Exercising Your Options

Most of us are aware that exercise, overall, is beneficial, and many of us are even familiar with how to perform a general exercise program. Certainly enough articles have been written about it. You zip over to the gym, jump into your snazzy outfit, and head out onto the main floor for a bit of aerobics and weight work. Simple enough. Of course, some professional guidance may and should be available to help you get the most out of your exercise program, but our notion of "exercise" often starts and stops at the doors of a popular health club or local gym.

Let's take a minute to look beyond those doors. In this article, I'd like to introduce you to some of the services available through a session of physical therapy. In addition, I'll offer some nutrition recommendations and tips that will be useful for anyone with HIV who plans to or has already embarked on an exercise program. Physical therapists (PTs) and Registered Dietitians (RDs) offer individual professional help to those who want to improve their overall physical status. Their services are available in a variety of settings, from the hospital to the outpatient clinic -- even in the comfort of your own home. Exercise isn't just for jocks anymore.

Exercise and The Immune System

Scientists are studying the effect of exercise on the overall functioning of the immune system, and the results are promising. We do not have all the pieces of the puzzle yet, but clinical research has been making some headway.

According to current research, regular moderate aerobic exercise can produce notable elevations in T-cell counts. So what's "regular," and what's "moderate"? The studies defined "regular" as three times a week for around 45 minutes per session. "Moderate" has been defined by the scientists according to a more complicated formula: seventy percent of a person's age-predicted heart rate maximum, or PHR. Your PHR is 220, minus your age. Then, according to the formula, you multiply that times .70.

"Huh?" you ask. Good question. The resulting number is your target pulse rate per minute during activity. If you subscribe to the theory that defining "moderate" shouldn't require more energy than the actual workout, don't worry about it. Try this first: On an exercise intensity scale of 1 to 10, with 1 being "nothing at all" and 10 being "very, very strong," a moderate level is between 3 and 4. Shoot for that. (You can try the other method later if you like; it's actually easier than it looks.)

Anyway, "regular, moderate" aerobic workouts -- running, biking, and stair climbing, for example -- appear to be best for HIV-positive individuals who are asymptomatic or who experience occasional symptoms.

Keep in mind that if you have never been involved in a regular exercise program, you will need to make some initial adjustments. Those with low T-cell counts, high viral loads, and/or frequent disease-related symptoms will require additional modifications. That's where healthcare professionals like physical therapists can really lend a hand. More on this later.

In addition to aerobic activities, resistance training -- lifting weights, for example -- is recommended to promote the production and maintenance of the muscle tissue so important in fighting HIV. The best strength-building regimen for HIV-positive people hasn't been definitively determined yet, although some seemingly effective programs have been established. For those without significant disease-related complications, doing strength-building exercises two to three times a week with a 48-hour rest period in between appears to be beneficial. Again, programs can and should be tailored to the individual and be based on the person's current health status. For example, resistance training may be inappropriate altogether for a person in the later stages of AIDS, but a physical therapist may be able to recommend adaptive exercises that help prevent further muscle breakdown.

Aerobic exercise and strength training are two great components of your workout. Finally, and also very important, be sure to include some flexibility training and stress management exercises. Take five to ten minutes to stretch tight muscles and perform some deep breathing and relaxation exercises. Stretch the muscles after they are warm (after five to ten minutes of aerobics and/or after your exercise session). Most people don't take the time. Take it.

When Not To Exercise

There's a time and place for everything, and exercise is no exception. Sometimes it's more important to let the body rest. The contraindications to exercise may appear to be common sense. They are. Yet many people ignore them, opting to push through their workouts anyway . . . only to end up hurting themselves more than helping. Bottom line: Be smart. Don't try to be a hero. Listen to your body. It will thank you later.

Here's a brief -- and not exhaustive -- list of contraindications to exercise:

• Fever, night sweats
• Moderate to severe diarrhea
• Nausea, vomiting
• Severe fatigue, dizziness, disorientation
• Blood in the urine or stool

A note about diarrhea: In most people, diarrhea is considered a contraindication to exercise. But loose and/or soft bowels are so common in people with HIV, whether from the virus or as a side effect of medications, etc., that it may be necessary to evaluate the relative severity of the diarrhea in order to rule in or rule out an exercise program. When in doubt, rule it out.

During Difficult Times

Remember when you had your tonsils out? Maybe not. If you managed to hang on to those little pink guys (boy, did you miss out on gobs of ice cream!), remember when you were flattened by the flu for a good week or so? You didn't want to eat, to drink, or even to move, for that matter. You felt like a bona fide lump -- and a sick one at that. Then you began to feel a bit better ... but even then, just getting out of bed made your legs quake. Now turn up the intensity of the situation -- longer hospital stay, greater complications from illness.

Where is this going? Here's the point: Unfortunately, bouts of illness secondary to opportunistic infections are a reality in HIV, and prolonged bed rest a commonplace. Indeed, bed rest is often essential for adequate recovery. And prolonged inactivity can lead to muscle wasting.

Under medical clearance and the assistance of a physical therapist, however, unnecessary muscle wasting may be avoided through the implementation of an adapted therapeutic exercise program.

Perhaps by now you're thinking, "You've got to be kidding! You want me to do what? When? Exercise when I feel worse than hospital food tastes?" But wait a minute. Believe it or not, a common reaction after an initial physical therapy session is, "Oh, you want me to do that? That I can do."

Simple exercise plans can be designed to meet the needs of each individual to help gain or maintain strength, flexibility, and mobility and/or to slow down a degenerative process. A program may consist of as little as one or two exercises. It may include breathing, energy conservation, or relaxation exercises. The exercise plan may focus solely on certain muscle groups, or it may include an array of exercises to improve overall functional ability. What does that really mean? It translates to this: Therapy can help someone achieve realistic goals, whether they be returning to work or simply getting out of bed and walking to the kitchen for a glass of water.

We tend to think we are exercising only if we're out of breath, straining to lift a weight, or sweating bullets. Not so. Exercise can be gentle. It can be performed with a minimum expenditure of energy and still be of substantial benefit. Programs can be and often are developed for people who are homebound and/or confined to bed. Simple exercises can even be initiated from a hospital bed. For example, two exercises commonly prescribed are quadricep and gluteal setting. Lie on your back with your legs straight and a pillow under your knee. Now, push the back of your knee into the pillow. You just did a "quad set." Relax. Now squeeze your cheeks together (the ones you sit on, that is). You just did a "glut set." Fairly easy exercises, but quite helpful in keeping your strength up when getting out of bed isn't in the day's plan.

Under certain circumstances, the physical therapist may help a person to move an arm or leg through space until adequate strength or range of motion can be achieved. This is usually referred to as "active-assistive" exercise. In addition, PTs may utilize passive range-of-motion exercises, in which movement of a body segment is performed solely by the therapist. Passive exercise may sound like an oxymoron, but it can be quite beneficial in keeping a person limber until he or she is allowed or able to move the body segment independently.

The applications for exercise are virtually endless. With a little creativity, motivation, encouragement, and professional guidance, the limits really have been lifted.

Chest Physical Therapy

Physical therapists are also educated and trained to deliver a less well-known service called chest physical therapy, or CPT. Individuals with certain opportunistic infections such as PCP, or who have developed respiratory illnesses due to prolonged bed rest, or who suffer from acute or chronic lung diseases may benefit from this particular form of therapy.

These people often have accumulated secretions that are produced in the lungs and that they cannot get rid of easily by simple coughing. CPT uses manual techniques coupled with body positioning to help loosen those secretions, thus enabling the person to breath more easily. In other words, it can help you cough up the gunk. Not the most pleasant thought, perhaps, but often quite effective. CPT may also help reduce the severity of an illness or its progression by removing the infectious secretions.

Therapeutic techniques used in CPT include postural drainage, percussion/vibration, deep breathing exercises, and assisted coughing.

• Postural drainage: The individual is placed in various strategic positions, each of which helps drain specific lung segments, thus facilitating secretion clearance.
• Percussion/vibration: With the client lying in one of the postural drainage positions, the PT performs certain manual techniques. Percussion involves "clapping" with a cupped hand over a specific area of the lung to loosen secretions. Vibration entails using a flat hand to shake secretions gently loose.
• Deep breathing exercises: Here the PT provides education and instruction on how to breath more efficiently and effectively. Instruction can include using the diaphragm muscle properly, using lung segments formerly affected by disease, and incorporating paced breathing to conserve energy.
• Assisted coughing: This is education and instruction again, this time on effective coughing techniques. When necessary, the PT may provide actual physical assistance with coughing.

CPT is usually performed in a hospital setting, but it can be done in the home if that is more appropriate. Again, be aware of what is available to you. If you're not sure you (or the person you are helping) are a candidate for such therapy, consult with your physician. Asking certainly cannot hurt and may be just what the doctor ordered.

A Word about Nutrition

Much has been written and spoken about nutrition and HIV/AIDS -- including in Body Positive -- and there are many sources of general nutrition information (see Resources, this page). For purposes of this article, I want to offer some nutrition guidelines as they relate to exercise, rather than rehashing what is available elsewhere.

• Water: Recommendation: Drink it! Dehydration is the number-one cause of muscle fatigue. We know that exercise makes us sweat, and that it is important to replenish the body's water reserve. Unfortunately, our body signals do not really help us out in this area. The human thirst mechanism isn't exactly our most sensitive measuring stick. By the time thirst kicks in, you're already well on your way down the dehydration road. To make matters worse, exercise actually blunts the thirst mechanism further. This is one case where listening to your body probably is not such a great idea. Better to follow the recommendations of the experts:
  • Before exercise: Drink 16 ounces of water or other beverage (see below) one to two hours before your workout. Then, about ten to fifteen minutes before your session begins, drink another 20 ounces.
  • During exercise: Drink 4 to 6 ounces every ten to fifteen minutes throughout the session.
  • After exercise: Weigh yourself immediately before your workout and again immediately after. For every pound lost during that exercise session drink yet another 16 ounces.

The body can digest and absorb up to one quart of liquid per hour. Cooler, less concentrated beverages leave the stomach faster, and are therefore absorbed more quickly, than lukewarm or heavier beverages. Plain filtered water is the hydrator of choice. If additional calories for weight support are needed, however, or if the exercise session is longer than an hour, or you are experiencing loose bowel movements or mild diarrhea secondary to medications, a sports drink may be a better choice. Drinks with a six to eight percent glucose solution are usually well tolerated. This equates to about fifty calories per 8-ounce serving. Check the label. Note: Fluid and electrolyte requirements are significantly elevated for those experiencing soft bowels or diarrhea, making post-exercise rehydration even more imperative.

• Meal composition: Recommendations for proper meal composition stress a balance of whole grains, fruits, vegetables, and protein-rich foods. Protein -- the macronutrient responsible for building and maintaining muscle mass and contributing to many of the body's structural components -- has been the buzzword in the exercise world for quite some time, and in many ways rightly so. Athletes in general have higher protein needs than couch potatoes -- not astronomically so, but couple that with the extra protein boost required for the novice exerciser, and the additional protein recommended for someone with HIV, and you potentially have a scenario requiring a notable spike in protein consumption.

The idea is to meet your body's protein needs without going overboard. Let's take a person matching the profile above -- Richard, a 160-pound, mildly symptomatic HIV-positive person who has just embarked on a regular program of moderate aerobic exercise and weight training. His protein needs should be adequately met with 115 to 130 grams of protein per day, or about 0.7 to 0.8 grams per pound of body weight. Higher than what the average Joe needs, yes, but certainly obtainable with a little planning.

Lean meats, fish, poultry, beans, and soy-based foods are all excellent sources of protein (1 ounce of meat provides about 7 grams of protein). Liquid supplements can help meet protein and overall calorie needs, but remember that more is not always better. The adult body's ability to utilize protein usually maxes out at about 0.9 grams per pound of body weight per day. Consuming more than that places an increased demand on the kidneys to rid the body of additional protein metabolites. This in turn requires greater fluid intake . . . and most people have a hard enough time swallowing the normal fluid recommendations for exercise. In addition, consuming too much protein can lead to gastrointestinal complaints such as diarrhea -- like you need that, right? Consuming excessive amounts of protein supplements really for the most part only leads to trouble. Bottom line: A little supplementation is fine; a lot is not.

• Meal timing: As the saying goes, timing is everything. Okay, so maybe it's not everything when it comes to eating and exercise, but it's something. Here are a few helpful guidelines about what to eat when, as it relates to exercise.

We've talked a bit about protein, the macronutrient responsible for building and maintaining muscle mass and contributing to many of the body's structural components. But when it comes to energy, carbohydrates are the fuel of choice. Carbohydrates are stored in the body as glycogen, which is found in the liver and muscle tissue.

During exercise, glycogen is broken down into individual units of sugar (glucose) and used to keep you going. Even during times when the body is burning adipose tissue (fat), a little glucose is needed to keep the fire going; glucose is the match, so to speak. So you can see that it's important to be sure you have adequate glycogen stores before and during exercise, as well as replenish its stock after the sweat session.

The first thirty minutes after exercise is often referred to as the "glycogen window," the period of time when our bodies have the greatest capacity for making glycogen from the carbohydrates we eat. Take advantage of it! Eat a bit of carbohydrate during that first thirty minutes (fruit and crackers are easy enough to carry with you). Not hungry right after your workout? That's not uncommon. You probably still have a good amount of glucose running around in your bloodstream, compliments of your exercise session. The appetite usually doesn't kick in until your blood sugar drops enough to trigger the hunger response. So if you don't feel like eating carbs, drink them. Although straight fruit juice may lead to stomach upset, diluting it with water will make a concentration that is both palatable and tolerable.

After that first thirty minutes, but within the next couple of hours, think about stopping for a good snack or meal. Include a good protein source, and keep the whole grains, fruits, and veggies to create a balance.

• A few additional comments while we're on the topic of nutrition as it relates to exercise:
  • For those who have difficulty gaining or maintaining weight, strength training is highly recommended. Coupled with a high-protein, high-calorie, well-balanced diet, it is an excellent aid to quality weight gain.
  • Looking to lose a few pounds safely? People tend to focus solely on diet and/or aerobic activities, neglecting the benefits of weight training. Cardiovascular (aerobic) activities do help to burn calories, but mild weight training will help build muscle, making you stronger and revving up your metabolism.
  • The importance of good nutrition also needs to be stressed to those who are exercising at home or in the hospital. You'll know you've given your body the best preparation for a successful physical therapy session if you have given it the fuel it needs. Eating well is not an option -- it's a must. You really will see and feel the difference. Meal timing and physical therapy sessions can and should be coordinated. Don't underrate the importance of doing so, or feel you are inconveniencing anyone. It's your session, your time, and your body. Treat them as such and everyone wins.

If someone told you there was a supplement out there that would make you stronger, stimulate your immune system, help you sleep better, and improve your sense of well-being, you'd sprint to the nearest store to buy it, right? Guess what ... surprise! You just took a dose of this miracle stuff on the way to the store -- you exercised. Oh, and while you're there, pick up some fish and salad for dinner tonight. Your body says "thanks" in advance.

Christine Hannema is a physical therapist and Registered Dietitian currently working in an outpatient physical therapy practice on eastern Long Island. She is a former HIV Nutrition Specialist at Gay Men's Health Crisis.

Back to the March 2000 Issue of Body Positive Magazine.