Exercise Prescription for Cardiac & Respiratory Diseases

Hazzaa M. Al-Hazzaa, Ph D, FACSM AlProfessor & Director Exercise Physiology Laboratory King Saud University Tel (office): 4678411 Lab: 4678406
http://faculty.ksu.edu.sa/hazzaa
RHS 514 - Fall 2010
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Part 1

Basic Concepts In Exercise Prescription

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Exercise Prescription

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Resources for Exercise & Health

AHA Statements 1992-1996 1992ACSM/CDC Joint Statement, JAMA, 1995 The US Surgeon General Report, 1996 WHO Global Strategy on Diet & Physical Activity, 2004 Physical Activity Guidelines for Americans, 1995 Global Recommendation on Physical Activity for Health, WHO, 2010 Toronto Charter for Physical Activity, May 2010
http://faculty.ksu.edu.sa/hazzaa/Resources/Forms/AllItems.aspx

Definitions
Physical Activity
Any bodily movement produced by the skeletal muscles resulting in energy expenditure above resting state.

Physical Fitness
A set of attributes that people have or achieve, which relates to the ability to perform physical activity.
Caspersen, et al., Public health Rep,1985
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Definitions
Metabolic Equivalent (MET)

The amount of energy expended during exercise relative to the energy expenditure during rest.
Energy expenditure during rest = 1 MET = 3.5 ml of O2 / kg. min = 1 kcal / kg. hr
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What is the Amount of Physical Activity that Promotes Optimal Health?

Moderate Intensity Physical Activity. Energy Expenditure = 3 - 6 MET That is: 30 min/day, 5 days/week. 150 min. per week.
ACSM, 2000; CDC, 1996

1000 k. calories/week.
Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000

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Physical Activity & Health Benefits

Health Benefits
Inactive

Moderately active

Very active

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Physical Activity Intensity in MET

Light: Less than 3 MET Moderate: 3 6 MET Vigorous: Above 6 MET

CDC, 1996

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Classification of Exercise Aerobic exercise:

Endurance type exercise, rhythmic, sustained for sometimes. Example: Walking, jogging, running, cycling, swimming, etc

Strength (Resistance) exercise:

Weight training with free weight, machine, elastic rope, calisthenics, etc

Flexibility exercise:
Stretching exercise.

Balance exercise for the Elderly

HealthHealth-Related Dimensions of Physical Activity

.(Caloric Expenditure)
.(Aerobic Intensity) .(Muscular Strength)
.(Flexibility )

.(Weight-bearing

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physical activity)

ACSM, 2000 al., 1998 Caspersen, et

Dimensions of health-enhancing Physical Activity health-

Energy Expenditure

Obesity

Diabetes

CHD

Moderate Intensity Aerobic Activity:

Walking, Swimming, Cycling, Badminton, tennisdouble, Daily living physical activity (taking stairs, working at home, gardening, etc..)
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Dimensions of health-enhancing Physical Activity health-

Aerobic Intensity

CHD

CV Efficiency

Max. O2 Uptake

Vigorous physical Activity (> 60% HR max):

Jogging, Running, Swimming, Cycling, Stepping, Rope skipping, Tennis-single, squash, Basketball.
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Dimensions of health-enhancing Physical Activity health-

Muscular Strength & Flexibility

Functional capacity

Low Back Health

Type of Activity:

Strength Exercise Muscular Endurance Exercise Flexibility Exercise

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Dimensions of health-enhancing Physical Activity health-

WeightWeight-bearing Physical activity

Osteoporosis
Type of Activity:

Walking, Jogging, Running. Strength Training. Jumping, Rope skipping.

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Screening before starting an Exercise Program

Evaluation of a Persons Readiness Person to engage in Physical Activity PARPAR-Q

The Flow Charts Approach

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Evaluation of Persons Readiness to Physical Activity

No
Does the person have symptom of CV disease? ** Does the person have diagnosed disease? *

Yes

Yes

Consider GXT and cardiology referral

No
Does the person have more than one risk factor? ***

Yes

Moderate activity is safe; vigorous activity: should have GXT

No
Is Age under 40 yrs for Men and under 50 yrs for women

Yes

No
Moderate or vigorous activity is safe

Readiness to Physical Activity (continued)

* Diagnosed Disease:
Cardiac disease
(excluding controlled hypertension)

Pulmonary Disease Metabolic disease

** Symptom of CV disease: Pain or discomfort in the chest, arms suggestive of ischemia Shortness of breath at rest or with exertion Dizziness or syncope Orthopnea or paroxysmal nocturnal Dyspnea Ankle edema Palpitations or unexplained tachycardia Intermittent claudication Known heart murmur Unusual extreme fatigue

*** Risk factors: Family history

Tobacco Use Hypertension Hyperlipidemia Diabetes Mellitus

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Components of Exercise Prescription

v Mode (Type of exercise) v Duration v Frequency v Intensity v Progression of Exercise Program v Safety/precaution
ACSM, 2000

Mode of Physical Activity

Based on current physical activity and fitness level. Individuals goals: for health; for fitness, to reduce
BP, to increase bone density, or to lose weight.

Individuals preference. Availability of time, facility (Gym, pool, etc) and weather condition.
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Duration of Physical Activity

There is an inverse relationship between activity duration and intensity. Individuals goals:
for Health: 30 - 60 min Health: for Fitness: 20 - 60 min Fitness: for Weight Loss: 60 - 90 Loss:

Consider additional time for warm-up and warmcoolcool-down (510 min each). (5 each).
ACSM, 2000: ACSM position Stand on Wt Loss, MSSE, 2010
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Frequency of Physical Activity

International guidelines & recommendations:
for Health: 5 days or more /week (preferably Health:
every day)

for Fitness: 3 5 days /week Fitness:

Consider the persons other commitments: job, family, etc.

ACSM, 2000

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Intensity of Physical Activity

Recommendations:
for Health: moderate intensity (3-6 MET or 40% to Health: (3 40% < 60% VO2R) 60%

for Fitness: vigorous intensity (65-90% HR max) Fitness: (65-90%

Consider starting with a lower intensity with beginners.

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The Relationship between Exercise Intensity and Health Benefits versus Fitness improvement
Health Benefits

Fitness

Light

moderate
Exercise Intensity

Vigorous

Moderate & Vigorous Intensity

Physical Activities
Moderate:
Brisk walking, Recreational swimming, Volleyball, Slow aerobics, Moderate cycling Gardening, Tennis-double, Badminton etc..

Vigorous:
Jogging, Running, Tennis-single, Basketball, Rope skipping, Squash, Fast aerobics, Fast cycling, Stepping, Soccer, etc
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Aerobic Exercises
Walking, brisk walking, mall walking, treadmill. Exercise bicycle (regular, stationary, recumbent, upper arm ergometer) . Elliptical trainer (exercise machine). Swimming/water aerobics Steppers Jump rope Most household activities.

Classification of Physical Activity Relative to Type of Contraction and level of Intensity Dynamic Exercise As % of VO2 max Moderate High Low %70- 40 %70 < %40 >
H Dynamic L Isometric M Dynamic L Isometric L Dynamic L Isometric

Type of Muscle Contraction Low %20 >

Moderate %50- 20

3
H Dynamic M Isometric

2
M Dynamic M Isometric

1
L Dynamic M Isometric

Isometric Exercise % of Maximum Voluntary Contraction

6
H Dynamic H Isometric

5
M Dynamic H Isometric

4
L Dynamic H Isometric

High %50 <

L = Low ; M = Moderate; H = High

Mitchell, et al, Med Sci Sports Exerc, 1994
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What can you tell from this Cartoon? Think in term of Intensity & Aerobic Exercises

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Progression
First, increase the frequency of physical activity. Then, increase the duration of physical activity. Lastly, increase the intensity of physical activity.

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Components of an Exercise Session

WarmWarm-up period
5-10 min

Exercise period
3030-60 min

Cool down period

5-10 min

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Why Cool Down?

Allows gradual recovery of heart, lungs and blood pressure to resting state. Maintain adequate venous return to reduce post exercise dizziness Reduce lactic acid and muscle soreness

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Resistance Exercise
Should include upper body, lower body and trunk Can be of any form of resistance such as:
l l l l

Free weights, or a heavy object to lift. Resistance Machine / Medicine Balls. Body weight (Callisthenic Exercise). Elastic bands or tubing.

Should be performed 2-3 times/week on nonconsecutive days

Resistance Exercise

(continued)

8-12 repetitions (The last repetition you do should feel like the last repetition you can do). Use functional exercise as possible. Functional exercise is specific to and closely mimics task to be completed.
For example, walking lunge is better to strengthen muscles to assist in increasing efficiency of walking / running than leg extensions.

Examples of simple Resistance Exercise

Elbow Curl
Knee Extension

Seated Row

Chair Squat

Elbow Extension

Chest Press

Contraindications to Resistance Training in Cardiac Patients Unstable angina

Uncontrolled High Blood pressure (> 160/100 mmHg) Uncontrolled Arrhythmia

Untreated heart failure Severe valvular stenosis Hypertrophic cardiomyopathy (HCM) ST segment depression
Pollock M, et al. Circulation 2000
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FLEXIBILITY

(1/2)

Stretch to maintain the ROM in all joints. ROM starts to decline at age 30. Warm-up first, then do stretching exercise. Perform static stretching to the end of ROM, no bounce or ballistic movements. What to stretch: shoulders, chest, calves, hamstrings, hips.

FLEXIBILITY

(2/2)

Hold each stretch for 15-30 s. You should feel a little uncomfortable but no pain Greatest benefit occur in the first 15 seconds; no greater benefit after 30 seconds. Ideally perform stretching 5-7 days per week. However, minimum is 2-3 days per week.

Classification of Exercise Intensity

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Classification of Exercise Intensity

% of Maximal Heart Rate

or % of Heart Rate Reserve

Maximal Heart Rate = 208 ( 0.7 X age (yrs))* Maximal Heart Rate = 220 age (yrs)) Heart Rate Reserve = HR max HR rest
* Tanaka, et al, 2000

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Classification of Exercise Intensity

Exercise Intensity Very Light Light Moderate Hard Very Hard Maximal % of Maximal Heart Rate < 50 % 50 63 % 64 76 % 77 93 % > 93 % 100 % % of Heart Rate Reserve < 20 % 20 39 % 40 59 % 60 84 % > 84 % 100 %
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ACSM, 2000 (Suppl) 2001; (6): S 367. Howley, MSSE

Patients using Beta Blockers

Previous equations are not suitable for them. Drugs affecting Beta receptors lower heart rate at rest, submaximal & maximal exercise.
ACSM, 2000

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Effects of Sympathetic and Parasympathetic Blockades on H. R.

200 180 160 140 120 100 80 60 40 20

Atropine
Propranolol

No Blockade Parasympathetic blockade Sympathetic blockade

Rest

25

50

75

100

% of Maximal Oxygen Uptake

Astrand & Rodahl,1977, p. 191 ( Data: Ekblom et al., 1972

HRR = VO2R
HHR = HR max HR rest. VO2R is the difference between VO2 max and resting VO2. 40-85% is recommended for VO2R and HRR. Resting MET level = 3.5 ml/kg/min .

HRR = VO2R
If a patient has a 17.5 ml/kg.min VO2 max, prescribe exercise intensity for him at 50% of his VO2 R? VO2 R = VO2 max VO2 rest = 17.5 - 3.5 = 14 ml/kg.min 50 % of VO2 R = 14.0 x 0.50 = 7 ml/kg.min Required exercise intensity = 7 + 3.5 = 10.5 ml/kg.min ( 3 METs)
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Energy Expenditure during Physical Activity!

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Energy Cost of Physical Activity

(k. calorie/kg. min)

Activity
Brisk walking Running (7.5 min per km) Running (5 min per km) Swimming Rope skipping (70/min) Rope skipping (80/min) Badminton Tennis Squash Basketball
McArdle, et., 1991

Calorei
0.07 0.13 0.208 0.162 0.162 0.165 0.097 0.109 0.212 0.138

Energy Cost of Physical Activity in MET

Activity
Walking (slow) Walking (Brisk) Running (7.5 min per km) Swimming Rope skipping (slow) Weight training Badminton Tennis (single) Squash Basketball
Ainsworth, et., 2000

MET
2.5 4 8 6 8 6 4.5 8 12 8

How to Calculate Energy Expenditure during Brisk Walking!

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Energy Expenditure during Brisk Walking

= 0.07 k. calorie per kg of body weight /

min. An Example:

a person weighing 76 kg would expend:

0.07 X 76 = 5.3 k. calorie per min.

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Energy Expenditure during Brisk Walking

If somebody has to expend 1200 k. calories per week. HOW much time he/she should walk per week?

1200 / 5.3 = 226.4 min. 226. = 45 min/ 5 days per week, or = 57 min/ 4 days per week.
Note: This includes resting energy expenditure
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