ACSM Guidelines for Exercise Testing and Prescription(Chapters 1 and 2)

Physical Inactivity

Global pandemic that has been identified as one of the four leading contributors to premature mortality, "Sitting is not good", they need to be active, "Sitting is the new smoking", It obviously isn't as bad but physical inactivity is very common nowadays -Globally, 31.1% of adults are physically inactive In the U.S.: -51.6% of adults meet aerobic activity guidelines -29.3% meet muscle strengthening guidelines -20.6% meet both the aerobic and muscle strengthening guidelines, Only 1/5 of our population meet both forms of exercise that is recommended, this is not good, Our careers need to help change this

Chapter 1

Benefits and Risks Associated with Physical Activity

The Bottom Line

-A large body of scientific evidence supports the role of physical activity in delaying premature morality and reducing the risks of many chronic diseases and health conditions, There is also clear evidence for a dose-relationship between physical activity and health, Thus, any amount of physical activity should be encouraged, "Some exercise is better than none, More exercise is better to an extent" -Ideally, an initial target should be 150 minutes a week of moderate intensity, aerobic activity, 75 minutes a week of vigorous intensity, aerobic activity, or an equivalent combination of moderate and vigorous intensity, aerobic activity, To minimize musculoskeletal injuries, physical activity bouts should be broken up during the week(e.g., 30 minutes of moderate intensity, aerobic activity on 5 days a week) -Additional health benefits result from greater amounts of physical activity, Individuals who maintain a regular program of physical activity that is longer in duration and/or is more vigorous in intensity are likely to derive greater benefit than those who do lesser amounts -Although the risks associated with exercise transiently increase while exercising, especially exercising at vigorous intensity, the benefits of habitual physical activity substantially outweigh the risks, In addition, the transient increase in risk is of lesser magnitude among individuals who are regularly physically active compared with those who are inactive

Exercise Benefits: Other Benefits

-Decreased anxiety and depression -Improved cognitive function -Enhanced physical function and independent living in older individuals -Enhanced feeling of well being -Enhanced performance of work, recreational, and sport activities -Reduced risk of falls and injuries from falls in older individuals -Prevention or mitigation of functional limitations in older adults -Effective therapy for many chronic diseases in older adults

Risks of Cardiac Events During Cardiac Rehabilitation

-In one survey, there was one nonfatal complication per 34,673 hours and one fatal cardiovascular complication per 116,402 hours of cardiovascular rehabilitation -More recent studies have found a lower rate, one cardiac arrest per 116,906 patient-hours, one MI per 219,970 patient-hours, one fatality per 752,365 patient-hours, and one major complication per 81,670 patient-hours -The mortality rate appears to be six times higher when patients exercised in facilities without the ability to successfully manage cardiac arrest

Exercise Benefits: Improvement in Cardiovascular and Respiratory Function

-Increased maximal oxygen uptake resulting from both central and peripheral adaptations -Decreased minute ventilation at a given absolute submaximal intensity -Decreased myocardial oxygen cost for a given absolute sumaximal intensity -Decreased heart rate and blood pressure at a given submaximal intensity -Increased capillary density in skeletal muscle -Increased exercise threshold for the accumulation of lactate in the blood -Increased exercise threshold for the onset of disease signs or symptoms(e.g., angina pectoris, ischemic ST-segment depression, claudication)

Self-Guided Methods

-Preparticipation health screening by self-reported medical history or health risk appraisal should be done for all individuals wishing to initiate a physical activity program -The self-guided method can be easily accomplished by using the PAR-Q+(see Figure 2.1), 2017 is the newest one, It is similar to the ACSM guidelines, It is a questionnaire for a patient to fill out, Common in exercise classes, gyms, etc.

Exercise Benefits: Decreased Morbidity and Mortality

-Primary prevention(i.e., interventions to prevent the initial occurrence) -Higher activity and/or fitness levels are associated with lower death rates from coronary artery disease -Higher activity and/or fitness levels are associated with lower incidence rates for CVD, CAD, stroke, Type 2 diabetes mellitus, metabolic syndrome, osteoporotic fractures, cancer of the colon and breast, and gallbladder disease -Secondary prevention(i.e., interventions after a cardiac event to prevent another) -Based on meta-analysis(i.e., pooled data across studies), cardiovascular and all-cause mortality are reduced in patients with post-myocardial infarction(MI) who participate in cardiac rehabilitation exercise training, especially as a component of multifactorial risk factor reduction -Randomized controlled trials of cardiac rehabilitation exercise training involving patients with post-MI do not support a reduction in the rate of nonfatal reinfarction

The New Preparticipation Health Screening Process is Based On

1.) The individual's current level of structured physical activity(first question), ASCM determines being physical active as 3 days a week of 30 minutes of moderate intensity per day for the last 3 months, If they are active, the are already at a lower risk so is the best first question to ask 2.) The presence of major signs or symptoms suggestive of CV, metabolic, or renal disease(See Table 2.1), Asks if they have any symptoms on the list or a previous diagnosis 3.) The desired exercise intensity, It asks them how intense they want the program to be, If they want vigorous intensity, they may need medical clearance

Risks Associated with Physical Activity and Exercise

Although the benefits of regular Physical Activity are well established, participation in exercise is associated with an increased risk for musculoskeletal injury(MSI) and cardiovascular complications such as sudden cardiac death(SCD) and acute myocardial infarction(AMI) -MSI is the most common exercise-related complication and is often associated with exercise intensity, the nature of the activity, preexisting conditions, and musculoskeletal anomalies -SCD and AMI are associated with vigorous intensity are much less common than MSI but may lead to long-term morbidity and mortality

American Association of Cardiovascular and Pulmonary Rehabilitation(AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease, Highest Risk

Characteristics of patients at high risk for exercise participation(any one or combination of these findings places a patient at higher risk) -Presence of complex ventricular dysrhythmias during exercise testing or recovery -Presence of angina or other significant symptoms(e.g., unusual shortness of breath, light-headedness, or dizziness at low levels of exertion [Under 5 METs] or during recovery) -High level of silent ischemia(ST-segment depression greater than or equal to 2 mm from baseline) during exercise testing or recovery -Presence of abnormal hemodynamics with exercise testing(i.e., chronotropic incompetence or flat or decreasing systolic BP with increasing workloads) or recovery(i.e., severe postexercise hypotension) Nonexercise Testing Findings(at rest) -Rest ejection fraction under 40% -History of cardiac arrest or sudden death -Complex dysrhythmias at rest -Complicated myocardial infarction or recascularized procedure -Presence of congestive heart failure -Presence of signs or symptoms of postevent/postprocedure ischemia -Presence of clinical depression

Introduction

Compared to previous editions of the Guidelines, the present version of Chapter 2: -Does not include risk factor analysis or risk level classification -Makes recommendations for physician clearance rather than specific recommendations for a medical examination or exercise test -Does not automatically refer individuals with pulmonary disease for medical clearance prior to the initiation of an exercise program

Exercise Preparticipation Health Screening Algorithm Recommendations(*refer to handout*)

Current version of ACSM screening, In the old guidelines they wanted everybody to have medical clearance before exercising, People over the age of 40 found this to be more of a barrier to exercising than a benefit -Algorithm very useful, Look at handout for more information and to see how it is used -Updated in 2015, we have a new health screening process, Updated every few years, Starts with "Does the individual currently exercise regularly?", and moves on from there in a tree format, If they answer no to exercising regularly, or yes to having a previous diagnosis or any symptoms they may need medical clearance before they can participate in exercise, Some may be able to start with light exercise, and some may be cleared for high intensity right away if no problems should arise(based on ACSM guidelines) -This can be used to guide us in our practices, There are many pages of literature and research that can back us up if something were to happen to an individual that was cleared for exercise

Health Benefits of Regular Physical Activity and Exercise

Evidence to support the inverse relationship between regular Physical Activity and/or exercise and premature mortality, CVD/CAD, hypertension, stroke, osteoporosis, Type II Diabetes Mellitus(T2DM), metabolic syndrome(Metsyn), obesity, 13 cancers, depression, functional health, falls, and cognitive function, Basically "Exercise is good" Box 1.4 lists these benefits: -Improvement in cardiovascular and respiratory function -Reduction in cardiovascular disease risk factors -Decreased morbidity and mortality -Other benefits

Chapter 2

Exercise Preparticipation Health Screening

These ACSM Guidelines

It is now in its 10th addition(2018), We will go over it more in Kinesiology 352, Says how exercise is important for public health, people need to take part in it, It is constantly being updated periodically, Research is always being done for it, Says some physical activity is better than none, And more physical activity is better up to a point where it is too much and can actually be dangerous(but most people don't get here)

Exercise Benefits: Reduction in Cardiovascular Disease Risk Factors

Our class is generally interested here, Basically says regular exercisers are less prone to risk factors in cardiovascular disease, These are risk factors that are modifiable and can be changed -Reduced resting systolic/diastolic pressure -Increased serum high-density lipoprotein cholesterol and decreased serum triglycerides -Reduced total body fat, reduced intra-abdominal fat -Reduced insulin needs, improved glucose tolerance -Reduce blood platelet adhesiveness and aggregation -Reduced inflammation

Public Perspective for Current Recommendations

Over 20 years, the American College of Sports Medicine(ACSM) in conjunction with the Centers for Disease Control and Prevention(CDC), the U.S. Surgeon General, and the National Institutes of Health(NIH) issued landmark publications on Physical Activity and health -What are the amount and intensity of Physical Activity needed to improve health, lower susceptibility to disease(morbidity), and decrease premature mortality -Documented the dose-response relationship between Physical Activity and health (i.e., some activity is better than none, and more activity, up to a point, is better than less), Additional health benefits result from greater amounts of Physical Activity, Individuals who maintain a regular program of Physical Activity that is longer in duration, of greater intensity, or both are more likely to derive greater benefit (less CAD and CVD) than those who engage in lesser amounts, More active people have less risk factors for these diseases compared to less active and sedentary individuals

Preparticipation Health Screening

Preparticipation Health Screening before initiation Physical Activity or an exercise program 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) -a.) In this absence of professional assistance, interested individuals may use self-guided methods 2.) If indicated during screening(see Figure 2.2), medical clearance should be sought from an appropriate health care provider -a.) The manner of clearance should be determined by the clinical judgement and discretion of the health care provider

Sedentary Behavior and Health

Prolonged periods of sitting or sedentary behavior are associated with deleterious health consequences independent of Physical Activity levels -50% of an average person's waking day involves activities associated with prolonged sitting such as watching the television viewing and being on the computer -However, sedentary time was associated with a 30% lower relative risk for all-cause mortality among those with high levels of Physical Activity as compared with those with low levels of Physical Activity

Dose-Response Relationship Between Physical Activity and Health

Real world example of a dose-relationship, Waking up with a headache, taking one tylenol and it improves, Since it is safe to take two you take the second and your headache improves even more, Its safe to take three so you take a third and your headache goes away, More dose means more response, such as with more physical activity means better health, up to a point

Major Signs or Symptoms Suggestive of Cardiovascular, Metabolic, and Renal Disease(Table 2.1)

Same symptoms listed before: -Pain, discomfort(or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may result from ischemia(lack of blood flow) -Shortness of breath at rest or with mild exertion -Dizziness or syncope(loss of consciousness because of lack of blood flow) -Orthopnea(difficulty breathing while laying down) and Paroxysmal nocturnal dyspnea(difficulty breathing at night) -Ankle edema -Palpitations or tachycardia(very fast HR) -Intermittent claudication(aching in calves) -Known heart murmur(irregular beat) -Unusual fatigue or shortness of breath with usual activities

The ACSM-AHA Primary Physical Activity(PA) Recommendations(Box 1.2)

Says 10 minute increments throughout the day is still beneficial for cardiovascular improvement, Strength exercises should be done at least two days a week, It says as follows: -All healthy adults aged 18 - 65 years should participate in moderate intensity aerobic Physical Activity for a minimum of 30 minutes on 5 days a week or vigorous intensity aerobic activity for a minimum of 20 minutes on 3 days a week -Combinations of moderate and vigorous intensity can be performed to meet this recommendation -Moderate intensity aerobic activity can be accumulated to total the 30 minutes minimum by performing bouts each lasting greater than or equal to 10 minutes -Every adult should perform activities that maintain or increase muscular strength and endurance for a minimum of 2 days a week -Because of the dose-relationship between Physical Activity and health, individuals who wish to further improve their fitness, reduce their risk for chronic diseases and disabilities, and/or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of Physical Activity

There Are Several Different Ways We Can Categorize Exercise Intensity

Table 1.1 lists some examples, MET is the metabolic equivalent of a task, 1 is sitting at rest, 0.9 is at rest, MET is the cost of Physical Activity Very light/Light(under 3.0 METs) -Walking slowly(2) -Standing light work(2-2.5) -Arts, bowling, fishing(1.5-2.5) -These are housework things Moderate(3-5.9 METs) -Walking 3 - 4 mph(3-5) -Heavy cleaning(3-3.5) -Mowing lawn(5.5) -Dancing, golf, recreational sports(3-4.5) Vigorous(Over 6.0 METs) -Walking 4.5 mph(6.3) -Jogging/walking 5 - 7 mph(8-11.5) -Shoveling/farming(7-8.5) -Bicycling, skiing, competitive sports(6-11) -These are heavy labor, most competitive sports fall in this category We can also look at respiration rate or breathing to determine exercise intensity -Moderate exercise involves noticeable changes in breathing rate -Vigorous exercise involves substantial changes in breathing rate We can also look at heart rate reserve(HRR) -Estimated max heart rate - resting heart rate -(MHR - RHR)

American College of Sports Medicine Preparticipation Screening Algorithm

The ACSM preparticipation screening algorithm(Figure 2.2) is a new instrument designed to identify participants at risk for CV complications during or immediately after aerobic exercise Although resistance training is growing in popularity, current evidence is insufficient regarding CV complications during resistance training to warrant formal prescreening recommendations -CV complications during resistance training, this risk cannot currently be determined but appears to be low

Exercise-Related Cardiac Events in Adults

The main thing as that even if fit, there is a higher risk of a potential heart issue while running 10 mph on a treadmill vs. sitting in class, It is an even greater risk for those who are not physically fit, Unhealthy people have a much higher risk to their heart when engaging in vigorous activity, In general, exercise does not provoke cardiovascular events(SCD or AMI) in healthy individuals with normal cardiovascular systems -Risk is related to the absence or presence of occult(not seen, invisible) CVD, exercise intensity, age, and Physical Activity, Many people may not be diagnosed of a disorder or show any symptoms, but are more at risk because of inactivity -The Onset Study showed that the risk of AMI during or immediately following vigorous intensity exercise was 50 times higher for the habitually sedentary compared to the individuals who exercised vigorously for 1 hour sessions more than 5 days a week -The diagram shows sedentary people are at risk of AMI at rest and at an extreme risk with vigorous activity, This is why we screen, The more exercise people get a week, the lower risks they already have

This updated preparticipation process is based on the outcomes of a scientific roundtable sponsored by the American College of Sports Medicine(ACSM) in 2014

The relative risk of a CV event is transiently increased during vigorous intensity exercise as compared with rest but that the absolute risk of an exercise-related acute cardiac event is low in healthy asymptomatic individuals(Figure 1.2) Among adults, the risk for activity-associated SCD and AMI is known to be highest among those with underlying CVD who perform unaccustomed vigorous Physical Activity Insufficient evidence is available to suggest that the presence of CVD risk factors without underlying disease confers substantial risk of adverse exercise-related CV events CVD risk factor-based exercise preparticipation health screening may be overly conservative due to the high prevalence of risk factors and may generate excessive physician referrals, particularly in older adults -Exercise professionals are encouraged to compete CVD risk factor assessment with their patients/clients as part of the preexercise evaluation(see Chapter 3)

Exercise Testing and the Risk of Cardiac Events

This is what we're testing, beneficial to risks that may occur, We may not test a VO2 max on a client that is sedentary and at risk, we'd do some functional tests instead -As with vigorous intensity exercise, the risk of cardiac events during exercise testing varies directly with the prevalence of diagnosed or occult CVD in the study population -These data indicate that in a mixed population the risk of exercise testing is low, with approximately six cardiac events per 10,000 symptom-limited maximum tests

Health Benefits of Improving Muscular Fitness

Usually people emphasize cardiovascular fitness, but their exercise programs should involve strength and muscular fitness as well, This is key for older people wanting to live independently at home, More research will be done on this in the future, The health benefits of enhancing muscular fitness(i.e., the functional parameters of muscle strength, endurance, and power) are well established -Higher levels of muscular strength are associated with a significantly better cardiometabolic risk factor profile, lower risk of all-cause mortality, fewer CVD events, lower risk of developing physical function limitations, and lower risk for nonfatal disease

Evidence-Based Practice and Literature Search Tips

We have notes on this which will be helpful to look at and review for our Two Article Critiques and Research Presentation(four articles)

Prevention of Exercise-Related Cardiac Events

We need to know signs, symptoms, and risks before we put someone on a treadmill, or give them an exercise routine -Health care professionals should know the pathologic conditions associated with exercise-related events so that physically active children and adults can be appropriately evaluated -Physically active individuals should know the nature of cardiac prodromal symptoms and seek prompt medical care if such symptoms develop(see Table 2.1)