to help the indi-vidual accomplish activities of daily living whileimproving intermittent claudication. Aerobicexercise, such as walking, has been utilized as ameans to increase VO2 PEAK, as well as pain freewalking distance in patients with PVD withimprovements seen in the onset of claudicationtime and time to maximal claudication pain.12

Time to onset is the moment during exercisewhen the patient begins to experience discom-forting leg pain. Time to maximal claudicationpain is the amount of time it takes the patient toexperience severe enough leg pain that they areunable to continue exercise.

Exercise interventions have also shown prom-ise in increasing peripheral adaptations, such asincreased capillary density, oxidative enzymes10

and central adaptations (e.g., stroke volume).12, 10

It also has been suggested that another possibleresponse to exercise training is an increase in paintolerance.12 As participants become acclimated tothe pain, they may be able to work through itmore effectively. When considering the level ofpain that must be tolerated during exertion, plusthe fact that the participants are usually unaccus-tomed to exercise, encouragement to persist withthe exercise rehabilitation can become an impor-tant factor for exercise adherence and long-termsuccess.

EXERCISE PRESCRIPTIONTypically, patients with PAD are considered

high risk and require medical clearance beforestaring an exercise program. Most will alsorequire monitoring during exercise (i.e., bloodpressure and heart rate). Consistent with theAmerican College of Sports Medicine (ACSM)guidelines, PAD patients should engage in car-diorespiratory exercise three to five days/week.Patients should walk at a speed and incline that

elicits claudication symptoms within three to fiveminutes and then continue to walk until theyreach symptoms of moderate claudication.1 TheACSM claudication pain rating scale (Table 1)may be a useful tool during training, keeping theclaudication pain at a moderate level (2 on theACSM scale).1

The initial duration should include 35 minutesof walking time; however, duration may start at15 minutes for more severely affected patientsand may include intervals if claudication pain issevere (!3 on ACSM scale). Duration shouldincrease five minutes each session until 30-50minutes (preferably continuous) of walking timecan be accomplished. The exercise interventionshould last for at least six months in order to seeimprovements in walking distance. Intensityshould be in the range of 50% – 80% VO2 PEAK orVO2 MAX (if max known) or 55% – 90%HRR.

Cycling can be used as a warm up or cooldown; however, it should not be used as the mainmode of exercise because it does not elicit claudi-cation pain and subsequent stimulus for claudica-tion improvements.10 Similarly, the Upper BodyErgometer can be a useful exercise modality formanaging risk factors and increasing cardiorespi-ratory fitness without the burden of claudicationpain. Claudication pain may not improve, butwalking ability may improve due to increases instroke volume.12

Resistance training (RT) programs consistingof exercises in the lower extremities may not beeffective at improving claudication pain. Onestudy found that RT was less effective than tread-mill training in improving peak treadmill walkingtime and did not result in increased VO2PEAK oronset to claudication pain.4 However, since RTdoes help maintain lean muscle mass andincrease bone density to prevent osteoporosis, itshould be included as part of a well designed fit-ness program for PAD patients and should fol-low ACSM Guidelines for general population.1

PAD AND SUCCESSFUL OUTCOMESCollectively, regular exercise would result in an

improved quality of life.3 It is necessary toimprove functional capacity (VO2 PEAK/MAX) in thesepatients because while performing everydayactivities, they may be working at their maximalwork capacity, become fatigued and stop morereadily, which would only perpetuate the pro-gression of the disease and complications.10

Exercise programs should focus on risk factorreduction and improvement of walking distanceto claudication. By reducing risk factors and clau-dication pain, patients may experience greaterindependence in their ability to perform activitiesof daily living, as well as a decreased risk ofcomorbidities. With appropriate supervised exer-cise and educational programs, exercise special-ists and PAD patients or those at risk for PAD,can work together to achieve health and fitness

goals that enable patients to live an independentlife with successful clinical outcomes.

References1. American College of Sports Medicine. Guidelines for Exercise

Testing and Prescription, 7th ed. Philadelphia, PA: LippincottWilliams & Wilkins, 2005.

2. American Diabetes Association. Peripheral Arterial Disease in Peoplewith Diabetes. Clinical Diabetes. 22; 4, 2004.

3. Gardner, A., Montgomery, P., & Parker, D. Metabolic syndromeimpairs physical function, health related quality of life, andperipheral circulation in patients with intermittent claudication.Journal of Vascular Surgery. 43:1191-1197, 2006.

4. Hiatt WR, Wolfel EE, Meier RH, Regensteiner JG. Superiority oftreadmill walking exercise versus strength training for patients withperipheral arterial disease. Implications for the mechanism of thetraining response. Circulation. 90:1866-1874, 1994.

5. National Heart, Lung, and Blood Institute, National Institute ofHealth, US Department of Health and Human Services. The seventhreport of the National Joint Committee on Prevention Detection,and Treatment of High Blood Pressure Express. 7, 2003.

6. National Heart, Lung, and Blood Institute, National Institute ofHealth, US department of Health and Human Services. ExectutiveSummary. Third Report of the National Cholesterol EducationProgram Expert Panel on Prevention Detection, and Treatment ofHigh Cholesterol, Adult Treatment Panel III, 2001.

7. Peripheral Arterial Disease. Retrived October 1, 2007, fromAmerican Heart Association. Website:http://www.americanheart.org/presenter.jhtml?identifier=3020242

8. Regensteiner, J. and Hiatt W. Current Medical therapies for patientswith peripheral arterial disease: a critical review. American Journalof Medicine. 112:49-57, 2002.

9. Rutherford, R.B. Standards for evaluating results of interventionaltherapy for peripheral vascular disease. Circulation. 83(suppl I):6-11,1991.

10. Skinner, J. Exercise Testing and Exercise Prescription for SpecialCases. Third Ed. Philadelphia, PA: Lippincott Williams & Wilkins,2005.

11. Tierney, S., Fennessy, F., & Hayes, D., ABC of arterial and vasculardisease. Secondary prevention of peripheral arterial disease. BritishMedical Journal. 320:1262-1265, 2000.

12. Zwierska, I., Walker, A., Choksy, S., Male, J., Pockly, A., Saxton,J.Relative tolerance to upper-limb and lower-limb aerobic exercise inpatients with peripheral arterial disease. Journal of Vascular Surgery.42:1122-1130, 2005.

About the AuthorNina Markil, B.S., is an exercise physiolo-gist currently completing a Master’s degreein Exercise Science and Health Promotionat Florida Atlantic University. As a gradu-ate assistant, she is currently teaching the undergraduate exer-cise physiology and exercise testing labs. Nina holds herACSM Clinical Exercise Specialist certification, and is a certi-fied Yoga and Spinning instructor. She has worked as an exer-

cise physiologist andfitness instructor inboth clinical and cor-porate settings.

9APRIL/MAY/JUNE 2009 | VOLUME 19; ISSUE 2 ACSM’s Certified NewsACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

Parkinson’s disease (PD) is a neurodegener-ative disease affecting the basal ganglia of thebrain, resulting in a deficiency of the neuro-transmitter dopamine.8 It is the second mostcommon neurodegenerative disease afterAlzheimer’s disease, and affects approxi-mately one million Americans.5 The overallnumber of individuals afflicted by this diseaseis difficult to obtain due to its slow develop-ment; however, it is estimated that 0.3% ofthe entire population and 1% of those overthe age of 60 years suffer from PD.5 Caucasianmales have been reported to be at higher riskcompared to their female counter parts, aswell as African American and Asians.6, 19

These differences, however, may be related tounder-sampling and lower response ratesfrom these ethnic groups in research studiesnot actual racial differences.

ETIOLOGY & PATHOGENESISAlthough the specific etiology of PD

remains unknown, genetic and environmentalfactors have been thought to influence the dis-ease; hence, two hypotheses have been devel-oped to further understand its development;the genetic hypothesis and the environmentaltoxin hypothesis.

The genetic hypothesis is based on the dis-

covery of ten genes associated to familial PD.These genes have been identified to beinvolved in the labeling of proteins for breakdown,4,8 as well as affecting the response tooxidative stress. Hence, why PD usually pres-ents in the later decades of life.8

The environmental toxin hypothesis is sub-stantiated by the discovery of the neurotoxin1-methyl-4-phenyl-1,2,3,6-tetrahydropyri-dine (MPTP) derived from the illicit produc-tion of the analgesic drug Demerol, whichcauses symptoms nearly identical to PD due tothe toxic effect of its metabolism on the sub-strantia nigra neurons- neurons affected byPD.4 This discovery allowed for the under-standing of how exogenous toxins mimic PDlike symptoms and led to the study of herbi-cides and insecticides as possible causes forPD; as they behave similarly to MPTP and actas poisons in the environment.4 This may sug-gest that individuals who live in rural areas,are exposed to pesticides, or drink well water,may be more susceptible to the disease; how-ever, these findings remain equivocal.4

CLINICAL CHARACTERISTICS, PREVENTION,AND TREATMENT

The syndrome of Parkinsonism, of whichParkinson’s disease is the most common(~80% of the cases),4 is defined as any diseasewith a dopamine deficiency resulting intremors at rest, slow movements (bradykine-sia), rigidity, loss of postural reflexes, flexedposture, and the inability to initiate movement(akinesia). A clinical diagnosis can be madewhen either tremors at rest or slow move-ments are present with other symptoms (seetable 1).4 Although the disease mainly affectsmotor functions, with disease progressionother non-motor features can be present (seetable 2).

Due to the nature of the disease and currentlack of identifiable biological markers or con-clusive risk factors, primary prevention is notpossible.17 Secondary prevention, should con-centrate on slowing down the neurodegenera-tive effects of the disease as the patient ages.The three established therapeutic optionsinclude; drug therapy, surgical treatment andrehabilitation.17 These treatment options havebeen well established in the literature and arebeyond the scope of this article.

The following section will concentrate on Parkinsons... Continued on Page 10

Care... Continued from Page 7

the effects of exercise as a therapeutic modal-ity in this population. Additional informationregarding PD, and the use of exercise as atherapeutic modality for these individuals canbe accessed from the National Institute ofNeurological Disorders and Stroke (NINDS)and the National Center on Physical Activityand Disability’s (NCPAD) websites.14, 15

THE EFFECTS OF EXERCISE ON PD The effects of exercise on PD have been less

studied than other chronic conditions, such ascardiovascular disease, diabetes, hypertensionor cancer. Nonetheless, a body of evidenceexists to support the notion that aerobic,resistance and flexibility exercises are benefi-cial for those suffering from PD. Recentlypublished evidence-based guidelines encour-age the use of exercises to improve balance,range of motion and muscular power toimprove functional capacity.11 Enhanced phys-ical function may result in improved activitiesof daily living and promote independence,hence improving quality of life.

One study found heart rate and rate of per-ceived exertion3 to be a useful tool when com-paring individuals with PD during twomaximal-effort exercise tests using an incre-mental protocol on a semi-recumbent cycleergometer.10 Investigators found no differencesbetween peak work rate, heart rate, or rate ofperceived exertion between the two tests. Sug-gesting these variables may be useful whenprescribing exercise to these individuals.

Brigewater and Sharpe3 reported improve-ments in functional ability, as well as increasesin cardiorespiratory fitness among individualsin the early stages of PD. Moreover, an inverse

Parkinson’s Disease

Etiology, Clinical Characteristicsand the role of Exercise.

By Yuri Feito, M.S., M.P.H., RCEPDepartment of Exercise, Sport and Leisure Studies at The University of Tennessee

Table 1: Clinical features of Parkinson’s disease• Tremors at rest• Rigidity• Bradykinesia/hypokinesia/akinesia• Flexed posture of neck, trunk, and limbs• Loss of postural reflexes• Freezing phenomenon

Table 2: Nonmotor features of Parkinson’s Disease

Reference: Protas EJ, Stanley RK. Parkinson's Disease. In:Myers J, Nieman D, editors. ACSM's Resources for ClinicalExercise Physiology: Musculoskeletal, Neuromuscular,Neoplastic, Immunulogic, and Hematologic Conditions.Baltimore, MD: LWW; 2009. p. 44-57.

NEUROPSYCHIATRIC• depression• dementia• anxiety• cognitive decline• psychotic hallucinations• loss of motivation,

apathy

AUTONOMIC• hypotension• urinary problems• gastrointestinal

problems• sexual dysfunction• sweating

SENSORY• pain• paresthesia (pins and

needles)• numbness• akathisia (inability to sit

still)• Fatigue

SLEEP PROBLEMS• difficulty falling asleep• hypersomnolencerestless leg syndrome• sleep fragmentation

PARTICIPATE INA WEBINAR & EARN CECS!

Cancer Exercise TrainerJune 2 – July 7;

Tuesdays at 7:00-8:30PM Eastern

Inclusive Fitness TrainerJuly 13 - August 17;

Mondays at 7:00-8:30PM Eastern

Health Fitness SpecialistJuly 14 – August 18;

Tuesdays at 7:00-8:30PM Eastern

Clinical Exercise SpecialistJuly 16 – August 20;

Thursdays at 7:00-8:30PM Eastern

Register at www.acsm.org/register

CNews19.2Final.JR:Layout 1 5/6/09 2:11 PM Page 9

Self-Test #1: Exercise and HIV

1. As recently as 2003, what percentage of HIV+individuals living in the United States were eitherundiagnosed or unaware of their condition?A. 25% B. 35%C. 40% D. None of the above

2. Which type of exercise training may be the best forindividuals suffering from lipodystrophy as a result ofHIV?A. Aerobic or cardiovascular training B. Resistance or weight trainingC. Combined aerobic and resistance trainingD. None of the above

3. Which of the following would be primary concerns of afitness professional working with the HIV+ population?a. Stage of diseaseb. Current fitness and/or physical activity levelc. Fatigabilityd. All of the above

4. Human immunodeficiency virus (HIV) is a retrovirusthat progressively lowers the body’s CD4+ cell countsand impairs the immune system.A. True B. False

5.The cost of improved immune function and lifeexpectancy for HIV-infected patients on HAART is severemetabolic complications.

A. True B. False

Self-Test #2: Osteoporosis and Osteopenia

1. What type of cells function to degrade bone duringthe remodeling process?A. Osteoblasts B. OsteoclastsC. Osteomasts D. Osteoplasts

2. Osteoporosis is defined by which level of BMD?A. ! 1.0 standard deviations below mean peak

values for young normal adultsB. ! 1.5 standard deviations below mean peak

values for young normal adultsC. ! 2.0 standard deviations below mean peak

values for young normal adultsD. ! 2.5 standard deviations below mean peak

values for young normal adults

3. What percentage of men and women over the age of50 will experience a fracture related to low BMD intheir lifetime?A. 25% of men and 75% of womenB. 25% of men and 50% of womenC. 10% of men and 50% of womenD. 10% of men and 25% of women

4. Many of the exercises recommended to reach peakBMD in young adults are contraindicated for peoplewith osteoporosis.A. True B. False

5. Activities that include trunk flexion are an importantcomponent of an exercise program for ostoeporoticpatients.A. True B. False

APRIL/MAY/JUNE 2009 | VOLUME 19; ISSUE 1 ACSM’s Certified News10

association between cardiorespiratory fitnessand severity of symptoms and depressionscores were reported, demonstrating theimportant role aerobic exercise may play inenhancing functional ability and quality oflife.3

In another aerobic training study, the effectsof a moderate intensity aerobic exercise(60% - 70% heart rate reserve) on movementinitiation, a measurable component of neuro-muscular coordination, was found to be sig-nificantly improved after 16 weeks of aerobictraining.2 Additionally, those in the exercisegroup improved their VO2 PEAK from 19.5ml/kg/min to 24.5 ml/kg/min (26%), as wellas increasing their power output on the cycleergometer by 32% (123 watts to 163 watts);meanwhile the PD-control group showed aslight decline in VO2 PEAK (15.9 ml/kg/min vs.14.1 ml/kg/min; 13%) and in power output(109 watts to 98 watts; 11%). The most sig-nificant finding however was that althoughthe mean movement initiation pre-tests werecomparable between the PD exercise groupand the PD controls, the movement initiationpost-tests for the PD exercise group were sim-ilar to the healthy controls’ pre-test, indicatingimprovements in neuromuscular motor con-trol following the aerobic training program.2

In addition to biological changes in musclewith age, the progressive nature of PD pro-motes the lost of physical conditioning, due toinactivity. Resistance training has demon-strated significant improvements in muscularstrength among healthy adults,13 andresearchers have considered it as a treatmentoption for PD patients; particularly those whohave experienced decreased effects of drug(Levodopa) therapy or have experienced med-ical complications, such as muscle atrophy orphysical injuries associated with falls.

The effects of a rigorous eight-week resist-ance training program on muscular strengthand gait between PD patients and controlswas assessed by Scandalis et al.18 Althoughsignificant increases in abdominal strength

were reported for both groups after training,the PD group performed significantly lowerabdominal exercises compared to the con-trols. Additionally, lower limb strength alsoincreased after eight weeks; however, signifi-cant differences were not observed betweenthe PD and normal groups before or aftertraining. When comparing gait analysis, PDpatients demonstrated a significant increase instride length without a significant change incadence, while the controls did not show anychanges in stride length or cadence. Thesefindings support the notion that PD patientswith mild-to-moderate disease respond simi-larly to a resistance-training program com-pared to healthy controls, even though theymay have limited function.

In a later study, a 12-week eccentric resist-ance training program found significantincreases in muscle volume, as well asimprovements in the six-minute walk test andstair descent and ascent time.7 This studydemonstrated the effects of high-intensityresistance training, thus providing a poten-tially useful modality for patients with PD.High-intensity resistance training may be aneffective mode of exercise allowing PDpatients to increase functional ability, andpromote muscle hypertrophy, leading to func-tional gains.

The use of creatine monohydrate supple-mentation for muscular strength gains hasbeen very popular among healthy individuals.To investigate the effects of a progressiveresistance-training program and creatinemonohydrate supplementation in muscularfitness among patients with diagnosed PDcompared to resistance training alone, investi-gators developed a resistance training pro-gram following the American College ofSports Medicine resistance training guidelines1

with a group of PD patients. They adminis-tered a creatine monohydrate supplement(loading phase 20 g/d for 7 days, maintenancephase 20 g/d 3-5 days/week) and a placebomix.9 After 12 weeks of resistance trainingboth groups significantly increased muscular

Implications... Continued from Page 9 strength. However, the improvements instrength were more pronounced in the crea-tine group (20%) versus the placebo group(12%). Muscular endurance, measured as thenumber of repetitions lifted at 60% of 1RM,also showed improvement between the twogroups, with the creatine group showinggreater improvements in chest press and legextension exercises compared to the placebogroup (38% and 95% vs. 33% and 59%,respectively). Based on these findings, theauthors concluded that resistance trainingwith creatine monohydrate supplementationmight be a beneficial option for patients withPD. The limited restrictions placed on the reg-ulation of dietary supplements demands cau-tion be used by the fitness professional whenworking with PD patients or any other popu-lation. Medical supervision or a recommenda-tion from a licensed dietary professionalwould be prudent, due to the vast amount ofside-effects that accompany many supple-ments.

GENERAL EXERCISE PROGRAMMING FOR PD A general aerobic exercise prescription

should include large muscle group exercisesthree times per week at 60% - 80% peakheart rate. Depending on the individual’sfunctional ability, walking on a treadmill maybe most beneficial. However, a cycle or row-ing ergometer may be more appropriate forthose with decreased mobility. Exercise timeshould be maintained to less than 60 minutesper session, with multiple bouts of 20-30 min-utes, or as tolerated by the individual (seetable 3).

Resistance training exercises for all majormuscle groups have been shown to be effec-tive and should be used. Two to three sessionsper week is preferred, with at least one day offbetween sessions. Individuals should beginwith one set of 8-12 repetitions, with a com-fortable resistance determined by both theindividual and fitness professional. Loadshould be increased when the individual isable to complete 12 repetitions without strainand without compromising safety or posture.

Flexibility exercises should be encouragedone to three times per week. Slow, staticstretches and range of motion exercisesinvolving all major muscle groups and jointsshould be prescribed. The stretch should bemaintained for 20 to 30 seconds, or as toler-ated by the individual. The shoulders andtrunk should be emphasized, as these areasare affected earlier in the disease and may leadto adhesive capsulitis (frozen shoulder) andloss of segmental movement in the spine withdisease progression, limiting upper bodyactivities.16 For a list of specific stretches thatmay be used with these individuals, the readeris referred to the NCPAD website or the workof Lieberman et al.12

ACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

Parkinsons... Continued on Page 12

April–June 2009 Continuing Education Self-TestsCredits provided by the American College of Sports Medicine • CEC Credit Offering Expires on June 30, 2010

Table 3: Exercise Programming for Parkinson’s disease

MODES GOALS INTENSITY/FREQUENCY/DURATION TIME TO GOALAerobic Maintain or improve work capacity 60% – 80% peak HR 3 days/wk ~ 3 monthsLeg & arm ergometry " 60 min/sessionRowing

Endurance Increase work capacity Speed dependent on individualShort walking bouts 4-6 sessions/day(20-30 m; well supervised)

Strength Maintain strength or arms, Use light weightsWeight machines shoulders, legs, and hips 1 set of 8-12 reps, 3 sessions/wk

Flexibility Increase or maintain ROM 1-3 sessions/wkStretching

Functional Maintain capacity to perform ADLs as many ADLs as possiblePosture changes

Reference: Protas EJ, Stanley RK. Parkinson's Disease. In: Durstine JL, More GE, editors. ACSM's Exercise Managementfor Persons with Chronic Diseases and Disabilities. Champaign, IL: Human Kinetics; 2005. p. 295

CNews19.2Final.JR:Layout 1 5/6/09 2:11 PM Page 10

PSelf-Test #4: Parkinson’s Disease

1. Clinical features that affect motor function inParkinson disease patients include tremors at rest,rigidity and...A. Paresthesia B. BradyphreniaC. Passivity D. Bradikinesia

2. Parkinson disease is a degenerative disease affectingthe:A. Medulla B. Basal gangliaC. Brain stem D. Cerebellum

3. The environmental hypothesis is substantiated by thediscovery of which of the following compounds?A. MPTP B. DemerolC. MPP+ D. Paraquat

4. Although the number of individuals afflicted by thedisease is difficult to obtain, what percent of thepopulation over 60 years is estimated to suffer fromParkinson’s Disease?A. 0.5% B. 1.0 %C. 1.2 % D. 1.5 %

5. The genetic hypothesis suggests that most cases ofPD are related to protein degeneration and a(n),hence its presence in the later decades of life.A. Decrease in LevadopaB. Decrease in dopamineC. Increase in toxic proteinsD. Increase in Paraquat

Self-Test #1: Exercise and HIV

1. As recently as 2003, what percentage of HIV+individuals living in the United States were eitherundiagnosed or unaware of their condition?A. 25% B. 35%C. 40% D. None of the above

2. Which type of exercise training may be the best forindividuals suffering from lipodystrophy as a result ofHIV?A. Aerobic or cardiovascular training B. Resistance or weight trainingC. Combined aerobic and resistance trainingD. None of the above

3. Which of the following would be primary concerns of afitness professional working with the HIV+ population?a. Stage of diseaseb. Current fitness and/or physical activity levelc. Fatigabilityd. All of the above

4. Human immunodeficiency virus (HIV) is a retrovirusthat progressively lowers the body’s CD4+ cell countsand impairs the immune system.A. True B. False

5.The cost of improved immune function and lifeexpectancy for HIV-infected patients on HAART is severemetabolic complications.

A. True B. False

Self-Test #2: Osteoporosis and Osteopenia

1. What type of cells function to degrade bone duringthe remodeling process?A. Osteoblasts B. OsteoclastsC. Osteomasts D. Osteoplasts

2. Osteoporosis is defined by which level of BMD?A. ! 1.0 standard deviations below mean peak

values for young normal adultsB. ! 1.5 standard deviations below mean peak

values for young normal adultsC. ! 2.0 standard deviations below mean peak

values for young normal adultsD. ! 2.5 standard deviations below mean peak

values for young normal adults

3. What percentage of men and women over the age of50 will experience a fracture related to low BMD intheir lifetime?A. 25% of men and 75% of womenB. 25% of men and 50% of womenC. 10% of men and 50% of womenD. 10% of men and 25% of women

4. Many of the exercises recommended to reach peakBMD in young adults are contraindicated for peoplewith osteoporosis.A. True B. False

5. Activities that include trunk flexion are an importantcomponent of an exercise program for ostoeporoticpatients.A. True B. False

PSelf-Test #3: PAD

1. ACSM Exercise Guidelines require the patient to:A. Exercise 3-5 days/weekB. Walk at an intensity that elicits claudication pain

within 3-5 minutesC. Accomplish a minimum of 35 minutes of walking

timeD. All are included in the exercise prescription

2. Which of the following exercise modalities should be themain focus of the exercise session?A. Recumbent BikeB. UBEC. TreadmillD. Resistance Training

3. The goal of risk factor modification should include:A. LDL " 100 ml/dLB. Blood pressure "130/80 mmHgC. HbA1c < 7.0D. All are risk factor modification goals

4. A beginning exercise plan for PAD patients will mostlikely require all EXCEPT:A. Non-stop exerciseB. Medical clearanceC. Exercise supervisionD. Encouragement

5. The ACSM claudication pain scale allows patients andprofessionals to assess intensity, at what pain levelshould the activity reach?A. 1- Minimal discomfortB. 2- Moderate painC. 3- Intense painD. 4- Unbearable pain

11APRIL/MAY/JUNE 2009 | VOLUME 19; ISSUE 1 ACSM’s Certified News

strength. However, the improvements instrength were more pronounced in the crea-tine group (20%) versus the placebo group(12%). Muscular endurance, measured as thenumber of repetitions lifted at 60% of 1RM,also showed improvement between the twogroups, with the creatine group showinggreater improvements in chest press and legextension exercises compared to the placebogroup (38% and 95% vs. 33% and 59%,respectively). Based on these findings, theauthors concluded that resistance trainingwith creatine monohydrate supplementationmight be a beneficial option for patients withPD. The limited restrictions placed on the reg-ulation of dietary supplements demands cau-tion be used by the fitness professional whenworking with PD patients or any other popu-lation. Medical supervision or a recommenda-tion from a licensed dietary professionalwould be prudent, due to the vast amount ofside-effects that accompany many supple-ments.

GENERAL EXERCISE PROGRAMMING FOR PD A general aerobic exercise prescription

should include large muscle group exercisesthree times per week at 60% - 80% peakheart rate. Depending on the individual’sfunctional ability, walking on a treadmill maybe most beneficial. However, a cycle or row-ing ergometer may be more appropriate forthose with decreased mobility. Exercise timeshould be maintained to less than 60 minutesper session, with multiple bouts of 20-30 min-utes, or as tolerated by the individual (seetable 3).

Resistance training exercises for all majormuscle groups have been shown to be effec-tive and should be used. Two to three sessionsper week is preferred, with at least one day offbetween sessions. Individuals should beginwith one set of 8-12 repetitions, with a com-fortable resistance determined by both theindividual and fitness professional. Loadshould be increased when the individual isable to complete 12 repetitions without strainand without compromising safety or posture.

Flexibility exercises should be encouragedone to three times per week. Slow, staticstretches and range of motion exercisesinvolving all major muscle groups and jointsshould be prescribed. The stretch should bemaintained for 20 to 30 seconds, or as toler-ated by the individual. The shoulders andtrunk should be emphasized, as these areasare affected earlier in the disease and may leadto adhesive capsulitis (frozen shoulder) andloss of segmental movement in the spine withdisease progression, limiting upper bodyactivities.16 For a list of specific stretches thatmay be used with these individuals, the readeris referred to the NCPAD website or the workof Lieberman et al.12

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Parkinsons... Continued on Page 12

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Moreover, functional training includinggait and balance exercises to prevent falls (acommon consequence of neural degenerationin PD), and exercises specific to activities ofdaily living should be included, emphasizingslow, controlled movements through a fullrange of motion.16 Although significant stud-ies in this area have not been completed, smallstudies have demonstrated some benefit.16

SUMMARY AND CONCLUSIONParkinson’s disease is a neurodegenerative

disease characterized by a decrease indopamine resulting in tremors at rest, slow

movement, rigidity, loss of postural reflexes,flexed posture, and the inability to initiatemovement. Although a number of medicaland surgical therapies are available, the role ofthe fitness professional should focus on atten-uation of the neurodegenerative effects of thedisease by promoting an active lifestyle withinthe capabilities of the individual.

Numerous investigators have establishedthe role of exercise for individuals with PD.Although these studies all share methodologi-cal limitations that may limit their applica-tion, a regular exercise program that includesaerobic, resistance, and flexibility compo-nents, as well as functional exercises, can be

considered a safe and effective option toimprove symptoms and gain functional abilityamong those with PD. Therefore, based onthe information currently available, and withcertain precautions in mind (Box 1-1) practi-tioners are encouraged to follow ACSMguidelines to develop a safe and effective exer-cise training program that enhances and pro-motes functional gains, may limit falling andmay lead to favorable changes in the ability toperform activities of daily living whileimproving quality of life and promoting inde-pendence as long as possible.

About the AuthorYuri Feito, MS, MPH is a graduate teach-ing associate in the Department of Exer-cise, Sport and Leisure Studies at TheUniversity of Tennessee, where he is pursuing a PhD in exer-cise physiology. He holds Master of Science degrees in exer-cise physiology and public health and is a Registered ClinicalExercise Physiologist and Certified Exercise Specialist withthe American College of Sports Medicine.

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Enjoy top-notch educational presentations andunmatched opportunities to network withfellow professionals. In addition, earn valuablecon tinuing education credits to keep yourcertification current. Below is a list of ACSMRegional Chapter meetings:• July 7–11, 2009 – Alaska Chapter Annual

Meeting, Sitka, AK• October 8–9, 2009 – Northland Chapter

Annual Meeting, Wayne, NE• October 15–16, 2009 – Central States Chapter

Annual Meeting, Columbia, MO• October 16–17, 2009 – Midwest Chapter

Annual Meeting, St. Charles, IL• October 23–24, 2009 – Southwest Chapter

Annual Meeting, San Diego, CA• November 5–6, 2009 – New England Chapter

Meeting, Providence, RI• November 6–7, 2009 – Mid-Atlantic Chapter

Meeting, Harrisburg, PA

FOR A COMPLETE LIST(including ACSM’s Annual Meeting in Seattle,

WA—May 27–30, 2009)VISIT WWW.ACSM.ORG/EDUCATION

Parkinsons... Continued from Page 11

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Box 1-1: Things to Consider by the Exercise Professional:

1. Individuals should be screened for additional conditions that may be affected by an exercise program (i.e.,cardiovascular or metabolic diseases, arthritis, and/or musculoskeletal conditions).

2. Exercise prescriptions should be individualized and revised as the disease progresses.3. Provide simple and clear verbal instructions for individuals to follow during each exercise.4. Demonstrate and closely observe the individual when performing all exercises.5. For those with movement difficulties, exercising during medication peak time may be most appropriate to prevent

injury.6. Unassisted walking and/or treadmill exercises may not be appropriate for those with advanced disease, a history of

falls and gait or balance problems.7. Use of other modalities (i.e., stationary or recumbent bicycle, arm ergometer, or swimming/water exercises) should be

considered as appropriate.8. When doing strength training, consider using plate-loaded machines instead of free weights.9. Groups exercise sessions may be beneficial to ensure safety and promote adherence and socialization.

10. Promote independence by instructing caregivers (i.e., spouse, friends, etc.) appropriate exercises to be done at home.

Find Parkinsons References on Page 5

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