Ex Phys- Final

Continued: >Risks of Beta Blockers -Most risk due to ___ -___ with asthma (Vasoconstriction in lungs) -Cardiac failure (in pt. with underlying cardiac dysfunction) -Heart block with bradycardia -___ (low BP) -___ (decreased insulin secretion) -Fatigue

prolonged use Bronchospasm Lightheadedness Hypoglycemia

Exercise Prescription: >Proven effects of aerobic exercise: (making heart work more efficiently) >Reduction of SBP and DBP of ___-___ mm Hg >Regression of vent wall ___ and left vent ___ >Heart works less hard, restores itself to original size, needs less oxygen, less likely to have MI >Some conflicting evidence that resistance training alone can reduce BP be very careful to avoid valsalva during resistance training

5-7 thickness mass

Amphetamines (speed) >CNS stimulants 🡪 Sympathomimetic amines >Proposed benefits: ___ ->Run faster, jump higher, throw farther, delay fatigue, increase concentration and alertness, state of euphoria- basically anything that relates to a sport, you would be better at >Proven Effects ->Decreased sense of ___ ->Increased SBP, DBP, HR ->Redistribution of blood to ___ ->Elevation of blood glucose and FFA → makes more energy available ->Increased muscle tension ->** ALL THIS TOGETHER = MAKES YOU MORE READY TO ___ ** ->Effect on performance: increased speed, power, endurance, fine motor coordination***

"fight or flight" fatigue skeletal muscles EXERCISE

Estimating Energy Expenditure >Not exact science due to difference in: -Skill -Coordination -Exercise economy -variable intensity within each activity >MET Equation for Energy Expenditure -To approximate caloric cost of exercise -___ = kcal/min

(METS x 3.5 x BW in kg)/200

___-___ met/minutes per week for more people- aerobically ->mets times the time you're doing ->ex. working at 7 mets for 30 minutes is 210 met-minutes

500-1000

Children and Adolescents 2008 Physical Activity Guidelines for Americans recommends: >"___ min/day of moderate-to-vigorous intensity physical activity, resistance exercise, and bone loading activity on at least 3 days/week" >___% of children aged 6-11 and ___% of adolescents aged 12-19 meet these guidelines In addition to exercise, limit screen time to <___ h/day >Excess screen time linked with increased adiposity, decreased fitness, elevated BP, blood lipids and glycohemoglobin in kids aged 5-17 ->Just over ___% of 6-11 year olds met this recommendation

60 42 8 2 50

Older Adults >Classified as adults ___ years old or older or age ___-___ with clinically significant limitations >Physical Activity has been shown to: -Slow ___ changes of aging -Optimize age-related changes in body composition -Promote psychological and physical well-being -Manage ___ dz -Reduce risk of physical disability -Increase ___ ***Despite this, only ___% of individuals ≥65 meet the guidelines → VERY INACTIVE!! ___% of those over age 85 meet the physical activity requirements

65 50-64 physiological chronic chronic 11 5

Cancer >___% in people age 55 or older, but can affect all ages >Specific exercise testing and prescription issues will be related to type of cancer and patient's response >Standard exercise testing methods are appropriate for patients once cleared for exercise ->No assessment needed to start a ___ intensity walking, progressive strength training or flexibility program in most survivors >Be aware that increased risk of fractures, cardiovascular events, and neuropathy are associated with many treatments

78 light

Parameters for Inpatient cardiac rehabilitation daily ambulation >No new or recurrent chest pain in previous ___ >Stable or falling ___ and ___ values >No indication of decompensated ___ (SOB at rest, crackles up middle and upper lobes) >Normal cardiac rhythm and stable EKG for previous ___

8 hours creatine kinase (CKMB) and troponin heart failure 8 hours

Exercise Testing >Several modifications to traditional testing warranted -For mild-moderate COPD a test duration of ___-___ minutes is optimal -For severe COPD a test duration of ___-___ minutes is recommended -Monitor closely for ___ (pulse ox) in testing and during exercise -Their oxygen saturation is typically lower, stop exercising at ___%

8-12 5-9 desaturation 88

Continued: Down Syndrome >Physician supervised testing >Full health screen before an exercise program >Several issues to consider ->___ instability in 30% ->___ in 50%

Atlantoaxial Congenital heart disease

Beta-blockers aka ___ >One of most common CV meds >Usually meds that end in ___ >Used to treat -___ -___ = chest pain -Previous MI → slows work of heart -Cardiac arrhythmias -Migraine HA -Anxiety ***designed to treat anything to lower the ___

Beta Adrenergic Blockers -ol HTN Angina pectoris workload

Continued: >Peripheral Factors: NOT about you, you can change these things, not person specific 1. ___ relationships -- length/tension, etc. 2. Fiber ___ (ex: scar tissue after injury) 3. Type of ___ -- eccentric > isometric > concentric 4. rest 5. ___ status (trained or untrained) 6. ___ available -- nutrition status

Biomechanical orientation/alignment contraction training energy

Digitalis >Prescribed for ___ -Limits movement of ___ and ___ across myocardial membrane -Increases ___ of heart muscle, which allows better pump action -B/c it has no effect on HR or BP, it is used routinely with ___ and ___ >Risks -Risks include ___ (affects heart pumping) and risk of drug toxicity >Benefits -Enhances ___ = used in exercise testing due to more accurate idea of HR and BP than nitrates, beta blockers, Ca2+ channel blockers

CHF Na+ and K+ efficiency ex and testing potassium deficiency contractility

Diuretics >really common in ___ patients and sometimes in HTN ->works on the kidneys to excrete urine output decreasing ___ so heart doesn't have to process as much fluid >Works on ___ not water***, but wherever the sodium goes the water goes as well >Affect the kidneys, increasing ___ >Used to treat ___, and to reduce ___ associated with CHF >Mechanism of action ->Work by eliminating ___ and ___ (water follows Na) ->Lowers blood pressure by decreasing ___

CHF preload sodium urine production HTN edema Na and water blood volume

Heart Failure >___ is #1 admitting diagnosis for older Americans -> >1 million hospitalizations per year -> 25% readmitted within 30d and 66% within 1 yr of initial HF admission -> 825,000 new cases per year -> Prevalence ~6,000,000 *Don't memorize numbers

Decompensated heart failure (heart isn't keeping up with normal cardiac demand - CO)

>___ = any substance or phenomenon that enhances performance- ex. running with a group of people >Ergolytic substance = has a detrimental effect on ___ ***Some substances that are thought to be ergogenic are ___!***

Ergogenic Aid performance ergolytic

___- how much stretch you have determines the contractility

Frank-Starling Principle

___ is the best predicter O2 consumption

HR

PRESCRIPTION: Overall, similar to FITT for younger adults >One key difference is ___ ->For younger adults we defined intensity based on ___ ->For elderly a ___ scale is used >In addition to aerobic, resistance and flexibility, consider ___ training for balance, agility, etc

Intensity METs 0-10 scale neuromotor

Duration/time (T) >___ related to Intensity ACSM recommends >___ min/day of CV exercise to improve aerobic capacity (excludes warm up and cool down) >Most people meet goals training ->20-30min, excluding warmup & cool down, ->@ 60%-80% HRR or 77-90% HRmax >Some evidence to support high intensity, low duration activity to increase VO2max ->Higher ___ rate, CV incidence, lower ___ >Duration can begin with multiple small bouts to achieve goal, and increase until goal is reached

Inversely 20 injury compliance

Modes of Strength Training >___ = no movement (wall sit, plank, etc) >___ = Force remains constant (free weights) >___ = constant velocity (biodex); hard to do

Isometric Isotonic Isokinetic

Rate of Progression Depends on: >Functional capacity >___ status >age >Individual ___ and ___ >Tolerance to current level of training

Medical/health preferences and goals

Components of Cardiopulmonary Ex Rx (FITT-VPP): ___, ___, ___, ___ >Mode (T) ->Exercises using ___ muscle groups ->Greatest improvement in ___ w/ large muscle groups, over prolonged periods ->Test the same way you ___ to be most accurate

Mode (type), Intensity, Frequency, Duration (time) (+ Volume, Progression, pattern) large VO2max train

Ergogenic Aids >Ex: Anabolic steroids, carb loading, hypnosis, home crowd cheering >Classification of Ergogenic Aids ->___ = drugs (including illegal ones) ->Hormones ->Physiological Agents ->Nutritional Agents

Pharmacological Agents

Effects of Aging on Selected Physiologic and Health Related Variables >Unchanged: ___ Lower: Max HR, Max CO, absolute and relative max oxygen uptake reserve, vital capacity, muscular strength, flexibility, bone mass, fat-free mass, glucose tolerance >Slower: ___ time >Longer: ___ time

RHR Reaction recovery

Continued: -___ system activated ->pro-renin in kidneys converted to renin -->renin released from kidney to stimulate the release of ___ -->angiotensin stimulates release of ___ -->aldosterone ___ reabsorption of water (___ the excretion of water) + ___ reabsorption of sodium and other ions -->with conservation of sodium and increased secretion of potassium, you increase water retention and have a higher plasma potassium concentration -->ALL OF THIS INCREASES ___ BECAUSE THE KIDNEY HAD LESS BLOOD AND SENSED ___ EVEN THOUGH IT WAS A HYPERTENSIVE ISSUE

Renin-angiotensin-aldosterone angiotensin aldosterone increases, decreases increases HTN HYPOTENSION

Physiologic Responses to acute exercise during pregnancy >Increased: oxygen uptake during WB ex, HR, SV, CO, tidal volume, minute ventilation, ventilator equivalent for O2 & CO2, >No change/decrease: ___ and ___ ***everything goes up except bp Exercise Prescription for Pregnancy >Consistent with healthy adults in absence of ___ >Modify according to woman's prior exercise history, symptoms, discomforts, and abilities across the time course of pregnancy >See Figure 7.1 for health screening tool for pregnancy

SBP, DBP complications

Exercise Testing >___ LIMITED testing is safe >Compared to healthy individuals, expect -___ peak HR, peak SV, and peak CO in response to exercise -Exercise tolerance reduced ___-___% >As a result, use an exercise test with low starting point and small increments

SYMPTOM Lower 30-40

Systems of Strength Training: none of these are THE way >___: 1 x 8-12 reps >___: 3 x 5-10 reps >___: 10 @ 55% 🡪 5 @ 75% 🡪 3 @ 90% >___: repeated sets for same muscle group (increase risk of injury if don't do it correctly) >___: 6-15 stations, 2-3 sets per station (BENEFIT = ___ in addition to strength conditioning) >Split routine: HARD to do with patients ->Mon/Thurs = chest, back, shoulders ->Tues/Fri = biceps, legs ->Wed/Sat = abs, triceps ->Benefit: rest specific muscles while exercising others; doesn't ___ >Fixed routine: (usually what we use for ___) ->MWF = same ex each day

Single set Multiple sets Pyramid Super set Circuit aerobic conditioning take as long HEP

Exercise testing >___ testing is usually okay >Use clinical judgment regarding subjective reports of ___ >Review PMHx and past level of ___ experience >Provide high levels of motivation and individualize test protocol as needed >Educate the patient on difference between post exercise ___ and normal fluctuations in pain and fatigue associated with fibromyalgia

Symptom limited pain exercise soreness and fatigue

Continued: >Effects compared to continuous moderate intensity exercise ->Greater improvement in ___ in patients with stable coronary heart disease and CHF ->Greater long term improvements in VO2peak in patients after CABG ->For all exercises (esp. HITT), ensure patients are not ___ (NO VALSALVA)

VO2peak holding their breath

Warning Signs to Stop Exercise during Pregnancy >___ or ___ >Shortness of breath prior to exertion >Dizziness, feeling faint, or headache (any signs of poor perfusion) >Chest pain >Muscle weakness >Calf pain or swelling >Decreased fetal movement >Preterm labor

Vaginal bleeding or amniotic fluid leakage

>ACE inhibitors -angiotensin converting enzyme (ACE) = converts ___ to ___ ->angiotensin 2 constricts vessels and increases ___ ->goal of ace inhibitors = block this conversion so less ___ therefore less vasoconstriction and decreased ___ -->this increases ___ to kidneys overall because less afterload ->Used in combo with other drugs because they only affect one part of the system ->Most end in ___ ->Used in treatment of ___, ___, and ___ ->Side effects: rash + **___- chronic is one of the biggest side effects that you see

angiotensin 1 to angiotensin 2 BP angiotensin 2 BP BF -il CHF, HTN, Kidney failure cough

Continued: See Table 9.1 and Table 9.2 for assessment tools >9.1 = fontaine classification (looking at severity of occlusion) 1 = ___ 2 = intermittent ___ (like angina for legs) -2a = pain onset > ___m of walking -2b pain onset < ___ m of walking 3 = pain at ___ 4 = gangrene/___ loss- most severe >9.2 = Resting ABI (systolic BP ankle-brachial index) > ___ = normal </= 0.90 = ___ overtime: decrease of resting ABI > ___ = significant progression *** post exercise *** >no change is normal >decrease of > ___ mmHg or >20% from resting ABI = PAD overtime: decrease of >0.15 = significant progression

asymptomatic claudication 200 200 rest tissue 0.90 PAD (poor blood supply to the leg) 0.15 30

Many health benefits associated with physical activity ->exercise = drug → more fit someone is the less ___ they have >Prevent DM related health complications, insulin resistance, T2DM >Improved ___ tolerance, increases ___ sensitivity, decreases ___ (want <7) ->don't need as much ___ to do the same thing (less accomodation for the patient) >Reduces ___ risk factors

complications glucose insulin HbA1C medication CVD

PNF >Combo of alternating ___ and ___ of agonist and antagonist through a designated series of motions >Requires a partner that is ___, may cause soreness, more time consuming Stretching Guidelines >Precede stretching with warm-up >Static stretching that exercises major muscle tendon units >Minimum of ___-___x/wk, ideally ___-___x/wk >Stretch to end range to point of tightness without ___ >Hold ___-___ sec, ___-___ reps each stretch

contractions and relaxation trained 2-3 5-7 discomfort 15-30 2-4

Exercise Testing >Hypertension is not an indication for ___ >Exercise testing recommendations vary depending on BP levels and other CVD risk factors >___ will blunt HR response to exercise and reduce max exercise capacity (except digitalis) >Diuretics may lead to ___ and ___ imbalances and can cause false positive tests

exercise testing Beta-blockers hypokalemia electrolyte

Exercise Prescription >Avoid ___ movements and high impact loading >Modify yoga/Pilates/etc to avoid excessive ___, ___, or ___ of spine especially in patients with very low bone density >Balance training ->Focus on quads, hams, glutes, trunk

explosive twisting, bending or compression

Pharmacological Agents >Alcohol -Classified as ->___ or ___ 🡪 energy ->antinutrient 🡪 interferes w/ ___ of other nutrients ->drug 🡪 due to ___ effect on CNS -Proposed Ergogenic Benefits ->Psychological effects 🡪 Calms nerves, reduces inhibitions and makes more alert ->Good carbohydrate source ->Reduces pain and muscle tremors

food or nutrient metabolism depressant

Anti-hyperlipidemic Agents (cholesterol patients) >Used in treatment of elevated ___ >Most have no effect on ___, ___, and ___ >Exception: ___ which elevates HR and BP and may cause arrhythmias Wrap Up >No matter what drugs people are taking, the risks of drug interactions increase dramatically as the ___ of drugs increases >Also consider OTC meds, vitamins, supplements!

serum lipids HR, BP, or ex capacity dextrothyoxine number

First thing you change in FITTVP: >in general, ___ is usually increased first until can do 20-30 minutes in a session ->once get good at this, we drop the time and increase the ___ >the longer the time and higher the intensity than the ___ the frequency

time intensity lower

Parkinson Disease >Common neurodegenerative disease often resulting in -Resting ___ -Bradykinesia -Rigidity -___ instability -___ abnormalities >Refer to ___ scale (Table 11.9) for staging (0-5 scale on severity of parkinsons) >Mainstays of treatment are ___ and ___

tremors Postural gait Hoehn and Yahr medication (Levadopa and Carbidopa) and exercise

Cross-Over concept: >point at which you start ___- still using both Training: >shifts graph to the ___- can burn fats longer before switch to carbs as the main energy source

using more carbs than fat right

>Easy to assess with ___ or ___ >Ultimate work: rest ratio has not been established for ___ >Cold environment will exacerbate the problem (causes ___) >___ training increases time & distance walked to initial onset of pain and to point of max tolerable pain >Increased pain-free walking time, distance and absolute walking ability all improve with exercise

walking test or on the treadmill PAD vasoconstriction Interval

Peripheral Arterial Disease really same process as coronary artery disease difference = difference is ___ >arthrosclerotic plaque builds up → ___ → limits ___ → difficult to get blood past ___ result = ___ changes due to lack of oxygen See Table 9.1 and Table 9.2 for assessment tools

where it happens stenosis vasodiation occlusion ischemic

Intensity Rx by VO2 >Target VO2 = ___ x ___ + ___ >What is target VO2 at 60% of VO2R with a VO2max of 30 ml/kg/min? ->Target VO2 = (30 - 3.5)(.60)+3.5 = 19.4 ml/kg/min VO2R Calculations >Once calculated, you can find work rate through metabolic equations or by selecting an activity with corresponding MET level >Problem: does not account for ___ (heat, humidity, altitude) and ___.

(VO2max - VO2rest) (ex intensity) + VO2rest environment hydration

More evidence at ___+ minutes a week for weight loss (150 minutes doesn't work well here).

250

>Expect low functional capacity, low peak HR >___ testing contraindicated (thought that they may have spontaneous avulsion fx) ->___ or higher recommended >Exercise training leads to: ->BP ___ ->Improved aerobic capacity, HR variability, muscular function, QoL >Kidney transplant recipients can initiate exercise soon after the kidney transplant once ___

1-RM 3-RM reduction cleared

Reasons to Discontinue Exercise >DBP > or = ___ mm Hg >Decrease in SBP > ___ mm Hg during exercise with increasing workload >Significant ventricular or atrial arrhythmias with or without associated ___ >Second or third degree ___ (atria and ventricle timing off- don't communicate properly and timing is off) >Signs/symptoms of exercise intolerance including angina, marked dyspnea, and EKG changes suggestive of ___

110 180 signs/symptoms heart block ischemia

Training considerations >May need to shoot for at least ___ minutes per week for maintenance of weight loss >Resistance training doesn't seem to result in significant ___, but it may be helpful in reducing ___ risk factors >Building metabolically active mass

250 weight loss CVD

What to do if Peak HR isn't known? → Use RPE to guide intensity > <___ (< ___on CR10 scale) is light or < 40% of HRR > ___-___ (___-___ on CR10 scale) is somewhat hard or 40-59% of HRR > ___-___ (___-___ on CR10 scale) is hard or 60-80% of HRR High Intensity Interval Training (HIIT) appears ___ and ___ for patients with cardiovascular disease >Involved alternating ___ min periods of exercise at 80-90% HRR with exercise at 60-70% HRR for approximately ___ minutes, 3x/week.

12 3 12-13 4-6 14-16 7-8 safe and effective 3-4 40

Exercise Prescription *Upper extremity strengthening and ROM should be restricted for up to ___ weeks due to median sternotomy *___ patients are denervated so they need a very long warm-up and cool down to elicit a response

12 Cardiac transplant

classes of hypertension normal >S = < ___ AND D = < ___ encourage lifestyle modification >no need for drug therapy preHTN >S = ___-___ OR D = ___-___ >NEED ___ >don't need drug therapy without compelling indications >NEED drug therapy if they have any compelling indications (previous heart concerns)

120 80 120 - 139 80-89 lifestyle modification

stage 1 >S = ___-___ OR D = ___-___ >NEED ___ >NEED ___ with and without compelling indications >drugs for ___ >drugs for ___ stage 2 >S >/= ___ OR D >/= ___ >NEED ___ >NEED ___ with and without compelling indications >drugs for ___ >multi-drug combo for ___

140-159 90-99 lifestyle modification drug therapy CI anti-HTN 160 100 lifestyle modification drug therapy CI anti-HTN

Static Stretching >Greatest change in flexibility in first ___ seconds → no additional improvement after ___ seconds >Optimal number of stretches per muscle group is ___-___ → No additional elongation with ___-___ reps >___ stretching generally safe for most population >Low injury risk, little assist or time, effective Dynamic Stretching >Uses momentum from repetitive ___ movements >Doesn't allow for stress-relaxation curve that takes some time → higher injury rate >More ___

15 30 2-4 5-10 Static bouncing muscle soreness

Energy Expenditure Goals >Net caloric expenditure due to interaction of intensity, duration, frequency >ACSM recommends ___-___kcal of energy expenditure from exercise per day >Lower end is ___kcal/wk which is assoc with ___-___% reduction in all-cause mortality ->Even if not losing weight, still getting ___ ->150 kcal/day or 1000 kcal/wk should be the goal for previously sedentary people >Recent evidence suggests ___ minutes per day may be needed for weight loss and control ->double the previous recs

150-400 1000kcal 20-30 healthy 60

HR ranges that correspond to mod intensity exercise for Low-Risk normal weight pregnant women and light Intensity Exercise for Low-risk overweight/obese pregnant women >Special Considerations -PA in supine should be avoided or modified after week ___ (increases pressure of venous system) -Avoid hot/humid environment, stay ___ -Metabolic demand increases by ~___ calories per day -Avoid contact sports/risks of falls -Avoid Valsalva maneuver, prolonged ___ and prolonged ___

16 hydrated 300 isometric contraction and prolonged standing

Overweight and Obesity >Overweight is BMI of ___-___ kg/m2 and obesity is ___ kg/m2 or greater (disease risk increases) >Approximately ___% of adults in the US are overweight or obese >Linked to CVD, DM, some forms of CA, musculoskeletal problems >Evidence suggests that weight loss of ___-___% can reduce CVD risk factors >Minimum goal of ___ min of exercise per week for weight loss (probably more)

25-29.9 30 68 2-5 150

Frequency (F) >ACSM recommends ___-___ days/wk ->Relates to improving or maintain VO2 max, not talking about ___. ->For athletes, may train daily so they don't lose skill ->At higher intensity, ___ days/week ->At lower intensity, ___ days/week >Increased rate of injury associated with training over ___

3-5 skill 3 5 6d/wk

Exercise Prescription: General Principles of Ex Rx >CDC, ACSM both recommend all adults accumulate ≥___ min of moderate intensity physical activity on most if not all days of the week (___ min as a minimum) ->Greater benefits (weight loss) with greater amounts of exercise (>___ min) >An exercise prescription specifies the mode, intensity, duration, frequency of training, and progression of physical activity (FITT-VP model) ->Ex. Walk at a level that you are breathing hard, but still able to talk, for 30 minutes every other day. Increase to 5 days/wk after 3 weeks.

30 150 250

ACSM Recommendations: >Most adults -Moderate (___-___% HRR or VO2R) to vigorous (___-___% HRR or VO2R) intensity aerobic exercise >Deconditioned -Light (___-___% HRR or VO2R) intensity aerobic can be beneficial- below training level of most people unless were bed-bound or ill >VO2R = diff btwn ___ and ___ >HRR = diff btwn ___ and ___

40-59 60-89 30-39 VO2max and resting VO2 (VO2reserve) maxHR and resting HR

Chronic Obstructive Pulmonary Disease (COPD) >___ leading cause of death throughout the world >Encompasses ___ and/or ___ >Cardinal sign is ___ resulting in PA limitations and deconditioning >Exercise is an effective intervention ->Effects seem to be adaptations in the ___ and ___ system that in turn reduce stress on the pulmonary system during exercise

4th chronic bronchitis and/or emphysema dyspnea cardiovascular and musculoskeletal

Cardiac Transplant >___ and ___ recommended after surgery to improve exercise capacity and QoL, restore bone density, reverse sarcopenia, and modify CV risk factors they have been sick and deconditions for years → very hard recovery process so have resistance and aerobic training to address all these issues >Concerns after transplant -Increased risk of vasculopathy, graft failure, cancer, hyperlipidemia, hypertension and diabetes

Aerobic and resistance training

2. Stimulus or Conditioning Phase >Includes ___ (endurance), resistance, and flexibility programming >Focus on one group over another depends on the individual's ___ 3. Recreational Activities (optional) >May be included during, or after endurance phase to increase ___ >Game rules can be changed to increase participation, reduce skill needed, etc. 4. Cool-down >Provides ___ from endurance/games phase >Exercise at lower intensity >___ of slower walking or jogging, cycling, and yoga, stretching >Get back close to ___

CR goals adherence gradual recovery 5 minute resting rate

Maintenance Stage >Goal is long term maintenance of ___ developed during improvement phase -dc from therapy and now on ___ program >Begins after participant reaches ___ >May no longer be increasing conditioning stimulus >New goals should be set @ this point >Goal of each participant should be to reach ___th percentile in all health related fitness parameters >To maintain CR fitness, ex rx should incorporate an intensity, frequency, duration consistent with long term goals -Should meet or exceed ___ thresholds -- regulates weight, HR, BP ect. >If further weight loss needed during this phase, caloric restriction + exercise should equal negative caloric balance of ___-___ kcal/day (1 to almost 2 lbs a week) >Provide variety of exercises, recreation, and enjoyed activities

CR fitness wellness fitness goals 50th minimum caloric 500-800

Continued: Improvement Stage >Provide a gradual increase in overall exercise stimulus to allow for significant improvements and adaptations in ___ (when we see adaptations/goals) >Participant progressed at more ___ rate >Typically lasts ___-___ months >Intensity progressively increased within the upper portion of the target range of 50-85% of HRR >Duration increased consistently, no more than ___% each week until participants able to exercise @ mod🡪vigorous intensity 20-30 minutes

CR fitness rapid 4-8 20

Testing Considerations >Due to age of most patients, ___ assessment may be warranted >Before exercise testing is performed, test balance, gait, strength, ROM, flexibility and general ROM >For advanced stages of PD or if unable to do a GXT, they may require a radionuclide stress test or stress echocardiography >Gait belt! Exercise Prescription >Goal of exercise is to delay disability, prevent secondary complications and improve QoL >Emphasize balance training as well as strengthening to promote proper posture >UE and trunk flexibility along with spinal/neck rotation and flexibility important >Music may be beneficial

CV

Risks of Amphetamines: Why shouldn't we all be on speed? -Mahoney >Increased stress on ___ ->Elevated ___ and ___ ->Trigger ___ in susceptible individuals >Don't delay onset of fatigue; delay ___ ->Dangerous! Athletes push beyond limit >they are also ___

CV system HR and BP arrhythmias sensation of fatigue Addictive

>Risks of Caffeine -___ 🡪 loss of water & Na ->blocks ___ receptors at kidney which leads to water and sodium loss ->Leads to ___ (acute) and ___ related illnesses ->study: 2-3 cups of coffee caused increased ___ in those who were used to it, but it does not affect those who are used to it -Nervousness, restlessness, insomnia, tremors, bladder irritant (bladder spasms) -Physically ___

Diuretic AD (adenosine) dehydration heat urine excretion addictive

Continued: Initial Conditioning Stage >___ warm-up period (10-15 min) >Moderate intensity aerobic activities (40%-60% of HRR) in interval format >___ intensity muscular fitness exercises - minimal muscle soreness, discomfort, injury >___ cool-down (10-15 min), mostly stretching >Stage may last ___-___ ->Depends on adaptation of individual >Duration may begin with ___ min (half of recommended dose) and progress to ___ of CV stimulus phase >For mod intensity, begin @ ___-___x/wk

Extended Low Extended 1-6 weeks 15 30 min 3-4

Continued: >Side Effects -___ and ___ imbalances ->Decreased ___, ___, and ___ (Could lead to MI) ->Likelihood of ___ increase -___ (low blood volume) -Loss of blood volume decreases ___ increases ___ -Most will report weakness & fatigue & occasional muscle cramps(Are they stable?)

Fluid and electrolyte Na, K, Mg arrhythmias Hypovolemia CO HR

Fatigue >___ = general sensation of tiredness and accompanying decrements in muscular performance ->the more resistance and cardiovascular training you do, the longer you can ___ >___ = body unable to keep up with demand & is not able to generate force to continue activity ->tend to stop ourselves at ___ vs. physiological fatigue

General put off fatigue Physiological general fatigue

Principles of Strength Training >Progressive Overload: ___ ->ex: lift heavier >Reversibility: ___ ->too much time in between bouts of exercise ->able to hold onto strength longer than endurance >Specificity: ___ ->Have to think about if it is: Velocity specific, train specific energy systems, recruit predominant fibers

Gradually increasing the workload to force the body to adapt to changes use it or lose it; you don't lose strength as soon as you lose endurance Degree to which the training specifies the activity

RPE to Determine Intensity >Usually as an adjunct to ___ methods >May be primary when unable to palpate pulse, or if HR response altered by ___ >___-___ on Borg scale associated w/ physiological/CV adaptations to exercise ->For 20 year old, 120-160 HR (60-80%)

HR meds 12-16 (120-160 HR range)

Exercise Testing for Children >Usually only if a health concern is present >If performed, similar guidelines as for adults assessment is similar: ___ and ___ >RPE is touchy unless old enough to ___ >May require extra motivation for ___ Physiologic Responses to Acute Exercise in Children Compared to Adults >Lower Response: (doesn't respond as quickly) ->Absolute ___ (raw number) Uptake (total VO2), ___, ___, ___, Tidal Volume (how much they breath in in one breath), Minute Ventilation, RER >Higher Response: ->Relative ___ uptake (VO2 relative to BW), HR, RR

HR and BP understand children O2 Cardiac output, SV, BP O2

Benefits of Cool Down Period >Attenuates circulatory responses >Return ___ and ___ to near resting values >Maintain adequate ___ 🡪 reduces potential for post-exercise hypotension + dizziness >Dissipates ___ >Lactic acid removal >Benefits of Cool Down Period >Reduced post-exercise ___ response 🡪 may reduce likelihood of harmful cardiac events

HR and BP venous return body heat catecholamine

Cardiovascular Meds *** beta blockers + calcium channel blockers + diuretics + vasodilators + ACE inhibitors *** >Brief Overview of HTN -BP = ___ -TPR increased with ___ -Blood flow through kidney is ___ -Kidney senses this as ___

HR x SV x TPR HTN reduced low BP

HR Reserve (Karvonen) >Resting HR is subtracted from ___ >Take % of HRR and add to RHR >Target HR range = ___ x ___ + ___ >Find HRR if RHR is 60, HRmax is 180 and goal is 60-80% ->Will have to do on test*** ->60% HR= ([180-60] x .6) + 60 = 132bpm ->80% HR = ([180-60] x .8) + 60= 156bpm >Karvonen Method more accurately depicts intensity relative to ___ >May be similar to Percent of HRmax method for some but is more closely linked to ___ for all fitness levels

HRmax ([HRmax-HRrest] x %intensity) + HRrest oxygen consumption VO2R

Continued: -Peripheral Vasodilators ->Used in ___ and some cases of ___ ->Produce smooth muscle dilation which decreases BP -- do this by the ___ same end results of nitrates

HTN CHF Radius effect

Osteoporosis > >54 million Americans with osteoporosis or low bone density > ___ increase risk of disability and death ->___-fold increase in all-cause mortality in 3 months after hip fracture in older adults >Evidence suggests exercise can delay onset of ___ and reduce ___ risk Exercise Testing >Normal procedures can be followed for testing, with several considerations -Cycle leg ergometry as an alternative for patients with severe vertebral osteoporosis -Multiple compression fractures can impact ventilatory capacity (fwd flexed kyphotic posture) -Max muscle strength testing may be contraindicated as there are no guidelines -Assess balance and fall risk

Hip fractures 5 osteoporosis fracture

Special Consideration - Hypoglycemia >___ is most common, acute concern for patients on insulin or other oral meds -Hypoglycemia (<___ mg/dL) is a relative contraindication to exercise -Rapid decrease in blood sugar can occur with ___ - patients may be symptomatic even with sugars above 70 mg/dL. Others may have low levels and not know it -Patients taking insulin or meds to increase insulin secretion should monitor glucose before, during (maybe), and after exercise (highest risk within an hour after exercise) -Hypoglycemia symptoms: shakiness, weakness, abnormal sweating, nervousness, anxiety, tingling of mouth and fingers, and hunger. More severe cases can result in headache, visual disturbances, mental dullness, confusion, amnesia, seizures, coma

Hypoglycemia 70 exercise

Training Specificity We have covered the basics of this one, but is there any carryover from different exercises? >Transfer of training effects: Some effects carry over to untrained limbs -___ VO2max and ___ submax HR -Evidence for central training >Suggested that about half of the increase in trained limb performance due to centralized training effect and half due to peripheral adaptations, specifically alterations in trained skeletal muscle -ex: pt with external fixator on the leg will still benefit from using UBE to keep up CV fitness

Increased reduced

Can use the ___ (Table 11.8) to classify level of disability of people with MS (0-10) >Minimal disability can follow FITT principle for ____ >As disease progresses, modifications will need to be incorporated >Other Considerations -Some medications cause ___ symptoms -___ is common, but improves with physical activity -Be cautious of ___ as some patients have bladder issues and may restrict fluids -Take measures to avoid ___

Kurtzke Expanded Disability Status Scale healthy adults flu-like Systemic fatigue dehydration hyperthermia

Spinal Cord Injury >Particular limitations and impacts on exercise linked to level of lesion -___-___ = lack voluntary control of bowel, bladder, sexual function but normal UE and trunk function remains -___-___= respiratory and motor control that depends on the functional capacity of the abs -___-___ = poor thermoregulation, hypotension, autonomic dysreflexia ->Heart rate often limited (115-130 bpm) due to lack of sympathetic innervation ->Breathing capacity diminished ->Normal arm function >___-___ = tetraplegia. Decreasing degree of arm function as lesion gets higher. Autonomic dysreflexia and orthostatic hypotension are concerns >___-___ = Vent support for breathing. Autonomic dysreflexia and orthostatic hypotension

L2-S1 T6-L2 T1-T6 C5-C8 C1-C4

Exercise Prescription→ ___ is very important >Recommendations similar to those for ___ >Goal is improvement of ___ fitness without joint damage >Small amount of ___ after exercise is normal. ->If pain ___ after exercise is higher than it was before exercise, reduce duration and/or intensity in future sessions ->Encourage exercise at time of day when pain is best controlled >Comfortable footwear, and incorporate functional activities >Pool therapy - water temp of ___-___℉ relaxes muscles and decreases pain yoga + tai chi: relaxation exercise for this group work really well

MODE apparently healthy adults cardiorespiratory discomfort 2h 83-88

Resistance Training in Pregnancy? >Limited data, but the data that does exist shows that compared to sedentary controls, resistance training has: AT WORST, IT SEEMS ___ & AT BEST, IT SEEMS TO BE ___ ->No effect: no difference in gestational age, preterm labor, or cesarean delivery ->OR Better outcomes: lower incidence of LBP, shorter labor duration, shorter recovery time/faster return to activity postpartum

NOT HARMFUL HELPFUL

Training Programs >___: max amount of weight that can be moved through a full ROM in a single repetition safely >Volume: How much ___ is done ->Calculated as: ___ x ___ x ___ ->ex: 3 sets of 10 reps with 20 lbs = 3 x 10 x 20 = 600 lb of volume >___: the load of the volume ->How hard you are working ->Represented as ___ >___: work per unit of time ->ex: 100 lbs: 4x25 or 2x50 ->same ___ of volume, different ___

One Rep Max work # sets x # reps x weight per rep Intensity % of 1 RM Power amount, intensity

Low Back Pain Considerations ___ Factors for Long-term disability and work loss associated with LBP (negative factors) -A negative attitude that back pain is harmful or potentially severely disabling >Fear avoidance behavior and reduced ___ levels >An expectation that ___, rather than active, treatment will be beneficial >A tendency to depression, low morale, and social withdrawal >Social or financial problems >Exercise Testing and LBP >Pain often leads to decreased activity resulting in decreased ___, ___, and ___ → deconditioning >Ex testing often symptom limited in first few weeks will be limited by pain long before limited by anything else >General recommendation is ___ testing for cardiorespiratory and muscle strength and endurance >Follow same guidelines as general population

Psychosocial activity passive endurance, strength and flexibility submax

Continued: >Proven Effects -___ VO2max, max vent capacity, submax and max HR, max CO, BP -Detrimental effect on ___ (run less) -Little effect on strength, power, local muscular endurance -Ergogenic (accuracy in shooting), ergolytic (endurance), no effect (power, strength) -More on Beta Blockers -In patients whose exercise capacity is limited by ___, beta blockers can improve ex tolerance ->Able to perform exercise vital to ___ -In patients not limited by angina, they will decrease ex capacity by limiting HR

Reduce endurance angina recovery

___ - The phenomenon by which your expectations of a substance determine your body's response to it. >Ariel and Saville (1972): 15 Male athletes; 4 months' train as hard as possible; 6 that make most gains will put you on steroid; gave placebo; ___% improvement after "fake steroids" >___ fold increase in rate of strength increase from the placebo!!*** ->pretty impressive (study was 48 years ago

The Placebo Effect 10 7.5

Determining Target HR >Direct Method: have a known ___ -plot measured HR against either measured VO2 or exercise intensity ->can also compare to ___ (useful with meds where HR response altered) -Allows for prescribing HR range below point of adverse signs or symptoms >Percent of HRmax (___ Method) -Uses a straight percentage of HRmax -Simple to compute, but ___ at low levels ->HRrest of 58 bpm. HRmax of 180bpm. ->Prescribing a cool down @ 30% HRmax yields a target HR of 54. -->This is below his resting HR!

VO2 RPE Zero to Peak inaccurate

Goal of exercise: >___: wide variety of exercises recruiting most muscle groups; goal it so make if fun and get them involved >___: focus on activity in question Designed to >Enhance ___ >Promote ___ (reducing risk factors for disease) >Ensure ___ during exercise participation

Vocational/recreational (wellness) Improve one activity (rehab) physical fitness health safety

Continued: Non-selective beta blockers affect both types of receptors >___ is responding not just heart >Will negatively affect an athlete >Beta 2 located in BVs, lungs, liver, skeletal muscle, intestines Proposed Ergogenic Benefits >Usually in sports where ___ and ___ could impair performance ->___ HR down, allows shooter to aim btwn heart beats >Enhance physiological adaptations to endurance training ->Chronic use increases the # of beta receptors - will allow for a bigger ___ response when drugs DC'ed 🡪 amplified NE effect

Whole body anxiety and tremor Slow sympathetic

Exercise Prescription >Precise prescription is hard due to variety of cancer ->Survivors should stay ___ during and after treatment >Use the FITT principles as a very broad guide as there is a large amount of ___ >Cancer ___ can be overwhelming, but evidence suggests improvement with aerobic exercise >Think safety - limit impact if bone mets, avoid water with in-dwelling catheters, immune suppressed, etc

active variability fatigue

Continued: >Frequency and magnitude of increments determined by how well participant ___ ***just guidelines- patient dependent >Increase ___ and ___ before increasing intensity -Once target duration and frequency reached, increase intensity by no more than ___% of HRR every 6th session as tolerated >More time should be given for adaptation in deconditioned individuals and elderly >Can use intervals or add one hard intensity workout per week until goal intensity achieved

adapts duration and frequency 5%

>Should always include an ___ component*** very important! >HIIT (up to ___% HRR) appropriate for some patients -VO2peak improved by ___% -Associated with reverse remodeling of left ventricle >Ensure the volume is ___, but consistently increased -For most patients volume should be 3-7 MET-hr per week → multiple time in hours per week time METS >Increase ___ and ___ before intensity >Add ___ when aerobic is tolerated (opposite from normal adult group)

aerobic 90 46 slowly duration and frequency resistance

Concerns specific to Down Syndrome >Low ___ and ___ (~50% of expected for age) >Low ___ >AA instability - ___ and ___ of the neck contraindicated >Skeletal muscle hypotonia and joint laxity is common ->Focus on muscle strength around ___ ->Very cautious with involvement in ___ >May need physician clearance for aquatics due to how common ear pathologies are

aerobic capacity and muscle strength HRmax hyperflexion and hyperextension major joints contact sports

Test Considerations >Those with ID, but not DS may not differ from their peers in ___ and ___ ->Muscle strength is usually ___ in this population >Those with DS usually have low ___ capacity and muscle strength and are often ___ >For DS, 220-age formula doesn't work ->Can use following formula to guide exercise. Not intended to be used for exercise prescription ->HRmax= ___(DS status) -->1 for DS ___ and 2 for ___

aerobic capacity and overweight/obesity low aerobic overweight/obese 210 - 56(age)-15.5 not present present

Vasodilators: >the less ___, the more the CO- less the heart has to work to pump the blood out >work at ___ >biggest problem- worried about ___, poor profusion leading to ___ and possible syncope ->ex. nitroglycerin- take and wait ___, should be better at this point, if not take another one, and a third if haven't gotten better- 10 min total, if not better, call doctor and possibly send to ER ->short term ->angina- usually happens often and symptoms are ___, it also goes away when they ___, and ___ usually helps

afterload smooth muscles orthostatic hypotension head 5 minutes producible rest nitroglycerin

Muscle Groups >Can be expressed as ___ (quads : hams) or contralateral groups (R biceps:L biceps) >Expressed in approximate ratio ___ quads:hams >Common Ratios ->PF/DF ___ ->Inv/Ev ___ ->Knee ext/flex ___ ->Hip ext/flex ___ ->Shoulder IR/ER ___ ->L-spine flex/ext ___ >Need to consider use of muscle groups with exercise program to get to that normal ratio >Training to improve ratios must follow general guidelines for designing resistance training program

antagonists 3:2 3:1 1:1 3:2 1:1 3:2 1:1

Risks of Alcohol >Poor source of CHO = ___ >Depressant effects dull ___ - not always a good thing! >Impaired psychomotor skills >Suppresses release of ___🡪 Increase urine production; Lower BP🡪___ >Causes peripheral vasodilation ->dilates blood vessels in the ___ ->because losing so much ___ through the skin, it increase risk of hypothermia in really cold environments (frostbite)

antinutrient pain sensation ADH Dehydration skin (flushed skin) heat

Dyslipidemia >Major risk for ___, affecting ~___% of adults in US >___, ___, and ___ all contributory >___ drugs are effective in treatment Exercise Testing >Exercise testing not usually needed for asymptomatic patient prior to ___ to ___ exercise >Use standard methods and protocols >Caution due to underlying CVD that may be ___

atherosclerotic CVD 30 diet, lifestyle, and genetics Statin light to moderate undetected

Exercise Prescription for LBP >Promote exercise and avoid ___ (subacute and chronic episodes) → PATIENT EDUCATION!! >Follow FITT for general population >Most favorable outcome when all of the following are addressed: -Psychological ___ -___ beliefs -Self-efficacy in controlling ___ -___ strategies

bed rest distress Fear avoidance pain Coping

Routine Risk and SYMPTOM Assessment for exercise: >Should be performed ___, ___, and ___, as deemed appropriate >Assessment should include: -HR -BP -Body weight -*Symptoms or evidence of change in ___ not necessarily related to activity (lightheadedness, dyspnea at rest, SOB, weight gain, ect.) -*Symptoms and evidence of ___ -Changes in ___ and adherence to prescribed medication regimen -___ and ___ surveillance

before, during, and after each exercise session status exercise intolerance meds ECG and HR

Bronchodilators >Used to prevent ___ in smooth muscle >Increases ex capacity by allowing oxygen to be utilized, but only in patients with ___ >No benefit to normal (can't go beyond your normal) >May affect ___ depending on mechanism

bronchospasm bronchospasm HR

Calcium channel blockers >AKA ___ or ___ >Calcium is generally excitatory (needed for contraction), so a calcium channel blocker is ___ -Block Ca dependent processes in vascular ___ and ___ -Selectively blocks ___ from calcium entry >Current calcium channel blockers all have similar mechanism, but diff degrees of effect >Reduce ___ and ___ -Treatment of angina, coronary artery spasm, HTN >Side Effects -No adverse effects result from coronary vasodilation, but resulting ___ produces symptoms: ->HA + Flushing + Orthostatic hypotension + Dizziness

calcium antagonists or blockers inhibitory smooth muscle and myocardial cells calcium transmembrane channels BP and HR peripheral vasodilation

Exercise Testing >Assessment should include ___, ___ before and after exercise, and ___ >If patient is on inhaled bronchodilators, use them ___ - don't wait for the emergency >Physician should be present if testing high risk individuals Exercise Prescription >Asthma meds can affect ability to use ___ variables >No exercise if in an exacerbation >Continue to monitor closely after exercise for asthma exacerbation, especially in high-___ environment

cardiopulmonary capacity, pulmonary function oxyhemoglobin saturation before testing HR allergen

Exercise Testing >Donor heart is ____ (lost sympathetic and parasympathetic control) -Without direct sympathetic stimulation, cardiac output is reduced ___-___% and ___ capacity is also reduced -Resting HR is high, but response to exercise is ___ -Will also take a long time for HR to return to normal -hard time ___ and ___ >Gradual exercise testing protocol recommended >Patient will not experience ___ symptoms (look for SOB, diaphoresis, ect.)********* Note that ___ not used to assess intensity due to denervation

denervated 20-35 exercise blunted warming up and cooling down anginal HR

Brief discussion of other selected diseases Arthritis >Leading cause of ___ in the US >Symptom limited exercise testing consistent with recs for healthy adults ->High intensity exercise (max stress test) contraindicated during ___ ->Select mode of exercise that is least ___ ->Be aware that ___ is probably going to impair max voluntary contraction

disability acute inflammation painful pain

Ex Rx should be based on person's response to exercise including: >HR, BP, RPE, ECG (when indicated), VO2max- least used (measured or *___) Prescription Objective >GOAL = Change in personal health behavior to include ___ >"The art of exercise prescription is the successful integration of exercise science with behavioral technique that result in ___ compliance and attainment of the individual's goals" ->Find what works for the pt/client

estimated habitual physical activity long-term program

Pulmonary diseases Asthma >Good evidence that pulmonary rehab is effective for a variety of pulmonary diseases, including asthma (see Box 9.9 for list of diseases) >Currently, no ___ exist for exercise training in patients with asthma >asthma = ___ >Symptoms are variable and often ___*** >___ is extremely helpful for exercise in asthma patients

evidence based guidelines Chronic inflammatory disorder of the airway reversible Water

>Risk is higher during and immediately after ___, but can occur up to ___ after exercise -Monitor ___ frequently >___ drugs and other compounds that enhance insulin secretion increase risk of hypoglycemia ->Monitor glucose frequently >___ of exercise is especially important for people taking insulin ->Early morning exercise may lead to elevated blood glucose levels instead of usual decrease with moderate activity careful exercising late at night → can cause hypoglycemia at night while ___ >Exercise with a ___ >Postpone exercise if hyperglycemic (≥ ____ mg/dL) Other Considerations Read pages 273-275 for further discussion on considerations including neuropathy, nephropathy, dehydration

exercise 12h glucose Sulfonylurea Timing asleep partner 250

Training Considerations >Adjust ___ according to changes in meds, nutrition, adverse events, etc >Maintain SBP ___ mm Hg and DBP ___ mm Hg when exercising ->never ___ if at these levels ->these are the ___ you can go to during exercise >Vigorous exercise is not contraindicated, but the general recommendation is ___ intensity >___ can lead to extremely high BP, dizziness, and fainting and should be avoided

exercise 220 105 start max moderate Valsalva maneuver

Pregnancy >Healthy women without contraindications are encouraged to ___ throughout pregnancy Benefits of Exercise during Pregnancy >Prevention of excessive gestational ___ and gestational diabetes mellitus >Decreased risk of ___ (HTN and organ damage) >Decreased incidence/symptoms of LBP >Decreased risk of urinary ___ >Prevention/improvement of depressive symptoms >Maintenance of fitness >Prevention of postpartum wt retention

exercise wt gain preeclampsia urinary incontinence

Exercise Testing >more often than not, someone will have an ___ before entering cardiac rehab >___ limited, using standard exercise procedures >Test should be completed while the patient is stable on guideline-based medications ->Timing of beta blockers with respect to exercise test is important >May occasionally see someone in cardiac rehab without an exercise test (___ issue)

exercise test Symptom insurance

Multiple Sclerosis >Generally report lower ___ and higher ___ compared to persons without MS >Possibly due to deconditioning, lower rates of physical activity, and higher energy cost of walking >Individuals with MS generally have low maximal aerobic capacity (<___% predicted peak VO2) and blunted HR and BP responses to exercise >Aerobic exercise improves peak VO2 in mild-to-moderately disabled Exercise Testing >Review meds, PMHx and conduct functional assessment prior to exercise testing >Common functional tests include: ->6-minute walk (endurance) ->Timed 5 rep sit to stand (strength) ->Time 25-meter walk (gait speed) ->Berg (balance) ->Dynamic Gait Index (dynamic balance) >No testing during acute exacerbation >Test ___ in the day in climate controlled environment >Use ___ in addition to HR bc HR might be blunted >Cycle ergometer preferred- requires less balance and coordination compared to treadmill

exercise tolerance perceived fatigue 60 early RPE

Outpatient Cardiac Rehab Goals for outpatient cardiac rehab >develop and assist the patient to implement a safe and effective ___ and ___ physical activity program >provide appropriate ___ to detect change in clinical status >provide ongoing surveillance to the patient's ___ in order to enhance medical management >return the patient to ___ and ___ activities or modify these activities based on patient's clinical status >provide patient and spouse/partner/family ___ to optimize secondary prevention (risk factor modification) through aggressive lifestyle >management and judicious use of ___ medications

formal exercise and lifestyle supervision and monitoring health care providers vocational and recreational education cardioprotective

Chronic kidney disease >Categorized by the ___ ->G1-G5: G score goes up, increased ___ of abnormal kidney function ->G1 = >___ → normal filt rate ->G5 < ___ → kidney failure >Affects about ___% of adult population >CVD, HTN, DM common in this population >Exercise testing will require medical clearance >For patients on dialysis ->Perform testing on ___ days ->Take BP in arm that doesn't contain ___- absolute contraindication

glomerular filtration rate (GFR) severity 90 15 10 non-dialysis A-V fistula (shunt)

Components of the Training Session (4 basic parts) 1. Warm-up ->purpose = ___, don't want a jolt to the system ->Facilitates transition from rest🡪exercise ->Stretches ___ muscles ->Augments ___ ->Elevates body temp ->Dissociates more ___ ->Increases metabolic rate ->May reduce risk of musculoskeletal injury -->Due to increased connective tissue extensibility, improved joint ROM and function, enhancing muscular performance

gradually reach working rate postural blood flow oxygen

Exercise Prescription >Prescription very similar to ___ >Major emphasis on maintaining a healthy ___ -___ activity is the mainstay of the program -Intermittent exercise of shorter bouts for those that can't do 30-60 min continuous >If over age ___, follow the older adults guidelines

healthy adults weight Aerobic 65

>Prevention ->Potentially reduce risk of ___ related problem due to sudden onset of strenuous exercise >___ of low intensity large muscle activity (10-30% VO2R) progressing to an intensity @ lower limit prescribed for endurance training ->___ is the oxygen uptake reserve >Stretching after initial large muscle warm-up phase

heart 5-10 minutes VO2R

Indications: >stable Contraindications: >unstable or uncompensated ->often people are just unready yet ->Ex. can regulate and make angina stable and then can work with them Aerobic >Frequency is often ___ because doing low levels at first Flexibility >not well planned out

high

Designing a Periodization Plan >Preparation Phase- preseason/ early season, base building ->Volume = ___ (running or lifting a lot) ->Specificity (technique) = ___ ->Intensity = mid-range >First Transition - approaching end of season ->Point at which ___ of intensity and volume occurs ->Volume ___ ->Intensity ___ ->Specificity ___

high low crossover declines increases increases

swimming is good for people with asthma because of the ___ and the pressure of the water helps gets the air ___ (which is the main problem with asthma) and breathing out underwater helps open up the airways IF THEY ARE IN AN EXACERBATION, YOU WILL NOT ___OR ___ >be careful in high ___ environments- can be a trigger

humidity out of the lungs EXERCISE THAT PERSON OR START A PROGRAM allergen

CVA >Consider patient's ___ when choosing exercise testing procedure >Always avoid ___ to avoid increasing BP >Consider harness or partial ___ if possible

physical limitations Valsalva unloading

Individuals with CVD Risk Factors Diabetes >Characterized by ___ due to impaired insulin secretion or inability to use insulin > 1 → can't ___ insulin > 2 → can't ___ glucose or use ___ appropriately >Elevated glucose levels increases risk of: ->___ disease (supply nerves and blood vessels) ->___ disease (larger blood vessels when disrupted can lead to amputation) ->___(important for mode of exercise)

hyperglycemia secrete take up insulin Microvascular Macrovascular Peripheral neuropathy

Special Considerations: >Strength training is safe with proper ___ and ___ >Immature ___ systems ->Caution with heat/humidity, maintain hydration- they overheat very easily >Children with ___ (CP, asthma, obesity, etc) should follow guidelines specific to their condition >Decrease ___ activity and promote ___!!!

instruction and supervision thermoregulatory diseases sedentary exercise

Treatment: simple - it's a muscle so you just push it to its limit and back off over and over and over >FITT is not that different except for how they measure ___ claudication pain scale (0-5) 0 = ___ 3 = ___ 4 = ___

intensity no pain intense pain where pt. attention can't be diverted excruciating pain

Exercise Prescription >Encourage higher ___ (safely) as it yields higher benefit >For mild COPD, can follow guidelines for ___ >For moderate to severe intensity representing > 60% of peak work rate recommended >Can use ___ scale for dyspnea instead of work rate (see Figure 9.1) → 0-10 scale based on SOB >Use of % of estimated HRmax or HRR may be inappropriate

intensity healthy older adults Borg scale

Antihypertensive meds: >Diuretics ->work at the ___ ->ex. lassicks ->usually very safe in normal ranges- low does it work ->directly decreasing ___ ->with potassium imbalance, we are most worried about the ___

kidneys volume (PRELOAD) heart

Exercise Testing >Patients with DM or prediabetes who are asymptomatic for CVD and low-risk generally okay to perform ___ to ___ intensity without exercise testing >ECG stress testing may be warranted for DM patient, particularly those who have been ___ and want to do vigorous intensity activities if they have been sedentary, you don't know how the ___ will respond >DM → autonomic neuropathy → ___ often undetected ->Annual ___ risk factor assessment should be conducted

light-to-moderate sedentary heart Silent ischemia CVD

HR for Measuring Intensity >HR works well due to ___ between HR and VO2 >Currently, ___ and ___ most common for measuring intensity >Issues with max HR equations: -Large standard errors of ___ (for 220-age) -___ specific work better in that pop -Certain ___ (beta-blockers) preclude use of HR equations- HR doesn't correlate to workload anymore ->Use RPE to determine how they are doing -Actual maxHR is specific to ___ -The best way is to obtain actual max HR through ___ -Goal is to maintain HR in ___ of prescribed range >Several equations exist for predicting max HR (Reproduced here from Table 6.2): -Won't be tested on, for our info only

linear relationship HR and RPE (6-20 scale) estimate Population meds mode of exercise max exercise test midrange

Special Training Considerations >Start at ___ level, progression is individualized (START LOW AND GO SLOW) >___ training important in this group >___ training especially beneficial (aspect of fitness that declines most rapidly; decreased power and most common with falls) ->Single and multiple joint exercises (1-3 sets, 6-10 reps @ 30-60% 1-RM, high velocity) >___ → need to work on strength before aerobic training can occur (muscle mass focus) >Encourage ___ intensity PA in those with cognitive decline >___ period important- need more time to attenuate the change because transition points are the most dangerous

low Strength Power Sarcopenia moderate Cool down

Exercise Training >No test usually needed prior to ___ to ___ exercise programs >Consider timing of meds for ___ (beta blockers, antidiabetic meds) >Musculoskeletal issues with weight bearing? OA → consider NWBing alternatives >Low initial ____ and small increments per testing stage recommended >START ___ AND KEEP GOING ___ >Equipment considerations >Weight limits for equipment >Proper size BP cuffs

low to moderate comorbidities workload SLOW SLOW

Exercise Testing While Pregnant >Maximal exercise testing should not be performed unless ___ >If done, only done after contraindications ruled out and under MD supervision >Most results will be skewed, making use of submax tests to predict max capacity less ___ >Works best to determine ___ rather than accurate estimation of aerobic power >if person is already exercising before pregnancy, they should exercise at a similar ___ as long as safe ***look at picture for absolute and relative contras

medically necessary effective training effectiveness intensity

Special Considerations >Medical supervision needed for exercise testing and vigorous exercise for patients with HTN at ___ to ___ risk of cardiac complications >Be cautious for sudden excessive reductions in ___ after exercise for those on meds

moderate to high BP

Determinants of Strength >Central/Neural Factors: -># of ___ → more you have more force you can produce due to more cross bridge formation ->___ of motor unit ->___ of firing (twitch → summation → sustained contraction) ->order of recruitment (___ to ___ muscle fibers=b/c more efficient) -- Reversed with ___ ->Decreased ___ influence ->Increased ___ influence

motor units size frequency small to large e-stim antagonist synergistic

Key Components (examples, not specific guidelines) >Order of exercise: ___ before ___ and ___ before ___ (this is for safety- don't wear out small muscles before do big WB movements); ___ activity last. ->safety → not wearing out the muscles before doing the more dangerous exercises ->Ex. Squats before knee extension >Intensity: ___ sets x ___-___ reps (% weight/how long) >Frequency: ___x/wk >Recovery: ___-___ min between sets

multi-joint before single joint large group muscle before small group muscles sport specific 3, 5-10 3 2-3

Single vs. Multiple Sets >Inconclusive data (depends on goal) >For the most part, depends on your goal ->Maximize potential - ___ (once they get stronger, increase to multiple sets) ->General conditioning - ___

multiple single

Exercise Testing >Select a mode that allows for largest possible ___ to be used >If using a wheelchair, use norm-referenced data for that ___ >After max exertion with tetraplegia look for signs of ___ ->Treat with rest, leg elevation, fluids, recumbency ***frequency is at least a couple times a week

muscle mass population post-exercise hypotension

Flexibility Exercise Prescription >Stretching = systematic elongation of ___ to create a persistent length of the muscle and a decrease in passive tension -gained ___ but lost just as ___ -Stretching believed to have ___ effect so needs to be done often (daily) ->can be done safely every day as compared to ___ and ___ training -static stretching generally safe for most population

musculotendinous units quickly quickly transient CV and strength

Proven Effects >Acts primarily as a ___ when ingested chronically ->Heart doesn't work as it should (___) >May provoke arrhythmias by depressing ___ >Does not alter resting or ex EKG, but may lessen pt's symptoms of ___ (lack of O2) ->Due to ___ (vasodilation=increases blood flow) >*** NO ERGOGENIC (GOOD) EFFECTS ON ___, ___. ___, ___, OR ___ *** >does not make you more ___!!

myocardial depressant heart arrhythmias SA rhythm angina relaxation STRENGTH, POWER, SPEED, LOCAL MUSCULAR OR CR ENDURANCE alert

Anti-arrhythmic Agents Classified by their electrophysiologic effects >Class I: -___ (depresses myocardium of the heart) -___ effect -- happening directly in the heart ->Decrease conduction velocity, excitability, and automaticity ->control arrhythmias >Class II, III, IV: -___ effect -- works outside the heart itself ->Decrease HR by suppressing ___ on heart- myocardium is never stimulated *Side effect of all AAA include excessive myocardial ___ and precipitation of ___ >By decreasing ___

myocardial depressants Intrinsic Extrinsic sympathetic activity depression CHF contractility

Fibromyalgia Characterized by: >Chronic widespread ___ >Generalized sensory ___ >Diffuse multiple tender points >Fatigue >Poor ___ >Morning stiffness >Memory impairment >Psychological distress >Thought to be a result of ___ and ___ >No signs of ___ or ___ abnormalities and they don't develop deformities >General deconditioning linked to inactivity as a result of widespread pain

nonarticular pain hypersensitivity sleep aberrant central pain and sensory processing acute inflammation or muscle tissue abnormalities

Beta Blocker Actions: >Prevents binding of ___ >Reduces the effect of the sympathetic nervous system 2 SUBTYPES: >Β1 receptors are ___ >B2 receptors are ___ Beta 1 blockers "___-selective" (used more for an athlete b/c just cardio affects) >Located mainly in the heart >Decreases ___ and ___ >Decreases ___ needs of heart ***non-selective has a greater affect (type II) but we usually want a selective (type I)

norepinephrine stimulatory relaxatory cardio HR and contractility oxygen

Training and Fatigue >Training for endurance and strength delays ___ ->Will still get fatigued if stress high enough >Benefits specific to type of training and method that endurance is measured ->Fatigue can be muscular, cardio, pulm, etc. ->___ principal

onset of fatigue SAID

Exercise Training Considerations >Most are ___ and have increased CVD risks keep ___ in mind which can lead to joint pain and overheating → ___ is good option >Encourage ___ training unless contraindicated ->Careful, monitored progression is important as they often have limited joint ___ >Completing ___ training prior to aerobic training may lower risk of hypoglycemia in T1DM- if do aerobic first may be completely fatigue and may not be able to do aerobic >___ training is good, but not a substitute for other forms of exercise (doesn't affect glucose, insulin, ect.) >Potential complications may affect appropriateness of some activities ->E.g. avoid weight bearing with a diabetic foot ulcer ->Risk of ___ event post exercise

overweight obesity pool resistance mobility resistance Flexibility hypoglycemic

ACSM Guidelines for resistance training (ACSM pg 168) >Comfortable through ___ >___-___ separate exercises >1 set of ___-___ reps ->Only increase by ___-___% each time ->___ is the longest you should go without changing the program ->Use a certain weight until you can build up to ___ reps, then increase weight and start over at 8 reps >Exercise ___-___x/wk >Sidenote: save ___ and ___ for last to save postural control during routine

pain free ROM 8-10 8-12 5-10 6 weeks 12 2-3 abs and back

Nicotine Continued: >Proven Effects -Detrimental to ___ -Cigarettes: lower ___ -Cigarettes and smokeless tobacco: ->decreased ex tolerance: Increased HR, BP, autonomic reactivity, vasoconstriction, ↓ peripheral circulation, increased secretion of ADH and catecholamines, increased blood lipid levels, plasma glucose, glucagon, insulin, and cortisol >More on Smokers -respiratory infections- paralyzes ___ which sweeps particles from getting into lungs -Leads to ___ -Raises blood cholesterol levels and promotes ___ 🡪MI, CVA -2x risk of ___; main risk for ___ -Impaired peripheral circulation ->Major factor contributing to ___ ->Frostbite in cold weather athletes due to less ___ to peripheral tissues

performance VO2max cilia emphysema atherosclerosis heart attack sudden cardiac death PVD BF

Cardiac, Peripheral & Cerebrovascular Disease Inpatient Cardiac Rehabilitation >Medicare and most insurance covers cardiac rehab for: ___ myocardial infarction, ___ coronary syndrome (described as chest pain), coronary ___ (stent or bypass), ___ angina pectoris (very reproducible chest pain), heart valve replacement or repair heart failure with reduced ejection fraction heart transplant ->mostly anything acute/recent

recent acute revascularization stable

Vasodilators >Nitrates -Act by directly ___ (Aspirin times 100) -Vasorelaxation (dilation) allows coronary perfusion, decreases ___ ->Converts to ___= POTENT VASODILATOR ->During Heart attack, chew 1 adult aspirin -Arteriolar dilation decreases systemic vascular resistance and arterial BP -How does dilation relate to Pouiselle? R bigger= less ___ (more flow) -No ___ effect on ability of heart to contract -May improve contractility by: ->Reducing resistance to emptying (___) -->Increases ___ (more flow) ->Improving perfusion 🡪 opening more vessels -Side Effects ->___ due to drop in systemic BP ->___ due to cerebral vascular dilation ->Flushing sensation in limbs ->Can build a ___

relaxing smooth vascular muscle angina nitric oxide (NO) resistance direct afterload dilation Postural hypotension HA tolerance

Angiotensin: >Work through ___ system >works to ___ >works at the ACE Calcium, Blockers also work on smooth muscle like vasodilators

renin-angiotensin system maintain BP

>Inpatient program is usually brief and is focused on: (usually short to get up on feet able to do ADLs) -Current clinical status assessment -Mobilization -Identification and provision of information regarding modifiable ___ and ___, diet, smoking, salt intake, ect. -Discharge planning with a home PA and ADL plan and referral to ___

risk factors and self-care outpatient cardiac rehab

Intellectual Disability and Down Syndrome: Intellectual Disability >PROBLEM = not good historians of PMH >Exercise testing generally ___, with ___ risk apparently not different from general population >Recommend a full health screen prior to beginning an exercise program >May require more than one staff member to ensure ____ >Population specific formulas exist to assess exercise >___ may be difficult due to coordination of pedaling

safe CVD safety Cycling

Exercise Testing >Most older adults don't require exercise testing prior to starting a moderate intensity PA program >If testing is done, note the higher ___ and lower ___ of EKG in this population higher sensitivity → ___ lower specificity → ___ ->Many more false-positives >No additional test-termination criteria than general, but it is more likely that a test will need to be ___ in this group

sensitivity specificity identify those who have heart conditions but also might identify people who don't (false positive) identifying people who don't have heart conditions as having them stopped

Special Testing Considerations >Start ____, and increase in ___ increments (e.g. modified Naughton treadmill protocol) >___ may be more appropriate for many people - balance, coordination, vision, impaired gait pattern, WB limitations, other ortho problems ->___ muscle fatigue (specificity -- not due to training this way) with cycling may lead to early test termination >Influence of ___ ->___ (blunt HR response), other things that cause orthostatic hypotension or low blood pressure (diuretics), and multiple drugs at once (balance and hydration issues)

slow, small Cycle Local prescription meds beta blockers

Caffeine >One of most widely used drugs in the world >CNS ___ >Proven effects -Similar to ___, but weaker -Has been shown to increase ___ (speed-like) in athletes, and reduce ___ in fixed distance workouts ->Ex: Faster time on 2 mile run -Questionable benefit for ___ and ___

stimulant amphetamines endurance time sprints and strength

Cocaine >CNS ___, sympathomimetic ->Similar effects to ____ >Masks ___, creates ___ >No evidence to support cocaine as an ergogenic aid >Risk far outweigh any possible benefits >Given people with chronic nose bleeds (liquid form in the hospital) in the hospital because it is such a potent ___****

stimulant amphetamines fatigue euphoria vasoconstrictor

Marijuana >Acts on CNS to elicits both ___ and ___ effects >Ergolytic ->Impairs ___ coord, fast rxn time, ___ coord, tracking, perceptual accur. proposed benefits = ___ and ___ Nicotine >this is a ___ >Includes cigarettes, chewing tobacco, snuff, compressed tobacco >Proposed Effects -Some athletes claim increased ___ and ability to ___, yet also more calm ->Body is addicted so that's why you get calmer when you get it -Weight Control? Questionable; don't have cig in hand → ___ (oral fixation)

stimulatory and depressant hand-eye motor Relaxation, euphoria Stimulant alertness, concentrate eat more

Resistance Training: Resistance Training Programs → trying to promote ___ >Strength = the ability of muscle to ___, measured many different ways >Clinically - ___, ___ >Community - ___, ___

strength exert force isometric, MMT dynamic, 1RM

Continued: >If aerobic activities are limited by ___ and ___, those should be addressed first >___ good for ID (not DS) -Flexibility and strength as well as social interaction -DS need to ensure no ___ >Consider motor control/balance issues

strength and endurance Yoga AA instability

Muscle Balance = relationship of ___ of one muscle to another >in terms of left vs right and agonist vs antagonist >Adequate ratios of ___ around joints >Limited data on injury prevention and performance

strength/endurance strength

Sympatholitic: >Beta Blockers ->work at the ___ and ___ ->___ the sympathetic response and heart rate ->decreases workload by decreasing the blood through the heart- good if have a really high BP ->___ for people with heart dysfunction but ___ for normal people ->this drops max heart rate so this decreases ___- max HR decreases 20-30 and it takes a long time to get to HR you are aiming for ->___- good way to measure exertion ->as PTs, we are worried about ___ >Alpha Blockers ->prevent ___ ->addressing P...'s law ->if decrease this, we decrease blood pressure ->also affect the ___ and ___ Often time- alpha blockers are combined with ___

sympathetic system and heart decreases ergogenic ergolinic exercise tolerance RPE orthostatic hypotension vasoconstrictions sympathetic nervous system and heart beta blockers

Hypertension >different than HBP >HBP = ___ >hypertension = ___ >Resting SBP ___ mm Hg and/or resting DBP ___ mm Hg on 2 separate days >Or people on ___ meds for BP control >Treated with diet, exercise, and meds >Many people on multiple meds ->Be aware of which meds will alter exercise responses

symptom constant HBP 140 90 antihypertensive

Exercise Prescription >Progression depends on ___ >Provide plenty of ___ >Minimize ___ exercise, especially during a flare up >Focus on realistic goals >___ and ___ have been shown to be effective

symptoms rest eccentric Tai Chi, yoga

Continued: >Competition Phase - Trying to peak for race day/ championship ->Volume declines further (___) ->Intensity ___ ->Specificity ___ ***competition phase may be skipped depending on what you're doing >Second Transition -- Active rest/post competition or season ->Volume ____ ->Intensity and specificity lower than peak, but will be higher than volume perpetual active recovery stage

taper peaks peaks at lowest point

Special Considerations >Use of bronchodilators for those with airflow limitations may improve exercise ___ and reduce ___ >Supplemental O2 indicated for patients with PaO2 ≤___ mm Hg or SaO2 ___% on room air -For those already on oxygen, may need to increase ____ during exercise- it is okay to exercise if already on oxygen >Hold exercise for patients in a pulmonary exacerbation until symptoms have ___

tolerance dyspnea 55 88 flow subsided

Intensity (I) >Intensity and duration determine ___ of training session -Are ___ related -Low intensity/high duration= health benefit (whats prescribed for most of our pts) -High intensity/low duration= improved ___ fitness for people that can tolerate it; also higher ___ rate so be careful who you prescribe to >___ to ___ exercise with longer duration (>20 min) good for most people -Deconditioned may need ___ to ___ >___ intensity/___ duration (<10 min) can improve VO2max -Highly motivated, apparently healthy, asymptomatic

total caloric expenditure (effort) inversely CR injury Mod to vigorous low to mod High/low

Review of a false positive, false negative, true positive, true negative: >___- got a positive result and it correlates with what is actually present >___- got a positive result but it does not correlate with what is actually present, ex. positive mammagram when no cancer ->very sensitive but not specific >___- get a negative result when what you are looking for is actually present >___- get a negative result when what you are looking for is actually not present *Highly sensitive test- more likely to get ___, a lot of tests are like this so don't miss anyone, rule in or out with additional testing SpPin and SnNout

true positive false positive false negative true negative false positives

Exercise training considerations >Frequency is somewhat ___ >Even short (<___ minutes) bouts can be a good starting point >goal for phase 2 cardiac rehab = ___-___ (however, do whatever they can to build up) >Encourage patient to exercise independently in addition to therapy >If patient has an ischemic threshold (reproducible point when patient begins having angina), upper limit of intensity should be at least ___ beats below that threshold >Exercise testing may need to be repeated if meds dose changes, or symptoms change >Be aware of volume depletion, hypokalemia, or orthostatic hypotension with patients on diuretics ***___ isn't added until out-patient

variable 10 20-60 10 Resistance

Continued: >Proven Effects -Lead to significant ___ ->"___" for Jockeys, wrestlers, gymnasts, Anorexics and bulimics ->"___"- flush things out of system faster 🡪 drug tests -No evidence supports other ergogenic effects ->No effect on ex capacity -Side effects are ergolytic → ___ decreases, SV decreases, decreases CO and therefore decreases performance in athletes, etc

weight loss Ergogenic Masking aerobic capacity