1. Principles Of Exercise Prescription
Dave Zanghi M.S., MBA, ATC/L, CSCS, FAACVPR

2. Figure 1.1 Role of physical activity and exercise in disease prevention and rehabilitation.

3. General Principles : Mode of exercise Intensity of exercise
Duration of exercise
Frequency of exercise
Rate of progression

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

5. Some Acute & Chronic Disease Pathologies Of Concern
Cardiac Disease - MI’s, CAD, IHD
Vascular Disease - PVD, HTN, Stroke Arteriosclerosis, Atherosclerosis

6. Cancer
Metabolic Disease - Diabetes, Neuro-Endocrine Disorders

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

8. Graded Exercise Tests Low Level Graded Exercise Test
Regular Graded Exercise Test
Some examples ……...

9. Low Level Exercise Stress Test
Stage Speed Grade Dur. METS
I mph 0 % 3 min
II mph 5 % 3 min
III mph 10 % 3 min
IV mph 12 % 3 min

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

11. Bruce Protocol GXT Stage Speed Grade Dur. I 1.7 mph 10 % 3 min
II 2.5 mph 12 % 3 min
III 3.4 mph 14 % 3 min
IV 4.2 mph 16 % 3 min
V 5.0 mph 18 % 3 min
VI 5.5 mph % 3 min

12. Modified Bruce Protocol GXT
Stage Speed Grade Dur.
I 1.7 mph 0 % 3 min
II 1.7 mph 5 % 3 min
III 1.7 mph 10 % 3 min
IV 2.5 mph 12 % 3 min
V 3.4 mph 14 % 3 min
VI 4.2 mph 16 % 3 min
VII 5.0 mph 18 % 3 min

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

14. Answer No !! Cardiac patients have some special concerns such as :
Intensity of the exercise
Static and dynamic balance
Syncope and falling
Degree of cardiovascular pathology
Medications

15. The Exercise Prescription

16. Mode of Exercise Any activity : that uses large muscle groups
that is rhthymic
that is sustained below the patient’s anaerobic threshold for minutes

17. Exercise Mode - Aerobic
biking
light rowing
rebounding
ballroom dance
walking
water aerobics
nordic track
slow jogging
slow jarming
skating
slow wogging

18. MET Equivalents Archery : 4 METs Canoeing & Rowing : 6-8 METs
Cycling : METS
Ballroom Dancing : METs
Fishing : METs
Golf : METs

19. Hiking & Walking : 4 - 8 METs
Judo & Tae Kwon Do : METs
Raquetball : METs
Rope Jumping : METs
Rebounding : METs
Shuffleboard : METs

20. Ping Pong : METs
Tennis : METs
Swimming : METs
Sailing : METs
Running 12 min/mile : 9 Mets
Running 10 min/mile : 11 METs
Running 8 min/mile : METs

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

22. Intensity Of Exercise
Exercise intensity is calculated from the results of the GXT
Some examples …...

23. The GXT Report Should Have
Resting heart rate
Maximum ex. heart rate
Resting blood pressure
Maximum ex. blood pressure
Maximum METs achieved

24. How Do I Use The GXT Data ?
Use the Modified Karvonen’s Formula to set the training exercise heart rate or the training exercise blood pressure for the population with pathology.

25. (HRmax - HRrest) x (.6 - .8) + HRrest
The Karvonen Formula
Karvonen’s Formula to determine target exercise heart rate was:
(HRmax - HRrest) x ( ) + HRrest
This formula needs to be modified for use in diseased populations.

26. The target exercise heart rate should look like this for special populations:
(HRmax - HRrest) X [ Max METs/100] + HRrest
The bracketed portion of the formula containing the Max METs value is called the Activity Fraction.

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

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

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

30. What value is a symptom limited GXT to the Exercise Specialist ?
It provides a maximum exercise HR and BP at which significant signs and symptoms of ischemia begin to appear.

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

32. However………...
Seldom does the prescription ever have all of the ideal data !!

33. So ……...
How do I write the exercise prescription with only part of the GXT information ?

34. Duration of Exercise
Duration of exercise should ideally be between minutes

35. If the patient is unable to perform 30 minutes of steady state exercise, break the time into 7-8 minute stages.

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

37. Frequency Of Exercise
Frequency begins with 3days/week and progresses to 5-7days/week.
How often a person exercises/week depends on their pathology and its severity.

38. Examples…...
A Type I Insulin-Dependent Diabetic should exercise 7 days per week for glucose regulation.
A Type II Non-Insulin-Dependent Diabetic should exercise 4-5 days per week for weight control.

39. Rate Of Progression….The Art Of Exercise Prescription
Rate of progression is impacted by many factors :
type of pathology
severity of pathology
aerobic work capacity

40. Some Thoughts ……. Increase duration to 45 - 60 min
Next, increase frequency
Lastly, increase intensity

41. Once, you are up to minutes per exercise session, increase frequency from 3 times/week to 4 times/week.
Then back off to 30 min/session to allow the patient to adjust to an increase in the frequency of exercise.

42. When the patient’s exercising minutes/session for 5 times/week, it is time to increase the intensity.
Once you increase intensity, the duration and frequency may need to be adjusted to let the patient accommodate to the new intensity.

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

44. Longer Cool Down Periods
It is smart to have the patient cool down for 6-10 minutes after a steady-state exercise bout.
Many cardiac events occur after cessation of exercise.

45. Monitoring The Patient
There are a number of ways to monitor the patient during exercise.
Anginal Scale
Borg Scale
Dyspnea Scale
Blood Pressure
Heart Rate

46. Anginal Scale 1+ Light, barely noticeable 2+ Moderately bothersome
3+ Severe, very uncomfortable
4+ Most severe pain ever experienced - must stop !!!

47. Stopping Points With Angina
When a person is exercising and they complain of 2+ or 3+ angina, you must stop the exercise (ACSM).
It would be better to stop at 2+ angina rather than allow the patient to get to level 3 angina.

48. Anginal Equivalents Umbilical pain Jaw or tooth pain
Tingling/numbness in fingers/hands
Shoulder pain
Low back pain
Chest pressure

49. Borg’s Ratings Of Perceived Exertion (RPE)
7 = Very, Very Light
9 = Very Light
11 = Fairly Light
13 = Somewhat Hard
15 = Hard
17 = Very Hard

50. Dyspnea Scale 2+ Moderate Breathlessness 3+ Severe Breathlessness
1+ Light Breathlessness
2+ Moderate Breathlessness
3+ Severe Breathlessness
4+ Most Severe Breathlessness Ever Experienced

51. Blood Pressure Stop Exercise If BP Is >260/115
If BP Is >200/115 At Rest, Don’t Exercise - Refer The Patient To Their Physician

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

53. Heart Rate
Initially, for a couple of weeks, HR should remain within the calculated target training zone determined from the HR values of the symptom limited GXT. It can be advanced in blocks of 5-6 beats as the patient tolerates this increase in intensity.