EXERCISE PRESCRIPTION

Goals of Exercise
To improve physical fitness and for health benefits.

Physical Fitness
Physical fitness: A set of attributes that people have or achieve that relates to the ability to perform physical activity.
Cardiorespiratory fitness- measured in VO2 max (maximal O2 uptake). Muscular strength, endurance and power- measured by 1 RM, number of RM (repetition maximum) performed and speed of repetition. Flexibility, balance, speed, reaction time.

Health
Definition of health goes beyond freedom from clinical disease to include a focus on functional capability or functional health status, including avoidance of functional disability and achievement of higher levels of functional capability.
-Blair, SN et al. 1992

Metabolic markers of health- insulin sensitivity, cholesterol profile, blood pressure, bone density, body compositionetc

Fitness and Health

Blair et al. 2001. Literature review (prospective observational studies) on health, physical activity and physical fitness. Found inverse dose-response gradient across both activity and fitness categories for morbidity from CAD, stroke, CA and all-cause mortality. Not possible to conclude whether activity or fitness is more important for health.
Dose-response relationship between physical activity to health and fitness thus blurring the distinction between fitness and health. Fitness and health viewed as a continuum on the same spectrum.

Maximal O2 uptake (VO2 max)

Best measure of cardiorespiratory fitness. Basis of ACSMs guidelines for aerobic exercise prescription.
VO2 = CO x (a-vo2 difference) = HR x SV (a-v02 diff.) - VO2 can be measured directly by spirometry. - VO2 is directly proportional to HR

Heart Rate Reserve and VO2 Reserve (Karvonen Formula)

HRR= Maximal HR- Resting HR
VO2 R= VO2 max- VO2 rest HRR has linear relationship to VO2 R, is the most accurate way to correlate HR to VO2.

Correlation of HRR to VO2 R

Swain et al. 1997. 63 healthy subjects ages 18-40, incremental maximal exercise test (3 min stages) on bicycle ergometer, measured HR and VO2 (via spirometry) at each stage. Data used to determine linear regression of HRR vs VO2 R. Later studies validating this relationship in older, healthy population and cardiac patients.

Using HRR (VO2 R) to Set Exercise Intensity

Objective measure.
Can reliably set exercise at intensity that will increase or maintain VO2 max.

Easy to use; only need to know resting HR and maximal HR.

Benefits of Increasing VO2 max

Health benefits.
Functional benefit- increased physiologic (cardiorespiratory) reserve- the ability of the body to increase the work of the heart to match an increased metabolic demand.

Purpose of Exercise Prescription

The goal of exercise prescription is to advise and motivate an individual to attain the maximum health benefits of exercise for a given indication with minimum risk and other "costs".

Preparticipation Considerations in Apparently Healthy Adults

Past medical history, cardiorespiratory status, orthopedic risk factors, physical capacity, physical exam.
Target goals

AHA Exercise Standards for Testing and Training (Circulation:2001)

Exercise Testing in Asymptomatic Persons Without Known CAD - Class I None - Class IIa Evaluation of asymptomatic persons with diabetes mellitus who plan to start vigorous exercise - Class IIb 1. Evaluation of persons with multiple risk factors as a guide to risk-reduction therapy. (HTN DM, Hyperchol., fam hx., smoking) 2. Evaluation of asymptomatic men older than 45 years and women older than 55 years: Who plan to start vigorous exercise (especially if sedentary) or Who are involved in occupations in which impairment might impact public safety or Who are at high risk for CAD due to other diseases (e.g., peripheral vascular disease and chronic renal failure)

Components of an Exercise Prescription

Mode- type of exercise performed. Intensity- how hard to exercise. Duration Frequency Progression

ACSMs Guidelines for Exercise Prescription- 2000

These recommendations are only guidelines and should not be implemented rigidly to all patients.
In considering these guidelines in the prescription of exercise, science meets art and each prescription should be individualized.

Mode of Aerobic Exercise

Any rhythmic activity that uses large muscle groups.
Walking, jogging, cycling, swimming

Which mode is better?

-Lieber et al. 1989. Run-trained vs. Swim-trained at 75% VO2 max over 12 wks. Similar increase in VO2 max. -Pollock et al. 1975. Walking, running, bicycling at same exercise intensity over 20 wks. Similar
improvements in VO2 max.

How Much Exercise is Enough?

Intensity, duration and frequency.
To effect what? Fitness/health variables and/or functional benefits. Individualize based on individual patient characteristics (initial fitness level of patient, medical limitations, goals).

ACSMs Recommendations for Aerobic Exercise Intensity

60-80% of HRR (VO2 R) provides sufficient stimulus needed to improve or maintain VO2 max in healthy untrained adults.
Goal is improvement in VO2 max. Based on HRR and correlation to VO2 R.
-Karvonen et al. 1957. Untrained med students training at different speeds. -Gasser et al. 1983. 2 exercise intensities, 40-45% VO2 max, 80-85% VO2 max, 18 wks. Both groups with significant increases in VO2 max and decreases in % body fat.

Ratings of Perceived Exertion

RATINGS OF PERCEIVED EXERTION - BORG(Old scale)
6 7 Very, very light 8 9 Very light 10 11 Fairly light 12 13 Somewhat hard 14 15 Hard 16 17 Very hard 18 19 Very, very hard 20

RATINGS OF PERCEIVED EXERTION - BORG (Newer scale)

0 Nothing at all 0.5 Very, very weak 1 Very weak 2 Weak 3 Moderate 4 Somewhat strong 5 Strong 6 7 Very strong 8 9 Very, very strong 10 Maximal

Correlation of RPE to HRR, VO2 R

ACSM recommendations of 12-16 (moderate to hard) on RPE scale correlating to 50-85% VO2 R to elicit training effect.

Validity of RPEs Correlation to Objective Measures

Whaley et al. 1997. Validity of RPE during exercise testing in apparently healthy and cardiac patients. Correlated HRR at 60 and 80% to RPE ratings. 39% healthy and 32% cardiac pt reported RPE outside 11-14 range for intensity at 60% HRR and 32% healthy and 52% cardiac pt reported RPE outside 14-17 range for intensity at 80% HRR.
Chow et al. 1984. Exercise groups utilizing 1) Heart rate (palpation method) 2) RPE to set intensity. Compared ability to keep heart rate within a specified range. Heart rate group- 55% accurate vs RPE 48% accurate. Control 24% accurate.

Use of RPE in Setting Exercise Intensity

In novices or institution of new exercises, patient will need time to adjust and learn exercise.
At onset of exercise, familiarization with exercise and own bodily response more important than exact intensity settings.

Use RPE in conjunction with HR to increase accuracy and objectivity.

ACSM Duration
20-60 minutes of continuous or intermittent (minimum of 10 minute bouts accumulated throughout the day) aerobic exercise.

ACSM- Duration Contd

When exercise is performed above the minimum intensity threshold, the total volume (kcal) of training is an important factor in fitness development and maintenance. This concept holds whether activity is continuous or intermittent (min 10 minutes)
DeBusk RF et al Am J Cardiol 1990. 2 groups of sedentary healthy men 40-60; moderate intensity 65-75% HR max, 5d/wk , 30 min vs 10+10+10 min; 8 wks; VO2 max increased in both groups, although higher in the long bout group (long bout group spent more time above target HR range); similar decrease in submax HR, increase in treadmill test duration. Jakicic JM et al Int J Obesity 1995. 56 obese sedentary females; LB vs SB group 40 min vs 10 min bouts), 5x/wk, 20 weeks, similar increase in VO2 max, better compliance in the SB group in terms of duration and frequency. Greater trend toward weight loss in SB group.

ACSM- Frequency
ACSM recommends 3-5 days/ week.
Need at least 2 days/ week to see improvement and maximal improvement in VO2 max seen at 4 days/ week.
Wenger et al. 1986. Review of literature, meta-analysis.

ACSM- Progression, Maintenance

Can increase duration, frequency, intensity to recommended amounts. - Initial conditioning stage - Improvement stage - Maintenance stage Variation

Sample Aerobic Exercise Prescription

40 yo sedentary male wishes to start an exercise program to increase fitness. Asymptomatic, apparently healthy.
Resting HR: 70 Maximal HR: 180 HRR = 180-70 = 110

Sample Aerobic Exercise Rx Contd

Mode- Jogging. Intensity 60-80% HRR Target HR range= ([HR max HR rest] x 0.60 and 0.80) + HR rest Target HR range = 136-158 Duration- 30 minutes of continuous exercise. Frequency- 3x / week. Progression- may increase duration, intensity, frequency in increments.

Resistance Training- Benefits/Goal

Benefits/Goals- increased strength, endurance, power.
Strength = Force x Distance Power = Force x Distance / Time

Muscular Endurance: measure of how well muscles can repeatedly generate force, and the amount of time they can maintain activity.

Principles of Resistance Training

Muscular strength and endurance are developed by the progressive overload principle.
Delorme. 1945. Restoration of muscle power by heavy-resistance exercise. Clinical observation of 300 cases in which progressive resistance exercise used to strengthen weakened muscles .

Different loading schemes for developing strength, muscular endurance and power. Effect of exercise training specific to area of body trained and to the ROM utilized.

ACSMs Guidelines for Resistance Training

Mode:
Consider specificity of exercise to goal, functional/fitness status, medical and orthopedic issues. Body weight, free weights, machines. Minimum of 8-10 exercises involving the major muscle groups (arms, shoulders, chest, abdomen, back, hips, legs).

ACSMs Guidelines for Resistance Training Contd

Intensity: Minimum of 1 set of 8-12 RM to develop both muscular strength and endurance.
Frequency: 2-3 days/ week. Progression: small, incremental increases in weight when can perform 2 repetitions above current goal. Variation

Resistance Training Variables Used in Setting Exercise Intensity

Variations of training variables:
Load, volume Exercise selection and order Rest periods Repetition velocity

Stroke Patients

Stroke Patients and Need for Exercise Training

Stroke survivors are often deconditioned and predisposed to a sedentary lifestyle that may limit performance of ADLs.
Increased energy demand of hemiparetic ambulation. Stroke survivors with peak VO2 ranging from 13.3-16.6 ml/kg/min.
Potempa et al 1995, Rimmer et al. 2000

Main Goals/ Benefits of Exercise in Stroke Patient

1) Regain prestroke level of activity as soon as possible. 2) Prevent recurrent stroke and cardiovascular events. 3) Improve aerobic fitness and thus increase cardiovascular reserve.

Macko et al. 2001. 19 stroke patients with chronic hemiparetic gait (> 6 months post CVA), treadmill exercise, 40 min sessions at 60% HRR, 3/wk x 6 months.

Economy of gait: determined by VO2 obtained during treadmill-exercise testing at a predetermined submaximal effort (with open-circuit spiromtery). Fractional utilization: the percentage of peak exercise capacity required to perform the constant load submaximal effort treadmill task. (Gait economy/ VO2 peak) x 100.

Preparticipation Considerations in the Stroke Population

Major impairments in stroke patients: - Hemiparesis, muscle atrophy - Spasticity - Cognition
Major disabilities in stroke patients: - Performance of ADLs - Gait deviations Diminished physiologic fitness reserve

Preparticipation Considerations in Stroke Patients Contd

Co-morbidities- CAD, HTN Consider AHA guidelines.

AHA Exercise Standards for Testing and Training (Circulation:2001)

Exercise Testing in Asymptomatic Persons Without Known CAD - Class I None - Class IIa Evaluation of asymptomatic persons with diabetes mellitus who plan to start vigorous exercise - Class IIb 1. Evaluation of persons with multiple risk factors as a guide to risk-reduction therapy.* (HTN DM, Hyperchol., fam hx., smoking) 2. Evaluation of asymptomatic men older than 45 years and women older than 55 years: Who plan to start vigorous exercise (especially if sedentary) or Who are involved in occupations in which impairment might impact public safety or Who are at high risk for CAD due to other diseases (e.g., peripheral vascular disease and chronic renal failure)

Mode of Exercise in the Stroke Population

Treadmill training:
1. Specificity of task to ADL of ambulation; increase function and fitness. May need hand rail or harnessing support. Ease of increasing exercise intensity by increasing grade while maintaining speed. Long-term orthopedic consequences for treadmill training with gait deviations.

2. 3.

4.

Other modes- arm-crank ergometer, cycling, wheelchair ergometer, aquatic exercises

Intensity of Aerobic Exercise in the Stroke Population

Aerobic exercise- 40-70% HRR, RPE scale 11-14.
Similar recommendations apply to the stroke population but applying principles of intensity setting in healthy populations directly to this population is difficult. Limitations: chronotropic medications, HR max and VO2max difficult to obtain in this population. Start slow, titrate the intensity and duration as patient becomes familiar with exercise and bodily response.

Might be beneficial to integrate stroke patients into phase II cardiac rehab program.

Monitoring Methods During Exercise

HR, BP, ECG, RPE scale, Dyspnea Scale, Anginal Scale

Resistance Exercise in Stroke Patients

There is some association between restoring strength and enhancing functional performance after stroke.
Duncan et al. 1998. Improvements in gait velocity in individuals with mild to moderate stroke after an 8 wk, 3x/wk, home-based endurance strength and balance training program. Weiss et al. 2000. 7 stroke patients 1 yr post CVA, underwent 12 week 2x/wk resistance program at 70% 1RM lower extremity exercises. Significant increases in LE strength, improved repeated chair stand time, Motor Assessment Scale, Berg balance scale.

Resistance Exercise in Stroke Patients Contd

Is resistance training safe in stoke patients?
Cardiovascular issues- BP response to resistance exercise is largely proportionate to % of MVC. - Thus, start with low weight.
Haslem et al. 1988. Intra-arterial pressures during weight-lifting in cardiac patients to be within clinically acceptable range with weight corresponding to 40-60% of 1 RM.

- Correct technique to avoid Valsalva manuever.

Future Directions in Exercise Prescription in Stroke Patients

Optimal time to start exercise program post stroke.
To further define the relationship between aerobic and resistance exercise variables and improvements in functional status and quality of life (i.e. mode of exercise, effect of accumulated exercise) Define relationship between aerobic exercise intensity/ volume and secondary prevention of stroke. Cost effective methods of implementing structured exercise programs for stroke patients.