Exercise Prescription for Cardiac & Respiratory Diseases

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Exercise Prescription forExercise Prescription forCardiac & RespiratoryCardiac & Respiratory

DiseasesDiseasesHazzaaHazzaa M. AlM. Al--HazzaaHazzaa,, PhPh D, FACSMD, FACSM

Professor & DirectorProfessor & Director

Exercise Physiology LaboratoryExercise Physiology LaboratoryKing Saud UniversityKing Saud UniversityTel (office):Tel (office): 46784114678411

Lab:Lab: 46784064678406http://faculty.ksu.edu.sa/hazzaa

http://faculty.ksu.edu.sa/hazzaa

RHS 514 RHS 514 - - Fall 2010 Fall 2010



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Basic ConceptsBasic Concepts

In ExerciseIn Exercise

PrescriptionPrescription

Part 1



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Exercise PrescriptionExercise Prescription



The US Surgeon General Report, 1996The US Surgeon General Report, 1996

ACSM/CDCACSM/CDC JointJoint Statement,Statement, JAMA,JAMA, 19951995

AHA StatementsAHA Statements – – 19921992--19961996

WHO “Global Strategy on Diet & Physical Activity”,WHO “Global Strategy on Diet & Physical Activity”,

20042004

Resources for Exercise & HealthResources for Exercise & Health

GlobalGlobal RecommendationRecommendation onon PhysicalPhysical ActivityActivity forforHealth,Health, WHO,WHO, 20102010

PhysicalPhysical ActivityActivity GuidelinesGuidelines forfor Americans,Americans, 19951995

TorontoToronto CharterCharter forfor PhysicalPhysical Activity,Activity, MayMay 20102010

http://faculty.ksu.edu.sa/hazzaa/Resources/Forms/AllItems.aspxhtt

p://faculty.ksu.edu.sa/hazzaa/Resources/Forms/AllItems.aspx



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DefinitionsDefinitions

Any bodily movement produced by the

skeletal muscles resulting in energyexpenditure above resting state.

Physical ActivityPhysical Activity

Physical FitnessPhysical Fitness

A set of attributes that people have orachieve, which relates to the ability toperform physical activity.

Caspersen, et al., Public health Rep,1985

11



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DefinitionsDefinitions

The amount of energy expended duringexercise relative to the energy expenditureduring rest.

Metabolic Equivalent (MET)Metabolic Equivalent (MET)

Energy expenditure during rest = 1 MET

= 3.5 ml of O 2 / kg. min

= 1 kcal / kg. hr

22



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What is the Amount of Physical ActivityWhat is the Amount of Physical Activity

that Promotes Optimal Health?that Promotes Optimal Health?

§ Moderate Intensity Physical Activity.

§ Energy Expenditure = 3 - 6 MET

§ That is: ≥ 30 min/day, ≥ 5 days/week.

§ ≥ 150 min. per week.ACSM, 2000; CDC, 1996

§ ≥ 1000 k. calories/week.

Drygas, et al., 2000 ; Fletcher, et al., 1996; Lee, et al., 2000



KSKS

UU

H e a l t h

B e n

e f i t s

H e a l t h

B e n

e f i t s

Inactive Moderately active Very active

Physical Activity & Health Benefits



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Physical Activity Intensity inPhysical Activity Intensity in METMET

Light: Less than 3 MET

Moderate: 3 – 6 MET

Vigorous: Above 6 MET

CDC, 1996



Classification of ExerciseClassification of Exercise

Aerobic exercise:Endurance type exercise, rhythmic,sustained for sometimes. Example:

Walking, jogging, running, cycling, swimming, etc…

Strength (Resistance) exercise:Weight training with free weight,machine, elastic rope, calisthenics, etc…

Flexibility exercise:Stretching exercise.

Balance exercise for the Elderly



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ACSM, 2000

HealthHealth--Related Dimensions of Physical ActivityRelated Dimensions of Physical Activity

أبعاد النشاط البدني المعزز للصحة

..))))Caloric ExpenditureCaloric Expenditureالطاقة المصروفة الطاقة المصروفة ••

..))))Aerobic Intensityاألنشطة اھلوایئة المرتفعة الشدةاألنشطة اھلوایئة المرتفعة الشدة ••

..))))Muscular Strengthالقوة العضیلةالقوة العضیلة ••

..))))Flexibilityالمرونةالمرونة ••

األنشطة البدینة التي یتم ھیفا حمل الجسماألنشطة البدینة التي یتم ھیفا حمل الجسم•• ))Weight-bearing physical activity((..

Caspersen, et al., 1998



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Dimensions of healthDimensions of health--enhancing Physical Activityenhancing Physical Activity

Energy ExpenditureEnergy Expenditure

CHDCHDDiabetesDiabetesObesityObesity

Moderate Intensity Aerobic Activity:Moderate Intensity Aerobic Activity:

Walking, Swimming, Cycling, Badminton, tennis-double, Daily living physical activity (taking

stairs, working at home, gardening, etc..)



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Vigorous physical ActivityVigorous physical Activity (> 60% HR max):

Jogging, Running, Swimming, Cycling, Stepping,

Rope skipping, Tennis-single, squash, Basketball.

Aerobic Intensity

CHDCHD CV EfficiencyCV Efficiency Max. OMax. O22 UptakeUptake




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Type of Activity:Type of Activity:

• Strength Exercise• Muscular Endurance Exercise

• Flexibility Exercise

Muscular Strength & FlexibilityMuscular Strength & Flexibility

Functional capacityFunctional capacity Low Back HealthLow Back Health




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WeightWeight--bearing Physical activitybearing Physical activity

OsteoporosisOsteoporosis


Type of Activity:Type of Activity:

• Walking, Jogging, Running.• Strength Training.

• Jumping, Rope skipping.



Screening beforeScreening beforestarting anstarting an

Exercise ProgramExercise Program



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Evaluation of a PersonEvaluation of a Person’’s Readinesss Readinessto engage in Physical Activityto engage in Physical Activity

PARPAR--QQ

The Flow Charts Approach



Evaluation of Person’s Readiness to Physical ActivityEvaluation of Person’s Readiness to Physical Activity

No

Does the person havesymptom of CV

disease? **

Yes

Does the person havediagnosed disease? *

No Yes

Consider GXT andcardiology referral

Does the person havemore than one risk

factor? ***

Yes Moderate activity issafe; vigorous activity:

should have GXT

No

Is Age under 40 yrs forMen and under 50 yrs

for women

No

Moderate or vigorousactivity is safe

Yes



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Readiness to Physical ActivityReadiness to Physical Activity (continued)(continued)

* Diagnosed Disease:

§ Cardiac disease(excluding controlled

hypertension)

§ Pulmonary Disease

§Metabolic disease

** Symptom of CV disease:

§ Pain or discomfort in the chest,

arms suggestive of ischemia

§ Shortness of breath at rest or

with exertion§ Dizziness or syncope

§ Orthopnea or paroxysmal

nocturnal Dyspnea

§ Ankle edema

§ Palpitations or unexplained

tachycardia

§ Intermittent claudication

§ Known heart murmur

§ Unusual extreme fatigue

*** Risk factors:

§ Family history

§ Tobacco Use

§ Hypertension

§ Hyperlipidemia

§ Diabetes Mellitus



Components of Exercise Prescription

vv Mode (Type of exercise)Mode (Type of exercise)

vv DurationDuration

vv FrequencyFrequency

vv IntensityIntensity

vv Progression of Exercise ProgramProgression of Exercise Programvv Safety/precautionSafety/precaution

ACSM, 2000



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Mode of Physical Activity

Based on current physical activity andBased on current physical activity and

fitness level.fitness level.

Individual’s preference.Individual’s preference.

Individual’s goals:Individual’s goals: for health; for fitness, to reducefor health; for fitness, to reduce

BP, to increase bone density, or to lose weight.BP, to increase bone density, or to lose weight.

Availability of time, facilityAvailability of time, facility (Gym, pool, etc)(Gym, pool, etc) andand

weather condition.weather condition.



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Duration of Physical Activity

There is an inverse relationship betweenThere is an inverse relationship between

activity duration and intensity.activity duration and intensity.

Individual’s goals:Individual’s goals:

§§ forfor HealthHealth:: 3030 -- 6060 minmin

§§ forfor FitnessFitness:: 2020 -- 6060 minmin

§§ forfor Weight LossWeight Loss:: 9090--6060

Consider additional time for warmConsider additional time for warm--up andup and

coolcool--down (down (55– –1010 min each)min each)..

ACSM, 2000: ACSM position Stand on Wt Loss, MSSE, 2010



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Frequency of Physical Activity

International guidelines & recommendations:International guidelines & recommendations:

§§ forfor HealthHealth:: 55 days or more /week (preferablydays or more /week (preferably

every day)every day)

§§ forfor FitnessFitness:: 33 – – 55 days /weekdays /week

Consider the person’s other commitments:Consider the person’s other commitments:

job, family, etc.job, family, etc.

ACSM, 2000



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Intensity of Physical Activity

Recommendations:Recommendations:

§§ forfor HealthHealth: moderate intensity (: moderate intensity (33--66 MET orMET or 4040% to% to

<< 6060% VO% VO22R)R)

§§ forfor FitnessFitness: vigorous intensity (: vigorous intensity (6565--9090% HR max)% HR max)

Consider starting with a lower intensityConsider starting with a lower intensity

with beginners.with beginners.



The Relationship between Exercise Intensity andHealth Benefits versus Fitness improvement

VigorousmoderateLight

F i t n

e s s

Exercise Intensity

H e a l t h

B e n e f i t s



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Moderate & Vigorous IntensityModerate & Vigorous Intensity

Physical ActivitiesPhysical Activities

Moderate:

Brisk walking, Recreational swimming,

Volleyball, Slow aerobics, Moderate cyclingGardening, Tennis-double, Badminton etc..

Vigorous:

Jogging, Running, Tennis-single, Basketball,Rope skipping, Squash, Fast aerobics, Fastcycling, Stepping, Soccer, etc



Aerobic Exercises

Walking, brisk walking, mall walking, treadmill.

Exercise bicycle (regular, stationary, recumbent,upper arm ergometer) .

Elliptical trainer (exercise machine).

Swimming/water aerobics

Steppers

Jump rope

Most household activities.



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Classification of Physical Activity Relative to Type ofClassification of Physical Activity Relative to Type ofContraction and level of IntensityContraction and level of Intensity

Mitchell, et al, Med Sci Sports Exerc, 1994

Type of MuscleContraction

Dynamic ExerciseDynamic ExerciseAs % of VO2 max

LowLow>>4040%%

ModerateModerate4040--7070%%

HighHigh<<7070%%

IsometricExercise

% ofMaximumVoluntary

Contraction

LowLow>>2020%%

LL DynamicDynamicLL IsometricIsometric

11

MM DynamicDynamicLL IsometricIsometric

22

HH DynamicDynamicLL IsometricIsometric

33

ModerateModerate

2020--5050%%

LL DynamicDynamicMM IsometricIsometric

44

MM DynamicDynamicMM IsometricIsometric

55

HH DynamicDynamicMM IsometricIsometric

66

HighHigh<<5050%%

LL DynamicDynamicHH IsometricIsometric

77

MM DynamicDynamicHH IsometricIsometric

88

HH DynamicDynamicHH IsometricIsometric

99

L = Low ; M = Moderate; H = HighL = Low ; M = Moderate; H = High



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الشاحنات تلزم

المسار ایألمن

What can you tell from thisCartoon? Think in term of

Intensity & Aerobic Exercises



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Progression

First, increase theFirst, increase the frequencyfrequency of physicalof physical

activity.activity.

Then, increase theThen, increase the durationduration of physicalof physical

activity.activity.

Lastly, increase theLastly, increase the intensityintensity of physicalof physicalactivity.activity.



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Components of an Exercise Session

WarmWarm--upup

periodperiod

55--1010 minmin

Cool downCool down

periodperiod

55--1010 minmin

ExerciseExercise

periodperiod

3030--60 min60 min



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Why Cool Down?

Allows gradual recovery of heart, lungs and blood

pressure to resting state.

Maintain adequate venous return to reduce postexercise dizziness

Reduce lactic acid and muscle soreness



Resistance Exercise

Should include upper body, lower body and trunk

Can be of any form of resistance such as:

l

Free weights, or a heavy object to lift.l Resistance Machine / Medicine Balls.

l Body weight (Callisthenic Exercise).

l Elastic bands or tubing.

Should be performed 2-3 times/week on non-consecutive days



Resistance Exercise (continued)

Use functional exercise as possible.

For example, walking lunge is better to strengthenmuscles to assist in increasing efficiency ofwalking / running than leg extensions.

Functional exercise is specific to and closelymimics task to be completed.

8-12 repetitions (The last repetition you do should feel

like the last repetition you can do).



Examples of simple Resistance Exercise

Chair SquatChair Squat

Knee ExtensionKnee Extension Seated RowSeated RowElbow CurlElbow Curl

Elbow ExtensionElbow Extension Chest PressChest Press



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Contraindications to Resistance Training inCardiac Patients

Unstable angina

Uncontrolled High Blood pressure (> 160/100 mmHg)

Uncontrolled Arrhythmia

Untreated heart failureUntreated heart failure

Severe valvular stenosis

Hypertrophic cardiomyopathy (HCM)

ST segment depressionST segment depression

Pollock M, et al. Circulation 2000



FLEXIBILITY (1/2)

Stretch to maintain the ROM in all joints.

ROM starts to decline at age 30.

Perform static stretching to the end of ROM, nobounce or ballistic movements.

Warm-up first, then do stretching exercise.

What to stretch: shoulders, chest, calves,hamstrings, hips.



Hold each stretch for 15-30 s. You should feel alittle uncomfortable but no pain

FLEXIBILITY (2/2)

Greatest benefit occur in the first 15 seconds; nogreater benefit after 30 seconds.

Ideally perform stretching 5-7 days per week.

However, minimum is 2-3 days per week.



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ClassificationClassification

of Exerciseof ExerciseIntensityIntensity



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Classification of Exercise IntensityClassification of Exercise Intensity

Maximal Heart Rate = 208 – ( 0.7 X age (yrs))*

Maximal Heart Rate = 220 – age (yrs))

Heart Rate Reserve = HR max – HR rest

% of Maximal Heart Rate% of Maximal Heart Rate % of Heart Rate% of Heart Rate ReserveReserveoror

** Tanaka, et al,Tanaka, et al, 2000 2000



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% of Heart% of HeartRate ReserveRate Reserve

% of Maximal% of MaximalHeart RateHeart Rate

ExerciseExerciseIntensityIntensity

<< 2020 %%<< 5050 %%Very LightVery Light

2020 – – 3939 %%5050 – – 6363 %%LightLight4040 – – 5959 %%6464 – – 7676 %%ModerateModerate

6060 – – 8484 %%7777 – – 9393 %%HardHard

8484 %%>>9393 %%>>Very HardVery Hard

100100 %%100100 %%MaximalMaximal

Classification of Exercise IntensityClassification of Exercise Intensity

Howley, MSSE (Suppl) 2001; (6): S 367.



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Patients using Beta Blockers

Previous equations are notPrevious equations are not

suitable for them. Drugssuitable for them. Drugs

affecting Beta receptors loweraffecting Beta receptors lower

heart rate at rest,heart rate at rest, submaximalsubmaximal &&

maximal exercise.maximal exercise.



2040

60

80

100120

140

160

180

200

Rest 25 50 75 100

No BlockadeParasympathetic blockade

Sympathetic blockade

Astrand & Rodahl,1977, p. 191 ( Data: Ekblom et al., 1972

% of Maximal Oxygen Uptake

Propranolol

Effects of Sympathetic andEffects of Sympathetic and

Parasympathetic Blockades on H. R.Parasympathetic Blockades on H. R.

Atropine



HRR = VO2R

HHR = HR max – HR rest.

VO2R is the difference between VO2 max and

resting VO2.

40-85% is recommended for VO2R and HRR.

Resting MET level = 3.5 ml/kg/min .



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HRR = VO2R

If a patient has a 17.5 ml/kg.min VO2 max,prescribe exercise intensity for him at 50% ofhis VO2 R?

VO2 R = VO2 max – VO2 rest

= 17.5 - 3.5 = 14 ml/kg.min

50 % of VO2 R = 14.0 x 0.50 = 7 ml/kg.min

Required exercise intensity =

7 + 3.5 = 10.5 ml/kg.min ( 3 METs)



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Energy ExpenditureEnergy Expenditure

duringduring

Physical Activity!Physical Activity!



CaloreiCaloreiActivityActivity

00..0707Brisk walkingBrisk walking

00..1313RunningRunning (7.5 min per km)(7.5 min per km)

00..208208RunningRunning (5 min per km)(5 min per km)

00..162162SwimmingSwimming

00..162162Rope skippingRope skipping (70/min)(70/min)

00..165165Rope skippingRope skipping (80/min)(80/min)

00..097097BadmintonBadminton

00..109109TennisTennis

00..212212SquashSquash

00..138138BasketballBasketball

Energy Cost of Physical ActivityEnergy Cost of Physical Activity(k. calorie/kg. min)(k. calorie/kg. min)

McArdle, et., 1991



METMETActivityActivity2.52.5WalkingWalking (slow)(slow)

44Walking (Walking (Brisk)Brisk)

88RunningRunning (7.5 min per km)(7.5 min per km)

66SwimmingSwimming

88Rope skippingRope skipping (slow)(slow)

66Weight trainingWeight training

4.54.5BadmintonBadminton

88TennisTennis (single)(single)

1212SquashSquash

88BasketballBasketball

Energy Cost of Physical ActivityEnergy Cost of Physical Activity in METin MET

Ainsworth, et., 2000



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How to CalculateHow to CalculateEnergy ExpenditureEnergy Expenditure

during Brisk Walking!during Brisk Walking!



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== 00..0707 k.k.caloriecalorie per kg of body weightper kg of body weight //min.min.

Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking

An Example:An Example:

aa person weighingperson weighing 7676 kg would expend:kg would expend:

00..0707 XX 7676 == 55..33 k.k. calorie per min.calorie per min.



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Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking

§§ If somebody has to expendIf somebody has to expend 12001200 k.k.caloriescaloriesper week.per week. HOW much time he/she should walkHOW much time he/she should walkper week?per week?

§§ 12001200 // 55..33 == 226226..44 min.min.

== 4545 min/min/ 55 days per week, ordays per week, or

== 5757 min/min/ 44 days per week.days per week.

Note: This includes resting energy expenditure Note: This includes resting energy expenditure



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Exercise Prescription for Cardiac & Respiratory Diseases

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