EXERCISE PRESCRIPTION, PROGRESSION AND RISK FACTOR MODIFICATION

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EXERCISE PRESCRIPTION, PROGRESSION AND RISK
FACTOR MODIFICATION

• Cathy K. Larson,EP
• Avera Sacred Heart Hospital

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EXERCISE PRESCRIPTION

• ART
• SCIENCE

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Art of Exercise

• The successful integration of exercise science
  with behavioral techniques that result in the
  long-term compliance and attainment of the
  individual goals.

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Factors to Consider

• Health Status
• Risk Factor Profile
• Behavior Characteristics
• Personal Goals
• Exercise Preferences
• Exposure to Exercise
• Changes in Health Status

• Expectations of Others
• Myth Busting
• Genetic Potential
• Ability to comply
• Your expectations vs theirs
• Physician Input
• Blend of exercise class

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Modifications Due To

• Observed individual responses (hr, bp, sao2, rpe
  telemetry)
• Adaptations to exercise
• Activities done outside of therapy

• Differences in exercise modalities
• Health Status
• Addition/Deletion of medications
• Health Status Change
• Work Status change

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SCIENCE OF EXERCISE

• Basic objective is to bring about a personal
  change in health behavior to make physical
  activities a habit.
• Uses formulas in conjunction with the bodys
  physiological response to activity.

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4 BASICS TO CONSIDER
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Components
Warm-up 2-10 minutes Cool Down 2-10 minutes
Conditioning 20-60 minutes Optimal goal Flexibility and Resistance Training
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2 MAJOR PRINCIPLES OF TRAINING PROGRESSION

• OVERLOAD Tissue or organ must be exposed to a
  greater stimulus than it is used to. Repeated
  exposure leads to
• increased functional capacity
• increased efficiency

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SPECIFICITY

• Training effects are specific to the exercise
  performed and muscles involved.
• Perform a wide variety of exercises that involves
  most of the muscle groups.

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WHERE DOES THE BLOOD GO?

• When exercising the skeletal muscle receives
  85-90 of Cardiac Output.
• Perhaps your mother was right when she told you
  not to swim after eating.

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WHY WARM-UP??(my patient always seems to be in
such a hurry)
Stretches postural muscles Increases metabolic rate from the resting 1 MET level
Augments blood flow Increases connective tissue extensibility. (think of warming up taffies)
Increases body temperature Improves Range of Motion
Dissociates more 02 May prevent transient ST depression, and global LV dysfunction, and ventricular dysrhythmias.
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CONDITIONING (STIMULUS PHASE)
AEROBIC RECREATIONAL
RESISTANCE WHAT EVER IT TAKES TO KEEP GOING
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WHY COOL DOWN?
Allows gradual recovery Tai Chi, Yoga options Maintain adequate venous return to reduce post exercise dizziness
Can use same modalities _at_ lower intensity Return Heart and Blood Pressure to resting. Reduce lactic acid and muscle soreness
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CONDITIONING
Develops aerobic capacity (measured in METS or VO2 max) Deconditioned patients can demonstrate greater increase in V02
VO2 max is increased by 5-30 by conditioning Conditioned athletes Have pre-existing high levels of conditioning, lean body weight)
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INTENSITY(As much fun as a root canal?)

• DOES NOT HAVE TO BE THIS PAINFUL
• MANY DIFFERENT OPTIONS
• FIND YOUR COMFORT LEVEL

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HEART RATE

• THERE IS A LINEAR RELATIONSHIP BETWEEN HR AND
  VO2.
• This is limited in patients with medications such
  beta blockers.
• Be mindful about patients ability to check pulse.

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KARVONEN HRR

• 220- RESTING HR HEART RATE RESERVE
• (60 is resting heart rate)
• 220-60 160 reserve 220-80 140
  reserve
• 160 x .50 80 140 x .50 70
  reserve
• 160 x .80 128 140x .80 112
  reser.
• 60 80 140 8070 150
• 60 128 188 80 112192

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HRR V02 max

• 60-80 og HRR is equal to about 60-80 of V02 max
  for most fit individuals.
• It is more closely linked to the VO2 R across the
  entire range of fitness levels.
• V02R is the difference between V02 max and
  resting V02. 40-85 is recommended
• for V02 R and HRR.

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Exercise Rx by V02

• ACSM position stand the exercise intensity has
  been reformulated from the straight of V02 max.
• Remember that 3.5 ml/kg/min is resting MET level.

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V02R

• Individual has a 17.5 mL/kg/min V02 max
• So 40 of his V02 max would be as follows
• (17.5-3.5)(.40) 3.5
• (14.0)(.40)3.5
• 5.6 3.5
• 9.1mL/kg/min

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EX RX BY METS

• Remember that 1MET 3.5ml/kg/min
• Walking at 2.0mph 2METS
• Running 6mph 10METS
• Take V02/3.5 to get METS
• So 17.5/3.5 5 METS
• 40 of this is 3METS

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WALK TEST

• If a patient walked 1000 feet in 6 minutes,
• 1000 feet x .0019 1.9 mph

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RPE

• Developed by a physician by the name of Gunnar
  Borg in the 1950s. 6-20 scale can correlate to
  HR when adding a 0 individuals without heart
  medications.
• CR10 (Category Ratio) from 0-10
• Either can be used

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BORG RPE SCALE

• 6 no exertion at all
• 7 extremely light
• 8
• 9
• 10
• 11 light
• 12
• 13 somewhat hard
• 14
• 15 hard
• 16
• 17 very hard
• 18
• 19 extremely hard
• 20 maximal exertion

• This scale increases linearly with physiological
  measures of HR and V02 as intensity increases.
  Also high correlation with ventilatory minute
  volume, CO2 production,lactate accumulation and
  body temperature.

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BORG CR 10 SCALE(Category Ratio Scale)

• 0 nothing at all
• 0.5 extremely weak
• 1 very weak
• 2 weak
• 3 moderate
• 4 somewhat strong
• 5 strong
• 6
• 7 very strong
• 8
• 9
• 10 extremely strong

• No parallel with physiological measures like the
  RPE, but can applied in statistical applications.
  i.e. it can make inter-individual comparisons.
• Wider range of applications then RPE

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RPE SCALE

• The average RPE of 12-16 elicits physiological
  adaptation to exercise.
• In our area most physicians prescribe an RPE of
  11-13 for Cardiac Rehab.
• This also takes into account the daily variables
  such as the environment, individual fitness
  level, exercise modes, age, mood states, general
  fatigue levels.

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KILOCALORIES

• The amount of heat required to raise the
  temperature of 1kg of water 1 degree C.
• It is the ordinary calorie discussed in food or
  exercise energy-expenditure tables and food
  labels.
• 3,500 kilocalories of food energy 1 of body
  weight. 1 calorie is the amount of heat required
  to raise the temp of 1 gram of water 1 degree C.
  (1000 calories 1 kilocalorie). When we see
  calorie labels on food, it is actually measuring
  kilocalories.

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ENERGY EXPENDITURES

• (METS)x 3.5.body weight in kg)/200 kcal/minute
• Burning 1,000 kcal/week 20-30 reduction in
  risk of all-cause mortality.

• Recent reports show that 60 or more min/day may
  be necessary for weight loss/maintenance.

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FREQUENCY

• ACSM recommends 3-5 days/week.
• lt 3 METS multiple sessions
• 3-5 METS 1-2 short sessions/day

• gt 6 days/week increases risk of musculoskeletal
  injury
• Vigorous training 7 days/ week not recommended
• 30 min. of moderate intensity most days is
  preferred.

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DURATION

• Usually 20-60 minutes
• Continual or intermittent
• Option of 10 minute bouts throughout the day
• Equal improvement in V02 max as 30 minutes

• JUST DO IT
• Encourage to park further away.
• Sneak some in over lunch.
• As one progresses exclude warm- up and cool- down
  time.

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MODE

• Use large muscle groups that are rhythmic or
  dynamic in nature.
• Examples Walking, Biking, Rowing Machine,
  Swimming, Hiking, Running, Elliptical.

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RESISTANCE TRAINING
Osteoporosis prevention/ improvement Increase or maintain LBW (lean body weight) Help low back pain
Increase strength of connective tissue Increase muscular strength and endurance Reduces age related reduction of fat free mass (FFM)
Reduce HTN Hypertrophy of muscle Increase in activities of daily living
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How Much/How Many?

• High Intensity Training OK for healthy
  individual. Spike in BP is inconsequential.
• Lower Intensity Better Choice for those with
  Hypertension, Diabetes, Heart Disease.
• Low to moderate risk cardiac pts should do 2-4
  weeks of aerobic training first .
• Initial goal of 12-13 RPE and final goal of 15-16
  for submaximal training.
• RPE 19-20 is for high intensity healthy
  population.

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REPS

• Improvements in bone density have been shown with
  7-10 reps versus 14-18 reps in older populations.
• To elicit gains in strength and endurance 8-12
  reps at high intensity for healthy population.

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General Guidlines

• Choose from free weights, therabands, machines
  according to comfort level, fit, and ROM.
• 8-10 different exercises to train most body
  parts.
• Maintain good form, no momentum, 3 sec for
  concentric and eccentric portions, dont rush.
• 2-3 non-consecutive days per week/muscle group
• Keep breathing, exhaling on work phase
• Warm-up before hand, cool down afterwards , then
  stretching.
• Cardiac pts d/c when concentric portion reaches
  RPE of 15-16 while maintaining good form.

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FLEXIBILITY

• Need to keep ROM maintained in all joints.
• Decline starts at age 30.
• Warm-up first (warm-up the taffy analogy)
• Static stretch the muscle to the end of ROM where
  comfortable and hold 15-30 sec.
• Greatest benefit first 15 seconds no greater
  benefit after 30 seconds.
• Ideally perform 5-7 days/week
• Minimum of 2-3days/week

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AACVPR Risk Stratification

• Provides guidelines for the duration of monitored
  exercise/and or education based on the risk
  factor profile.
• This aids in the determination of risk for
  cardiovascular complications during exercise.
• AHA also has guidelines but they do not account
  for comorbidities.

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LIMITATIONS

• Not clearly defined in the literature if exercise
  is the risk itself or if it is the patients
  overall morbidity and mortality.
• Sometimes difficult to place a patient in one
  category
• The risk during exercise seems to be the greatest
  in pts with poor LV function, significant
  ventricular dysrhythmias or non-Q MI because of
  of increased risk of later ischemic events.

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LIMITATIONS cont.

• Pts who do not fit in either category are
  classified as moderate risk.
• Pts who have not had a stress test or have had a
  non-diagnostic stress test may not be
  appropriately categorized. I.e. LBBB,WPW,
• Limited exertional capacities.

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LOWEST RISK

• ALL characteristics must be present.
• Absence of complex ventricular dysrhythmias
  during exercise testing and recovery.
• Absence of angina or other significant symptoms
  (unusual SOB, light-headedness, or dizziness
  during exercise testing or recovery).
• Presence of normal hemodynamics during exercise
  testing and recovery( I.e., appropriate increases
  and decreases in HR, SBP with increasing
  workloads and recovery).
• Functional Capacity of gt 7 METS.

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LOW RISK NON-EXERCISE FINDINGS

• Resting EF gt50
• Uncomplicated MI or revascularization procedure.
• Absence of complicated ventricular dysrhythmias
  at rest.
• Absence of CHF (HF)
• Absence S/S of postevent/post procedure ischemia.
• Absence of clinical depression.

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MODERATE RISK

• ANY ONE OR A COMBINATION OF THESE QUALIFIES AS
  MODERATE.
• Presence of angina or other significant sx
  (unusual SOB, light-headedness, or dizziness
  occurring only at high levels of exertion
  gt7METS)
• Mild to moderate level of silent ischemia during
  exercise testing or recovery (ST-segment
  depressionlt2mm from baseline)
• Functional Capacity lt5METS
• Non-exercise Test Findings
• Rest EF of 40-49

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HIGH RISK

• ANY ONE OR A COMBINATION OF THESE QUALIFIES.
• Presence of complex ventricular dysrhythmias
  during exercise testing or recovery.
• Presence of angina or other significant symptoms
  (unusual SOB, lightheadedness, or dizziness at
  low levels of exertion lt5METS or during
  recovery).
• High level of silent ischemia (ST-segment
  depressiongt2mm from baseline) during exercise
  testing or recovery.
• Presence of abnormal hemodynamics with exercise
  testing (chronotropic incompetence or flat or
  decreasing SBP with increasing workloads) or
  recovery (severe post-exercise hypotension).

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HIGH RISK

• NON-EXERCISE TESTING FINDINGS
• Resting EF lt40
• History of cardiac arrest or sudden death
• Complex dysrhythmias at rest.
• Complicated MI or revascularization procedure.
• Presence of CHF (HF)
• Presence of s/s of post-event/post-procedure
  ischemia.
• Presence of clinical depression

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LENGTH OF STAY

• Low Risk 8 weeks
• Moderate Risk 10 weeks
• High Risk 12 weeks

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ART AND SCIENCE

• Exercise Prescription is like a good recipe.
• Formulate your favorite one.
• It sometimes needs amending due to unforeseen
  circumstances.
• Sometimes people want a different version of your
  recipe and they tweak it themselves.
• Physicians love recipes.

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YOU CAN DO IT

• Come together with a blend of art and science for
  an optimal exercise experience.