Exercise Prescription for Special Populations

Exercise Prescription For Special Populations

David Arnall, Ph.D., PT.David Arnall, Ph.D., PT.

Important Ideas To Remember

Mode of exerciseMode of exerciseIntensity of exerciseIntensity of exerciseDuration of exerciseDuration of exerciseFrequency of exerciseFrequency of exerciseRate of progressionRate of progression

Special Populations

Patients With DiabetesPatients With DiabetesPatients With HypertensionPatients With HypertensionExpectant MothersExpectant Mothers

Patients Who Are HIV +Patients Who Are HIV +Patients With Intermittent Patients With Intermittent

ClaudicationClaudicationPatients In End-Stage Renal FailurePatients In End-Stage Renal FailurePatients With OsteoporosisPatients With Osteoporosis

Patients With Diabetes

There are two types of diabetes with There are two types of diabetes with different exercise prescription needs :different exercise prescription needs :

Type I Diabetes MellitusType I Diabetes MellitusType II Diabetes MellitusType II Diabetes Mellitus

• All diabetics have special needs :All diabetics have special needs :good hydrationgood hydrationadequate blood glucose before adequate blood glucose before

exerciseexerciseaerobic exercise of moderate aerobic exercise of moderate

intensityintensitydo not excessively fatiguedo not excessively fatigue

Type I Diabetes Mellitus

They cannot get adequate glucose They cannot get adequate glucose clearance from the blood because clearance from the blood because their beta cells in the pancreas are their beta cells in the pancreas are not producing insulin. not producing insulin.

With loss of native insulin With loss of native insulin production, they are constrained to production, they are constrained to exogenously supplement themselves exogenously supplement themselves with insulin and to chronically with insulin and to chronically exercise.exercise.

• How does exercise help blood How does exercise help blood glucose clearance ?glucose clearance ?

• Exercise causes the GLUT-4 Exercise causes the GLUT-4 transporters in muscle cells to transporters in muscle cells to migrate to the cell membrane and migrate to the cell membrane and pickup glucose from the circulation.pickup glucose from the circulation.

Acute and chronic exercise improves Acute and chronic exercise improves glycemic control and stimulates glycemic control and stimulates improved GLUT-4 performance and improved GLUT-4 performance and #’s of transporters.#’s of transporters.

These changes are restricted to the These changes are restricted to the muscles that are being trained.muscles that are being trained.

Type I Diabetes

A Suggested Starting Ex. ProgramA Suggested Starting Ex. ProgramMode : AerobicMode : AerobicFrequency : 7 days a weekFrequency : 7 days a weekDuration : 20-30 minutesDuration : 20-30 minutesIntensity : 45% - 85% of Max HRIntensity : 45% - 85% of Max HRBorg Scale : 10 - 14 RPEBorg Scale : 10 - 14 RPE

• Some Ideas :Some Ideas :

– Need to exercise 7 days per week Need to exercise 7 days per week for glycemic control - not worried for glycemic control - not worried about weight controlabout weight control

– Need to check blood glucose every Need to check blood glucose every 30 minutes unless pre-exercise 30 minutes unless pre-exercise blood glucose was very highblood glucose was very high

Type II Diabetes

A Suggested Starting Ex. ProgramA Suggested Starting Ex. ProgramMode : AerobicMode : AerobicFrequency : 4 days a weekFrequency : 4 days a weekDuration : 15 - 60 minutesDuration : 15 - 60 minutesIntensity : 45% - 70% of Max HRIntensity : 45% - 70% of Max HRBorg Scale : 10 - 14 RPEBorg Scale : 10 - 14 RPE

• Some Ideas :Some Ideas :

– Needs to exercise 4-5 days per Needs to exercise 4-5 days per week for weight controlweek for weight control

– Do not need to check blood glucose Do not need to check blood glucose every 30 minutes unless pre-every 30 minutes unless pre-exercise blood glucose was very exercise blood glucose was very lowlow

General Considerations

Avoid exercising during peak insulin Avoid exercising during peak insulin activity for Type I diabeticsactivity for Type I diabetics

Always exercise with a partnerAlways exercise with a partnerCarry money with you so you can Carry money with you so you can

call for helpcall for helpWear good foot wearWear good foot wear

Practice scrupulous foot inspectionsPractice scrupulous foot inspectionsInject the insulin (Type II diabetics) Inject the insulin (Type II diabetics)

in muscle groups not involved in the in muscle groups not involved in the exercise trainingexercise training

Do not exercise if your blood glucose Do not exercise if your blood glucose is in excess of 300 mg/dlis in excess of 300 mg/dl

Learn to monitor your blood glucose Learn to monitor your blood glucose and determine if there is a duration and determine if there is a duration and intensity that regularly and intensity that regularly decreases your blood glucose in a decreases your blood glucose in a dependable fashion.dependable fashion.

If your blood glucose is close to 80 - If your blood glucose is close to 80 - 100 mg/dl pre-exercise, eat before 100 mg/dl pre-exercise, eat before exercisingexercising

Learn to decrease insulin Learn to decrease insulin requirements once exercise is a requirements once exercise is a routine part of your daily scheduleroutine part of your daily schedule

Never take beta-blockers because Never take beta-blockers because they mask the symptoms of they mask the symptoms of hypoglycemiahypoglycemia

Know the signs of hypoglycemia :Know the signs of hypoglycemia :SweatingSweatingLoss of co-ordinationLoss of co-ordinationMood swingsMood swingsDizzinessDizzinessLightheadednessLightheadedness

Tingling In The ExtremitiesTingling In The ExtremitiesHungerHungerHeadachesHeadachesAnxietyAnxiety

IrritabilityIrritabilitySeizuresSeizuresDrowsinessDrowsinessSlurred SpeechSlurred Speech

Patients With Hypertension

Most patients ( 90% ) will have Most patients ( 90% ) will have Essential Hypertension or Essential Hypertension or hypertension of unknown originhypertension of unknown origin

Some may have hypertension due to Some may have hypertension due to renal disease or other causes such as renal disease or other causes such as pheochromocytomapheochromocytoma

It will be important to find out the It will be important to find out the cause for the patient’s hypertension cause for the patient’s hypertension if it does not fall into the category of if it does not fall into the category of essential hypertensionessential hypertension

Categories Of Hypertension

Category Systolic BP Diastolic BP

Normal < 140 < 90

Mild HTN 140 - 159 90 - 99

Moderate HTN 160 - 179 100 - 109

Severe HTN 180 - 209 110 - 119

Very Severe HTN > 209 > 119

Any patient with moderate to severe Any patient with moderate to severe hypertension should be evaluated for hypertension should be evaluated for other coronary artery risk factorsother coronary artery risk factors

Ideally, any male over the age of 40 Ideally, any male over the age of 40 years or a female over the age of 50 years or a female over the age of 50 years must have a GXT before an years must have a GXT before an exercise prescription is written.exercise prescription is written.

Know The Rules

• The American College of Sports The American College of Sports Medicine Medicine Guidelines For Exercise Guidelines For Exercise Testing & PrescriptionTesting & Prescription is the authority is the authority on exercise prescription. Read and place on exercise prescription. Read and place at your disposal the criterion for patient at your disposal the criterion for patient inclusion in and exclusion from exercise inclusion in and exclusion from exercise programs.programs.

ACSM Guidelines Say …….

If the resting pre-exercise blood If the resting pre-exercise blood pressure is >200/115, you should pressure is >200/115, you should consider not exercising at all. The consider not exercising at all. The patient should be referred to their patient should be referred to their physician for improved control.physician for improved control.

If the exercising blood pressure is If the exercising blood pressure is >260/115, you should stop the >260/115, you should stop the exercise bout or at the very exercise bout or at the very minimum reduce the intensity of minimum reduce the intensity of the exercise bout.the exercise bout.

Hypertension

A Suggested Starting Ex. ProgramA Suggested Starting Ex. ProgramMode : AerobicMode : AerobicFrequency : 3 - 4 days/weekFrequency : 3 - 4 days/weekDuration : 15 - 30 minutesDuration : 15 - 30 minutesIntensity : 40% - 70% of SLGXTIntensity : 40% - 70% of SLGXTBorg Scale : 10 - 14 RPEBorg Scale : 10 - 14 RPE

Things To Think About …….

Patients with HTN should :Patients with HTN should :Avoid weight lifting for the first Avoid weight lifting for the first

several weeks of their exercise several weeks of their exercise programprogram

Not routinely be engaged in Not routinely be engaged in isometric exercisesisometric exercises

Avoid exhaustive exerciseAvoid exhaustive exerciseReduce % BF if appropriateReduce % BF if appropriateLimit salt intakeLimit salt intake

Restrict alcohol consumptionRestrict alcohol consumptionStop smokingStop smokingAvoid stressAvoid stress

Expectant Mothers

Pregnancy is not a sickness or a Pregnancy is not a sickness or a disease conditiondisease condition. However, . However, there are several conditions that there are several conditions that you should be aware of that may you should be aware of that may impact the mother’s ability to impact the mother’s ability to exercise.exercise.

The ACSM Guidelines State….

There are absolute contraindications There are absolute contraindications to exercise. They are :to exercise. They are :

heart diseaseheart diseaseruptured membranesruptured membraneshistory or presence of premature history or presence of premature

laborlabor

multiple fetusesmultiple fetusesvaginal or uterine bleedingvaginal or uterine bleedingplacenta previaplacenta previaan incompetent cervixan incompetent cervixhistory of spontaneous abortionshistory of spontaneous abortions

There are relative contraindications There are relative contraindications to exercise. They are :to exercise. They are :

high blood pressurehigh blood pressureanemia or other blood disorderanemia or other blood disorderthyroid diseasethyroid diseasediabetesdiabetes

diabetesdiabetesdysrhythmiasdysrhythmiasbreech presentationbreech presentationexcessive obesityexcessive obesityextreme underweightextreme underweight

• history of bleeding during history of bleeding during pregnancypregnancy

• extremely sedentary lifestyleextremely sedentary lifestyle

• history of intrauterine growth history of intrauterine growth retardationretardation

• history of precipitous birthshistory of precipitous births

Some things to Think About ….

Exercise in a cool environment with Exercise in a cool environment with a low humidity (80:80 rule)a low humidity (80:80 rule)

Wear high quality shoes with good Wear high quality shoes with good arch supportarch support

Be sure the Mother is well hydratedBe sure the Mother is well hydrated

Exercise with a partner in case Exercise with a partner in case Mother needs helpMother needs help

Wear an abdominal supportWear an abdominal supportMake sure that the Mother is well Make sure that the Mother is well

nourishednourishedDo not exhaustively exerciseDo not exhaustively exercise

Patients Who Are HIV +

Persons with HIV may exercise Persons with HIV may exercise according to their desires as long as according to their desires as long as their CD4+ count is above 200/ml. their CD4+ count is above 200/ml. CD4+ counts below this number set CD4+ counts below this number set the condition for a diagnosis of AIDS the condition for a diagnosis of AIDS and exercise should be on a case by and exercise should be on a case by case basis.case basis.

Things To Remember…..

Mild/moderate ex. is immunosupportive - Mild/moderate ex. is immunosupportive - it enables the CD4+ , NK killer cells, and it enables the CD4+ , NK killer cells, and the CD8+ killer cellsthe CD8+ killer cells

Heavy exercise is immunosuppressiveHeavy exercise is immunosuppressive

Patients With Intermittent Claudication

Intermittent claudication (IC) is a Intermittent claudication (IC) is a peripheral vascular disease peripheral vascular disease characterized by leg pain with characterized by leg pain with exercise.exercise.

• Intermittent claudication occurs Intermittent claudication occurs because of obstruction of blood flow because of obstruction of blood flow through the arteries of exercising leg through the arteries of exercising leg muscles. It is the obstruction of muscles. It is the obstruction of blood flow by fatty plagues blood flow by fatty plagues (arteriosclerosis) that leads to the (arteriosclerosis) that leads to the intense pain during exercise.intense pain during exercise.

When the patient walks for several When the patient walks for several minutes, the amount of blood that minutes, the amount of blood that the muscle needs does not perfuse the muscle needs does not perfuse through the obstructed arteries. The through the obstructed arteries. The patient then feels moderately intense patient then feels moderately intense to severe pain.to severe pain.

It has been shown that after a six It has been shown that after a six week exercise program, the patient week exercise program, the patient can walk three times more distance can walk three times more distance without leg pain than before the without leg pain than before the exercise training was begun.exercise training was begun.

A Suggested Starting Ex. ProgramA Suggested Starting Ex. ProgramMode : Aerobic Weight Bearing Mode : Aerobic Weight Bearing

ExercisesExercisesFrequency : 3 days/week Frequency : 3 days/week Duration : QID > BID > QD for Duration : QID > BID > QD for

periods up to 15 - 60 minutesperiods up to 15 - 60 minutesIntensity : Grade II ---> III PainIntensity : Grade II ---> III Pain

Ischemic Grades Pain Descriptors

Grade I Pain Mild Pain - Can Continue

Grade II Pain Moderate Pain - Patient CanBe Diverted From Pain

Grade III Pain Intense Pain - Patient Can'tBe Diverted From Pain

Grade IV Pain Excruciating Pain - MustStop Exercise

Strategies…...

These patients may have to be These patients may have to be convinced to exercise - they must convinced to exercise - they must walk in pain for as long as they walk in pain for as long as they can tolerate it.can tolerate it.

These patients may have to exercise These patients may have to exercise several times a day for small several times a day for small durations of time in order to build durations of time in order to build up to a sustained intensity of steady up to a sustained intensity of steady state exercise.state exercise.

Patients In End-Stage Renal Failure

Renal failure usually occurs in the Renal failure usually occurs in the 4th through the 7th decade.4th through the 7th decade.

The largest single group of patients The largest single group of patients in renal failure are patients with in renal failure are patients with diabetes.diabetes.

Patients in renal failure typically are Patients in renal failure typically are frail individuals and may have frail individuals and may have extensive muscle wasting, HTN, extensive muscle wasting, HTN, hyperlipidemia, muscle cramping, hyperlipidemia, muscle cramping, bone disease, fatigue & psychosocial bone disease, fatigue & psychosocial problems.problems.

Exercise is therapeutic for these Exercise is therapeutic for these patients because it blunts the patients because it blunts the wasting effects of sedentary living.wasting effects of sedentary living.

A Suggested Starting Ex. ProgramA Suggested Starting Ex. ProgramMode : Aerobic - walking, bikingMode : Aerobic - walking, bikingFrequency : 3 days/week Frequency : 3 days/week Duration : 20 - 60 minutesDuration : 20 - 60 minutesIntensity : To ToleranceIntensity : To Tolerance

Considerations……...

These patients should be exercised in These patients should be exercised in the first half of their dialysis session the first half of their dialysis session to avoid the fatigue they experience to avoid the fatigue they experience at the end of dialysis. A recumbent at the end of dialysis. A recumbent bike is useful.bike is useful.

They should be encouraged to walk They should be encouraged to walk and perform weight bearing exercise and perform weight bearing exercise on their off-dialysis days to blunt the on their off-dialysis days to blunt the osteoporosis that many of them osteoporosis that many of them sustain because of sedentary sustain because of sedentary lifestyles.lifestyles.

Patients With Osteoporosis

These patients experience bone These patients experience bone wasting that eventually leads to wasting that eventually leads to pathological fractures of the long pathological fractures of the long bones and the vertebral column - a bones and the vertebral column - a $ 7 billion health care problem.$ 7 billion health care problem.

Type I Osteoporosis

Type I Osteoporosis : occurs with Type I Osteoporosis : occurs with menopause in female patients and is menopause in female patients and is associated with an accelerated loss of associated with an accelerated loss of trabecular bone.trabecular bone.

It is characterized by crush fractures It is characterized by crush fractures of the spine within 20 years after the of the spine within 20 years after the onset of menopause (Ages 50 - 75).onset of menopause (Ages 50 - 75).

• Type I osteoporosis is associated Type I osteoporosis is associated with :with :

estrogen deficiencyestrogen deficiencyincreased bone resorption increased bone resorption

activityactivitytoo much glucocorticosteroid too much glucocorticosteroid

intakeintakealcoholismalcoholism

Type II Osteoporosis

Type II osteoporosis is associated Type II osteoporosis is associated with advancing age (> 70) and with advancing age (> 70) and involves the loss of trabecular and involves the loss of trabecular and cortical bone.cortical bone.

It is characterized by fractured hips It is characterized by fractured hips and wedge fractures of the vertebral and wedge fractures of the vertebral bodies (Ages 70 +).bodies (Ages 70 +).

Other factors effecting osteoporosis :Other factors effecting osteoporosis :SmokingSmokingSedentary - no exerciseSedentary - no exerciseExcessive ETOH consumptionExcessive ETOH consumptionLow dietary calcium intakeLow dietary calcium intakeProlonged amenorrheaProlonged amenorrheaNulliparity - women who bore no Nulliparity - women who bore no

childrenchildren

• By the age of 80 years, 1 out of 3 By the age of 80 years, 1 out of 3 women will fracture their hips while women will fracture their hips while only 1 out of 6 men will experience a only 1 out of 6 men will experience a fractured hip.fractured hip.

• By the age of 90, women have lost By the age of 90, women have lost 50% of their trabecular bone while 50% of their trabecular bone while men have lost only 20% - 25% of men have lost only 20% - 25% of their trabecular bone mass.their trabecular bone mass.

Some Solutions……...

Estrogen replacement therapy Estrogen replacement therapy reduces bone resorption by 50% - reduces bone resorption by 50% - 60% - is enhanced with progesterone60% - is enhanced with progesterone

Calcium supplementation - calcium Calcium supplementation - calcium carbonate is the best supplement - carbonate is the best supplement - 1500 mg/day1500 mg/day

• Fosamax - encourages osteoblasisFosamax - encourages osteoblasis

• Vitamin D - 800 IU per dayVitamin D - 800 IU per day

• Calcitonin - inhibits osteoclasisCalcitonin - inhibits osteoclasis

• Thiazide diuretics cause calcium Thiazide diuretics cause calcium resorption from the glomerular resorption from the glomerular filtratefiltrate

• Testosterone - increases bone mass Testosterone - increases bone mass in men and womenin men and women

• Parathyroid hormone - in Parathyroid hormone - in combination with estrogen helps combination with estrogen helps bone massbone mass

• Bisphosphonates - etidronate, Bisphosphonates - etidronate, residronate, alendronate all inhibit residronate, alendronate all inhibit bone resorptionbone resorption

• Exercise is helpful in blunting the Exercise is helpful in blunting the onslaught of osteoporosisonslaught of osteoporosis

A Suggested Starting Ex. ProgramA Suggested Starting Ex. ProgramMode : Aerobic & Weight BearingMode : Aerobic & Weight BearingFrequency : 3 - 5 days a weekFrequency : 3 - 5 days a weekDuration : 20 - 30 minutesDuration : 20 - 30 minutesIntensity : 50% - 70% of Max HRIntensity : 50% - 70% of Max HRBorg Scale : 10 - 14 RPEBorg Scale : 10 - 14 RPE

Exercise should be weight bearingExercise should be weight bearingTypes of exercise should be varied to Types of exercise should be varied to

take continual stress off of the same take continual stress off of the same jointsjoints

Water aerobics, swimming, kick Water aerobics, swimming, kick boards and wogging are all good for boards and wogging are all good for conditioning even though they are conditioning even though they are not weight bearingnot weight bearing

Water exercises are helpful because Water exercises are helpful because they increase ROM and increase they increase ROM and increase muscle strengthmuscle strength

Rheumatoid Arthritis

• Criterion For Classifying A Patient Criterion For Classifying A Patient With RA - must have 4 out of 7With RA - must have 4 out of 7

• Morning stiffness lasting more Morning stiffness lasting more than 1 hour before improvementthan 1 hour before improvement

• Arthritis in at least 3 joints - Arthritis in at least 3 joints - PIP, MCP, wrist, elbow, knee, PIP, MCP, wrist, elbow, knee, ankle, MTP joints, etc.ankle, MTP joints, etc.

• Simultaneous involvement of Simultaneous involvement of bilateral jointsbilateral joints

• At least one area of involvement At least one area of involvement must be in the wrist, MCP, or must be in the wrist, MCP, or PIP jointPIP joint

• Rheumatoid nodules over bony Rheumatoid nodules over bony prominences or next to jointsprominences or next to joints

• A positive serum rheumatoid A positive serum rheumatoid factorfactor

• Radiological changesRadiological changes

Functional Capacity CriteriaAmerican Rheumatology Association

• Class 1 : complete ability to carry on Class 1 : complete ability to carry on usual duties without handicapsusual duties without handicaps

• Class 2 : adequate ability for normal Class 2 : adequate ability for normal activities despite handicap, activities despite handicap, discomfort, or limited motion at one discomfort, or limited motion at one or more jointsor more joints

• Class 3 : ability limited to little or Class 3 : ability limited to little or none of the duties of usual occupation none of the duties of usual occupation or to self-careor to self-care

• Class 4 : incapacitated, largely or Class 4 : incapacitated, largely or wholly. Bedridden or confined to a wholly. Bedridden or confined to a wheelchair; litle or no self-carewheelchair; litle or no self-care

Clinical Effects Of The Disease

• PainPain

• Lost ROMLost ROM

• Lost joint integrityLost joint integrity

• Reduced work capacity Reduced work capacity

• Muscular weakness & wastingMuscular weakness & wasting

• Onset of osteoporosis & fragilityOnset of osteoporosis & fragility

• Class 1 patients can do any type of Class 1 patients can do any type of exercise but should probably should exercise but should probably should not perform hard physical exercise.not perform hard physical exercise.

• Class 2 & 3 patients may perform Class 2 & 3 patients may perform most types of aerobic exercise as most types of aerobic exercise as long as their disease process is not in long as their disease process is not in an active phase. If the disease an active phase. If the disease process is active & progressive, then process is active & progressive, then no-load light workouts are advised.no-load light workouts are advised.

• Class 4 patients by definition are too Class 4 patients by definition are too incapacitated for weight bearing incapacitated for weight bearing exercise but may participate in non-exercise but may participate in non-weight bearing exercise modes - i.e. - weight bearing exercise modes - i.e. - water exercises where their weight is water exercises where their weight is supportedsupported

Exercise Prescription• ModeMode

• must be matched to the level of must be matched to the level of disease - class 1, 2, 3, or 4disease - class 1, 2, 3, or 4

• must be matched to the number must be matched to the number of involved jointsof involved joints

• must be matched with subjective must be matched with subjective symptoms in mindsymptoms in mind

• Mode Choices Influenced By....Mode Choices Influenced By....• need to be low impactneed to be low impact

• use large muscle groups in a use large muscle groups in a rhythmic slow fashionrhythmic slow fashion

• exercises emphasizing ROMexercises emphasizing ROM

• static exercises for strengthstatic exercises for strength

• Good Mode Choices…..Good Mode Choices…..• Tai Chi Tai Chi

• woggingwogging

• treadmilltreadmill

• stationary or free bikestationary or free bike

• soft or light rebounding soft or light rebounding

• swimming or snorkelingswimming or snorkeling

• Frequency…..Frequency…..• 3-5 days/week3-5 days/week

• variable depending on phase of the variable depending on phase of the disease - remissions or exacerbationsdisease - remissions or exacerbations

• patient education to know when to patient education to know when to rest & postpone exerciserest & postpone exercise

• Duration……Duration……• 15-45 minutes per exercise bout15-45 minutes per exercise bout

• variable day to day depending variable day to day depending on symptomson symptoms

• need to remember longer warm need to remember longer warm up and cool down sessionsup and cool down sessions

• Intensity…..Intensity…..• activity fraction of : .4 - .6 if GXT activity fraction of : .4 - .6 if GXT

data is availabledata is available

• 75% of age-adjusted HR in the non-75% of age-adjusted HR in the non-cardiopulmonary populationcardiopulmonary population

• Borg scale of 10 - 13Borg scale of 10 - 13

• low impactlow impact

• variable day-to-day depending on variable day-to-day depending on the symptomsthe symptoms

• Monitoring the patient during Monitoring the patient during exercise ……exercise ……

• Borg scaleBorg scale

• Dyspnea ScaleDyspnea Scale

• Pain ScalePain Scale

• Blood pressure & HRBlood pressure & HR

• Auscultate the lungsAuscultate the lungs

Resources

• Exercise Testing and Exercise Prescription Exercise Testing and Exercise Prescription For Special Cases : Theoretical Basis & For Special Cases : Theoretical Basis & Clinical Application, 2nd ed., Lea & Fibeger Clinical Application, 2nd ed., Lea & Fibeger Publishers, 1993 by James S. SkinnerPublishers, 1993 by James S. Skinner

• ACSM’s Exercise Management for Persons ACSM’s Exercise Management for Persons with Chronic Diseases & Disabilities, with Chronic Diseases & Disabilities, Human Kinetics Publishers, 1997.Human Kinetics Publishers, 1997.

• Sports & Exercise for Children with Sports & Exercise for Children with Chronic Health Conditions, Human Chronic Health Conditions, Human Kinetics Publishers, 1995 by Barry Kinetics Publishers, 1995 by Barry Goldberg.Goldberg.

• ACSM’s Guidelines for Exercise Testing ACSM’s Guidelines for Exercise Testing & Prescription, 5th edition, Williams & & Prescription, 5th edition, Williams & Wilkins Publishers, 1995.Wilkins Publishers, 1995.

Exercise Prescription for Special Populations

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