1. Exercise Prescription for the Certified Cardiac Rehab Professional
Erik Ostrowski, MS, ACSM-RCEP, CCRP
Southern Illinois Healthcare Herrin Hospital

2. Today Exercise prescription (Ex Rx) as it relates to the CCRP exam
Certified Cardiac Rehab Professional
Specific Ex Rx recommendations for pulmonary patients have been omitted
Most Ex Rx concepts for cardiac patients remain interchangeable with other chronic disease conditions
How many of you have taken the CCRP exam?
How many of you are planning to take the CCRP exam?

3. CCRP Exam Categories 10 Categories Patient assessment
Nutritional management
Weight management
Blood lipid management
Blood pressure management
Diabetes management
Tobacco Cessation
Pyschosocial Management
Physical Activity Counseling
Exercise Training

4. CCRP Exam Blueprint Exercise Training
Design and modify an aerobic exercise training program
(10.11, 10.12, 10.13)
Understand and consider various physiologic measures for use in an Ex Rx
HR, HRR, VO2, VO2R and METs
(10.6)
The numbers represent the sections subsections of the exam blueprint that we’ll be discussing today
The bulk of our discussion today will be about the first two bullet points
Design and modify a resistance training program
(10.15)

5. Components of the Ex Rx FITT Principle F – Frequency I – Intensity
There are four primary variables that need to be considered when designing a basic Ex Rx
Frequency
# of days per week
Intensity (difficulty)
%HRmax, %HRR, %VO2max, %VO2R, METs, RPE
Time (duration)
minutes per session
Type (mode)
Continuous, rhythmic activities that involve large muscle groups
F – Frequency
I – Intensity
T – Time
T - Type

6. Components of the Ex Rx What are we missing??? Progression Volume
FITT Principle becomes the FITT-VP Principle
F – Frequency
I – Intensity
T – Time
T – Type
V – Volume
P – Progression
We will start seeing this exercise prescription component more often as greater amounts of research is published demonstrating the health benefits of using a specific volume of exercise, rather than just a specific duration or intensity. But until then, Volume as a specific component of the exercise prescription is beyond the scope of this presentation.

7. Type (Mode)
What types of exercises are appropriate for patients with CVD?
Continuous, rhythmic activities that involve large muscle groups
Practical Examples:
Equipment Examples:

8. Frequency How many times per week should a patient with CVD exercise?
3-5 days/wk
Up to 7 days/wk is safe and effective
EXERCISE
EXERCISE
EXERCISE
EXERCISE
EXERCISE
EXERCISE
EXERCISE
Cardiopulmonary benefits occur (and can be maintained) with as little as 2 days/wk (intensity/duration dependent)
Will depend on an individual’s current fitness level and goals

9. Time (Duration)
How many minutes should a patient with CVD exercise during a given session?
20-60 minutes
May be accumulated in shorter intervals of at least 10 minutes per interval
In extremely deconditioned individuals, shorter intervals are acceptable with a goal to attain 10 minutes of continuous exercise before resting

10. Intensity How intense should exercise be for a CVD patient?
“ACSM Guidelines indicate that a minimal intensity threshold lies between 30-40% of the patient’s HRR or VO2R, with the upper range at approximately 80% HRR or VO2R”
ACSM Intensity Level Guidelines:
Light (low): < 40% HRR or VO2R
Moderate (medium): 40-60% HRR or VO2R
Vigorous (high): 60-80% HRR or VO2R
Near Maximal (very high): 80-90% HRR or VO2R

11. Intensity
What about an upper limit to exercise intensity levels for patients with CVD?
Up to 80% HRR or VO2R is safe during continuous exercise
Up to 90-95% peak HR for short bouts during HIIT
In other words, don’t be afraid to allow your patients to continue exercising past their age-predicted or estimated values if they are NOT asymptomatic!

12. Physiological Measures
Heart Rate Maximum (HRmax)
An individual’s maximum achievable heart rate
Expressed in beats-per-min (bpm)
Heart Rate Reserve (HRR)
The difference between maximal and resting HR values
Expressed in beats-per-min (bpm)
Also called “Maximal Heart Rate Reserve (MHRR)”

13. Heart Rate Max (HRmax) Method
Find HRmax
Directly measure using a maximal cardiopulmonary stress test OR Estimate using equation: 220-age
Find a % of HRmax
Multiply the HRmax by the desired ACSM intensity level guidelines
Example: What HR level (bpm) would a 60 year-old male need to maintain in order to be exercising at 50% of his HRmax ?
Estimate HRmax using 220-age equation: = 160 bpm
Multiply 160 by 50% (i.e., 0.50): 160 x 0.50 = 80 bpm

14. Heart Rate Reserve (HRR) Method
Karvonen Formula: ((HRmax – HRrest) x %) + HRrest
Also referred to as the Karvonen Method
Find HRmax
Directly measure using a maximal cardiopulmonary stress test
Estimate through equation (220-age)
Find HRrest
Directly measure via palpation (or pulse oximeter) at rest
Pick the desired ACSM intensity level (%)
Input numbers into Karvonen Formula
HRmax, HRrest, and the desired ACSM intensity level

15. HRR Example
What HR (bpm) would a 60 year-old male need to maintain in order to be exercising at 50% of his HRR?
Find HRmax using 220-age equation: = 160 bpm
Find HRrest via pulse oximeter: 74 bpm
Pick desired ACSM Intensity Level: 50% = 0.50
Plug into Karvonen Formula
((HRmax – HRrest) x %) + HRrest
((160 – 74) x 0.50) + 74 = 117 bpm
Remember: To find an intensity range (i.e., 50-80%) you must perform this equation twice!

17. Physiological Measures
Maximal Volume of O2 Consumption (VO2max)
The maximal amount of O2 the body can take in and utilize
Usually expressed in ml/kg/min
Adults with CVD are more likely to have a max capacity of ml/kg/min
Volume of O2 Consumption Reserve (VO2R)
The difference between maximal and resting O2 consumption values
Metabolic Equivalent (METs)
An expression of O2 utilization in the body
MET = ml/kg/min ÷ 3.5
Adults with CVD are more likely to have a max capacity of METs

18. VO2max Method Find VO2max Find a % of VO2max
Directly measure using a maximal cardiopulmonary stress test
Find a % of VO2max
Multiply the VO2max by the desired ACSM intensity level guidelines
Example: What VO2 ml/kg/min would a 50 year-old female need to maintain in order to be exercising at 45% of her VO2max ? Let’s assume a cardiopulmonary stress test yielded a VO2max of 35 ml/kg/min.
Directly measure VO2max using a maximal cardiopulmonary stress test
Multiply 35 ml/kg/min by 45% (i.e., 0.45): 35 x 0.45 = ml/kg/min

19. VO2 Reserve (VO2R) Method
Formula: ((VO2max – VO2rest) x %) + VO2rest
Find VO2max
Directly measure using a maximal cardiopulmonary stress test
Find VO2rest
3.5 ml/kg/min for everyone! (1 MET)
Pick the desired ACSM intensity level (%)
Input numbers into formula
VO2max, VO2rest, and the desired ACSM intensity level

20. VO2R Example
What VO2 ml/kg/min would a 200 lb., 50 year-old female need to maintain in order to be exercising at 50% of her VO2R?
Find VO2max using a maximal CP stress test = Ex ml/kg/min
Constant VO2rest = ml/kg/min
Pick desired ACSM Intensity Level: 50% =
Plug into Karvonen Formula
((VO2max – VO2rest) x %) + VO2rest
((24.5 – 3.5) x 0.50) = 14 ml/kg/min
Remember: To find an intensity range (i.e., 50-70%) you must perform this equation twice!

21. VO2R Example Continued…
So what now?
Convert to METs
14 ml/kg/min 3.5 = 4.0 METs
Use metabolic equations to determine equipment settings
Treadmill = 3.3/1.0 (speed/incline)
Airdyne = 58 watts
Arm Ergometer = 41 watts
Recumbent Bike = 41 watts
Recumbent Stepper (NuStep) = 125 watts
For a helpful calculator visit:

22. Intensity – Other Considerations
Peak exercise HR should generally be set at least 10 bpm below the HR associated with any of the below criteria:
ICD firing threshold
Onset of angina
Plateau or decrease in systolic BP
> or = 250 SBP
> or = 115 DBP
> or = 1mm ST-segment depression
Increased frequency of ventricular dysrhythmias
Other significant ECG disturbances (2nd or 3rd degree AV block)
Other signs/symptoms of exercise tolerance

23. Prescribing Exercise Intensity w/o Exercise Test Data
How do we prescribe exercise intensity w/o an exercise stress test?
Use RPE
Use HR and/or MET levels derived from the 6MWT as a target intensity early on
If you use HR, remember 220-age with caution because it is just an estimate and HR is genetically extremely variable!
Remember: 220-age is invalid if a patient is taking beta blockers!

24. Prescribing Exercise Intensity w/o Exercise Test Data
Example: Larry walked 1260 ft. during his 6MWT without any complaints. How can we determine a starting exercise intensity with just this information?
Convert 6MWT speed to miles-per-hour
1,260 6min/ft x 10 6min/hr. = 12,600 ft/hr
12,600 ft/hr ÷ 5,280 ft/mi = mph
Treadmill setting = 2.4 mph / 0.0 incline
Convert treadmill setting to METs using the metabolic equation
See ACSM’s Guidelines for Exercise Testing and Prescription (9th ed.) or use computer system software if available
Larry’s treadmill setting = 2.8 METs
Set all equipment workload settings to 2.8 METs
Titrate equipment individually every 3 minutes until an RPE of is reached

25. RPE Rating of Perceived Exertion (RPE)
Subjective scale of exercise intensity
6–20 (traditional); 1–10 (modified)
Valuable when exercise stress test data is unavailable
Relative intensity equivalents:
Light: % HRR/VO2R = RPE ~8-11
Moderate: % HRR/VO2R = RPE ~12-14
Vigorous: % HRR/VO2R = RPE ~15-17

26. Progression Starting exercise goal: Progression goals:
Attain minutes of continuous exercise at a low- moderate intensity (RPE 11-13) per session
Progression goals:
Gradually titrate upward the frequency, intensity and duration of exercise until the patient achieves:
5-7 sessions per week (this includes home exercise!)
mins per week
50-60 mins per session
12-16 RPE (somewhat hard - hard)
Gradually increase exercise VOLUME

27. Volume What is exercise volume?
Exercise Volume = Duration x Intensity x Frequency
Expressed as MET-min-wk or kcal/wk
Why is understanding exercise volume important?
Standardized measurement being used in research
Excellent way to track exercise progression
Recommend 5-10% increase in exercise volume per week
Strive for MET-min-wk
Exercise volume impact on atherosclerotic lesion progression:
<1000 kcal/wk = Likely progression
kcal/wk = Little/No progression
>2200 kcal/wk = Possible regression

28. Resistance Training
One exercise for each major muscle group (8-10 in total)
Upper Body
Chest
Back
Shoulders
Biceps
Triceps
Mid/Lower Body
Abdomen
Gluteals
Quadriceps
Hamstrings
Calves
1-2 Sets
8-12 Reps
2-3 mins Rest/Sets
48-72 hrs Rest/Sessions

29. Resistance Training Do’s & Don’ts
Wait to use with PTCA/PCI/MI patients for 2-3 weeks post procedure
Wait to use with CABG/Valve/Surgery patients for 4-5 weeks post procedure
Safe for HF patients
Avoid excessive isometric contractions
Utilize proper breathing technique (avoid Valsalva)
Start light and progress gradually
Don’t utilize resistance exercise in patients with:
Uncontrolled arrhythmias
Symptomatic HF
Severe valvular disease
Large aortic aneurysms
Uncontrolled HTN (resting SBP >160, resting DBP >105)

30. Take Home Points
If you use HR, remember 220-age with caution because it is just an estimate and HR is genetically extremely variable
It’s safe to allow patients to exceed the HR ranges you set for them so long as they are asymptomatic
220-age is invalid if a patient is taking beta blockers
Even if you do not plan to take the CCRP exam, this material is the foundation for how and why to prescribe exercise for patients with CVD
It meets all AACVPR and ACSM guidelines
Most patients enrolled in cardiac rehab (2-3x/wk) achieve < kcal/wk or MET/min/wk of energy expenditure
This is NOT enough exercise to reduce CVD risk
All programs should emphasize the need to exercise at home

31. References AACVPR CCRP Study Guide
ACSM’s Guidelines for Exercise Testing and Prescription (9th ed.)
Clinical Exercise Physiology (3rd ed.)
Brawner, C. (2010). Prescribing Exercise in Cardiac Rehabilitation without an Exercise Test. ACSM Certified News, 20, 7-13.
Brawner, C., et al. (2004). Predicting maximum heart rate among patients with coronary heart disease receiving β-adrenergic blockade therapy. American Heart Journal, 148,
Keteyian, S. et al. (2012). Predicting maximal HR in heart failure patients on β-blockade therapy. Medicine and Science in Sports and Exercise, 44,

32. Thank You! Erik Ostrowski, MS, ACSM-RCEP, CCRP
Southern Illinois Healthcare Herrin Hospital