a viscous cyclelenorsjourney.com/lf physical reconditioning.pdfa program of regular exercise can...

PHYSICAL CONDmONING

A VISCOUS CYCLEShortness of breath and weakness are two common problems of

persons with a chronic lung disease. In order to avoid shortness ofbreath, many people stop doing some of the activities that make themshort of breath. This leads to muscles that are out of shape or"deconditioned". Deconditioned muscles are inefficient and use moreoxygen than muscles that are conditioned. Eventually deconditionedmuscles become even weaker and the person becomes short of breathwith activity. A vicious cycle can result in less and less activity and moreshortness of breath.

A program of regular exercise can help break this vicious cycle.Exercise can help strengthen your muscles and make them moreefficient (require less oxygen to do the same amount of work). The goalof getting in shape from exercise is to make you stronger, improve yourendurance and make you better able to do things with less shortness ofbreath.

A conditioning program can involve many types of exercises. Inpulmonary rehabilitation, there are three major types of exercises used:

.:. FLEXIBILITY EXERCISES: designed to increase the mobility ofyour muscles and joints. Examples include range of motion and

gentle stretching exercises..:. MUSCLE TONING OR STRENGTH BUILDING EXERCISED: designed to

make your muscles more efficient and stronger. Examplesinclude arm curls with small weights and working againstresistance (watch out, muscle men and women!!!)

.:. ENDURANCE BUILDING EXERCISES: designed to increase yourstamina. Examples include stationary biking, walking, andswimming for the lower extremities and arm lifts with a dowel forthe upper extremities.

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CONCEPTS TO KEEP IN MIND

.:. DURATIONDuration refers to the length of time you exercise for. As youprogress through your exercise program, longer duration helps youincrease your exercise capacity. For example, if your goal is to beable to walk longer without breathlessness, you need to work onsustaining your endurance exercises for longer periods of time. A15 minute walk helps more with stamina than a 5 minute walk.

.:. FREQUENCYFrequency refers to the number of times a week you do the activity.In order to get the best benefit from exercise, it must be done on aregular basis. Generally, strength-building exercises are done on anevery other day basis, endurance building exercises are done 3-5days a week and flexibility exercises are done 5 or more days aweek. The pulmonary rehabilitation staff will help you determinethe frequency of each type of exercise.

.:. INTENSITYIntensity refers to the degree of effort you put into your exercises.At the beginning of an exercise program, intensity is low. Forexample, walking is done at a slow to moderate pace until you reacha certain duration. Intensity is increased by increasing your speedor adding on stairs or incline. In strength training, weights orresistance increase intensity. The pulmonary rehabilitation staff willhelp you determine the intensity you should exercise at.

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BEFORE YOU BEGIN

Keep in mind these principles of exercise:

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To get the benefit from exercise, it must be done on a regularbasis (frequency) and for enough durationStalt slowly, build up gradually. This means begin your exerciseprogram where you are at. If you have not exercised for yearsor if you are recovering from an acute episode of your lungdisease, start with low level exercise and increase the numberand difficulty of the exercises gradually.Any exercise session should consist of a warm up period, a workphase and cool down period. This is particularly important withthe endurance building exercises as these tend to make yourheart beat faster, and your breathing faster.Remember your breathing exercises. Do the hardest palt of thework while exhaling. EX:EX- EXhale while EXerting. (Clever,aren't we?)Exercise at the time of day you feel best, when your breathing isat its best and you have a reasonable amount of energy.Keep a record of what you do each day--a diary or calendar maybe helpful. It is nice (and encouraging) to have a written accountof the progress you are making. A sample exercise log isincluded..Avoid high-level endurance activities when the weather or airquality is not good. Hot and humid days are bad for some, cold,windy, damp and stormy days are bad for most. It is good tohave an alternative activity you can do indoors on bad days:stationary biking, mall or grocery store. walking, or low impactmarching in place are alternatives to being outside.Wait one and a half to two hours after eating a meal to exercise,particularly vigorous exercise. Eating and digestion require a lotof energy.

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NORMAL FEELINGS WITH EXERCISE (i n other words I don'tworry)./ mild shortness of breath or increased awareness of breathing./ sweating - your body is trying to maintain normal temperature

, mi Id fatigue

./ some soreness in the belly of the muscle (especially as you begin).~ Shooting pains in the muscles or joints are never normal and

may mean you are doing the exercise incorrectly. Consult yournurse or therapist for instruction.

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INCREASING FLEXIBILITY

Many people with lung disease suffer from tightness or pain in theirmuscles and joints. Particular areas that may suffer from lack of flexibilityinclude the neck, shoulders, back and calves. Discomfort may comefrom poor posture, increased tension, holding your neck and shoulderstight during times of breathing difficulty or failure to stretch afterexercise.

EXERCISES FOR STRETCHING

Flexibility exercises should be done slowlyand gently. Stretches shouldbe held for 20-30 seconds to get the best benefit. Breathe during thestretches.

. Calf stretches. Stand and lean against the wall, with one leg infront of the other. Keep your back leg straight and your heel downon the floor. lean forward into your front leg and bend that knee.You should feel the stretch In your back leg. Repeat on the oppositeleg.

Quadriceps stretches. Hold onto something for balance. Bringyour right heel up in back and hold onto your ankle with your righthand. Gently pull back on your ankJe until you feel a stretch in yourthigh. Be careful not to strain your knee. Repeat on the other leg.You could also rest your knee that's stretching on a chair to help youbalance better

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~ If you have special problems with your muscles,bones or joints (such as osteoporosis, arthritis orspine problems) ask your doctor, nurse orphysical therapist if these exercises are safe foryou.


GETTING YOUR ARMS IN SHAPESome of the shortness of breath you may be experiencing may be

from arms that are out of shape. Toning your arm muscles may makeyou tire less easily when performing over the head activities, such asbrushing and washing your hair, reaching for objects and so on.

If exercising both arms at the same time is too tiring, do theexercises one arm at a time. Do each exercise five times to start, thenincrease by five until you are doing each one 20 to 25 times each. If theexercises become too easy, you can add on small weights (1 to 2pounds) to add more resistance and increase muscle tone.

. EXERCISE 1 (warming up): Begin with both arms at you sides.Inhale as you swing your arms out from you sides and bring yourfinger tips together above your head. Exhale as you lower them backdown to your sides.

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. EXERCISE 2 (muscle toning): Inhale with your arms at your sides in arelaxed position. Exhale as you make fists, tighten your arms andbend your elbows (a POPEYE muscle!). Inhale as you relax your armsdown and exhale again to make your muscle.

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. EXERCISE 3 (muscle toning): Inhale with your arms relaxed at yoursides. Exhale as you straighten your arms out behind you, and liftthem up to shoulder level while continuing to exhale. Inhale as youbring your arms back down to a relaxed position. Exhale as youstraighten them out behind you again.

. EXERCISE 4 (muscle toning and endurance): Inhale as you bendyour arms and hold each shoulder with the opposite hand (crossingthem in front of you). Exhale as you straighten each arm out at yoursides at shoulder level.

Pulmonary RehabilitationNorwalk Hospital. Norwalk CT

. EXERCISE 5-the reach and grab (muscle toning and endurance):Reach up with you right hand as you inhale. Exhale as you make afist and pull it down to your side. Repeat on the left. Alternate arms.To make this one harder, reach up with both hands while Inhaling.Make fists and pull your arms down while exhaling. .

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. EXEROSE 6-the arm swing (muscle toning and endurance): Swingyour arm way up and forward while Inhaling, then way back whileexhaling. You can also do this exercise continuously, swinging yourarms in opposite directions. You need to get a rhythm going withyour breathing, (for example when you raise your right arm, inhale,then exhale while swinging your arms 2 to 3 times).

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. EXERCISE 7-arm circles (muscle toning and endurance): Place youright arm strait out to your side, at shoulder level, with your fingerspointing up. Move your arm forward in a small circle while inhaling.Continue making 2 to 3 circles while exhaling. Inhale again duringone circle, and exhale while making 2 to 3 circles. You can also dothe exercise making backward circles. Repeat on the left.


UNSUPPORTED ARM EXERCISE WITH THE DOWEL

A Physician by the name of Celli has done work on unsupported armexercises for people with lung disease. The goal of unsupported armexercise is to decrease the amount of shortness of breath a person mayexperience with arm activities - mopping, vacuuming, raking, making

beds, dressing, combing/washing hair, etc. Celli used a dowel to helpwith the exercise. A dowel is a wooden pole (similar to a broomhandle); We use a 4 ft by 1 inch dowel.

DOWEL TRAINING

.:. Sit in a straight-backed chair with your back supported. Hold a dowel,broom handle or cane in your hands with your arms straight out in frontof you.

.:. Raise and lower your arms from 2 Inches above your knee to eye levelwhile breathing in and out.

.:. Start by lifting and lowering for one full minute without stopping.

.:. Repeat for 2 more sets.

.:. Each week add to the length of each set. For example, lift for one and ahalf minute; gradually build up until you can lift for 2 minutes withoutstopping. Keep the rest periods at 1 to 2 minutes. Build up the totalnumber of sets to 7 to 8 at 2 minutes each ( a total of 15 minutes oflifting and 15 minutes of resting).

.:. Start by doing the exercises every other day. Once you're at amaintenance program, you can maintain fitness by doing it three days aweek.

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MAKING YOUR LEGS STRONG

Strong legs are important for increasing your endurance for

exercises such as walking and climbing stairs. Muscles In your calves

and thighs help to support your weight. Many of you are already doing

some sort of endurance training such as walking, biking or swimming to

improve your stamina and decrease the amount of shortness of breath

you have with activities. You still may be having some trouble with

walking, stairclimbing and every day activities like getting out of a chair

more easily. In addition, some of you may be taking corticosterolds

(prednisone, medrol, etc.) which may weaken some of your leg

muscles.

Research from Tufts University has demonstrated the benefits of

strength training for the legs as part of a well-rounded exercise program.

Strength training improves muscles' mass (size) and power (ability to lift,

pull, push).

BEFORE YOU BEGIN

If you have very weak muscles, have muscle or bone problems,

are unsteady on your feet or have recently been acutely sick, you should

check with your doctor before trying these exercises. It may also help

to have your rehabilitation nurse or therapist demonstrate the exercises

for you before you start on your own program.

39Pulmonary RehobilitotionNorwolk Hospital, Norwalk CT

.:. Lunges: Stand with your feet together, then bring one foot forward,

shift your weight to the front foot, bend both knees down (but not all

the way down), then stand back up and move your foot back beside

the other one. Alternate legs.

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.:. Hamstrings: Stand with your feet together, bend one knee behind

you with your heel raised toward your buttock, then slowly back

down. Alternate legs.

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TONING YOUR STOMACH MUSCLES

Strong stomach muscles do several things: protect your back frominjury, help you with your diaphragm breathing, improve your posture,and make you look better. Remember, when doing stomach orabdominal muscle exercises, always bend your knees and make sureyour back Is flat on the floor or bed. It Is never normal to feel back painwhile doing these exercises.

.:. Lie on your back with both knees bent. Inhale. Then exhale asyou tighten your stomach muscles and aim your belly towardsyour back. Hold the tightening for 3-5 seconds and then relax.

.:. LIe on your back with both legs bent (to protect your back).Inhale. Exhale while lifting your bent knees toward your chestand slowly back down. Tighten your stomach muscles while

lifting.


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BUILDING ENDURANCE

Endurance building exercises involve continuous motion. Walkingand stationary biking are examples of endurance building activities. It isimportant to warm up slowly and cool down gradually. Comfortableshoes are also important, especially for walking. Shoes with a goodcushion make your walk more comfortable and injury less likely.

IF YOU ARE CURRENTLY VERY INACTIVE: Walk 1-2 minutes at least 5times a day. (Sounds silly, but it works). If you walk 1 minute, 6 timesa day, that is 6 minutes you have walked that day. Each week, increaseyour walks by 1 minute. The minutes will add up in no time. Onewoman coming to rehab started out walking 3 minutes, 5 times a day.At the end of 6 weeks, she was walking 25 minutes twice a day withoutstopping! The important thing is to start at a level you can accomplish(whether it is 30 seconds or 30 minutes). Try to walk for yourprescribed time without stopping. Remember to pick a pace you canmaintain. Remember, also, to pace your breathing - inhale for one or

two steps, exhale for twice as long. Warming up and cooling down atthe beginning and end of exercise is also important. (Walk more slowlyat the beginning and end of walks).

WHERETO WALK: Many people do not have an ideal place for walkingoutdoors. There are many alternatives.

Walk in your house - yes, we said walk in your house. One mancoming to rehab began a walking program up and down his halls and inand out of rooms. He started walking 8 minutes, 3 times a day. Overseveral weeks he increased his walking to over 1 hour (withoutstopping!) still inside his house. To make the time go by faster, listen tomusic while walking.

OTHER PLACES TO WALK: The grocery store can be a great place towalk. Grab a cart and push it up and down every aisle without stoppingto shop for your exercise. After your walk, you can then go back andshop. Pushing the cart may help your breathing (it makes you leanslightly forward and may help you keep your shoulders relaxed).Another place to walk is a shopping mall during non-peak shopping

45Pulmonary RehabilitationNorwalk Hospital. Norwalk CT

times. Some malls even open early for walkers. Malls are Ideal placesto walk because the air Is conditioned and the terrain Is even. Again,walked for a given length of time (1, 2 or more minutes) then rest forseveral minutes and repeat your walk one or more times.

OTHER PLACES TO WALK: Your driveway, the beach, woods or yourbackyard. Your ability to walk outdoors may be affected by the terrain(hills, uneven ground, soft sand, etc.) and the weather.

AL TERNAl1VE ENDURANCE EXERasE: Here is another alternativeexercise for days when outdoor walking is not possible and the malls andgrocery store are too far away. Marching In place can also be done. Tostart begin stepping in place being careful not to lift your foot completelyoff the floor. Wear athletic shoes with good cushion and lift up your heelonly. This will protect your ankle, knees, back and hips from too muchimpact. Once you get a rhythm going you can start adding on armactivity like arm swings. Begin with 5 minutes, then add on 5 minuteseach week. To make It more fun, march to music. HAPPY MARCHING!!!

STAT10NARY BIKE: A stationary bike is another way to buildendurance. Talk with your doctor, nurse or therapist of ways to designan exercise bike-routine.

Warm up for several minutes by biking slowly without tension.Coordinate your breathing with the biking. Inhale while making one ortwo rotations, exhale for twice as long.

Then bike faster for several minutes. Five minutes is a good startingpoint. Every week or so, increase biking by 5 minutes until you get to30 minutes. Once you can maintain 30 minutes of biking, you can addsome tension. Cool down for several minutes by slowIng the pedalIngdown. Do not stop until your breathing slows down and your heart Isslower. If you take your pulse when you exercise, you may stop whenyour pulse is less than 100.

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STAIRCUMBING: Another form of endurance building is stairclimbing.(Yes, we said, stairclimbing). While many people with lung problemsavoid stairs, they can be a great endurance builder.

For those of you who want to Improve your endurance on stairs orhills, stalrclimblng can be used as part of your regular exercise routine.Stalrcllmblng will also Improve the strength in your legs and buttocks.

.Here is an approach to using stairclimbing for exercise:

Begin by climbing the number of stairs you can withoutmuch shortness of breath.Climb in a steady, paced, continuous manner.Add on stairs or flights of stairs each week.

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For example:Week 1: climb up and down 1 flight of stairs each day.Week 2: climb up and down 2 flights In a row, or...Week 1: climb up and down 4 steps.Week 2: climb up and down 4 steps two times and so on.Each person will need to start at a different number of stairs

depending on his or her general condition. What is important is to setsmall reasonable goals and to make slow, steady progress.

Again, stairclimbing, while not a favorite activity for many, need notbe so hard. It can also be a great for of building strength andendurance. Here is to everyone reaching their own personal Mt.Everest! ! !

Other forms of endurance building include rowing, walking on atreadmill and swimming. Talk with your doctor, nurse or therapist aboutways to design an exercise program using these methods.


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KEEPING AN ExEROSE DIARY OR LOGAn exercise diary is a way of recording your progress. It can serve

as a visual reminder of the progress you are making in your physical

reconditioning program.

Things To Record In Your Log. The date: this helps you determine if you are exercis.ing

enough days per week.. The type of exercise.. arm exercise, walking, biking,

etc.. The amount of exercise: put down the amount of each

type of exercise. For example, if you walked 3 minutes,Stimes that day, mark - walked 5 X 3. If you have done 5repetitions of each of the arm exercises, mark - arm X 5.

. Comments: record anything special that happened thatday that may have influenced how well you exercised. Itmay be helpful to record what the weather was like, if youwere sick and skipped exercise that day or if it is a "badday" and you don't feel motivated.

WHAT To Do WITH YOUR DIARY:Every few weeks look over your diary. Compare how you are doing

now to how you were doing a few weeks ago. How well are youreaching your exercise goals? Use your diary as a way to rewardyourself for your hard work or as a motivator to "get the lead out!" Ifyou have had an illness and can't exercise for a while, use the diary as away to restart an exercise program by following the gradual increase inactivity you began with. Bring your diary to pulmonary rehabilitationmeetings.


SICK DAY RULES

You've finally become a believer in exercise and now there's thesetback - when you're sick or have hurt a muscle or joint. Do you keep

on plugging along or give up exercise?

For many, exercise has become a part of your daily routine - you've

gotten a "healthy addiction". When you're sick or injured, however, the"addiction" can be harmful. So here are a few sick day rules.

.:. When you're sick, your body requires rest, rest, REST (get it?). Goodfood, taking your medication and fluids help too (those on a fluidrestriction should ask their doctors for amounts).

.:. Hold off on your endurance exercises (walking, biking, rowing, etc.)until you're over the cold, bronchitis, flu, acute asthma and so on.


~ WHILE YOU'RE SICK DO THE FOLLOWING:EXERCISES TO Do IN BED OR IN A CHAIR TO GET YOUR ARMS, LEGSAND BREATHING STRONG

* DEEP BREATHING

Every hour you are awake-take 10 slow, deep breaths.Breathe in your nose and out your mouth. Try to breathe from thelower part of the chest. If you get tired after 5 breaths, rest a minuteor two and do the second 5. If you have sputum, practice yourcoughing techniques to get the sputum out. Some of you may benefitfrom doing postural drainage.

* LEG WORKAnkle Pumps: Slowly point your toes toward your head whilebreathing in. Point your toes down while you breathe out.Quad Sets: Take a breath in and as you breathe out tighten yourknee and press it into the bed or chair.Buttocks Squeeze: Take a breath in and as you breathe outsqueeze your buttocks together.Leg lifts: As you breathe In bend your knee up toward your chest.Lower your knee slowly back down on the bed as you breathe out.

* ARM WORKRaise your arm above your head as you take a deep breath in. Loweryour arm slowly as you breathe out.

How often do r do these great exercises???Try doing five of each arm or leg exercise every two to three hours.Pretty soon you'll feel stronger and improve your stamina.

» GETTING BACK ON YOUR REGULAR EXERCSE PROGRAM

When you're feeling better, begin your regular exercise program again.Remember to start slowly and build up gradually. For example, startwith a few minutes of slow walking or biking and gradually build It up to5, 10, 20 or 30 minutes.


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