By Polly Swingle, PT, GCS, CEEAA
It is not exactly breaking news that exercise is good for you. In fact, the health benefits are significant enough that exercise can be (and often is) justifiably prescribed by a physician as part of a therapeutic or preventative treatment regime. Like medicine, exercise is known to reduce an individual’s risks for a wide range of diseases, to help a patient’s recovery from a disease process or injury, and to reduce the chances of a premature death.
Unlike medicine, however, exercise has not typically come with dosing instructions.
The current (extremely broad) guidelines from governmental and health organizations call for 150 minutes of moderate exercise per week to help build and maintain health and fitness. Unfortunately, that is simply not enough information to be truly useful. Because whether that two and a half hours of exercise represents the minimum amount that someone should be striving for (the smallest effective “dose”) or is instead considered to be the ideal amount of exercise remains uncertain.
For most individuals, medical science has yet to determine whether there is a safe upper limit on exercise, beyond which its negative effects begin to diminish its benefits—or perhaps even becomes potentially dangerous. It is also unclear whether specific intensities of exercise are more effective than others at prolonging lives—although new information is beginning to shed some light on the subject (more on that later).
Rehabilitation and Recovery
Scientists have, however, made more progress identifying the ideal amount of exercise for individuals who suffer from specific diseases and/or conditions. Specifically, researchers have made the determination that, with certain neurological disorders, it is possible to prescribe specific exercise regimens and “dosages” that have been demonstrated to be more effective in facilitating recovery.
Some of the neurological diseases or injuries that are commonly seen in rehab centers have been studied extensively, and the recommended exercise dosages and approaches are as follows:
Parkinson’s disease patients should perform large amplitude movements, with moderate to vigorous intensity; aerobic exercise, with moderate to vigorous intensity; dynamic balance activities, with moderate to vigorous intensity; and engage in dual-tasking exercises. The dosage recommended to optimize health outcomes is to engage in those activities three times a week. Scientific evidence supports the notion that exercising at the above dosage and taking the appropriate Parkinson’s medication provides the best possible benefits for those with the disease.
Multiple Sclerosis (MS)
Individuals with MS should engage in aerobic exercise with moderate intensity; resistive training with moderate intensity—and multiple repetitions to facilitate motor neuroplasticity; functional electrical stimulation (FES) to facilitate motor neuroplasticity; and body weight-supported treadmill training to improve gait speed, endurance, and quality. The recommended dosage is two to three sessions weekly, with each exercise session including all of the above elements.
Traumatic Brain Injuries
Those who have been affected by a cerebrovascular accident (CVA) or stroke, or patients dealing with the effects of a traumatic brain injury (TBI), can enhance their recovery prospects by engaging in aerobic exercise with moderate intensity; multiple repetitions of resistive training at moderate intensity; functional electrical stimulation (FES) for motor neuroplasticity; and body weight-supported treadmill training to improve gait speed, endurance, and step-length symmetry. The recommended dosage is two to three weekly sessions.
Spinal Cord Injuries
The prescription for individuals who are recovering from a spinal cord injury includes regular sessions of functional electrical stimulation (FES) for motor neuroplasticity, control of spasticity, and cardiovascular—as well as additional endurance and a positive overall impact on bone density. Those with incomplete injuries should also include moderate exercise and body weight-supported treadmill training. The frequency and duration of these exercise sessions is case- and patient-specific and will vary depending on the nature and extent of the injury and the individual’s unique circumstances. The most recent studies suggest that an individual with an incomplete SCI never plateaus, and that recovery will continue to progress as long as the central nervous system is stimulated with different forms of exercise.
The effectiveness of a fitness program tailored to individual needs is largely dependent upon using the right equipment and using it correctly. The Recovery Project offers its clients access to several industry-leading machines, including the NuStep Cross Trainer from NuStep LLC, Ann Arbor, Mich, designed to give clients of all fitness levels a total-body workout. A number of circuit strength training machines are also utilized, such as the leg press, rowing machines, hip abduction/adduction machines, and lat pulldown machines. In addition, the clinic’s parallel bars are commonly used to help clients regain balance, mobility, and range of motion. All of the equipment is operated under the instruction of a certified staff to safely facilitate the skilled therapy sessions.
The Insurance Dilemma—and the Wellness Solution
Wellness classes that have been developed to address insurance restrictions not only give patients access to the kind of cutting-edge therapies and exercise programs that incorporate the recommended exercise principles outlined above, but also allow them to benefit from a continuum of care that would have otherwise been inaccessible or impossible.
Unfortunately, individuals who require skilled therapies often do not have the luxury of unlimited insurance benefits that may be required to cover the nature and extent of the therapies needed to achieve optimal recovery. Some leading therapeutic and rehabilitation institutions have recognized this frustrating state of affairs and subsequently began developing wellness programs at a reasonable cost to provide opportunities for their patients to continue to exercise and recover.
Most quality wellness programs should incorporate the following basic elements:
• Aerobic activity. At least 150 minutes of moderate aerobic activity or 75 minutes of vigorous aerobic activity a week, or a combination of moderate and vigorous activity. Guidelines suggest that this exercise should be spread out throughout the week. Moderate aerobic exercise includes activities such as brisk walking, swimming, and mowing the lawn. Vigorous aerobic exercise includes activities such as running and aerobic dancing.
• Strength training. Strength training exercises for all major muscle groups at least two times a week. This should include a single set of each exercise, using a weight or resistance level heavy enough to fatigue muscles after 12 to 15 repetitions. Strength training can include the use of weight machines, exercises that feature body-weight resistance, resistance tubing, resistance paddles in the water, or activities such as rock climbing.
Therapeutic Exercise Technologies
The quality of a wellness program is also impacted by the exercise equipment made available to clients. Perceptions about the program can be positively affected by equipment that appears to be clean, up to date, and safe for use. Whether new or used, the equipment in the PT gym should be in excellent working condition and able to withstand heavy use, so the service options any equipment provider offers should be weighed as part of the purchase decision.
Professional-quality treadmills, for example, are an important piece of equipment for many fitness programs that will get a lot of use, and several sources provide treadmills designed especially for clinical use to the therapy market. Some of the desirable features found on models in the current market include session data tracking that can measure, record, and compare results; these features are found on the SciFit AC5000M Medical Treadmill from SciFit, Tulsa, Okla. Another device, the MT200 Gait Trainer Treadmill from Dyaco/Spirit Fitness, can provide data about basic gait assessment and training with graphical and numeric measurements. It is also built with a bidirectional belt and adjustable full-length handrails.
Expanding the feature set strength and endurance technologies is the AlterG Anti-Gravity Treadmill from AlterG, Fremont, Calif. This is a highly specialized treadmill that uses air to reduce gravitational load, thereby allowing natural gait mechanics and unrestricted movement. And, for a stair climbing dimension the Dynamic Stair Trainer DST8000 Triple Pro from Clarke Health Care Products, Oakdale, Pa, is built with remote-controlled elevating steps that allow clients to begin their stair-climbing work at a level commensurate with their ability. The DST8000 Triple Pro also displays the user’s current and past session performance.
The following companies provide equipment for therapeutic exercise and fitness:
An Emerging Science
Several recent studies have finally begun to shed a little light on the benefits and limitations of various types of exercise, and to provide the kind of prescriptive specificity that has long been lacking in this space.
One study in particular examined exercise habits and their effect on individuals as they age—looking at more than 661,000 adults, most of whom were middle-aged. Researchers stratified the adults by their weekly exercise time, ranging from those who did not exercise at all, to those who worked out for 10 times the current recommendations or more (meaning that they exercised moderately for 25+ hours per week). They then cross-referenced that data against 14 years’ worth of mortality records for the group. The results were intriguing.
Subjects who did not exercise at all were at the highest risk for early death. But those who exercised a small amount (ie, not meeting the recommendations, but at least doing something) lowered their risk of premature death by 20%. Those who exercised in precise accordance with the guidelines, engaging in 150 minutes of moderate exercise weekly, enjoyed greater longevity benefits and a 31% reduced risk of dying during the 14-year period relative to those who never exercised. The “sweet spot” for exercise benefits, however, turned out to be among those individuals who tripled the recommended level of exercise, working out moderately (mostly walking) for 450 minutes per week, or a little more than an hour a day. Individuals in that group were 39% less likely to die prematurely than their sedentary counterparts. At that point, the benefits plateaued—but they never significantly declined. Those rare individuals who engaged in 10 times or more the recommended exercise allotment gained about the same reduction in mortality risk as those who simply met the guidelines.
A Prescription for Health (the Bottom Line)
As a general goal, most individuals should aim for at least 30 minutes of moderate physical activity every day. For individuals who want to lose weight, maintain weight loss, or meet specific fitness goals, a greater amount of exercise may be required. Those looking to aim higher can potentially achieve additional health benefits by ramping up their exercise regime to include 300 minutes or more a week.
Reducing sitting time is important, too. The more hours spent seated each day, the higher a person’s risk of metabolic problems, which can impact health and longevity. Of note, this phenomenon is observed even in those who achieve the recommended daily dose of physical activity.
Finally, recognize that exercise is possible even for those with busy schedules or other limitations. Even small amounts of physical activity are helpful, and accumulated activity throughout the day adds up to provide a potentially meaningful health benefit. If a 30-minute walk isn’t doable, try a few 5-minute walks instead. Any activity is better than none at all. Ultimately, what is most important is making regular physical activity part of one’s lifestyle. PTP
Polly Swingle, PT, GCS, CEEAA, is co-founder and lead physical therapist of The Recovery Project (www.therecoveryproject.net), which provides progressive, effective, evidence-based neuro rehab therapies that improve the quality of life and functionality of patients with spinal cord, neurological, and traumatic brain injuries at its three Michigan-based locations. For more information, contact PTPEditor@medqor.com.