ACSM's Guidelines for Exercise Testing and Prescription Chapters 1-12

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Physical Activity
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AgilityThe ability to change the position of the body in space with speed and accuracyCoordinationThe ability to use the senses, such as sight and hearing, together with body parts in performing tasks smoothly and accuratelyBalanceThe maintenance of equilibrium while stationary or movingPowerThe ability or rate at which one can perform workReaction timeThe time elapsed between stimulation and the beginning of the reaction to itSpeedThe ability to perform a movement within a short period of timeLight intensity PA = ? METs2.0-2.9 METsModerate intensity PA = ? METs3.0-5.9 METsVigorous intensity PA = ? METs>=6.0 METsThe ACSM-AHA Primary Physical Activity Recommendations- All healthy adults aged 18-65 yr should participate in moderate intensity aerobic PA for a minimum of 30 min on 5d/wk OR vigorous intensity intensity aerobic activity for a minimum of 20 min on 3d/wk - Combinations of mod and vig intensity exercise can be performed to meet this recommendation - Moderate intensity aerobic exercise can be accumulated to total the 30 min minimum by performing bouts each lasting >10 min - Every adult should perform activities that maintain or increase muscular strength and endurance for a min of 2d/wk - Because of the dose-response relationship between PA & health, individuals who wish to further improve their fitness + other benefits may exceed the minimum rec. of PA for more benefitsTwo important conclusions from the Physical Activity Guidelines Advisory Committee Report- Important health benefits can be obtained by performing a moderate amount of PA on most, if not all days of the week - Additional health benefits result from greater amounts of PA. Individuals who maintain a regular program of PA that is longer in duration, of greater intensity, or both are likely to derive greater benefit than those who engage in lesser amounts.Globally, ___% of adults are physically inactive31.1%In the United States, ___% of adults meet aerobic guidelines, ___% meet muscle strengthening guidelines, ___% meet both51.6% 29.3% 20.6%______ is the most common exercise-related complication and is often associated with exercise intensity, the nature of the activity, preexisting conditions, and musculoskeletal anomalies.Musculoskeletal injuryMost common cause of sudden cardiac death among young individualsCongenital & hereditary abnormalitiesExercise preparticipation health screening algorthim with respect to?- Determining current PA levels - Identifying signs and symptoms of underlying CV, metabolic, and renal disease - Identifying individuals with diagnosed CV and metabolic disease - Using signs and symptoms, disease history, current exercise participation, and desired exercise intensity to guide recommendations for preparticipation medical clearancePreparticipation health screening before initiating PA or an exercise program for gen. pop is a two-stage process:1. The need for medical clearance before initiating or progressing exercise programming is determined using the updated and revised ACSM screening algorithm (see Figure 2.2) and the help of a qualified exercise or health care professional. In the absence of professional assistance, interested individuals may use self-guided methods (discussed later). 2. If indicated during screening (see Figure 2.2), medical clearance should be sought from an appropriate health care provider (e.g., primary care or internal medicine physician, cardiologist). The manner of clearance should be determined by the clinical judgment and discretion of the health care provider.Major Signs or Symptoms Suggestive of Cardiovascular, Metabolic, and Renal Disease- Pain; discomfort (or other anginal equivalent) in the chest, neck, jaws, or other areas that may result from myocardial ischemia - Shortness of breath at rest or with mild exertion - Dizziness or Syncope - Orthopnea or paroxysmal nocturnal dyspnea - Ankle edema - Palpitations or tachycardia - Intermittent claudication - Known heart murmur - Unusual fatigue or shortness of breath with usual activitiesPreparticipation Screening algorithm- Apparently healthy participants who do not currently exercise and have no history or signs or symptoms of CV, metabolic, or renal disease can immediately, and without medical clearance, initiate an exercise program at light-to-moderate intensity. If desired, progression beyond moderate intensity should follow the principles of Ex Rx covered in Chapter 6. - Participants who do not currently exercise and have (a) known CV, metabolic, or renal disease and (b) are asymptomatic should obtain medical clearance before initiating a structured exercise program of any intensity. Following medical clearance, the individual may embark on light-to-moderate intensity exercise and progress as tolerated following ACSM Guidelines. - Symptomatic participants who do not currently exercise should seek medical clearance regardless of disease status. If signs or symptoms are present with activities of daily living, medical clearance may be urgent. Following medical clearance, the individual may embark on light-to-moderate intensity exercise and progress as tolerated following ACSM Guidelines (see Chapter 6). - Participants who already exercise regularly and have no history or signs or symptoms of CV, metabolic, or renal disease may continue with their current exercise volume/ intensity or progress as appropriate without medical clearance. - Participants who already exercise regularly; have a known history of CV, metabolic, or renal disease; but have no current signs or symptoms (i.e., are clinically "stable") may continue with moderate intensity exercise without medical clearance. However, if these individuals desire to progress to vigorous intensity aerobic exercise, medical clearance is recommended. - Participants who already exercise regularly but experience signs or symptoms suggestive of CV, metabolic, or renal disease (regardless of disease status) should discontinue exercise and obtain medical clearance before continuing exercise at any intensity.American Association of Cardiovascular and Pulmonary Rehabilitation Risk Stratification Criteria for Patients with Cardiovascular DiseaseIf an individual is referred for medical clearance, the extent of the preexercise evaluation is based on the discretion of the _____Health Care ProviderA comprehensive preexercise evaluation in the clinical setting generally includesa medical history and risk factor assessment, physical examination, and laboratory tests, the results of which should be documented in the client's or patient's file.Although the content and extent of consent forms may vary, enough information must be present in the informed consent process to ensure that the participant knows and understandsthe purposes and risks associated with the test or exercise program in health/ fitness or clinical settings.Atherosclerotic Cardiovascular Disease (CVD) Risk Factors and defining criteriaAge: Men > 45 yr, Women > 55 yr Family History: MI, coronary revascularization, or sudden death before 55 yr in father or other male first-degree relative or before 65 yr in mother or other female first-degree relative Cigarette smoking: Current cigarette smoker or those who quit within the previous 6 mo or exposure to environmental tobacco smoke Sedentary lifestyle: Not participating in at least 30 min of moderate intensity, physical activity (40%-<59% VO2R) on at least 3 d of week for at least 3 mo Obesity: Body mass index >30 kg*m or waist girth >102 cm (40 in) for men and >88 cm (35 in) for women Hypertension: Systolic BP >140 mm Hg and/or diastolic >90 mm Hg, measurements for two separate occasions Dyslipidemia: LDL cholesterol >130 mg dL or HDL <40 mg dL or on lipid-lowering medication If total serum cholesterol all that is available, use >200 mg*dL Diabetes: Fasting plasma glucose =>126 mg*dL or 2 h plasma glucose values in oral glucose tolerance test (OGTT) =>200 mg*dL or HbA1C >6.5% Negative risk factors: HDL cholesterol >60 mg * dL, if present, one positive risk factor is removedJNC 7A classification scheme for hypertension in adultsJNC 8Does not address the classification of prehypertension or hypertension in adults but rather recommends thresholds for pharmacologic treatmentsFor individuals aged 40- 70 yr, each increment of 20 mm Hg in systolic blood pressure (SBP) or 10 mm Hg in diastolic blood pressure (DBP) doubles the risk of CVD across the entire BP range of ________115/75-185/115 mm HgLifestyle modification cornerstone of antihypertensive therapy- PA - Weight reduction - Dietary Approaches to Stop Hypertension (DASH) eating plan (i.e., a diet rich in fruits, vegetables, low-fat dairy products with a reduced content of saturated and total fat), - Dietary sodium reduction (no more than 2 g sodium per day), - Moderation of alcohol consumptionClassification and Management of Blood Pressure for AdultsNormal: <120 SBP and <80 DBP Prehypertension: 120-139 SBP, 80-89 DBP Stage 1 Hypertension: 140-159 SBP, 90-99 DBP Stage 2 Hypertension: Greater than or equal to 160 SBP, greater than or equal to 100 DBPMain goal of BP treatmentDecrease the risk of CVD morbidity and mortality and renal morbidity.Recommended BP goal for most patients is<140./90JNC 8 guideline recommends initiating pharmacologic therapy for patients ≥60 yr atSBP ≥ 150 mm Hg or DBP ≥ 90 mm Hg and to treat to an SBP goal of < 150 mm Hg and a DBP goal of < 90 mm Hg.Classification of LDL<100 Optimal 100-129 near optimal/ above optimal 130-159 Borderline high 160-189 High ≥190 Very highClassification of Total Cholesterol<200 Desirable 200-239 Borderline high ≥240 HighClassification of HDL<40 low ≥60 highClassification of Triglycerides<150 Normal 150-199 Borderline high 200-499 High >500 Very highWhen triglycerides are >500 mg*dL, they become the primary target of therapy due to the increased risk of ____PancreatitisHigh intensity statin therapy is generally recommended for those with 10-yr risk estimated to be ___% (high risk)≥7.5%Pulmonary function testing with a spirometry is recommended for- All smokers > 45 yr old - In any individual presenting with dyspnea (i.e., shortness of breath), - Chronic cough - Wheezing - Excessive mucus productionFVCForced Vital CapacityFEV 1.0Forced expiratory volume in one secondGOLD IMild FEV 1.0 ≥80% of predictedGOLD IIModerate 50% < FEV 1.0 < 80% predictedGOLD IIISevere 30% < FEV 1.0 < 50% predictedGOLD IVVery Severe FEV 1.0 < 30% predicted respiratory failureATS based on FEV 1.0 MildLess than the LLN but >70%Moderate60-69%Moderately severe50-59%Severe35-49%Very Severe<35The term COPD can be used when ______ are present and spirometry documents an obstructive defectChronic bronchitis, emphysema, or bothThe information obtained from health-related physical fitness testing, in combination with the individual's medical and exercise history, is used for the following:- *Collecting baseline data and educating participants about their present health/ fitness status* relative to health-related standards and age- and sex-matched norms. - *Providing data that are helpful in development of individualized exercise prescriptions* (Ex Rx) to address all health/ fitness components. - *Collecting follow-up data that allow evaluation of progress* following an Ex Rx and long-term monitoring as participants age. - *Motivating participants* by establishing reasonable and attainable health/ fitness goalsThe following steps should be taken to ensure client safety and comfort before administering a health-related physical fitness test:- *Perform the informed consent process* and allow time for the individual undergoing assessment to have all questions adequately addressed (see Figure 3.1). - *Perform exercise preparticipation health screening* (see Chapter 2). - *Complete a preexercise evaluation including a medical history and a cardiovascular disease (CVD) risk factor assessment *(see Chapter 3). A minimal recommendation is that individuals complete a self-guided questionnaire such as the Physical Activity Readiness Questionnaire + (PAR-Q +) (see Figure 2.1). Other more detailed medical history forms may also be used. - *Follow the list of preliminary testing instructions* for all clients located in Chapter 3 under "Participant Instructions" section. These instructions may be modified to meet specific needs and circumstances.The following should be accomplished before the client/ patient arrives at the test site:- Ensure consent and screening forms, data recording sheets, and any related testing documents are available in the client's file and available for the test's administration. - *Calibrate all equipment* (e.g., cycle ergometer, treadmill, sphygmomanometer) *at least monthly*, or more frequently based on use; certain equipment such as ventilatory expired gas analysis systems should be calibrated prior to each test according to manufacturers' specifications; and document equipment calibration. Skinfold calipers should be regularly checked for accuracy and sent to the manufacturer for calibration when needed. - *Ensure a room temperature between 68 ° F and 72 ° F* (20 ° C and 22 ° C) and humidity of less than 60% with adequate airflowA comprehensive health/ fitness assessment includes the following:- Informed consent and exercise preparticipation health screening - Preexercise evaluation - Resting measurements - Circumference measurements and body composition analysis - Measurement of CRF - Measurement of muscular fitness - Measurement of flexibility.Basic body composition can be expressed as therelative percentage of body mass that is fat and fat-free tissue using a two-compartment modelBMIWeight relative to height calculated by dividing body weight in kilograms height in meters squaredClassification of Disease Risk Based on BMIUnderweight: <18.5 Normal: 18.5-24.9 Overeight: 25-29.9 (Increased) Obesity Class I: 30-34.9 (HIgh) Obesity Class II: 35-39.9 (V High) Obesity Class III: Greater than or equal to 40 (Extremely high)Waist to hip ratioCircumference of the waist divided by the circumference of the hipsDisease risk increases with total waist-to-hip measurement above.0.95 for men 0.86 for womenAn average of the two measures is used provided they do not differ by more than ___ mm5 mmCircumference Sites- Abdomen - Arm - Buttocks/hips - Calf - Forearm - Hips/ thigh - Mid-thigh - WaistRisk Criteria for Waist Circumference in AdultsVery low: Women- <70 cm (<28.5 in) Men- <80 cm (31.5 in) Low Women- 70-89 cm (28.5-35 in) Men- 80-99 cm (31.5-39 in) High Women- 90-110 cm (35.5-43 in) Men- 100-120 cm (39.5-47 in) Very high Women: >110 cm (>43.5 in) Men: >120 cm (>47 in)The principle behind the skinfold technique is that the amount ofsubcutaneous fat is proportional to the total amount of body fatSkinfold Sites- Abdominal - Triceps - Biceps- not in seven fold - Chest/Pectoral - Medial calf- not in seven fold - Midaxillary - Subscapular - Suprailliac - ThighSeven-Site Formula Sites- Chest - Midaxillary - Triceps - Subscapular - Abdomen - Suprailiac - ThighSiri Equation%Fat = [(495/body density) - 450] x 100Norms of body fatMen: 10-22% Women: 20-32%VO2Max is the product ofmaximal cardiac output and arterial-venous oxygen differenceMost apparently healthy subjects reach their subjective limit of fatigue at an RPE of ___ on Borg scale, or ___ on the category-ratio scaleRPE 18-19 9-10General Indications for stopping an Exercise Test- Onset of angina or angina-like symptoms - Drop in SBP of >10 mm Hg w an increase in work rate or if SBP decreases below the value obtained in the same position prior to testing - Excessive rise in BP: systolic pressure >250 diastoliv > 115 - Shortness of breath, wheezing, leg cramps, or claudication - Signs of poor perfusion: light-headedness, confusion ataxia, pallor, cyanosis, nausea, or cold and clammy skin - Failure of HR to increase with increased exercise intensity - Noticeable changes in heart rhythm by palpation or auscultation - Subject requests to stop - Physical or verbal manifestations of severe fatigue - Failure of the testing equipmentPrimary submax testCycle ergometerField TestsConsist of walking or running for a predetermined time or distance Advantages: Easy to administer to to large numbers of individuals at one time Disadvantages: Can be maximal or near maximal for some individualsCooper 12 minute testObjective is to cover greatest distance in 12 min can get VO2max w equation1.5 mi testcover distance in shortest amount of time can get VO2max w equationRockport 1 mile testIndividual walks as fast as possible for 1 mile then HR is measured immediately after completion of 1 mile can get VO2max w equation6 min walk testUsed to estimate CRF in population considered to have reduced CRF and other clinical populations can get VO2peak w equation completing less than 300 meters demonstrate poorer short term survivalSingle stage and multistage submax exefcise tests are available to estimate VO2max from ___ measurementsHRFactors that can alter submax HR response- Environmental - Dietary - BehavioralAstrand-Rhyming Cycle Ergometer Test- Single stage test lasting 6 min - Pedal rate 50 rpm - Goal to obtain HR between 125-175 - HR measured during 5th & 6th min - Average of the two HRs is used to estimate VO2maxSuggested work rate based on sex for AR cycle testUnconditioned men: 300 or 600 kg*m*min Conditioned men: 600 or 900 Unconditioned woman: 300 or 450 Condition women: 450 or 600general procedures for submaximal testing of cardiorespiratory fitness1) HR & BP right before exercise 2) Familiarize patient w equipment (treadmill/cycle) (upright posture, 25 degree bend in knee, hands proper position 3) 2-3 min warm up 4) 2 or 3 min stages 5) HR taken at end of 2nd & 3rd min. If HR is >110 steady state (within 5 beats) should be reached before increasing workload 6. BP last min of each stage 7. RPE near end of min and end of each stage 8. Monitor clients symptoms 9. Stop test when reaches 70% HR from 85% predicted, fails protocol, symptoms, asks to stop, emergency 10. Physiologic observations monitored for at least 5 min. Continue low level exercise until HR & BP stabelYMCA cycle ergometer- 2-4 3 min stages - HR at end of stage determines amount of resistance for next stage, plot and determine VO2maxTwo consecutive HR measurements between ___ & ___ should be obtained to predict VO2max110 BPM 70% HRRYMCA Step test- 3 min - 12 in bench - 24 steps per minute - After 3 min, sit client down, take HR first 5 s, take 15 s HRMuscular strength and endurance are health-related fitness components that may improve or maintain the following important health-related fitness characteristics- Bone mass, which is related to osteoporosis - Muscle mass, which is related to sarcopenia - Glucose tolerance, which is pertinent in both the prediabetic and diabetic state - Musculotendinous integrity, which is related to a lower risk of injury including low back pain - The ability to carry out the activities of daily living, which is related to perceived quality of life and self-efficacy among other indicators of mental health - FFM and resting metabolic rate, which are related to weight managementMuscular StrengthMuscles ability to exert a max force on one occasionMuscular EnduranceMuscles ability to continue to continue to perform successive exertions or repetitions against a submax loadMuscular PowerMuscles ability to exert force per one unit of timemuscular fitness test results can be compared to established standards and can be helpful in identifying weaknesses in certain muscle groups or ________ that could be targeted in exercise training programs.muscle imbalancesMuscle function tests are very specific to- The muscle group and joint( s) tested, - The type of muscle action - Velocity of muscle movement - Type of equipment - Joint range of motionStandardized conditions for muscular fitness assessment- Aerobic warm-up - Equipment familiarization - Strict posture - Consistent repetition duration (movement speed) - Full ROM - Use of spotters (When necessary)Measures of ____ strength are specific to the muscle group and joint angle involved in testing and thus may be limited in describing overall muscular strength.static or isometricPeak force developmentMaximum voluntary contractionthe ____, the greatest resistance that can be moved through the full ROM in a controlled manner with good posture, has been the standard for dynamic strength assessment.1 RM1 RM and Multiple RM test procedures1) Testing should be completed after subject *participates in familiarization/practice session* 2) Warm up by completing # of submax reps that will be used to determine 1 RM 3) Determine 1 RM within *4 trials w rest periods of 3-5 min between trials* 4) Select initial weight within subjects percieved capacity *(~50-70%)* 5) Resistance progressively increased by *5-10% upper body, 10-20% lower body* 6) Final weight lifted successfully as the absolue 1 RM or multiple RM5-10 RM must be performed tillFailureWhen using multiple RM tests to predict 1 RM, accuracy increases with theleast number of repsA conservative approach to assessing maximal muscle strength should be considered in patients at high risk for or with known ______ . For these groups, assessment of ___ to ___ RM that approximates training recommendations may be prudentCVD, pulmonary, and metabolic diseases and health conditions 10-151 RM Test protocols1. Warm up- submit reps of same lift that client will be doing during test 2. Determine 1RM or multiple RM within FOUR(4) trials/ sets , resting 3-5 min between each set 3. Initial weight should be within subjects perceived capacity (50-70%RM) 4. Increase weight by 2-20kg (5.5-44 lb) until client cannot successfully lift one more rep with constant speed and proper technique- last weight is recorded at 1RM______ testing involves the assessment of maximal muscle tension throughout an ROM set at a constant angular velocityIsokineticMuscular Endurance Tests# of reps at 1RM (absolute muscular endurance) #of reps at % of 1RM (relative muscular endurance) field tests: push up YMCA bench press test tests for older adults: (60-94 yrs) Senior Fitness TestPush Up Test Procedures for Measurement of Muscular Endurance1. Men start "standard" start position, women in modified push up position 2. Down position until chin touches mat, stomach should not touch mat 3. Back must be straight 4. *Stop test when client forcibly or unable to maintain appropriate technique within two reps*Flexibility depends on specific variables including:- Distensibility of joint capsule - Adequate warm up - Muscle viscosity_____ of other tissues such as ligaments and tendons affects ROMCompliance (tightness)Sit and reach used to assess ______ & _____ flexibilitylow back & hamstringSit and Reach ProceduresW.U: stretches , no jerky risky movements, take off shoes Start : (Box method) person sit infront of box, soles of feet within 2cm of scale - *zero point of box is 26 cm mark* t reaches as far as can, exhaling while dropping head between arms, hands together fingers may overlap- hold farthest stretch for 2 seconds- record distance Perform 2 trials- best of 2 is taken as measurement **If box method starts at 23 cm then subtract 3 from scoreClinical exercise testing has been part of the differential diagnosis of patients with suspected _____ for more than 50 yr.ischemic heart disease (IHD)The ______ exercise test typically continues until the patient reaches a sign (e.g., ST-segment depression) or symptom-limited (e.g., angina, fatigue) maximal level of exertion.clincalWhen an exercise test includes the analysis of expired gases during exercise, it is termed a _______ testcardiopulmonary exerciseIndications for clinical exercise testing encompass:- Diagnosis (e.g., presence of disease or abnormal physiologic response), - Prognosis (e.g., risk for an adverse event), - Evaluation of the physiologic response to exercise (e.g., blood pressure [BP] and peak exercise capacity).ACC & AHA logistic approach to determine type of GXT w stable chest painA symptom limited max ex test with ECG monitoring only should be considered when: - The diagnosis of IHD is not certain - Patient has interpretable resting ECG - Patient is able to exerciseEvidence does not support the use of exercise testing with ECG alone to diagnose IHD in which individuals-On digitalis therapy with ST-segment depression on their resting ECG - For those who meet the ECG criteria for left ventricular hypertrophy with ST-segment depression on their resting ECG - Wolff-Parkinson-White, - Ventricular pacing, - > 1 mm of ST-segment depression on their resting ECG, - LEeft bundle branch blockExercise testing after STEMI-assess functional capacity and ability to perform home/work loads -evaluate medical therapy -assess the risk of another cardiac eventWhen can you start to perform low level exercise after STEMI?-if you have had inpatient rehab -no symptoms of angina or HF -stable baseline ECG 48-72h before testingTwo protocols for post MI testing:-traditional submax test (done at 3-5 days if patients with no symptoms) -symptom-limited exercise test (done at 5 days or later)When can NSTE -ACS patients undergo symptom limited stress tests?-when they have been asymptomatic and clinically stable for 12-24 hoursWhen is standard ECG testing recommended for a suspected IHD?-patients with intermediate pretest probability of IHD -have at least moderate physical function -no disabling comorbidityWhen is standard ECG testing recommended for a stable IHD?-patients who are able to exercise to an adequate workload -have interpretable ECGWhen is standard ECG testing recommended for symptomatic patients with stable IHD?-when patients have new or worsening symptoms -have at least moderate physical functioning -interpretable ECGFollow up assessment for asymptomatic patients with known stable IHD:-standard exercise ECG test performed 1 yr later (maybe longer for patients with stable IHD)When is cardiopulmonary exercise testing considered?In a preoperative cardiovascular evaluation -patients who undergo elevated risk procedures (functional capacity is unknown)Why should exercise testing be considered with chronic HF in adults?-to detect reversible myocardial ischemia -to aid in the prescription of exercise training -to obtain prognostic infoWhat should and should not be performed with a patient who has Percutaneous Coronary Intervention (PCI)-treadmill exercise test is reasonable -routine periodic stress testing should not be performedEx testing in patients w valvular heart disease is reasonable in patients w asymptomatic severe VHD to:1. Confirm the absence of symptoms 2. assess hemodynamic response to exercise 3. Determine prognosisGenerally, exercise testing may be appropriate for patients:- Whose symptoms have resolved, - Have a normal ECG, - Had no change in enzymes reflecting cardiac muscle damage.Additional indications that might warrant the use of a clinical exercise test include:- The assessment of various pulmonary diseases (e.g., chronic obstructive pulmonary disease) - Exercise intolerance and unexplained dyspnea - Exercise-induced bronchoconstriction - Exercise-induced arrhythmias - Pacemaker or heart rate (HR) response to exercise - Preoperative risk evaluation - Claudication in peripheral arterial disease - Disability evaluation - Physical activity (PA) counselingThere is an inverse relationship between cardiorespiratory fitness measured from an exercise test and ____- The risk of of mortality among apparently healthy individuals - Patients at risk for IHD - Those with diagnosed heart disease - Heart failure - Lung diseaseGold standard to objectively measure exercise capacityMaximal exercise testBest measurement of exercise capacity is viaRespiratory gas analysis using open circuit indirect spirometry for determination of maximal volume of oxygen consumed per unit of timeWhen administering clinical exercise tests, it is important to consider:- Contraindications - The exercise test protocol and mode - Test endpoint indicators, - Safety, - Medications - Staff and facility emergency preparednessThe ____ has outlined both absolute and relative contraindications to exercise testingAHAPrior to the exercise test- Patients should be provided informed consent to understand purpose, expectations, risks associated with test - Educate patient on about what they may experience during test (fatigue, dyspnea, chest pain) - Medical history, current medications, indications for test should be noted - Resting ECG should be examined for abnormalities that may preclude testingPurpose of exercise test is the assessment of _____exercise-induced myocardial ischemiaHow many times should an individual perform exercise testing with physician supervision?at least 50 -200 has also been recommendedAbsolute Contraindications of Symptom Limited Max Exercise Testing-Acute MI within 2 days -Ongoing unstable angina - Active endocarditis -Symptomatic severe aortic stenosis - Decompensated heart failure - Acute pulmonary embolism, pulmonary infarctionn, or deep vein thrombosis -Acute myocarditis or pericarditis - Acute aortic dissection - Physical disability not safe for testingRelative Contraindications of Symptom Limited Max Exercise Testing- Known obstructive left main coronary artery stenosis - Moderate to severe aortic stenosis w uncertain relationship to symptoms - Tachyarrhythmias w uncontrolled ventricular rates - Acquired advanced or complete heart block - Recent stroke or transient ischemia attack - Mental impairment with limited ability to cooperate - Resting hypertension w systolic >200 or diastolic >110 - Uncorrected medical conditions, such as significant anemia, important electrolyte imbalance, and hyperthyroidismMode of test based on:- Test purpose - Patient preferenceMost frequently used mode in U.S. , EuropeU.S. Treadmill Europe cycle ergometerPeak exercise capacity can be __to__% lower during max ex test on cycle ergometer compared to treadmill due to regional muscle fatigue5 to 20%a __% difference is typically used by clinicians when comparing peak exercise responses between cycle ergometer & treadmill exercise10%Most widely used exercise protocol in the U.S.Bruce treadmill protocolRecommended that exercise testing protocol results between __ to __ min6 to 12 minBruce Protocol aerobic requirementsFirst stage ~ 5 METs increases ~3 METs every stageVariables that are typically monitored during clinical exercise testing include:- HR - ECG - Cardiac rhythm - BP - Perceived exertion - Clinical signs and patient-reported symptoms suggestive of myocardial ischemia, inadequate blood perfusion, inadequate gas diffusion - Limitations in pulmonary ventilationMonitoring ECG HR BP before exercise testMonitor continuously; record in supine position and position of exercise (e.g., standing)During the test, how should you monitor the ECG?Record during the last 5-10 s of each stage or every 2 minutes for the ramp protocolDuring the test, how should you monitor the HR?Record during the last 5-10s of each minutesDuring the test, how should you monitor the BP?Record during the last 30-60 s of each stage or every 2 min of the ramp protocolDuring test, how do you monitor RPERecord during the last 5-10 s each stage or every 2 min for ramp protocolAfter the test, how should you monitor ECG?Record immediately post exercise, after 60 s of recovery and then every 2 minutes Regularly through at least 6 min of recoveryAfter the test, how should you monitor HR?Record during the last 5-10 s of each minutesAfter the test, how should you monitor BP?Record immediately post ex, after 60 s of recovery and then every 2 minutesAfter test RPEObtain peak exercise shortly after exercise is terminatedScale used for angina, claudication, and dyspnea:0-4 scale 0- no pain 4 most severeThe CPET is useful in the differentiation of the- Cause of exertional dyspnea - The risk stratification of many patient groups, particularly those with heart failureAn absolute decrease in SpO2 ≥ __% during exercise is considered an abnormal response suggestive of exercise-induced hypoxemia, and follow-up testing with arterial blood gases may be indicated5%An SpO2 ≤ ___% with signs or symptoms of hypoxemia is an indication to stop a test80ABSOLUTE Indications for Terminating a Symptom-Limited Maximal Exercise Test- ST elevation (> 1.0 mm) in leads without preexisting Q waves because of prior MI (other than aVR, aVL, or V1) - Drop in systolic blood pressure of > 10 mm Hg, despite an increase in workload, when accompanied by other evidence of ischemia - Moderate-to-severe angina - Central nervous system symptoms (e.g., ataxia, dizziness, or near syncope) - Signs of poor perfusion (cyanosis or pallor) - Sustained ventricular tachycardia or other arrhythmia, including second- or third-degree atrioventricular block, that interferes with normal maintenance of cardiac output during exercise - Technical difficulties monitoring the ECG or systolic blood pressure - The subject's request to stopRELATIVE Indications for Terminating a Symptom-Limited Maximal Exercise Test- Marked ST displacement (horizontal or downsloping of > 2 mm, measured 60 to 80 ms after the J point in a patient with suspected ischemia) - Drop in systolic blood pressure > 10 mm Hg (persistently below baseline) despite an increase in workload, in the absence of other evidence of ischemia - Increasing chest pain - Fatigue, shortness of breath, wheezing, leg cramps, or claudication - Arrhythmias other than sustained ventricular tachycardia, including multifocal ectopy, ventricular triplets, supraventricular tachycardia, and bradyarrhythmias that have the potential to become more complex or to interfere with hemodynamic stability - Exaggerated hypertensive response (systolic blood pressure > 250 mm Hg or diastolic blood pressure > 115 mm Hg) - Development of bundle-branch block that cannot be distinguished from ventricular tachycardia - SpO2 ≤ 80% (3)The sensitivity of the exercise test for the diagnosis of IHD can be maximized when the patient is placed in a ______ or ______ position immediately following exerciseSeated or supineWhy is it often practice to have an active recovery post exercise?To support venous return and hemodynamic stabilityExercise cessation can cause an excessive drop in venous return resulting in profound ______ during recovery and ischemia secondary to decreased perfusion pressure into the myocardium.HypotensionThe normal HR response to incremental exercise is to increase with increasing workloads at a rate of ≈ ___ beats ∙ min − 1 per 1 MET10A failure of the HR to decrease by at least __ beats during the first minute or ___ beats by the end of the second minute of active postexercise recovery is strongly associated with an increased risk of mortality in patients diagnosed with or at increased risk for IHD12 22The normal systolic blood pressure (SBP) response to exercise is to increase with increasing workloads at a rate of ~ ___ mm Hg per 1 MET10Specific SBP responses are defined in the following:- Hypertensive response: An SBP > 250 mm Hg is a relative indication to stop a test (see Box 5.4) (17). An SBP ≥ 210 mm Hg in men and ≥ 190 mm Hg in women during exercise is considered an exaggerated response (17). A peak SBP > 250 mm Hg or an increase in SBP > 140 mm Hg during exercise above the pretest resting value is predictive of future resting hypertension - Hypotensive response: A decrease of SBP below the pretest resting value or by > 10 mm Hg after a preliminary increase, particularly in the presence of other indices of ischemia, is abnormal and often associated with myocardial ischemia, left ventricular dysfunction, and an increased risk of subsequent cardiac events (17). - Blunted response: In patients with a limited ability to augment cardiac output (), the response of SBP during exercise will be slower compared to normal. - Postexercise response: SBP typically returns to preexercise levels or lower by 6 min of recovery (17). Studies have demonstrated that a delay in the recovery of SBP is highly related both to ischemic abnormalities and to a poor prognosisA peak DBP > 90 mm Hg or an increase in DBP > 10 mm Hg during exercise above the pretest resting value is considered an abnormal response and may occur with _____exertional ischemiaRate-pressure product (also known as double product) is calculated by multiplying the values for ___ and ___ that occur at the same time during rest or exercise. It is a surrogate for myocardial oxygen uptakeHR & SBPNormal ranges for RPP is ___ to ____ mm Hg beats min25,000 to 40,000There is a ______ relationship between myocardial oxygen uptake and both coronary blood flow and exercise intensityLinearNormal response of the ECG:- P-wave: increased magnitude among inferior leads - PR segment: shortens and slopes downward among inferior leads QRS: Duration decreases, septal Q-waves increase among lateral leads, R waves decrease, and S waves increase among inferior leads. - J point (J junction): depresses below isoelectric line with upsloping ST segments that reach the isoelectric line within 80 ms - T-wave: decreases amplitude in early exercise, returns to preexercise amplitude at higher exercise intensities, and may exceed preexercise amplitude in recovery - QT interval: Absolute QT interval decreases. The QT interval corrected for HR increases with early exercise and then decreases at higher HRs.The interpretation of ST segments may be affected by the resting ECG configuration and the presence of ______ therapyDigitalisConsiderations That May Necessitate Adjunctive Imaging When the Indication Is the Assessment of Ischemic Heart Disease- Resting ST-segment depression > 1.0 mm - Ventricular paced rhythm Left ventricular hypertrophy with repolarization abnormalities - Left bundle-branch block - Leads V1 through V3 will not be interpretable with right bundle-branch block. - Wolff-Parkinson-White - Digitalis therapyAbnormal responses of the ST segment during exercise include the following- To be clinically meaningful, ST-segment depression or elevation should be present in at least three consecutive cardiac cycles within the same lead. The level of the ST segment should be compared relative to the end of the PR segment. Automated computer-averaged complexes should be visually confirmed. - Horizontal or downsloping ST-segment depression ≥ 1 mm (0.1 mV) at 80 ms after the J point is a strong indicator of myocardial ischemia. - Clinically significant ST-segment depression that occurs during postexercise recovery is an indicator of myocardial ischemia. - ST-segment depression at a low workload orlow rate-pressure product is associated with worse prognosis and increased likelihood for multivessel disease. - When ST-segment depression is present in the upright resting ECG, only additional ST-segment depression during exercise is considered for ischemia. - When ST-segment elevation is present in the upright resting ECG, only ST-segment depression below the isoelectric line during exercise is considered for ischemia. - Upsloping ST-segment depression ≥ 2 mm (0.2 mV) at 80 ms after the J point may represent myocardial ischemia, especially in the presence of angina. However, this response has a low positive predictive value; it is often categorized as equivocal. - Among patients after myocardial infarction (MI), exercise-induced ST-segment elevation (> 1 mm or > 0.1 mV for 60 ms) in leads with Q waves is an abnormal response and may represent reversible ischemia or wall motion abnormalities. - Among patients without prior MI, exercise-induced ST-segment elevation most often represents transient combined endocardial and subepicardial ischemia but may also be due to acute coronary spasm. - Repolarization changes (ST-segment depression or T-wave inversion) that normalize with exercise may represent exercise-induced myocardial ischemia but is considered a normal response in young subjects with early repolarization on the resting ECG.A high exercise capacity is indicative of a high peak ___ and therefore suggests the absence of serious limitations of left ventricular function. .Q/ Cardiac outputThe standard error in estimating exercise capacity from various published prediction equations is at least ± __ MET1In order to provide a comparative reference specific to patients with established heart disease, Ades et al. developed nomograms stratified by ___ , _____ , and _____ based on patients with heart disease entering cardiac rehabilitation.- Age - Gender - Heart disease diagnosisCPET is particularly useful in identifying whether the cause of dyspnea has a _____ or _____ etiologycardiac or pulmonaryCriteria used to confirm that a maximal effort has been elicited during GXT- *A plateau in VO2* (or failure to increase O2 by 150 mL ∙ min − 1) with increased workload (59,60). This criterion has fallen out of favor because a plateau is not consistently observed during maximal exercise testing with a continuous protocol (51). - *Failure of HR to increase* with increases in workload (59) - *A postexercise venous lactate concentration > 8.0 mmol ∙ L − 1* (41) - A rating of perceived exertion *(RPE) at peak exercise > 17* on the 6- 20 scale or > 7 on the 0- 10 scale - A peak *RER ≥ 1.10.* Peak RER is perhaps the most accurate and objective noninvasive indicator of subject effort during a GXTThe factors that determine the diagnostic value of exercise testing (and other diagnostic tests) are the _______ and ______ of the test procedure and prevalence of IHD in the population testedSensitivity & specificitySensitivityrefers to the ability to positively identify patients who truly have IHDTrue positive testpositive for myocardial ischemia and patient truly has IHDFalse Negative Testnegative for myocardial ischemia but patient truly has IHDThe sensitivity of an exercise test is decreased by:- Inadequate myocardial stress - Medications that attenuate the cardiac demand to exercise or reduce myocardial ischemia (e.g., β-adrenergic blockers, nitrates, calcium channel blocking agents), - Insufficient ECG lead monitoring. .In many clinics, a test is not classified as "negative," unless the patient has attained an adequate level of myocardial stress based on achieving ≥ ___% of predicted HRmax (17,21) and/ or a peak rate-pressure product ≥ _____ mm Hg ∙ beats ∙ min − 1.85% 25,000 mm Hg ∙ beats ∙ min − 1.SpecificityRefers to the ability to correctly identify patients who do not have IHDTrue negative testTest is negative for myocardial ischemia and patient if free of IHDFalse positive testTest is positive for myocardial ischemia but patient does not have IHDThe Duke Score/ Nomogram (Figure 5.6) considers: (3) The calculated score is related to annual and 5-yr survival rates and allows the categorization of patients into ___, ____, & ____ risk subgroups.- Exercise capacity - The magnitude of ST-segment depression, - The presence and severity of angina pectoris low-, moderate-, and high-Myocardial Perfusion Imaging (Nuclear Testing)Two most common isotopes: - thallium - technetium sestambi (Cardiolite) These agents cross cell membranes of metabolically active tissue either actively (thallium) or passively (sestamibi). - In the case of an MI, the isotope does not cross the cell membrane of the necrotic tissue, and thus a permanent reduction of isotope activity is observed on the image, referred to as a nonreversible, or fixed, perfusion defect. - In the case of exertional myocardial ischemia, the tissue uptake in the ischemic region is reduced during exercise by virtue of the relative reduction of blood flow (and thus isotope) to the ischemic tissue.Echocardiographic examination:allows evaluation of wall motion, wall thickness, and valve function.Radionuclide myocardial perfusion imaging and echocardiography:allow the physician to identify the location and magnitude of myocardial ischemia.6 Minute walk testOriginally developed to assess patients with pulmonary diseaseAn exercise training program ideally is designed to meet individual health and physical fitness goals within the context of ______ health status, function, and the respective physical and social environment.IndividualFITT-VP principle of Ex RxFrequency- How often Intensity - How hard Time - Duration or how long Type - Mode or what kind total Volume - Amount Progression - AdvancementFor most adults, an exercise program including aerobic, resistance, flexibility, and neuromotor exercise training is indispensable to improve and maintain physical fitness and health Medicine, American College of Sports. ACSM's Guidelines for Exercise Testing and Prescription (Kindle Locations 4603-4604). LWW. Kindle Edition.For most adults, an exercise program including _____, _____, _____, & ______ exercise training is indispensable to improve and maintain physical fitness and healthaerobic, resistance, flexibility, and neuromotorThe optimal Ex Rx should address: 5- Cardiorespiratory fitness - Muscular strength and endurance - Flexibility - Body composition - Neuromotor fitnessMusculoskeletal injuries (MSIs) are of concern to adults and may be reduced by including:- Warm-up and cool-down, - Stretching exercises - Gradual progression of volume and intensityThe risk of CVD complications, a concern in middle-aged and older adults, can be minimized by:- Following the *preparticipation health screening and evaluation procedures* - Beginning a new program of exercise at *light-to-moderate intensity* - Employing a *gradual progression* of the quantity and quality of exerciseComponents of Exercise Training Session- Warm up - Conditioning and/ or sports related exercise - Cool Down - Stretching- Warm up - Conditioning and/ or sports related exercise - Cool Down - StretchingWarm-up: at least *5- 10 min of light-to-moderate intensity* cardiorespiratory and muscular endurance activities Conditioning: at least *20- 60 min of aerobic, resistance, neuromotor, and/ or sports activities (exercise bouts of 10 min are acceptable if the individual accumulates at least 20- 60 min* ∙ d − 1 of daily aerobic exercise) Cool-down: at least *5- 10 min of light-to-moderate intensity* cardiorespiratory and muscular endurance activities Stretching: at least *10 min of stretching* exercises performed after the warm-up or cool-down phaseAn individual's ______ (7) should be considered when designing the FITT-VP principle of Ex Rx.goals, physical ability, physical fitness, health status, schedule, physical and social environment, available equipment and facilitiesA ______, cardiorespiratory endurance exercise warm-up is superior to static flexibility exercises for the purpose of enhancing the performance of cardiorespiratory endurance, aerobic exercise, sports, or resistance exercise, especially activities that are of long duration or with many repetitionsDynamicThe purpose of the cool-down period:is to allow for a gradual recovery of heart rate (HR) and blood pressure (BP) and removal of metabolic end products from the muscles used during the more intense exercise conditioning phase.Improvements in CRF are attenuated with exercise frequencies < __ d ∙ wk − 1 and plateau in improvement with exercise done > __ d ∙ wk − 1<3 >5AEROBIC EXERCISE FREQUENCY RECOMMENDATIONModerate intensity aerobic exercise done at least 5 d ∙ wk − 1, or vigorous intensity aerobic exercise done at least 3 d ∙ wk − 1, or a weekly combination of 3- 5 d ∙ wk − 1 of moderate and vigorous intensity exercise is recommended for most adults to achieve and maintain health/ fitness benefits.Methods of Estimating Intensity of Cardiorespiratory and Resistance ExerciseTable 6.1The overload principle of training states exercise below a minimum intensity, or ______ , will not challenge the body sufficiently to result in changes in physiologic parameters, including increased maximal volume of oxygen consumed per unit of time (VO2max)Threshold______ training involves varying the exercise intensity at fixed intervals during a single exercise session, which can increase the total volume and/ or average exercise intensity performed during that session.IntervalDuring interval training, several aspects of the Ex Rx can be varied depending on the goals of the training session and physical fitness level of the client or patient. These variables include:- The exercise mode - The number - Duration - Intensity of the work and recovery intervals - The number of repetitions of the intervals - The duration of the between-interval rest periodAerobic Exercise Intensity RecommendationModerate (e.g., 40%- 59% heart rate reserve [HRR] or O2R) to vigorous (e.g., 60%- 89% HRR or O2R) intensity aerobic exercise is recommended for most adults, and light (e.g., 30%- 39% HRR or O2R) to moderate intensity aerobic exercise can be beneficial in individuals who are deconditioned. Interval training may be an effective way to increase the total volume and/ or average exercise intensity performed during an exercise session and may be beneficial for adults.Measured or estimated measures of absolute exercise intensity include (3) These absolute measures can result in misclassification of exercise intensity (e.g., moderate and vigorous intensity) because they do not take into consideration individual factors such as body weight, sex, and fitness level- caloric expenditure (kcal ∙ min − 1), - absolute oxygen uptake (mL ∙ min − 1 or L ∙ min − 1), and - METs.For individual Ex Rx, a ______ measure of intensity (i.e., the energy cost of the activity relative to the individual's peak or maximal capacity such as *%VO2* [i.e., VO2 mL ∙ kg − 1 ∙ min − 1], *HRR*, and *VO2R*, or using a threshold method, [i.e., VT or RCP]) is more appropriate, especially for older, deconditioned individuals and people with chronic diseasesRelativeHRR method:Target HR (THR) = [( HRmax/ peaka − HRrest ) × % intensity desired] + HRrestVo2R Method:Target VO2Rc = [( VO2max/ peakb − VO2rest) × % intensity desired + VO2restHR method:Target HR = HRmax/ peak × % intensity desiredVO2 methodTarget VO2 = VO2max/peak - % intensity desiredMET methodTarget MET = [(Vo2max/peak) / 3.5 mL * kg * min] x % intensity desiredSummary of methods for prescribing exercise intensity using HR, O2, METa) HRmax/ peak is the highest value obtained during maximal/ peak exercise or it can be estimated by 220 − age or some other prediction equation (see Table 6.2). b) VO2max/ peak is the highest value obtained during maximal/ peak exercise or it can be estimated from a submaximal exercise test. c) Activities at the target VO2 and MET can be determined using a compendium of physical activity (1,2) or metabolic calculations (46) (see Table 6.3). HRmax/ peak, maximal or peak heart rate; HRR, heart rate reserve; HRrest, resting heart rate; VO2max/ peak, maximal or peak volume of oxygen consumed per unit of time; VO2R, oxygen uptake reserve; VO2rest, resting volume of oxygen consumed per unit of time.The ________ is a valid and reliable measure of exercise intensity that is a reasonable surrogate of the lactate threshold, VT, and RCP across a broad range of individuals and can now be recommended as an effective primary method for prescribing and monitoring exercise intensityTalk TestAerobic Exercise Time (Duration) RecommendationMost adults should accumulate 30- 60 min ∙ d − 1 (≥ 150 min ∙ wk − 1) of moderate intensity exercise, 20- 60 min ∙ d − 1 (≥ 75 min ∙ wk − 1) of vigorous intensity exercise or a combination of moderate and vigorous intensity exercise daily to attain the recommended targeted volumes of exercise. This recommended amount of exercise may be accumulated in one continuous exercise session or in bouts of ≥ 10 min over the course of a day. Durations of exercise less than recommended can be beneficial in some individuals.Less than 20 min of exercise a day can be beneficial, especially forpreviously sedentary individualsThe specificity principle states:that the physiologic adaptations to exercise are specific to the type of exercise performedAerobic Exercise Type RecommendationRhythmic, aerobic exercise of at least moderate intensity that involves large muscle groups and requires little skill to perform is recommended for all adults to improve health and CRF. Other exercise and sports requiring skill to perform or higher levels of fitness are recommended only for individuals possessing adequate skill and fitness to perform the activity.aerobic or cardiorespiratory endurance exercises categorized by the intensity and skill demands.- Type A exercises, recommended for all adults, require little skill to perform, and the intensity can easily be modified to accommodate a wide range of physical fitness levels. - Type B exercises are typically performed at a vigorous intensity and are recommended for individuals who are at least of average physical fitness and who have been doing some exercise on a regular basis. - Type C exercises require skill to perform and therefore are best for individuals who have reasonably developed motor skills and physical fitness to perform the exercises safely. - Type D exercises are recreational sports that can improve physical fitness but which are generally recommended as ancillary PAs performed in addition to recommended conditioning PAs. Type D PAs are recommended only for individuals who possess adequate motor skills and physical fitness to perform the sport; however, many of these sports may be modified to accommodate individuals of lower skill and physical fitness levels.Exercise Volumethe product of Frequency, Intensity, and Time (duration) or FIT of exercise._____ & _____ can be used to estimate exercise volume in a standard manner- MET-min ∙ wk − 1 - kcal ∙ wk − 1Calculations of METs, MET-min, and kcal*minMetabolic Equivalents (METs): An index of energy expenditure (EE). "A MET is the ratio of the rate of energy expended during an activity to the rate of energy expended at rest. . . . [One] MET is the rate of EE while sitting at rest . . . by convention . . . [1 MET is equal to] an oxygen uptake of 3.5 [mL ∙ kg − 1 ∙ min − 1]" . MET-min: An index of EE that quantifies the total amount of physical activity performed in a standardized manner across individuals and types of activities (80). Calculated as the product of the number of METs associated with one or more physical activities and the number of minutes the activities were performed (i.e., METs × min), usually standardized per week or per day as a measure of exercise volume. Kilocalorie (kcal): The energy needed to increase the temperature of 1 kg of water by 1 ° C. To convert METs to kcal ∙ min − 1, it is necessary to know an individual's body weight, kcal ∙ min − 1 = [( METs × 3.5 mL ∙ kg − 1 ∙ min − 1 × body wt in kg) ÷ 1,000)] × 5. Usually standardized as kilocalorie per week or per day as a measure of exercise volume. Example: Jogging (at ~ 7 METs) for 30 min on 3 d ∙ wk − 1for a 70-kg male: 7 METs × 30 min × 3 times per week = 630 MET-min ∙ wk − 1 [( 7 METs × 3.5 mL ∙ kg − 1 ∙ min − 1 × 70 kg) ÷ 1,000)] × 5 = 8.575 kcal ∙ min − 1 8.575 kcal ∙ min − 1 × 30 min × 3 times per week = 771.75 kcal ∙ wk − 1a total EE of ≥ ____-____ MET-min ∙ wk − 1 is consistently associated with lower rates of CVD and premature mortality. Thus, ≥ ____- ____ MET-min ∙ wk − 1 is a reasonable target volume for an exercise program for most adults500-1000This volume is approximately equal to: (3)(a) 1,000 kcal ∙ wk − 1 of moderate intensity PA (or about 150 min ∙ wk − 1), (b) an exercise intensity of 3- 5.9 METs (for individuals weighing ~ 68- 91 kg [~ 150- 200 lb]) (c) 10 MET-h ∙ wk − 1Recommended # of steps/ day7,000Aerobic Exercise Volume RecommendationA target volume of ≥ 500- 1,000 MET-min ∙ wk − 1 is recommended for most adults. This volume is approximately equal to - 1,000 kcal ∙ wk − 1 of moderate intensity PA, ~ 150 min ∙ wk − 1 of moderate intensity exercise, - or pedometer counts of ≥ 5,400- 7,900 steps ∙ d − 1. Because of the substantial errors in prediction when using pedometer step counts, use steps per day combined with currently recommended time/ durations of exercise. Lower exercise volumes can have health/ fitness benefits for deconditioned individuals; however, greater volumes may be needed for weightIncrease in exercise time/ duration __________ is reasonable for the average adultper session of 5-10 min every 1-2 weeks over the first 4-6 weeks of an exercise training programOlder adults (>65) may benefit from ____ training because this element of muscle fitness most rapidly declines with agepowerGoals for a health-related resistance training programFor adults of all ages, the goals of a health-related resistance training program should be to (a) make activities of daily living (ADL) (e.g., stair climbing, carrying bags of groceries) less stressful physiologically and (b) effectively manage, attenuate, and even prevent chronic diseases and health conditions such as osteoporosis, Type 2 diabetes mellitus, and obesity. For these reasons, although resistance training is important across the age span, its importance becomes even greater with ageResistance Training Frequency RecommendationResistance training of each major muscle group 2- 3 d ∙ wk − 1 with at least 48 h separating the exercise training sessions for the same muscle group is recommended for allTypes of Resistance ExercisesMany types of resistance training equipment can effectively be used to improve muscular fitness. Both multijoint and single-joint exercises targeting agonist and antagonist muscle groups are recommended for all adults as part of a comprehensive resistance training program.Amount of sets needed for strength games for a novice1To improve muscular endurance rather than strength and mass, a higher number of repetitions, perhaps ___- ____ , should be performed per set along with shorter rest intervals and fewer sets Typically no more than ___% 1-RM15-25 50%Volume of Resistance Exercise (Sets & Reps) RecommendationIdeally, adults should train each muscle group for a total of 2- 4 sets with 8- 12 repetitions per set with a rest interval of 2- 3 min between sets to improve muscular fitness. However, even a single set per muscle group will significantly improve muscular strength, particularly among novices. Older adults or deconditioned individuals should begin a training regimen with ≥ 1 set of 10- 15 repetitions of very light-to-light intensity (i.e., 40%- 50% 1-RM) resistance exercise for muscular fitness improvements.Resistance Exercise Technique RecommendationsAll individuals should perform resistance training using correct technique. Proper resistance exercise techniques employ controlled movements through the full ROM and involve concentric and eccentric muscle.Muscular strength may be maintained by training muscle groups as little as __ d ∙ wk − 1 as long as the training intensity or the resistance lifted is held constant1Progression/ Maintenance of Resistance Training RecommendationAs muscles adapt to a resistance exercise training program, the participant should continue to subject them to overload to continue to increase muscular strength and mass by gradually increasing resistance, number of sets, or frequency of training.The ROM around a joint is improved immediately after performing flexibility exercise and shows chronic improvement after about __- __ wk of regular stretching at a frequency of at least __- __ times ∙ wk3-4 wk 2-3 times/ weekIt is most effective to perform flexibility exercise when muscle temp. is increased through _____ exerciseswarm-up_______ stretching exercises may result in a short-term decrease in muscle strength, power, and sports performance when performed immediately prior to the muscle strength and power activity, especially with longer duration (> 45 s) stretchingStaticFlexibility Exercise RecommendationROM is improved acutely and chronically following flexibility exercises. Flexibility exercises are most effective when the muscles are warm. Static stretching exercises may acutely reduce power and strength, so it is recommended that flexibility exercises be performed after exercise and sports where strength and power are important for performance.Ballistic methods or "bouncing stretches"use the momentum of the moving body segment to produce the stretchDynamic or slow movement stretchesinvolves a gradual transition from one body position to another and a progressive increase in reach and range of motion as the movement is repeated several timesStatic Stretchinginvolves slowly stretching a muscle/ tendon group and holding the position for a period of time (i.e., 10- 30 s). Static stretches can be active or passiveActive static stretchinginvolves holding the stretched position using the strength of the agonist muscle as is common in many forms of yogaPassive static stretchinginvolves assuming a position while holding a limb or other part of the body with or without the assistance of a partner or device (such as elastic bands or a ballet barre)Proprioceptive neuromuscular facilitation (PNF)methods take several forms but typically involve an isometric contraction of the selected muscle/ tendon group followed by a static stretching of the same group (i.e., contract-relax)Flexibility Volume RecommendationA total of 60 s of flexibility exercise per joint is recommended. Holding a single flexibility exercise for 10- 30 s to the point of tightness or slight discomfort is effective. Older adults can benefit from holding the stretch for 30- 60 s. A 20%- 75% maximum voluntary contraction held for 3- 6 s followed by a 10- to 30-s assisted stretch is recommended for PNF techniques. Performing flexibility exercises ≥ 2- 3 d ∙ wk − 1 is recommended with daily flexibility exercise being most effective. Repetition of each flexibility exercise 2-4 times is recommendedNeuromotor exercise training involves motor skills such as: (5) and is sometimes called functional fitness training.- balance - coordination - gait - agility - proprioceptive trainingNeuromotor Exercise RecommendationsNeuromotor exercises involving balance, agility, coordination, and gait are recommended on ≥ 2- 3 d ∙ wk − 1 for older individuals and are likely beneficial for younger adults as well. The optimal duration or number of repetitions of these exercises is not known, but neuromotor exercise routines of ≥ 20- 30 min in duration for a total of ≥ 60 min of neuromotor exercise per week are effective.The 2008 Physical Activity Guidelines for Americans call for children and adolescents to engage in at least ___ min ∙ d − 1 of moderate-to-vigorous intensity PA and to include vigorous intensity PA, resistance exercise, and bone loading activity on at least ___ d ∙ wk60 min at least 3 days/weekChildren have a much lower _____ capacity than adults limiting their ability to perform sustained vigorous intensityanaerobicChildren physiologic responses during exercise differ from those of adults so that the following issues should be considered:- Exercise testing for clinical purposes is generally not indicated for children or adolescents unless there is a health concern. - The exercise testing protocol should be based on the reason the test is being performed and the functional capability of the child or adolescent. - Children and adolescents should be familiarized with the test protocol before testing to minimize stress and maximize the potential for a successful test. - Treadmill and cycle ergometers should be available for testing. Treadmills tend to elicit a higher peak oxygen uptake (VO2peak) and maximal heart rate (HRmax). Cycle ergometers provide less risk for injury but need to be correctly sized for the child or adolescent. - Children and adolescents may require extra motivation and support during the test compared to adults.Physiologic responses higher to acute exercise in children compared to adults- Relative oxygen uptake - Heart rate - Respiratory ratePhysiologic responses lower to acute exercise in children compared to adults- Absolute oxygen uptake - Cardiac output - Stroke volume - SBP - DBP - Tidal volume - Minute ventilation - Respiratory Exchange RatioFITT Recommendations for Children and Adolescents AerobicF: Daily I: Moderate to vigorous, include vigorous intensity at least 3 d/w Ti: As part of >60 min/ day of exercise Ty: Enjoyable and devlopmentally appropriateFITT Recommendations for Children and Adolescents ResistanceF: =>3 d/w I: Use of body weight as resistance or 8-15 submax reps to the point of moderate fatigue w/ good mechanical form Ti: As part of >60 min/ day of exercise Ty: Can be structured or unstructuredThree broad categories of LBPa) LBP potentially associated with another specific spinal cause (e.g., cancer, fracture, infection, ankylosing spondylitis or cauda equina syndrome) b) LBP potentially associated with radiculopathy or spinal stenosis; and c) and nonspecific LBP, which encompass over 85% of all casesFor prognosis and outcome purposes, LBP can be described as- acute (< 6 wk), - subacute (6- 12 wk) - chronic (> 12 wk)Ex Rx for LBP- Recommend staying physically active and avoiding bed rest - May be best to avoid exercise in the first few days immediately following an acute and severe episode of LBP so as not to exacerbate symptoms - Within 2 weeks of an acute LBP episode, activities can be carefully introduced.Special considerations for LBP- Trunk coordination, strengthening, and endurance exercises can be used to reduce LBP and disability in individuals with subacute and chronic LBP with movement coordination impairments (34). However, there is insufficient evidence for any benefit of emphasizing single-dimension therapies such as abdominal strengthening (62,86). - Individual response to back pain symptoms can be improved by providing assurance, encouraging activity, and emphasizing that more than 90% of LBP complaints resolve without any specific therapies (62). - There is a lack of agreement on the definition, components, and assessment techniques related to core stability. Furthermore, the majority of tests used to assess core stability have not demonstrated validity (73,75). - Abdominal bracing (cocontraction of trunk muscles) (77) should be used with extreme caution because the increases in spinal compression that occur with abdominal bracing may cause further harm to the individual (4). - Certain exercises or positions may aggravate symptoms of LBP. Walking, especially downhill, may aggravate symptoms in individuals with spinal stenosis (97). - Certain individuals with LBP may experience a "peripheralization" of symptoms, that is, a spread of pain into the lower limbs with certain sustained or repeated movements of the lumbar spine (76). Limits should be placed on any activity or exercise that causes spread of symptoms (114). - Repeated movements and exercises such as prone push-ups that promote centralization (i.e., a reduction of pain in the lower limb from distal to proximal) are encouraged to reduce symptoms in patients with acute LBP with related lower extremity pain (34). - Flexibility exercises are generally encouraged as part of an overall exercise program. Hip and lower limb flexibility should be promoted, although no stretching intervention studies have shown efficacy in treating or preventing LBP (36). It is generally not recommended to use trunk flexibility as a treatment goal in LBP (111). - Consider progressive, low intensity aerobic exercise for individuals with chronic LBP with generalized pain (pain in more than one body area) and moderate-to-high intensity aerobic exercise for individuals with chronic LBP without generalized pain (34).Effects of aging on selected physiologic and health-related variables What is lower?- Max HR - Max cardiac output - Absolute & Relative oxygen uptake reserve - Vital Capacity - Musc Strength - Flexibility - Bone mass - Fat-free body mass - Glucose toleranceEffects of aging on selected physiologic and health-related variables What is higher?- Resting and exercise BP - Residual volume - % body fatMost older adults do not require an Ex test prior to initiating a ____ intensity PA programModerateSpecial considerations when testing older older adults- Light initial workload (<3 METs) and small increment workloads (0.5-1.0 METs) - Cycle ergometer preferred for those w/ poor balance coordination, etc. Local muscle fatigue may cause premature test termination - Treadmill hand support for impaired adults. Will reduce accuracy of estimating MET or peak workload achieved - Many older adults exceed APHRMax, take into account -Senior Fitness Testwas developed using a large, healthy community-dwelling sample and has published normative data for men and women aged 60- 94 yr for items representing upper and lower body strength, upper and lower body flexibility, CRF, agility, and dynamic balance (101). Senior Fitness investigators have now published thresholds for each test item that define for adults ages 65- 85 yr the level of capacity needed at their current age, within each domain of functional fitness, to remain independent to age 90 yr Seven items: 30 s chair stand, 30 s arm curls, 8 ft up and go, 6-min walk, 2-min step test, sit & reach, and back scratch with normative scales for each testPhysical Performance Battery TestPhysical Performance Battery (SPPB) (56), a test of lower extremity functioning, is best known for its predictive capabilities for disability, institutionalization, and death, but it also has known ceiling effects that limit its use as an outcome for exercise interventions in generally healthy older adults. Combines scores from usual gait speed and timed tests of balance and chair standsUsual Gait SpeedUsually assessed as the better of two time trials to walk a short distance (3-10 m) at a usual pace6 min walk testWidely used as an indicator of cardiorespiratory endurance Assessed most distance walked in 6 min. A change of 50 m is considered substantial changeContinuous Scale Physical Performance TestIn contrast for older adults, activities should be defined relative to an individual's physical fitness within the context of a perceived 10-point physical exertion scale which ranges from 0 (an effort equivalent to sitting) to 10 (an all-out effort), with moderate intensity defined as __ or __ and vigorous intensity as ≥ ___.5 or 6 7Neuromotor training is effective in reducing and preventing falls if performed __ to __ d/w2 to 3FITT recommendations for older adultsp. 193Relative Contraindications for Exercising during Pregnancy- Severe anemia - Unevaluated maternal cardiac dysrhythmia - Chronic bronchitis - Poorly controlled Type 1 diabetes mellitus - Extreme morbid obesity - Extreme underweight - History of extremely sedentary lifestyle Intrauterine growth restriction in current pregnancy - Poorly controlled hypertension - Orthopedic limitations - Poorly controlled seizure disorder - Poorly controlled hyperthyroidism - Heavy smokerAbsolute Contraindications for Exercising during Pregnancy- Hemodynamically significant heart disease - Restrictive lung disease - Incompetent cervix/ cerclage - Multiple gestation at risk for premature labor - Persistent second or third trimester bleeding - Placenta previa after 26 wk of gestation - Premature labor during the current pregnancy - Ruptured membranes - Preeclampsia/ pregnancy-induced hypertensionBenefits of Exercise during Pregnancy- Prevention of excessive gestational weight gain - Prevention of gestational diabetes mellitus - Decreased risk of preeclampsia - Decreased incidence/ symptoms of low back pain - Decreased risk of urinary incontinence - Prevention/ improvement of depressive symptoms - Maintenance of fitness - Prevention of postpartum weight retentionPhysiologic Responses to Acute Exercise during Pregnancy Compared to Nonpregnancy What increases- Oxygen uptake - HR - SV - CO - Tidal Volume - Minute Ventilation - Ventilatory equivalent for Oxygen - Vetilatory equivalent for carbon dioxidePhysiologic Responses to Acute Exercise during Pregnancy Compared to Nonpregnancy What has no change/ decreases- SBP - DBPEx Rx for preg. womanAccumulation of at least 150 min/week of mod. intensity aerobic ex. or 75 min of vig. intensityHealth Screening for Preg. women before participation in exercise- Physical Activity Readiness Medical Examination for Pregnancy (PARmed-X for Pregnancy) - or the electronic Physical Activity Readiness Medical Examination (ePARmed-X +)Warning Signs to Stop Exercise during Pregnancy- Vaginal bleeding or (amniotic) fluid leakage - Shortness of breath prior to exertion - Dizziness, feeling faint, or headache - Chest pain - Muscle weakness - Calf pain or swelling - Decreased fetal movement - Preterm laborSpecial Considerations for Preg. Woman- PA in supine position should be avoided - Avoid exercise in hot humid environment, always hydrated, dress to avoid heat stress - Metabolic demand increases by ~ 300 kcal/d - Obese or gestational DM or hypertension should consult physician before beginning exercise - Avoid contact sports - Avoid valsalva maneuver, prolonged isometric contractions, and motionless standing - Exercise can begin 4-6 weeks after normal birth, 8-10 weeks if cesarean birthAerobic FITT for preg. womenF: >3-5 d/w I: Moderate (3-5.9 METs; RPE of 12-13); Vigorous intensity exercise (>6 METs; RPE 14-17) Ti: ~30 min/d of accumulated mod. intensity ex. to total 150 min/ week or 75 min/ week of vig. intensity Ty: Weight & non-weight bearingResistance FITT for preg. womenF: 2-3 nonconsecutive d/w I: Multiple submax reps (8-10 or 12-15) to be performed to point of mod. fatigue Ti: 1 set for beginners, 2-3 for intermediate & advancedFlexibility FITT for preg. womenF: > 2-3 d/w I: to point of discomfort Ti: 10-30 s Ty: static & dynamicThe progressive decrease in atmospheric pressure associated with ascent to higher altitudes reduces the partial pressure of oxygen in the inspired air, resulting in decreased _____ oxygen levels.ArterialThe immediate compensatory responses to this include increased ______ and ______- Ventilation - Cardiac outputPhysical performance decreases with increasing altitude >______ m1200 mWith altitude exposure of ≥ __ wk, significant altitude acclimatization occurs (i.e., increased ventilation and arterial oxygen content and restored acid-base balance).1Primary altitude illnesses- Acute mountain sickness (AMS) - High-altitude cerebral edema (HACE) - High-altitude pulmonary edema (HAPE)Acute Mountain Sickness (AMS)- Most common form of altitude sickness - Symptoms include headache, nausea, fatigue, decreased appetite, and poor sleep, and in severe cases, poor balance and mild swelling in the hands, feet, or face. - AMS develops within the first 24 h of altitude exposure. - AMS symptoms peak at about 18-22 h and recovery occurs over the next 24-48 hHigh-altitude cerebral edema (HACE)- Potentially fatal, not common - Occurs in <2% of indv. ascending >3,658 m - Exacerbation of unresolved, severe AMS. - Occurs in indv. who have AMS symptoms but keep ascendingHigh altitude pulmonary edema (HAPE)- potentially fatal, not common - Occurs in <10% ascending >3,658 m - Indv. making repeated ascents and descents and who exercise strenuously early in the exposure have increased susceptibility - Presence of crackles and rales in lungs and severe dyspnea may indicate increased susceptibility to developing HAPE_____ is the best countermeasure to all altitude sicknessAltitude acclimatization_______ sustained exercise/ PA and maintaining adequate hydration and food intake will reduce susceptibility to altitude sickness and facilitate recovery.MinimizingWhen moderate-to-severe symptoms and signs of an altitude-related sickness develop, the preferred treatment is to _______descend to a lower altitude.Descents of _______ m with an overnight stay are effective in prevention and recovery of all altitude sickness.305- 915 m (1,000- 3,000 ft)_______ is a carbonic anhydrase inhibitor that promotes excretion of bicarbonate in the urine and production of carbon dioxide to stimulate ventilation.DiamoxHeadache is most effectively treated with ____Ibuprofen________ therapy will usually relieve AMS symptoms and the accompanied poor sleep.Oxygen or hyperbaric chamber________ may be used to help relieve nausea and vomiting.Prochlorperazine (i.e., Compazine)________ may be used if other treatments are not available or effectiveDexamethasone (i.e., Decadron, Hexadrol)Treatment of individuals diagnosed with HACE or HAPE includes- descent, - oxygen therapy, - hyperbaric bag therapy.Monitoring exercise ____ provides a safe, easy, and objective means to quantify exercise intensity at altitude, as it does at sea level.HRIn addition to achieving acclimatization by residing continuously at a given target altitude, at least partial altitude acclimatization can develop by living at a moderate elevation, termed ______ , before ascending to a higher target elevation.stagingFor individuals ascending from low altitude, the first stage of all staged ascent protocols should be ≥ __ d of residence at moderate altitude.3At any given altitude, almost all of the acclimatization response is attained between __ and __ d of residence at that altitude.7 and 12 dShort stays of __ -___ d at moderate altitudes will decrease susceptibility to altitude sickness at higher altitudes.3-7 dStays of __- __ d are required to improve physical work performance.6-12 dThe best indices of altitude acclimatization over time at a given elevation are:- Decline (or absence) of altitude sickness, - Improved physical performance, - Decreased HR (both resting and exercise), - Increase in percent saturation of arterial oxygenEx Rx for high altitudes- During the first few days at high altitudes, individuals should minimize their exercise/ PA to reduce susceptibility to altitude illness. - After this period, if the Ex Rx specifies a target heart rate (THR), the individual should maintain the same exercise HR at higher altitudes. - The personalized number of weekly training sessions and the duration of each session at altitude can remain similar to those used at sea level for a given individual..Factors that should be considered to further minimize the negative effects of high altitude- Monitor the environment - Modify the activity at high altitudes - Clothing - Education_______ develops when heat loss exceeds heat production, causing the body heat content to decreaseHypothermia______ occurs when tissue temp. falls lower than 0 degree Celsius Most common in exposed skin but also occurs in the hands and feetFrostbitePrincipal cold stress determinants for frostbite: (3)- Air temp. - Wind speed - WetnessThe _______ integrates wind speed and air temperature to provide an estimate of the cooling power of the environment. It is specific in that its correct application only estimates the danger of cooling for the exposed skin of individuals walking at 1.3 m ∙ s −Wind Chill Temperature Index (WCT)Important information about wind and the WCT incorporates the following considerations:- Wind does not cause an exposed object to become cooler than the ambient temperature. - Wind speeds obtained from weather reports do not take into account man-made wind (e.g., running, skiing). - The WCT presents the relative risk of frostbite and predicted times to freezing (see Figure 8.1) of exposed facial skin. Facial skin was chosen because this area of the body is typically not protected. - Frostbite cannot occur if the air temperature is > 0 ° C (32 ° F). - Wet skin exposed to the wind cools faster. If the skin is wet and exposed to wind, the ambient temperature used for the WCT table should be 10 ° C lower than the actual ambient temperature (9). - The risk of frostbite is < 5% when the ambient temperature is greater than − 15 ° C (5 ° F), but increased safety surveillance of exercisers is warranted when the WCT falls lower than − 27 ° C (− 8 ° F). In those conditions, frostbite can occur in 30 min or less in exposed skin_______ typically occur when tissues are exposed to cold-wet temperatures between 0 ° and 15 ° C (32 ° and 60 ° F) for prolonged periods of timeNonfreezing cold injuriesNFCIs may occur due toactual immersion or by the creation of a damp environment inside boots or gloves, as often seen during heavy sweatingMost common NFCIs- Trench foot - ChilblainsTrench foot- Trench foot is accompanied by aches, increased pain, and infections, making peripheral pulses hard to detect. - The exposure time needed to develop trench foot is quite variable, with estimates ranging from 12 h to 3- 4 d in cold-wet environments (24,42). - Most commonly, trench foot develops when wet socks and shoes are worn continuously over many days.Activities that involve the upper body or increase metabolism potentially increase risk:- Shoveling snow raises the HR to 97% maximal heart rate (HRmax), and systolic blood pressure increases to 200 mm Hg (17). - Walking in snow that is either packed or soft significantly increases energy requirements and myocardial oxygen demands so that individuals with atherosclerotic CVD may have to slow their walking pace. - Swimming in water < 25 ° C (77 ° F) may be a threat to individuals with CVD because they may not be able to recognize angina symptoms and therefore may place themselves at greater riskWhen the amount of metabolic heat exceeds heat lossHyperthermiaDuring exercise-induced heat stress, dehydration increases physiologic strain as measured by: (3)- Core temperature, - HR, - Perceived exertion responsesdehydration of ≥ __% loss in body mass negatively impacts endurance exercise performance, whereas strength and power are negatively affected to a smaller degree2%Active individuals should drink ___ L (1 pint) of fluid for each pound of body weight lost.0.5Fluid Replacement Recommendations Before, During, and After ExerciseBefore: - 5-7mL/kg at least 4 h before ex. During: Composition of fluid include - 20-30 mEq of sodium - 2-5 mEq of potassium - 5-10% carbs After: - Normal consumption - If rapid recovery is needed, 1.5 L* Kg of body weight lostOverdrinking hypotonic fluid (e.g., water) can lead to exercise-associated_______ , a state of lower than normal blood sodium concentration (typically < 135 mEq ∙ L − 1) accompanied by altered cognitive status.HyponatremiaExertional heat crampsBegins as feeble localized, wandering spasms that may progress to debilitating heat crampsHeat SyncopeTemporary circulatory failure caused by the pooling of blood in the peripheral veins, particularly of the lower extremities Symptoms: light-headedness, loss of consciousnessHeat ExhaustionMost common form of heat illness Occurs during exercise/ PA in heat when body cannot sustain the level of Q needed to support skin blood flow for thermoregulation Symptoms: Prominent fatigue and progressive weakness without hyperthermiaExertional HeatstrokeCaused by hyperthermia Characterized by elevated body temp (>40 C, 104 F), CNS dysfunction, multiple organ system failure that can cause delirium, convulsions, comaManifestations of Cardiovascular DiseaseAcute coronary syndrome — the manifestation of coronary artery disease as increasing symptoms of angina pectoris, myocardial infarction, or sudden death Cardiovascular disease — diseases that involve the heart and/ or blood vessels; includes hypertension, coronary artery disease, peripheral arterial disease; includes but not limited to atherosclerotic arterial disease Cerebrovascular disease — diseases of the blood vessels that supply the brain Coronary artery disease — disease of the arteries of the heart (usually atherosclerotic) Myocardial ischemia — temporary lack of adequate coronary blood flow relative to myocardial oxygen demands; often manifested as angina pectoris Myocardial infarction — injury/ death of the muscular tissue of the heart Peripheral arterial disease — diseases of arterial blood vessels outside the heart and brainGuidelines for the inpatient CR program should focus on the following: (4)- Current clinical status assessment - Mobilization - Identification and provision of information regarding modifiable risk factors and self-care - Discharge planning with a home PA and activities of daily living (ADL) plan and referral to outpatient CRAmerican Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Parameters for Inpatient Cardiac Rehabilitation Daily Ambulation (5)- No new or recurrent chest pain in previous 8 h - Stable or falling creatine kinase and troponin values - No indication of decompensated heart failure (e.g., resting dyspnea and bibasilar rales) - Normal cardiac rhythm and stable electrocardiogram for previous 8 hActivities during inpatient CR- Self care - Arm and leg ROM - Postural changes - Limited, supervised ambulationAdverse Responses to Inpatient Exercise Leading to Exercise Discontinuation- Diastolic blood pressure (DBP) ≥ 110 mm Hg - Decrease in systolic blood pressure (SBP) > 10 mm Hg during exercise with increasing workload - Significant ventricular or atrial arrhythmias with or without associated signs/ symptoms - Second- or third-degree heart block - Signs/ symptoms of exercise intolerance including angina, marked dyspnea, and electrocardiogram (ECG) changes suggestive of ischemiaIndications and Contraindications for Inpatient and Outpatient CRINDICATIONS - Medically stable postmyocardial infarction - Stable angina Coronary artery bypass graft surgery - Percutaneous transluminal coronary angioplasty - Stable heart failure caused by either systolic or diastolic dysfunction (cardiomyopathy) - Heart transplantation Valvular heart disease/ surgery - Peripheral arterial disease - At risk for coronary artery disease with diagnoses of diabetes mellitus, dyslipidemia, hypertension, or obesity - Other patients who may benefit from structured exercise and/ or patient education based on physician referral and consensus of the rehabilitation team CONTRAINDICATIONS - Unstable angina - Uncontrolled hypertension — that is, resting systolic blood pressure > 180 mm Hg and/ or resting diastolic blood pressure > 110 mm Hg - Orthostatic blood pressure drop of > 20 mm Hg with symptoms - Significant aortic stenosis (aortic valve area < 1.0 cm2) - Uncontrolled atrial or ventricular arrhythmias - Uncontrolled sinus tachycardia (> 120 beats ∙ min − 1) - Uncompensated heart failure - Third-degree atrioventricular block without pacemaker - Active pericarditis or myocarditis - Recent embolism (pulmonary or systemic) - Acute thrombophlebitis - Aortic dissection - Acute systemic illness or fever - Uncontrolled diabetes mellitus - Severe orthopedic conditions that would prohibit exercise - Other metabolic conditions, such as acute thyroiditis, hypokalemia, hyperkalemia, or hypovolemia (until adequately treated) - Severe psychological disorderPA activities for inpatient CR Ex RxPatients should progress from self-care activities (e.g., sitting, toileting) to walking short-to-moderate distances with minimal or no assistance three to four times per day to independent ambulation on the hospital unit.FITT Recommendations for Inpatient CRF: 2-4 sessions/day for first 3d of hospital stay I: Seated or standing HRrest +20 for patients with an MI HRrest +30 for those recovering from heart surgery Upper limit of 120 BPM, corresponds RPE 13 Ti: Intermittent bouts of walking 3-5 min Attempt to achieve 2:1 exercise/rest ratio Progress to 10-15 min of walking Type: Walking, other aerobic modes in facilityOutpatient CR- at time of physician referral or program entry, following assessments should be performed- Medical and surgical history including the most recent cardiovascular event, comorbidities, and other pertinent medical history - Physical examination with an emphasis on the cardiopulmonary and musculoskeletal systems - Review of recent cardiovascular tests and procedures including 12-lead electrocardiogram (ECG), coronary angiogram, echocardiogram, stress test (exercise or pharmacological studies), cardiac surgeries or percutaneous (exercise or pharmacological studies), cardiac surgeries or percutaneous interventions, and pacemaker/ implantable defibrillator implantation - Current medications including dose, route of administration, and frequency - CVD risk factorsRoutine assessment of risk for exercise (see Chapters 3 and 5) should be performed before, during, and after each CR session, as deemed appropriate by the qualified staff and include the following- HR - Blood pressure (BP) - Body weight - Symptoms or evidence of change in clinical status not necessarily related to activity (e.g., dyspnea at rest, light-headedness or dizziness, palpitations or irregular pulse, chest discomfort, sudden weight gain) - Symptoms and evidence of exercise intolerance - Change in medications and adherence to the prescribed medication regimen - ECG and HR surveillance that may consist of telemetry, Bluetooth or hardwire monitoring, "quick-look" monitoring using defibrillator paddles, periodic rhythm strips depending on the risk status of the patient and the need for accurate rhythm detection, or non-ECG HR monitoring devicesAerobic FITT for Outpatient CRF: min 3d, preferably >5d I: W/ exercise test, 40-80% ex. capacity using HRR, VO2R, VO2Peak W/o exercise test, seated or standing HRrest +20-30 BPM or an RPE of 12-16 Ti: 20-60 min Ty: workResistance FITT for outpatient CRF: 2-3 nonconsecutive days/ week I: 10-15 reps w/o fatigue, RPE 11-13 or 40-60% 1RM Ti: 1-3 sets, 8-10 diff exercises focused on maj. muscle groups Ty: Safe and comfy to useFlexibility FITT for outpatient CRF: >2-3d/w I: point of slight discomfort Ti: 15 s hold for static, >4reps of each exercise Ty: Static, Dynamic, consider PNFExercise Prescription w/o a preparticipation Exercise TestUse RPE to guide exercise Closely monitored for signs and symptomsAerobic FITT Recommendations for Individuals w/ HFF: 3-5 d/w I: If HR data available from GXT, set intensity between 60-80% of HRR If no GXT or if a-fib present, use RPE 11-14 Ti: Progressively increase to 30 min then up to 60 min Ty: Treadmill, walking, cyclingResistance FITT Recommendations for Individuals w HFF: 1-2 nonconsecutive d/w I: Begin at 40% 1RM for Upper and 50% 1RM for lower. Gradually increase to 70% Ti: 2 sets of 10-15 reps Ty: Machines may be best due to loss of strength & balanceFor most patients, the prescribed volume of exercise should be _____ METS3-7 METsDuration and frequency of effort should be increased before ____ intensityexercise intensityResistance training can be added after __ weeks4LVAD Exercise Considerations- BP measured by Doppler - HR during exercise increases linear w workload - Early onset of fatigue common w exercise - RPE of 11-13 to prescribe exercise is appropriateSternotomy- Restrict ROM in upper body, 8-12 weeks after surgery - 5-10lb limit for 10-12 weeksRate-responsive pacemakersIncrease or decrease HR to match level of PASingle-chambered pacemakersHas 1 lead placed in right atrium or right ventricle For patients w chronic A-fibDual-chambered pacemakersTwo leads, one in right atrium and one in right ventricle Indicated for physiologic pacing to reestablish a normal sequence and timing of contractions between upper and lower chambers of heartCardiac resynchronization therapy pacemakersHas 3 leads Indicated for patients with HF who have LBBB and a low functional capacityImplantable Cardioverter DefibrillatorDevice that monitors heart rhythm and delivers shock if life threatening rhythms are detected. Used for high-rate V-tach or ventricular fibrillation Tries to first attempt to pace heart into normal rhythm and rate but shocks person to try and reset to normal HRICD Ex Training Considerations- Programmed pacemaker modes, HR limits, and ICD rhythm detection algorithms should be obtained from the patient's cardiologist prior to exercise testing or training. - Exercise testing should be used to evaluate HR and rhythm responses prior to beginning an exercise program. Exercise training should not begin in patient's whose HR does not increase during the exercise test. In these cases, the exercise sensing mechanism (i.e., movement or respiration) needs adjustment to allow the HR to increase with PA. - When an ICD is present, the peak heart rate (HRpeak) during the exercise test and exercise training program should be maintained 10- 15 beats ∙ min − 1 below the programmed HR threshold for antitachycardia pacing and defibrillation. - After the first 24 h following the device implantation, mild upper extremity ROM activities can be performed and may be useful to avoid subsequent joint complications. - To maintain device and incision integrity, for 3- 4 wk after implant, rigorous upper extremity activities such as swimming, bowling, lifting weights, elliptical machines, and golfing should be avoided. However, lower extremity activities are allowable. - Isolated pacemaker and ICD implantation are not indications for CR. However, supervised exercise can be important for these patients, particularly those with a long history of sedentary living. Fewer supervised exercise sessions might be appropriate for those with normal cardiac function versus others with significantly reduced cardiac function and/ or a history of sudden cardiac death.Aerobic FITT for Individuals w Cardiac TransplantF: 3-5 d/w I: 11-14 RPE Ti: Progressively increase from 15-20 min/d up to 30-60 min/d Ty: Treadmill, cycleResistance FITT for Cardiac TransplantF: 1-2 nonconsecutive d/w I: Begin at 40% 1RM for Upper and 50% 1RM for lower. Gradually increase to 70% Ti: 2 sets of 10-15 repsPeripheral Artery Diseaseatherosclerotic plaque leads to significant stenosis and limitations of vasodilation, resulting in the reduction of blood flow to regions distal to the area of occlusion.Major symptom of PADIntermittent claudication Characterized by reproducible aching, cramping, sensation of fatigue usually affecting muscles of the calf, typically triggered by weight bearing exercisePAD Exercise Testing- Medication dose and timing should be noted and repeated in an identical manner in subsequent exercise tests assessing potential therapeutic changes. - Ankle and brachial artery systolic blood pressure (SBP) should be measured bilaterally after 5- 10 min of rest in the supine position following standardized ABI procedures (61). The ABI is calculated by dividing the higher ankle SBP reading by the higher brachial artery SBP reading. - A standardized motorized treadmill protocol should be used to ensure reproducibility of pain free maximal walking time (63). Claudication pain perception may be monitored using a numerical rating scale (see Figure 5.3) (126). - The exercise test should begin with a slow speed and have gradual increments in grade - Following the completion of the exercise test, patients should recover in the seated position. - The 6MWT may be used to objectively assess ambulatory functional limitations in those not amenable to treadmill testingAerobic FITT Recommendations for PADF: 3-5 d/w I: Mod intensity (40-59% VO2R) to point of moderate pain (3-4 on claudication pain scale) Ti: 30-45 min for up to 12 weeks, progress up to 60 min Ty: Weight-bearing intermittent exercise w seated rest when moderate pain is reached, resume when pain is completely goneResistance FITT for PADF: At least 2d/w on nonconsecutive days I: 60-80% 1RM Ti: 2-3 sets 8-12 reps, 6-8 exercisesAerobic FITT suffering a cerebral vascular accidentF: 3-5 d/w I: If HR available from GXT, 40-70% HRR Otherwise RPE 11-14 Ti: Progressively increase from 20 min to 60 min. Consider multiple 10 min sessionsResistance FITT suffering cerebral vascular accidentF: 2 nonconsecutive d/w I: 50-70% 1 RM Ti: 1-3 sets, 8-15 repsAsthmaAirway obstruction because of inflammation and bronchospasm that is mostly reversibleExercise Induced BronchoconstrictionAirway narrowing that occurs as a result of exerciseExercise testing EIBFEV1.0 measured from baseline and measured at 5, 10, 15, and 30 min Oxyhemoglobin <80% used as test termination 6MWT used in individuals w mod-sev asthmaAerobic FITT AsthmaF: 3-5 d/w I: 40-59% HRR or VO2R. If tolerated, progress to 60-70% Ti: Progressively increas to at least 30-40 minCardinal symptom of COPDDyspnea or shortness of breath w exertionCOPD Exercise Testingmild to moderate COPD: 8-12 min test Severe to very severe: 5-9 min test 6MWT assess more severe pulmonary disease Exertional Dyspnea (Borg Category Ratio 1-10) Test terminate if Sat. <80%COPD Exercise Training Considerations- Light intensity ex. is appropriate for those w severe COPD or very deconditioned indv. - Alternative VO2Peak, use dyspnea 3-6, correspond w 53%-80% of VO2PeakAerobic FITT COPDF: At least 3-5d/w I: mod-vig intensity (50-80& peak work rate or 4-6 on Borg scale) Ti: 20-60 min. If not achievable, >20 min of ex. interpersed w intermittent ex. rest periods of lower intensity of lower intensity work or restResistance FITT COPDF: 2-3d/w I: Strength: 60-70% 1RM for Begin., >80% 1RM for experienced Endurance: <50% 1RM Ti: Strength: 2-4 sets, 8-12 reps Endurance: <2 sets, 15-20 repsT1DMAbsolute insulin deficiency and high tendency for ketoacidosisT2DMCaused by insulin-resistant skeletal muscle, adipose tissue, and lover combined w an insulin secretory defect Common feature is excess body fatElevated blood glucose in response to dietary carbohydrateImpaired Glucose Tolerance IGTElevated blood glucose in fasting stateImpaired Fasting Glucose IFGDiagnostic criteria for diabetesHbA1C >6.5% Fasting Plasma Glucose >126 mg*dL or 7,0 mmol 2-h Plasma Glucose >200 mg * dL during an OGTTAerobic FITT for DiabetesF: 3-7 d/w I: Mod. (40-59% VO2R or 11-12 RPE) to vig. (60-89% VO2R or 14-17 RPE) Ti: T1DM: 150 min/w at mod or 75 min/w at vig or combination T2DM: 150 min/w at mod-vig intensitySpecial Considerations for Diabetes- Hypoglycemia <70 mg*dL is a relative contraindication to exercise - Patients who take insulin should check BG before, occsionally during, and after exercise - Timing of exercise is important for indv. taking insulin - Most insulin users need to consume up to 15g of carbs prior to ex - Hyperglycemia >300 mg*dL - Postpone exercise when hyperglycemia or ketones are present. Indv. w/ T1DM check urine for ketones when BG >250 mg*dL - For indv. w/ peripheral neuropathy, proper care of feetDyslipidemiaAbnormal amount of lipids in blood Further defined by presence of elevated levels of cholesterol or LDL, elevated triglycerides, low levels of HDLMetabolic syndrome (Metsyn)Presence of high TG levelsFoundation for treatmentt of dyslipidemiaLifestyle changesAerobic exercise training consistently reduces____ by 3-6 mg*dL but has no effect on HDL or TGLDLResistance traing reduces _____ & _____ by 6-9 mg*dLLDL & TGDrug very effective for treatment of dyslipidemiaStatinExercise Testing Dyslipidema- Ex. test not required for asymptomatic patients prior to starting light to mod exercise - Special consideration given to presence of other chronic diseasesWeight loss and maintenance min per week250-300 min/wAerobic FITT DyslipidemiaF: >5 d/w to maximize caloric expenditure I: 40-75% VO2R or HRR Ti: 30-60 min to promote or maintain weight loss, 50-60 min or more of daily exercise is recommended Adults >65 y/o follow acsm guidlines for older adultsSpecial Consderations DyslipidemiaIndv taking lipid lowering meds may experience muscle weakness and soreness term MYALGIAExercise testing hypertension- 140/90 mmHg should consult physician to determine if ex test is needed - stage 2 hypertension (160/100) must not engage in ex. prior to medical evaluation and adequate BP management. Med supervised symptom lim. ex test is rec.Aerobic FITT HypertensionF: 5-7 d/w I: mod. intensity (40-59% VO2R or HRR; RPE 12-13) Ti: >30 min of continious or accum. exercise. 10 min bouts if intermittentMaintain BP during exercise<220 mmHg SBP & <105mmHgAntihypertensive meds may lead to sudden excessive drop in BP post exercise. Therefore:Termination of exercise should be gradual, prolong cool-downMetsyn criteria- Hyperglycemia - Elevated BP - Dyslipidemia - Waist circumferenceTreatment guidelines for Metsyn (3)- Weight control (5-10% weight loss within 1 year) - PA (30 min of mod ex on most days of week) - Treatment of CVD risk factors (change in dietary composition)Overweight Obese25-29.9 BMI >30 BMISustained weight loss of __ to __% is likely to result in reduction of several CVD risk factors3 to 5%Aerobic FITT for overweight or obeseF: >5d/w I: initial intensity mod (40-59& VO2R or HRR); progress to vig (>60%) for greater health benfits Ti: 30 min/d (150 min/w); increase to 60 min/d or more (250-300 min/w)Special considerations obese overweightgoal reduce body weight 3-10% over 3-6 mos Reduction of 500-100 kcal/d_____ and other rheumatic diseases are the leading cause of disability in the USarthritisarthritis is characterized bypain , impaired physical function, fatigue and adverse changes in body compositiontwo of the most common rheumatic diseasesosteoarthritis and rheumatoid arthritis____ is a progressive local degenerative joint disease affecting one or multiple jointsosteoarthritis_______ is a chronic systemic inflammatory autoimmune disease of unknown aetiology in which the inflammatory response locally causes inflammation of the joint lining (synovitis) bony erosions and systematically muscle loss fat gain and accelerated atherosclerosisrheumatoid arthritisother common rheumatoid diseases include-fibromyalgia - GOUT - spondyloarthropathies - specific connective tissue diseaserheumatoid diseaseaaffect your joints and muscles. Some, like osteoarthritis, are the result of wear and tear. Others, such as rheumatoid arthritis, are immune system problemspharmaceutical treatments of _____ primary involves analgesics, glucocorticoids, nonsteriodal anti-inflammatory drugs (NSAIDS) and for rheumatoid arthritis disease modified anti rheumatic drugs (DMARDS).arthritisif individuals with arthritis are experiencing acute ______ exercise testing should be postponedinflammationfor patients with arthritis monitor pain levels during testing using a validated pain scale such as the Bord scale or the _____visual numeric scalegeneral population recommendation of increasing duration is5-10 mins every 1-2 weeks over the first 4-6 weeks of exercise training programavoid____ exercise during actor flare ups of arthritis however appropriate to gently move through full ROM during these periodsstrenuousif arthritis patients pain rating 2 hours after exercising is higher than it was prior to excess the duration and or intensity of exercise should be _____ in future sessions (pain 48-72 hours later could be do to DOMS)reducedfor pool based exercise a water temp of ___-___ C aids in relaxing and increasing the compliance of muscles and reducing pain in arthritis patients28-31________ develop from the epithelial cells of organs and compose at least 80% of cancerscarcinomascancer of the immune systemlymphomacancer of connective tissuesarcomarecent indication that ____ may be less reliable for monitoring aerobic exercise intensity for cancer survivors currently undergoing treatment or early post treatment due to difference in resting and max HRHRRindividuals with _____ should wear a compression sleeve during resistance traininglymphedema_____ is a common site for metastases in many cancers survivors with metazoic disease to the bone require modifications to their exercise programbone_____ or muscle wasting is prevalent in individuals with advance gastrointestinal cancers and may limit exercise capacitycachexia____ is a nonprogressive lesion of the brain occurring before, at or soon after birth that interferes with normal brain developmentcerebral palsyCerebral palsy (CP) predominately exists in 2 forms1. spastic 2. athetoidspastic CPcharacterized by an increase muscle tone typically involving the flexor muscle groups of the upper extremity and extensor muscle groups of the lower extremitiesthe _____ muscles of the hypertonic muscles are usually weak in spastic CP patientsantagonistichypertonicity is observed in the ______ and hypotonicity is commonly found int he head, neck and trunkextremetiesathetoid CPcharacterized by involuntary and/or uncontrolled movement that occurs primarily in the extremities. these movements may increase with effort and emotional stressclasses 1-4 on the table for CP classification are described as though who are _____ userswheelchairbefore exercise testing a patient with CP a _____ should be taken of the trunk and upper and lower extremity involvement that includes ROM, strength flexibility and balancefunctional assessment______ modes are preferred for individuals with athetoid CParm and leg ergometry_____ is recommend for individuals with moderate limitations (CP classes 3 and 4)wheel chair ergometry____ tests may be more appropriate to measure CRF in CP patientssub max testin individuals with athetoid CP strength tests should be preformed through movement in a _____ chainclosedrestance exercises designed to target weak muscles groups that oppose hypertonic muscle groups improve the strength of the weak muscle group and normalize the tone in the opposing muscle group through _________reciprocal inhibitionbefore initiating open kinetic chain strengthening exercises with patients with CP always check the impact of _______ on performanceprimitive reflexesin children with CP ____ strength training increases eccentric torque production throughout the ROM while decreasing EMG activity in the exercising muscleeccentrichypertonic muscles should be stretched slowly to their limits through workouts with CP patients.However _____ stretching should be avoidedballisticindividuals with CP are more susceptible to ____ injuries because of their higher incidence of inactivity and associated conditionsoveruse_____ injections decrease spasticity in CP patientsbotoxfibromyalgiasyndrome characterized by chronic widespread nonparticular pain, generalized sensory hypersensitivity, diffuse multiple tender points, fatigue, poor sleep morning stiffness, memory impairment and psychological distressfibromyalgia affects approximately 1-4% of the population in canada, europe and the US, with which gender being more affected?womenthe prevalence of fibromyalgia in the general population increases with age, peaking between the ____ and ____ decade of lifefifth and eighthfibromyalgia is not considered a true form of arthritis but is instead thought to be th result of ______ and ________aberrant central pain and sensory processingfatigue affects 78-94% of individuals with fibromyalgia and often is linked to poor nonrestoritive sleepfibromyalgiaindividuals with fibromyalgia have reduced aerobic capacity and ______ as well as overall reductions in physical activity functional performancemuscle functionwhich test is ally used to assess impact of fibromyalgia before exercise testing?fibromyalgia impact questionnaireminimize ____ component of dynamic resistane exercises to lesson exercise-induced muscle imcrotraumaeccentricconsider including complementary therapies such as ___ and ____ because they have been shown to reduce symptoms in individuals with fibromyalgiatai chi and yogaassist individuals with fibromyalgia set realistic goals, improvement in function and and pain my take over ____ weeks7use of _____ has really increased life expectancy for those who live with HIVantiretroviral therapy (ART)ART drugs are associated with metabolic and anthropomorphic health concerns such asdyslipidemia, abnormal distribution of fat and insulin resistance (which can lead to type 2 diabetes)_____ will dramatically reduce exercise time, VO2 peak and possibly produce abnormal nervous and endocrine responsesAIDSindividuals with HIV/AIDS should reported increased general feelings of fatigue, perceived effort, ______ and SOB if they occurlower gastrointestinal distress_________ is the most common developmental disability that occurs before age 18 yeats in the USA with an estimated prevalence of 2.3% of the populationintellectual disabilitypersons with intellectual disability experience significant limitations in what 2 main areas?1. intellectual functioning 2. adaptive behaviourIQ <70mild-moderate intellectual disabilityIQ <35severe/profound intellectual disabilityExercise preparticipation health screening for those with down syndrome should be carefully monitored by a physician why?50% of DS patients have congenital heart failure and 30% have atlantoaxial instability_________ should not be used for aerobic testing in those with intellectual disability- RUNNING treadmill protocols - Cycle or Arm ergometry - 1-1.5 mi runs_________ should not be used for muscular strength and endurance testing in those with intellectual disability- 1Rm using FREE weights - Push ups - Flexed arm hangbecause HR max is altered for those with down syndrome what method should be used for exercise testing rather then 220-age210-56(age)-15.5(DS status) 1 for DS not preset and 2 for DS presentaerobic exercise training programs for those with intellectual disabilities should aim to have a EE=>_____ kcal/week2000all individuals with down syndrome have low HRmax likey caused by dampened _____ response to exercisecatecholaminewhat should be the priority in exercise prescription for those with down syndromeincreasing muscle strength, especially around major joints (such as the knee)individuals are diagnosed with chronic kidney disease if they have either kidney damage evidence by _______ or reduced kidney function as indicated by a glomerular filtration rate (GFR) <60mL/min/1.73m2 for >3 monthsmicroalbuminuriaGFR = 15-29severely decreasedGFR <15kidney failureGFR >90normal or highShould medical clearance be obtained for kidney disease?Yesfor patients who are receiving hemodialysis, testing should take place when?on opposite day and BP should be monitroed in the arm that does not contain the arteriovenous fistulapatients receiving maintenance hemodialysis the HR is often unreliable , because of this ____ may be used insteadRPEisotonic strength training for those with kidney disease should us a ___-RM or higher instead of a 1RM3Some individuals with CKD are unable are unable to do continuous exercise and therefore should perform intermittent exercise with intervals as short as __ min interspersed with 3 min of rest (i.e., 1: 1 work-to-rest ratio). As the individual adapts to training, the duration of the work interval can be gradually increased, whereas the rest interval can be decreased. Initially, a total exercise time of 15 min can be used, and this can be increased within tolerance to achieve up to 20- 60 min of continuous activity.3Recipients of kidney transplants During periods of rejection, the intensity of exercise should be _____ , but exercise can still be continued.reduced________ is a chronic inflammatory autoimmune disease of central nervous system. ____ is characterized by nerve demylenation due to an attack from activated T cells that cross the blood brain barrier. Following the initial inflammatory response damged myelin form scare like plagues int he brain and spinal cord that can impair nerve conduction and transmissionmultiple sclerosisinitial symptoms of MS includenumbness, weakness, blurred or double vision, cognitive dysfunction and balance problems.onset of MS usually occurs between ages ___ and ____ and affects women more then men20-504 different types of MS1. relapsing-remitting 2. primary progressive (continuous) 3. secondary progressive ( slow and steady progression that transitioned from the relapsing-remitting type) 4. progressive-relapsin_________ is commonly used to indicate the level of disability related to MSkurtzke expanded disability status scale____ and ____ responses in people with MS seeem to be blunted during exerciseHR and BPwhat time of day is best to perform exercise test on someone with MS?morning (fatigue later in the day)Use ___ in addition to HR to evaluate exercise intensity for MSRPEin most patients with MS a _____ is the recommended method of testing aerobic fitnesscycle ergometerassessment of _______ in those with MS is important because of increase muscle tone and spasticity may be evidentflexibilityuhthoff phenomenonis the worsening of neurologic symptoms in multiple sclerosis (MS) and other neurological, demyelinating conditions when the body gets overheated from hot weather, exercise, fever, or saunas and hot tubs. symptoms can be minimized by suing cooling strategies and adjusting exercise time and intensityIndiv. who have significant paresis, consider assessing RPE of the extremities separately using the 0-10 ____ scale to evaluate local muscle fatigue on exercise toleranceOMNI________ is a skeletal disease that is characterized by low BMD and changes in the microarchitecture of bone that increase susceptibility to fractureosteoporosis_______ in particular are associated with increased risk of disability and deathhip fracturesosteoporosis in post menopausal women and in men is defined as a BMD Tscore of the lumbar spine, total hip or femoral neck of <______-2.5Maximal muscle strength testing may be ____ in patients with osteoporosisContraindicated_____ testing should be considered for those with osteoporosisbalancethere are currently no established guidelines regarding contraindications to exercise for indiviualds with osteoporosis the general recommendation is to prescribe ...moderate intensity weight-bearing exercise that does not cause or exacerbate pain. twisting exercises (yoga) should be avoided. Form is important to avoid fractures! - should focusing on strengthening balancing muscles such as quads,, glutes, trunk and hamstrings______ is one of the most common neurodegenerative diseases that is a chronic, progressive neurological disordered characterized cliniallt by symptoms consisting of resting tremor, bradykinesia, rigidity, postural instability and gait abnormalities. caused be a decrease in dopamineparkinsons disease______ is the most common effective drug to treat Parkinsons diseaselevodopalevodopa is now always combined with ____ to precent systemic adverse effectscarbidopaTests of _____ and muscular strength are recommended before exercise testing is performed. Results of the tests can guide how to safely exercise test the individual with PD.balance, gait, general mobility, ROM, flexibility, and muscular strengthindividuals with very advanced parkinsons that can't preform a GXT may require a ______ test insteadradionuclide stress test or stress echocardiographyfor individuals with PD that have a DBS (deep brain stimulation) the signal from the DBS interferes with the ECG recording and performing the test when the DBS is deactivated may cause issues so a ____ should be consulted before a test with these patients is preformedneurologist4 key health outcomes of an exercise program for individuals with parkinsons are improved:1. gait 2. transfers 3. balance 4. joint mobility and muscle power to improve functional capacityduring resistance training PD patients emphasize the ____ muscles of the trunk and hip to prevent faulty posture. Train all major muscles of lower extremities to maintain mobilityextensor____ flexibility should be emphasized for patients with PD because of its relation to posture, gait , balance and functional mobilityneck_____ prevention should be incoorporated into PD exercise precriptionfall_____ training should be emphasized in individuals with PDBalanceactivities that require ______ should be avoided in exercise with patients with parkinsonsmultitasking______ and ______ cueing can be used to improve gait in persons with PD during exercisevisual, auditory______ results in a loss of somatic, sensory and autonomic functions below the lesion levelspinal cord injurylesion in the (C) region typically results in _____ or _____ (complete or incomplete loss of function below the C level of lesion)tetraplegia or tetraparesislesion to the thoracic lumbar or sacral regions leads to _____ (Complete or incomplete loss of function below the T, L, or S level of lesion)paraplegia or paraparesis (at the level of lesion)L2-S2 lack voluntary control of _____,____ and _____ however the upper extremities and trunk usually have normal functionbladder, bowels and sexual functionT6-L2 have respiratory and motor control that depends not he functional capacity of the ______musclesabdominalT1-T6 can experience poor thermoregulation, orthostatic/exercise hypotension, autonomic dysreflexia, (an unregulated spinally mediated reflex response called the ____ that can be life threatening) . when there is no sympathetic innervation tot he heart resting HR may be bradycardia due to cardiac vagal dominance and HR peak is limited to 115-130 bpm. breathing capacity is further diminished intercostal muscle paralysis, however arm function is normalmass reflexthose with C-5- C8 lesions are tetraplegic. But those with C-8 lesions have voluntary control ofscapula, shoulder, elbow and wrist but decreased hand functionthose with C5 lesions rely on what muscles for self care?bicep brachii and shoulder muscleslesions about ____ require ventilator support for breathingC4for those who are wheelchair bound the prime movers (anterior shoulder, chest) should be _______ and the antagonists (posterior shoulder, scapula, back) should be ______lengthened, strengthenedbecause of the functional ability that tenodesis allows some with paralysis the _______ muscles should never be stretchedfinger flexorindividuals with spinal cord injuries tend to endure _____ core temperatureshigherFor SCI, choose exercise mode that allows person to engage the _____largest possible muscle massThe goal of exercise training for SCi include the prevention of ____DeconditioningFor SCI patients, avoid ___ motionspushingFor SCI, all muscles should be stretched ____DailyFor indv. with one or more chronic conditions, should follow disease recommendations with most ______ guidelinesConservativeEx Rx recommendations allow for flexibility in the different combinations of _____ and _____ to achieve them.Frequency and TimeA commonly held belief was that flexibility in terms of the time/ duration and exercise volume recommended would allow individuals to overcome the most frequently reported barrier to regular exercise, that is, lack of _____TimeThere is evidence that individuals with more exercise experience fare better with _____ intensity programs (___%- ___% heart rate reserve [HRR]), whereas those adopting exercise for the first time may be better suited to, and self-select, _______ intensity programs (___%- ___% HRR)Higher Intensity; 65-75% Moderate Intensity; 45-55%Although the traditional approach in Ex Rx is to provide structured, supervised exercise programs, studies have shown comparable or greater adherence to _____ programs that include the provision of remotely delivered supporthome-based____ is a comprehensive theoretical framework that has been extensively employed in understanding, describing, and changing exercise behavior. ____ is based on the principle of reciprocal determinism; that is, the individual (e.g., emotion, personality, cognition, biology), behavior (e.g., past and current achievement), and environment (i.e., physical, social, and cultural) all interact to influence behaviorSocial Cognitive TheoryCentral to SCT is the concept of _____ , which refers to one's beliefs in his or her capability to successfully complete a course of action such as exerciseSelf-efficacy_____ self-efficacy refers to an individual's belief he or she can actually do the behavior in question,Task self-efficacy______ self-efficacy refers to whether an individual believes he or she can regularly exercise in the face of common barriers such as lack of time and poor weather.Barriers________ , key concepts of SCT, are anticipatory results of a behavior and the value placed on these resultsOutcome expectations and expectancies_______ is a person's ability to set goals, monitor progress toward those goals (or self-monitor), problem solve when faced with barriers, and engage in self-reward.Self-regulation/ self-controlThe Transtheoretical Model includes 5 stages of change- precontemplation (i.e., no intention to be regularly active in the next 6 mo) - contemplation (i.e., intending to be regularly active in the next 6 mo) - preparation (i.e., intending to be regularly active in the next 30 d), - action (i.e., regularly active for < 6 mo) maintenance (i.e., regularly active for ≥ 6 mo).__________ theorizes that an individual's beliefs about whether or not he or she is susceptible to disease, and his or her perceptions of the benefits of trying to avoid it, influence his or her readiness to actThe health belief model (HBM)Six constructs of the HBM- Believe they are susceptible to the condition (i.e., perceived susceptibility). - Believe the condition has serious consequences (i.e., perceived severity). - Believe taking action reduces their susceptibility to the condition or its severity (i.e., perceived benefits). - Believe costs of taking action (i.e., perceived barriers) are outweighed by the benefits. - Are confident in their ability to successfully perform an action (i.e., self-efficacy). - Are exposed to factors that prompt action (e.g., seeing their weight on the scale, a reminder from one's physician to exercise) (i.e., cues to action).The underlying assumption of ______ is individuals have three primary psychosocial needs that they are trying to satisfy: (a) self-determination or autonomy (b) demonstration of competence or mastery (c) relatedness or the ability to experience meaningful social interactions with others. The theory proposes that motivation exists on a continuum from amotivation to intrinsic motivation.Self-determination TheoryAccording to the _______ , intention to perform a behavior is the primary determinant of actual behaviortheory of planned behavior (TPB)Intensions are determined by: (3)- An individuals attitude - Subjective norms - Perceived behavioral control______ are influenced by behavioral beliefs that exercise will lead to certain outcomes (positive or negative) combined with the evaluation of those outcomes.Attitudes_______ are the social component and are influenced by individual's beliefs that others want him or her to be physically active (normative beliefs) combined with his or her motivation to comply with the desires of significant others.Subjective norms______ is influenced by the individual's belief about how easy or difficult performance of the behavior is likely to be (control beliefs) combined with the perceived power of the barrier or facilitator.Perceived behavior control_______ models posit that behavior results from influences at multiple levels, including intrapersonal factors (e.g., biological, psychological), interpersonal/ cultural factors (e.g., family, friends, culture), organizational factors (e.g., schools, worksites, churches), physical environments (e.g., built, natural), and policies (e.g., laws, regulations, codes)EcologicalCognitive and Behavioral Strategies for Increasing Physical Activity Barriers- Self-Efficacy (SCT, TTM, HBM, TPB) - Goal Setting (SMARTS) - Reinforcement (SCT, SDT, TTM) - Social Support (SCT, TTM, TPB) - Self-Monitoring (SCT, TTM) - Problem Solving - Relapse Prevention______ is a person-centered method of communication where the professional and the client/ patient work collaboratively for change.Motivational interviewingTort LawGoverns the legal rights and obligations between individuals as well as between collective bodies in relationship to injuries, death, or civil wrong doings Tort by definition is is a wrongful act whether intentional or accidental which results in injury or deathNegligence and Standard of CareSOC refers to the application of a degree of prudence and caution required by an indv. or org. that owes a duty of care Failure to exercise that degree of care represents negligenceEP-C should ___ & ___ liability insurance that affords protection from negligence claimsGeneral & ProfessionalOSHA GuidelinesEnforcement of safety and health legislation in workplace Blood-borne pathogensContract LawThe law of contracts governs agreements that are enforceable in courtCivil Rights ActProhibits discrimination based on race gender color relgion national originAmericans w Disabilities Act (ADA)Prohibits employment discrimination on basis of disabilities or perceived disabilities