Fitness Assessment/Prescription: EXSC U455

Recommended Sequence of Evaluation

- informed consent - exercise pre-participation health screening - health history - CV risk factor analysis

Exercise

A type of PA consisting of planned, structured, and repetitive bodily movement done to improve and/or maintain one or more components of physical fitness

______ is the most common exercise-related complication and is often associated with exercise intensity, the nature of the activity, preexisting conditions, and musculoskeletal anomalies

MSI

The most commonly used prediction equation to estimate percent body fat from body density was derived from the two-component model of body composition.

[(4.95 / Db) - 4.50] X 100

When the goal is a symptom-limited maximal exercise test, ___________________

a predetermined termination criteria should not be used as a reason to end the test.

The assessment of CRF fitness is an important part of ____________________________

a primary or secondary prevention and rehabilitation programs.

Physical fitness

a set of attributes or characteristics individuals have or achieve that relate to their ability to perform PA and activities of daily living

The waist circumference can be used alone ______________________________

as an indicator of health risk because abdominal obesity is the primary issue.

Current evidence does not support the routine use of exercise testing to screen for IHD in ______________________

asymptomatic individuals who have a very low or low pretest probability of IHD.

Percent body fat can be estimated once ______________________

body density has been determined.

The limiting factor in the measurement of body density is the accuracy of the ____________

body volume measurement because body mass is measured simply as body weight.

VO2max is the product of _________________

cardiac output (Q) and arterial venous oxygen difference (A-VO2 diff).

Physically active individuals should know the nature of __________________

cardiac prodromal symptoms and seek prompt medical care if such symptoms develop.

A useful alternative to using skinfolds to predict body fat is to track ______________

change in measurements (mm) at individual skinfold sites or use the sum of skinfolds (mm).

Body composition can be estimated with methods that vary in terms of ________

complexity, cost, and accuracy.

When administering clinical exercise tests, it is important to consider _________

contraindications, the exercise test protocol and mode, test endpoint indicators, safety, medications, and staff and facility emergency preparedness.

The use of a standardized exercise protocol (Figure 4.1) represents a ___________

convenient and repeatable way to conduct the exercise test.

The IC should be verbally __________________

described, and the individual be given every chance to ask questions before signing.

Increased visceral fat (i.e., fat within and surrounding thoracic and abdominal cavities) confers a higher risk for development of the metabolic syndrome compared to ______________________________-

distribution of fat within the subcutaneous compartment.

Athletes with known cardiac conditions or a family history should be ___________

evaluated prior to competition using established guidelines.

An exercise test can be useful in the _______________________________

evaluation of individuals who present to emergency departments with chest pain.

Body composition can be expressed as the relative percentage of mass that is _________________________

fat (FM) and fat-free (FFM) using a two-component model.

Android obesity presents a much greater health risk compared to __________

gynoid or gynecoid obesity.

Although the benefits of regular PA 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).

Algorithm components

o Classifying individuals who do (Yes) or do not (No) currently participate in regular exercise o Identifying individuals with known CV, metabolic, or renal diseases or those with signs or symptoms suggestive of cardiac, peripheral vascular, or cerebrovascular disease, Types 1 and 2 diabetes mellitus (DM), and renal disease o Identifying desired exercise intensity

High school and college athletes should undergo __________________________

preparticipation screening by qualified professionals.

Protocols most suitable for clinical exercise testing include a low intensity warm-up phase followed by _______________________

progressive, continuous exercise in which the demand is elevated to an individual's maximal level.

The IC should ensure that individuals know and understand the ________________

purpose(s) and risks associated with screening, assessment, and the exercise program.

The mortality rate appears to be 6 times higher when individuals exercised in facilities without the ability to successfully manage cardiac arrest; however, a _______________________________________

review of home-based cardiac rehab programs found no increase in cardiovascular complications compared to formal center-based exercise programs

Health-related changes in body composition that accompany aging include ______.

sarcopenia

The clinical utility of exercise testing is described in _______________________________

several evidence-based guideline statements aimed at specific cardiac diagnoses.

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. This self-guided method can be easily accomplished by using the PAR-Q+.

The GXT/CPX typically continues until a ____________________

sign or symptom-limited maximal level of exertion is reached.

The principle behind skinfold measurements is that the amount of _______________

subcutaneous fat is proportional to the total amount of body fat.

Exercise test supervision has shifted to nonphysician allied health professionals, ___________________

such as clinical exercise physiologists, nurses, physical therapists, and physician assistants.

Generally, exercise testing may be appropriate for individuals whose _____________

symptoms have resolved, have a normal ECG, and had no change in enzymes reflecting cardiac muscle damage.

Health care professionals should know the pathologic conditions associated with exercise-related events so ____________________________________

that physically active children and adults can be appropriately evaluated.

When two individuals have the same total body mass, _________________________________ compared to the individual with less FFM.

the individual with more fat-free mass (FFM) (i.e., the leaner individual) weighs more in water and has a higher body density and lower percentage of body fat

dual energy x-ray absorptiometry (DEXA)

the most widely used technology to measure bone density. Two X-ray beams are aimed at the patient's bones and the density of the bone is determined by the absorption of each X-ray beam.

Absolute oxygen uptake

(VO2; mL ∙ min−1 or L ∙ min−1)

Obtaining informed consent (IC) from individuals is an important ethical and legal consideration and should be completed prior to ____________________

(a) the collection of any personal and confidential information, (b) any form of fitness testing, or (c) exercise participation (see Figure 2.1).

Body composition determined from skinfold thickness correlates well ___________

(r = 0.70-0.90) with hydrodensitometry values.

Skinfold Measurement Procedures

- All measurements should be made on the right side of the body with the individual standing upright. - Caliper should be placed directly on the skin surface, 1 cm away from the thumb and finger, perpendicular to the skinfold, and halfway between the crest and the base of the fold. - Pinch should be maintained while reading the caliper. - Wait 1-2 s (not longer) before reading caliper. - Take duplicate, but not consecutive, measures at each site, and retest if duplicate measurements are not within 1-2

Commonly used modes for exercise testing:

- Field tests o1.5-mi run/walk test oCooper 12-min test oRockport One-Mile Fitness Walking Test oThe 6-min walk test oStep tests - Motor-driven treadmills - Mechanically braked cycle ergometers

Hydrodensitometry

measures body density by weighing the person first on land and then again while submerged in water

Factors that may contribute to measurement error within skinfold assessment include the following:

- Poor anatomical landmark identification - Poor measurement technique - An inexperienced evaluator - An extremely obese or extremely lean individual - An improperly calibrated caliper

Preparticipation health screening before initiating PA 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 ACSM screening algorithm (see Figure 2.2). a)Self-guided screenings can be an acceptable substitute for this method. 2.If indicated during screening, medical clearance should be sought from an appropriate health care provider. a)The manner of clearance should be determined by the clinical judgment and discretion of the health care provider.

Nearly one-third ____ of American children and adolescents are overweight or obese.

31.8%

Approximately _____ of American adults are classified as either overweight or obese, and more than a third _____ are classified as obese.

70.2%; 37.7%

Bioelectrical Impedance Analysis (BIA)

A body composition assessment technique that estimates body fat percentage by measuring the resistance to the flow of electrical currents introduced into the body.

A clinical exercise test is often referred to as a graded exercise test (GXT), an exercise stress test, or an exercise tolerance test (ETT).

A cardiopulmonary exercise test (CPX or CPET) or a metabolic exercise test includes the analysis of expired gases during exercise testing.

Physical Activity (PA)

Any bodily movement produced by the contraction of skeletal muscles that results in a substantial increase in caloric requirements over resting energy expenditure

Although resistance training is growing in popularity, current evidence is insufficient regarding ____________________________

CV complications during resistance training to warrant formal prescreening recommendations.

____________ has been used as a reference or criterion standard for assessing body composition for many years.

Densitometry

_____________________ and ________________ have recently gained popularity and also provide great precision in body composition assessment.

Dual-energy X-ray absorptiometry (DXA), multicomponent modeling

Circumference measures should be taken with a cloth tape.

Duplicate measurements are recommended at each site; however, it is suggested to take measurements of all sites once and then repeat the sequence. The final value is the average of the two measures, provided they do not differ by more than 5 mm.

Total body electrical conductivity (TOBEC)

Electrical current passes through animal muscle and bone (highly conductive); fat (lowly conductive). Less current passes through a fat animal.

Body weight should be measured using a calibrated balance beam or electronic scale.

Individual should wear minimal clothing with empty pockets and shoes removed.

This variable can be expressed in relative (mL · kg−1 · min−1) or absolute (mL · min−1) values.

Relative values allow for comparisons amongst individuals of different body sizes.

_____ and _____ are associated with vigorous intensity and are much less common than MSI but may lead to long-term morbidity and mortality.

SCD & AMI

The need for medical clearance before initiating or progressing exercise programming is determined using the ACSM screening algorithm (see Figure 2.2).

Self-guided screenings can be an acceptable substitute for this method.

Symptoms - Clinical testing

Symptoms that are consistent with myocardial ischemia (e.g., angina, dyspnea) or hemodynamic instability (e.g., light-headedness) should be noted and correlated with ECG, HR, and BP abnormalities (when present).

If indicated during screening, medical clearance should be sought from an appropriate health care provider.

The manner of clearance should be determined by the clinical judgment and discretion of the health care provider.

submaximal exercise test

Treadmill & Step test protocols

Maximal volume of oxygen consumed per unit of time (VO2max) is __________

accepted as the criterion measure of CRF.

AHA absolute and relative contraindications should be ____________________

adhered to during all clinical exercise testing (Box 4.1).

According to the ACC and AHA, the nonphysician allied health care professional who administers clinical exercise tests should have cognitive skills similar to, ________________________

although not as extensive as, the physician who provides the final interpretation (Box 4.2).

PAR-Q (Physical Activity Readiness Questionnaire)

an assessment tool to initially screen apparently healthy clients who want to engage in low-intensity exercise and identify clients who require additional medical screening - determines safety/risk of exercising - identifies individuals who need med eval (if client answers YES to 1+ questions, refer to physician)

Plethysmography

any technique for measuring changes in the volume of blood in a part of the body

The BMI is used to assess weight relative to ___________________________

height and is calculated by dividing body weight in kilograms by height in meters squared (kg · m−2).

The ACSM preparticipation screening algorithm (Figure 2.2) is designed to _____

identify individuals at risk for CV complications during or immediately after aerobic exercise.

The purpose of the CPX is to observe physiological responses to _______________

increasing or sustained metabolic demand.

Guidelines have consistently recommended that the protocol should be ______

individualized based on a given individual's age, exercise tolerance, or symptoms.

The direct measurement of VO2 is the most accurate measure of exercise capacity,______________________________

is a useful index of overall cardiopulmonary health, and may help overcome potential inaccuracies associated with estimating exercise capacity from peak workload (e.g., treadmill speed and grade).

The most common diagnostic indication is the assessment of symptoms suggestive of ______________________

ischemic heart disease (IHD).

Health care facilities should ensure that their staff are trained in __________________

managing cardiac emergencies, have a specified plan, and have appropriate resuscitation equipment.

Evaluating exercise capacity is an important aspect of exercise testing.

oA high exercise capacity is indicative of a high peak Q and therefore suggests the absence of serious limitations of left ventricular function. oA significant issue relative to exercise capacity is the imprecision of estimating exercise capacity from exercise time or peak workload. §The standard error in estimating exercise capacity from various published prediction equations is at least ±1 MET.

Estimates of VO2max from HR response to submaximal exercise tests are based on the following assumptions:

oA steady state HR is established for each work rate. oA liner relationship exists between HR and work rate. oThe difference between predicated and actual MHR is small. oMechanical efficiency is the same for everyone. oThe individual is not on any HR altering medications (see Appendix A) or OTC products.

Indications for clinical exercise testing encompass three general categories:

oDiagnosis (e.g., presence of disease or abnormal physiologic response) oPrognosis (e.g., risk for an adverse event) oEvaluation of the physiologic response to exercise (e.g., blood pressure [BP] and peak exercise capacity)

FITT-VP principle of exercise prescription

oFrequency (how often) oIntensity (how hard) oTime (duration or how long) oType (mode or what kind) §Total Volume (amount) §Progression (advancement) vBased on application of existing scientific evidence vIntended as guidelines for apparently healthy adults

Anthropometric methods

oHeight, weight, and body mass index (BMI) oCircumferences oSkinfold measurements

Densitometry

oHydrodensitometry oPlethysmography

CRF is a health-related component of fitness

oLow levels of CRF fitness have been associated with a markedly increased risk of premature death from all causes and specifically from cardiovascular disease. oIncreases in CRF fitness are associated with a reduction in death from all causes. oHigh levels of CRF fitness are associated with higher levels of habitual PA, which in turn are associated with many health benefits.

Testing Mode and Protocol The mode selected for the exercise test can impact the results and should be selected based on the test purpose and individual preference.

oTreadmill oCycle ergometer oOther exercise testing modes may be considered.

Risk is related to the absence or presence of __________________________

occult CVD, exercise intensity, age, and PA.

Contraindications are intended to avoid unstable ischemic, rhythm, or hemodynamic conditions or other situations in which __________________________

the risk associated with undergoing the exercise test is likely to exceed the benefit.

The principle behind skinfold measurements is that the amount of subcutaneous fat is proportional to _______________________

the total amount of body fat.

Before collecting data for body composition assessment, the technician must be __________________________

trained, experienced in the techniques, and already have demonstrated reliability in taking measurements, independent of the technique being used.

Cardiopulmonary Exercise Testing

vA major advantage of measuring gas exchange during exercise is a more accurate measurement of exercise capacity. vCPET data may be particularly useful in defining prognosis and defining the timing of cardiac transplantation and other advanced therapies in individuals with heart failure. vCPET is also helpful in the differential diagnosis of individuals with suspected cardiovascular and respiratory diseases.

Rate Pressure Product

vRate-pressure product (RPP, also known as double product) is calculated by multiplying the values for HR and SBP that occur at the same time during rest or exercise. RPP is a surrogate for myocardial oxygen uptake (MVO2). vThere is a linear relationship between MVO2 and both coronary blood flow and exercise intensity. vThe normal range for peak RPP is 25,000-40,000 mm Hg × beats × min−1.

Heart Rate Responses

vThe normal HR response to incremental exercise is to increase with increasing workloads at a rate of ≈10 beats × min−1 per 1 MET. vEquations exist to predict HRmax in individuals who are not taking a b-adrenergic blocking agent (see Table 5.3). vHRmax decreases with age and is attenuated in individuals on b-adrenergic blocking agents. All HRmax estimates have large interindividual variability with standard deviations of 10 beats or more. vAmong individuals referred for testing secondary to IHD, and in the absence of b-adrenergic blocking agents, failure to achieve an age-predicted HRmax >85% in the presence of maximal effort is an indicator of chronotropic incompetence and is independently associated with increased risk of morbidity and mortality. vA failure of the HR to decrease by >12 beats during the first minute or >22 beats by the end of the second minute of active postexercise recovery is strongly associated with an increased risk of mortality in individuals diagnosed with or at increased risk for IHD.

Blood Pressure Response

vThe normal systolic blood pressure (SBP) response to exercise is to increase with increasing workloads at a rate of ~10 mm Hg per 1 MET. There is normally no change or a slight decrease in diastolic blood pressure (DBP) during an exercise test. oPotential SBP responses §Hypertensive response §Hypotensive response §Blunted response §Postexercise response

Physically active individuals should modify their exercise program in response to _____________________

variations in their exercise capacity, habitual activity level, and the environment.

VO2

volume of oxygen consumed per minute

Although BMI and waist circumference are correlated, _________________________

waist circumference is a better measure of visceral adiposity which can be varied within a given BMI.

The estimate of total body fat percentage can be derived from a measurement of ______________________

whole-body density using the ratio of body mass to body volume.

It is well established that excess body fat is associated ____________________

with many chronic conditions.

Age, gender, race, training status, and certain disease states may affect the density of FFM, _________________________

with much of this variance related to the bone mineral density component of FFM.

The accuracy of predicting percent body fat from skinfolds is approximately ___________________________

±3.5%, assuming appropriate techniques and equations have been used.