Exercise

Prescription in
Diseased
Populations

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 How much is too much???!!!

How much gives you much???!!!

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 General Principles of Exercise
Prescription
oRecent ACSM/CDC recommendations for exercise
accommodate individuals who wouldn’t participate
in structured exercise program
• Moderate activities (3-6 METs) could result in health
benefits even without changes in VO2 values
• Accumulation of 30 mints/day of any activities
• Achieving higher level of fitness requires training at
higher intensity.

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 General Principles of Exercise
Prescription
oSpecificity
• Training effects of exercise training program are
specific (limited) to exercise performed and
muscle used
• Muscle endurance exercise-cause muscle change
that result in improvements in endurance
• Number of mitochondria
• Stretching shoulder joint will improve flexibility of
shoulder joint only

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 General Principles of Exercise
Prescription
oOverload
• Tissue improvements in performance result from
repeatedly exposing it to a load to which its not
normally accustomed to.
• Ex. Prescription components are used to overload
different body systems
• Intensity
• Duration
• Frequency
• Progression
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 General Principles of
Exercise Prescription

• Individualization
• Different gains from exercise training weighs
differently to different individuals
• Personal goals
• Sedentary person at risk for premature chronic disease
adapting a moderately active lifestyle may provide
important health benefits and represent a more
attainable goal than higher VO2max.

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 General Principles of
Exercise Prescription

• Individualization
• Different individuals have different capabilities
• Athlete vs. CAD patients
• Risk factor profile
• Physiological responses to acute exercise
• Physiological adaptations to exercise training
• Constricts
• Time
• Facilities
• Equipment
• Exercise preference

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 General Principles of Exercise
Prescription

• Exercise recommendations are only

guidelines and CAN NOT be implemented in
a rigidly manner by simply applying
mathematical calculations to test data.
• NEVER FORGET that a fundamental objective
of ex. prescription is to achieve personal
health behavior

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 Components of Training Session
• Warm-up
• Elicits heart rate
• Prepares the body for more vigorous activities
• Reduces susceptibility of musculoskeletal injury
• Increases connective tissue extensibility
• Improves range of motion
• Enhances muscle performance
• Decreases the occurrence of ST-segment depression
• 5-10 minutes activities lower intensity exercises
• Stretching!!!!!
• Muscle, tendon, ligaments and joints maybe more responsive while the body is warm (i.e. cool
down)
• Slow walking or slow jogging

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 Components of Training Session

• Endurance phase
• Involves large muscle group for prolong period of time
• To develop cardiorespiratory fitness
• Include 20-60 of continuous or intermittent aerobic
activities
• Duration depends on the intensity

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 Components of Training
Session
• Recreational activities
• Add fun to the training session
• Increase adherence to exercise
• Modifications for the game rules to decrease:
• Competition
• Skill requirements
• Energy cost
• Heart rate responses
• Cool-down
• Low intensity exercise (i.e. walking and/or
stretching)

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 Components of Exercise
Prescription
• Intensity
• ACSM 40/50 to 85% of HRR
• Duration
• 20-60 of continuous or intermittent (minimum of 10-
minute bouts) aerobic activities
• Duration is negatively proportionate to intensity
• Frequency
• 3-5 X/wk.
• Extra sessions appear have minimum effects

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Components of Exercise Prescription

• Progression
• Initial conditioning stage
• Improvement stage
• Maintenance stage
• Mode
• Activities involve large muscle groups

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 Intensity
• Intensity and duration are inversely related
• Similar improvements can be achieved with a low-
intensity, longer duration as with a higher
intensity, shorter duration
• With high intensity exercises risk of injury increases
• Higher adherence is associated with lower exercise
intensities
• METs, VO2R, HRR, HRmax, as well as RPEs have
been used to prescribe exercise.
• Which one is more appropriate?

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 Intensity

• Deconditioned individuals can achieve

improvements in fitness level at low intensity
whereas already physically fit individuals
should use the upper limit of the continuum.
• For most individuals, intensities of 70-80 HRmax
or 60-80 HRR are sufficient to improve CR
fitness when combined with the appropriate
frequency and duration.

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 Duration

• Depends on:
• Intensity
• Disease status
• Individuals with debilitating disease/low level fitness are
can start with 4-6, 5-minute bouts with rest periods in-
between.
• Can be increased until a goal is achieved
• Increase in ex. duration should be made as the individual
adapts to training without evidence of undue fatigue.

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 Frequency
• Individuals with low intensity can improve level of
fitness exercising 2X/Wk.
• Optimal training frequency appears to be 3-5X/Wk.
• Depends on intensity of exercise
• 3X/Wk seems to be sufficient to improve/maintain VO2max for
individuals exercising at 60-80% of HRR
• Lower intensities might require more frequent exercise
sessions to achieve goals, particularly fitness level.
• Weight loss, more sessions help achieve sufficient energy
expenditure.
• Multiple brief daily sessions (1-2/day) might be most appropriate for
patients with functional capacities of < 3 METs

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 Rate of Progression

• Functional capacity
• Medical and health status
• Age
• Individual activity preference &
goals
• Individual’s tolerance to the
current level of training.
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 Flexibility
• Type
• Static or PNF
• Frequency
• Minimum of 2-3X/wk
• Intensity
• To a position of a mild discomfort
• Duration
• 10-30 secds
• Repetitions
• 3-4 for each stretch

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 Muscular Fitness
• 1 set
• 8-12 repetitions to fatigue
• Older individuals 10-15 repetitions
• Muscular endurance 10-15 repetitions
• 2-3X/Wk
• Additional sets of training sessions may result in larger
strength gains, however these gains are relatively small
for sedentary individuals.
• Risk of injury

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 Muscular Fitness

• Typically, 1-RM is measured as the weight

that can be lifted for only 1 time (direct
method). However this method is considered:
• unsafe, inaccurate as well as time consuming
• due to the number of attempts performed to
achieve 1, and only 1, repetition of a given
weight.

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 Muscular Fitness

• Therefore, 1-RM can be estimated using the

indirect method
• This method is based on the relationship between the
%1-RM and the number of RM achieved by lifting a
weight 5-10 RM.
• Subsequently the values will be added to the following
equation:
• 1-RM = kg at # RM 2 to 20/1-(# RM * 0.02)
• Notes:
• 1-RM: one repetition maximal
• # RM: number of repetitions possible
• 1.00: 100% as a decimal
• 0.02: 2% as a decimal
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 Safety Features of
Resistance Exercise Machines
• Exercising with machines is recommended in older
and diseased population
• Weights can be applied at low levels with small
increments for gradual progression
• Exercise is usually in seated position, limiting balance
problems and providing back support
• Weight stacks can be “double-pinned” to adjust ROM
• Less concern about injury related to lifting techniques
• Require less skill

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 Contraindications RS
• Resistance training is not recommended for those
with…
• Uncontrolled arrhythmia's
• Uncontrolled hypertension (>160/90)
• Unstable angina
• Unstable CHF
• Poor LVF (EF<30%)
• Abnormal hemodynamic responses
• Orthopedic limitations
• Uncontrolled metabolic diseases (i.e. diabetes)
Prescribing Resistance Training

• Low resistive exercise may be performed in

phase II cardiac rehabilitation as early as 2
to 8 weeks after MI or CABG surgery,
provided the patient has performed a SL-
GXT
• A good way to prescribe the appropriate
resistance is to use the lightest weight
available, initially and require the pt to
perform 10-12 reps
• RPE’s should be  13
• Weight can be increased in approx. 5 lb.
increments as necessary
Prescriptions for
specific diseases

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 Diabetes Mellitus
• Intensity: 60-90% of HR peak or 50-85% of VO2 peak
• Monitor RPE
• Frequency: 4-7X/Wk
• Daily is preferred to ensure blood glucose control
• Timing: important for those with IDDM
• Avoid ex at times of peak insulin action
• Duration: 20-60 minutes/session
• 5-10 mints of warm-ups & cool-downs
• Strength:
• Recommended but no specific guidelines
• Flexibility:
• Recommended but no specific guidelines

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 Hypertension
• Intensity: 50-85% of VO2 peak or RPE 11-13
• 40-70 for elevated BP or with initiation of BP lowering medications
• Mode: Aerobic (i.e. walking or cycling)
• Frequency: 3-7X/Wk
• Duration: 20-60 minutes/session
• 700-2000 kcal/wk
• 16 wks seems to be minimum for reduction in BP
• RT:
• Circuit training
• High repetitions, low resistance

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 Peripheral Atrial
Disease
• Intensity: 50-75% of VO2 peak or HRR
• Intermittent walk to 3 out 4 on claudication scale (1-5 scale)
• Keep monitoring HR, but claudication scale is the primary
endpoint.
• Gradual progression is essential
• Frequency: 3-5 days/Wk
• Duration: 20-50 minutes/session
• Start with as little as the patient can tolerate (can be only 5 mints)
until reach 50 mints
• Mode: walking is recommended

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 Peripheral Atrial
Disease
• Should be preceded by warm-ups and
followed by cool-downs (>5 mints each)
• A minimum of 3 months are required to see
significant improvements
• No specific RT guidelines,
• Walking vs. RT

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 Myocardial Infarction
• Intensity: 40-85%HRR or RPE 11-16
• Intensity must be kept below ishcemic threshold
• Frequency: 3-4X/Wk
• Duration: 20-40 minutes/session
• 5-10 minutes warm-up and cool down
• Strength:
• 40-50% MVC avoid Valsalva
• 2-3X/Wk
• 1-3 sets, 10-15 repetitions
• Flexibility: 2-3 d/wk

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 Coronary Artery Bypass
Grafting & Angioplasty
• Intensity: 40-85%HRR or RPE 12-14
• Intensity must be kept below ishcemic threshold
• Frequency: 3-7X/Wk
• Duration: 20-60 minutes/session
– 5-10 minutes warm-up and cool down
• Strength:
– 40-50% MVC avoid Valsalva
– 2-3X/Wk
– 1-3 sets, 10-15 repetitions
– Start with 1-2 #. Wait 6 wks postoperation before using heavier
weight
• Flexibility: 2-3 d/wk

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 Angina & Silent Ischemia

• Intensity: HR 10-25 b/min below

ishcemic or angina pain threshold
• Frequency: 3-7X/Wk
• Duration: 20-60 minutes/session
• 5-10 minutes warm-up and cool down
• Strength:
• Light resistance/40-50% MVC avoid Valsalva
• 2-3X/Wk
• 15-20 minutes/session
• Flexibility: 2-3 d/wk

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 Congestive Heart Failure

• Intensity: 40-70%HRR or RPE 11-16

• Frequency: 3-7X/Wk
• Duration: 20-40 minutes/session
• Strength:
• Circuit training
• High repetitions, low resistance
• Flexibility: 2-3 d/wk

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 Cardiac Transplant

• Intensity: RPE 11-16 or 50-75% of VO2 peak

• Frequency: 4-6X/Wk
• Duration: 15-60 minutes/session
• Strength:
• Low to moderate intensity
• 2X/Wk
• 15-20 minutes/session
• Flexibility: 2-3 d/wk

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