Other Clinical Conditions Influencing Exercise Prescription

Cardiac Wellness Institute of Calgary Updated May 2010

Material to be Covered

ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6 th ed.) Chapters 7, 8, 23, 24, 36, 37, 38 ACSM’s Guidelines for Exercise Testing and Prescription (8 th ed.) Chapter 10

Diabetes Mellitus

ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6 th Edition) Chapters 8, 24, 37 ACSM’s Guidelines for Exercise Testing and Prescription (8 th Edition) - Chapter 10

Diabetes Mellitus

 Complex metabolic disorder  Characterized by: – Abnormal glucose metabolism defects in insulin release, action, or both – Secondary microvascular degeneration

Diabetes Mellitus



IDDM (Type I):

– Caused by an acute or gradual loss of insulin producing beta cells in the pancreas – Maintain high levels of plasma glucose – Subject to ketoacidosis –  loss of water and sugar through urine  Secondary thirst, weight loss and increased appetite

Diabetes Mellitus



NIDDM (Type II)

– Decreased sensitivity of peripheral receptors especially in SM and liver – Decreased plasma glucose – Plasma insulin usually increases

Diabetes Mellitus

Characteristics

Age of onset Frequency Family Hx Symptoms

Type I

< 20 0.5% Probable Thirst, polyuria, weight loss,  appetite

Type II

> 40 4-5% Frequent Mild or frequently none Obesity Serum insulin Insulin Tx + Low to zero Always ++ High (initially) 20-30%

Diagnostic Criteria for Diabetes

   Symptoms of diabetes plus casual plasma glucose concentration of ≥200 mg/dL (11.1mmol/L) Fasting plasma glucose of ≥126 mg/dL (7.0 mmol/L) (fasting is defined as no caloric intake for at least 8 hours) 2 hour plasma glucose ≥200 mg/dL -1 oral glucose tolerance test (OGTT) during

Complications

 Wide-ranging Complications – Hypo or hyperglycemia – Retinopathy – Hypertension and CAD – Autonomic neuropathy – Peripheral neuropathy – Nephropathy

Treatment



IDDM

– Subcutaneous injections of insulin (SA and LA) – Dietary regulation – Exercise daily 

NIDDM

– Weight loss – Oral hypoglycemics – Possibly insulin

Benefits of Exercise

 Improved insulin sensitivity  Decreased risk of CV disease: – Improved blood lipids –  caloric expenditure (improve BMI) – BP in those with hypertension  Increased fitness − Aerobic, strength and endurance, flexibility  Improved psychological well being

Benefits of Exercise



NIDDM

– Reduced blood glucose and HgA1c levels – Improved glucose tolerance – Improved insulin response to oral glucose 

IDDM

– Improvement in insulin sensitivity may be transient

Response to Exercise

 Acute exercise results in  glucose use  Therefore  glucose production necessary to maintain normal levels  Compromised in the diabetic state

Screening Procedures

 History and Physical Exam  Diabetes Evaluation  Cardiovascular Exam – Often includes clinical exercise testing

Clinical Exercise Testing

Other Considerations

 Modality – change to standard protocols or arm ergometry  Hypertensive response  Presence of silent ischemia  Postural hypotension or blunted HR response  Glucose monitoring and adjust insulin  Sub-max exercise to determine training intensity

Exercise Prescription:



Frequency

– 3-7 d/wk – Low – mod intensity if 7 days/week (IDDM) 

Intensity

– Target Heart Rate or MET level 

50 -80

% Karvonen method or VO 2 test max RPE/talk 

12-16 on a 6-20 scale

FITT Intensity

Other Considerations

 THR always 10bpm below: –  1mm horizontal or downsloping ST segment depression – Anginal symptoms or other CV insufficiency – SBP  240mmHg, plateau SBP or  SBP – DBP  110mmHg

FITT Intensity

Other Considerations

 THR always 10bpm below: –  frequency ventricular dysrhythmias – Other significant ECG disturbances – Radionuclide evidence LV dysfunction – Mod/sev wall motion abnormal with exercise – Other signs/symptoms of intolerance

Exercise Prescription



Time

– 20-60 minutes/session – 5-10 min WU and CD 

Type

–

Aerobic:

may require non-wt bearing –

Resistance:

may be contraindicated, if not as per guidelines for cardiac patients

Prescription Guidelines: RT

 1 set, 10-15 reps, 8-10 exercises  2-3 days/week  RPE 11-14  Rate pressure product (RPP) during RT  exceed RPP during aerobic exercise training  Avoid Valsalva, tight grip  Exhale on exertion

Exercise Prescription

Other Considerations

 Encourage to wear medical alert ID  Encourage to exercise with a partner  Ensure adequate hydration  Reinforce proper footwear  Exercise with caution in temperature extremes  May need to limit isometric exercise

Precautions for Avoiding Hypoglycemic Events



Aware of signs and symptoms

– Diaphoresis – Weakness – Pallor – Lightheadedness – Tremor – Fatigue – – Tachycardia Headache – Memory loss – Palpitations – Seizure or coma – Visual disturbance – Mental confusion

Precautions for Avoiding Hypoglycemic Events

 Measure blood glucose before, during and after exercise – < 100mg/dL (5.5 mmol/L) eat CHO snack – Delay exercise if >300 mg/dL or > 240 mg/dL with postive ketones  Adjust insulin dosages associated with exercise − Avoid exercise during periods of peak insulin activity  Insulin should not be injected into an exercising muscle  Exercise late in the evening  hypoglycemia risk of nocturnal

Precautions for Avoiding Hyperglycemic Events

 Aware of signs and symptoms of hyperglycemia: – Dehydration – Hypotension and reflex tachycardia – Frequent urination – Impaired consciousness – Nausea – Vomiting – Abdominal pain – Hyperventilation – Odor of acetone on breath  Measure blood glucose and ketones before, during and after exercise − Postpone exercise if blood glucose >300mg/dL (~16.5mmol/L)or 240 mg/dL (~ 13 mmol/L) with ketones

Hypertension

ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6 th Edition) - Chapters 38 ACSM’s Guidelines for Exercise Testing and Prescription (8 th Edition) - Chapter 10

Hypertension

 Prevalence: 15-20% in western civilization  BP is determined by

Cardiac Output and Total Peripheral Resistance

Classification of Hypertension

 Essential (Primary) hypertension: – No single cause  Secondary hypertension: – Hypertension secondary to other disorders of the renal, endocrine, and nervous systems

Associated Complications

 Primary risk factor for cardiovascular disease – Changes extent and presence of calcium  End-organ damage – LVH – Arteriosclerosis in retina – Renal failure

Lifestyle Modifications for Hypertension

 Weight Loss  Limit alcohol intake  Increase aerobic physical activity  Reduce sodium intake  Maintain adequate intake of dietary potassium

Lifestyle Modifications for Hypertension Continued

 Maintain adequate intake of dietary calcium and magnesium for general health  Stop smoking  Reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health

Benefits of Exercise

 Reduce BP – Reduced Cardiac Output – Reduced Total Peripheral Resistance – Changes in body composition  Improve risk factor profile

Response to Exercise

 Gradually increase SBP – Response > in those with hypertension – Should increase > 10mmgHg and not decrease  Decrease or no change DBP  Typical range 180-210/60-85  Exaggerated response (>230/100) may predict future hypertension and/or CAD

Screening Procedures

 To diagnose should have three separate readings  If high risk would require CV Exam often includes clinical exercise testing

Clinical Exercise Testing

Other Considerations

 Standard methods and protocols  Medications taken at normal time  ECG may show LVH  Possible dysrhythmias due to diuretic treatment  Observe for exaggerated pressure response – SBP > 260 mmHg – DBP 115 mmHg

Exercise Prescription



Frequency

– Most, preferably all days of the week 

Intensity

– Target Heart Rate or MET level   40-<60% heart rate reserve (HRR) or VO 2 max Aim for 700 – 2000 kcal/week

Exercise Prescription



Time

– 30-60 minutes/session; intermittent: minimum of 10 minute bouts accumulated to 30-60 minutes – 5-10 min WU and CD 

Type

–

Aerobic

–

Resistance:

may be contraindicated, if not as per guidelines for cardiac patients  Need to monitor BP with isometric activity

Exercise Prescription

Other Considerations

 Do not exercise if resting BP: – SBP > 200 mmHg or – DBP > 110 mmHg  Some antihypertensives may cause post exercise hypotension therefore adequate CD important  Diuretics may cause a

↓

in K + in arrhythmias which may result  Avoid Valsalva maneuvers during RT

Peripheral Arterial Disease (PAD)

ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6 th Edition) - Chapters 38 ACSM’s Guidelines for Exercise Testing and Prescription (8 th Edition) - Chapter 10

Peripheral Arterial Disease (PAD)

 Common manifestation of atherosclerosis  Prevalence: 10% in age 60+  Have similar risk factor profile as CV disease

Peripheral Arterial Disease (PAD)



Acute:

– Muscle blood flow supply/demand mismatch 

Chronic:

– Deconditioning – Impaired oxidative metabolism – Lack of blood flow limits ability to do ADLs

Diagnosis of PAD

 Symptoms – Claudication – Intermittent muscular pain relieved with rest  Based on history and physical exam – Risk factors – Hemodynamic assessment  Auscultation of femoral arteries  ABI  Arteriography

Ankle/Brachial Index

 Resting SBP in ankle and arm by Doppler  Used to measure the severity of PAD  Abnormal ABI: <0.9 at rest or 20% ↓ after exercise  Severity not correlated to treadmill performance

Associated Complications

 Detrimental effects on functional status – < 1-3 blocks – VO 2 max typically 10-16 ml/kg/min  Prevents ability to do ADLs  Ischemic ulceration  Gangrene and tissue loss

Treatment

 Medical management is marginally effective – Trental (  blood viscosity), Cilostazol  Lifestyle Modification to reduce risk factors (hypertension, smoking, and diabetes)  Surgery or angioplasty

Benefits of Exercise

 Improved functional tolerance  15-30%  in oxygen consumption  Improved walking ability –  speed and duration – Delayed onset of claudication (improvements of 106 177% of pain free walking) – Improved perception of physical functioning  Increased level of habitual exercise

Benefits of Exercise

 Improved functional tolerance may result from: –  peripheral blood flow – improved muscle metabolism – walking efficiency  Improved functional tolerance may result from: −  peripheral blood flow − Improved muscle metabolism − Walking efficiency

Response to Exercise

 With onset of activity there is a mismatch of local muscle blood flow supply/demand  Results in localized ischemic pain that limits activity

Screening Procedures

 CV screening should be done to assess the presence or extent of CAD – History and physical exam – Includes clinical exercise testing

Clinical Exercise Testing

Other Considerations

 Protocols should be adapted – Discontinuous to achieve VO 2 max – Consider arm ergometry – Slower speed and less rapidly changing grade  Use scale for subjective ratings of pain  Record time of pain onset and point of maximal pain  Assess with functional status questionnaires

Subjective Grading Scale for PVD Pain



Grade 1

- Definite discomfort or pain, but only of initial or modest levels (established, but minimal) 

Grade 2

- Moderate discomfort or pain from which the patient’s attention can be diverted, for example by conversation 

Grade 3

- Intense pain (short of grade 4) from which the patient’s attention cannot be diverted 

Grade 4

- Excruciating and unbearable pain

Exercise Prescription



Frequency

– Weight-bearing aerobic exercise 3-5 d/wk 

Intensity

– Target Heart Rate or MET level  Moderate intensity (40- <60% HRR or VO 2 max  A pain score of 3/4. Individuals should have time to allow ischemic pain to subside before resuming exercise.

Exercise Prescription



Time

– 30-60 minutes/session (can start with 10-minute bouts and exercise intermittently to accumulate 30-60 minutes) – 5-10 min WU and CD 

Type

–

Aerobic:

 Weight bearing exercise preferred; Non-weight bearing may be used for WU and CD  Non-weight bearing activity is encouraged –

Resistance:

 As per guidelines for cardiac patients

Exercise Prescription



Progression

– Start with work load that brings on claudication pain at a level of ¾ on PVD pain scale –  work load when duration > 10 minutes – Start with 35 mins, which may be intermittent – Progress to 50 mins, 3-5 days/wk

Exercise Prescription

Other Considerations

 A cold environment may aggravate the symptoms of claudication; therefore a longer warm-up may be required  Beta blockers may  time to claudication  Improved tolerance may unmask CV ischemia

Pulmonary Disease

ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription (6 th Edition) Chapters 7, 23, 36 ACSM’s Guidelines for Exercise Testing and Prescription (8 th Edition) - Chapter 10

Pulmonary Disease

 Diseases of the respiratory tract are classified as: – Obstructive Disease – Restrictive Disease – Vascular Disease

Chronic Obstructive Airway Disease (COPD)

 Results from non-uniform narrowing in the airways secondary to inflammation  Narrowing  resistance and results in uneven distribution of minute ventilation (VE)  Characterized by: – Expiratory flow obstruction – Dyspnea at rest and with exertion – Reversible airway hyperactivity

COPD disorders



Chronic Bronchitis:

– Inflammatory disorder of the small airways in the lungs – – Characterized by coughing, wheezing and sputum production  arterial O 2 saturation and  CO 2 hypoventilation levels due to – – Flow rates can be improved with bronchodilators Considered a “blue bloater” due to stocky habitus with central and peripheral cyanosis – Eventually can lead to right heart failure

COPD disorders



Emphysema:

– Gradual destruction of lung tissue as well as airway inflammation – Abnormal enlargement of the airspaces by destruction of the alveolar walls – Loss of lung elasticity and elastic recoil pressure – Unresponsive to bronchodilators  Pursed lips breathing – Usually not cyanotic and little sputum production – High VE – “Pink puffer” due to significant dyspnea and barrel chest with marked lung hyperinflation

COPD Disorders



Asthma:

– – Characterized by increased airway reactivity to various stimuli Airways respond with  mucous and constriction – Results in non-productive cough and wheezing – Symptoms controlled by inhaled and oral bronchodilators

Diagnosis



Pulmonary Function Testing

–

Spirometry

 Airway patency and air volume in/out of lungs –  Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV 1.0

) and FEV 1 /FVC

Lung volume

 Total lung capacity (TLC), residual volume (RV) –

Diffusing capacity

 Rate at which gases diffuse from the lung (alveoli) to the blood in the pulmonary capillaries

Diagnosis

 Cardiopulmonary Exercise Testing (CPX) – Maximal exercise tolerance – Ventilatory limitations – Pulmonary gas exchange – CV responses to exercise

Treatment

 Medical management  Discontinuation of smoking  Exercise

Benefits of Exercise

 Psychological benefits – Mastering something difficult – Social interaction – Distraction  Improved functional tolerance – Perceived exercise tolerance increases – Exercise endurance improves – Improvement in ability to do ADLs – Avoid downward spiral of deconditioning

Response to Exercise

 Tissues  VO 2 and CO 2  Cardiac Output and VE  production to meet the demands  Typically exercise capacity is not limited by the pulmonary system as O 2 transport capacity > that of the heart

Physiological Limiting Factors in COPD

 Impaired lung mechanics  Inefficient pulmonary gas exchange  Pulmonary vascular insufficiency  Abnormal skeletal muscle metabolism

Screening Procedures

 History and Physical Exam  Pulmonary Evaluation  Cardiovascular Exam – Often includes CPX

Clinical Exercise Testing

Other Considerations

 CPX for specific exercise prescription and pre/post evaluation  Cycle ergometry is often used  Monitor arterial oxygen saturation (SaO 2 ) – <90% may require supplemental O 2 during exercise  Use scale for subjective ratings of dyspnea  Keep in mind absolute and relative contraindications

Dyspnea Scale

Nothing 0 Very, very slight 0.5

Very slight 1 Slight Moderate 2 3 Somewhat severe 4 Severe 5 6 Very severe 7 8 9 Very, very severe 10

Dyspnea Scale

+1 Light, barely noticeable +2 Moderate, bothersome +3 Moderately severe, very uncomfortable +4 Most severe or intense dyspnea ever experienced

Exercise Prescription



Frequency

– 3-5 d/wk 

Intensity

– No consensus as to the optimal exercise intensity – MET level (or THR)  60-80% peak work rates – Maximal limits as tolerated by symptoms – 3-5 on Dyspnea Scale – Talk test/RPE

Exercise Prescription



Time:

May need to start with intermittent exercise until patient is able to sustain higher intensities and durations of activity – – 30-50 minutes/session 5-10 min WU and CD 

Type

–

Aerobic

:  Activities involving large muscle groups  Arm ergometry –

Resistance

:  As per guidelines in Chapter 7 – Guidelines for Exercise Testing and Prescription

Exercise Prescription

Other Considerations

 Maintain SaO2 at > 88%  Use pursed-lips breathing  Carry bronchodilators if prescribed  Exercise indoors during times of inclement weather or if environmental irritants exist

Alternative Modes of Exercise Training

 Continuous positive airway pressure  Upper body resistance training  Ventilatory muscle training

Guidelines for Inspiratory Muscle Training

1. Frequency-- Minimum of 4 to 5 d·wk -1 2. Intensity---30% of maximal inspiratory pressure (PI max ) measured at functional residual capacity 3. Duration---Two 15-minute sessions or one 30 minute session per day. If this cannot be achieved, the intensity should be reduced