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Exercise Prescription forExercise Prescription forCardiac & RespiratoryCardiac & Respiratory
DiseasesDiseasesHazzaaHazzaa M. AlM. Al--HazzaaHazzaa,, PhPh D, FACSMD, FACSM
Professor & DirectorProfessor & Director
Exercise Physiology LaboratoryExercise Physiology LaboratoryKing Saud UniversityKing Saud UniversityTel (office):Tel (office): 46784114678411
Lab:Lab: 46784064678406http://faculty.ksu.edu.sa/hazzaa
http://faculty.ksu.edu.sa/hazzaa
RHS 514 RHS 514 - - Fall 2010 Fall 2010
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Basic ConceptsBasic Concepts
In ExerciseIn Exercise
PrescriptionPrescription
Part 1
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Exercise PrescriptionExercise Prescription
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The US Surgeon General Report, 1996The US Surgeon General Report, 1996
ACSM/CDCACSM/CDC JointJoint Statement,Statement, JAMA,JAMA, 19951995
AHA StatementsAHA Statements – – 19921992--19961996
WHO “Global Strategy on Diet & Physical Activity”,WHO “Global Strategy on Diet & Physical Activity”,
20042004
Resources for Exercise & HealthResources for Exercise & Health
GlobalGlobal RecommendationRecommendation onon PhysicalPhysical ActivityActivity forforHealth,Health, WHO,WHO, 20102010
PhysicalPhysical ActivityActivity GuidelinesGuidelines forfor Americans,Americans, 19951995
TorontoToronto CharterCharter forfor PhysicalPhysical Activity,Activity, MayMay 20102010
http://faculty.ksu.edu.sa/hazzaa/Resources/Forms/AllItems.aspxhtt
p://faculty.ksu.edu.sa/hazzaa/Resources/Forms/AllItems.aspx
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DefinitionsDefinitions
Any bodily movement produced by the
skeletal muscles resulting in energyexpenditure above resting state.
Physical ActivityPhysical Activity
Physical FitnessPhysical Fitness
A set of attributes that people have orachieve, which relates to the ability toperform physical activity.
Caspersen, et al., Public health Rep,1985
11
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DefinitionsDefinitions
The amount of energy expended duringexercise relative to the energy expenditureduring rest.
Metabolic Equivalent (MET)Metabolic Equivalent (MET)
Energy expenditure during rest = 1 MET
= 3.5 ml of O 2 / kg. min
= 1 kcal / kg. hr
22
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What is the Amount of Physical ActivityWhat is the Amount of Physical Activity
that Promotes Optimal Health?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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KSKS
UU
H e a l t h
B e n
e f i t s
H e a l t h
B e n
e f i t s
Inactive Moderately active Very active
Physical Activity & Health Benefits
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Physical Activity Intensity inPhysical Activity Intensity in METMET
Light: Less than 3 MET
Moderate: 3 – 6 MET
Vigorous: Above 6 MET
CDC, 1996
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Classification of ExerciseClassification 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
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ACSM, 2000
HealthHealth--Related Dimensions of Physical ActivityRelated Dimensions of Physical Activity
أبعاد النشاط البدني المعزز للصحة
..))))Caloric ExpenditureCaloric Expenditureالطاقة المصروفة الطاقة المصروفة ••
..))))Aerobic Intensityاألنشطة اھلوایئة المرتفعة الشدةاألنشطة اھلوایئة المرتفعة الشدة ••
..))))Muscular Strengthالقوة العضیلةالقوة العضیلة ••
..))))Flexibilityالمرونةالمرونة ••
األنشطة البدینة التي یتم ھیفا حمل الجسماألنشطة البدینة التي یتم ھیفا حمل الجسم•• ))Weight-bearing physical activity((..
Caspersen, et al., 1998
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Dimensions of healthDimensions of health--enhancing Physical Activityenhancing Physical Activity
Energy ExpenditureEnergy Expenditure
CHDCHDDiabetesDiabetesObesityObesity
Moderate Intensity Aerobic Activity:Moderate Intensity Aerobic Activity:
Walking, Swimming, Cycling, Badminton, tennis-double, Daily living physical activity (taking
stairs, working at home, gardening, etc..)
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Vigorous physical ActivityVigorous physical Activity (> 60% HR max):
Jogging, Running, Swimming, Cycling, Stepping,
Rope skipping, Tennis-single, squash, Basketball.
Aerobic Intensity
CHDCHD CV EfficiencyCV Efficiency Max. OMax. O22 UptakeUptake
Dimensions of healthDimensions of health--enhancing Physical Activityenhancing Physical Activity
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Type of Activity:Type of Activity:
• Strength Exercise• Muscular Endurance Exercise
• Flexibility Exercise
Muscular Strength & FlexibilityMuscular Strength & Flexibility
Functional capacityFunctional capacity Low Back HealthLow Back Health
Dimensions of healthDimensions of health--enhancing Physical Activityenhancing Physical Activity
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WeightWeight--bearing Physical activitybearing Physical activity
OsteoporosisOsteoporosis
Dimensions of healthDimensions of health--enhancing Physical Activityenhancing Physical Activity
Type of Activity:Type of Activity:
• Walking, Jogging, Running.• Strength Training.
• Jumping, Rope skipping.
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Screening beforeScreening beforestarting anstarting an
Exercise ProgramExercise Program
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Evaluation of a PersonEvaluation of a Person’’s Readinesss Readinessto engage in Physical Activityto engage in Physical Activity
PARPAR--QQ
The Flow Charts Approach
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Evaluation of Person’s Readiness to Physical ActivityEvaluation of Person’s Readiness to Physical Activity
No
Does the person havesymptom of CV
disease? **
Yes
Does the person havediagnosed disease? *
No Yes
Consider GXT andcardiology referral
Does the person havemore than one risk
factor? ***
Yes Moderate activity issafe; vigorous activity:
should have GXT
No
Is Age under 40 yrs forMen and under 50 yrs
for women
No
Moderate or vigorousactivity is safe
Yes
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Readiness to Physical ActivityReadiness to Physical Activity (continued)(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
vv Mode (Type of exercise)Mode (Type of exercise)
vv DurationDuration
vv FrequencyFrequency
vv IntensityIntensity
vv Progression of Exercise ProgramProgression of Exercise Programvv Safety/precautionSafety/precaution
ACSM, 2000
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Mode of Physical Activity
Based on current physical activity andBased on current physical activity and
fitness level.fitness level.
Individual’s preference.Individual’s preference.
Individual’s goals:Individual’s goals: for health; for fitness, to reducefor health; for fitness, to reduce
BP, to increase bone density, or to lose weight.BP, to increase bone density, or to lose weight.
Availability of time, facilityAvailability of time, facility (Gym, pool, etc)(Gym, pool, etc) andand
weather condition.weather condition.
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Duration of Physical Activity
There is an inverse relationship betweenThere is an inverse relationship between
activity duration and intensity.activity duration and intensity.
Individual’s goals:Individual’s goals:
§§ forfor HealthHealth:: 3030 -- 6060 minmin
§§ forfor FitnessFitness:: 2020 -- 6060 minmin
§§ forfor Weight LossWeight Loss:: 9090--6060
Consider additional time for warmConsider additional time for warm--up andup and
coolcool--down (down (55– –1010 min each)min each)..
ACSM, 2000: ACSM position Stand on Wt Loss, MSSE, 2010
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Frequency of Physical Activity
International guidelines & recommendations:International guidelines & recommendations:
§§ forfor HealthHealth:: 55 days or more /week (preferablydays or more /week (preferably
every day)every day)
§§ forfor FitnessFitness:: 33 – – 55 days /weekdays /week
Consider the person’s other commitments:Consider the person’s other commitments:
job, family, etc.job, family, etc.
ACSM, 2000
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Intensity of Physical Activity
Recommendations:Recommendations:
§§ forfor HealthHealth: moderate intensity (: moderate intensity (33--66 MET orMET or 4040% to% to
<< 6060% VO% VO22R)R)
§§ forfor FitnessFitness: vigorous intensity (: vigorous intensity (6565--9090% HR max)% HR max)
Consider starting with a lower intensityConsider starting with a lower intensity
with beginners.with beginners.
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The Relationship between Exercise Intensity andHealth Benefits versus Fitness improvement
VigorousmoderateLight
F i t n
e s s
Exercise Intensity
H e a l t h
B e n e f i t s
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Moderate & Vigorous IntensityModerate & Vigorous Intensity
Physical ActivitiesPhysical Activities
Moderate:
Brisk walking, Recreational swimming,
Volleyball, Slow aerobics, Moderate cyclingGardening, Tennis-double, Badminton etc..
Vigorous:
Jogging, Running, Tennis-single, Basketball,Rope skipping, Squash, Fast aerobics, Fastcycling, 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.
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Classification of Physical Activity Relative to Type ofClassification of Physical Activity Relative to Type ofContraction and level of IntensityContraction and level of Intensity
Mitchell, et al, Med Sci Sports Exerc, 1994
Type of MuscleContraction
Dynamic ExerciseDynamic ExerciseAs % of VO2 max
LowLow>>4040%%
ModerateModerate4040--7070%%
HighHigh<<7070%%
IsometricExercise
% ofMaximumVoluntary
Contraction
LowLow>>2020%%
LL DynamicDynamicLL IsometricIsometric
11
MM DynamicDynamicLL IsometricIsometric
22
HH DynamicDynamicLL IsometricIsometric
33
ModerateModerate
2020--5050%%
LL DynamicDynamicMM IsometricIsometric
44
MM DynamicDynamicMM IsometricIsometric
55
HH DynamicDynamicMM IsometricIsometric
66
HighHigh<<5050%%
LL DynamicDynamicHH IsometricIsometric
77
MM DynamicDynamicHH IsometricIsometric
88
HH DynamicDynamicHH IsometricIsometric
99
L = Low ; M = Moderate; H = HighL = Low ; M = Moderate; H = High
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الشاحنات تلزم
المسار ایألمن
What can you tell from thisCartoon? Think in term of
Intensity & Aerobic Exercises
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Progression
First, increase theFirst, increase the frequencyfrequency of physicalof physical
activity.activity.
Then, increase theThen, increase the durationduration of physicalof physical
activity.activity.
Lastly, increase theLastly, increase the intensityintensity of physicalof physicalactivity.activity.
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Components of an Exercise Session
WarmWarm--upup
periodperiod
55--1010 minmin
Cool downCool down
periodperiod
55--1010 minmin
ExerciseExercise
periodperiod
3030--60 min60 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 postexercise 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
Free weights, or a heavy object to lift.l Resistance Machine / Medicine Balls.
l Body weight (Callisthenic Exercise).
l Elastic bands or tubing.
Should be performed 2-3 times/week on non-consecutive days
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Resistance Exercise (continued)
Use functional exercise as possible.
For example, walking lunge is better to strengthenmuscles to assist in increasing efficiency ofwalking / running than leg extensions.
Functional exercise is specific to and closelymimics task to be completed.
8-12 repetitions (The last repetition you do should feel
like the last repetition you can do).
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Examples of simple Resistance Exercise
Chair SquatChair Squat
Knee ExtensionKnee Extension Seated RowSeated RowElbow CurlElbow Curl
Elbow ExtensionElbow Extension Chest PressChest Press
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Contraindications to Resistance Training inCardiac Patients
Unstable angina
Uncontrolled High Blood pressure (> 160/100 mmHg)
Uncontrolled Arrhythmia
Untreated heart failureUntreated heart failure
Severe valvular stenosis
Hypertrophic cardiomyopathy (HCM)
ST segment depressionST 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.
Perform static stretching to the end of ROM, nobounce or ballistic movements.
Warm-up first, then do stretching exercise.
What to stretch: shoulders, chest, calves,hamstrings, hips.
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Hold each stretch for 15-30 s. You should feel alittle uncomfortable but no pain
FLEXIBILITY (2/2)
Greatest benefit occur in the first 15 seconds; nogreater benefit after 30 seconds.
Ideally perform stretching 5-7 days per week.
However, minimum is 2-3 days per week.
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ClassificationClassification
of Exerciseof ExerciseIntensityIntensity
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Classification of Exercise IntensityClassification of Exercise Intensity
Maximal Heart Rate = 208 – ( 0.7 X age (yrs))*
Maximal Heart Rate = 220 – age (yrs))
Heart Rate Reserve = HR max – HR rest
% of Maximal Heart Rate% of Maximal Heart Rate % of Heart Rate% of Heart Rate ReserveReserveoror
** Tanaka, et al,Tanaka, et al, 2000 2000
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% of Heart% of HeartRate ReserveRate Reserve
% of Maximal% of MaximalHeart RateHeart Rate
ExerciseExerciseIntensityIntensity
<< 2020 %%<< 5050 %%Very LightVery Light
2020 – – 3939 %%5050 – – 6363 %%LightLight4040 – – 5959 %%6464 – – 7676 %%ModerateModerate
6060 – – 8484 %%7777 – – 9393 %%HardHard
8484 %%>>9393 %%>>Very HardVery Hard
100100 %%100100 %%MaximalMaximal
Classification of Exercise IntensityClassification of Exercise Intensity
Howley, MSSE (Suppl) 2001; (6): S 367.
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Patients using Beta Blockers
Previous equations are notPrevious equations are not
suitable for them. Drugssuitable for them. Drugs
affecting Beta receptors loweraffecting Beta receptors lower
heart rate at rest,heart rate at rest, submaximalsubmaximal &&
maximal exercise.maximal exercise.
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2040
60
80
100120
140
160
180
200
Rest 25 50 75 100
No BlockadeParasympathetic blockade
Sympathetic blockade
Astrand & Rodahl,1977, p. 191 ( Data: Ekblom et al., 1972
% of Maximal Oxygen Uptake
Propranolol
Effects of Sympathetic andEffects of Sympathetic and
Parasympathetic Blockades on H. R.Parasympathetic Blockades on H. R.
Atropine
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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 .
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HRR = VO2R
If a patient has a 17.5 ml/kg.min VO2 max,prescribe exercise intensity for him at 50% ofhis 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 ExpenditureEnergy Expenditure
duringduring
Physical Activity!Physical Activity!
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CaloreiCaloreiActivityActivity
00..0707Brisk walkingBrisk walking
00..1313RunningRunning (7.5 min per km)(7.5 min per km)
00..208208RunningRunning (5 min per km)(5 min per km)
00..162162SwimmingSwimming
00..162162Rope skippingRope skipping (70/min)(70/min)
00..165165Rope skippingRope skipping (80/min)(80/min)
00..097097BadmintonBadminton
00..109109TennisTennis
00..212212SquashSquash
00..138138BasketballBasketball
Energy Cost of Physical ActivityEnergy Cost of Physical Activity(k. calorie/kg. min)(k. calorie/kg. min)
McArdle, et., 1991
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METMETActivityActivity2.52.5WalkingWalking (slow)(slow)
44Walking (Walking (Brisk)Brisk)
88RunningRunning (7.5 min per km)(7.5 min per km)
66SwimmingSwimming
88Rope skippingRope skipping (slow)(slow)
66Weight trainingWeight training
4.54.5BadmintonBadminton
88TennisTennis (single)(single)
1212SquashSquash
88BasketballBasketball
Energy Cost of Physical ActivityEnergy Cost of Physical Activity in METin MET
Ainsworth, et., 2000
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How to CalculateHow to CalculateEnergy ExpenditureEnergy Expenditure
during Brisk Walking!during Brisk Walking!
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== 00..0707 k.k.caloriecalorie per kg of body weightper kg of body weight //min.min.
Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking
An Example:An Example:
aa person weighingperson weighing 7676 kg would expend:kg would expend:
00..0707 XX 7676 == 55..33 k.k. calorie per min.calorie per min.
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Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking
§§ If somebody has to expendIf somebody has to expend 12001200 k.k.caloriescaloriesper week.per week. HOW much time he/she should walkHOW much time he/she should walkper week?per week?
§§ 12001200 // 55..33 == 226226..44 min.min.
== 4545 min/min/ 55 days per week, ordays per week, or
== 5757 min/min/ 44 days per week.days per week.
Note: This includes resting energy expenditure Note: This includes resting energy expenditure
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