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ACSM's Guidelines for Exercise Testing and Prescription Chapters 1-12
Terms in this set (573)
Any bodily movement produced by the contraction of skeletal muscles that result in substantial increase in caloric requirements over resting energy expenditure
Type of physical activity consisting of planned, structured, and repetitive bodily movement done to improve and/ or maintain one or more components of physical fitness
Ability to carry out daily tasks with vigor and alertness, without undue fatigue, and with ample energy to to enjoy leisure-time pursuits and meet unforeseen emergencies
Health-Related Physical Fitness Components
1) Cardiorespiratory Endurance
2) Body Composition
3) Muscular Strength
4) Muscular Endurance
The ability of the circulatory and respiratory system to supply oxygen during sustained physical activity
The relative amounts of muscle, fat, bone, and other vital parts of the body
The ability of muscle to exert force
The ability of muscle to continue to perform without fatigue
The range of motion available at a joint
Skill-Related Physical Fitness Components
5) Reaction time
The ability to change the position of the body in space with speed and accuracy
The ability to use the senses, such as sight and hearing, together with body parts in performing tasks smoothly and accurately
The maintenance of equilibrium while stationary or moving
The ability or rate at which one can perform work
The time elapsed between stimulation and the beginning of the reaction to it
The ability to perform a movement within a short period of time
Light intensity PA = ? METs
Moderate intensity PA = ? METs
Vigorous intensity PA = ? METs
The 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 benefits
Two 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 inactive
In the United States, ___% of adults meet aerobic guidelines, ___% meet muscle strengthening guidelines, ___% meet both
______ is the most common exercise-related complication and is often associated with exercise intensity, the nature of the activity, preexisting conditions, and musculoskeletal anomalies.
Most common cause of sudden cardiac death among young individuals
Congenital & hereditary abnormalities
Exercise 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 clearance
Preparticipation 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 activities
Preparticipation 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 Disease
If an individual is referred for medical clearance, the extent of the preexercise evaluation is based on the discretion of the _____
Health Care Provider
A comprehensive preexercise evaluation in the clinical setting generally includes
a 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 understands
the purposes and risks associated with the test or exercise program in health/ fitness or clinical settings.
Atherosclerotic Cardiovascular Disease (CVD) Risk Factors and defining criteria
Age: 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
Negative risk factors: HDL cholesterol >60 mg * dL, if present, one positive risk factor is removed
A classification scheme for hypertension in adults
Does not address the classification of prehypertension or hypertension in adults but rather recommends thresholds for pharmacologic treatments
For 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 Hg
Lifestyle modification cornerstone of antihypertensive therapy
- 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 consumption
Classification and Management of Blood Pressure for Adults
Normal: <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 DBP
Main goal of BP treatment
Decrease the risk of CVD morbidity and mortality and renal morbidity.
Recommended BP goal for most patients is
JNC 8 guideline recommends initiating pharmacologic therapy for patients ≥60 yr at
SBP ≥ 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
100-129 near optimal/ above optimal
130-159 Borderline high
≥190 Very high
Classification of Total Cholesterol
200-239 Borderline high
Classification of HDL
Classification of Triglycerides
150-199 Borderline high
>500 Very high
When triglycerides are >500 mg*dL, they become the primary target of therapy due to the increased risk of ____
High intensity statin therapy is generally recommended for those with 10-yr risk estimated to be ___% (high risk)
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
- Excessive mucus production
Forced Vital Capacity
Forced expiratory volume in one second
FEV 1.0 ≥80% of predicted
50% < FEV 1.0 < 80% predicted
30% < FEV 1.0 < 50% predicted
FEV 1.0 < 30% predicted respiratory failure
ATS based on FEV 1.0
Less than the LLN but >70%
The term COPD can be used when ______ are present and spirometry documents an obstructive defect
Chronic bronchitis, emphysema, or both
The 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.
by establishing reasonable and attainable health/ fitness goals
The 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
F* (20 ° C and 22 ° C) and humidity of less than 60% with adequate airflow
A 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 the
relative percentage of body mass that is fat and fat-free tissue using a two-compartment model
Weight relative to height calculated by dividing body weight in kilograms height in meters squared
Classification of Disease Risk Based on BMI
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 ratio
Circumference of the waist divided by the circumference of the hips
Disease risk increases with total waist-to-hip measurement above
.0.95 for men
0.86 for women
An average of the two measures is used provided they do not differ by more than ___ mm
- Hips/ thigh
Risk Criteria for Waist Circumference in Adults
Women- <70 cm (<28.5 in)
Men- <80 cm (31.5 in)
Women- 70-89 cm (28.5-35 in)
Men- 80-99 cm (31.5-39 in)
Women- 90-110 cm (35.5-43 in)
Men- 100-120 cm (39.5-47 in)
Women: >110 cm (>43.5 in)
Men: >120 cm (>47 in)
The principle behind the skinfold technique is that the amount of
subcutaneous fat is proportional to the total amount of body fat
- Biceps- not in seven fold
- Medial calf- not in seven fold
Seven-Site Formula Sites
%Fat = [(495/body density) - 450] x 100
Norms of body fat
VO2Max is the product of
maximal cardiac output and arterial-venous oxygen difference
Most apparently healthy subjects reach their subjective limit of fatigue at an RPE of ___ on Borg scale, or ___ on the category-ratio scale
General 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 equipment
Primary submax test
Consist 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 individuals
Cooper 12 minute test
Objective is to cover greatest distance in 12 min
can get VO2max w equation
1.5 mi test
cover distance in shortest amount of time
can get VO2max w equation
Rockport 1 mile test
Individual walks as fast as possible for 1 mile then HR is measured immediately after completion of 1 mile
can get VO2max w equation
6 min walk test
Used 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 survival
Single stage and multistage submax exefcise tests are available to estimate VO2max from ___ measurements
Factors that can alter submax HR response
Astrand-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 VO2max
Suggested work rate based on sex for AR cycle test
Unconditioned men: 300 or 600 kg
Conditioned men: 600 or 900
Unconditioned woman: 300 or 450
Condition women: 450 or 600
general procedures for submaximal testing of cardiorespiratory fitness
1) 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 stabel
YMCA cycle ergometer
- 2-4 3 min stages
- HR at end of stage determines amount of resistance for next stage, plot and determine VO2max
Two consecutive HR measurements between ___ & ___ should be obtained to predict VO2max
YMCA 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 HR
Muscular 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 management
Muscles ability to exert a max force on one occasion
Muscles ability to continue to continue to perform successive exertions or repetitions against a submax load
Muscles ability to exert force per one unit of time
muscular 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 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 motion
Standardized 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 isometric
Peak force development
Maximum voluntary contraction
the ____, 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 RM and Multiple RM test procedures
1) 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
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 RM
5-10 RM must be performed till
When using multiple RM tests to predict 1 RM, accuracy increases with the
least number of reps
A 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 prudent
CVD, pulmonary, and metabolic diseases and health conditions
1 RM Test protocols
1. 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 velocity
Muscular Endurance Tests
# of reps at 1RM (absolute muscular endurance)
#of reps at % of 1RM (relative muscular endurance)
YMCA bench press test
tests for older adults: (60-94 yrs)
Senior Fitness Test
Push Up Test Procedures for Measurement of Muscular Endurance
1. 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
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 ROM
Sit and reach used to assess ______ & _____ flexibility
low back & hamstring
Sit and Reach Procedures
W.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 score
Clinical 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.
When an exercise test includes the analysis of expired gases during exercise, it is termed a _______ test
Indications 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 pain
A 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 exercise
Evidence 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
- Ventricular pacing,
- > 1 mm of ST-segment depression on their resting ECG,
- LEeft bundle branch block
Exercise testing after STEMI
-assess functional capacity and ability to perform home/work loads
-evaluate medical therapy
-assess the risk of another cardiac event
When 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 testing
Two 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 hours
When is standard ECG testing recommended for a suspected IHD?
-patients with intermediate pretest probability of IHD
-have at least moderate physical function
-no disabling comorbidity
When is standard ECG testing recommended for a stable IHD?
-patients who are able to exercise to an adequate workload
-have interpretable ECG
When is standard ECG testing recommended for symptomatic patients with stable IHD?
-when patients have new or worsening symptoms
-have at least moderate physical functioning
Follow 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 info
What 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 performed
Ex 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 prognosis
Generally, 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) counseling
There 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 disease
Gold standard to objectively measure exercise capacity
Maximal exercise test
Best measurement of exercise capacity is via
Respiratory gas analysis using open circuit indirect spirometry for determination of maximal volume of oxygen consumed per unit of time
When administering clinical exercise tests, it is important to consider:
- The exercise test protocol and mode
- Test endpoint indicators,
- Staff and facility emergency preparedness
The ____ has outlined both absolute and relative contraindications to exercise testing
Prior 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 testing
Purpose of exercise test is the assessment of _____
exercise-induced myocardial ischemia
How many times should an individual perform exercise testing with physician supervision?
at least 50
-200 has also been recommended
Absolute 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 testing
Relative 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 hyperthyroidism
Mode of test based on:
- Test purpose
- Patient preference
Most frequently used mode in U.S. , Europe
Europe cycle ergometer
Peak exercise capacity can be __to__% lower during max ex test on cycle ergometer compared to treadmill due to regional muscle fatigue
5 to 20%
a __% difference is typically used by clinicians when comparing peak exercise responses between cycle ergometer & treadmill exercise
Most widely used exercise protocol in the U.S.
Bruce treadmill protocol
Recommended that exercise testing protocol results between __ to __ min
6 to 12 min
Bruce Protocol aerobic requirements
First stage ~ 5 METs
increases ~3 METs every stage
Variables that are typically monitored during clinical exercise testing include:
- Cardiac rhythm
- Perceived exertion
- Clinical signs and patient-reported symptoms suggestive of myocardial ischemia, inadequate blood perfusion, inadequate gas diffusion
- Limitations in pulmonary ventilation
Monitoring ECG HR BP before exercise test
Monitor 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 protocol
During the test, how should you monitor the HR?
Record during the last 5-10s of each minutes
During 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 protocol
During test, how do you monitor RPE
Record during the last 5-10 s each stage or every 2 min for ramp protocol
After 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 recovery
After the test, how should you monitor HR?
Record during the last 5-10 s of each minutes
After the test, how should you monitor BP?
Record immediately post ex, after 60 s of recovery and then every 2 minutes
After test RPE
Obtain peak exercise shortly after exercise is terminated
Scale used for angina, claudication, and dyspnea:
0- no pain
4 most severe
The CPET is useful in the differentiation of the
- Cause of exertional dyspnea
- The risk stratification of many patient groups, particularly those with heart failure
An 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 indicated
An SpO2 ≤ ___% with signs or symptoms of hypoxemia is an indication to stop a test
ABSOLUTE 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 stop
RELATIVE 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 exercise
Seated or supine
Why is it often practice to have an active recovery post exercise?
To support venous return and hemodynamic stability
Exercise cessation can cause an excessive drop in venous return resulting in profound ______ during recovery and ischemia secondary to decreased perfusion pressure into the myocardium.
The normal HR response to incremental exercise is to increase with increasing workloads at a rate of ≈ ___ beats ∙ min − 1 per 1 MET
A 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 IHD
The normal systolic blood pressure (SBP) response to exercise is to increase with increasing workloads at a rate of ~ ___ mm Hg per 1 MET
Specific 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 prognosis
A 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 _____
Rate-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 uptake
HR & SBP
Normal ranges for RPP is ___ to ____ mm Hg beats min
25,000 to 40,000
There is a ______ relationship between myocardial oxygen uptake and both coronary blood flow and exercise intensity
Normal 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 ______ therapy
Considerations 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.
- Digitalis therapy
Abnormal 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 output
The standard error in estimating exercise capacity from various published prediction equations is at least ± __ MET
In 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.
- Heart disease diagnosis
CPET is particularly useful in identifying whether the cause of dyspnea has a _____ or _____ etiology
cardiac or pulmonary
Criteria 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
- 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 GXT
The 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 tested
Sensitivity & specificity
refers to the ability to positively identify patients who truly have IHD
True positive test
positive for myocardial ischemia
and patient truly has IHD
False Negative Test
negative for myocardial ischemia
but patient truly has IHD
The 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.
25,000 mm Hg ∙ beats ∙ min − 1.
Refers to the ability to correctly identify patients who do not have IHD
True negative test
Test is negative for myocardial ischemia and patient if free of IHD
False positive test
Test is positive for myocardial ischemia but patient does not have IHD
The 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
Two most common isotopes:
- 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.
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 test
Originally developed to assess patients with pulmonary disease
An 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.
FITT-VP principle of Ex Rx
Frequency- How often
Intensity - How hard
Time - Duration or how long
Type - Mode or what kind
total Volume - Amount
Progression - Advancement
For 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 health
aerobic, resistance, flexibility, and neuromotor
The optimal Ex Rx should address: 5
- Cardiorespiratory fitness
- Muscular strength and endurance
- Body composition
- Neuromotor fitness
Musculoskeletal 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 intensity
The 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
- Employing a
of the quantity and quality of exercise
Components of Exercise Training Session
- Warm up
- Conditioning and/ or sports related exercise
- Cool Down
- Warm up
- Conditioning and/ or sports related exercise
- Cool Down
Warm-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 phase
An individual's ______ (7) should be considered when designing the FITT-VP principle of Ex Rx.
physical and social environment,
available equipment and facilities
A ______, 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 repetitions
The 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
AEROBIC EXERCISE FREQUENCY RECOMMENDATION
Moderate 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 Exercise
The 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)
______ 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.
During 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
- Intensity of the work and recovery intervals
- The number of repetitions of the intervals
- The duration of the between-interval rest period
Aerobic Exercise Intensity Recommendation
Moderate (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
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
[i.e., VO2 mL ∙ kg − 1 ∙ min − 1],
d *VO2R*, or using a threshold method, [i.e., VT or RCP]) is more appropriate, especially for older, deconditioned individuals and people with chronic diseases
Target HR (THR) = [( HRmax/ peaka − HRrest ) × % intensity desired] + HRrest
Target VO2Rc = [( VO2max/ peakb − VO2rest) × % intensity desired + VO2rest
Target HR = HRmax/ peak × % intensity desired
Target VO2 = VO2max/peak - % intensity desired
Target MET = [(Vo2max/peak) / 3.5 mL
min] x % intensity desired
Summary of methods for prescribing exercise intensity using HR, O2, MET
a) 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 intensity
Aerobic Exercise Time (Duration) Recommendation
Most 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 for
previously sedentary individuals
The specificity principle states:
that the physiologic adaptations to exercise are specific to the type of exercise performed
Aerobic Exercise Type Recommendation
Rhythmic, 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.
the 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 − 1
Calculations of METs, MET-min, and kcal*min
Metabolic 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]" .
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.
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 − 1
a 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 adults
This 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 − 1
Recommended # of steps/ day
Aerobic Exercise Volume Recommendation
A 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 weight
Increase in exercise time/ duration __________ is reasonable for the average adult
per session of 5-10 min every 1-2 weeks over the first 4-6 weeks of an exercise training program
Older adults (>65) may benefit from ____ training because this element of muscle fitness most rapidly declines with age
Goals for a health-related resistance training program
For 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 age
Resistance Training Frequency Recommendation
Resistance 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 all
Types of Resistance Exercises
Many 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 novice
To 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-RM
Volume of Resistance Exercise (Sets & Reps) Recommendation
Ideally, 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 Recommendations
All 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 constant
Progression/ Maintenance of Resistance Training Recommendation
As 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 ∙ wk
2-3 times/ week
It is most effective to perform flexibility exercise when muscle temp. is increased through _____ exercises
_______ 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) stretching
Flexibility Exercise Recommendation
ROM 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 stretch
Dynamic or slow movement stretches
involves 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 times
involves 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 passive
Active static stretching
involves holding the stretched position using the strength of the agonist muscle as is common in many forms of yoga
Passive static stretching
involves 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 Recommendation
A 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 recommended
Neuromotor exercise training involves motor skills such as: (5)
and is sometimes called functional fitness training.
- proprioceptive training
Neuromotor Exercise Recommendations
Neuromotor 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 ∙ wk
at least 3 days/week
Children have a much lower _____ capacity than adults limiting their ability to perform sustained vigorous intensity
Children 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 rate
Physiologic responses lower to acute exercise in children compared to adults
- Absolute oxygen uptake
- Cardiac output
- Stroke volume
- Tidal volume
- Minute ventilation
- Respiratory Exchange Ratio
FITT Recommendations for Children and Adolescents
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 appropriate
FITT Recommendations for Children and Adolescents
F: =>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 unstructured
Three broad categories of LBP
a) 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 cases
For 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
- Bone mass
- Fat-free body mass
- Glucose tolerance
Effects of aging on selected physiologic and health-related variables
What is higher?
- Resting and exercise BP
- Residual volume
- % body fat
Most older adults do not require an Ex test prior to initiating a ____ intensity PA program
Special 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 Test
was 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 test
Physical Performance Battery Test
Physical 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 stands
Usual Gait Speed
Usually assessed as the better of two time trials to walk a short distance (3-10 m) at a usual pace
6 min walk test
Widely used as an indicator of cardiorespiratory endurance
Assessed most distance walked in 6 min.
A change of 50 m is considered substantial change
Continuous Scale Physical Performance Test