Exercise Prescription Test #3

What is used as the bypass graft?

1.Internal mammary artery 2.Radial artery 3.Saphenous vein (most common)

Hemorrhage

Excessive Bleeding •Ruptured Cerebral Artery •Can be caused by HTN, Head Injury or Aneurysms bleeding occurs inside or around brain tissue

Which artery is most commonly occluded in a stroke?

Middle cerebral artery - because when the clot travels up it's a straight shot and gets stuck easier

Flexibility: Volume Older Adults

Older adults can benefit from holding the stretch for 30-60 s.

T

Time (duration or how long)

V

Total Volume (amount)

Ty

Type (mode or what kind)

walking equation

VO2 = 3.5 + (0.1) (speed) (26.8) + (1.8) (speed) (26.8) (grade)

Dynamic or slow movement stretching

involves a gradual transition from one body position to another, and a progressive increase in reach and range of motion as the movement is repeated several times

VO2R method

target VO2R = [(VO2max - VO2rest) x % intensity desired + VOrest

FITT Recommendations for Outpatient Programs Intensity

Exercise intensity may be prescribed using one or more of the following methods: •Based on results from the baseline exercise test, •40%-80% HRR or VO2R or VO2peak •Without an exercise test... •HRrest +20-30 beats/min •RPE of 11-16 on a scale of 6-20 (6) •Exercise intensity should be prescribed at a HR below the ischemic threshold •If peak HR is unknown, the RPE method should be used to guide exercise intensity using the following relationships: •<12 (<3 on CR10 Scale) is light or <40% of HRR •12-13 (4-6 on CR10 Scale) is somewhat hard or 40%-59% of HRR •14-16 (7-8 on CR10 Scale) is hard or 60%-80% of HRR

F

Frequency (how often)

Aerobic: Volume

Frequency x Intensity x Time •A total EE of ≥500-1,000 MET-min ∙ wk−1 is a reasonable target volume for most adults. •Associated with lower rates of CVD and premature mortality. • •MET-min: METs x min

Cardiac Rehabilitation Phases Phase 1

Inpatient, after event or surgery in hospital patient period

I

Intensity (how hard)

If a patient with a sternotomy cannot push or pull... how do they get out of bed?

Log rolling or raise the head the bed high enough for them to swing the legs off of the side

P

Progression (advancement)

Flexibility - pregnancy Time and Type

T: •Static stretch, 10-30 sec. Ty: •Static and dynamic

What is vo2R?

VO2 max - VO2 at rest (3.5)

PCA (posterior) stroke

facial

Stepping

hc: 0.2 x steps vc: 1.33 x (1.8 x step ht x step/min)

Walking

horizontal component: 0.1 x speed vertical component: 1.8 x speed x grade

Active static stretching

involves holding the stretched position using the strength of the agonist muscle as is common in many forms of yoga

Static stretching

involves slowly stretching a muscle/tendon group and holding the position for a period of time (i.e., 10-30 s). Static stretches can be active or passive

ACA (anterior) stroke

lower extremity is always probably or typically have more impairment in LE

Aerobic: Type The specificity principle states

that the physiologic adaptations to exercise are specific to the type of exercise performed. Other exercise and sports requiring skill to perform or higher levels of fitness are recommended only for individuals possessing adequate skill and fitness to perform the activity.

Muscular Fitness: Frequency CONT

•All muscle groups to be trained may be done so in the same session (i.e., whole body), or each session may "split" the body into selected muscle groups so that only a few of groups are trained in any one session. •LEs - Monday, Wednesday •UEs - Tuesday, Thursday

hyperthermia •Sweat loss varies

•Amount and intensity of PA, clothing, environment, etc.

O2 Sat - altitude sickness

•Assessing individual altitude acclimatization status •Measurement of SaO2 by noninvasive pulse oximetry is a very good indicator of acclimatization. •Pulse oximetry should be performed under quiet, resting conditions. From its nadir on the first day at a given altitude, SaO2 should progressively increase over the first 3-7 d before stabilizing.

General Considerations for Exercise Prescription Bone health

•Bone health is of great importance to younger and older adults (see Chapters 8 and 10), especially among women.

What is a pacemaker?

•Controls the abnormal heart rhythm using electrical pules

Flexibility Exercise (Stretching)

•Joint ROM or flexibility can be improved across all age groups by engaging in flexibility exercises. •The ROM around a joint is improved immediately after performing flexibility exercise and shows chronic improvement after about 3-4 wk of regular stretching at a frequency of at least 2-3 times ∙ wk−1. •Postural stability and balance can also be improved by engaging in flexibility exercises, especially when combined with resistance exercise.

•Individuals with LBP can be classified into one of three broad categories:

•LBP associated with another specific spinal cause (e.g., cancer or fracture) •LBP associated with radiculopathy or spinal stenosis •Nonspecific LBP, which encompass over 85% of cases

Aerobic: Intensity •Most Adults:

•Moderate: 40%-59% HRR or VO2R to •Vigorous: 60%-89% HRR or VO2R

Side effects of albuterol

•Nervousness •Shakiness •Headache •Throat/nasal irritations •Muscle aches •Tachycardia Palpitations

Neuromotor Exercise General recommendations:

•Stressing postural muscle groups •heel and toe stands •Reducing sensory input •standing with eyes closed •Tai chi Patients may need supervision and/or assistance.

Supplemental Oxygen

•Supplemental oxygen is indicated for patients with an SaO2 < 88% while breathing room air. •This recommendation applies when considering supplemental oxygen during exercise. •In patients using ambulatory supplemental oxygen, flow rates will likely need to be increased during exercise to maintain SaO2 > 88%. •Individuals suffering from acute exacerbations of their pulmonary disease should limit exercise until symptoms have subsided.

Muscular Fitness: Volume •Older and very deconditioned individuals

•more susceptible to musculotendinous injury •begin a resistance training program conducting more repetitions (i.e., 10-15) •at a moderate intensity of 40%-50% of 1-RM, •or an RPE of 5-6 on a 10-point scale •assuming the individual has the capacity to use this intensity while maintaining proper lifting technique. •Subsequent to a period of adaptation to resistance training and improved musculotendinous conditioning, older individuals may choose to follow guidelines for younger adults (higher intensity with 8-12 repetitions per set) (see Chapter 8).

Psychosocial factors for long-term disability and work loss associated with LBP

-a nagative attitude that back pain is harmful or potentially severely disabling -fear avoidance behavior and reduced anxiety levels -an expectation that passive, rather than active, treatment will be beneficial -a tendency to depression, low morale, and social withdrawal -social or financial problems

Absolute contraindications for exercise during pregnancy

-hemodynamically significant heart disease -restrictive lung disease -incompetent cervix/cerciage -multiple gestation at risk for premature labor -persistent second or third trimester bleeding -placenta previa after 25 wk of gestation -premature labor during the current pregnancy -ruptured membrane

benefits of exercise during pregnancy

-prevention of excessive gestational weight gain -prevention of gestational diabetes -decreased risk of preeclampsia -decreased incidence/symptoms of lbp -decreased risk of urinary incontinence -prevention/improvement of depressive symptoms -maintenance of fitness -prevention of postpartum weight retention

Relative contraindications for exercise during pregnancy

-severe anemia -unevaluated maternal cardiac dysrhythmia -chronic bronchitis -poorly controlled T1 DM -extreme morbid obesity -extreme underweight -hx of extremely sedentary lifestyle -poorly controlled seizure disorder -poorly controlled hyperthyroidism -heavy smoker

Flexibility: Volume

A 20%-75% maximum voluntary contraction held for 3-6 s followed by a 10-30 s assisted stretch is recommended for PNF techniques. Performing flexibility exercises ≥2-3 d ∙ wk−1 is recommended with daily flexibility exercise being most effective.

Flexibility: Volume Normal adults

A total of 60 s of flexibility exercise per joint is recommended. Holding a single flexibility exercise for 10-30 s to the point of tightness or slight discomfort is effective.

Progression/Maintenance of Resistance Training Recommendation

As muscles adapt to a resistance exercise training program, the participant should continue to subject them to overload to continue to increase muscular strength and mass by gradually increasing resistance, number of sets, or frequency of training.

What can be done to prevent a Stroke?

Brining down blood pressure - decrease sodium, change diet, exercise, watch weight, watch alcohol consumption Encourage healthy eating - decreases plaque build up that could dislodge Decrease atherosclertotic risk factors

resistance - pregnancy F & I

F: •2-3 nonconsecutive days/wk I: •Multiple submaximal repetitions •8-10RM or 12-15RM to moderate fatigue

Flexibility - FITT Older adults F & I

F: •≥2 d ∙ wk−1. I: Stretch to the point of feeling tightness or slight discomfort.

Flexibility - pregnancy F & I

F: •≥2-3 nonconsecutive days/wk •Daily is the most effective I: •Point of feeling tightness or slight discomfort

Aerobic FITT - Pregnancy Freq & Intensity

F: •≥3-5 days/wk I: •Moderate intensity •3-5.9 METs •Borg RPE 12-13 •Vigorous intensity •For highly active prior •Progressed to higher fitness levels during pregnancy

Goals for a Health-Related Resistance Training Program

For adults of all ages, the goals of a health-related resistance training program should be to (a) make activities of daily living (ADL) less stressful physiologically; and (b) effectively manage, attenuate, and even prevent chronic diseases and health conditions such as osteoporosis, Type 2 diabetes mellitus, and obesity. For these reasons, although resistance training is important across the age span, its importance becomes even greater with age.

Hemiparetic Stroke

Half the VO2 of age-matched individuals

FITT Recommendations for Outpatient Programs Type (cont.):

High-intensity interval training •Alternating 3-4 min periods at •high intensity (90%-95% HRpeak) •moderate intensity (60%-70% HRpeak) •40 min, three times per week •Shown to yield a greater improvement in patients with stable coronary heart disease, HF and after CABG

Cardiac Rehabilitation Phases Phase 4

Independent, Ongoing Rehab maintenance

Cardiac Rehabilitation Phases Phase 2

Initial Outpatient, cardiac response to exercise is closely monitored, pt educated on safety with exercises including HR and RPE, pt should begin to be independent with exercise/activity post discharge pre exercise period

Cardiac Rehabilitation Phases Phase 3

Intensive Outpatient, pt starts to become more and more independent exercise and education programme

Which is more prevalent, ischemic strokes or hemorrhagic strokes?

Ischemic strokes - 80-87%

FITT Recommendations for Outpatient Programs Frequency

Minimally 3 d but preferably on most days of the week. •Frequency of exercise vary based on baseline, tolerance, intensity, goals, and types of exercise. •General guidelines for adults and older adults suggest exercise bouts of at least 10 min each. •For patients with very limited exercise capacities, multiple short (<10 min) daily sessions may be prescribed. •Patients should be encouraged to perform some exercise sessions independently (i.e., without direct supervision) following the recommendations outlined in this chapter.

Calculations walking speed

Pt's VO2max = 34 mL/kg/min •What % of VO2max would be moderate? - 46-63% •What is this pt's target %VO2? - Target VO2 - 22.08 to 30.24 .46 x 48 = 22.06 .63 x 48 = 30.24 •Walking at an incline of 10%, what should be the range of speed? - 22.08 = 3.5 + 2.68x + 4.824x 18.05 = 7.504x x = 2.5mph -30.24 = 3.5 + 2.68x + 4.824x 26.4 = 7.7504x x= 3.6mph •Conversion factors Mph to m/min: 26.8

Calculations running speed

Pt's VO2max = 34 mL/kg/min (48) •What % of VO2max would be vigorous? •64-90% •What is this pt's target %VO2? •30.72 to 43.2 •Running at an incline of 10%, what should be the range of speed? •Conversion factors Mph to m/min: 26.8 30.72 = 3.5 + 5.36x + 2.412x 27.22 = 7.772x x = 3.5 mpg 43.2 = 3.5 + 5.36x + 2.412x 39.7 = 7.772x x = 5.1 mph

Overload Principle

Stimulus greater than the normal stimulus - stressing tissues Intensity needs to be above the daily load they are doing daily

resistance - pregnancy T & T

T: •1 set for beginners •2-3 sets for intermediate to advance •Target major muscle groups Type: •Machines, free weights, and body weight are all tolerated

Aerobic FITT - Pregnancy Time & Type

T: •~30 mins/day •Accumulate 150 mins/wk Or •75 mins/wk of vigorous Type: •Weight and nonweight bearing •Hiking, group exercise, swimming

HRR method

THR = [(HRmax - HRrest) x % intensity] + HRrest

MET method

Target MET = [(VO2max)/3.5 mL/kg/min] x % intensity desired

FITT Recommendations for Outpatient Programs Type

The aerobic exercise portion of the session should include rhythmic, large muscle group activities •Emphasis on increased caloric expenditure for maintenance of a healthy body weight and its many other associated health benefits. •To promote whole body physical fitness, conditioning that includes the upper and lower extremities and multiple forms of aerobic activities and exercise equipment should be incorporated into the exercise program.

General Considerations for Exercise Prescription

The optimal Ex Rx should address the health-related physical fitness components of •cardiorespiratory (aerobic) fitness, •muscular strength and endurance, •flexibility, •body composition, and neuromotor fitness. •The Ex Rx should include a plan to decrease periods of physical inactivity in addition to an increase in physical activity. • •Reduce musculoskeletal injury and complications with the warm-up and cool-down, stretching exercises, and gradual progression of volume and intensity.

What is a met?

VO2 required for work rate / 3.5 MET level

What's an LVAD?

Ventricular assist device - machine helps pumps blood for the body

FITT Recommendations for Outpatient Programs Time

Warm-up and cool-down activities of 5-10 min, including static stretching, ROM, and light intensity aerobic activities •Aerobic conditioning goal ~20-60 min per session. •Lower level patients start with multiple shorter session of <10 minutes bouts.

Ischemia

Without Oxygen •Restriction of the Blood Flow to the Brain •Cerebral Artery is Blocked by a Blood Clot a clot blocks blood flow to an area of the brain

Stretching

at least 10 min of stretching exercises performed after the warm-up or cool-down phase

Conditioning

at least 20-60 min of aerobic, resistance, neuromotor, and/or sports activities (exercise bouts of 10 min are acceptable if the individual accumulates at least 20-60 min · d−1 of daily aerobic exercise)

Cool-down:

at least 5-10 min of light-to-moderate intensity cardiorespiratory and muscular endurance activities

Warm-up

at least 5-10 min of light-to-moderate intensity cardiorespiratory and muscular endurance activities

Children and Adolescents definitions

defined as individuals 6-17 yr more physically active than their adult counterparts. •Only the youngest children (6-7 yr) are as physically active as recommended by experts, and most young individuals older than the age of 10 yr do not meet prevailing physical activity guidelines.

emphysema

destruction and enlargement of air spaces

Neuromotor Exercise The optimal effectiveness of the various types of neuromotor exercise

doses (i.e., FIT), and training regimens are not known for adults of any age. Studies that have resulted in neuromotor improvements have mostly employed training frequencies of ≥2-3 d wk−1 with exercise sessions of ≥20-30 min duration for a total of ≥60 min of neuromotor exercise per week.

Running

hc: 0.2 speed vc: 0.9 x speed x grade

Bronchitis

increased mucus and inflammation

Passive static stretching

involves assuming a position while holding a limb or other part of the body with or without the assistance of a partner or device (such as elastic bands or a ballet barre)

Flexibility exercises - COPD

may help overcome the effects of postural impairments that limit thoracic mobility and therefore lung function.

Proprioceptive neuromuscular facilitation (PNF)

methods take several forms but typically involve an isometric contraction of the selected muscle/tendon group followed by a static stretching of the same group (i.e., contract-relax) (39,42). Adapted from

Muscular Fitness: Type Single joint exercises

targeting major muscle groups such as biceps curls, triceps extensions, quadriceps extensions, leg curls, and calf raises can also be included in a resistance training program.

Flexibility - FITT Older adults T & T

time: Hold stretch for 30-60 s. type: •Slow movements for sustained, static stretches •Avoid rapid ballistic movements

MCA (middle) stroke

typically more issues with UEs

Ballistic methods or "bouncing" stretches

use the momentum of the moving body segment to produce the stretch

Heart Failure approximately

•% of patients with HF are compliant with prescribed exercise at the end of 1 yr, which is not different than long-term adherence for patients with established coronary artery disease. Because numerous barriers to exercise adoption and adherence exist in this population, factors amenable to interventions such as treating anxiety and depression, improving motivation, seeking additional social support, and managing logistical problems such as transportation should be addressed

Aerobic: Intensity •Methods of estimating the relative intensity of exercise

•%HRR •%HRmax •%VO2R •%VO2max •%METs

# Reps to % 1 RM

•1 100% •2 95% •4 90% •6 85% •8 80% 10 75% •12 70% •14 65% •16 60% •18 55% •20 50%

Aerobic FITT - older adults Intensity

•10-point RPE Scale •5-6 for moderate intensity 7-8 for vigorous intensity

Neuromotor Exercise - Older adults

•2-3 d ∙ wk−1 •Training for balance, agility, proprioception •Reduce and prevent falls

Aerobic: Frequency

•3-5 d ∙ wk−1 •Improvements in cardiorespiratory fitness (CRF) are attenuated with exercise frequencies more than 3 d ∙ wk−1 and a plateau in improvement with exercise done more than 5 d ∙ wk−1.

Aerobic FITT - older adults Time

•30 - 60 min ∙ d−1 of moderate •20 - 30 min ∙ d−1 of vigorous •bouts of at least 10 min each

Muscle Strengthening - older adults Time

•8-10 exercises with major muscle groups •1-3 sets of 8-12 repetitions

•For prognosis and outcome purposes, LBP can be described as:

•Acute (< 6 wk) •Subacute (6-12 wk) •Chronic (> 12 wk)

Patients with Sternotomy

•Adequate sternal stability in 8-10 wks. •Sternal instability in 16% of cases •Sternal wires are use to close •Sternal precautions taught RIGHT AWAY! •Reinforced for 8-12 wks following surgery. •It is important for you to monitor the sternotomy for signs and symptoms of instability or infection and informing the surgeon if necessary.

Exercise in Cold Environments •Clothing considerations

•Adjust insulation to minimize sweating. •Use vents to reduce sweat accumulation. •Do not wear an outer layer unless rainy or very windy. •Decrease clothing insulation as intensity increases. •Do not impose a single clothing standard on an entire group of exercisers. •Wear appropriate footwear to minimize the risks of slipping and falling in snowy or icy conditions.

Muscular Fitness: Volume •To improve muscular strength, mass and - to some extent - endurance

•Adults should train each muscle group... •2-4 sets •8-12 repetitions •60-80% of 1RM

Why is Resistive Training Important in Older Adults?

•After age 50, rate of muscle mass loss doubles. •Degenerative diseases with aging are related to loss of muscle mass & strength. Muscle strength declines by15% per decade in the 6th & 7th decade and by 30% thereafter.

Ex Rx - older adults

•Age should not be a barrier to PA because positive improvements are attainable at any age. •The relative adaptations to exercise and the percentage of improvement in the components of physical fitness among older adults are comparable with those reported in younger adults and are important for maintaining health and functional ability and attenuating many of the physiologic changes that are associated with aging.

Prevention altitude sickness

•Altitude acclimatization is the best countermeasure to all altitude sickness •Minimizing sustained exercise/physical activity •Maintaining adequate hydration and food intake. •When moderate to severe symptoms and signs of an altitude-related sickness develop, the preferred treatment is to descend to a lower altitude. •Treatment of individuals diagnosed with HACE or HAPE includes descent, oxygen therapy, and/or hyperbaric bag therapy. • •Different types of medication to help with condition and symptoms.

An important distinction between older and younger adults should be made relative to intensity.

•Apparently healthy younger adults - moderate and vigorous intensity PA defined relative to METs (moderate intensity, 3-5.9 METs; vigorous intensity ≥6 METs) •For older adults, activities should be defined relative to an individual's physical fitness within the context of a perceived 10-point physical exertion scale which ranges from 0 (an effort equivalent to sitting) to 10 (an all out effort), with moderate intensity defined as 5 or 6, and vigorous intensity as ≥7.

Assessing EIB CONT

•Appropriately supervised by trained clinician or physician with high risk patients. • •Potential severe bronchoconstriction with high risk patients after testing. • •Immediate administration of nebulized bronchodilators with oxygen is usually successful for relief.

LBP stats

•Approximately 90% of acute low back episodes resolve within 6 weeks, regardless of treatment. •To reduce the probability of disability, individuals with LBP should stay active, continue ordinary activity within pain limits, avoid bed rest, and return to work as soon as possible. •Many individuals with LBP have fear, anxiety, or misinformation regarding their LBP, exacerbating a persistent pain state. A combination of therapeutic and aerobic exercise, and pain education, improves individual attitudes, outcomes, perceptions, and pain thresholds.

Muscular Fitness: Progression

•As muscles adapt to a resistance exercise training program... overload or greater stimuli to continue to increase muscular strength and mass. •The most common approach is to increase the amount of resistance lifted during training. •Other ways to progressively overload muscles include performing more sets per muscle group and increasing the number of days per week the muscle groups are trained. •Increasing the overload by adding resistance, sets, or training sessions per week is not required during a maintenance resistance training program. •Muscular strength may be maintained by training muscle groups as little as 1 d · wk−1 as long as the training intensity or the resistance lifted is held constant.

Assessing EIB

•Assess EIB using vigorous intensity exercise achieved within 2-4 min and lasting 4-6 min with the subject breathing relatively dry air. •Evaluate the change in forced expiratory volume in one second (FEV1.0) from baseline and the value measured at 5, 10, 15, and 30 min following the exercise test. •The criterion for a diagnosis of EIB varies, but many laboratories use a decrease in FEV1.0 from baseline of >15% because of its greater specificity.

Exercise testing - asthma

•Assessment cardiopulmonary capacity, pulmonary function (before and after exercise), and O2sat. • •Administration of an inhaled bronchodilator prior to testing may be indicated to prevent EIB, thus providing optimal assessment of cardiopulmonary capacity. • •Exercise testing is typically on a treadmill or bike. Targets for high ventilation and HRs are better achieved using the treadmill. For athletes, a sports-specific mode may be more relevant.

Inpatient CARDIAC Rehab

•At hospital discharge, the patient should have specific instructions regarding strenuous activities (e.g., heavy lifting, climbing stairs, yard work, household activities) that are permissible and those they should avoid . •A safe, progressive plan of exercise should be formulated before leaving the hospital. •Until evaluated with an exercise test or entry into a clinically supervised outpatient CR program, the upper limit of heart rate (HR) or RPE noted during exercise should not exceed those levels observed during the inpatient program . •Patients should be counseled to identify abnormal signs and symptoms suggesting exercise intolerance and the need for medical evaluation. •All eligible patients should be strongly encouraged to participate in a clinically supervised outpatient CR program.

Inpatient cardiac rehab

•Before beginning a formal physical activity in the inpatient setting, a baseline assessment should be conducted by a health care provider. •The individual supervising an ambulatory session should possess the skills and competencies necessary to assess and document vital signs and heart and lung sounds, and provide feedback on the patient's musculoskeletal strength and flexibility.

Aerobic (Cardiorespiratory Endurance) Exercise •Methods of estimating the absolute intensity of exercise

•Caloric expenditure (kcal · min−1) •Absolute oxygen uptake (VO2; mL ∙ min−1 or L ∙ min−1) •NOTE: this is NOT relative oxygen uptake (VO2; mL ∙ kg ∙ min−1) •Metabolic equivalents (METs) •These absolute measures can result in misclassification of exercise intensity because they do not take into consideration body weight, sex, and fitness level.

Special Considerations - asthma

•Caution is suggested in using HR target intensities based on prediction of maximal heart rate (HRmax) because of the wide variability in its association with ventilation and the potential HR effects of asthma control medications. • •Patients should not exercise during exacerbations until symptoms and airway function have improved. •Use of short-acting bronchodilators may be necessary before or after exercise to prevent or treat EIB. • •Individuals on prolonged treatment with oral corticosteroids may experience peripheral muscle wasting and may benefit from resistance training.

Children and Adolescents Special Considerations

•Children and adolescents may safely participate in strength training activities provided they receive proper instruction and supervision. Generally, adult guidelines for resistance training may be applied. •Because of immature thermoregulatory systems, youth should avoid exercise in hot humid environments, be properly hydrated, and appropriately modify activities. •Overweight or physically inactive children or adolescents may not be able to meet the recommended 60 min ∙ d−1. Start out with moderate intensity as tolerated and gradually increase frequency and time. •Efforts should be made to decrease sedentary activities (i.e., television watching, surfing the Internet, and playing video games) and increase activities that promote lifelong activity and fitness (i.e., walking and cycling).

Ex Rx - kids

•Children and adolescents should be encouraged to participate in various physical activities that are enjoyable and age appropriate. • •PA in young children should include unstructured active play, which typically consists of sporadic bursts of moderate- and vigorous-intensity PA alternating with brief periods of rest. •These small bouts of PA, however brief, count toward FITT recommendations.

Coronary Revascularization •2 Primary Interventions

•Coronary Artery Bypass Graft (CABG) •Percutaneous Transluminal Coronary Angioplasty (PTCA) "Coronary revascularization, comprising coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI), is among the most common major medical procedures provided by the US health care system, with more than 1 million procedures performed annually."

Coronary Artery Bypass Graft (CABG)

•Coronary: relating to the heart • •Artery: • •Bypass: a surgically established shunt • •Graft: to implant tissue surgically

Inpatient cardiac rehab Guidelines for the inpatient CR program should focus on the following:

•Current clinical status assessment •Mobilization •Identification and provision of information regarding modifiable risk factors and self-care •Discharge planning with a home PA and activities of daily living (ADL) plan and referral to outpatient CR

Aerobic: Volume Daily Goal

•Daily Goal = at least 7,000 step, up to 10,000 •1 mile = 2,000 steps • •Walking, moderate intensity x 30 mins •3,000-4,000 steps • •Weight management •8,000 - 12,000 steps (women) •11,000 - 12,000 steps (men)

Hyponatremia

•Decrease sodium concentration in the blood •accompanied by altered cognitive status •Usually caused by... •Long duration physical activities •Overdrinking of water •Excessive Sweating • •Prevented by consuming salt-containing fluids or foods when participating in exercise events that result in many hours of continuous or near continuous sweating.

•Exercise-induced bronchoconstriction (EIB)

•Defined as airway narrowing that occurs as a result of exercise, is experienced in a substantial proportion of people with asthma, but people without a diagnosis of asthma may also experience EIB.

Other Lung Diseases

•Despite substantially less investigation into the benefits of exercise training in non- COPD chronic lung diseases, strong scientific evidence supports the inclusion of exercise training for many lung diseases other than COPD with demonstrated clinical and physiologic benefits. •The programs should be modified to include disease-specific strategies. •CF •Lung Transplantation •PAH •ILD

Counteracting dehydration

•Determining sweat rate (L ∙ h−1 or q ∙ h−1) •Measuring body weight before and after exercise provides a fluid replacement guide. • •Active individuals should drink 0.5 L (1 pint) of fluid for each pound of body weight lost. • •Urine Color •A paler color indicates adequate hydration; a darker yellow/brown color, the greater the degree of dehydration

Muscular Fitness: Volume

•Each muscle group should be trained for a total of two to four sets. •These sets may be derived from the same exercise or from a combination of exercises affecting the same muscle group. •Reasonable rest interval between sets is 2-3 min. •Using different exercises to train the same muscle group adds variety, may prevent long-term mental "staleness," and may improve adherence to the training program. •Four sets per muscle group is more effective than two sets; however, even a single set per exercise will significantly improve muscular strength, particularly among novices. •The resistance training intensity and number of repetitions performed with each set are inversely related.

Exercise Testing - asthma

•Evidence of oxyhemoglobin desaturation <80% should be used as test termination criteria in addition to standard criteria. •The 6MWT may be used in individuals with moderate-to-severe persistent asthma when other testing equipment is not available.

Exercise Testing - COPD

•Evidence supports the use of exercise testing in adults with COPD as well as other chronic lung disease. • •Establishes objective measure of CRF, exercise capacity, exercise intolerance, prognosis, and disease progression and treatment response.

Special Considerations - asthma cold environments

•Exercise in cold environments or those with airborne allergens or pollutants should be limited to avoid triggering bronchoconstriction in susceptible individuals. •EIB can also be triggered by prolonged exercise durations or high intensity exercise sessions.

Exercise testing - kids

•Exercise testing for clinical purposes is generally not indicated for children or adolescents unless there is a health concern. •The exercise testing protocol should be based on the reason the test is being performed and the functional capability of the child or adolescent. •Children and adolescents should be familiarized with the test protocol and procedure before testing to minimize stress and maximize the potential for a successful test.

Pacemaker and ICD

•Exercise testing should be used to evaluate HR and rhythm responses prior to beginning an exercise program. Exercise training should not begin in patient's whose HR does not increase during the exercise test. In these cases, the exercise sensing mechanism (i.e., movement or respiration) needs adjustment to allow the HR to increase with PA. •When an ICD is present, the peak heart rate (HRpeak) during the exercise test and exercise training program should be maintained 10-15 beats × min-1 below the programmed HR threshold for antitachycardia pacing and defibrillation. •After the first 24 h following the device implantation, mild upper extremity ROM activities can be performed and may be useful to avoid subsequent joint complications. •To maintain device and incision integrity, for 3-4 wk after implant, vigorous upper extremity activities such as swimming, bowling, lifting weights, elliptical machines, and golfing should be avoided. However, lower extremity activities are allowable.

HR and LVAD

•Exercise training (and testing) of patients that received an LVAD for either bridge-to-transplant or as a destination therapy for end-stage disease is becoming increasingly more common. These patients have a low functional capacity with a V ̇O2peak in the range of 7-23 mL × kg-1 × min-1. •Early-onset fatigue is common with exercise. When starting an exercise training program, fatigue later in the day may be reported. If fatigue occurs, intermittent exercise may reduce the level of fatigue experienced from subsequent exercise training sessions. •Until more definitive information describing the relationship between HR and exercise intensity are available, using RPE of 11-13 to prescribe exercise intensity is appropriate.

Cold Environments - Risk of morbidity/mortality

•Exercise-related cold stress may increase the risk of morbidity and mortality in at-risk populations such as those with CVD and asthmatic conditions. •Inhalation of cold air may also exacerbate these conditions.

Heat stroke

•Exertional heatstroke is caused by hyperthermia and is characterized by elevated body temperature (>40 °C or 104 °F), profound central nervous system dysfunction, and multiple organ system failure that can result in delirium, convulsions, or coma. •The greatest risk for heatstroke exists during very high intensity exercise of short duration or prolonged exercise when the ambient wet-bulb globe temperature (WBGT) exceeds 28 °C (82 °F). •It is a life-threatening medical emergency that requires immediate and effective whole body cooling with cold water and ice water immersion therapy.

An Introduction to the Principles of Exercise Prescription

•For most adults, an exercise program should include aerobic, resistance, flexibility, and neuromotor exercise training •Some will need less than the suggestions of the guidelines presented in later chapters. •Performing some exercise is beneficial and should be encouraged except if there are safety concerns.

Outpatient Cardiac Exercise training considerations

•For patients who have had a b-blocker dose change but have not had an exercise test since this change, the following recommendations for guiding exercise intensity may be used: (a) Monitor signs and symptoms and (b) note the RPE and HR responses at the workload most recently used in CR. The HR and RPE observed may serve as the patient's new target for exercise intensity.

COPD

•Fourth leading cause of death and a major cause of chronic morbidity throughout the world. •Preventable and treatable and characterized by predisposing risk factors resulting in chronic airway inflammation chiefly due to exposure to noxious gases and particles, especially tobacco smoke and various environmental and occupational exposures. COPD encompasses chronic bronchitis and/or emphysema symptoms include dyspnea, chronic cough, and sputum production

Aerobic FITT for kids

•Frequency: Daily •Intensity: •Most should be Moderate-to-vigorous intensity •Vigorous intensity at least 3 d ∙ wk−1 •Time: ≥60 min ∙ d−1 •Type: Enjoyable and developmentally appropriate aerobic physical activities, including running, brisk walking, swimming, dancing, bicycling, and sports such as soccer, basketball, or tennis.

Muscular Strengthening FITT - kids

•Frequency: ≥3 d ∙ wk−1 •Intensity: Body weight for resistance or 8-15 submaximal repetitions to moderate fatigue with good mechanics. •Time: As part of their 60 min ∙ d−1 or more of exercise. •Type: Muscle strengthening physical activities can be unstructured (e.g., playing on playground equipment, climbing trees, tug-of-war) or structured (e.g., lifting weights, working with resistance bands).

Bone Strengthening - kids

•Frequency: ≥3 d ∙ wk−1. •Time: As part of 60 min ∙ d−1 or more of exercise. •Type: Bone strengthening activities include running, jumping rope, basketball, tennis, resistance training, and hopscotch.

•PA can be resumed after pregnancy but should be done so gradually because of normal deconditioning in the initial postpartum period.

•Generally, gradual exercise may begin ~4-6 wk after a normal vaginal delivery or about 8-10 wk (with medical clearance) after a cesarean section delivery •Women with higher CRF levels and more rigorous exercise routines prior to and during pregnancy may be able to resume exercise sooner. •Light to moderate intensity exercise in the postpartum period is important for return to prepregnancy body mass index and does not interfere with breastfeeding.

FITT Recommendations for Outpatient Programs Progression

•Gradually increase in aerobic exercise time of 1-5 min per session or an increase in time per session of 10%-20% per week. •no standard format for the rate of progression •individualized to patient tolerance •Resistance training volume can be increased in 2%-10% increments when an individual patient is able to comfortably complete one to two repetitions over the desired number of repetitions on two consecutive training days. •It is preferable for individuals to take their prescribed medications at their usual time as recommended by their health care providers. •Individuals on a b-adrenergic blocking agent (i.e., b -blocker) may have an attenuated HR response to exercise and an increased or decreased maximal exercise capacity. •For patients whose b -blocker dose was altered after an exercise test or during the course of CR, a new graded exercise test may be helpful.

HACE

•HACE is a potentially fatal, although not common •Occurs in <2% of individuals ascending >12,000 ft (3,658 m). •HACE is an exacerbation of unresolved, severe AMS. •HACE most often occurs in individuals who have AMS symptoms and continue to ascend.

HAPE

•HAPE is a potentially fatal, although not common. •Occurs in <10% of individuals ascending >12,000 ft (3,658 m). •Individuals making repeated ascents and descents >12,000 ft (3,658 m) and who exercise strenuously early in the exposure have an increased susceptibility to HAPE. •The presence of crackles and rales in the lungs may indicate increased susceptibility to developing HAPE.

Fitnessgram - kids

•Health/fitness testing may be performed outside of the clinical setting. •The components of the Fitnessgram test battery include body composition (BMI or skinfold thicknesses), cardiorespiratory fitness (1-min walk/run, PACER), muscular fitness (curl-up test, pull-up/push-up tests), and flexibility (sit-and-reach test).

Heat exhaustion

•Heat exhaustion occurs during exercise/PA in the heat when the body cannot sustain the level of cardiac output needed to support skin blood flow for thermoregulation and blood flow for metabolic requirements of exercise. •Characterized by prominent fatigue and progressive weakness without severe hyperthermia. •Oral fluids are preferred for rehydration in individuals who are conscious, able to swallow, and not losing fluid (i.e., vomiting and diarrhea). Intravenous fluid administration facilitates recovery in those unable to ingest oral fluids or who have severe dehydration.

Hypothermia:

•Heat loss exceeds heat production •Impacted by the environment, individual characteristics, and clothing

Heat syncope

•Heat syncope is a temporary circulatory failure caused by the pooling of blood in the peripheral veins, particularly of the lower extremities. •Occurs more often among physically unfit, sedentary, and nonacclimatized individuals. •Caused by standing erect for a long period, or at the cessation of strenuous, prolonged, upright exercise because maximal cutaneous vessel dilation results in a decline of blood pressure and insufficient oxygen delivery to the brain. •Symptoms range from light-headedness to loss of consciousness; however, recovery is rapid once individuals sit or lay supine.

Muscular Fitness: Volume •Text Example: Shoulder Press

•If 1 RM = 100 lbs •What should be the training resistance for 60-80% 1RM? •First set should be at or near 12 reps •Last set should be about 8 reps .60 x 100 = 60 lbs .80 x 100 = 80 lbs

Hypothermia Increase the risk:

•Immersion, rain, wet clothing, low body fat, older age (≥60 yr), and hypoglycemia.

Patients after Cardiac Transplantation

•In patients with end-stage HF for whom expected 1-yr survival is poor and standard medical therapy fails to control symptoms, cardiac transplant may be a surgical option for those who are eligible. •Approximately 4,000 such procedures are performed worldwide annually and, depending on age, 3-yr survival rates are 75%-81%. •V ̇O2peak may improve 15% - 30%

Ex rx - pregnancy

•In the absence of obstetric or medical complications, the exercise recommendations during pregnancy are consistent with recommendations for healthy adults •The recommended Ex Rx for women who are pregnant should be modified according to the woman's symptoms, discomforts, and abilities during pregnancy. •The Physical Activity Readiness Medical Examination for Pregnancy (PARmed-X for Pregnancy) or the electronic Physical Activity Readiness Medical Examination (ePARmed-X+) should be used for the health screening of pregnant women before their participation in exercise programs

FITT Recommendations for Inpatient Cardiac Programs Progression

•Increase to 10-15 min of continuous walking.

dehydration during exercise

•Increases physiologic strain as measured by core temperature, HR, and perceived exertion responses •Decreased sweating rate •Decreased cutaneous blood flow Decrease endurance performance

Ex Rx - heat

•Individuals whose Ex Rx specifies a target heart rate (THR) will achieve this THR at a lower absolute workload when exercising in a warm/hot versus a cooler environment. •As heat acclimatization develops, a progressively higher exercise intensity will be required to elicit the THR. •The first exercise session in the heat may last as little as 5-10 min for safety reasons but can be increased gradually.

Inspiratory Muscle Training

•Inspiratory muscle weakness is a contributor to exercise intolerance and dyspnea in those with COPD. •Patients who present with inspiratory muscle weakness and breathlessness may benefit from IMT. •IMT improves inspiratory muscle strength and endurance, functional capacity, dyspnea, and quality of life which may lead to improvements in exercise tolerance.

•Cerebrovascular Accident (CVA)

•Ischemic vs Hemorrhagic Stroke •Transient Ischemic Attack (TIA): "mini-stroke"

Outpatient Cardiac Exercise training considerations CONT

•It is recommended that an exercise test be performed any time that symptoms or clinical changes warrant. For example, in patients who have a change in their level of chest pain or dyspnea; or possibly for those with an ischemic etiology who have not undergone a coronary revascularization procedure, or who have been incompletely revascularized (i.e., residual obstructive coronary lesions are present), or who have rhythm disturbances and desire to exercise to a higher intensity level. However, another exercise test may not be medically necessary in patients who have undergone complete coronary revascularization, who are asymptomatic, or when it is logistically impractical.

Aerobic: Duration

•It is recommended that most adults accumulate •30-60 min ∙ d−1 (≥150 min ∙ wk−1) of moderate intensity exercise •20-60 min ∙ d−1 (≥75 min ∙ wk−1) of vigorous exercise •or a combination of moderate and vigorous exercise per day •Continuous or Intermittent •One or more sessions of physical activity per day •At least 10 min ∙ session−1. •Very deconditioned individuals: less than 10 min may yield favorable adaptations

Muscle Strengthening - older adults Intensity

•Light intensity •40%-50% 1-RM for beginners •Progress to Moderate/Vigorous intensity •60%-80%1-RM •10-point RPE Scale can be used instead of 1RM •moderate (5-6) or vigorous (7-8) intensity

Aerobic: Intensity •Deconditioned:

•Light: 30%-39% HRR or VO2R to •Moderate: 40%-59% HRR or VO2R

Ex Rx - older adults - CONT

•Low aerobic capacity, muscle weakness, and deconditioning are more common in older adults than in any other age group and contribute to loss of independence, and therefore an appropriate Ex Rx should include aerobic, muscle strengthening/endurance, and flexibility exercises. •Individuals who are frequent fallers or have mobility limitations may also benefit from specific neuromotor exercises to improve balance, agility, and proprioceptive training (e.g., Tai Chi), in addition to the other components of health-related physical fitness.

FITT Recommendations for Inpatient Cardiac Programs Intensity

•MI: HRrest +20 beats ∙ min−1 •Heart Surgery: HRrest +30 beats ∙ min−1 •Upper limit ≤120 beats ∙ min−1 •RPE ≤13 on a scale of 6-20 Heart surgery higher? Remember with MI ischemic occurs so the tissues begin to die so after a MI and they don't have an intervention in place whatever caused the ischemic hasn't been resolved.

Cold Environments - factors

•Many factors including the environment, clothing, body composition, health status, nutrition, age, and exercise intensity interact to determine if exercising in the cold elicits additional physiologic strain and injury risk beyond that associated with the same exercise done under temperate conditions. • •In most cases, exercise in the cold does not increase cold injury risk.

Muscular Fitness: Type

•Many types of resistance training equipment can effectively be used to improve muscular fitness... •Free weights •Machines with stacked weights or pneumatic resistance Resistance bands

Exercise testing - pregnancy

•Maximal exercise testing should not be performed on women who are pregnant unless medically necessary. •If a maximal exercise test is warranted, the test should be performed with physician supervision after the woman has been medically evaluated for contraindications to exercise.

Muscular Fitness Older Adults

•May benefit from power training •Muscle fitness declines most rapidly with aging •Insufficient power has been associated with a greater risk of accidental falls. •Importantly, aged individuals can safely perform the fast-velocity muscular contractions, or repetitions, that optimally develop muscular power.

Which exercise test? COPD

•May need to modify protocols or use smaller work rate increments depending on functional limitations and the onset of dyspnea. •A test duration of 8-12 min is optimal in those with mild-to-moderate COPD, whereas a test duration of 5-9 min is recommended for patients with more severe disease.

Outpatient Cardiac Rehab At program entry, the following assessments should be performed:

•Medical and surgical history including the most recent cardiovascular event, comorbidities, and other pertinent medical history. •Physical examination with an emphasis on the cardiopulmonary and musculoskeletal systems. •Review of recent cardiovascular tests and procedures including 12-lead electrocardiogram (ECG), coronary angiogram, echocardiogram, stress test (exercise or imaging studies), revascularization, and pacemaker/implantable defibrillator implantation. •Current medications including dose, route of administration, and frequency. •CVD risk factors

frostbite

•Medical considerations: cold injuries - frost bite •Frostbite occurs when tissue temperatures fall lower than 0° C (32° F). •Frostbite is most common in exposed skin but also occurs in the hands and feet. •Contact frostbite may occur by touching cold objects with bare skin, particularly highly conductive metal or stone that causes rapid heat loss. •The principal cold stress determinants for frostbite are air temperature, wind speed, and wetness. Wind exacerbates heat loss by facilitating convective heat loss and reducing the insulative value of clothing.

hyperthermia

•Metabolic heat exceeds heat loss •Elevated internal body temperature •Sweat provides no cooling benefits

Exercise prescription - AS

•Minimize exercise/physical activity the first few days to reduce susceptibility to altitude illness. • •After this period, individuals whose Ex Rx specifies a THR should maintain the same exercise HR at higher altitudes. • •The number of sessions and duration can stay the same as at sea level.

FITT Recommendations for Inpatient Cardiac Programs Frequency

•Mobilization: two to four times per day for the first 3 d

Aerobic: Frequency For most adults to achieve & maintain health/fitness benefits:

•Moderate intensity: at least 5 d ∙ wk−1 or •Vigorous intensity: at least 3 d ∙ wk−1; or •A weekly combination of 3-5 d ∙ wk−1 of moderate and vigorous intensity exercise

Exercise testing cont COPD

•Monitor O2sat • •Submaximal exercise testing may be used • •Using age-predicted HRmax to determine when to terminate the submaximal GXT may not be appropriate due to breathing difficulties.

Special considerations - heat

•Monitor the environment: Use the WBGT index to determine appropriate action. •Provide ample fluid •Longer and/or more rest breaks •Shorten or delay playing times •Exercise when conditions are cooler (early morning, later evening) •Children and older adults should modify activities in conditions of high temperature and humidity

What is an ICD?

•Monitors/records heart rhythm and if the rhythm is dangerous delivers a shock (defibrillation)

AMS

•Most common form of altitude sickness. •Symptoms include headache, nausea, fatigue, decreased appetite, and poor sleep and, in severe cases, poor balance and mild swelling in the hands, feet, or face. •Develops within the first 24 h of altitude exposure. •Its incidence and severity increases in direct proportion to ascent rate and altitude. •If ascent is stopped and physical exertion is limited, recovery from AMS occurs over 24-48 h after symptoms have peaked.

Heat exchange

•Muscular contractions produce metabolic heat that is transferred from the active muscles to the blood and then to the body's core. Subsequent body temperature elevations elicit heat loss responses of increased skin blood flow and increased sweat secretion so that heat can be dissipated to the environment via evaporation. •Heat exchange between skin and environment via sweating and dry heat exchange is governed by biophysical properties dictated by surrounding temperature, humidity and air motion, sky and ground radiation, and clothing.

Older Adults Special Considerations

•Muscular strength decreases rapidly with age, especially for those >50 yr. Although resistance training is important across the lifespan, it becomes more rather than less important with increasing age. • •Older adults may particularly benefit from power training because this element of muscle fitness declines most rapidly with aging, and insufficient power has been associated with a greater risk of accidental falls. •Increasing muscle power in healthy older adults should include both single- and multiple-joint exercises (1-3 sets) using light to moderate loading (30-60% of 1RM) for 6-10 repetitions with high velocity. • • •Individuals with sarcopenia, a marker of frailty, need to increase muscular strength before they are physiologically capable of engaging in aerobic training. •Structured physical activity sessions should end with an appropriate cool-down, particularly among individuals with CVD. The cool-down should include a gradual reduction of effort and intensity and optimally, flexibility exercises.

NFCIs

•NFCIs typically occur when tissues are exposed to cold-wet temperatures between 0-15 °C (32-60 °F) for prolonged periods of time. These injuries may occur due to actual immersion or by the creation of a damp environment inside boots or gloves, as often seen during heavy sweating.

Neuromotor Exercise

•Neuromotor exercise training involves motor skills, such as balance, coordination, gait, and agility, and proprioceptive training and is sometimes called functional fitness training. •Neuromotor exercise training results in improvements in balance, agility, and muscle strength and reduces the risk of falls and the fear of falling among older adults.

Neuromotor Exercise Recommendations

•Neuromotor exercises involving balance, agility, coordination, and gait are recommended on ≥2-3 d ∙ wk−1 for older individuals and are likely beneficial for younger adults as well. The optimal duration or number of repetitions of these exercises is not known, but neuromotor exercise routines of ≥20-30 min in duration for a total of ≥60 min of neuromotor exercise per week are effective.

Sternal Precautions

•No pushing or pulling with arms •No lifting more than 5-8 lbs (or 10 lbs) •No reaching behind your back •No elbows above head •Cough with counter pressure

Older adult stats

•Older adults are the least physically active of all age groups. • •Only 11% of individuals aged ≥65 yr engage in regular aerobic and muscle strengthening activities. • •Less than 5% of individuals aged >85 yr engaging in regular aerobic and muscle strengthening activities.

Special Considerations - pregnancy

•PA in the supine position should be avoided or modified after 16 wk of pregnancy. •Women who are pregnant should avoid exercising in a hot humid environment, be well hydrated, and dressed appropriately to avoid heat stress. •During pregnancy, the metabolic demand increases by ~300 kcal∙d−1. Women should increase caloric intake to meet the caloric costs of pregnancy and exercise. •PA may help regulate weight gain during pregnancy •Women who are pregnant and severely obese and/or have gestational diabetes mellitus or hypertension should consult their physician before beginning an exercise program and have their Ex Rx adjusted to their medical condition, symptoms, and physical fitness level. •Women who are pregnant should avoid contact sports and sports/activities that may cause loss of balance or trauma to the mother or fetus. •In any activity, avoid using the Valsalva maneuver, prolonged isometric contraction, and motionless standing.

Percutaneous transluminal coronary angioplasty (PTCA) Length of stay?

•PCI: discharged within 24 hours •MI, acute coronary syndrome, CABG, open valve surgery, transluminal valve interventions: discharge within 5 days.

Aerobic: Volume Pedometers

•Pedometers are effective tools for promoting physical activity and can be used to approximate exercise volume in steps per day. • •The goal of 10,000 steps ∙ d−1 is often cited, but it appears that achieving a pedometer step count of at least 5,400-7,900 steps ∙ d−1 can meet recommended exercise targets.

Percutaneous transluminal coronary angioplasty (PTCA)

•Percutaneous: through the skin •Trans: passing across, on the other side •Luminal (Lumen): tube •Blood vessel or catheter •Coronary: heart •Angio: blood vessel Plasty: restoration

Special Considerations - COPD

•Peripheral muscle dysfunction contributes to exercise intolerance and is significantly and independently related to increased use of health care resources, poorer prognosis, and mortality. •Possibly use bronchodilators before exercise training to reduce dyspnea and improve exercise tolerance. •Because individuals with COPD may experience greater dyspnea while performing ADL involving the upper extremities, include resistance exercises for the muscles of the upper body.

exercise test - older adults physical performance

•Physical performance testing has largely replaced exercise stress testing for the assessment of functional status of older. Most physical performance tests require little space, equipment, and cost; can be administered by lay or health/fitness personnel with minimal training; and are considered extremely safe in healthy and clinical populations

Ex Training Considerations - pregnancy

•Previously inactive women should progress from 15 min∙d−1 (~3 d∙wk−1) at the appropriate RPE or target HR to approximately 30 min∙d−1 on most days of the week •Women who habitually participate in resistance training should continue during pregnancy and should discuss how to adjust their routine with their health care provider. •Kegel exercises and those that strengthen the pelvic floor are recommended to decrease the risk of incontinence during and after pregnancy.

Muscle Strengthening - older adults Type

•Progressive weight-training program/weight-bearing •Stair climbing

PTCA Therapy should include...

•Pt and Family Education •Precautions, CVD risk factors, PA counseling •Self-care •Toileting, grooming, etc. •Arm and Leg ROM •Depending on intervention •Postural changes •Simple exposure to orthostatic and gravitational stress, intermittent sitting or standing within 12-24 hours •Ambulation •Short distances supervised, progress to independent on unit. •Stair training •Car transfers

Flexibility Exercise (Stretching) ROM

•ROM is improved acutely and chronically following flexibility exercises. Flexibility exercises are most effective when the muscles are warm. Static stretching exercises may acutely reduce power and strength so it is recommended that flexibility exercises be performed after exercise and sports where strength and power are important for performance.

Aerobic (Cardiorespiratory Endurance) Exercise •Methods of estimating the intensity of exercise

•Rating of perceived exertion (RPE) •Affective valence •OMNI Scale •Talk Test Feeling Scale

Aerobic: Type

•Recommendation for all adults to improve health and CRF. •Rhythmic •Aerobic exercise •At least moderate intensity •Large muscle groups Little skill to perform

Breathlessness Positions

•Regardless of the prescribed exercise intensity, the exercise professional should closely monitor initial exercise sessions and adjust intensity and duration according to individual responses and tolerance. In many cases, the presence of symptoms, particularly dyspnea/breathlessness supersedes objective methods of Ex Rx.

Prevention of NFCIs

•Remain active to increase blood flow to the feet •Change socks often •Prophylactic treatment of feet with anti-perspirants containing aluminum hydroxide •Wipe and dry vapor barrier boots and liners

Muscular Fitness: Frequency

•Resistance train each major muscle group (chest, shoulders, upper and lower back, abdomen, hips, legs) •2-3 d · wk−1 •At least 48 h separating the exercise training sessions for the same muscle group.

Muscular Fitness: Type multijoint or compound exercises

•Resistance training regimens should include multijoint or compound exercises that affect more than one muscle group (e.g., chest press, shoulder press, pull-down, dips, lower back extension, abdominal crunch/curl-up, leg press, squats).

Exercise Testing - older adults

•Start with light work load (<3 METs) •Small workload increments (0.5-1.0 MET) •Example: Naughton treadmill test •Cycle ergometer over treadmill •poor balance, poor neuromotor coordination, impaired vision, impaired gait patterns, weight-bearing limitations, and/or foot problems. BUT local muscle fatigue may cause premature test termination when using a cycle ergometer

CABG: Special Considerations

•Surgical Wounds •Sternotomy •Donor Graft Sites •Chest Tubes & Catheter •Keep close to floor •Ventilators •Supplemental Oxygen •Telemetry •Sternal Precautions

Outpatient Exercise Programs Cont

•Symptoms or evidence of change in clinical status not necessarily related to activity (e.g., dyspnea at rest, light-headedness or dizziness, palpitations or irregular pulse, chest discomfort) •Symptoms and evidence of exercise intolerance •Change in medications and adherence to the prescribed medication regimen •ECG and HR surveillance that may consist of telemetry, Bluetooth or hardwire monitoring, "quick-look" monitoring using defibrillator paddles, periodic rhythm strips depending on the risk status of the patient and the need for accurate rhythm detection, or non-ECG HR monitoring devices

Muscular fitness

•The ACSM uses the phrase "muscular fitness" to refer collectively to muscular strength, endurance, and power. •Muscular strength and endurance are often the foundation of a general training regimen focusing on health/fitness outcomes for young and middle-aged adults, however, muscular power should be equally emphasized.

Outpatient Exercise Programs Exercise Testing

•The American College of Cardiology (ACC)/American Heart Association (AHA) 2002 guideline update for exercise testing states exercise testing early (2-3 wk) or later (3-6 wk) after hospital discharge is useful for the development of an Ex Rx in patients who suffered from MI without or with coronary revascularization. •An exercise test may also be used periodically in patients who continue to participate in supervised exercise training and CR.

altitude acclimatization

•The best indices of altitude acclimatization over time at a given elevation is a decline (or absence) of altitude sickness, improved physical performance, decreased HR, and an increase in arterial oxygen saturation (SaO2). •The presence and severity of AMS may be evaluated by the extent of its symptoms and signs. •The uncomplicated resolution of AMS or its absence in the first 3-4 d following ascent indicates a normal acclimatization response. •After about 1-2 wk of acclimatization, physical performance improves.

Patients after Cardiac Transplantation CONT

•The cardiac rehabilitation team should be aware of the following hemodynamic alterations that are commonly present during this time: •HRrest is elevated. •The HR response to exercise is abnormal such that the increase in HR during exercise is delayed and HRpeak is below normal.

Heart Failure The clinician responsible

•The clinician responsible for writing the Ex Rx and overseeing the patient's progress needs to ensure that the volume of exercise performed each week is slowly but consistently increased over time. For most patients, the prescribed volume of exercise should approximate 3-7 MET-hr × wk-1. •In general, the duration and frequency of effort should be increased before exercise intensity. •After patients have adjusted to and are tolerating aerobic training, which usually requires at least 4 wk, resistance training activities can be added.

BORG SCALE

•The modified Borg Category-Ratio 0-10 (CR10) Scale has been used extensively to measure dyspnea before, during, and after exercise. • •Give pt specific and standardized instructions. • •Being subjective, some caution is advised in their interpretation as exercise intolerance may be accompanied by exaggerated dyspnea scores without corresponding physiological confirmation.

PAD

•The pathophysiologic development of peripheral artery disease (PAD) is caused by the same process as coronary artery disease in which atherosclerotic plaque leads to significant stenosis and limitations of vasodilation, resulting in the reduction of blood flow to regions distal to the area of occlusion. •This reduction in blood flow creates a mismatch between oxygen supply and demand causing ischemia to develop in the affected areas. PAD severity can be ranked based on the presence of signs and symptoms or by the ankle/brachial pressure index (ABI).

Exercise in High Altitude

•The progressive decrease in atmospheric pressure associated with ascent to higher altitudes reduces the partial pressure of oxygen in the inspired air, resulting in decreased arterial oxygen levels.

Aerobic: Progression

•The recommended rate of progression in an exercise program depends on the individual's health status, physical fitness, training responses, and exercise program goals. Progression may consist of increasing any of the components of the FITT principle of Ex Rx as tolerated by the individual •An increase in exercise time/duration per session of 5-10 min every 1-2 wk over the first 4-6 wk of an exercise training program is reasonable for the average adult. After the individual has been exercising regularly for at least 1 month, the FIT of exercise is gradually adjusted upward over the next 4-8 months — or longer for older adults and very deconditioned individuals — to meet the recommended quantity and quality of exercise presented in the Guidelines

Muscular Fitness: Type To avoid creating muscle imbalances

•To avoid creating muscle imbalances that may lead to injury, opposing muscle groups (i.e., agonists and antagonists), such as the lower back and abdomen or the quadriceps and hamstring muscles, should be included in the resistance training routine.

Exercise Testing (cont.) - older adults

•Treadmill handrail support •Due to reduced balance, decreased muscular strength, poor neuromotor coordination, and fear. •Decrease accuracy with estimating peak MET capacity based on the exercise duration or peak workload achieved. •Treadmill workload may need to be adapted according to walking ability by increasing grade rather than speed.

trenchfoot

•Trenchfoot is accompanied by aches, increased pain, and infections, making peripheral pulses hard to detect. The exposure time needed to develop trenchfoot is quite variable, with estimates ranging from 12 hours to 3-4 days in cold-wet environments.

Other Exercise Tests COPD

•Use 6MWT and shuttle walking test on patients with severe pulmonary disease or if equipment is not available. •Commercially available instruments may help identify individuals with dynamic hyperinflation and increased dyspnea because of expiratory airflow limitations. Use of bronchodilator therapy may be beneficial for such individuals.

Aerobic FITT - older adults Type

•Walking is the most common •Aquatic exercise •Stationary cycle

exercise testing - COPD cont again

•Walking protocols may be more suitable for individuals with severe disease who lack the muscle strength to overcome the increasing resistance of cycle leg ergometers. • •Arm ergometry may result in increased dyspnea that may limit the intensity and duration of the activity. •The exercise test should be terminated with SaO2 < 80%. • •The exercise testing mode is typically walking or stationary cycling. •Intensity targets based on percentage of estimated HRmax or HRR may be inappropriate. • •HRrest can already be elevated. • •Ventilatory limitations and medications can prohibit attainment of the predicted HRmax and thus its use in intensity calculations.

Certain exercises or positions may aggravate symptoms of LBP

•Walking, especially downhill, may aggravate symptoms in individuals with spinal stenosis. •Limit any activity that causes a peripheralization of symptoms (spread of pain into lower limbs)

FITT Recommendations for Inpatient Cardiac Programs Type

•Walking. Treadmill, NuStep, Cycle can work too.

Heat cramps

•Water loss and sweating... may be a contributing factors and may play a role in cramping •Treatment includes: prolonged stretching, dietary sodium chloride (i.e., 1/8-1/4 tsp of table salt or one to two salt tablets added to 300-500 mL of fluid, bullion broth, or salty snacks), and intravenous normal saline fluid has anecdotally been reported to provide relief.

Exercise in HOT Environments

•Wear appropriate clothing •High wicking to assist with evaporation •Remove clothing or equipment (ex. Headgear) to allow heat loss •Educate others •Participants, coaches, fitness personnel, etc. •Know the signs and symptoms •Dehydration, assessment of dehydration, and fluid replacement.

Heart Failure

•When compared to normal controls, exercise tolerance is reduced approximately 30%-40%. •Because of this limitation, an exercise protocol that starts at a lower work rate and imposes smaller increases in work rate per stage should be used. •Possible advance therapies: •Continuous flow left ventricular assist device (LVAD) •Cardiac transplant

There is insufficient evidence supporting

•a clinical benefit from inspiratory muscle training (IMT) in individuals with asthma. •Use of a nonchlorinated pool is preferable because this will be less likely to trigger an asthma event. •Be aware of the possibility of asthma exacerbation shortly after exercise particularly in a high-allergen environment.

Exercise in High Altitude Medical considerations

•altitude illnesses •Rapid ascent to high and very high altitude increases individual susceptibility to altitude illness. •The primary altitude illnesses are acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE).

Children and adolescents

•are physiologically adaptive to endurance exercise training, resistance training, and bone loading exercise. •Exercise training produces improvements in cardiometabolic risk factors, weight control, bone strength, and psychosocial well-being, and may help prevent sports-related injuries; thus, the benefits of exercise are much greater than the risks

chilblains

•are the painful inflammation of small blood vessels in your skin that occur in response to repeated exposure to cold but not freezing air. Also known as pernio, chilblains can cause itching, red patches, swelling and blistering on your hands and feet.

The most common NFCIs

•are trenchfoot and chilblains. NFCIs initially appear as swollen and edematous with a feeling of numbness. The initial color is red but soon becomes pale and cyanotic if the injury is more severe.

Low back pain (LBP) is defined

•as pain, muscle tension, or stiffness localized below the rib margin and above the inferior gluteal folds, with or without leg pain. •Anywhere between 4% and 33% of the adult population experience LBP at any given point in time, and recurrent episodes of LBP can occur in over 70% of cases. •Approximately 20% of cases become chronic and about 10% of the cases progress to a disability

Outpatient Exercise Programs Routine pre exercise

•assessment of risk for exercise (see Chapters 3 and 5) should be performed before, during, and after each rehabilitation session, as deemed appropriate by the qualified staff and include the following: •HR •Blood pressure (BP) Body weight (weekly)

Chronic inflammatory disorder

•bronchial hyperresponsiveness •variable airflow limitation •recurring wheeze, dyspnea, chest tightness, and coughing that occur particularly at night or early morning. •Symptoms are often variable and reversible.

Muscular Fitness: Technique

•correct form and technique, •performing the repetitions deliberately and in a controlled manner, •moving through the full ROM of the joint, •and employing proper breathing techniques (i.e., exhalation during the concentric phase and inhalation during the eccentric phase and avoid the Valsalva maneuver).

The term older adult

•defined as individuals ≥65 yr and individuals 50-64 yr with clinically significant conditions or physical limitations that affect movement, physical fitness, or physical activity) represents a diverse spectrum of ages and physiologic capabilities. •Health and functional status are often better indicators of ability to engage in PA than chronological age.

Flexibility Exercise (Stretching) The goal of a flexibility program is to

•develop ROM in the major muscle/tendon groups in accordance with individualized goals. • •Static stretching exercises may result in a short-term decrease in muscle strength, power, and sports performance when performed immediately prior to the muscle strength and power activity is important to performance, especially with longer duration (>45 s) stretching.

Current literature - LBP

•does not support a definitive cause for initial bouts of LBP, however, previous LBP is one of the strongest predictors for future back pain episodes. •Current guidelines place a heavy emphasis on preventive measures and early interventions to minimize the risk of an acute LBP episode from becoming chronic and/or disabling. •Current best evidence guidelines for treating LBP indicate PA as a key component in managing the condition

In chronic LBP

•exercise programs that incorporate individual tailoring, supervision, stretching, and strengthening are associated with the best outcomes. •For the most favorable outcomes, use an individualized approach that addresses psychological distress, fear avoidance beliefs, self-efficacy in controlling pain, and coping strategies.

Special considerations Optimize but do not maximize

•fluid intake that (a) matches the volume of fluid consumed to the volume of sweat lost and (b) limits body weight change to <2% of body weight •Screen and monitor at-risk participants and establish specific emergency procedures •Consider heat acclimatization status, physical fitness, nutrition, sleep deprivation, and age of participants; intensity, time/duration, and time of day for exercise; availability of fluids; and playing surface heat reflection (i.e., grass vs. asphalt). Allow at least 3 h, and preferably 6 h, of recovery and rehydration time between exercise sessions.

Patients after Cardiac Transplantation Ex Rx

•for these patients does not include use of a THR but rather should include •an extended warm-up and cool-down to patient tolerance if the patient is limited by muscular deconditioning, •using RPE to monitor exercise intensity aiming for an RPE of 11-14, and •incorporation of stretching and ROM exercises

Neuromotor Exercise General recommendations for static

•gradually reduce the base of support •two-legged stand, semitandem stand, tandem stand, and one-legged stand)

Most young individuals are

•healthy and able to start moderate intensity exercise training without medical screening. Vigorous exercise can be initiated after safely participating in moderate exercise. •Because prepubescent children have immature skeletons, younger children should not participate in excessive amounts of vigorous intensity exercise.

Muscular Fitness: Volume •If the objective is mainly to improve muscular endurance rather than strength and mass...

•higher number of repetitions, perhaps 15-25, •lower intensity no more than 50% 1 RM, •shorter rest intervals and •fewer sets (i.e., 1 or 2 sets per muscle group).

Designing the FITT-VP principle of Ex Rx should include

•individual's goals •physical ability •physical fitness •health status •schedule •physical •social environment •available equipment •facilities

FITT Recommendations for Inpatient Cardiac Programs Time

•intermittent walking bouts lasting 3-5 min as tolerated •progressively increasing duration •rest period with slower walk or complete rest that is shorter than the exercise duration •Attempt to achieve a 2:1 exercise/rest ratio.

The use of oximetry

•is recommended for the initial exercise training sessions to evaluate possible exercise-induced oxyhemoglobin desaturation and to identify the workload at which desaturation occurred.

Aerobic: Duration For weight management

•longer durations of exercise (≥60-90 min ∙ d−1) may be needed, especially in individuals who spend large amounts of time in sedentary behaviors.

Exercise in Cold Environments •Swimming in water <25° C (77° F):

•may be a threat to individuals with CVD because they may not be able to recognize angina symptoms and therefore may place themselves at greater risk.

Muscular Fitness: Volume Each set should be performed to the point of

•muscle fatigue but not failure, because exerting muscles to the point of failure increases the likelihood of injury or debilitating residual muscle soreness, particularly among novices. Muscle fatigue - tired, can't finish the rep, compensating, starting to slow down Muscle failure - muscle gives out, not good

Aerobic: Frequency Vigoruous Intensity

•performed more than 5 d ∙ wk−1 can increase musculoskeletal injury •not recommended for adults who are not well conditioned.

Neuromotor Exercise General recommendations for dynamic

•perturb the center of gravity •tandem walk and circle turns

Exercise in Cold Environments •Shoveling Snow:

•raises the HR to 97% HRmax •systolic BP increases to 200 mm Hg

Exercise in Cold Environments •Walking in Snow:

•significantly increases energy requirements and myocardial oxygen demands •individuals with atherosclerotic CVD may have to slow their walking pace

Overwhelming evidence exists that supports the benefits of physical activity in

•slowing physiologic changes of aging that impair exercise capacity, •optimizing age-related changes in body composition, •promoting psychological and cognitive well-being, •managing chronic diseases, •reducing the risks of physical disability, and •increasing longevity.

Repeated movements and exercises - lbp

•such as prone pushups that promote centralization (i.e., a reduction of pain in the lower limb from distal to proximal), are encouraged to reduce symptoms in patients with acute LBP with related lower extremity pain •Flexibility exercises are generally encouraged as part of an overall exercise program. •Hip and lower limb flexibility should be promoted, although no stretching intervention studies have shown efficacy in treating or preventing LBP.

The 2008 Physical Activity Guidelines for Americans call for children and adolescents

•to engage in at least 60 min ∙ day−1 of moderate-to-vigorous intensity PA and to include vigorous intensity PA, resistance exercise, and bone loading activity on at least 3 d ∙ wk−1 •In addition to the PA guidelines, an expert panel from the National Heart, Lung, and Blood Institute and the American Academy of Pediatrics also recommend that children limit total entertainment screen time to <2 hours per day

General Considerations for Exercise Prescription Serious risk of CVD complications

•which is of particular concern in middle-aged and older adults, can be minimized by •following the preparticipation health screening and evaluation procedures outlined in Chapters 2 and 3, •beginning a new program of exercise at light-to-moderate intensity, and •employing a gradual progression of the quantity and quality of exercise.

Muscle Strengthening - older adults F

•≥2 d ∙ wk−1.

Aerobic FITT - older adults F

•≥5 d ∙ wk−1 for moderate intensity •≥3 d ∙ wk−1 for vigorous intensity •combination of moderate and vigorous intensity exercise 3-5 d ∙ wk−1.