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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

Exercise

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

Physical Fittness

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
5) Flexibility

Cardiorespiratory Endurance

The ability of the circulatory and respiratory system to supply oxygen during sustained physical activity

Body Composition

The relative amounts of muscle, fat, bone, and other vital parts of the body

Muscular Strength

The ability of muscle to exert force

Muscular Endurance

The ability of muscle to continue to perform without fatigue

Flexibility

The range of motion available at a joint

Skill-Related Physical Fitness Components

1) Agility
2) Coordination
3) Balance
4) Power
5) Reaction time
6) Speed

Agility

The ability to change the position of the body in space with speed and accuracy

Coordination

The ability to use the senses, such as sight and hearing, together with body parts in performing tasks smoothly and accurately

Balance

The maintenance of equilibrium while stationary or moving

Power

The ability or rate at which one can perform work

Reaction time

The time elapsed between stimulation and the beginning of the reaction to it

Speed

The ability to perform a movement within a short period of time

Light intensity PA = ? METs

2.0-2.9 METs

Moderate intensity PA = ? METs

3.0-5.9 METs

Vigorous intensity PA = ? METs

>=6.0 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

31.1%

In the United States, ___% of adults meet aerobic guidelines, ___% meet muscle strengthening guidelines, ___% meet both

51.6%

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 injury

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
HbA1C >6.5%

Negative risk factors: HDL cholesterol >60 mg * dL, if present, one positive risk factor is removed

JNC 7

A classification scheme for hypertension in adults

JNC 8

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

- 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 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

<140./90

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 Optimal

100-129 near optimal/ above optimal

130-159 Borderline high

160-189 High

≥190 Very high

Classification of Total Cholesterol

<200 Desirable

200-239 Borderline high

≥240 High

Classification of HDL

<40 low

≥60 high

Classification of Triglycerides

<150 Normal

150-199 Borderline high

200-499 High

>500 Very high

When triglycerides are >500 mg*dL, they become the primary target of therapy due to the increased risk of ____

Pancreatitis

High 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 production

FVC

Forced Vital Capacity

FEV 1.0

Forced expiratory volume in one second

GOLD I

Mild

FEV 1.0 ≥80% of predicted

GOLD II

Moderate

50% < FEV 1.0 < 80% predicted

GOLD III

Severe

30% < FEV 1.0 < 50% predicted

GOLD IV

Very Severe

FEV 1.0 < 30% predicted respiratory failure

ATS based on FEV 1.0

Mild

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.

- Motivating participants 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 ° FF* (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

BMI

Weight relative to height calculated by dividing body weight in kilograms height in meters squared

Classification of Disease Risk Based on BMI

Underweight: <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 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

5 mm

Circumference Sites

- Abdomen
- Arm
- Buttocks/hips
- Calf
- Forearm
- Hips/ thigh
- Mid-thigh
- Waist

Risk Criteria for Waist Circumference in Adults

Very 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 of

subcutaneous fat is proportional to the total amount of body fat

Skinfold Sites

- Abdominal
- Triceps
- Biceps- not in seven fold
- Chest/Pectoral
- Medial calf- not in seven fold
- Midaxillary
- Subscapular
- Suprailliac
- Thigh

Seven-Site Formula Sites

- Chest
- Midaxillary
- Triceps
- Subscapular
- Abdomen
- Suprailiac
- Thigh

Siri Equation

%Fat = [(495/body density) - 450] x 100

Norms of body fat

Men: 10-22%
Women: 20-32%

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

RPE 18-19

9-10

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

Cycle ergometer

Field Tests

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

- Environmental
- Dietary
- Behavioral

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 kgmmin

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

110 BPM

70% HRR

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

Muscular Strength

Muscles ability to exert a max force on one occasion

Muscular Endurance

Muscles ability to continue to continue to perform successive exertions or repetitions against a submax load

Muscular Power

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 imbalances

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

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 (~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 RM

5-10 RM must be performed till

Failure

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

10-15

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

Isokinetic

Muscular 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 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

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 ROM

Compliance (tightness)

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.

clincal

When an exercise test includes the analysis of expired gases during exercise, it is termed a _______ test

cardiopulmonary exercise

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

- Wolff-Parkinson-White,

- 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

-interpretable ECG

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:

- Contraindications

- The exercise test protocol and mode

- Test endpoint indicators,

- Safety,

- Medications

- Staff and facility emergency preparedness

The ____ has outlined both absolute and relative contraindications to exercise testing

AHA

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

U.S. Treadmill

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

10%

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:

- 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 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:

0-4 scale
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.

Hypotension

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

12

22

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 _____

exertional ischemia

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

Linear

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

Digitalis

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.

- Wolff-Parkinson-White

- Digitalis therapy

Abnormal responses of the ST segment during exercise include the following

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.

- Age
- Gender
- 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

Sensitivity

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.

85%

25,000 mm Hg ∙ beats ∙ min − 1.

Specificity

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

(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 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.

Individual

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
- Flexibility
- 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 light-to-moderate intensity
- Employing a gradual progression of the quantity and quality of exercise

Components of Exercise Training Session

- Warm up
- Conditioning and/ or sports related exercise
- Cool Down
- Stretching

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.

goals,
physical ability,
physical fitness,
health status,
schedule,
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

Dynamic

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

<3

>5

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

Table 6.1

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)

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.

Interval

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
- Duration
- 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
- 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 VO2Rd *VO2R*, or using a threshold method, [i.e., VT or RCP]) is more appropriate, especially for older, deconditioned individuals and people with chronic diseases

Relative

HRR method:

Target HR (THR) = [( HRmax/ peaka − HRrest ) × % intensity desired] + HRrest

Vo2R Method:

Target VO2Rc = [( VO2max/ peakb − VO2rest) × % intensity desired + VO2rest

HR method:

Target HR = HRmax/ peak × % intensity desired

VO2 method

Target VO2 = VO2max/peak - % intensity desired

MET method

Target MET = [(Vo2max/peak) / 3.5 mL kg 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

Talk Test

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.

Exercise Volume

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]" .

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 − 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

500-1000

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

7,000

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

power

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

15-25

50%

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

3-4 wk

2-3 times/ week

It is most effective to perform flexibility exercise when muscle temp. is increased through _____ exercises

warm-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) stretching

Static

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

Static Stretching

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.

- balance
- coordination
- gait
- agility
- 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

60 min

at least 3 days/week

Children have a much lower _____ capacity than adults limiting their ability to perform sustained vigorous intensity

anaerobic

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
- SBP
- DBP
- Tidal volume
- Minute ventilation
- Respiratory Exchange Ratio

FITT Recommendations for Children and Adolescents

Aerobic

F: 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 appropriate

FITT Recommendations for Children and Adolescents

Resistance

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
- Flexibility
- 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

Moderate

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

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