Mark David S. Basco, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila
Mark David S. Basco, PTRPDepartment of Physical TherapyCollege of Allied Medical ProfessionsUniversity of the Philippines Manila
ObjectivesAt the end of the session, students should be able
toDetermine the components of an exercise
programApply principles of a conditioning program for
patients withCoronary Artery DiseaseStroke and/or history of HypertensionPeripheral Vascular DiseaseCOPDDiabetes MellitusWell population
ObjectivesDetermine criteria for initiating an exercise
session for different clients / patients. Decide when to terminate an exercise session
based on established protocols and guidelines
What do we need for this topic?Background knowledge of:Cardiovascular physiologyExercise physiologyMuscle physiologyKnowledge of different conditions presenting
with impaired aerobic capacity Most importantly:An open and inquisitive mind
EnduranceAbility to work for prolonged periods of time
and resist fatigueTypes
Cardiovascular Muscular
INTENSITYDURATIONFREQUENCYMODE
IntensityOverload principleSpecificity principleQuantifying intensity
Heart RateVO2 MaxRating of Perceived Exertion
IntensityHeart RateMaximum Heart Rate
220-ageKarvonens Formula
THR= RHR + (MHR - RHR) (60-80%)Deconditioned – 40-50%Cardiopulmonary disease – 40 – 60%Healthy individuals – 60 – 80%
For UE workMHR = 220 – age - 11
IntensityRating of Perceived ExertionUseful for patients with heart rate
suppressors e.g. Beta blockers
OriginalRevised
IntensityRating of Perceived ExertionOriginal version ( 6-20 )
Remember only the ODD numbers
7 – VERY VERY9 - VERY11 - LIGHT13 – SOMEWHAT HARD 15 - HARD17 - VERY 19 – VERY VERY
12- 60% HR range
13- 65 – 70% HR range 16- 85% HR range
IntensityRating of Perceived ExertionRevised version ( 0-10 )0.5 – VERY VERY1- VERY2 - WEAK3 – MODERATE4 - SOME - WHAT5 - STRONG7 – VERY10 VERY VERY
IntensityExercising 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
IntensityGoalAchievement of intensity 60-90% MHR OR
50-85% VO2 MaxBeginners: 50-60% VO2 MaxAverage: 60-70% VO2 MaxFit: 75-85% VO2 Max
DurationDependent onTotal work performedIntensityFrequencyFitness level
HIGH intensity SHORT durationLOW intensity LONG duration
DurationPoor functional capacity
5 - 10 minutesBeginners
10 - 20 minutesAverage
15 - 45 minutesFit
30 – 60 minutes
DurationModerate to Minimal intensity20 – 30 minutesHigh intensity10 – 15 minutes
Exercise longer than 45 minutes increases the risk for musculoskeletal complications
FrequencyDependent on the health and age of the
individual
LOW intensity HIGH frequencyHIGH intensity LOW frequency
FrequencyPOOR
DailyBeginner
Every other dayOptimal frequency
3-4 times a week2 times a week does not generally evoke CV
changes for well populationIncrease in frequency beyond optimal range,
increases risk for musculoskeletal complications30-45 mins 3x a week protects against CV
disorders
Frequency3 – 5 sessions / weekGreater than 5 METS
Daily or multiple daily sessionsLess than 5 METS
ModeLarge musclesRhythmicLong durationLower extremity versus Upper extremity
exercise
ModeLower extremity Upper extremityLarger muscle massHigher VO2 maxHR increases linearly as
a function of increased workload / VO2 max
HR plateaus just before maximal VO2 max
Systolic BP increasesDiastolic BP remains the
same
Smaller muscle massLower VO2 max than LE
exerciseHR higherStroke volume lowerSystolic AND Diastolic
BP higher
Warm-upAerobic exercise periodCool-down
Warm-up Muscle temperatureNCVVasodilationAdaptation of respiratory centersVenous return
Warm-up 2 componentsGraduated low intensity warm-up (5-10
minutes) of total body movementHR increase 20bpm
Flexibility exercises
Warm-up Should NOT cause fatigueDecreases
Risk for ECG changes (arrythmias)Musculoskeletal disorder
Aerobic exerciseContinuousIntervalCircuitCircuit-interval
ContinuousSubmaximal and sustainedAchievement of the steady stateDuration; 20 – 60 minutesIntensity: 60 – 85% VO2 MaxMost effective in increasing endurance for
healthy individuals
ContinuousTwo types:Intermediate Slow Distance
20-60 minutes continuous exerciseMost commonly used for managing weight
Long Slow DistanceLonger than 60 minutes for athletic trainingProvided after 6months of successful ISD
IntervalDesigned to improve strength and power
more than enduranceIncorporates recovery after continual
exerciseUseful for beginnersWork – rest - work
IntervalExercise period is followed by rest interval
Rest relief (Passive recovery)Work relief (Active recovery)
Work recovery ratio1:1 to 1:5
1 : 1.5 work interval allows the succeeding exercise interval to begin before recovery is complete
IntervalAerobic Interval TrainingFor patients with poor CV fitness2-15 minutes at 50-80% functional capacity
Anaerobic Interval TrainingFor patients with high CV fitness30 sec – 4 minutes at 85-100% functional
capacityUsually results in greater lactic acid
concentrations
Circuit Series of exercise activitiesSeveral exercise modesImproves both strength and endurance
Circuit interval Stresses both aerobic and anerobic systemsDelays the need for glycolysis and lactic acid
production
Cool-down Prevents
Pooling of bloodPost-exercise syncopeIschemia, arrythmias, and other complications
Increases oxidation of metabolic waste
Cool-down Length of cool-down phase proportional to
intensity and length of the conditioning phaseTypical 30-40 aerobic exercise period
Warrants a 5-10 minute cool-down phase
Coronary Artery DiseaseStroke and/or history of HypertensionPeripheral Vascular DiseaseCOPDDiabetes MellitusWell population
Coronary Artery DiseaseIn-patient phaseOut-patient phaseMaintenance phase
In – patient phase3 - 5 daysObjectives
Initiate early return to independencePrevent deleterious effect of bed restHelp allay anxiety and depressionPromote risk factor modification
In – patient phaseRole of PT
Sit- to- stand 1-3 days post-opOrthostatic challenge to the CV system 3-5
days post-opLow-level exercise program (1-3 METS)
In – patient phaseExercise recommendationsIntensity
2-3 METS progressing to 3-5 METS by d/cRPE < 13 (6-20)Post-MI: HR <120 bpm or RHR + 20 bpmTo tolerance, if asymptomatic
In – patient phaseExercise recommendationsDuration
Begin with intermittent bouts lasting 3-5 minutes, as tolerated
Rest periods can be slow walk or complete restAttempt 2:1 exercise/rest ratio
FrequencyEarly mobilization: 3-4 times / day (days 1-3)Later mobilization: 2 times/day (beginning on
day 4) with increased duration
In – patient phaseExercise recommendationsMode
ADLsSelected arm and leg exercisesEarly supervised ambulation
Out-patient phaseInitiated 6-8 weeks upon dischargeObjectives
Improve functional capacityPromote early return to normal activityPromote positive lifestyle changes
9 METS functional capacity: suggested exit point
Weaned from continuous monitoring to self-monitoring
Out-patient phaseExercise recommendationsIntensity: 40-60% MHRDuration: Initial 10-15 minutes, Target 30-60
minutesFrequency: 3 – 4 times / weekMode: Continuous / Circuit interval
Walking, treadmill, cycle ergometer
Maintenance phase3 - 6 months post-cardiac patientObjectives
Maintenance of functionCompliance with exercise programRisk factor modification
Entry-level criteriaFunctional capacity of 5 METSClinically stable anginaMedically controlled arrhythmias during
exercise
Maintenance phaseExercise recommendationsIntensity
40-75% MHRDuration
45 minutes to tolerance / sessionFrequency
3 – 5 days / weekMode:
Continuous / Interval
Coronary artery diseaseMode of exercisePatient preferenceSkill required for proper performancePotential for carryover at homeAvailability of exercise equipment
Stroke and HypertensionAvoid valsalva maneuverAvoid isometric componentCircuit training (weight training +
endurance)RPE when patient is taking anti-HTNInstruct patients to move slowly
Stroke and HypertensionExercise recommmendationsIntensity: 40-70% VO2 Max / 40-65% MHRDuration: Gradual warm-ups and cool-down /
30-60 minute/session (aerobic training)Frequency: 3-7 days/weekMode: Large muscle group aerobic exercise,
walking, swimming
Stroke and HypertensionSpecial considerationsNO exercise if resting systolic BP > 200
mmHg or diastolic BP > 110 mmHgRisk of heat intolerance for patients taking
beta blockers and diureticsAnti-HTN may provoke syncope post-
exercise: good cool-downIndividuals with BP > or equal 160/100
should add endurance exercise after initiating pharmacologic therapy
Peripheral Vascular Disease (PVD)Relieve claudicationImprove walking capacity and qolEnsourage daily exercise with frequent rest
periodsLow impact, NWB activities (swimming,
cycling)Add WB exercise as condition improvesAvoid exercising in COLD air or waterInterval training is appropriateFEET care
Peripheral Vascular Disease (PVD)
Peripheral Vascular Disease (PVD)Exercise recommmendationIntensity: Grade II – III on the claudiaction
painFrequency: 3-5 days / weekDuration: initial: 35 minutes of intermittent
walking; increased 5 minutes each session until 50 minutes of intermittent walking can be completedGoal: 35-50 minutes of continuous walking
Mode: non-impact aerobic exercise
COPDKeep the exercise intensity low and gradually
increase over timeReduce intensity if symptoms occurMind the environmentUse of supplemental oxygen / bronchodilatorsBreathing exercisesWalking strongly recommended
COPDExercise recommendationsIntensity: low intensity, adjust according to
patient’s responseDuration: maximal limits tolerated by the
symptomsFrequency: 3 – 5 times / week; if reduced
functional capacity , dailyMode: walking, staionary cycling progress
with upper body resistive exercises
Diabetes MellitusExercise improves glucose control and
circulationReduces cardiovascular riskAssists in weight controlReduces stressPatients should undergo exercise testing
prior to initiation of an exercise program
Diabetes MellitusExercise recommendationsIntensity: 50 – 80% HR ReserveDuration: 20 – 60 minutesFrequency: 3 – 4 /weekMode: walking, treadmill, stationary cycle
Diabetes MellitusConsiderationsMonitor glucose levels prior to and following
exerciseShould exercise with glucose level between
100 – 200 mg /dlHave carbohydrate snack readily available
during exerciseDo not exercise when
Fasting glucose > 250mg/dl + ketosisUse caution when glucose > 300 mg/dl
Maintain hydration during exercise session
Diabetes MellitusDo not exercise aloneAvoid exercising body part injected by insulinDo not exercise patients with poorly
controlled complicationsDo not exercise in extreme environmental
temperaturesLate-onset hypoglycemia can occur up to 48
hours following exercise especially when beginning or modifying program
Diabetes MellitusIngest 20 – 30 grams of additional
carbohydrates if pre-exercise glucose is <100 mg/dl
Avoid valsalva and jarring/pounding activitiesMonitor for signs of autonomic neuropathy
(hypoglycemia / hyperglycemia)Proper feet careLimit WB activities for patients with
peripheral neuropathy
Well PopulationModeSeason
Well PopulationModeLong Slow Distance trainingPace / TempoIntervalRepetitionFartlek
Long Slow DistanceIntensity
Achievement of 70% VO2 max (80& MHR)Duration
Training distance > race distanceLasts from 30 minutes – 2 hours
Frequency1-2 per week
Conversation exercise
Long Slow DistanceBenefits: IncreaseCV and thermoreg functionMitochondriaOxidative capacityFat utilization and lactate clearanceDisadvantagesNot specific with lower intensity sportsDoes not stimulate neurologic pattern
Pace / TempoIntensity: At the lactate threshold or slightly
above the race paceDuration: 20 -30 minutesFrequency: 1 -2 / week“Threshold training”
Pace / TempoBenefitsDevelops race paceEnhance body to sustain exerciseIncreases running economyIncreases lactate threshold
IntervalIntensity: Close to the VO2 MaxDuration: 3 – 5 minutes; Work/Rest ratio 1:1Frequency: 1 – 2 / weekBenefit
Increase VO2 maxNot to be performed if unfit
RepetitionIntensity: Greater than VO2 MaxDuration: 30 – 90 seconds; Work/Rest ratio
1:5Frequency: Once a weekHigh reliance on anaerobic metabolismBenefits
Increases running speedHigh capacity for anaerobic metabolismBeneficial for final kick / push
FartlekIntensity: Varies between LSD and paceDuration: 20 – 60 minutesFrequency: Once a weekBenefits
Challenges all the systemIncreases VO2 maxReduce boredomIncreases lactate thresholdIncreases running conomy
Sports SeasonSeason Objective Freq Duration Intensity
Off-season (Base training)
Develop sound conditioning base
5-6 Long Low-mod
Preseason Improve factors important to aerobic endurance and performance
6-7 Long-mod Mod-high
In –season (Competition)
Maintain factors 5-6 Short Race distance
Low-trainingHigh-racing
Postseason(active rest )
Recovery 3-5 Short Low
ReferencesRothstein, 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
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