Principles of Clinical Exercise

Testing & Prescription

PHTH 652: Integrated Clinical
Exercise Rehabilitation

Date: Friday September 5
th
, 2014
Jadranka Spahija, PhD, pht,
Associate Professor
School of Physical & Occupational Therapy
PHTH 652: Integrated Clinical Exercise Rehabilitation

Introduction
Course outline: course structure, objectives, materials, evaluation
Course schedule (preliminary)

Overview and Terminology
Physical activity, exercise, fitness
Health benefits and ACSM recommendations

Assessment
Health screening and risk assessment (class exercise)
General assessment
Exercise testing :
Purpose, contraindications, procedures, normal/ abnormal responses
Interpretation (class exercise)

Exercise prescription (FITT)
Methods for calculating exercise intensity: HRR, VO2R, METS

General principles of exercise prescription (Dr. Preuss)

Definitions related to Physical Activity
Physical activity:
Any form of body movement generated by skeletal muscle contraction
that results in a significant metabolic demand and energy expenditure.
Exercise:
Planned and purposeful physical activity with repetitive bodily movement
done for health and fitness pursuits.
Physical fitness:
A set of attributes or characteristics that individuals have or achieve that
relates to their ability to perform physical activity


Cardiorespiratory endurance: The ability of the circulatory and respiratory
system to supply oxygen during sustained physical activity.
Body composition: The relative amounts of muscle, fat, bone, and other
vital parts of the body.
Muscular strength: The ability of muscle to exert force.
Muscular endurance: The ability of muscle to continue to perform without
fatigue.
Flexibility: The range of motion available at a joint.
Neuromotor fitness: Motor skills such as balance, agility, coordination and
gait
HEALTH-RELATED PHYSICAL FITNESS COMPONENTS
Physical Activity and Fitness Terminology
Dose-response relationship
between physical activity and health

Important health benefits obtained by performing a moderate amount of physical
activity on most, if not all, days of the week.
Additional health benefits from greater amounts of physical activity.
Individuals who maintain a regular program of physical activity that is longer in
duration and/or is more vigorous in intensity are likely to derive greater benefit.
Type and amount of activity
What are the health benefits?
Reduction of all cause mortality
Reduction of cardiovascular events
Improved diabetic control
Improved hypertension control
Improved lipid profile
Weight reduction
Improved musculoskeletal health
Improved psychological well-being
Improved health-related quality of life
Reduced health care utilization

Increased physical activity delays premature
mortality and reducing the risks of many
chronic diseases and health conditions.
Bottom line: physical activity should be encouraged!!
ACSM-AHA Primary Physical Activity
- Recommendations -
Healthy adults, 1865 yrs of age (Initial target):

Moderate intensity aerobic physical activity for
30 minutes, 5 d/wk
or
Vigorous intensity aerobic activity for a
minimum of 20 min 3 d/wk
Combinations of moderate and vigorous
intensity exercise can be performed to meet
this recommendation.
Moderate intensity, aerobic activity can be
accumulated to total the 30 min minimum by
performing bouts each lasting 10 min.
Every adult should perform activities that
maintain or increase muscular strength and
endurance for a minimum of 2 d/wk.
Additional health benefits result from greater
amounts of physical activity. (dose-response
relationship) i.e. 300 min/wk or more of
moderate intensity, aerobic activity; 150 min/
wk or more of vigorous intensity, aerobic
activity; or an equivalent combination of
moderate and vigorous intensity, aerobic
activity.

To minimize musculoskeletal injuries, physical
activity bouts can be broken up during the
week (e.g., 30 min of moderate intensity,
aerobic activity on 5 d/wk.)




ACSM-AHA Primary Physical Activity
- Recommendations -
All individuals wishing to initiate a physical activity program should be
screened at minimum by a self-reported medical history or health risk
appraisal questionnaire.
Emphasizes identifying individuals with known disease because at greatest
risk for an exercise-related cardiac event.



ACSM Pre-participation Health Screening
- Recommendations -








Physical Activity Readiness Questionnaire (PAR-Q)
self-reported medical
history or health risk
appraisal
AHA/ACSM Health/Fitness Facility
- Pre-participation Screening Questionnaire -
CV, cardiovascular; CVD, cardiovascular disease. Ex R
x
, exercise prescription; HR, heart rate; METs, metabolic
equivalents; VO
2
R, oxygen uptake reserve.
Severe headache
Key point: Low intensity exercise is feasible for
most patients regardless of risk level
Case for Risk Assessment
Man, 55 years old, smokes at work (10-20 cigs).
Height = 70 in (177.8 cm), weight = 217 lbs (98.4 kg).
RHR=80 bpm, RBP=140/80.
Total serum cholesterol 178 mg/dL (4.61 mmol/L), LDH=106 mg/dL
(2.75 mmol/L), HDL=52mg/dL (1.35 mmol/L).
FBG=140 mg/dL (7.8 mmol/L).
Walks 1 mile twice a week.
Father had Type 2 diabetes and died at 68 years of cancer, mother alive
and well.
No CVD, no medications, reports no symptoms.

High, moderate or low risk??
Patient Assessment
General Interview
Demographics: Age, sex, height, weight
History of Present Illness
Reasons for referral, nature of admission
Chief complaint, medical diagnosis, cause and mechanism of injury
Length of illness, surgical procedures
Types of symptoms: onset, quality, quantity (intensity), frequency, duration,
exacerbating/alleviating factors, chronicity of symptoms, major interventions,
current disease status)
Other manifestations of the illness (mobility restrictions, system dysfunction)
Comorbid conditions
Medications
Dosage, route, frequency, meds including over the counter and herbal
supplements, drug intolerances
Known allergies, irritants



Patient Assessment
General Interview
Past Medical & Surgical History
All bodily systems:
o CHD = severity of CAD, date of previous MI, types of bypasses, target
vessels, pain on exertion (i.e. angina or intermittent claudication?
o Lung disease = asthma versus COPD, acute versus chronic
Family History
relevant heritable disorders in first-degree family members (cancer,
diabetes, hypercholesterolemia, sudden death, premature CAD)
Social History:
marital status, employment, transportation, housing, routine/leisure
activities, assistance at home
habits (smoking, drugs alcohol, diet etc.)
occupational, environmental & recreational exposures
social supports

Patient Assessment
General Interview
Health Care Utilization
Number of hospital admissions, average hospital LOS over the previous 12
months
Number of visits to the ER
Number of visits to the GP or specialist
Functional History
Stairs
Ambulation, assistive devices/gait aids
Activities that are particularly tiring or difficult to do?
Regular exercise: frequency, intensity, type, and duration?
Exercise capacity
What limits exercise?
Clients goals
Patient Assessment
Physical Examination
Observation
General appearance, body build, posture, position, spinal
deformities, shape of chest
Facial expression, eye movements
Interaction with family or environment, level of alertness, anxiety,
stress or distress, cognitive function
Skin integrity, coloration i.e. cyanosis, bruising , surgical incisions,
vascular insufficiency, pressure sores, etc.
Finger clubbing, ankle edema, JVD
Respiratory rate, chest expansion
Amount & quality of active movement, movement patterns,
involuntary movements, i.e. tremors, willingness to move or
guarding, ADLs, etc.
Presence of lines, leads, devices, splints, bandages etc.
Patient Assessment
Physical Examination
Pulmonary/cardiovascular
Vital signs: BP, HR (pulses), RR, temp
Height, Weight, BMI
Breathing pattern, chest expansion, auscultation, percussion, diaphragm
excursion
SaO2 rest and exercise
MSK
ROM
Strength
Functional mobility: bed, transfers, ambulation, stairs
ADLs, IADLs, transfers, ortho limitations (i.e chair to standing, floor to
standing)
Gait
Balance
Exercise tolerance: 6MWT, SWT
Neuro
Reflexes
Sensation
Muscle tone
Coordination

Patient Assessment
Previous tests
Blood work: ABGs, Complete blood count (CBC), clotting factors,
cholesterol, electrolytes, glucose, liver function tests, renal function tests
PFTs
X-ray, MRI, CT, PET, EEG, bone scans, etc.
ECG, Holter monitoring, coronary angiography, radio nucleotide or
echocardiography studies
Assessments of anxiety & depression
Nutritional assessments
Exercise tests
Exercise Testing
- Purpose -
Used to assess a patients ability to tolerate increasing intensities of
exercise.
Diagnosis
Disease severity/prognosis
Effects of medical/surgical interventions
Physical activity counseling & exercise prescription
Exercise Testing
- Participant Instructions -
No food, alcohol, or caffeine or tobacco products within 3 h of testing
No significant exertion or exercise on day of assessment.
Clothing should permit freedom of movement + walking or running shoes.
For functional or exercise prescription purposes, patients should continue
their medication regimen on their usual schedule exercise responses
consistent with responses expected during exercise training.


Exercise Testing
- Contraindications -
ABSOLUTE
Recent ischemia, MI within 2 d, or other acute cardiac event
Unstable angina
Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic
compromise
Symptomatic severe aortic stenosis
Uncontrolled symptomatic heart failure
Acute pulmonary embolus or pulmonary infarction
Acute myocarditis or pericarditis
Suspected or known dissecting aneurysm
Acute systemic infection, accompanied by fever, body aches, or swollen
lymph glands
Exercise Testing
- Contraindications -

RELATIVE
(L) main coronary artery stenosis
Moderate stenotic valvular heart disease
Electrolyte abnormalities (hypokalemia or hypomagnesemia)
Severe hypertension (resting SBP >200 mm Hg and/or DBP >110 mm Hg)
Tachydysrhythmia or bradydysrhythmia
Hypertrophic cardiomyopathy
Neuromotor, musculoskeletal, or rheumatoid disorders exacerbated by
exercise
High-degree atrioventricular block ( 2
nd
& 3
rd
degree)
Ventricular aneurysm
Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or
myxedema)
Chronic infectious disease (e.g., HIV, mononucleosis, hepatitis)
Mental or physical impairment leading to inability to exercise adequately

Exercise Testing
- Modes -
Field tests : 6MWT, SWT
Graded exercise tests: cycle ergometer, treadmill tests
Functional tests: step, sit to stand, timed up and go
Exercise Testing
- Cardiorespiratory Measures -
Hemodynamics:
HR, SBP/DBP responses.
ECG waveforms:
ST segment displacement and supraventricular/ventricular
dysrhythmias
Subjective ratings
RPE (Borg 6-22 or 0-10; VAS)
Limiting clinical signs or symptoms
Patient appearance,
Pain: angina, legs etc
Gas exchange and ventilatory response ( e.g. VO2 max and VE)
SpO2
NOTE: ST-segment changes that occur only during the post-exercise
period currently recognized as an important diagnostic part of the
test.

Heart Rate Response during Exercise
Normal HR response:
Linear increase (10 2 beats MET
1
) with progressive exercise
(physically inactive individuals)
HRmax = 220-age
HR recovery:
12 beats /min at 1 min (walking in recovery)
22 beats / min at 2 min (supine position in recovery)

Chronotropic incompetence :
Failure of HR to despite workload
Unable to reach 85% of the age-predicted HR
max
(when not on any -
blockers)
Slowed HR recovery associated with poor prognosis

Blood Pressure Response during Exercise
Normal BP response:
Progressive increase in SBP = 10 2 mm Hg MET
1
; a possible
plateau at peak exercise
no change or slight decrease in DBP

Abnormal BP response:
Hypertensive response: SBP >250 mm Hg or DBP >115 mm Hg
SBP that fails to rise or falls [>10 mm Hg]) is abnormal response
may signify MI and/or LV dysfunction
A widening of the pulse pressure
SBP <140 mm Hg at max exercise suggests poor prognosis

Normal VE response:
ventilatory demand ( VE )
metabolic rate
PaCO
2

VD/VT
VEmax/MVV ratio normally 0.80.
VEmax/MVV > 0.80 = possible pulmonary limitation to exercise
ventilatory capacity ( MVV)
in both obstructive and restrictive lung diseases
(MVV estimated from FEV
1
x 40)
Combination of reduced MVV and increased VE

Ventilatory Response during Exercise
Ventilatory Efficiency
Normal VE/VCO
2
slope value <30.
slope = strongly prognostic in
patients with heart failure and
patients with pulmonary
hypertension.
Values of 45 = particularly poor
prognosis in patients with heart
failure.
Elevated values clearly indicative of
worsening ventilation perfusion
abnormalities in heart failure and
pulmonary hypertension
accurate depiction of
disease severity
Indications for Terminating GXT
SBP >10 mm Hg from baselines despite work rate or if SBP decreases
below value obtained in same position prior to testing
Hypertensive response: SBP > 250mm Hg and/or DBP > 115 mmHg
Onset of angina or angina like symptoms
Failure of HR to despite workload
Signs of hypoperfusion:
light-headedness, confusion, ataxia, dizziness, pallor, cyanosis,
nausea, or cold and clammy skin.
ST elevation (+1.0 mm); ST depression > 2mm horizontal
Fatigue, SOB, wheezing, leg cramps, or claudication
Technical difficulties monitoring the ECG or SBP
Subject requests to stop


GXT Interpretation
Predicted Maximum Exercise Values
HRmax
HRmax = 220-age

VO
2
max
Males: VO
2
max (L/min) = [3.45* ht (m)] [0.028 * age (yrs)] + [0.022 * wt (kg)] - 3.76
Females: VO2max (L/min) = [2.49* ht (m)] [0.018 * age (yrs)] + [0.010 * wt (kg)] 2.26

Workload
Males: ([2169 * ht (m)] [9.63 * age (yrs)] + [4.00 * wt (kg)] 2413) 6.12
Females: ([950*ht (m)] [9.21* age (yrs)] + [6.1* wt (kg)] 765) 6.12

Oxygen Pulse
O
2
pulse = VO
2
max predicted/HR predicted


CPET Interpretation: Normal reference values

Variables Criteria of Normality
Maximum or Peak VO
2
& Cycle Work Rate >85% predicted
Anaerobic (AT) or Ventilatory (T
vent
) Threshold >40% predicted VO
2
max
Respiratory exchange ration (RER) > 1.10
Maximum or Peak Heart Rate >85% age predicted
Maximum or Peak Heart Rate Reserve <20 beats/min
Maximum or Peak Blood Pressure <220/90
Maximum or Peak O
2
pulse (VO
2
HR) >80% predicted
Maximum or Peak Ventilatory Reserve >11 L/min or <80%MVV
Maximum or Peak Breathing Frequency <60 breaths/min
Maximum or Peak Tidal Volume <80% IC or <70% of VC
V
E
/VCO
2
ratio at AT or T
vent
and at Maximum or Peak

<32-34 and <36-40
V
E
/VCO
2
slope <30
Maximum or Peak V
D
/V
T
<0.28 for age < 40 yrs; <0.30 for age > 40 yrs
Maximum or Peak SaO
2
(arterial blood O
2
saturation) Change in SaO
2
of <5% from baseline
Maximum or Peak Dyspnea & Leg Discomfort ratings 5-8 at a peak VO
2
or WR >85% predicted
Modified from Dennis Jensen EDKP 485: Exercise Pathophysiology course notes 2012
Case study
50yearold male long time smoker, referred for exertional dyspnea.
Symptomatic after walking one block.
Height 168 cm; weight 66 kg; BMI 23.4
Table 1. Demographic information and resting PFT data
Measurement Predicted Measured % Pred
VC, L 4.06 4.10 101
IC, L 2.71 3.30 122
TLC, L 5.92 7.07 119
FEV
1
, L 3.22 2.57 80
FVC, L 4.08 4.08 100
FEV
1
/FVC (%) 79 63 80
MVV, L/min 141 91 65
DLCO (mL/mmHg/min) 25.4 14.7 58%
Case study
GXT on cycle ergometer: 3 min
resting breathing, 3 minutes
without added load and WR
then increased by 15 watts per
min to tolerance.
Patient stopped exercise
because of SOB (Dyspnea 7
Borg, leg fatigue 7 Borg)
No chest pain, occasional
multifocal PVCs during exercise
and recovery.
Selected cardiopulmonary exercise test data
Measurement Predicted Measured % Pred
Peak WR (watts) 166 113 68
Peak VO2 (L/min) 2.09 1.39 67
Peak HR (beats/min) 170 126 74
Peak O2 pulse (mL /beat) 12.2 11.0 90
Peak VE (L/min) MVV = 91 89 98
Exercise breathing reserve (L/min) >15 2
VE/VCO2 ratio at AT 27.2 53.3 195
SaO2 (%) [Rest , Peak Exercise ] 93, 88 -
Time
(min)
Work Rate
(Watts)
BP
(mmHg)
HR
(beats/min)
Fb
(bpm)
VE
(L/min)
VO2
(L/min)
VCO2
(L/min)
O2 pulse
(mL/beat)
RER PETCO2
(mmHg)
VE/VCO2
(%)
0 (Rest) 120/80 77 18 17.8 0.33 0.27 4.3 0.82 22 60
6 0 140/90 88 22 31.9 0.67 0.57 7.6 0.85 23 53
7 15 88 22 33.2 0.67 0.60 7.6 0.90 24 52
8 30 140/90 91 25 40.9 0.69 0.68 7.6 0.99 22 57
9 45 93 25 44.9 0.86 0.80 9.2 0.93 24 53
10 60 150/92 105 28 55.3 0.99 1.01 9.4 1.02 24 52
11 75 111 31 66.8 1.12 1.21 10.1 1.08 24 53
12 90 160/100 117 37 75.2 1.22 1.35 10.4 1.11 24 53
13 105 124 41 87.9 1.34 1.54 10.8 1.15 24 55
13.5 (Peak) 113 160/100 126 41 89.3 1.39 1.60 11.0 1.15 23 54
Exercise Prescription
FITT-VP principle
Frequency (how often)
Intensity (how hard)
Time (duration or how long)
Type (mode or what kind)
Total Volume (amount)
Progression (advancement)


Exercise prescription
- Heart Rate Reserve Method (Karvonen) -
Predicted HRmax = 220-age

Direct method of HR max determination from GXT is preferred method for
persons with:
low fitness levels
cardiovascular and/or pulmonary disease
taking medications (e.g. Beta-blockers) that affect the HR response to
exercise.
Aerobic Exercise Prescription
- Heart Rate Reserve Method (Karvonen) -
Heart rate reserve (HRR) = HRmax HRrest
HRrest = 60 bpm ; HRmax = 180 bpm
HRR = 180 - 60 = 120 bpm

Target HR (THR) = [HRR % intensity desired] + HRrest
Desired exercise intensity range: 50-60% HRR
50% HRR = (120x0.50) = 60 bpm
60% HRR= (120x0.60) = 72 bpm

THR range (THRR)
Lower THR = 60+60 + 120 bpm
Upper THR = 72+70=132 bpm
THRR = 120-132 bpm

Aerobic Exercise Prescription
- VO
2
Reserve Method -
VO
2
reserve (VO
2
R) = VO2max-VO2rest
VO2 max = 30 ml/kg/min
VO2rest = 3.5 ml/kg/min
VO2R = 30-3.5=26.5 ml/kg/min

Target VO
2
= (VO
2
R x %intensity)+VO
2
rest
Desired exercise intensity range: 50-60%
50% VO
2
R: = (26.5*0.5) = 13.3 ml/kg/min

60% VO
2
R = (26.5*0.6) = 15.9 ml/kg/min

Target VO
2
R range
Lower target range = 13.3+3.5 = 16.8 ml/kg/min
Upper target range = 15.9+3.5 = 19.4 ml/kg/min
Target VO2 range = 16.8-19.4 ml/kg/min
Aerobic Exercise Prescription
MET calculation
Target VO
2
range = 16.8-19.4 ml/kg/min
1 MET = 3.5 ml/kg/min

Lower MET target= 16.8/3.5 = 4.8 METS
Upper MET target= 19.4/3.5=5.5 METS

Identify physical activities requiring EE within from the table the
Target range