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EXRX Final Study Guide

Terms in this set (188)

1. Patients should be seated quietly for at least 5 min in a chair with back support (rather than on an examination table) with their feet on the floor and their arms supported at heart level. Patients should refrain from smoking cigarettes or ingesting caffeine for at least 30 min preceding the measurement.

2. Measuring supine and standing values may be indicated under special circumstances.

3. Wrap cuff firmly around upper arm at heart level; align cuff with brachial artery.

4. The appropriate cuff size must be used to ensure accurate measurement. The bladder within the cuff should encircle at least 80% of the upper arm. Many adults require a large adult cuff.

5. Place stethoscope chest piece below the antecubital space over the brachial artery (Coronoid Fossa). Bell and diaphragm side of chest piece appear equally effective in assessing BP (15).

6. Quickly inflate cuff pressure to 20 mm Hg above first Korotkoff sound.

7. Slowly release pressure at rate equal to 2-5 mm Hg • s−1.

8. SBP is the point at which the first of two or more Korotkoff sounds is heard (phase 1), and DBP is the point before the disappearance of Korotkoff sounds (phase 5).

9. At least two measurements should be made (minimum of 1 min apart) and the average should be taken.

10. BP should be measured in both arms during the first examination. Higher pressure should be used when there is consistent interarm difference.

11. Provide to patients, verbally and in writing, their specific BP numbers and BP goals.
Wandering Pacemaker
- P wave changes due to changes in foci, normal rate

Premature atrial complexes (PACs)
- Non-sinus node atrial site (cell) depolarizes the atrial tissue and spreads to the ventricles via normal conduction through the AV node.
- Occurs prior to the sinus node's development of an action potential, thus termed premature

Atrial tachycardia
- Relatively common
- May be the result of rapid firing of an automatic or triggered atrial focus or reentry within the atrium
- Ventricular rate depends on atrial rate and AV node repolarization rate.

Atrial fibrillation
- Common
- Results from multiple reentrant waves of depolarization in the atria
- No uniform atrial contraction, and thus blood can coagulate in atria.
--- Patients should be on Coumadin to reduce risk of thrombus formation.
- Irregular ventricular rhythm caused by irregular bombardment of AV node by fibrillatory action potentials
- May compromise cardiac output
- Need to control ventricular rate with β-blockers, digoxin, calcium channel blockers, or other antiarrhythmic medications
- Patients can live long term with chronic atrial fibrillation.
- Other treatments include cardioversion to NSR or ablation performed in an electrophysiology laboratory.

Atrial flutter
- Common and flutter waves are at 250-350 bpm with variable ventricular rates
- Flutter waves are saw tooth-shaped and are best seen in leads II, III, aVF, or lead V1.
- AV blocks lead to flutter: ventricular beat ratios of 2:1, 3:1, or 4:1.
- Treatment is similar to atrial fibrillation.

Supraventricular tachycardia (SVT)
- Refers to any arrhythmia occurring in the atria (i.e., before the AV node)
- The following should be accomplished before the client/patient arrives at the test site:
------ Ensure that all forms, score sheets, tables, graphs, and other testing documents are organized and available for the test's administration.
------ Calibrate all equipment (e.g., metronome, cycle ergometer, treadmill, sphygmomanometer, and skinfold calipers) 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 in a designated folder.
- Organize equipment so that tests can follow in sequence without stressing the same muscle group repeatedly.
- Provide informed consent form.
- Maintain room temperature between 68° F and 72° F (20° C and 22° C) and humidity of <60%.

- Measurements:
----- Resting measurements should be obtained first:
----- Heart rate
----- Blood pressure
----- Height
----- Weight
----- Body composition
-- Always do things that will not effect performance first

Research has not established an optimal testing order for multiple health-related components of fitness (i.e., cardiorespiratory [CR] endurance, muscular fitness, body composition, and flexibility), but sufficient time should be allowed for HR and BP to return to baseline between tests conducted serially.

Because certain medications, such as β-blockers which lower HR, will affect some physical fitness test results, use of these medications should be noted. (we will not work with people who are in this state/have high risk factors)
Maximal Oxygen Uptake (VO2max)
VO2max is the most valid measure of the cardiorespiratory system's functional capacity.
VO2max reflects
Maximal ability of cardiorespiratory system to deliver O2 and nutrients to muscles and ability of muscles to use them.
Higher VO2max (the higher they can perform more intense exercises)
VO2peak Versus VO2 max
Peak criteria:
HR fails to increase with increasing workload
Blood Hla- 8 mmol/L
RER 1.15
RPE 17 on Borg 6 to 20 scale
Max criteria:
All of the above plus
50 ml/min change with increasing workload (plateau attained)
Absolute Vo2
A discrete volume of O2 consumption in reference to time
Expressed in L/min or ml/min
Used for nonweight-bearing modalities
Directly related to body weight
(does take into county the body weight)
Relative Vo2
A volume of O2 consumption relative to unit of body mass and time
Expressed as ml/kg/min
Used for weight-bearing modalities
Best for comparing people of different body size
Can express as ml/kgFFM/min to look at O2 consumption of muscle mass
Gross Vs. Net VO2
Not synonymous terms
Gross VO2 = caloric cost of exercise and rest (Gross = exercise + rest)
Net VO2 = caloric cost of exercise only (Net = Gross - rest)
Example ( 23.5 - 3.5 = 20 ml)
Express in either absolute or relative terms
Rest is 3.5 ml/kg/min or 1 MET
VO2max
Estimates of VO2max from the HR response to submaximal exercise tests are based on these assumptions:
A steady state HR is obtained for each exercise work rate.
A linear relationship exists between HR and work rate.
The difference between actual and predicted maximal HR is minimal.
Mechanical efficiency (i.e., VO2 at a given work rate) is the same for everyone.
The subject is not on medications that alter HR, using high quantities of caffeine, under large amounts of stress, ill, or in a high temperature environment, all of which may alter HR.
Modes of Testing Submaximal
Commonly used modes for exercise testing:
Field tests
Cycle ergometer tests
Treadmill tests

Step tests
Field Tests
Cooper 12- min test
1.5 mile (2.4 km) test for time
Rockport One-Mile Fitness Walking Test
Predicting Maximal Heart Rate
Maximal HR is fundamental to submaximal tests, so must be predicted using a formula.
Predicted by equations with standard error ranges between ± 10 and 15 bpm
Most commonly used age-based equation
220 − age (yr)
HHR = (MaxHR-RestHR) - Don't max past 70% of HRR or 85% of HRmax
Abdomen:
With the subject standing upright and relaxed, a horizontal measure taken at the height of the iliac crest, usually at the level of the umbilicus.

Arm
With the subject standing erect and arms hanging freely at the sides with hands facing the thigh, a horizontal measure midway between the acromion and olecranon processes.

Buttocks/Hips:
With the subject standing erect and feet together, a horizontal measure is taken at the maximal circumference of buttocks. This measure is used for the hip measure in a waist/hip measure.

Calf:
With the subject standing erect (feet apart —20 cm), a horizontal measure taken at the level of the maximum circumference between the knee and the ankle, perpendicular to the long axis.

Forearm:
With the subject standing, arms hanging downward but slightly away from the trunk and palms facing anteriorly, a measure is taken perpendicular to the long axis at the maximal circumference.

Hips/Thigh:
With the subject standing, legs slightly apart (~10 cm), a horizontal measure is taken at the maximal circumference of the hip/proximal thigh, just below the gluteal fold.

Mid-Thigh:
With the subject standing and one foot on a bench so the knee is flexed at 90 degrees, a measure is taken midway between the inguinal crease and the proximal border of the patella, perpendicular to the long axis.

Waist:
With the subject standing, arms at the sides, feet together, and abdomen relaxed, a horizontal measure is taken at the narrowest part of the torso (above the umbilicus and below the xiphoid process). The National Obesity Task Force (NOTF) suggests obtaining a horizontal measure directly above the iliac crest as a method to enhance standardization. Unfortunately, current formulae are not predicated on the NOTF suggested site.
For the Canadian Trunk Forward Flexion test, the client sits without shoes and the soles of the feet flat against the flexometer (sit-and-reach box) at the 26 cm mark. Inner edges of the soles are placed within 2 cm of the measuring scale. For the YMCA sit-and-reach test, a yardstick is placed on the floor and tape is placed across it at a right angle to the 15 in mark. The client/patient sits with the yardstick between the legs, with legs extended at right angles to the taped line on the floor. Heels of the feet should touch the edge of the taped line and be about 10 to 12 in apart. (Note the zero point at the foot/box interface and use the appropriate norms.)

The client/patient should slowly reach forward with both hands as far as possible, holding this position approximately 2 s. Be sure that the participant keeps the hands parallel and does not lead with one hand. Fingertips can be overlapped and should be in contact with the measuring portion or yardstick of the sit-and-reach box.

The score is the most distant point (cm or in) reached with the fingertips. The best of two trials should be recorded. To assist with the best attempt, the client/patient should exhale and drop the head between the arms when reaching.

Testers should ensure that the knees of the participant stay extended; however, the participant's knees should not be pressed down. The client/patient should breathe normally during the test and should not hold her/his breath at any time. Norms for the Canadian test are presented in Table 4.16. Note that these norms use a sit-andreach box in which the "zero" point is set at the 26 cm mark. If a box is used in which the zero point is set at 23 cm (e.g., Fitnessgram), subtract 3 cm from each value in this table.
The recommended rate of progression in an exercise program depends on the individual's health status, physical fitness, training responses, and exercise program goals.
Progression may consist of increasing any of the components of the FITT principle of Ex Rx as tolerated by the individual.
An increase in exercise time/duration per session of 5-10 min every 1-2 wk over the first 4-6 wk of an exercise training program is reasonable for the average adult.
After the individual has been exercising regularly for at least 1 month, the FIT of exercise is gradually adjusted upward over the next 4-8 months — or longer for older adults and very deconditioned individuals
• Initiation stage (Progression)
Must allow time for adaptation to occur
Often at lower intensity and duration compared to later stages, especially in those who are not previous exercisers
Goal is to limit extreme fatigue and muscle soreness.
• Improvement stage (Progression)
Initiate the progressive overload principle
Indicators of progression that is too rapid include the following:
Failure to complete an exercise session
Lack of normal interest in training
Increased HR or rating of perceived exertion at the same rate of external work
Increase in minor aches and pains
Frequency, intensity, and duration should not be increased together in any single week, and total weekly training volume should not be advanced by more than 10%.
• Maintenance stage (Progression)
Goal is long-term maintenance.
Some try new activities to avoid boredom or monotony.
Novice Lifters

Frequency : 2-3 days/wk
Intensity : ≤50% 1-RM
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression - A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.

Intermediate Lifters

Frequency : 3-4 days/wk
Intensity : 50-70% 1-RM
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.

Advanced Lifters

Frequency : 4-6 days/wk
Intensity : 30-80% 1-RM
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.
Novice Lifters
Frequency : 2-3 days/wk
Intensity : 85-100% 1-RM for force, 30-60% 1-RM for upper body, and 0-60% 1-RM for lower body exercises for velocity
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.

Intermediate Lifters
Frequency : 2-4 days/wk
Intensity : 85-100% 1-RM for force, 30-60% 1-RM for upper body, and 0-60% 1-RM for lower body exercises for velocity
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.

Advanced Lifters
Frequency : 4-6 days/wk
Intensity : 85-100% 1-RM for force; 30-60% 1-RM for velocity
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.
Novice Lifters
Frequency : 2-3 days/wk
Intensity : 70-85% 1-RM
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.

Intermediate Lifters
Frequency : 3-4 days/wk
Intensity : 70-85% 1-RM
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.

Advanced Lifters
Frequency : 4-6 days/wk
Intensity : 70-100% 1-RM
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.
Novice Lifters
Frequency : 2-3 days/wk
Intensity : 60-70% 1-RM
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.

Intermediate Lifters
Frequency : 3 days/wk for whole-body workouts; 4 days/wk for split workouts
Intensity : 70-80% 1-RM
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.

Advanced Lifters
Frequency : 4-6 days/wk
Intensity : 80-100% 1-RM, periodized
Time : No Set time of duration
Type : Resistance exercises involving each major muscle group are recommended. MJ exercises more than one muscle group and targeting agonist/antagonist muscle groups are recommended for all adults. SJ exercises targeting major muscle groups may also be included in a resistance training program, typically after performing MJ exercises for that particular muscle group. A variety of exercise equipment and/or body weight can be used to perform these exercises.
Progression : A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended.
Children and adolescents may safely participate in strength training activities provided that they receive proper instruction and supervision. Generally, adult guidelines for resistance training may be applied. Eight to 15 submaximal repetitions of an exercise should be performed to the point of moderate fatigue with good mechanical form before the resistance is increased.

Because of immature thermoregulatory systems, youth should avoid exercise in hot humid environments and be properly hydrated.

Children and adolescents who are overweight or physically inactive may not be able to achieve 60 min ∙ d−1 of moderate-to-vigorous physical activity. These individuals should start out with moderate intensity, physical activity as tolerated and gradually increase the frequency and time of physical activity to achieve the 60 min • d−1 goal. Vigorous intensity, physical activity can then be gradually added at least 3 d ∙ wk−1.

Efforts should be made to decrease sedentary activities (i.e., television watching, surfing the Internet, and playing video games) and increase activities that promote lifelong activity and fitness (i.e., walking and cycling).

Most children >10 yr do not meet the recommended physical activity guidelines. Children and adolescents should participate in a variety of age-appropriate physical activities to develop CRF and muscular and bone strength. Exercise supervisors and leaders should be mindful of the external temperature and hydration levels of children who exercise because of their immature thermoregulatory systems.
AEROBIC EXERCISE

To promote and maintain health, older adults should adhere to the following Ex Rx for aerobic (cardiorespiratory) physical activities. When older adults cannot do these recommended amounts of physical activity because of chronic conditions, they should be as physically active as their abilities and conditions allow.
Frequency: ≥5 d ∙ wk−1 for moderate intensity, physical activities or ≥3 d ∙ wk−1 for vigorous intensity, physical activities or some combination of moderate and vigorous intensity exercise 3-5 d ∙ wk−1.

Intensity: On a scale of 0-10 for level of physical exertion, 5-6 for moderate intensity and 7-8 for vigorous intensity (82).
Time: For moderate intensity, physical activities, accumulate at least 30 or up to 60 (for greater benefit) min ∙ d−1 in bouts of at least 10 min each to total 150-300 min • wk−1, or at least 20-30 min • d−1 of more vigorous intensity, physical activities to total 75-100 min ∙ wk−1 or an equivalent combination of moderate and vigorous intensity, physical activity.

Type: Any modality that does not impose excessive orthopedic stress — walking is the most common type of activity. Aquatic exercise and stationary cycle exercise may be advantageous for those with limited tolerance for weight-bearing activity.

Muscular Strengthening/Endurance
Frequency: ≥2 d ∙ wk−1.
Intensity: Moderate intensity (i.e., 60%-70% one repetition maximum [1-RM]). Light intensity (i.e., 40%-50% 1-RM) for older adults beginning a resistance training program. When 1-RM is not measured, intensity can be prescribed between moderate (5-6) and vigorous (7-8) intensity on a scale of 0-10 (82).
Type: Progressive weight-training program or weight-bearing calisthenics (8-10 exercises involving the major muscle groups; ≥1 set of 10-15 repetitions each), stair climbing, and other strengthening activities that use the major muscle groups.

Flexibility Exercises
Frequency: ≥2 d ∙ wk−1.
Intensity: Stretch to the point of feeling tightness or slight discomfort.
Time: Hold stretch for 30-60 s.
Type: Any physical activities that maintain or increase flexibility using slow movements that terminate in sustained stretches for each major muscle group using static stretches rather than rapid ballistic movements.
Older adults should gradually exceed the recommended minimum amounts of physical activity and attempt continued progression if they desire to improve and/or maintain their physical fitness.
If chronic conditions preclude activity at the recommended minimum amount, older adults should perform physical activities as tolerated to avoid being sedentary.

Older adults should consider exceeding the recommended minimum amounts of physical activity to improve management of chronic diseases and health conditions for which a higher level of physical activity is known to confer a therapeutic benefit.
Moderate intensity, physical activity should be encouraged for individuals with cognitive decline given the known benefits of physical activity on cognition. Individuals with significant cognitive impairment can engage in physical activity but may require individualized assistance.

Structured physical activity sessions should end with an appropriate cool-down, particularly among individuals with CVD. The cool-down should include a gradual reduction of effort and intensity and optimally, flexibility exercises.

Incorporation of behavioral strategies such as social support, self-efficacy, the ability to make healthy choices, and perceived safety all may enhance participation in a regular exercise program.

The health/fitness and clinical exercise professional should also provide regular feedback, positive reinforcement, and other behavioral/programmatic strategies to enhance adherence.
All older adults should be guided in the development of a personalized Ex Rx or physical activity plan that meets their needs and personal preferences.

The Ex Rx should include aerobic, muscle strengthening and endurance, flexibility, and neuromotor exercises, and focus on maintaining and improving functional ability. In addition to standard physical fitness assessments, physical performance tests can be used. These tests identify functional limitations associated with poorer heath status that can be targeted for exercise intervention.
Counteracting dehydration
• Dehydration (i.e., 3%-5% body mass loss) likely does not degrade muscular strength or anaerobic performance.
• Dehydration >2% of body mass decreases aerobic exercise performance in temperate, warm, and hot environments; and as the level of dehydration increases, aerobic exercise performance is reduced proportionally.

Counteracting dehydration
The critical water deficit (i.e., >2% body mass for most individuals) and magnitude of performance decrement are likely related to environmental temperature, exercise task, and the individuals' unique biological characteristics (e.g., tolerance to dehydration).
Acute dehydration impairs endurance performance regardless of whole body hyperthermia or environmental temperature; and endurance capacity (i.e., time to exhaustion) is reduced more in a hot environment than in a temperate or cold one.

Counteracting dehydration
Overdrinking hypotonic fluid is the mechanism that leads to exercise-associated hyponatremia, a state of lower than normal blood sodium concentration (typically <135 mEq • L−1) accompanied by altered cognitive status.
Hyponatremia tends to be more common in long duration physical activities and is precipitated by consumption of hypotonic fluid (water) alone in excess of sweat losses (typified by body mass gains).

The syndrome can be prevented by not drinking in excess of sweat rate and by consuming salt-containing fluids or foods when participating in exercise events that result in many hours of continuous or near continuous sweating.
Intensity (cont.): For the purposes of the Ex Rx, it is preferable for individuals to take their prescribed medications at their usual time as recommended by their health care providers. Individuals on a β-adrenergic blocking agent (i.e., β-blocker) may have an attenuated HR response to exercise and an increased or decreased maximal exercise capacity. For patients whose β-blocker dose was altered after an exercise test or during the course of rehabilitation, a new graded exercise test may be helpful, particularly in patients who have not undergone a coronary revascularization procedure or who have been incompletely revascularized (i.e., residual obstructive coronary lesions are present) or who have rhythm disturbances. However, another exercise test may not be medically necessary in patients who have undergone complete coronary revascularization, or when it is logistically impractical.

When patients whose β-blocker dose has been altered exercise without a new exercise test, signs and symptoms should be monitored, and RPE and HR responses should be recorded at previously performed workloads. These new HRs may serve as the patient's new exercise target HR (THR) range. Patients on diuretic therapy may become volume depleted, have hypokalemia, or demonstrate orthostatic hypotension particularly after bouts of exercise. For these patients, the BP response to exercise, symptoms of dizziness or light- headedness, and arrhythmias should be monitored while providing education regarding proper hydration (3). See Appendix A for other medications that may influence the hemodynamic response during and after exercise.
Time: Warm-up and cool-down activities of 5-10 min, including static stretching, ROM, and light intensity (i.e., <40% VO2R, <64% peak heart rate [HRpeak], or <11 RPE) aerobic activities, should be a component of each exercise session and precede and follow the conditioning phase.

The goal for the duration of the aerobic conditioning phase is generally 20-60 min per session. After a cardiac-related event, patients may begin with as little as 5-10 min of aerobic conditioning with a gradual increase in aerobic exercise time of 1-5 min per session or an increase in time per session of 10%-20% per week.
Type: The aerobic exercise portion of the session should include rhythmic, large muscle group activities with an emphasis on increased caloric expenditure for maintenance of a healthy body weight and its many other associated health benefits (see Chapters 1, 7, and 10). To promote whole body physical fitness, conditioning that includes the upper and lower extremities and multiple forms of aerobic activities and exercise equipment should be incorporated into the exercise program.

The different types of exercise equipment may include the following:
Arm ergometer
Combination of upper or lower (dual action) extremity cycle ergometer
Upright and recumbent cycle ergometer
Recumbent stepper
Rower
Elliptical
Stair climber
Treadmill for walking

Type (cont....): Aerobic interval training (AIT) involves alternating 3-4 min periods of exercise at high intensity (90%-95% HRpeak) with exercise at moderate intensity (60%-70% HRpeak). Such training for approximately 40 min, three times per week has been shown to yield a greater improvement in VO2peak in patients with heart failure (44) and greater long-term improvements in VO2peak in patients after CABG (27) compared to standard continuous, moderate intensity exercise.

Although AIT has routinely been used in athletes, its use in patients with CVD appears to have potential but cannot yet be universally recommended until further data regarding safety and efficacy are available.

Progression: There is no standard format for the rate of progression in exercise session duration. Thus, progression should be individualized to patient tolerance. Factors to consider in this regard include initial physical fitness level, patient motivation and goals, symptoms, and musculoskeletal limitations. Exercise sessions may include continuous or intermittent exercise depending on the capability of the patient. Table 9.1 provides a sample progression using intermittent exercise.
Physical activity combined with oral hypoglycemic agents has not been well studied and little is known about the potential for interactions. Sulfonylurea drugs, glucagon-like peptide 1
(GLP-1) agonists, and other compounds that enhance insulin secretion probably do increase the risk for hypoglycemia because the effects of insulin and muscle contraction on blood glucose uptake are additive.

The few data that exist on the common biguanide (e.g., metformin) and thiazolidinedione (TZD) drugs suggest that the interactions are complex and may not be predictable based on individual effects of the drug or exercise alone (see Appendix A). Extra blood glucose monitoring is prudent when beginning a program of regular exercise in combination with oral agents to assess whether changes in medication dose are necessary or desirable.

Adjust carbohydrate intake and/or medications before and after exercise based on blood glucose levels and exercise intensity to prevent hypoglycemia associated with exercise.
For individuals with Type 1 DM using insulin pumps, insulin delivery during exercise can be markedly reduced or the pump can be disconnected depending on the intensity and duration of exercise. Reducing basal delivery rates for up to 12 h postexercise may be necessary to avoid hypoglycemia.

The use of continuous glucose monitoring (CGM) can be very useful to detect patterns in blood glucose across multiple days and evaluate both the immediate and delayed effects of exercise. Adjustments to insulin dose, oral medications, and/or carbohydrate intake can be fine-tuned using the detailed information provided by CGM.
Assessment of physiologic function should include cardiopulmonary capacity, pulmonary function (preexercise and postexercise), and oxyhemoglobin saturation via noninvasive methods.

The mode of exercise testing is typically a motor-driven treadmill or an electronically braked cycle leg ergometer.

Age-appropriate (i.e., child, adult, and older adult) standard progressive maximal testing protocols may be used.

Administration of an inhaled bronchodilator (i.e., β2-agonists) (see Appendix A) prior to testing may be indicated to prevent exercise-induced bronchoconstriction, thus providing optimal assessment of cardiopulmonary capacity.

Assessment of exercise-induced bronchoconstriction should be assessed via high intensity exercise (i.e., 80% of predicted HRmax or 40%-60% of measured or estimated maximal voluntary ventilation) lasting 4-6 min on a motor-driven treadmill or an electronically braked cycle leg ergometer and may be facilitated by inhalation of cold, dry air. The testing should be accompanied by spirometry performed prior to and 5, 10, 15, and 20 min following the exercise challenge. Use of age-predicted HRmax for setting exercise intensity or for estimation of VO2peak may not be appropriate because of possible ventilatory limitation to exercise.
Evidence of oxyhemoglobin desaturation ≤80% should be used as test termination criteria in addition to standard criteria.

Measurement of exertional dyspnea may also be useful using the Borg CR10 scale (see Figure 9.1). Patients and clients should be instructed to relate the wording on the scale to their level of breathlessness. Patients and clients should be informed that 0 or nothing at all corresponds to no discomfort with your breathing, whereas 10 or maximal corresponds to the most severe discomfort with your breathing that you have ever experienced or could imagine experiencing.

6-min walk testing may be used in individuals with moderate-to-severe persistent asthma when other testing equipment is not available.
Assessment of physiologic function should include CRF, pulmonary function, and determination of arterial blood gases or arterial oxyhemoglobin saturation (SaO2) via direct or indirect methods.
Perceptions of dyspnea should be measured during exercise testing using the Borg CR10 Scale.

Modifications of traditional protocols (e.g., smaller increments, slower progression) may be warranted depending on functional limitations and the early onset of dyspnea. Additionally, it is now recommended that the duration of the GXT be between 5 and 9 min in patients with severe and very severe disease.

The measurement of flow volume loops using commercially available instruments may help identify individuals with dynamic hyperinflation and increased dyspnea because of expiratory airflow limitations. Use of bronchodilator therapy may be beneficial for such individuals.

As indicated in Chapter 5, submaximal exercise testing may be used depending on the reason for the test and the clinical status of the patient. However, it should be noted that individuals with pulmonary disease may have ventilatory limitations to exercise; thus, prediction of VO2peak based on age-predicted HRmax may not be appropriate. In recent years, the 6-min walk test has become popular for assessing functional exercise capacity in individuals with more severe pulmonary disease and in settings that lack exercise testing equipment.

In addition to standard termination criteria, exercise testing may be terminated because of severe arterial oxyhemoglobin desaturation (i.e., SaO2 ≤80%).

The exercise testing mode is typically walking or stationary cycling. Walking protocols may be more suitable for individuals with severe disease who may lack the muscle strength to overcome the increasing resistance of cycle leg ergometers. Furthermore, if arm ergometry is used, upper extremity aerobic exercise may result in increased dyspnea that may limit the intensity and duration of the activity.