1. The only notes from chapter 9 & 10 you will need to know for the final

2. Chapter 9 Exercise Prescription for Patients with Cardiac Disease

6. Coronary Angiogram Showing Area of Occlusion

7. Outpatient Programs 1-2 weeks post discharge Phase 1: is in patient. Ambulate 2-4 times per day for 3-5 minutes to 10-15 minutes. Limit HR to + 20 bpm above rest for CHF and Post MI. For post surgery limit HR to + 30 bpm above rest. Phase 2: Review entire medical history. 12 weeks monitored, outpatient basis. BP taken at regular intervals. Pre, during, post exercise. RPE as well. Phase 3: Outpatient, unmonitored but supervised.

8. Exercise Prescription: Frequency Most days of the week (4–7 d·wk -1 ) If very limited, multiple short (1- to 10-minute) sessions Encourage independent exercise. Hobbies, work, shopping. Walking ~ 30 mins/day or 3,000-4,000 steps.

9. Exercise Prescription: Intensity RPE of 11 to 16 on scale of 6 to 20 GXT data available – 40% to 80% exercise capacity using HRR, %VO 2 R, or VO 2peak GXT data not available HR below ischemic threshold (if determined) Concerns: medication effects..

10. Exercise Prescription: Intensity (Without GXT Data) Table 9-1

13. Exercise Prescription: Time (Duration) Warm-up (5–10 minutes) and cool-down (5–10 minutes) – Static stretching – Range-of-motion exercises – Low-intensity aerobic activities Aerobic conditioning (20–60 minutes)

14. Exercise Prescription: Progression Initial duration of 5 to 10 minutes per session Progress 1 to 5 minutes per session (or increase time 10%–20% per week), continuous or intermittent Individualized to patient tolerance considering: physical fitness level, patient motivation and goals, signs and symptoms, and musculoskeletal limitations.

15. Exercise Prescription: Type Rhythmic, large muscle group activities with emphasis on caloric expenditure to include both upper extremity and lower extremity May include: – ergometers (arm, leg, or combination), – elliptical, – rower, – stair climber, and – treadmill.

16. Chapter 10 Exercise Prescription for Other Clinical Populations

17. Diabetes Mellitus Diabetes mellitus is a group of metabolic diseases characterized by an elevated fasting blood glucose level (i.e., hyperglycemia) as a result of either defects in insulin secretion or an inability to use insulin. Sustained elevated blood glucose levels place patients at risk for micro- and macrovascular diseases as well as neuropathies (peripheral and autonomic).

18. Diabetes Mellitus Currently, 7% of the U.S. population has diabetes mellitus, with 1.5 million new cases diagnosed each year. Four types of diabetes are recognized based on etiologic origin: type 1, type 2, gestational (i.e., diagnosed during pregnancy), and other specific origins (i.e., genetic defects and drug induced); however, most patients have type 2 (90% of all cases) followed by type 1 (5%–10% of all cases).

19. Diabetes Mellitus (cont.) Type 1 diabetes mellitus is most often caused by the autoimmune destruction of the insulin producing beta- cells of the pancreas, although some cases are idiopathic in origin. The primary characteristics of patients with type 1 diabetic mellitus are absolute insulin deficiency and a high propensity for ketoacidosis. No insulin is available so fat is used as a fuel source.

20. Exercise and Diabetes Lower fasting blood glucose Improves insulin sensitivity Improves glucose tolerance Reduces disease risk - CVD, dyslipidemia, HTN and obesity. Improves quality of life Stress Management Prevents and delays Type II – epidemilogical evidence showing sedentary lifestyle plays a large role

21. Diabetes Mellitus (cont.) Type 2 diabetes mellitus is caused by insulin resistance with an insulin secretory defect. Type 2 diabetes mellitus is associated with excess body fat. A common feature of type 2 diabetes is an upper body fat distribution regardless of the amount of total body fat. In contrast to type 1 diabetes mellitus, type 2 is often associated with elevated insulin concentrations.

22. Diabetes Mellitus: Exercise Prescription Frequency: 3 to 7 d·wk -1 Intensity: 50% to 80% VO 2 R or HRR corresponding to a rating of perceived exertion (RPE) of 12 to 16 on a 6 to 20 scale Time: 20 to 60 min·d -1 continuous or accumulated in bouts of at least 10 minutes of activity to total 150 min/w of moderate physical activity with additional benefits of increasing to 300 minutes or more of moderate physical activity Type: emphasize activities that use large muscle groups in a rhythmic and continuous fashion. Personal interest and desired goals of the exercise program should be considered..

23. Diabetes Mellitus: Exercise Prescription (Resistance Training) Frequency: 2 to 3 d·wk -1 with at least 48 hours separating the exercise sessions Intensity: two to three sets of 8 to 12 repetitions at 60% to 80% 1-RM Time: 8 to 10 multijoint exercises of all major muscle groups in the same session (whole body) or sessions may be split into selected muscle groups

24. Diabetes Mellitus: Exercise Prescription (Resistance Training) (cont.) Type: given that many patients may present with comorbidities, it may be necessary to tailor the resistance exercise prescription accordingly. Emphasize proper technique including minimizing sustained gripping, static work, and the Valsalva maneuver to prevent an exacerbated BP response.

25. © 2009 Human Kinetics

26. Precautions for Avoiding Exercise-Induced Hypoglycemia Measure blood glucose immediately before and 15 min after exercise. Consume carbohydrate if glucose is less than 100 mg · dl –1. Delay exercise if glucose is more than 250 mg · dl –1 with ketone bodies or over 300 mg · dl –1 without ketones. Avoid exercising during times of peak insulin action. (continued)

27. Hypoglycemia AKA Insulin shock and insulin reaction Side effect that occurs with glucose levels at 60-70. Causes: – Too much insulin or oral agents – Too little CHO intake – Missed meals – Excessive or poorly planned exercise May occur during exercise or hours later.

28. HYPOGLYCEMIA Monitor blood glucose before and after exercise. Autonomic symptoms: – Shaking, weakness, sweating, anxiety – Nervousness, tingling in mouth & fingers Neuroglycopenic symptoms: – Headache, visual disturbances, mental dullness, confusion, amnesia, seizures or coma Some have hypoplycemic unawareness

29. TREATMENT OF HYPOGLYCEMIA Test blood Ingest 15g of CHO with no fat & allow 20 minutes for symptoms to resolve Tablets 1 cup of nonfat milk ½ cup of orange juice ½ can of regular soda 6-7 Life Savers 1 tbsp of sugar, honey, or corn syrup Unconscious – glucagon injection or 911

30. Pulmonary Diseases Pulmonary diseases typically result in dyspnea or shortness of breath with exertion. As a result of dyspnea, patients with pulmonary disease limit physical activity and deconditioning results. Consequently, patients with pulmonary disease experience dyspnea even at low levels of physical exertion.

31. Pulmonary Diseases (cont.) This adverse cycle can lead to eventual functional impairment and disability. Exercise is an effective intervention that lessens the development of functional impairment and disability in patients with pulmonary disease. Chronic bronchitis, emphysema, and cystic fibrosis are classified as chronic obstructive pulmonary diseases (COPDs), resulting in a permanent diminution of airflow, whereas asthma has a reversible component to airway obstruction.

33. Emphysema Definitions

36. SYMPTOMS cough sputum dyspnea EXPOSURE TO RISK FACTORS tobacco occupation indoor/outdoor pollution SPIROMETRY Diagnosis of COPD è è

37. Pulmonary Diseases: Exercise Prescription For individuals with well-controlled asthma or mild COPD, the following exercise prescription for cardiovascular fitness is recommended. Frequency: at least 3 to 5 d·wk -1 Intensity: presently there is no consensus as to the “optimal” exercise intensity for patients with pulmonary disease.

38. Pulmonary Diseases: Exercise Prescription Time: 20 to 60 min·d -1 of continuous or intermittent physical activity Type: walking is strongly recommended because it is involved in most activities of daily living. Stationary cycling may be used as an alternate type of training. Additionally, resistance training and flexibility exercises should be incorporated into the exercise prescription.

39. Pulmonary Diseases: Exercise Prescription For individuals with moderate to severe COPD, the following exercise prescription for cardiovascular fitness is recommended. Frequency: at least 3 to 5 d·wk -1

40. Pulmonary Diseases: Exercise Prescription Intensity: for those patients with severe COPD whose exercise tolerance may be ventilatory limited, exercise intensities as high as 60% to 80% of peak work rates are suggested. Intensity may also be based on dyspnea ratings determined from the graded exercise test with ratings between 3 (moderate shortness of breath) and 5 (strong or hard breathing) on a scale of 0 to 10 corresponding to the desired exercise intensity that can be tolerated.

41. Pulmonary Diseases: Exercise Prescription Time: persons with moderate or severe COPD may be able to exercise only at a specified intensity for a few minutes at the start of the training program. Intermittent exercise may also be utilized for the initial training sessions until the patient tolerates exercise at sustained higher intensities and durations of activity. Type: walking and/or cycling. Additionally, resistance training and flexibility exercises should be incorporated into the exercise prescription.