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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