1. Other Clinical Conditions Influencing Exercise Prescription
Cardiac Wellness Institute of Calgary
Updated May 2010

2. Material to be Covered
ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6th ed.)
Chapters 7, 8, 23, 24, 36, 37, 38
ACSM’s Guidelines for Exercise Testing and Prescription (8th ed.)
Chapter 10

3. Diabetes Mellitus
ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6th Edition) - Chapters 8, 24, 37
ACSM’s Guidelines for Exercise Testing and Prescription (8th Edition) - Chapter 10

4. Diabetes Mellitus Complex metabolic disorder Characterized by:
Abnormal glucose metabolism defects in insulin release, action, or both
Secondary microvascular degeneration

5. Diabetes Mellitus IDDM (Type I):
Caused by an acute or gradual loss of insulin-producing beta cells in the pancreas
Maintain high levels of plasma glucose
Subject to ketoacidosis
 loss of water and sugar through urine
Secondary thirst, weight loss and increased appetite

6. Diabetes Mellitus NIDDM (Type II)
Decreased sensitivity of peripheral receptors especially in SM and liver
Decreased plasma glucose
Plasma insulin usually increases

7. Diabetes Mellitus Characteristics Type I Type II Age of onset < 20
> 40
Frequency
0.5%
4-5%
Family Hx
Probable
Frequent
Symptoms
Thirst, polyuria, weight loss,  appetite
Mild or frequently none
Obesity + ++
Serum insulin
Low to zero
High (initially)
Insulin Tx
Always
20-30%

8. Diagnostic Criteria for Diabetes
Symptoms of diabetes plus casual plasma glucose concentration of ≥200 mg/dL (11.1mmol/L)
Fasting plasma glucose of ≥126 mg/dL (7.0 mmol/L) (fasting is defined as no caloric intake for at least 8 hours)
2 hour plasma glucose ≥200 mg/dL-1 during oral glucose tolerance test (OGTT)

9. Complications Wide-ranging Complications Hypo or hyperglycemia
Retinopathy
Hypertension and CAD
Autonomic neuropathy
Peripheral neuropathy
Nephropathy

10. Treatment IDDM NIDDM Subcutaneous injections of insulin (SA and LA)
Dietary regulation
Exercise daily
NIDDM
Weight loss
Oral hypoglycemics
Possibly insulin

11. Benefits of Exercise Improved insulin sensitivity
Decreased risk of CV disease:
Improved blood lipids
 caloric expenditure (improve BMI)
BP in those with hypertension
Increased fitness
Aerobic, strength and endurance, flexibility
Improved psychological well being

12. Benefits of Exercise NIDDM IDDM Reduced blood glucose and HgA1c levels
Improved glucose tolerance
Improved insulin response to oral glucose
IDDM
Improvement in insulin sensitivity may be transient

13. Response to Exercise Acute exercise results in  glucose use
Therefore  glucose production necessary to maintain normal levels
Compromised in the diabetic state

14. Screening Procedures History and Physical Exam Diabetes Evaluation
Cardiovascular Exam
Often includes clinical exercise testing

15. Clinical Exercise Testing Other Considerations
Modality – change to standard protocols or arm ergometry
Hypertensive response
Presence of silent ischemia
Postural hypotension or blunted HR response
Glucose monitoring and adjust insulin
Sub-max exercise to determine training intensity
Similar as in general population, these things need to be considered
Protocol: the old debate about sub-max vs. max; ramped protocols.
Absolute indications are clear cut, relative contraindications can be reevaluated with sound clinical judgment (know these inside-out)

16. Exercise Prescription:
Frequency
3-7 d/wk
Low – mod intensity if 7 days/week (IDDM)
Intensity
Target Heart Rate or MET level
50 -80% Karvonen method or VO2 max RPE/talk test
12-16 on a 6-20 scale
Deleted % HRmax
Deleted esp. for those with autonomic neuropathy

17. FITT Intensity Other Considerations
THR always 10bpm below:
1mm horizontal or downsloping ST segment depression
Anginal symptoms or other CV insufficiency
SBP 240mmHg, plateau SBP or SBP
DBP 110mmHg

18. FITT Intensity Other Considerations
THR always 10bpm below:
 frequency ventricular dysrhythmias
Other significant ECG disturbances
Radionuclide evidence LV dysfunction
Mod/sev wall motion abnormal with exercise
Other signs/symptoms of intolerance
Other signif ECG disturbance= 2 or 3 degree AV block, a fib, SVT, complex v. ectopy

19. Exercise Prescription
Time
20-60 minutes/session
5-10 min WU and CD
Type
Aerobic: may require non-wt bearing
Resistance: may be contraindicated, if not as per guidelines for cardiac patients

20. Prescription Guidelines: RT
1 set, reps, 8-10 exercises
2-3 days/week
RPE 11-14
Rate pressure product (RPP) during RT  exceed RPP during aerobic exercise training
Avoid Valsalva, tight grip
Exhale on exertion

21. Exercise Prescription Other Considerations
Encourage to wear medical alert ID
Encourage to exercise with a partner
Ensure adequate hydration
Reinforce proper footwear
Exercise with caution in temperature extremes
May need to limit isometric exercise

22. Precautions for Avoiding Hypoglycemic Events
Aware of signs and symptoms
Diaphoresis
Pallor
Tremor
Tachycardia
Palpitations
Visual disturbance
Mental confusion
Weakness
Lightheadedness
Fatigue
Headache
Memory loss
Seizure or coma

23. Precautions for Avoiding Hypoglycemic Events
Measure blood glucose before, during and after exercise
< 100mg/dL (5.5 mmol/L) eat CHO snack
Delay exercise if >300 mg/dL or > 240 mg/dL with postive ketones
Adjust insulin dosages associated with exercise
Avoid exercise during periods of peak insulin activity
Insulin should not be injected into an exercising muscle
Exercise late in the evening  risk of nocturnal hypoglycemia

24. Precautions for Avoiding Hyperglycemic Events
Aware of signs and symptoms of hyperglycemia:
Dehydration
Hypotension and reflex
tachycardia
Frequent urination
Impaired consciousness
Nausea
Measure blood glucose and ketones before, during and after exercise
Postpone exercise if blood glucose >300mg/dL (~16.5mmol/L)or 240 mg/dL (~ 13 mmol/L) with ketones
Vomiting
Abdominal pain
Hyperventilation
Odor of acetone on breath

25. Hypertension
ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6th Edition) - Chapters 38
ACSM’s Guidelines for Exercise Testing and Prescription (8th Edition) - Chapter 10

26. Hypertension Prevalence: 15-20% in western civilization
BP is determined by Cardiac Output and Total Peripheral Resistance

27. Classification of Hypertension
Essential (Primary) hypertension:
No single cause
Secondary hypertension:
Hypertension secondary to other disorders of the renal, endocrine, and nervous systems

28. Associated Complications
Primary risk factor for cardiovascular disease
Changes extent and presence of calcium
End-organ damage
LVH
Arteriosclerosis in retina
Renal failure

29. Lifestyle Modifications for Hypertension
Weight Loss
Limit alcohol intake
Increase aerobic physical activity
Reduce sodium intake
Maintain adequate intake of dietary potassium

30. Lifestyle Modifications for Hypertension Continued
Maintain adequate intake of dietary calcium and magnesium for general health
Stop smoking
Reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health

31. Benefits of Exercise Reduce BP Improve risk factor profile
Reduced Cardiac Output
Reduced Total Peripheral Resistance
Changes in body composition
Improve risk factor profile

32. Response to Exercise Gradually increase SBP Decrease or no change DBP
Response > in those with hypertension
Should increase > 10mmgHg and not decrease
Decrease or no change DBP
Typical range /60-85
Exaggerated response (>230/100) may predict future hypertension and/or CAD

33. Screening Procedures To diagnose should have three separate readings
If high risk would require CV Exam often includes clinical exercise testing

34. Clinical Exercise Testing Other Considerations
Standard methods and protocols
Medications taken at normal time
ECG may show LVH
Possible dysrhythmias due to diuretic treatment
Observe for exaggerated pressure response
SBP > 260 mmHg
DBP 115 mmHg
Similar as in general population, these things need to be considered
Protocol: the old debate about sub-max vs. max; ramped protocols.
Absolute indications are clear cut, relative contraindications can be reevaluated with sound clinical judgment (know these inside-out)

35. Exercise Prescription
Frequency
Most, preferably all days of the week
Intensity
Target Heart Rate or MET level
40-<60% heart rate reserve (HRR) or VO2 max
Aim for 700 – 2000 kcal/week

36. Exercise Prescription
Time
30-60 minutes/session; intermittent: minimum of 10-minute bouts accumulated to minutes
5-10 min WU and CD
Type
Aerobic
Resistance: may be contraindicated, if not as per guidelines for cardiac patients
Need to monitor BP with isometric activity

37. Exercise Prescription Other Considerations
Do not exercise if resting BP:
SBP > 200 mmHg or
DBP > 110 mmHg
Some antihypertensives may cause post exercise hypotension therefore adequate CD important
Diuretics may cause a ↓ in K+ which may result in arrhythmias
Avoid Valsalva maneuvers during RT

38. Peripheral Arterial Disease (PAD)
ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6th Edition) - Chapters 38
ACSM’s Guidelines for Exercise Testing and Prescription (8th Edition) - Chapter 10

39. Peripheral Arterial Disease (PAD)
Common manifestation of atherosclerosis
Prevalence: 10% in age 60+
Have similar risk factor profile as CV disease

40. Peripheral Arterial Disease (PAD)
Acute:
Muscle blood flow supply/demand mismatch
Chronic:
Deconditioning
Impaired oxidative metabolism
Lack of blood flow limits ability to do ADLs

41. Diagnosis of PAD Symptoms – Claudication
Intermittent muscular pain relieved with rest
Based on history and physical exam
Risk factors
Hemodynamic assessment
Auscultation of femoral arteries
ABI
Arteriography

42. Ankle/Brachial Index Resting SBP in ankle and arm by Doppler
Used to measure the severity of PAD
Abnormal ABI: <0.9 at rest or 20% ↓ after exercise
Severity not correlated to treadmill performance

43. Associated Complications
Detrimental effects on functional status
< 1-3 blocks
VO2 max typically ml/kg/min
Prevents ability to do ADLs
Ischemic ulceration
Gangrene and tissue loss

44. Treatment Medical management is marginally effective
Trental ( blood viscosity), Cilostazol
Lifestyle Modification to reduce risk factors (hypertension, smoking, and diabetes)
Surgery or angioplasty

45. Benefits of Exercise Improved functional tolerance
15-30%  in oxygen consumption
Improved walking ability
 speed and duration
Delayed onset of claudication (improvements of % of pain free walking)
Improved perception of physical functioning
Increased level of habitual exercise

46. Benefits of Exercise Improved functional tolerance may result from:
 peripheral blood flow
improved muscle metabolism
walking efficiency
Improved muscle metabolism
Walking efficiency

47. Response to Exercise
With onset of activity there is a mismatch of local muscle blood flow supply/demand
Results in localized ischemic pain that limits activity

48. Screening Procedures
CV screening should be done to assess the presence or extent of CAD
History and physical exam
Includes clinical exercise testing

49. Clinical Exercise Testing Other Considerations
Protocols should be adapted
Discontinuous to achieve VO2 max
Consider arm ergometry
Slower speed and less rapidly changing grade
Use scale for subjective ratings of pain
Record time of pain onset and point of maximal pain
Assess with functional status questionnaires
Similar as in general population, these things need to be considered
Protocol: the old debate about sub-max vs. max; ramped protocols.
Absolute indications are clear cut, relative contraindications can be reevaluated with sound clinical judgment (know these inside-out)

50. Subjective Grading Scale for PVD Pain
Grade 1 - Definite discomfort or pain, but only of initial or modest levels (established, but minimal)
Grade 2 - Moderate discomfort or pain from which the patient’s attention can be diverted, for example by conversation
Grade 3 - Intense pain (short of grade 4) from which the patient’s attention cannot be diverted
Grade 4 - Excruciating and unbearable pain

51. Exercise Prescription
Frequency
Weight-bearing aerobic exercise 3-5 d/wk
Intensity
Target Heart Rate or MET level
Moderate intensity (40- <60% HRR or VO2 max
A pain score of 3/4. Individuals should have time to allow ischemic pain to subside before resuming exercise.

52. Exercise Prescription
Time
30-60 minutes/session (can start with 10-minute bouts and exercise intermittently to accumulate minutes)
5-10 min WU and CD
Type
Aerobic:
Weight bearing exercise preferred; Non-weight bearing may be used for WU and CD
Non-weight bearing activity is encouraged
Resistance:
As per guidelines for cardiac patients

53. Exercise Prescription
Progression
Start with work load that brings on claudication pain at a level of ¾ on PVD pain scale
 work load when duration > 10 minutes
Start with 35 mins, which may be intermittent
Progress to 50 mins, 3-5 days/wk

54. Exercise Prescription Other Considerations
A cold environment may aggravate the symptoms of claudication; therefore a longer warm-up may be required
Beta blockers may  time to claudication
Improved tolerance may unmask CV ischemia

55. Pulmonary Disease
ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6th Edition) - Chapters 7, 23, 36
ACSM’s Guidelines for Exercise Testing and Prescription (8th Edition) - Chapter 10

56. Pulmonary Disease Diseases of the respiratory tract are classified as:
Obstructive Disease
Restrictive Disease
Vascular Disease

57. Chronic Obstructive Airway Disease (COPD)
Results from non-uniform narrowing in the airways secondary to inflammation
Narrowing  resistance and results in uneven distribution of minute ventilation (VE)
Characterized by:
Expiratory flow obstruction
Dyspnea at rest and with exertion
Reversible airway hyperactivity

58. COPD disorders Chronic Bronchitis:
Inflammatory disorder of the small airways in the lungs
Characterized by coughing, wheezing and sputum production
 arterial O2 saturation and CO2 levels due to hypoventilation
Flow rates can be improved with bronchodilators
Considered a “blue bloater” due to stocky habitus with central and peripheral cyanosis
Eventually can lead to right heart failure

59. COPD disorders Emphysema:
Gradual destruction of lung tissue as well as airway inflammation
Abnormal enlargement of the airspaces by destruction of the alveolar walls
Loss of lung elasticity and elastic recoil pressure
Unresponsive to bronchodilators
Pursed lips breathing
Usually not cyanotic and little sputum production
High VE
“Pink puffer” due to significant dyspnea and barrel-chest with marked lung hyperinflation

60. COPD Disorders Asthma:
Characterized by increased airway reactivity to various stimuli
Airways respond with  mucous and constriction
Results in non-productive cough and wheezing
Symptoms controlled by inhaled and oral bronchodilators

61. Diagnosis Pulmonary Function Testing Spirometry
Airway patency and air volume in/out of lungs
Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1.0) and FEV1/FVC
Lung volume
Total lung capacity (TLC), residual volume (RV)
Diffusing capacity
Rate at which gases diffuse from the lung (alveoli) to the blood in the pulmonary capillaries

62. Diagnosis Cardiopulmonary Exercise Testing (CPX)
Maximal exercise tolerance
Ventilatory limitations
Pulmonary gas exchange
CV responses to exercise

63. Treatment
Medical management
Discontinuation of smoking
Exercise

64. Benefits of Exercise Psychological benefits
Mastering something difficult
Social interaction
Distraction
Improved functional tolerance
Perceived exercise tolerance increases
Exercise endurance improves
Improvement in ability to do ADLs
Avoid downward spiral of deconditioning

65. Response to Exercise Tissues  VO2 and CO2 production
Cardiac Output and VE  to meet the demands
Typically exercise capacity is not limited by the pulmonary system as O2 transport capacity > that of the heart

66. Physiological Limiting Factors in COPD
Impaired lung mechanics
Inefficient pulmonary gas exchange
Pulmonary vascular insufficiency
Abnormal skeletal muscle metabolism

67. Screening Procedures History and Physical Exam Pulmonary Evaluation
Cardiovascular Exam
Often includes CPX

68. Clinical Exercise Testing Other Considerations
CPX for specific exercise prescription and pre/post evaluation
Cycle ergometry is often used
Monitor arterial oxygen saturation (SaO2)
<90% may require supplemental O2 during exercise
Use scale for subjective ratings of dyspnea
Keep in mind absolute and relative contraindications

69. Dyspnea Scale Nothing 0 Very, very slight 0.5 Very slight 1 Slight 2
Moderate
Somewhat severe 4
Severe 6
Very severe 8 9
Very, very severe 10

70. Dyspnea Scale +1 Light, barely noticeable +2 Moderate, bothersome
+3 Moderately severe, very uncomfortable
+4 Most severe or intense dyspnea ever experienced

71. Exercise Prescription
Frequency
3-5 d/wk
Intensity
No consensus as to the optimal exercise intensity
MET level (or THR)
60-80% peak work rates
Maximal limits as tolerated by symptoms
3-5 on Dyspnea Scale
Talk test/RPE

72. Exercise Prescription
Time: May need to start with intermittent exercise until patient is able to sustain higher intensities and durations of activity
30-50 minutes/session
5-10 min WU and CD
Type
Aerobic:
Activities involving large muscle groups
Arm ergometry
Resistance:
As per guidelines in Chapter 7 – Guidelines for Exercise Testing and Prescription

73. Exercise Prescription Other Considerations
Maintain SaO2 at > 88%
Use pursed-lips breathing
Carry bronchodilators if prescribed
Exercise indoors during times of inclement weather or if environmental irritants exist

74. Alternative Modes of Exercise Training
Continuous positive airway pressure
Upper body resistance training
Ventilatory muscle training

75. Guidelines for Inspiratory Muscle Training
1. Frequency---Minimum of 4 to 5 d·wk-1
2. Intensity---30% of maximal inspiratory pressure (PImax) measured at functional residual capacity
3. Duration---Two 15-minute sessions or one 30-minute session per day. If this cannot be achieved, the intensity should be reduced