Clinical Exercise Physiology

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Clinical Exercise Physiology

• Chapter 11

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Definition, Description, Focus

• Clinical Exercise Physiology-Involves the
  application of exercise science to prevent and
  delay the onset of chronic disease in healthy
  participants or provide therapeutic or functional
  benefits to patients with underlying pathologies.
  
• Clinical Exercise physiologists are healthcare
  professionals who use fundamental principles of
  exercise physiology in clinical settings to
  minimize the risk of chronic diseases associated
  with physical inactivity and to treat those
  already afflicted.
• Services may be provided in several medical
  settings such as hospitals, rehabilitation
  centers, and outpatient clinics.

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Continued

• Services are also offered in community,
  corporate, commercial, university fitness and
  wellness centers, nursing homes, and senior
  citizen centers.

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Scope

• The scope of practice ranges from apparently
  healthy individuals with no known medical
  problems to patients with documented
  cardiovascular, pulmonary, metabolic, rheumatoid,
  orthopedic, and/or neuromuscular diseases and
  conditions.

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Scope continued

• Clinical exercise physiologists are responsible
  for Exercise testing and evaluation and
  supervision of safe and effective exercise
  programs in a healthcare setting .
• A knowledge of normal physiological responses to
  acute and chronic exercise is essential before
  attempting to prevent, manage, or rehabilitate
  disease.
• Exercise Therapy may be altered by specific
  treatments such as drugs and medications,
  surgical procedures, radiation therapy,
  orthopedic bracing, casting, or splinting
  dialysis, and diet therapy.

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Scope continued

• For example heart rate and blood pressure
  responses to exercise can be reduced
  significantly by a drug called Beta Adrenergic
  Blocking Agent which is commonly used to manage
  angina or hypertension.
• Exercise itself can produce effects requiring
  alterations in other therapies the patient is
  receiving.
• For example It is often necessary for insulin
  dosages to be reduced in patients with Type I
  Diabetes because exercise changes the
  pharmacokinetics of subcutaneously injected
  drugs.
• Clinical exercise Physiologists should have a
  solid background in basic exercise physiology
  combined with more advanced training, including
  pathophysiology of chronic diseases, pharmacology
  of drugs and medicines, medical terminology,
  medical record keeping and charting, ECG
  interpretation, exercise testing, business
  management and marketing, and nutrition and diet
  therapy.

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Clinical Testing and Evaluation Principles

• An important tool in clinical settings to
  clear individuals for safe participation in
  physical activity and also as a basis for
  exercise prescription.
• Two broad classifications of exercise testing
• 1. Diagnostic Testing- performed to see how
  sick someone is
• 2. Functional Capacity Testing- performed to
  see how well someone is
• In other words the diagnostic test is performed
  to uncover underlying disease while the
  functional test is performed to determine the
  capacity for exercise.

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Exercise Tests

• Exercise tests, weather for diagnostic or
  functional purposes, are usually incremental in
  nature and as such are referred to as a graded
  exercise test (GXT).
• Graded-means that the exercise is progressed in a
  stepwise fashion from light to maximum levels.
• A number of Exercise Protocols, usually
  performed on the treadmill or cycle ergometer,
  are available to the examiner, depending on the
  purpose of the test and the population being
  tested.
• For example The same GXT test would not be
  performed on a young adult as would be performed
  on a 70 year old person.

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Screening

• Is extremely important in determining an
  individuals suitability for an exercise program.
• Exercise may not be safe for everyone especially
  people with pre-existing medical conditions, such
  as coronary artery disease.
• For a limited number of individual, exercise
  TESTING alone could be harmful to them and should
  not be done for medical reasons.

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Physical Examination

• Many patients require a physicians referral
  before they can undergo exercise testing or enter
  into an exercise program.
• The ACSM has developed guidelines to aid the
  healthcare professional in determining the safety
  of exercise for individuals.
• These guidelines suggest that it is unnecessary
  for men under the age of 40 and women under the
  age of 50 who have no symptoms of heart disease
  are apparently healthy, and have fewer than two
  risk factors for Coronary Artery Disease to have
  a medical evaluation by a physician before
  starting an exercise program.
• Exercise programs conducted in non-medical
  settings require a for anyone over the age of 35.

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Health History

• The purpose is to a) Identify and exclude
  individuals with medical contraindications to
  exercise, b) identify individuals with clinically
  significant disease conditions who should be
  referred to a medically supervised exercise
  program, c) identify individuals with symptoms
  and risk factors for a disease who should receive
  further medical evaluation before starting an
  exercise program, d) identify individuals with
  special needs for safe exercise participation.

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Physiologic Measurements

• Heart Rate
• Blood Pressure
• Blood Glucose
• Serum cholestrol
• Resting ECG (before diagnostic test)
• Abnormalities in any of these measurements may
  indicate underlying health problems such as heart
  disease, hypertension, or diabetes, which may
  warrant further medical evaluation before
  proceeding with the actual test. (Often expected
  in diagnostic testing)

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Heart Rate

• Resting HR usually measured for at least 60 secs.
  after the individual has been sitting for 5 mins.
• Methods chest auscultation w/ sensitive
  stethoscope or radial pulse or carotid artery
  palpitation.
• Exercise and Clinical settings HR is determined
  through readings obtained from the ECG recordings
  and directly off the digital display of the
  oscilloscope.

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Blood Pressure

• Arterial blood pressure is a function of the
  arterial blood flow each minute (cardiac output)
  and the resistance offered by the vasculature to
  that flow.
• When the heart contracts and pushes blood, the
  vessels do not allow all the blood to instantly
  flow to all areas of the body as fast as it is
  being ejected from the heart.?This creates
  pressure which can be recorded.
• The highest pressure recorded during a heart beat
  occurs during the contraction aka the systole of
  the left ventricle and is called the systolic
  blood pressure. provides estimate of work by
  heart and the pressure exerted on the walls.
• During relaxation phase of the heart-diastole-pres
  sure decreases.
• This decrease in pressure is called Diastolic
  blood pressure which gives and indirect
  indication of total peripheral resistance or the
  ease with which blood flows through the arteries
  to the capillaries.
• BP-is the product of cardiac output and
  peripheral resistance.

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Blood Pressure Cont

• Hypertension-resting BP that is chronically
  elevated.
• Normal BP is approx. 120/180 mm Hg for males and
  110/170 mm Hg for females.
• Exercise will result in an increase in cardiac
  output causing and increase in BP.
• Systolic BP can increase approx. 200 mm Hg in
  health, fit men and women.
• Systolic BP multiplied by the heart rate is
  called Double Product (also referred to as the
  rate pressure product) which provides an estimate
  of the myocardial (heart tissue) oxygen demand.

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Rating of Perceived Exertion(RPE)

• It is important during GXT to determine the
  participants psychological perception of the
  intensity of the exercise.
• Psychologist Borg developed the original scale.
• The numerical scale 6-20 closely related to HR
  from resting to maximum when multiplied by 10
  (60-200 bpm)
• A new scale has been developed that measures from
  1-10.

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Electrocardiogram (ECG)

• ECG is important for diagnosing problems
  associated with abnormal cardiac electrical
  conductivity and rhythm, insufficient supply of
  oxygen to the myocardium, and presence of damage
  to the myocardium.

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ECG Cont

• The outer surface of the heart cells is positive
  and the inner surface is negative. This
  electrical condition of the cell is referred to
  as being polarized. Immediately before
  contraction the cell receives a jolt of
  electrical activity, which causes a complete
  reversal of the cells polarity, meaning the
  positive charge is now on the inside of the cell.
  This process is called depolarization, which
  produces action potential.

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Submaximum GXT

• Gives an estimate of ones maximum fitness level.
• Done by evaluating ones cardio respiratory
  response to a sub maximal exercise.
• Give an estimate of ones VO2 Max.
• Less expensive to perform and safer for the
  participant.
• VO2max Can be estimated from equations that
  either calculate V02max from the last work
  achieved on the GXT, from the oxygen requirement
  for horizontal and graded walking on a treadmill,
  or from a subjects HR response to a series of
  submaximum work rates.
• Test is usually taken to a workload that elicits
  70-85 of the age predicted maximum HR.
• See youtube video

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Maximum GXT

• Is used for many reasons, ranging from
  measurement of VO2max in the world-class athletes
  to the diagnosis of abnormal cardiorespiratory
  function in cardiac patients.
• This test is taken until complete exhaustion or
  until the point at which abnormal physiologic
  responses occur.
• Abnormal signs and symptoms may include blood
  pressure and ECG changes as well as chest
  pain-angina pectoris, shortness of
  breath-dyspnea, or lightheadedness.
• Maximum GXT are important because many
  abnormalties dont occur until the workload is at
  a high intensity.
• See youtube video

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Special Populations and Clinical Exercise
Physiology Practice

• Major disease states served by clinical exercise
  physiologists
• Cardiovascular Disease
• Pulmonary Disorders
• Metabolic Disorders
• Inflammatory Disorders
• Orthopedic Disorders
• Neurovascular Diseases and Conditions

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Cardiovascular Disease

• Leading cause of death in the U.S.
• For individuals that survive, a program that
  emphasizes both physical and psychosocial
  rehabilitation is important.
• People who have the atherosclerosis
  susceptibility gene are 50 more likely to have
  CHD.

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Cardiovascular Disease Cont..

• Atherosclerosis-normally involves injury to the
  endothelial wall on the artery.
• Lipids accumulate between the junction of the
  inner and middle linings of the artery, resulting
  in obstruction of blood flow.

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Pulmonary Disorders

• Commonly separated into 3 Groups
• Obstructive (asthma, chronic bronchitis, and
  emphasema)
• Restrictive (Pulmonary fibrosis, chest wall
  deformity, and neuromuscular weakness)
• Disordered Control of Breathing (sleep apnea and
  obesity pypoventilation)
• Hypoxemia-Deficiency of oxygen in arterial blood

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Metabolic Disorders

• Any defect in the metabolic processes that allows
  for fuels to be properly stored in the body,
  delivered to active muscles, and oxidized for
  energy.
• Can interfere with exercise performance.

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Diabetes

• Diabetes Mellitus-is a serious health problem in
  the U.S. resulting in significant morbidity and
  mortality in approx. 16 million Americans.
• Caused by inadequate secretion of the pancreatic
  hormone insulin, by problems related to
  inadequate action on insulin, or by a combination
  of both defective insulin action and impaired
  insulin secretion.

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Type I Diabetes (Insulin dependant mellitus)

• Occurs primarily as the result of a defect in
  which the immune system mistakenly turns on its
  own body and destroys the insulin producing
  B-Cells .
• After the autoimmune destruction of the B-cells,
  little or no endogenous insulin is produced, and
  the body is unable to move glucose through the
  blood stream into body cells to be used for
  energy or to be stored as glycogen.
• Symptoms include frequent urination, unusual
  thirst, weight loss, blurred vision, extreme
  fatigue, and increased susceptibility to
  infection.

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Type II Diabetes (noninsulin-dependent diabetes
mellitus

• Occurs as a result of insulin resistance and
  account for 90-95 of all diabetes cases.
• Insulin resistance is strongly associated with
  physical inactivity.
• Strong genetic predisposition for developing type
  II diabetes.
• See youtube video

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Obesity

• Obesity is the excess accumulation of body fat,
  and is an important health problem in the U.S.
• Obesity is associated with and increased
  frequency of atherogenic risk factors including
  Hypertension, Hyperinsulinemia, type II diabetes,
  and reduced HDL, it also is associated with
  osteoarthritis and various types of cancer.
• You are obese is your body mass index is
  30.0-39.9 and morbidly obese if your BMI exceeds
  40.0.
• Develops from a combination of genetic and
  environmental factors.

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What is wrong with this picture???
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How much does this represent the children of this
generation?
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Rheumatologic Diseases

• Encompass disorders of the musculoskeletal
  system.
• Often chronic and often leads to disability
• Clinical exercise physiologists can play a role
  in minimizing disability through appropriate
  evaluation and exercise prescription.

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Osteoarthritis

• Most common type of arthrisis
• Characterized by local deterioration of
  cartilage, leading to joint space loss and new
  bone formation.
• Typically affects weight-bearing joints,
  specially the knees and hips.
• Risk factors include advanced age, obesity,
  genetic factors, trauma, and repetitive use.

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Rheumatoid Athritis

• Present in only 1 of the population.
• A systematic autoimmune disease of unknown cause
  whose major features are redness, swelling,
  warmth, and significant stiffness of the joints.
• Pre-disposing factors include age, female sex,
  lower socioeconomic status, and genetics.
• Has been reported to have increased mortality
  rates, and patients with severe forms of this
  disease may die 10 to 15 years earlier than
  expected.

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Orthopedic and Neuromuscular Diseases and
Conditions

• These range from relatively rare diseases
  affecting the central nervous system and the
  muscle cells, to the widespread occurrence of
  pain affecting to neck and back.

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Lower Back Pain

• Is the most frequent musculoskeletal complaint
  for all people at all ages.
• Acute lower back pain is typically, first treated
  with a mild analgesic, such as acetaminophen,
  along with a warm shower.
• Other treatments include better posture and
  exercise to strengthen and relieve the stress
  from the back.

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Muscular Dystrophy

• Most common muscular disease in children.
• It is a collection of hereditary conditions that
  lead to biochemical and structural changes within
  the muscle cell.
• Results in the muscle wasting with and
  incremental disease in muscle strength, leading
  to disability, deformity, and often death.

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Duchene MD

• Most common and destructive MD.
• Caused by a sex-linked recessive genetic defect
  and affects young boys at a rate of 1 out of
  every 3,500 live births.
• Usually appears between the ages of 2-6 yrs. Old
• No cure for MD, although exercise therapy maybe
  useful in maintaining mobility.

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Multiple Sclerosis

• Most common neurological disease in early to
  middle adulthood.
• Twice as common in women.
• Disease of the central nervous system
  characterized by loss of myelin sheath.
• Suffer from reduced lifespan, bust most will
  survive at least 25 years from diagnosis.
• Important to work closely with members of a
  healthcare team,, as the disease progresses, to
  plan appropriate levels of activity and to adapt
  exercise performance and exercise equipment to
  allow patients with MS to maintain their highest
  level of functional ability.

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Advances in Clinical Exercise Physiology

• Important breakthrough in basic research have led
  to meaningful applications in the treatment of
  chronic disease.
• Physical activity is now considered to be a
  critical role therapies that at one time wouldnt
  have been imagined.

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Heart Transplantation

• Approx. 2,800 heart transplants are performed
  each year.
• Established treatment for advanced heart disease
• 1 year survival rates are now over 80
• Exercise appears to have a critical role in
  post-transplant therapy.

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Heart Transplant Cont

• Although advances are being made there is
  currently no way to establish nervous system
  connections between the patient and the new
  heart.
• The heart beats faster at rest, typically from
  100-110 bpm and responds more slowly to exercise.

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