Cardiopulm Unit 3 Exercise Training and Prescription

Question 1

What are the Indications for Exercise Stress Test?

Answer 1

Question 2

What is the purpose of Exercise Testing for PTs?

Answer 2

• Evaluate activity limitations
• Establish safety for physical activity/exercise participation
• Collect the necessary information to write an appropriate physical activity/exercise prescription that is less likely to be under- or over-dosed
• Collect baseline data for outcome assessment

Question 3

What is VO2?

Answer 3

A measure of oxygen consumption

HR x SV x (aO2 - vO2)

(HR x SV = Cardiac output)

This chart is basically saying during work output during exercise, as oxygen consumption goes up so does cardiac output (pretty much parallel)

aO2: oxygen in arteries (pre-capillary)
vO2: oxygen in veins (post-capillary)

Question 4

From rest to maximal exercise, how much does Cardiac output, HR, SV, a-VO2 and VO2increase? When a person is ~40% of maximum work, what happens to their SV?

Answer 4

• Cardiac output can increase ~4x
• HR can increase ~3x
• SV can increase ~1.5x
• By ~40% maximum work, rate of increase in SV tapers and remainder of increasing CO is due to HR
• a-VO2 difference can increase ~3x
• The body can account for increase ~12x between rest and maximal exercise

Question 5

What can having a “Normal” VO2 mean, and how is this important?

Answer 5

Having a “Normal” VO2 (around >85% predicted for your age, gender etc.) essentially rules out significant cardiovascular and pulmonary disease

The greater the amount of oxygen consumed at peak exercise, the more fit the individual

Question 6

Is HR more useful for Aerobic or Anaerobic exercise training?

Answer 6

Aerobic

Question 7

What is the normal HR response to incremental exercise?

Answer 7

There is an increase with progressive workloads at a rate of ~10bpm per 1 MET

MET: A unit that describes how much oxygen someone is consuming at rest

For ex: If a person is doing an exercise at 2 METS of intensity, this means that the exercise is having the person consume twice the amounnt of oxygen as they perform at rest

Question 8

What makes heart rate a reliable indicator for exercise intensity during an incremental exercise test?

Answer 8

Heart rate is a reliable indicator because it has a linear relationship with %VO2max, enabling accurate assessment and prescription of exercise intensity.

Question 9

Exercise intensity is directly associated to what?

Answer 9

Both the amount of improvement in exercise capacity and the risk of adverse events during exercise

Question 10

HR responses to exercise provide information to what?

Answer 10

The fitness of the individual where exaggerated responses suggest relatively less fitness
- Exercise training promotes a decreased HR responseto submaximal workload

Question 11

What is the normal BP response to exercise?

Answer 11

• Systolic BP (SBP): Gradual rate of rise (~10mmHG/MET) until reaching steady state
• Diastolic BP (DBP): Increases or decreases withing 10mmHG

Question 12

What is a Hypertensive Response to exercise?

Answer 12

• A SBP ≥ 210 mmHG in men and ≥ 190 mmHG in women during exercise is often considered a hypertensive response
• A DBP ≥ of 110 mmHG is often considered a hypersensive response

Question 13

What is a Hypotensive Response to exercise? What is this often associated with?

Answer 13

• A decrease of SBP by > 10 mmHG with or without a preliminary increase is considered abnormal and often associated with myocardial ischemia, left ventricular dysfunction, and an increase risk of subsequent cardiac events

This is a serious concern

Question 14

What does the term “Regular Exercise” mean?

Answer 14

Performing planned structured physcial activity for at leat 30 minutes at a moderate intensity at least 3 days per week for the last 3 months

Anyone who does not meet that criteria is said to not be a regular exercise participant

Question 15

What is considered Light-Intensity Exercise?

Answer 15

30-39% HRR or VO2R, 2-2.9 METs, RPE 9-11. An intensity that causes slight increases in HR and breathing

(HRR: Heart Rate Reserve), (VO2R: Oxygen uptake reserve)

Question 16

What is considered Moderate-Intensity Exercise

Answer 16

40-59% HRR or VO2R, ≥ 3-5.9 METs, RPE 12-13. An intensity that causes noticible increases in HR and breathing

Question 17

What is considered Vigorous-Intensity Exercise?

Answer 17

≥60% HRR or VO2R, ≥ 6METs, RPE ≥14. An intensity that causes substantial increases in HR and breathing

Question 18

Pre-Exercise Screen

What is recommended for a person that does not participate in regular exercise and does not have CV, metabolic, or renal disease AND no S/S suggestive of CV, metabolic or renal disease?

Answer 18

• Medical Clearance is not necessary
• Light to moderate-intensity exercise recommended
• May gradually progress to vigorous-intensity exercise follwing ACSM guidelines

Medical clearance is approval from a healthcare progessional

Question 19

Pre-exercise Screen

What is recommended for a person that does not participate in regular exercise and has Known CV, Metabolic, or Renal disease and Asymptomatic?

Answer 19

• Medical Clearance Recommended
• Following medical clearance, light to moderate-intensity exercise recommended
• May gradually progress as tolerated following ACSM guidelines

Question 20

Pre-exercise Screening

What is recommended for a person that does not participate in regular exercsie and has any S/S suggestive of CV, metabolic or Renal disease (regardless of disease status)?

Answer 20

• Medical Clearance Recommended
• Following medical clearance, light-moderate intensity exercise recommended
• May gradually progress as tolerated following ACSM guidelines

Question 21

Pre-exercise Screen

What is recommended for a person that does participate in regular exercise and does not have CV, metabolic, or Renal disease and S/S suggestive of CV, metabolic or renal disease?

Answer 21

• Medical clearance is not necessary
• Continue moderate or vigorous-intensity exercise
• May gradually progress following ACSM guidelines

Question 22

Pre-exercise Screen

What is recommended for a person that does participate in regular exercise and has Known CV, Metabolic, or Renal disease and Asymptomatic?

Answer 22

• Medical clearance for moderate-intensity exercise NOT necessary
• Medical clearance (within the past 12 months if no change in S/S) recommended before engaging in vigorous-intensity exercise
• Continue with moderate-intensity exercise
• Following medical clearance, may gradually progress as tolerated following ACSM guidelines

Question 23

Pre-exercise Screen

What is recommended for a person that does participate in regular exercsie and has any S/S suggestive of CV, metabolic or Renal disease (regardless of disease status)?

Answer 23

• Discontinue exercise and seek medical clearance
• May return to exercise following medical clearance
• Gradually progress as tolerated following ACSM guidelines

Question 24

What is a Symptom (Sx) Limited/Max Exercise Test (ET)?

Answer 24

Exercise terminated at maximal exertion or clinical limitation

Question 25

What are the Common Indications of doing Sx-Limited/Max Exercise Test (ET)?

Answer 25

- Dx suspected myocardial Ischemia/CAD - Risk stratification, prognosis, assessing medical therapy and cardiopulmonary reserve - Assessing **Cardiorespiratory Fitness** (CRF), the ability of the circulatory and respiratory systems to supply oxygen to skeletal muscles during sustained physical activity. These may or may not utilize **ventilatory gas analysis (Cardiopulmonary Exercise Test [CPET])**

Question 26

What is Submaximal Exercise Testing (ET)?

Answer 26

Exercise terminated on achievement of a predetermined end point Examples of endpoints: - *x* bpm above resting, & predicted max HR (PMHR), %HRR - Targert RPE or Dyspnea rating - Workload (e.g. MET, Watts) - Time (e.g., 6 MWT) - Distance (Cooper 1.5 mile run test)

Question 27

What is Low-Level ET?

Answer 27

A **subset** of submax testing that is sometimes described as being useful in acute setting (e.g., post-MI/CABG) in attempt to **identify the high risk patient** (e.g., before discharging from acute care) - Steady intensity or ramping/increasing workload to about 2-6 METs

Question 28

What are the steps taken to Prepare an ET?

Answer 28

- Ensure the pt has no absolute contraindications. Ensure all relative contraindications are considered - Determine the **Mode**: -What mode best represents the **activity** limitations the pt needs to improve -The ET mode should resemble the eventual exercise you're going to prescribe --**What does the patient want or like to do?** - If not standardized, determine the **end-point** of the test -**Standard submaximal testing works up to 85% of age-predicted maximal heart rate** -A **total rest time of 8-12 min is often recommended** as it is sufficient to evaluate cardiovascular function without overly fatiguing a pt.

Question 29

What are the Absolute Indications that the patient is unstable and Treatment should (Totally) be withheld?

Answer 29

- S/S of decompensated Cogestive Heart Failure - > 10 PVCs/minute **at rest** - Mutlifocal PVCs, unstable angina, and ECG changes associatd with ischemia/injury - Dissecting aortic aneurism - New Onset (< 24 hrs) A-fib with rapid ventricular response (RVR) > 100bpm (at rest) - 2nd degree-heart block coupled with ventricular tachycardia - 3rd degree heart block - Chest pain with new ST segment changes on ECG

Question 30

What are the Relative (it depends) indications that a patient is unstable and treatment should be Modified or withheld?

Answer 30

- **Resting** tachycardia (especially if new) - **Resting** SBP > 160 or DBP > 90 (Escpecially if new) - **Resting** SBP < 80 - Ventricular ectopy **at rest** - MI or extension of infarction within previous 2 days - Uncontrolled Metabolic Disease (e.g., DM) - Psychosis or other unstable psychologic condition

Question 31

With ETs, what are Modes?

Answer 31

Question 32

What are considerations PT need to have with ETs?

Answer 32

- ETs generally become more useful the closer they approximate a maximal test. This is because: --Predicting maximal work and physiological capacity becomes more accurate --Testing at higher intensities provides the clinician with a sense of how safe higher intensity exercise might be - Beta blockers and some calcium-channel blockers reduce both resting and exercising heart rates but do not affect the relationship between HR percentage and oxygen consumption percentage --**It is crucial for individuals to be in constant medication during both the initial exercise test and subsequent training**, if there is any change in medication or dosage, a repeat exercise test is necessary to accurately set the training heart rate

Question 33

What are different methods to predict max HR and work capacity?

Answer 33

- 220-age= predicted max HR (PMHR) (This may overestimate true HRmax in young adults and underestimate true HRmax in persons older than 40) - **208-(0.7 x age)** (This more accurately identifies true HRmax among healthy adults across the life span, Still has a wide variation of 10-12bpm) -With this, you also multiply by 85% (.85) to get the endpoint bpm

Question 34

What is the method to predict max HR and work capacity specifically for individuals on Beta-Blockers?

Answer 34

164-(0.7 x age)

Question 35

Why should Rate of Perceived Exertion scales **always be considered** with ET?

Answer 35

For collaborating HR-based measures and/or as a standalone way to assess exercise intensity. RPE is especially useful in accounting for medication effects on HR, autonomic dysfunction and arrythmias

Question 36

With RPEs, why would this scale be useful for PTs?

Answer 36

This scale is used for steady state aerobic work (e.g., walking, biking). It provides a **LINEAR** correlation between perceived exertion and HR, ranging from 6-20, corresponding to a heart rate range of 60 to 200bpm in health individuals. - So if a person says the exercise was a 11 on the scale, we would multiply by 10 and we would estimate their HR to be 110bpm.

Question 37

With RPEs, why would this scale be useful for PTs?

Answer 37

The Category-Ratio (CR10) scale employs a **non-linear scale**, which can provide finer differentiation of more intense symptoms such as pain, shortness of breath, resistance training efforts, and high-intensity aerobic exercise.

Question 38

According to the ACSM, what are the ET Protocol General Format?

Answer 38

- Assess resting vitals - Based on subjective and physcial inspection, define an individualized work rate progression that will achieve the desired end-point within about 8 to 12 miin after a low intensity warm-up - Perform warm-up/familiarization period - Assess vitals 1-2 times during each stage. Consider assessment of other subjective information (e.g., RPE, dyspnea) -consider remaining in each stage until HR stabilizes - Terminate test upon achievement or predetermined end-poin, observations of adverse S/S or upon patient request to stop - Provide cool-down / recovery period around the 1 stage work rate - Perform physiologic observation for at least 15 minutes following ET -Failure of the HR to decrease by at least **12bpm** during the first minute or 22mbp by end of 2 min after exercise suggest increased risk of mortality in individuals with ischemic heart disease -SBP typically returns to pre-exercise levles or lower by **6 min** of recovery -**Some individuals pay experience post-exercise/recovery ischemia or other dysrhythmias (e.g., PVCs)**

Question 39

What are some reasons for Termination of Submaximal Testing?

Answer 39

- Pt request to stop - A predetermined physiologic or other end-point has been reached - Technical failure of any monitoring equipment - Excessive dyspnea (using 0-10 Borg scale; will depend on case by case level) - Sustained ventricular tachycardia - Changes to cardiac rhythm as assessed by ECG, palpation or auscultion - SpO2 drops below prescribed levels - ST-Stegmetn depression ≥ 1 mm or reports of sx that could be angina - Max tolerable (Grade 3) claudication pain - Decreased in SBP > 10 mmHG or if SBP decreases from resting value obtained in same postural position prior to testing - Consider cut off at a exaggerated BP response (SBP > 210 mmHG or Diastolic >115 mmHG; this will vary case-by-case)

Question 40

With findings from an ET, what can we say about the patients likely maximal work capacity?

Answer 40

We can likely estimate peak workload to be **1-2 stages above near-maximal performance** to provide information for exercise prescription