Principles Of Exercise Prescription Dave Zanghi M.S., MBA, ATC/L, CSCS, FAACVPR

Figure 1.1 Role of physical activity and exercise in disease prevention and rehabilitation.

General Principles : Mode of exercise Intensity of exercise Duration of exercise Frequency of exercise Rate of progression

The general parameters of exercise prescription hold true for individuals who are healthy as well as those patients who have disease pathology. However, there must be some special considerations for those that have disease.

Some Acute & Chronic Disease Pathologies Of Concern Cardiac Disease - MI’s, CAD, IHD Vascular Disease - PVD, HTN, Stroke Arteriosclerosis, Atherosclerosis

Cancer Metabolic Disease - Diabetes, Neuro-Endocrine Disorders

Patient’s With Pathology Exercise is not prescribed for these individuals until the patient has undergone a graded exercise stress test (GXT) under the direction of their physician.

Graded Exercise Tests Low Level Graded Exercise Test Regular Graded Exercise Test Some examples ……...

Low Level Exercise Stress Test Stage Speed Grade Dur. METS I 1.7 mph 0 % 3 min 2.3 II 1.7 mph 5 % 3 min 3.5 III 1.7 mph 10 % 3 min 4.6 IV 2.5 mph 12 % 3 min 6.8

The low level GXT is given to patient’s with significant cardiac damage and who have an exercise capacity lower than 8 METs

Bruce Protocol GXT Stage Speed Grade Dur. I 1.7 mph 10 % 3 min II 2.5 mph 12 % 3 min III 3.4 mph 14 % 3 min IV 4.2 mph 16 % 3 min V 5.0 mph 18 % 3 min VI 5.5 mph 20 % 3 min

Modified Bruce Protocol GXT Stage Speed Grade Dur. I 1.7 mph 0 % 3 min II 1.7 mph 5 % 3 min III 1.7 mph 10 % 3 min IV 2.5 mph 12 % 3 min V 3.4 mph 14 % 3 min VI 4.2 mph 16 % 3 min VII 5.0 mph 18 % 3 min

Question ? Are the same aerobic activities appropriate for both the cardiac patient and the healthy individual ?

Answer No !! Cardiac patients have some special concerns such as : Intensity of the exercise Static and dynamic balance Syncope and falling Degree of cardiovascular pathology Medications

The Exercise Prescription

Mode of Exercise Any activity : that uses large muscle groups that is rhthymic that is sustained below the patient’s anaerobic threshold for 20-60 minutes

Exercise Mode - Aerobic biking light rowing rebounding ballroom dance walking water aerobics nordic track slow jogging slow jarming skating slow wogging

MET Equivalents Archery : 4 METs Canoeing & Rowing : 6-8 METs Cycling : 5 - 8 METS Ballroom Dancing : 5 - 9 METs Fishing : 4 - 6 METs Golf : 4 - 7 METs

Hiking & Walking : 4 - 8 METs Judo & Tae Kwon Do : 10 - 16 METs Raquetball : 8 - 14 METs Rope Jumping : 9 - 12 METs Rebounding : 6 - 10 METs Shuffleboard : 3 - 4 METs

Ping Pong : 3 - 6 METs Tennis : 4 - 12 METs Swimming : 4 - 12 METs Sailing : 4 - 9 METs Running 12 min/mile : 9 Mets Running 10 min/mile : 11 METs Running 8 min/mile : 13 - 15 METs

The various modes of exercise must be specifically tailored to the patient’s physical needs such as : aerobic work capacity physical condition & disease state availability of equipment patient’s interest & family support

Intensity Of Exercise Exercise intensity is calculated from the results of the GXT Some examples …...

The GXT Report Should Have Resting heart rate Maximum ex. heart rate Resting blood pressure Maximum ex. blood pressure Maximum METs achieved

How Do I Use The GXT Data ? Use the Modified Karvonen’s Formula to set the training exercise heart rate or the training exercise blood pressure for the population with pathology.

(HRmax - HRrest) x (.6 - .8) + HRrest The Karvonen Formula Karvonen’s Formula to determine target exercise heart rate was: (HRmax - HRrest) x (.6 - .8) + HRrest This formula needs to be modified for use in diseased populations.

The target exercise heart rate should look like this for special populations: (HRmax - HRrest) X [.6 - .8 + Max METs/100] + HRrest The bracketed portion of the formula containing the Max METs value is called the Activity Fraction.

Advantages Of This Modified Karvonen’s Formula Advantage # 1 : The modified Karvonen’s Formula has a low starting activity fraction to accommodate exercising patients with cardiac disease.

Advantage # 2 : The adjusted target heart rate for the patient with disease is calculated on the heart rate, blood pressure and Max METs achieved during the symptom limited GXT .

What Is A Symptom Limited GXT ? A symptom limited GXT is a stress test in which the physician recorded the onset of symptoms (angina, ST segment depression) at the specific heart rate, blood pressure and stage of the GXT.

What value is a symptom limited GXT to the Exercise Specialist ? It provides a maximum exercise HR and BP at which significant signs and symptoms of ischemia begin to appear.

All exercise prescriptions are written using the modified Karvonen’s Formula to insure that the patient’s exercise training intensity is significantly lower than the maximum symptom limited exercise HR & BP values avoiding the onset of myocardial ischemia.

However………... Seldom does the prescription ever have all of the ideal data !!

So ……... How do I write the exercise prescription with only part of the GXT information ?

Duration of Exercise Duration of exercise should ideally be between 30 - 60 minutes

If the patient is unable to perform 30 minutes of steady state exercise, break the time into 7-8 minute stages.

Research has shown that multiple small bouts of exercise added together have the same training effect as a single bout of exercise of the same total duration.

Frequency Of Exercise Frequency begins with 3days/week and progresses to 5-7days/week. How often a person exercises/week depends on their pathology and its severity.

Examples…... A Type I Insulin-Dependent Diabetic should exercise 7 days per week for glucose regulation. A Type II Non-Insulin-Dependent Diabetic should exercise 4-5 days per week for weight control.

Rate Of Progression….The Art Of Exercise Prescription Rate of progression is impacted by many factors : type of pathology severity of pathology aerobic work capacity

Some Thoughts ……. Increase duration to 45 - 60 min Next, increase frequency Lastly, increase intensity

Once, you are up to 45 - 60 minutes per exercise session, increase frequency from 3 times/week to 4 times/week. Then back off to 30 min/session to allow the patient to adjust to an increase in the frequency of exercise.

When the patient’s exercising 45 - 60 minutes/session for 5 times/week, it is time to increase the intensity. Once you increase intensity, the duration and frequency may need to be adjusted to let the patient accommodate to the new intensity.

Warm Up & Cool Down All patients with pathology as well as the healthy individual should have a 4-6 minute warm up period and a 6-10 minute cool down period.

Longer Cool Down Periods It is smart to have the patient cool down for 6-10 minutes after a steady-state exercise bout. Many cardiac events occur after cessation of exercise.

Monitoring The Patient There are a number of ways to monitor the patient during exercise. Anginal Scale Borg Scale Dyspnea Scale Blood Pressure Heart Rate

Anginal Scale 1+ Light, barely noticeable 2+ Moderately bothersome 3+ Severe, very uncomfortable 4+ Most severe pain ever experienced - must stop !!!

Stopping Points With Angina When a person is exercising and they complain of 2+ or 3+ angina, you must stop the exercise (ACSM). It would be better to stop at 2+ angina rather than allow the patient to get to level 3 angina.

Anginal Equivalents Umbilical pain Jaw or tooth pain Tingling/numbness in fingers/hands Shoulder pain Low back pain Chest pressure

Borg’s Ratings Of Perceived Exertion (RPE) 7 = Very, Very Light 9 = Very Light 11 = Fairly Light 13 = Somewhat Hard 15 = Hard 17 = Very Hard

Dyspnea Scale 2+ Moderate Breathlessness 3+ Severe Breathlessness 1+ Light Breathlessness 2+ Moderate Breathlessness 3+ Severe Breathlessness 4+ Most Severe Breathlessness Ever Experienced

Blood Pressure Stop Exercise If BP Is >260/115 If BP Is >200/115 At Rest, Don’t Exercise - Refer The Patient To Their Physician

Sometimes the diastolic pressure rises 8 - 10 mm Hg pressure during exercise. If it rises more than this, consider referring the patient to their physician. In most cases, diastolic pressure remains the same or falls during exercise from its pre-exercise rest value.

Heart Rate Initially, for a couple of weeks, HR should remain within the calculated target training zone determined from the HR values of the symptom limited GXT. It can be advanced in blocks of 5-6 beats as the patient tolerates this increase in intensity.