Mark David S.

Basco, PTRP
Department of Physical Therapy
College of Allied Medical Professions
University of the Philippines Manila

Objectives
At the end of the session, students should be able to
Determine the components of an exercise program
Apply principles of a conditioning program for
patients with
Coronary Artery Disease
Stroke and/or history of Hypertension
Peripheral Vascular Disease
COPD
Diabetes Mellitus
Well population

Objectives
Determine criteria for initiating an exercise

session for different clients / patients.

Decide when to terminate an exercise session
based on established protocols and guidelines

What do we need for this

topic?

Background knowledge of:

Cardiovascular physiology
Exercise physiology
Muscle physiology
Knowledge of different conditions presenting
with impaired aerobic capacity
Most importantly:
An open and inquisitive mind

Endurance
Ability to work for prolonged periods of time

and resist fatigue

Types
Cardiovascular
Muscular

INTENSITY
DURATION
FREQUENCY
MODE

Intensity
Overload principle
Specificity principle
Quantifying intensity
Heart Rate
VO2 Max
Rating of Perceived Exertion

Intensity

Heart Rate
Maximum Heart Rate
220-age

Karvonens Formula
THR= RHR + (MHR - RHR) (60-80%)
Deconditioned 40-50%
Cardiopulmonary disease 40 60%
Healthy individuals 60 80%
For UE work
MHR = 220 age - 11

Intensity
Rating of Perceived Exertion
Useful for patients with heart rate suppressors
e.g. Beta blockers
Original
Revised

Intensity
Rating of Perceived Exertion
Original version ( 6-20 )
Remember only the ODD
numbers

7 VERY VERY
9 - VERY
11 - LIGHT
13 SOMEWHAT HARD
15 - HARD
17 - VERY
19 VERY VERY

12- 60% HR
range
13- 65 70% HR
range

Intensity
Rating of Perceived Exertion
Revised version ( 0-10 )

0.5 VERY VERY

1VERY
2 - WEAK
3 MODERATE
4 - SOME - WHAT
5 - STRONG
7
VERY
10
VERY VERY

Intensity
Exercising at a high intensity elicits a greater

improvement of the VO2 max

The higher the intensity, the longer the

exercise intervals, the faster the training

effect
Exercising at high intensities increases the

risk for CV complications and musculoskeletal

injury

Intensity
Goal
Achievement of intensity 60-90% MHR OR 5085% VO2 Max
Beginners: 50-60% VO2 Max
Average: 60-70% VO2 Max
Fit: 75-85% VO2 Max

Duration
Dependent on
Total work performed
Intensity
Frequency
Fitness level
HIGH intensity

duration
LOW intensity

SHORT
LONG duration

Duration
Poor functional capacity
5 - 10 minutes
Beginners
10 - 20 minutes

Average
15 - 45 minutes

Fit
30 60 minutes

Duration
Moderate to Minimal intensity
20 30 minutes
High intensity
10 15 minutes
Exercise longer than 45 minutes increases the
risk for musculoskeletal complications

Frequency
Dependent on the health and age of the

individual
LOW intensity
HIGH intensity

HIGH frequency
LOW frequency

Frequency

POOR

Daily

Beginner
Every other day

Optimal frequency
3-4 times a week
2 times a week does not generally evoke CV
changes for well population
Increase in frequency beyond optimal range,
increases risk for musculoskeletal complications
30-45 mins 3x a week protects against CV
disorders

Frequency
3 5 sessions / week
Greater than 5 METS
Daily or multiple daily sessions
Less than 5 METS

Mode
Large muscles
Rhythmic
Long duration
Lower extremity versus Upper extremity

exercise

Mode
Lower extremity

Upper extremity

Larger muscle mass

Higher VO2 max

Smaller muscle mass

Lower VO2 max than LE

HR increases linearly as

exercise
HR higher
Stroke volume lower
Systolic AND Diastolic BP
higher

a function of increased
workload / VO2 max
HR plateaus just before
maximal VO2 max
Systolic BP increases
Diastolic BP remains the
same

Warm-up
Aerobic exercise period
Cool-down

Warm-up
Muscle temperature
NCV
Vasodilation
Adaptation of respiratory centers
Venous return

Warm-up
2 components
Graduated low intensity warm-up (5-10

minutes) of total body movement

HR increase 20bpm

Flexibility exercises

Warm-up
Should NOT cause fatigue
Decreases
Risk for ECG changes (arrythmias)
Musculoskeletal disorder

Aerobic exercise
Continuous
Interval
Circuit
Circuit-interval

Continuous
Submaximal and sustained
Achievement of the steady state
Duration; 20 60 minutes
Intensity: 60 85% VO2 Max
Most effective in increasing endurance for

healthy individuals

Continuous
Two types:
Intermediate Slow Distance
20-60 minutes continuous exercise
Most commonly used for managing weight

Long Slow Distance

Longer than 60 minutes for athletic training
Provided after 6months of successful ISD

Interval
Designed to improve strength and power

more than endurance

Incorporates recovery after continual exercise
Useful for beginners
Work rest - work

Interval
Exercise period is followed by rest interval
Rest relief (Passive recovery)
Work relief (Active recovery)
Work recovery ratio
1:1 to 1:5

1 : 1.5 work interval allows the succeeding

exercise interval to begin before recovery is

complete

Interval
Aerobic Interval Training
For patients with poor CV fitness
2-15 minutes at 50-80% functional capacity
Anaerobic Interval Training
For patients with high CV fitness
30 sec 4 minutes at 85-100% functional
capacity
Usually results in greater lactic acid
concentrations

Circuit
Series of exercise activities
Several exercise modes
Improves both strength and endurance

Circuit interval
Stresses both aerobic and anerobic systems
Delays the need for glycolysis and lactic acid

production

Cool-down
Prevents
Pooling of blood
Post-exercise syncope
Ischemia, arrythmias, and other complications

Increases oxidation of metabolic waste

Cool-down
Length of cool-down phase proportional to

intensity and length of the conditioning phase

Typical 30-40 aerobic exercise period
Warrants a 5-10 minute cool-down phase

Coronary Artery Disease

Stroke and/or history of Hypertension
Peripheral Vascular Disease
COPD
Diabetes Mellitus
Well population

Coronary Artery Disease

In-patient phase
Out-patient phase
Maintenance phase

In patient phase
3 - 5 days
Objectives
Initiate early return to independence
Prevent deleterious effect of bed rest
Help allay anxiety and depression
Promote risk factor modification

In patient phase
Role of PT
Sit- to- stand 1-3 days post-op
Orthostatic challenge to the CV system 3-5
days post-op
Low-level exercise program (1-3 METS)

In patient phase
Exercise recommendations
Intensity
2-3 METS progressing to 3-5 METS by d/c
RPE < 13 (6-20)
Post-MI: HR <120 bpm or RHR + 20 bpm
To tolerance, if asymptomatic

In patient phase
Exercise recommendations
Duration
Begin with intermittent bouts lasting 3-5

minutes, as tolerated
Rest periods can be slow walk or complete rest
Attempt 2:1 exercise/rest ratio

Frequency
Early mobilization: 3-4 times / day (days 1-3)
Later mobilization: 2 times/day (beginning on

day 4) with increased duration

In patient phase
Exercise recommendations
Mode
ADLs
Selected arm and leg exercises
Early supervised ambulation

Out-patient phase
Initiated 6-8 weeks upon discharge
Objectives
Improve functional capacity
Promote early return to normal activity
Promote positive lifestyle changes

9 METS functional capacity: suggested exit

point
Weaned from continuous monitoring to selfmonitoring

Out-patient phase
Exercise recommendations
Intensity: 40-60% MHR
Duration: Initial 10-15 minutes, Target 30-60
minutes
Frequency: 3 4 times / week
Mode: Continuous / Circuit interval
Walking, treadmill, cycle ergometer

Maintenance phase
3 - 6 months post-cardiac patient
Objectives
Maintenance of function
Compliance with exercise program
Risk factor modification

Entry-level criteria
Functional capacity of 5 METS
Clinically stable angina
Medically controlled arrhythmias during exercise

Maintenance phase
Exercise recommendations
Intensity
40-75% MHR

Duration
45 minutes to tolerance / session

Frequency
3 5 days / week

Mode:
Continuous / Interval

Coronary artery disease

Mode of exercise
Patient preference
Skill required for proper performance
Potential for carryover at home
Availability of exercise equipment

Stroke and Hypertension

Avoid valsalva maneuver
Avoid isometric component
Circuit training (weight training + endurance)
RPE when patient is taking anti-HTN
Instruct patients to move slowly

Stroke and Hypertension

Exercise recommmendations
Intensity: 40-70% VO2 Max / 40-65% MHR
Duration: Gradual warm-ups and cool-down /
30-60 minute/session (aerobic training)
Frequency: 3-7 days/week
Mode: Large muscle group aerobic exercise,
walking, swimming

Stroke and Hypertension

Special considerations
NO exercise if resting systolic BP > 200 mmHg
or diastolic BP > 110 mmHg
Risk of heat intolerance for patients taking
beta blockers and diuretics
Anti-HTN may provoke syncope post-exercise:
good cool-down
Individuals with BP > or equal 160/100 should
add endurance exercise after initiating
pharmacologic therapy

Peripheral Vascular Disease

(PVD)

Relieve claudication
Improve walking capacity and qol
Ensourage daily exercise with frequent rest
periods
Low impact, NWB activities (swimming, cycling)
Add WB exercise as condition improves
Avoid exercising in COLD air or water
Interval training is appropriate
FEET care

Peripheral Vascular Disease

(PVD)

Peripheral Vascular Disease

(PVD)

Exercise recommmendation
Intensity: Grade II III on the claudiaction pain
Frequency: 3-5 days / week
Duration: initial: 35 minutes of intermittent
walking; increased 5 minutes each session
until 50 minutes of intermittent walking can
be completed
Goal: 35-50 minutes of continuous walking

Mode: non-impact aerobic exercise

COPD
Keep the exercise intensity low and gradually

increase over time

Reduce intensity if symptoms occur
Mind the environment
Use of supplemental oxygen / bronchodilators
Breathing exercises
Walking strongly recommended

COPD
Exercise recommendations
Intensity: low intensity, adjust according to
patients response
Duration: maximal limits tolerated by the
symptoms
Frequency: 3 5 times / week; if reduced
functional capacity , daily
Mode: walking, staionary cycling progress
with upper body resistive exercises

Diabetes Mellitus
Exercise improves glucose control and

circulation
Reduces cardiovascular risk
Assists in weight control
Reduces stress
Patients should undergo exercise testing prior
to initiation of an exercise program

Diabetes Mellitus
Exercise recommendations
Intensity: 50 80% HR Reserve
Duration: 20 60 minutes
Frequency: 3 4 /week
Mode: walking, treadmill, stationary cycle

Diabetes Mellitus
Considerations
Monitor glucose levels prior to and following
exercise
Should exercise with glucose level between 100

200 mg /dl
Have carbohydrate snack readily available during
exercise

Do not exercise when

Fasting glucose > 250mg/dl + ketosis
Use caution when glucose > 300 mg/dl
Maintain hydration during exercise session

Diabetes Mellitus
Do not exercise alone
Avoid exercising body part injected by insulin
Do not exercise patients with poorly controlled

complications
Do not exercise in extreme environmental
temperatures
Late-onset hypoglycemia can occur up to 48
hours following exercise especially when
beginning or modifying program

Diabetes Mellitus
Ingest 20 30 grams of additional

carbohydrates if pre-exercise glucose is <100

mg/dl
Avoid valsalva and jarring/pounding activities
Monitor for signs of autonomic neuropathy
(hypoglycemia / hyperglycemia)
Proper feet care
Limit WB activities for patients with peripheral
neuropathy

Well Population
Mode
Season

Well Population
Mode
Long Slow Distance training
Pace / Tempo
Interval
Repetition
Fartlek

Long Slow Distance

Intensity
Achievement of 70% VO2 max (80& MHR)

Duration
Training distance > race distance
Lasts from 30 minutes 2 hours

Frequency
1-2 per week

Conversation exercise

Long Slow Distance

Benefits: Increase
CV and thermoreg function
Mitochondria
Oxidative capacity
Fat utilization and lactate clearance
Disadvantages
Not specific with lower intensity sports
Does not stimulate neurologic pattern

Pace / Tempo
Intensity: At the lactate threshold or slightly

above the race pace

Duration: 20 -30 minutes
Frequency: 1 -2 / week
Threshold training

Pace / Tempo
Benefits
Develops race pace
Enhance body to sustain exercise
Increases running economy
Increases lactate threshold

Interval
Intensity: Close to the VO2 Max
Duration: 3 5 minutes; Work/Rest ratio 1:1
Frequency: 1 2 / week
Benefit
Increase VO2 max

Not to be performed if unfit

Repetition
Intensity: Greater than VO2 Max
Duration: 30 90 seconds; Work/Rest ratio 1:5
Frequency: Once a week
High reliance on anaerobic metabolism
Benefits
Increases running speed
High capacity for anaerobic metabolism
Beneficial for final kick / push

Fartlek
Intensity: Varies between LSD and pace
Duration: 20 60 minutes
Frequency: Once a week
Benefits
Challenges all the system
Increases VO2 max
Reduce boredom
Increases lactate threshold
Increases running conomy

Sports Season

Season

Objective

Off-season
Develop sound
(Base training) conditioning base
Preseason

Freq

Duration Intensity

5-6

Long

Improve factors important 6-7

to aerobic endurance and
performance

Low-mod

Long-mod Mod-high

In season
Maintain factors
(Competition)

5-6

Short
Race
distance

Low-training
High-racing

Postseason
(active rest )

3-5

Short

Low

Recovery

References
Rothstein, J.M., Roy, S.H., & Wolf, S.L. (2005). The

rehabilitation specialists handbook. Philadelphia: F.A. Davis.

Whaley, M.H., Brubaker, P.H., & Otto, R.M. (2005). ACSMs
guidelines for exercise testing and prescription.
Philadelphia: Lippincott Williams & Wilkins.
Kisner, C., & Colby, L.A. (2007). Therapeutic exercise:
Foundations and techniques. Philadelphia: F.A. Davis.
Seigelman, R.P., & O Sullivan, S.B. (2006). National physical
therapy examination review and study guide. Philadelphia:
International Education Resources.
Powerpoint presentation of Prof. Mitch B. Encabo, MPA,
PTRP, RPT, CSCS

If none,
THANK YOU VERY MUCH...
Have a nice day ahead of you...