1. Mark David S. Basco, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila

2. Objectives At the end of the session, students should be able to Determine the components of an exercise program Apply principles of a conditioning program for patients with Coronary Artery Disease Stroke and/or history of Hypertension Peripheral Vascular Disease COPD Diabetes Mellitus Well population

3. Objectives Determine criteria for initiating an exercise session for different clients / patients. Decide when to terminate an exercise session based on established protocols and guidelines

4. What do we need for this topic? Background knowledge of: Cardiovascular physiology Exercise physiology Muscle physiology Knowledge of different conditions presenting with impaired aerobic capacity Most importantly: An open and inquisitive mind

5. Endurance Ability to work for prolonged periods of time and resist fatigue Types Cardiovascular Muscular

6. INTENSITY DURATION FREQUENCY MODE

7. Intensity Overload principle Specificity principle Quantifying intensity Heart Rate VO2 Max Rating of Perceived Exertion

8. Intensity Heart Rate Maximum Heart Rate 220-age Karvonens Formula THR= RHR + (MHR - RHR) (60-80%) Deconditioned – 40-50% Cardiopulmonary disease – 40 – 60% Healthy individuals – 60 – 80% For UE work MHR = 220 – age - 11

9. Intensity Rating of Perceived Exertion Useful for patients with heart rate suppressors e.g. Beta blockers Original Revised

10. Intensity Rating of Perceived Exertion Original version ( 6-20 ) Remember only the ODD numbers 7 – VERY VERY 9 - VERY 11 - LIGHT 13 – SOMEWHAT HARD 15 - HARD 17 - VERY 19 – VERY VERY 12- 60% HR range 13- 65 – 70% HR range 16- 85% HR range

11. Intensity Rating of Perceived Exertion Revised version ( 0-10 ) 0.5 –VERY VERY 1- VERY 2 - WEAK 3 – MODERATE 4 - SOME - WHAT 5 - STRONG 7 – VERY 10 VERY VERY

12. Intensity Exercising at a high intensity elicits a greater improvement of the VO2 max The higher the intensity, the longer the exercise intervals, the faster the training effect Exercising at high intensities increases the risk for CV complications and musculoskeletal injury

13. Intensity Goal Achievement of intensity 60-90% MHR OR 50-85% VO2 Max Beginners: 50-60% VO2 Max Average: 60-70% VO2 Max Fit: 75-85% VO2 Max

14. Duration Dependent on Total work performed Intensity Frequency Fitness level HIGH intensity SHORT duration LOW intensity LONG duration

15. Duration Poor functional capacity 5 - 10 minutes Beginners 10 - 20 minutes Average 15 - 45 minutes Fit 30 – 60 minutes

16. Duration Moderate to Minimal intensity 20 – 30 minutes High intensity 10 – 15 minutes Exercise longer than 45 minutes increases the risk for musculoskeletal complications

17. Frequency Dependent on the health and age of the individual LOW intensity HIGH frequency HIGH intensityLOW frequency

18. Frequency POOR Daily Beginner Every other day Optimal frequency 3-4 times a week 2 times a week does not generally evoke CV changes for well population Increase in frequency beyond optimal range, increases risk for musculoskeletal complications 30-45 mins 3x a week protects against CV disorders

19. Frequency 3 – 5 sessions / week Greater than 5 METS Daily or multiple daily sessions Less than 5 METS

20. Mode Large muscles Rhythmic Long duration Lower extremity versus Upper extremity exercise

21. Mode Lower extremity Upper extremity Larger muscle mass Higher VO2 max HR increases linearly as a function of increased workload / VO2 max HR plateaus just before maximal VO2 max Systolic BP increases Diastolic BP remains the same Smaller muscle mass Lower VO2 max than LE exercise HR higher Stroke volume lower Systolic AND Diastolic BP higher

22. Warm-up Aerobic exercise period Cool-down

23. Warm-up Muscle temperature NCV Vasodilation Adaptation of respiratory centers Venous return

24. Warm-up 2 components Graduated low intensity warm-up (5-10 minutes) of total body movement HR increase 20bpm Flexibility exercises

25. Warm-up Should NOT cause fatigue Decreases Risk for ECG changes (arrythmias) Musculoskeletal disorder

26. Aerobic exercise Continuous Interval Circuit Circuit-interval

27. Continuous Submaximal and sustained Achievement of the steady state Duration; 20 – 60 minutes Intensity: 60 – 85% VO2 Max Most effective in increasing endurance for healthy individuals

28. Continuous Two types: Intermediate Slow Distance 20-60 minutes continuous exercise Most commonly used for managing weight Long Slow Distance Longer than 60 minutes for athletic training Provided after 6months of successful ISD

29. Interval Designed to improve strength and power more than endurance Incorporates recovery after continual exercise Useful for beginners Work – rest - work

30. Interval Exercise period is followed by rest interval Rest relief (Passive recovery) Work relief (Active recovery) Work recovery ratio 1:1 to 1:5 1 : 1.5 work interval allows the succeeding exercise interval to begin before recovery is complete

31. Interval Aerobic Interval Training For patients with poor CV fitness 2-15 minutes at 50-80% functional capacity Anaerobic Interval Training For patients with high CV fitness 30 sec – 4 minutes at 85-100% functional capacity Usually results in greater lactic acid concentrations

32. Circuit Series of exercise activities Several exercise modes Improves both strength and endurance

33. Circuit interval Stresses both aerobic and anerobic systems Delays the need for glycolysis and lactic acid production

34. Cool-down Prevents Pooling of blood Post-exercise syncope Ischemia, arrythmias, and other complications Increases oxidation of metabolic waste

35. Cool-down Length of cool-down phase proportional to intensity and length of the conditioning phase Typical 30-40 aerobic exercise period Warrants a 5-10 minute cool-down phase

36. Coronary Artery Disease Stroke and/or history of Hypertension Peripheral Vascular Disease COPD Diabetes Mellitus Well population

37. Coronary Artery Disease In-patient phase Out-patient phase Maintenance phase

38. In – patient phase 3 - 5 days Objectives Initiate early return to independence Prevent deleterious effect of bed rest Help allay anxiety and depression Promote risk factor modification

39. In – patient phase Role of PT Sit- to- stand 1-3 days post-op Orthostatic challenge to the CV system 3-5 days post-op Low-level exercise program (1-3 METS)

40. In – patient phase Exercise recommendations Intensity 2-3 METS progressing to 3-5 METS by d/c RPE < 13 (6-20) Post-MI: HR <120 bpm or RHR + 20 bpm To tolerance, if asymptomatic

41. In – patient phase Exercise recommendations Duration Begin with intermittent bouts lasting 3-5 minutes, as tolerated Rest periods can be slow walk or complete rest Attempt 2:1 exercise/rest ratio Frequency Early mobilization: 3-4 times / day (days 1-3) Later mobilization: 2 times/day (beginning on day 4) with increased duration

42. In – patient phase Exercise recommendations Mode ADLs Selected arm and leg exercises Early supervised ambulation

43. Out-patient phase Initiated 6-8 weeks upon discharge Objectives Improve functional capacity Promote early return to normal activity Promote positive lifestyle changes 9 METS functional capacity: suggested exit point Weaned from continuous monitoring to self- monitoring

44. Out-patient phase Exercise recommendations Intensity: 40-60% MHR Duration: Initial 10-15 minutes, Target 30-60 minutes Frequency: 3 – 4 times / week Mode: Continuous / Circuit interval Walking, treadmill, cycle ergometer

45. Maintenance phase 3 - 6 months post-cardiac patient Objectives Maintenance of function Compliance with exercise program Risk factor modification Entry-level criteria Functional capacity of 5 METS Clinically stable angina Medically controlled arrhythmias during exercise

46. Maintenance phase Exercise recommendations Intensity 40-75% MHR Duration 45 minutes to tolerance / session Frequency 3 – 5 days / week Mode: Continuous / Interval

47. Coronary artery disease Mode of exercise Patient preference Skill required for proper performance Potential for carryover at home Availability of exercise equipment

51. Stroke and Hypertension Avoid valsalva maneuver Avoid isometric component Circuit training (weight training + endurance) RPE when patient is taking anti-HTN Instruct patients to move slowly

52. Stroke and Hypertension Exercise recommmendations Intensity: 40-70% VO2 Max / 40-65% MHR Duration: Gradual warm-ups and cool-down / 30-60 minute/session (aerobic training) Frequency: 3-7 days/week Mode: Large muscle group aerobic exercise, walking, swimming

53. Stroke and Hypertension Special considerations NO exercise if resting systolic BP > 200 mmHg or diastolic BP > 110 mmHg Risk of heat intolerance for patients taking beta blockers and diuretics Anti-HTN may provoke syncope post-exercise: good cool-down Individuals with BP > or equal 160/100 should add endurance exercise after initiating pharmacologic therapy

54. Peripheral Vascular Disease (PVD) Relieve claudication Improve walking capacity and qol Ensourage daily exercise with frequent rest periods Low impact, NWB activities (swimming, cycling) Add WB exercise as condition improves Avoid exercising in COLD air or water Interval training is appropriate FEET care

55. Peripheral Vascular Disease (PVD)

56. Exercise recommmendation Intensity: Grade II – III on the claudiaction pain Frequency: 3-5 days / week Duration: initial: 35 minutes of intermittent walking; increased 5 minutes each session until 50 minutes of intermittent walking can be completed Goal: 35-50 minutes of continuous walking Mode: non-impact aerobic exercise

57. COPD Keep the exercise intensity low and gradually increase over time Reduce intensity if symptoms occur Mind the environment Use of supplemental oxygen / bronchodilators Breathing exercises Walking strongly recommended

58. COPD Exercise recommendations Intensity: low intensity, adjust according to patient’s response Duration: maximal limits tolerated by the symptoms Frequency: 3 – 5 times / week; if reduced functional capacity, daily Mode: walking, staionary cycling progress with upper body resistive exercises

59. Diabetes Mellitus Exercise improves glucose control and circulation Reduces cardiovascular risk Assists in weight control Reduces stress Patients should undergo exercise testing prior to initiation of an exercise program

60. Diabetes Mellitus Exercise recommendations Intensity: 50 – 80% HR Reserve Duration: 20 – 60 minutes Frequency: 3 – 4 /week Mode: walking, treadmill, stationary cycle

61. Diabetes Mellitus Considerations Monitor glucose levels prior to and following exercise Should exercise with glucose level between 100 – 200 mg /dl Have carbohydrate snack readily available during exercise Do not exercise when Fasting glucose > 250mg/dl + ketosis Use caution when glucose > 300 mg/dl Maintain hydration during exercise session

62. Diabetes Mellitus Do not exercise alone Avoid exercising body part injected by insulin Do not exercise patients with poorly controlled complications Do not exercise in extreme environmental temperatures Late-onset hypoglycemia can occur up to 48 hours following exercise especially when beginning or modifying program

63. Diabetes Mellitus Ingest 20 – 30 grams of additional carbohydrates if pre-exercise glucose is <100 mg/dl Avoid valsalva and jarring/pounding activities Monitor for signs of autonomic neuropathy (hypoglycemia / hyperglycemia) Proper feet care Limit WB activities for patients with peripheral neuropathy

65. Well Population Mode Season

66. Well Population Mode Long Slow Distance training Pace / Tempo Interval Repetition Fartlek

67. Long Slow Distance Intensity Achievement of 70% VO2 max (80& MHR) Duration Training distance > race distance Lasts from 30 minutes – 2 hours Frequency 1-2 per week Conversation exercise

68. Long Slow Distance Benefits: Increase CV and thermoreg function Mitochondria Oxidative capacity Fat utilization and lactate clearance Disadvantages Not specific with lower intensity sports Does not stimulate neurologic pattern

69. Pace / Tempo Intensity: At the lactate threshold or slightly above the race pace Duration: 20 -30 minutes Frequency: 1 -2 / week “Threshold training”

70. Pace / Tempo Benefits Develops race pace Enhance body to sustain exercise Increases running economy Increases lactate threshold

71. Interval Intensity: Close to the VO2 Max Duration: 3 – 5 minutes; Work/Rest ratio 1:1 Frequency: 1 – 2 / week Benefit Increase VO2 max Not to be performed if unfit

72. Repetition Intensity: Greater than VO2 Max Duration: 30 – 90 seconds; Work/Rest ratio 1:5 Frequency: Once a week High reliance on anaerobic metabolism Benefits Increases running speed High capacity for anaerobic metabolism Beneficial for final kick / push

73. Fartlek Intensity: Varies between LSD and pace Duration: 20 – 60 minutes Frequency: Once a week Benefits Challenges all the system Increases VO2 max Reduce boredom Increases lactate threshold Increases running conomy

74. Sports Season SeasonObjectiveFreqDurationIntensity Off-season (Base training) Develop sound conditioning base 5-6LongLow-mod PreseasonImprove factors important to aerobic endurance and performance 6-7Long-modMod-high In –season (Competition) Maintain factors5-6Short Race distance Low-training High-racing Postseason (active rest ) Recovery3-5ShortLow

75. References Rothstein, J.M., Roy, S.H., & Wolf, S.L. (2005). The rehabilitation specialist’s handbook. Philadelphia: F.A. Davis. Whaley, M.H., Brubaker, P.H., & Otto, R.M. (2005). ACSM’s guidelines for exercise testing and prescription. Philadelphia: Lippincott Williams & Wilkins. Kisner, C., & Colby, L.A. (2007). Therapeutic exercise: Foundations and techniques. Philadelphia: F.A. Davis. Seigelman, R.P., & O’ Sullivan, S.B. (2006). National physical therapy examination review and study guide. Philadelphia: International Education Resources. Powerpoint presentation of Prof. Mitch B. Encabo, MPA, PTRP, RPT, CSCS

76. If none, THANK YOU VERY MUCH... Have a nice day ahead of you...