Principles Of Exercise Prescription …… Art and Science David Arnall, Ph.D., PT

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

n 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 ªCardiac Disease - MI’s, CAD, IHD ªVascular Disease - PVD, HTN, Stroke Arteriosclerosis, Atherosclerosis

ªCancer ªMetabolic Disease - Diabetes, Neuro- Endocrine Disorders

Patient’s With Pathology n 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 n Low Level Graded Exercise Test n 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

n 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 StageSpeedGradeDur. I1.7 mph 10 %3 min II2.5 mph 12 %3 min III3.4 mph 14 %3 min IV4.2 mph 16 %3 min IV4.2 mph 16 %3 min V5.0 mph 18 %3 min V5.0 mph 18 %3 min VI5.5 mph 20 % 3 min

Modified Bruce Protocol GXT StageSpeedGradeDur. I1.7 mph 0 %3 min II1.7 mph 5 %3 min III1.7 mph 10 %3 min IV2.5 mph 12 %3 min IV2.5 mph 12 %3 min V3.4 mph 14 %3 min V3.4 mph 14 %3 min VI4.2 mph 16 %3 min VII5.0 mph 18 %3 min

USAFSAM GXT StageSpeedGradeDur. I2.0 mph 0 %3 min II3.3 mph 0 %3 min III3.3 mph 5 %3 min IV3.3 mph 10%3 min V3.3 mph 15%3 min VI3.3 mph 20%3 min

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

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

The Exercise Prescription

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

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

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

l Hiking & Walking : METs l Judo & Tae Kwon Do : METs l Raquetball : METs l Rope Jumping : METs l Rebounding : METs l Shuffleboard : METs

l Ping Pong : METs l Tennis : METs l Swimming : METs l Sailing : METs l Running 12 min/mile : 9 Mets l Running 10 min/mile : 11 METs l Running 8 min/mile : METs

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

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

The GXT Report Should Have ªResting heart rate ªMaximum ex. heart rate ªResting blood pressure ªMaximum ex. blood pressure ªMaximum METs achieved

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

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

The target exercise heart rate should look like this for special populations: (HR max - HR rest ) X [ Max METs/100] + HR rest 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 ? ªA 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.

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

n 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 ?

What If……... n Only the blood pressure data is available : u Max. Exercise Systolic BP = 180 mm Hg u Resting Systolic BP = 88 mm Hg Target Ex. Systolic BP = (180-88) x (.6) + 88 = 143 mm Hg = 143 mm Hg

What If……... n Only the heart rate data is available : u Max. Ex. HR = 140 BPM u Rest HR = 80 BPM Target Ex. HR = ( ) x (.6) + 80 = 116 BPM = 116 BPM

What If……... n Only the Max METs data is available : u Max METs Achieved = 7 METs Ex. MET level = 7 METs x (.6 + 7/100) = 4.69 METs = 4.69 METs

What Is A MET ? n A MET is a metabolic equivalent and has the value of : 3.5 ml O 2 /Kg/min

So…... n If I am performing a 10 MET activity, the oxygen utilization for this activity is : 10 METs x 3.5 = 35 ml O 2 /Kg/min

Examples…... n A MET is a measure of energy cost for a particular activity. u Fishing In A Stream = 5-6 METs u Social Dancing = 6-9 METs u Touch Football = 6-10 METs u Scuba Diving = METs

n METs can be a useful measure for a variety of calculations particularly in terms of helping patients to understand physical work capacity (VO2 = ml/Kg/min measurements) or in terms of loosing weight (see next slide).

¤ The ACSM recommends minimal thresholds of 300 kcals per exercise session performed 3 days/week or 200 kcals per exercise session performed 4 days/week.

¤ This minimum recommendation suggests that exercise prescription target a weekly exercise caloric expenditure of about 1,000 kcals.

¤ For optimal results in physical fitness, the ACSM recommends bringing the weekly caloric expenditure up to 2,000 kcals as health and fitness permits.

How Can I Transform METs Into Calories Expended ? Kcal/min = (METs) x 3.5 x (Weight in Kg)

Problem …... Goal : To expend 1,000 Kcals/wk Ex. : 3.5 mph (6.1 METs) Weight : 70 Kg (154 lbs.) (6.1 x 3.5) x 70 = 7.47 kcals/min 200

Practical Application - Prob. # 1 Take 1,000 kcals/week = 134 min/week 7.47 kcals/min 7.47 kcals/min F Prescription : 45 min per day/3 days/week 33 min per day/4 days/week 27 min per day/5 days/week 22 min per day/6 days/week 19 min per day/7 days/week

Problem # 2 n Goal : To expend 2,000 Kcals/wk n Ex. : 3.5 mph = 6.1 METs n Weight : 127 Kg ( 279 lbs.) (6.1 x 3.5) x 127 = 13.6 kcal/min

n 2,000 kcals/week = 148 min ex./week 13.5 kcals/min 13.5 kcals/min Prescription : 49 min of exercise 3 days/week 37 min of exercise 4 days/week 30 min of exercise 5 days/week 25 min of exercise 6 days/week 21 min of exercise 7 days/week

Duration of Exercise ª Duration of exercise should ideally be between minutes

ª If the patient is unable to perform 15 minutes of steady state exercise, break the time into two 7-8 minute stages.

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

Examples…... n A Type I Insulin-Dependent Diabetic should exercise 7 days per week for glucose regulation. n 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 n Rate of progression is impacted by many factors : u type of pathology u severity of pathology u aerobic work capacity

Some Thoughts ……. ª Increase duration to min ª Next, increase frequency ª Lastly, increase intensity

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

ª When the patient’s exercising minutes/session for 5 times/week, it is time to increase the intensity. ª 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 ª 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 ª It is smart to have the patient cool down for 6-10 minutes after a steady-state exercise bout. ª Many cardiac events occur after cessation of exercise.

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

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

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

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

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

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

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

n Sometimes the diastolic pressure rises 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 n 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.