Fitness And Rehabilitation
DEFINING FITNESS
Physical fitness is to the human body what fine tuning is to an engine. It enables us to perform up to our potential. Fitness can be described as a condition that helps us look, feel and do our best. More specifically, it is:
“The ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure- time activities and meeting emergency demands. It is the ability to endure, to bear up, to withstand stress, to carry on in circumstances where an unfit person could not continue, and is a major basis for good health and well-being.”
Physical fitness involves the performance of the heart and lungs, and the muscles of the body. And, since what we do with our bodies also affects what we can do with our minds, fitness influences to some degree qualities such as mental alertness and emotional stability.
As you undertake your fitness program, it’s important to remember that fitness is an individual quality that varies from person to person. It is influenced by age, sex, heredity, personal habits, exercise and eating practices. You can’t do anything about the first three factors. However, it is within your power to change and improve the others where needed.
KNOWING THE BASICS
Physical fitness is most easily understood by examining its components, or “parts.” There is widespread agreement that these four components are basic:
Cardiorespiratory Endurance - the ability to deliver oxygen and nutrients to tissues, and to remove wastes, over sustained periods of time. Long runs and swims are among the methods employed in measuring this component.
Muscular Strength - the ability of a muscle to exert force for a brief period of time. Upper-body strength, for example, can be measured by various weight-lifting exercises.
Muscular Endurance - the ability of a muscle, or a group of muscles, to sustain repeated contractions or to continue applying force against a fixed object. Pushups are often used to test endurance of arm and shoulder muscles.
Flexibility - the ability to move joints and use muscles through their full range of motion. The sit-and- reach test is a good measure of flexibility of the lower back and backs of the upper legs.
Body Composition is often considered a component of fitness. It refers to the makeup of the body in terms of lean mass (muscle, bone, vital tissue and organs) and fat mass. An optimal ratio of fat to lean mass is an indication of fitness, and the right types of exercises will help you decrease body fat and increase or maintain muscle mass.
A WORKOUT SCHEDULE
How often, how long and how hard you exercise, and what kinds of exercises you do should be determined by what you are trying to accomplish. Your goals, your present fitness level, age, health, skills, interest and convenience are among the factors you should consider. For example, an athlete training for high-level competition would follow a different program than a person whose goals are good health and the ability to meet work and recreational needs.
Your exercise program should include something from each of the four basic fitness components described previously. Each workout should begin with a warmup and end with a cooldown. As a general rule, space your workouts throughout the week and avoid consecutive days of hard exercise.
Here are the amounts of activity necessary for the average healthy person to maintain a minimum level of overall fitness. Included are some of the popular exercises for each category.
WARMUP - 5-10 minutes of exercise such as walking, slow jogging, knee lifts, arm circles or trunk rotations. Low intensity movements that simulate movements to be used in the activity can also be included in the warmup.
MUSCULAR STRENGTH - a minimum of two 20-minute sessions per week that include exercises for all the major muscle groups. Lifting weights is the most effective way to increase strength.
MUSCULAR ENDURANCE - at least three 30-minute sessions each week that include exercises such as calisthenics, pushups, situps, pullups, and weight training for all the major muscle groups.
CARDIORESPIRATORY ENDURANCE - at least three 20-minute bouts of continuous aerobic (activity requiring oxygen) rhythmic exercise each week. Popular aerobic conditioning activities include brisk walking, jogging, swimming, cycling, rope-jumping, rowing, cross-country skiing, and some continuous action games like racquetball and handball.
FLEXIBILITY - 10-12 minutes of daily stretching exercises performed slowly, without a bouncing motion. This can be included after a warmup or during a cooldown.
COOL DOWN - a minimum of 5-10 minutes of slow walking, low-level exercise, combined with stretching.
A MATTER OF PRINCIPLE
The keys to selecting the right kinds of exercises for developing and maintaining each of the basic components of fitness are found in these principles:
SPECIFICITY - pick the right kind of activities to affect each component. Strength training results in specific strength changes. Also, train for the specific activity you’re interested in. For example, optimal swimming performance is best achieved when the muscles involved in swimming are trained for the movements required. It does not necessarily follow that a good runner is a good swimmer.
OVERLOAD - work hard enough, at levels that are vigorous and long enough to overload your body above its resting level, to bring about improvement.
REGULARITY - you can’t hoard physical fitness. At least three balanced workouts a week are necessary to maintain a desirable level of fitness.
PROGRESSION - increase the intensity, frequency and/or duration of activity over periods of time in order to improve.
Some activities can be used to fulfill more than one of your basic exercise requirements. For example, in addition to increasing cardiorespiratory endurance, running builds muscular endurance in the legs, and swimming develops the arm, shoulder and chest muscles. If you select the proper activities, it is possible to fit parts of your muscular endurance workout into your cardiorespiratory workout and save time.
MEASURING YOUR HEART RATE
Heart rate is widely accepted as a good method for measuring intensity during running, swimming, cycling, and other aerobic activities. Exercise that doesn’t raise your heart rate to a certain level and keep it there for 20 minutes won’t contribute significantly to cardiovascular fitness.
The heart rate you should maintain is called your target heart rate. There are several ways of arriving at this figure. One of the simplest is: maximum heart rate (220 - age) x 70%. Thus, the target heart rate for a 40 year-old would be 126.
Some methods for figuring the target rate take individual differences into consideration. Here is one of them:
- Subtract age from 220 to find maximum heart rate.
- Subtract resting heart rate (see below) from maximum heart rate to determine heart rate reserve.
- Take 70% of heart rate reserve to determine heart rate raise.
- Add heart rate raise to resting heart rate to find target rate.
CONTROLLING YOUR WEIGHT
The key to weight control is keeping energy intake (food) and energy output (physical activity) in balance. When you consume only as many calories as your body needs, your weight will usually remain constant. If you take in more calories than your body needs, you will put on excess fat. If you expend more energy than you take in you will burn excess fat.
Exercise plays an important role in weight control by increasing energy output, calling on stored calories for extra fuel. Recent studies show that not only does exercise increase metabolism during a workout, but it causes your metabolism to stay increased for a period of time after exercising, allowing you to burn more calories.
How much exercise is needed to make a difference in your weight depends on the amount and type of activity, and on how much you eat. Aerobic exercise burns body fat. A medium-sized adult would have to walk more than 30 miles to burn up 3,500 calories, the equivalent of one pound of fat. Although that may seem like a lot, you don’t have to walk the 30 miles all at once. Walking a mile a day for 30 days will achieve the same result, providing you don’t increase your food intake to negate the effects of walking.
If you consume 100 calories a day more than your body needs, you will gain approximately 10 pounds in a year. You could take that weight off, or keep it off, by doing 30 minutes of moderate exercise daily. The combination of exercise and diet offers the most flexible and effective approach to weight control.
Since muscle tissue weighs more than fat tissue, and exercise develops muscle to a certain degree, your bathroom scale won’t necessarily tell you whether or not you are “fat.” Well-muscled individuals, with relatively little body fat, invariably are “overweight” according to standard weight charts. If you are doing a regular program of strength training, your muscles will increase in weight, and possibly your overall weight will increase. Body composition is a better indicator of your condition than body weight.
Lack of physical activity causes muscles to get soft, and if food intake is not decreased, added body weight is almost always fat. Once-active people, who continue to eat as they always have after settling into sedentary lifestyles, tend to suffer from “creeping obesity.”
CLOTHING
All exercise clothing should be loose-fitting to permit freedom of movement, and should make the wearer feel comfortable and self-assured.
As a general rule, you should wear lighter clothes than temperatures might indicate. Exercise generates great amounts of body heat. Light-colored clothing that reflects the sun’s rays is cooler in the summer, and dark clothes are warmer in winter. When the weather is very cold, it’s better to wear several layers of light clothing than one or two heavy layers. The extra layers help trap heat, and it’s easy to shed one of them if you become too warm.
In cold weather, and in hot, sunny weather, it’s a good idea to wear something on your head. Wool watch or ski caps are recommended for winter wear, and some form of tennis or sailor’s hat that provides shade and can be soaked in water is good for summer.
Never wear rubberized or plastic clothing, such garments interfere with the evaporation of perspiration and can cause body temperature to rise to dangerous levels.
The most important item of equipment for the runner is a pair of sturdy, properly-fitting running shoes. Training shoes with heavy, cushioned soles and arch supports are preferable to flimsy sneakers and light racing flats.
WHEN TO EXERCISE
The hour just before the evening meal is a popular time for exercise. The late afternoon workout provides a welcome change of pace at the end of the work day and helps dissolve the day’s worries and tensions.
Another popular time to work out is early morning, before the work day begins. Advocates of the early start say it makes them more alert and energetic on the job.
Among the factors you should consider in developing your workout schedule are personal preference, job and family responsibilities, availability of exercise facilities and weather. It’s important to schedule your workouts for a time when there is little chance that you will have to cancel or interrupt them because of other demands on your time.
You should not exercise strenuously during extremely hot, humid weather or within two hours after eating. Heat and/or digestion both make heavy demands on the circulatory system, and in combination with exercise can be an overtaxing double load.
REHABILITATION
Rehabilitation focuses on function. Being able to continue to function is key to maintaining or regaining independence and quality of life, particularly after an illness or injury. Starting rehabilitation early can help you maintain function and increase your chances of returning to your previous level of function as much as possible.
In restorative rehabilitation, the goal is to restore a function that you have lost. It is often funded by Medicare or other payers. Examples include short-term rehabilitation that usually follows a stroke or a hip fracture. In maintenance rehabilitation, the goal is to maintain and strengthen a function. Maintenance rehabilitation is less intense, with physical therapy or occupational therapy continued three times a week as an outpatient. With longer-term therapy, possibly more function can be gained or more functional loss can be prevented.
Settings for Rehabilitation Programs
Rehabilitation can take place in many types of settings:
- special units in acute care hospitals or rehabilitation hospitals
- nursing facilities
- outpatient centers
- homes
- private offices
Special rehabilitation units
Rehabilitation programs within hospitals or special rehabilitation hospitals use a multidisciplinary team approach, which involves the combined efforts of many specialists. The members of the rehabilitation team focus on different parts of health and manage different rehabilitation activities. The specific team members will vary significantly depending on the specific disability and situation.
In general, to qualify for Medicare or other insurance coverage of comprehensive rehabilitation at the hospital level, the person must need the following:
- close medical supervision and care by a rehabilitation physician
- rehabilitation nursing on a 24-hour basis
- participation in more than one discipline, such as physical therapy, occupational therapy, and speech therapy
- a team approach to therapy, with a coordinated rehabilitation program
- clear, realistic goals in rehabilitation, with the expectation of significant improvement during the rehabilitation program
Nursing facilities
In this setting, maintaining function may be the goal of care. In contrast to the Medicare requirements for the hospital level of rehabilitation, the requirements for insurance coverage at the nursing level of rehabilitation do not include occupational therapy, a multidisciplinary approach, or the services of a rehabilitation physician. However, the requirements do specify that a person must need daily physical therapy and skilled nursing care and that continued, significant functional improvement must be documented. To be eligible for skilled nursing benefits through Medicare, the person must have had a hospital stay of at least 3 days in the past 30 days. The length of Medicare coverage for rehabilitation in nursing homes is limited.
Outpatient rehabilitation
Outpatient rehabilitation offers a wide range of services from private practitioners’ offices that offer fee-for-service care, to outpatient rehabilitation facilities that provide the same comprehensive team efforts as in hospital rehabilitation units. Generally, these outpatient units are appropriate for people with short-term illnesses, such as low back pain or minor trauma. Other services may be appropriate for people who need follow-up services after being discharged from a rehabilitation hospital or for whom an inpatient rehabilitation program is not suitable. Often, the availability of transportation is what determines whether the person can participate in an outpatient rehabilitation program.
Home-based rehabilitation
Home-care rehabilitation programs can be an important part of follow-up care for people who have been discharged from any type of inpatient rehabilitation program. In addition, home rehabilitation services can help provide short-term or maintenance therapy. Medicare provides home-health benefits to patients who need intermittent or part-time skilled nursing care and therapy services, and who are homebound or leave the home only occasionally. Physicians must certify the person for services, but they are rarely involved in the supervision of care. There is no requirement for prior hospitalization, and there is no limit on the number of visits a person may receive but only for the time that the person needs to have a nurse come to his or her home. Home-health services provide skilled nursing and home-health aides, therapeutic services, medical and social services, and supplies.
Advantages and disadvantages
Each site of care has advantages and disadvantages. Inpatient care is the most intense but may not be possible for frail elderly patients, because it requires 3 hours per day of active (and tiring) therapy. Skilled nursing offers 24-hour care for those who cannot care for themselves or do not have a full-time caregiver. Patients often prefer to return to their own homes for outpatient services, but the care-giving they need may not be available. Participation in a day hospital or outpatient clinic requires transportation, which can be costly and time consuming.
Rehabilitation for Specific Diseases
Several common diseases of old age usually require rehabilitation. These include stroke, hip fracture, and diseases that result in amputation being necessary (eg, severe problems with circulation).
Stroke rehabilitation
Most stroke therapy programs take place in a rehabilitation hospital, a rehabilitation unit in an acute-care hospital, or a nursing facility. Patients with acute stroke who receive coordinated, multidisciplinary evaluation and services do better than patients who do not. The goal of physical therapy in these programs is the ability to walk safely again, usually using a cane, walker, or other assistive device. Generally, occupational therapists address problems with weakness and coordination of the arms, as well as with difficulties in thinking or perception. For people who have difficulty speaking, speech therapists develop specific treatment programs that include trying to restore speech ability and, if necessary, developing another way to communicate.
After someone suffers a stroke, a speech or occupational therapist may evaluate how well the person can swallow. Difficulty swallowing is a common complication of strokes that frequently is not recognized.
The involvement and education of family or caregivers during the stroke rehabilitation program is crucial to the entire rehabilitation process. This is important in establishing the appropriate goals for rehabilitation and in planning for discharge. Before the patient is discharged, physical and occupational therapists generally visit the home to evaluate it for safety and the need for any adaptive equipment. Depression after a stroke is common and may also seriously affect rehabilitation.
Prevention
Someone who has had one stroke is at very high risk for a second stroke. The rehabilitation phase is a good time to make sure that risk factors for stroke have been evaluated and any preventive treatments are started. For example, narrowing of the arteries that go to the brain (eg, carotid arteries) and certain heart conditions can lead to stroke. If someone has one or both of these conditions, the use of aspirin or other blood thinners might be considered. Other risk factors to investigate include smoking, high blood pressure, high cholesterol levels, and diabetes.
Hip fracture rehabilitation
The goal of rehabilitation for people who have had a hip fracture is to regain as much function as possible. Rehabilitation focuses on physical therapy to strengthen the leg muscles. Stronger leg muscles can prepare the person for walking and can also help keep a hip fracture that has been fixed with pins or screws more stable. During therapy, arm muscles are also strengthened to help with use of walking aids such as walkers. In addition, arm strength and function are important for bathing and dressing, which may be affected by the leg problems. Generally, people progress from using a walker, to using a wide-based four-prong cane, to walking with a single-point cane, and hopefully eventually to walking without any aid at all, although many people still need a walking aid even a year after a fracture.
Several factors influence both the course and outcome of rehabilitation after a hip fracture. Whether a person can stand bearing their full weight depends on the type and severity of the fracture and the surgery. Most people are allowed to put full weight on their leg the first day after surgery. People who are able to bear their full weight early on generally need less physical therapy than others. What kind of shape the person was in before the surgery is also very important. Unfortunately, some people are not able to fully recover after a hip fracture, and may need to either have someone move in with them or move to a nursing home.
Prevention
People who fracture a hip often have a tendency to all and osteoporosis (brittle bones), which puts them at increased risk of more fractures. Key parts of rehabilitation include the following:
- treating osteoporosis
- improving balance
- reducing the risk of injury