Principles Of Exercise Prescription

……Art and Science

Principles Of Exercise Prescription

……Art and Science

David Arnall, Ph.D., PTDavid Arnall, Ph.D., PT

General PrinciplesGeneral Principles : : Mode of exerciseMode of exercise Intensity of exerciseIntensity of exercise Duration of exerciseDuration of exercise Frequency of exerciseFrequency of exercise Rate of progressionRate of progression

The The general parametersgeneral parameters of exercise of exercise prescription hold true for prescription hold true for individuals who are healthy as well individuals who are healthy as well as those patients who have disease as those patients who have disease pathology. However, there must be pathology. However, there must be some special considerations for some special considerations for those that have disease.those that have disease.

Some Acute & Chronic Disease Pathologies Of

Concern

Some Acute & Chronic Disease Pathologies Of

Concern

Cardiac Disease - MI’s, CAD, IHDCardiac Disease - MI’s, CAD, IHD Vascular Disease - PVD, HTN, Stroke Vascular Disease - PVD, HTN, Stroke

Arteriosclerosis, AtherosclerosisArteriosclerosis, Atherosclerosis

CancerCancer Metabolic Disease - Diabetes, Neuro-Metabolic Disease - Diabetes, Neuro-

Endocrine Disorders Endocrine Disorders

Patient’s With PathologyPatient’s With Pathology

Exercise is not prescribed for Exercise is not prescribed for these individuals until the patient these individuals until the patient has undergone a graded exercise has undergone a graded exercise stress test (GXT) under the stress test (GXT) under the direction of their physician.direction of their physician.

Graded Exercise TestsGraded Exercise Tests

Low Level Graded Exercise TestLow Level Graded Exercise Test Regular Graded Exercise TestRegular Graded Exercise Test

Some examples ……...Some examples ……...

Low Level Exercise Stress TestLow Level Exercise Stress Test

Stage Speed Grade Dur. METSStage Speed Grade Dur. METS

II 1.7 mph 0 % 1.7 mph 0 % 3 min 2.3 3 min 2.3

IIII 1.7 mph 5 % 1.7 mph 5 % 3 min 3.5 3 min 3.5

III 1.7 mph 10 %III 1.7 mph 10 % 3 min 4.6 3 min 4.6

IVIV 2.5 mph 12 % 3 min 6.8 2.5 mph 12 % 3 min 6.8

The low level GXT is given to The low level GXT is given to patient’s with significant cardiac patient’s with significant cardiac damage and who have an damage and who have an exercise capacity lower than 8 exercise capacity lower than 8 METsMETs

Bruce Protocol GXTBruce Protocol GXTStageStage SpeedSpeed GradeGrade Dur. Dur.

II 1.7 mph 10 %1.7 mph 10 % 3 min3 min

IIII 2.5 mph 12 %2.5 mph 12 % 3 min3 min

IIIIII 3.4 mph 14 %3.4 mph 14 % 3 min3 min

IVIV 4.2 mph 16 %4.2 mph 16 % 3 min3 min

VV 5.0 mph 18 %5.0 mph 18 % 3 min3 min

VIVI 5.5 mph5.5 mph 20 % 3 min 20 % 3 min

Modified Bruce Protocol GXTModified Bruce Protocol GXTStageStage SpeedSpeed GradeGrade Dur. Dur.

II 1.7 mph 0 %1.7 mph 0 % 3 min3 min

IIII 1.7 mph 5 %1.7 mph 5 % 3 min3 min

IIIIII 1.7 mph 10 %1.7 mph 10 % 3 min3 min

IVIV 2.5 mph 12 %2.5 mph 12 % 3 min3 min

VV 3.4 mph 14 %3.4 mph 14 % 3 min3 min

VIVI 4.2 mph 16 %4.2 mph 16 % 3 min3 min

VIIVII 5.0 mph5.0 mph 18 % 18 % 3 min3 min

USAFSAM GXTUSAFSAM GXTStageStage SpeedSpeed GradeGrade Dur.Dur.

II 2.0 mph2.0 mph 0 % 0 % 3 min3 min

IIII 3.3 mph3.3 mph 0 % 0 % 3 min3 min

IIIIII 3.3 mph3.3 mph 5 % 5 % 3 min3 min

IVIV 3.3 mph3.3 mph 10% 10% 3 min3 min

VV 3.3 mph3.3 mph 15% 15% 3 min3 min

VIVI 3.3 mph3.3 mph 20% 20% 3 min3 min

Question ?Question ?

Are the same aerobic activities Are the same aerobic activities appropriate for both the cardiac appropriate for both the cardiac patient and the healthy individual ?patient and the healthy individual ?

AnswerAnswer No !! Cardiac patients have some special No !! Cardiac patients have some special

concerns such as :concerns such as :Intensity of the exerciseIntensity of the exerciseStatic and dynamic balanceStatic and dynamic balanceSyncope and fallingSyncope and fallingDegree of cardiovascular pathologyDegree of cardiovascular pathology MedicationsMedications

The Exercise PrescriptionThe Exercise Prescription

Mode of ExerciseMode of Exercise Any activity :Any activity :

that uses large muscle groupsthat uses large muscle groups that is rhthymicthat is rhthymic that is sustained below the that is sustained below the

patient’s anaerobic threshold for patient’s anaerobic threshold for 15-60 minutes15-60 minutes

Exercise Mode - AerobicExercise Mode - Aerobic bikingbiking light rowinglight rowing reboundingrebounding ballroom danceballroom dance walkingwalking water aerobicswater aerobics

nordic tracknordic track slow joggingslow jogging slow jarmingslow jarming skatingskating slow woggingslow wogging

MET EquivalentsMET Equivalents

Archery : 4 METsArchery : 4 METs Canoeing & Rowing : 6-8 METsCanoeing & Rowing : 6-8 METs Cycling : 5 - 8 METSCycling : 5 - 8 METS Ballroom Dancing : 5 - 9 METsBallroom Dancing : 5 - 9 METs Fishing : 4 - 6 METsFishing : 4 - 6 METs Golf : 4 - 7 METsGolf : 4 - 7 METs

Hiking & Walking : 4 - 8 METsHiking & Walking : 4 - 8 METs Judo & Tae Kwon Do : 10 - 16 METsJudo & Tae Kwon Do : 10 - 16 METs Raquetball : 8 - 14 METsRaquetball : 8 - 14 METs Rope Jumping : 9 - 12 METsRope Jumping : 9 - 12 METs Rebounding : 6 - 10 METsRebounding : 6 - 10 METs Shuffleboard : 3 - 4 METsShuffleboard : 3 - 4 METs

Ping Pong : 3 - 6 METsPing Pong : 3 - 6 METs Tennis : 4 - 12 METsTennis : 4 - 12 METs Swimming : 4 - 12 METsSwimming : 4 - 12 METs Sailing : 4 - 9 METsSailing : 4 - 9 METs Running 12 min/mile : 9 MetsRunning 12 min/mile : 9 Mets Running 10 min/mile : 11 METsRunning 10 min/mile : 11 METs Running 8 min/mile : 13 - 15 METsRunning 8 min/mile : 13 - 15 METs

The various modes of exercise The various modes of exercise must be specifically tailored to the must be specifically tailored to the patient’s physical needs such as :patient’s physical needs such as : aerobic work capacityaerobic work capacity physical condition & disease statephysical condition & disease state availability of equipmentavailability of equipment patient’s interest & family supportpatient’s interest & family support

Intensity Of ExerciseIntensity Of Exercise

Exercise intensity is Exercise intensity is calculatedcalculated from the results of the GXTfrom the results of the GXT

Some examplesSome examples …... …...

The GXT Report Should HaveThe GXT Report Should Have Resting heart rateResting heart rate Maximum ex. heart rateMaximum ex. heart rate Resting blood pressureResting blood pressure Maximum ex. blood pressureMaximum ex. blood pressure Maximum METs achievedMaximum METs achieved

How Do I Use The GXT Data ?How Do I Use

The GXT Data ?

Use the Modified Karvonen’s Use the Modified Karvonen’s Formula to set the training Formula to set the training exercise heart rate or the training exercise heart rate or the training exercise blood pressure for the exercise blood pressure for the population with pathology.population with pathology.

The Karvonen FormulaThe Karvonen Formula

Karvonen’s Formula to determine Karvonen’s Formula to determine target exercise heart rate was:target exercise heart rate was:

(HR(HRmaxmax - HR - HRrestrest) x) x (.6 - .8) + HR(.6 - .8) + HRrestrest

This formula needs to be modified for use in This formula needs to be modified for use in diseased populations.diseased populations.

The target exercise heart rate should The target exercise heart rate should look like this for special populations:look like this for special populations:

(HR(HRmaxmax - HR - HRrestrest) ) XX [.4 - .8 + Max METs/100][.4 - .8 + Max METs/100] + HR+ HRrestrest

The bracketed portion of the formula containing the Max The bracketed portion of the formula containing the Max METs value is called the METs value is called the Activity FractionActivity Fraction..

Advantages Of This Modified Karvonen’s Formula

Advantages Of This Modified Karvonen’s Formula

Advantage # 1 : The modified Advantage # 1 : The modified Karvonen’s Formula has a Karvonen’s Formula has a low low starting activity fractionstarting activity fraction to to accommodate exercising patients accommodate exercising patients with cardiac disease. with cardiac disease.

Advantage # 2 : The adjusted Advantage # 2 : The adjusted target heart rate for the patient target heart rate for the patient with disease is calculated on the with disease is calculated on the heart rate, blood pressure and heart rate, blood pressure and Max METs achieved during the Max METs achieved during the symptom limited GXTsymptom limited GXT . .

What Is A Symptom Limited GXT ?

What Is A Symptom Limited GXT ?

A symptom limited GXT is a stress A symptom limited GXT is a stress test in which the physician recorded test in which the physician recorded the onset of symptoms (angina, ST the onset of symptoms (angina, ST segment depression) at the specific segment depression) at the specific heart rate, blood pressure and stage heart rate, blood pressure and stage of the GXT.of the GXT.

What value is a symptom limited What value is a symptom limited GXT to the Exercise Specialist ?GXT to the Exercise Specialist ? It provides a maximum exercise HR It provides a maximum exercise HR

and BP at which significant signs and BP at which significant signs and symptoms of ischemia begin to and symptoms of ischemia begin to appear. appear.

All exercise prescriptions are written using All exercise prescriptions are written using the modified Karvonen’s Formula to insure the modified Karvonen’s Formula to insure that the patient’s exercise training intensity is that the patient’s exercise training intensity is significantly lower than the maximum significantly lower than the maximum symptom limited exercise HR & BP values symptom limited exercise HR & BP values avoiding the onset of myocardial ischemia.avoiding the onset of myocardial ischemia.

However………...However………...

Seldom does the prescription ever Seldom does the prescription ever have all of the ideal datahave all of the ideal data !!!!

So ……...So ……...

How do I write the exercise How do I write the exercise prescription with only part of the prescription with only part of the GXT information ?GXT information ?

What If……...What If……... Only the blood pressure data is Only the blood pressure data is

availableavailable : : Max. Exercise Systolic BP = 180 mm HgMax. Exercise Systolic BP = 180 mm Hg Resting Systolic BP = 88 mm HgResting Systolic BP = 88 mm Hg

Target Ex. Systolic BP = (180-88) x (.6) + 88Target Ex. Systolic BP = (180-88) x (.6) + 88

= = 143 mm Hg143 mm Hg

What If……...What If……... Only the heart rate data is availableOnly the heart rate data is available : :

Max. Ex. HR = 140 BPMMax. Ex. HR = 140 BPM Rest HR = 80 BPMRest HR = 80 BPM

Target Ex. HR = (140 - 80) x (.6) + 80Target Ex. HR = (140 - 80) x (.6) + 80

= = 116 BPM116 BPM

What If……...What If……... Only the Max METs data is availableOnly the Max METs data is available : :

Max METs Achieved = 7 METsMax METs Achieved = 7 METs

Ex. MET level = 7 METs x (.6 + 7/100)Ex. MET level = 7 METs x (.6 + 7/100)

= 4.69 METs= 4.69 METs

What Is A MET ?What Is A MET ?

A MET is a metabolic equivalent A MET is a metabolic equivalent and has the value of :and has the value of :

3.5 ml O3.5 ml O22/Kg/min/Kg/min

So…...So…... If I am performing a 10 MET If I am performing a 10 MET

activity, the oxygen utilization for activity, the oxygen utilization for this activity is :this activity is :

10 METs x 3.5 = 35 ml O10 METs x 3.5 = 35 ml O22/Kg/min/Kg/min

Examples…...Examples…...

A MET is a measure of energy A MET is a measure of energy cost for a particular activity.cost for a particular activity. Fishing In A Stream = 5-6 METsFishing In A Stream = 5-6 METs Social Dancing = 6-9 METsSocial Dancing = 6-9 METs Touch Football = 6-10 METsTouch Football = 6-10 METs Scuba Diving = 10-12 METsScuba Diving = 10-12 METs

METs can be a useful measure for a METs can be a useful measure for a variety of calculations particularly in variety of calculations particularly in terms of helping patients to terms of helping patients to understand physical work capacity understand physical work capacity (VO2 = ml/Kg/min measurements) (VO2 = ml/Kg/min measurements) or in terms of loosing weight (see or in terms of loosing weight (see next slide).next slide).

The ACSM recommends minimal The ACSM recommends minimal thresholds of 300 kcals per exercise thresholds of 300 kcals per exercise session performed 3 days/week or session performed 3 days/week or 200 kcals per exercise session 200 kcals per exercise session performed 4 days/week.performed 4 days/week.

This This minimumminimum recommendation recommendation suggests that exercise prescription suggests that exercise prescription target a weekly exercise caloric target a weekly exercise caloric expenditure of about 1,000 kcals.expenditure of about 1,000 kcals.

For For optimal results in physical optimal results in physical fitnessfitness, the ACSM recommends , the ACSM recommends bringing the weekly caloric bringing the weekly caloric expenditure up to 2,000 kcals as expenditure up to 2,000 kcals as health and fitness permits.health and fitness permits.

How Can I Transform METs Into Calories Expended ?

How Can I Transform METs Into Calories Expended ?

Kcal/min = Kcal/min = (METs) x 3.5 x (Weight in Kg)(METs) x 3.5 x (Weight in Kg)

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Problem …...Problem …...Goal : To expend 1,000 Kcals/wkGoal : To expend 1,000 Kcals/wk

Ex. : Walking @ 3.5 mph (6.1 METs)Ex. : Walking @ 3.5 mph (6.1 METs)Weight : 70 Kg (154 lbs.)Weight : 70 Kg (154 lbs.)

(6.1 x 3.5) x 70(6.1 x 3.5) x 70 = 7.47 kcals/min = 7.47 kcals/min

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Practical Application - Prob. # 1Practical Application - Prob. # 1

Take Take 1,000 kcals/week1,000 kcals/week = 134 min/week = 134 min/week

7.47 kcals/min7.47 kcals/minPrescriptionPrescription : :

45 min per day/3 days/week45 min per day/3 days/week

33 min per day/4 days/week33 min per day/4 days/week

27 min per day/5 days/week27 min per day/5 days/week

22 min per day/6 days/week22 min per day/6 days/week

19 min per day/7 days/week19 min per day/7 days/week

Problem # 2Problem # 2

Goal : To expend 2,000 Kcals/wkGoal : To expend 2,000 Kcals/wk Ex. : Walking @ 3.5 mph = 6.1 METs Ex. : Walking @ 3.5 mph = 6.1 METs Weight : 127 Kg ( 279 lbs.)Weight : 127 Kg ( 279 lbs.)

(6.1 x 3.5) x 127 (6.1 x 3.5) x 127 = 13.6 kcal/min = 13.6 kcal/min

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2,000 kcals/week 2,000 kcals/week = 148 min ex./week = 148 min ex./week

13.5 kcals/min13.5 kcals/min

PrescriptionPrescription : :

49 min of exercise 3 days/week49 min of exercise 3 days/week

37 min of exercise 4 days/week37 min of exercise 4 days/week

30 min of exercise 5 days/week30 min of exercise 5 days/week

25 min of exercise 6 days/week25 min of exercise 6 days/week

21 min of exercise 7 days/week21 min of exercise 7 days/week

Duration of ExerciseDuration of Exercise

Duration of exercise should Duration of exercise should ideally be between 15 - 60 ideally be between 15 - 60 minutesminutes

If the patient is unable to If the patient is unable to perform 15 minutes of steady perform 15 minutes of steady state exercise, break the time into state exercise, break the time into two 7-8 minute stages.two 7-8 minute stages.

Research has shown that Research has shown that multiple small bouts of exercise multiple small bouts of exercise added together have the same added together have the same training effect as a single bout of training effect as a single bout of exercise of the same total exercise of the same total duration.duration.

Frequency Of ExerciseFrequency Of Exercise

Frequency begins with 3days/week Frequency begins with 3days/week and progresses to 5-7days/week.and progresses to 5-7days/week.

How often a person exercises/week How often a person exercises/week depends on their pathology and its depends on their pathology and its severity.severity.

Examples…...Examples…... A Type I Insulin-Dependent Diabetic A Type I Insulin-Dependent Diabetic

should exercise 7 days per week for should exercise 7 days per week for glucose regulation.glucose regulation.

A Type II Non-Insulin-Dependent A Type II Non-Insulin-Dependent Diabetic should exercise 4-5 days per Diabetic should exercise 4-5 days per week for weight control.week for weight control.

Rate Of Progression….The Art Of Exercise PrescriptionRate Of Progression….The Art Of Exercise Prescription

Rate of progression is impacted Rate of progression is impacted by many factors :by many factors : type of pathologytype of pathology severity of pathologyseverity of pathology aerobic work capacityaerobic work capacity

Some Thoughts …….Some Thoughts …….

Increase duration to 45 - 60 minIncrease duration to 45 - 60 min Next, increase frequencyNext, increase frequency Lastly, increase intensityLastly, increase intensity

Once, you are up to 45 - 60 minutes Once, you are up to 45 - 60 minutes per exercise session, increase per exercise session, increase frequency from 3 times/week to 4 frequency from 3 times/week to 4 times/week.times/week.

Then back off to 30 min/session to Then back off to 30 min/session to allow the patient to adjust to an allow the patient to adjust to an increase in the frequency of exercise.increase in the frequency of exercise.

When the patient’s exercising 45 - 60 When the patient’s exercising 45 - 60 minutes/session for 5 times/week, it is minutes/session for 5 times/week, it is time to increase the intensity.time to increase the intensity.

Once you increase intensity, the Once you increase intensity, the duration and frequency may need to duration and frequency may need to be adjusted to let the patient be adjusted to let the patient accommodate to the new intensity.accommodate to the new intensity.

Warm Up & Cool DownWarm Up & Cool Down

All patients with pathology as well as All patients with pathology as well as the healthy individual should have a the healthy individual should have a 4-6 minute warm up period and a 6-10 4-6 minute warm up period and a 6-10 minute cool down period.minute cool down period.

Longer Cool Down PeriodsLonger Cool Down Periods

It is smart to have the patient cool It is smart to have the patient cool down for 6-10 minutes after a down for 6-10 minutes after a steady-state exercise bout.steady-state exercise bout.

Many cardiac events occur after Many cardiac events occur after cessation of exercise.cessation of exercise.

Monitoring The PatientMonitoring The Patient

There are a number of ways to There are a number of ways to monitor the patient during exercise.monitor the patient during exercise. Anginal ScaleAnginal Scale Borg ScaleBorg Scale Dyspnea ScaleDyspnea Scale Blood PressureBlood Pressure Heart RateHeart Rate

Anginal ScaleAnginal Scale

1+1+ Light, barely noticeableLight, barely noticeable 2+2+ Moderately bothersomeModerately bothersome 3+3+ Severe, very uncomfortableSevere, very uncomfortable 4+4+ Most severe pain ever Most severe pain ever

experienced - must experienced - must stop !!!stop !!!

Stopping Points With AnginaStopping Points With Angina

When a person is exercising and they When a person is exercising and they complain of 2+ or 3+ angina, you complain of 2+ or 3+ angina, you must stop the exercise (ACSM).must stop the exercise (ACSM).

It would be better to stop at 2+ It would be better to stop at 2+ angina rather than allow the patient angina rather than allow the patient to get to level 3 angina.to get to level 3 angina.

Anginal EquivalentsAnginal Equivalents Umbilical painUmbilical pain Jaw or tooth painJaw or tooth pain Tingling/numbness in fingers/handsTingling/numbness in fingers/hands Shoulder painShoulder pain Low back painLow back pain Chest pressureChest pressure

Borg’s Ratings Of Perceived Exertion (RPE)

Borg’s Ratings Of Perceived Exertion (RPE)

7 7 = Very, Very Light= Very, Very Light

9 9 = Very Light= Very Light

1111 = Fairly Light= Fairly Light

1313 = Somewhat Hard= Somewhat Hard1515 = Hard= Hard

1717 = Very Hard= Very Hard

Dyspnea ScaleDyspnea Scale

1+1+ Light BreathlessnessLight Breathlessness

2+2+ Moderate BreathlessnessModerate Breathlessness

3+3+ Severe BreathlessnessSevere Breathlessness

4+4+ Most Severe Breathlessness Most Severe Breathlessness Ever Ever ExperiencedExperienced

Blood PressureBlood Pressure

Stop Exercise If BP Is >260/115Stop Exercise If BP Is >260/115

If BP Is >200/115 At Rest, Don’t If BP Is >200/115 At Rest, Don’t Exercise - Refer The Patient To Exercise - Refer The Patient To Their PhysicianTheir Physician

Sometimes the diastolic pressure rises Sometimes the diastolic pressure rises 8 - 10 mm Hg pressure during 8 - 10 mm Hg pressure during exercise. If it rises more than this, exercise. If it rises more than this, consider referring the patient to their consider referring the patient to their physician. In most cases, diastolic physician. In most cases, diastolic pressure remains the same or falls pressure remains the same or falls during exercise from its pre-exercise during exercise from its pre-exercise rest value.rest value.

Heart RateHeart Rate Initially, for a couple of weeks, Initially, for a couple of weeks,

HR should remain within the HR should remain within the calculated target training zone calculated target training zone determined from the HR values determined from the HR values of the symptom limited GXT. It of the symptom limited GXT. It can be advanced in blocks of 5-6 can be advanced in blocks of 5-6 beats as the patient tolerates this beats as the patient tolerates this increase in intensity. increase in intensity.