Transcript Exercise Prescription
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