ACSM's
:l=;;b • • • • •
SENIOR EDITOR Mitchell H. Whaley, PhD, FACSM
Professor and Chair School of Physical Education, Sport and Exercise SCience Ball State University

••

••

GUIDELINES FOR EXERCISE TESTING AND PRESCRIPTION
SEVENTH EDITION

MunCie, Indiana ASSOCIATE EDITOR-CLINICAL Peter H. Brubaker, PhD, FACSM Associate Professor and Executive Director
Healthy Exercise and lifestyle Programs Department of Health and Exercise Science Wake Forest University Winston-Salem, North Carolina

ASSOCIATE EDITOR-FITNESS Robert M. Otto, PhD, FACSM Professor and Director
Human Performance Laboratory Department of Health, Physical Education, and

AMERICAN COLLEGE OF SPORTS MEDICINE

Human Performance Sciences
Adelphi University Garden City, New York

AUTHORS
Lawrence Armstrong, PhD, FACSM Gary J. Balady, MD Michael J. Berry, PhD, FACSM Shala E. Davis, PhD, FACSM Brenda M. Davy, PhD, RD, LC Kevin P. Davy, PhD, FACSM Barry A. Franklin, PhD, FACSM Neil F. Gordon, MD, PhD, MPH, FACSM I-Min Lee, MD, FACSM Timothy McConnell, PhD, FACSM Jonathan N. Myers, PhD, FACsM Frank X Pizza, PhD, CSM Thomas W. Rowland, MD, FA Kerry Stewart, EdD, FAC;~CSM Paul D. Thompson, MD, CSM Janet P. Wallace, PhD, FA

4~ L1pPINCOn WILLIAMS & WILKINS
..

A Wolters Kluwer Company

Philadelphia' Bahimorc • New York· london

Buenos Aires . Hoog Kong. Sydney . Tokyo

xii

CONTRIBUTORS

Jonathan N. Myers, PhD, fACSM
Clinical Assistant Professor of t\ledicine Dep;:uilllent of Cardiology Stanl'orJ Unin~rsity Palo Alto \'A Ilcalth Care System Palo Alto. CaJifornia

Kerry Stewart, EdD, fACSM
Associate Professor of Medicine Di\ision of Cardiology Dire<.:tor. Johns I (opkins ((cart

Contents
Preface Nota Bene Contributors Abbreviations

Health
Johns Hopkins Bayview ]\·ledkal Center Baltimore, !\Iaryland

vii

x
xi
XiX

Francis X. Pizza, PhD
Professor Department of Kinesiology The Uni\'ersity ol'1'oledo Toledo, Ohio

Paul D. Thompson, MD, fACSM
Director, Pre\'enh\'e Cardiology ("\lifoI'd I Jospital Hmiford, Connecticut

Section I

Health Appraisal. Risk Assessment. and Safety of Exercise
Benefits and Risks Associated With Physical Activity
Physical Activity and Fitness Terminology Public Health Perspective for Current Recommendations

Thomas W. Rowland, MD, fACSM
Professor, Departmcnt of Pediatrics Tufts Uni\'ersih' School of Medicine Boston. Massachusptts Director, PeJiatric Cardiology Bm State t\ledieal Center Sp~illgfield, Massa<;htlsetts

Janet P. Wallace, PhD, fACSM
Proft'ssor and Director of Adult
Fitnes~

3 3 5
6 7

Dep;uiment of Kinesiology I ndianil U ni\'crsity Bloomington. (ndiana

Divergent Physical Activity Recommendations
Benefits of Regular Physical Activity and/or ExerCise

Dose-Response Relationship Risks Associated With ExerCIse Sudden Death Among Young Individuals ExerCise Events in Those With Sickle Celf Trait Exercise-Related Cardiac Events in Adults Risks of Cardiac Events During Exercise Testing Risks of Cardiac Events During Cardiac Rehabilitation Prevention of Exercise-Related Cardiac Events

7
10

11 12 12 12
13 13 19 19

2

Preparticipation Health Screening and Risk Stratification
Preparticipation Screening Algorithm

Risk Stratification and Medical Clearance Additional Preparticipation Assessments

21

28

Exercise Testing and Testing Supervision Recommendations
Risk Stratification for Cardiac Patients

29
30

Section II
3

Exercise Testing
Pre-Exercise Evaluations
MedICal History, Physical Examination, and Laboratory Tests

39
39

Blood Pressure lipids and lipoproteins Blood Profile Analyses Pulmonary Function

43 45 46 47

xiii

xiv CONTENTS Contraindications to Exercise Testing Informed Consent Participant Instructions 49 49 51 55 55 56 56 56 56 57 57 64 65 66 66 66 67 6B 76 78 79 80 81 83 85 89 93 93 93 94 94 95 96 99 102 102 103 103 105 106 107 108 108 108 4 Health-Related Physical Fitness Testing and Interpretation Purposes of Health-Related Fitness Testing Basic Principles and Guidelines Pretest Instructions Test Order Test Environment Body Composition Anthropometric Methods Densitometry Other Techniques Body Composition Norms Cardiorespiratory Fitness The Concept of Maximal Oxygen Uptake Maximal versus Submaximal Exercise Testing Modes of Testing Cardiorespiratory Test Sequence and Measures Test Termination Criteria Interpretation of Results Muscular Strength and Muscular Endurance r I ~ Muscular Strength Muscular Endurance Flexibility A Comprehensive Health Fitness Evaluation 5 Clinical Exercise Testing Indications and Applications ~ Diagnostic Exercise Testing Exercise Testing for Disease Severity and Prognosis Exercise Testing After Myocardia/Infarction Functional Exercise Testing Exercise Test Modalities Exercise Protocols Upper Body Exercise Testing Testing for Return to Work Measurements During Exercise Testing ~ Heart Rate and Blood Pressure Electrocardiographic Monitoring Subjective Ratings and Symptoms Gas Exchange and Ventilatory Responses Blood Gases Indications for Exercise Test Termination Postexercise Period .

CONTENTS xv Exercise TestlOg With Imaging Modalities Exercise Echocardiography Exercise Nuclear Imaging Pharmacologic Stress Testing Electron Beam Computed Tomography SuperviSion of Exercise Testing 110 110 110 111 111 112 115 115 116 116 6 Interpretation of Clinical Exercise Test Data Exercise Testing As a Screening Tool for Coronary Artery Disease Interpretation of Responses to Graded ExefCIse Testing Heart Rate Response Blood Pressure Response Electrocardiographic Waveforms Limiting Signs and Symptoms Gas Exchange and Ventilatory Responses DiagnostIC Value of ExerCise Testing Sensitivity Specificity Predictive Value Comparison With Imaging Stress Tests Prognostic Applications of the Exercise Test 119 119 123 123 124 124 125 125 126 126 Section III 7 Exercise Prescription General Principles of Exercise Prescription Principles of Training OvervIew of the Exercise PrescriptIon The Art of ExerCise Prescnption Components of the Training Session Warm-up Stimulus or Conditioning Phase RecreadonalAcd0des Cool-Down Cardiorespiratory ExerCise Prescription Mode of Exercise Exercise Intensity Exercise Duration Energy Expenditure Goals Rate of Progression Initial Conditioning Stage Improvement Stage Maintenance Stage Training SpecifiCity Summary of Guidelines for Cardiovascular Stimulus Phase 133 134 135 136 136 137 138 138 138 139 139 141 146 148 149 150 150 151 151 153 .

xvi CONTENTS Resistance Exercise Prescription Flexibility Exercise Prescription Maintenance of the Training Effect Program Supervision Methods for Changing Exercise Behaviors Strategies for Increasing Exercise Adherence Encourage Lifestyle Physical Activity 8 154 158 160 161 163 165 165 174 174 177 178 181 182 183 184 186 188 189 189 190 190 191 191 191 193 194 197 199 205 205 206 206 207 207 208 208 210 211 212 Exercise Prescription Modifications for Cardiac Patients Inpatient Rehabilitation Programs Outpatient Exercise Programs Exercise Intensity for the Cardiac Patient Modes of ExerCise for Cardiac Patients Progression of Exercise for the Cardiac Patient Recommended Total Dose or Volume of Exercise for Cardiac Patients Exercise Prescription Without a Preliminary Exercise Test Types of Outpatient Programs Benefits of Endurance Training in Cardiac Patients Resistance Training for Cardiac Patients Eligibility and Exclusion Criteria for Resistance Training Time Course for Resistance Training Resistance Training Prescription for Cardiac Patients Exercise Training for Return to Work Special Cardiac Patient Populations Myocardial Ischemia Congestive Heart Failure Pacemakers and Implantable Cardioverter Defibrillators Cardiac Transplant Recipient Cardiac Surgery and Percutaneous Transluminal Coronary Intervention 9 Other Clinical Conditions Influencing Exercise Prescription Arthritis Exercise Testing Exercise Prescription Special Considerations Diabetes Mellitus Exercise Testing Exercise Prescription Special Considerations Dyslipidemia Exercise Testing .

CONTENTS xvii Exercise Prescription Special Considerations 212 212 Hypertension Exercise Testing 213 214 Exercise Prescription Special Considerations 21 5 21 5 216 217 217 218 218 219 220 221 221 222 222 223 223 223 224 224 225 225 226 226 226 227 227 228 229 229 231 231 231 Obesity Exercise Testing Exercise Prescription Special Considerations Recommended Weight Loss Programs Metabolic Syndrome Exercise Testing and Prescription Immunology Exercise and Upper Respiratory Tract Infections Immune Responses to Exercise Exercise Testing Exercise Prescription Special Considerations OsteoporosIs Exercise Testing Exercise Prescription Special Considerations Peripheral Arterial Disease Exercise Testing Exercise Prescription Special Considerations Pulmonary Diseases Exercise Testing Exercise Prescription Special Considerations Pregnancy Exercise Testing Exercise Prescription Special ConsideratIOns 10 Exercise Testing and Prescription for Children and Elderly People 237 Children Clinical laboratory Testing 237 237 240 241 Fitness Testing Exercise Prescription Elderly People Exercise Testing Exercise Prescription 246 246 247 .

xviii CONTENTS Section IV Appendices A B Common Medications Emergency Management 255 267 C Electrocardiogram IECG) Interpretation Metabolic Calculations Environmental Considerations American College of Sports Medicine Certifications 279 286 o E F 300 309 351 Index .

o coronary artery dIsease Centers for Disease Control and Prevention congestive heart failure carbohydrate pressure index anglotensin·converting enzyme American Conference of Governmental Industrial cardiac Index chronic obstructive pulmonary disease continuous positive airway pressure cardiopulmonary resuscitation creatine phosphokinase ACOG Hygienists American College of Obstetricians and GynecologIsts American College of ACP ACSM ADl AHA AICD AIHA AMA AMS AST AV BIA BlS BMI BP BR BUN C CABG(S) Chronic Respiratory Questionnaire diastolic blood pressure delayed onset muscle soreness electrocardiogram (electrocardiographic) ejection fraction exercise-Induced bronchoconstrictlon exerCIse-induced hypotension expiratory reserve volume Exercise Speciallst<!l functional capaCIty forced expiratory volume in one second fat-free mass fraction of inspired oxygen fraction of inspired carbon dioxide false negative false positive functional residual volume forced Vital capaCIty Physicians American College of Sports Medicine adivities of daily livIng American Heart Association automatic implantable cardioverter defibnllator American Industrial Hygiene Association American Medical Association acute mountain sickness aspartate aminotransferase atrioventricular bioelectrical impedance analysis basic life support body mass mdex blood pressure breathing reserve blood urea nitrogen ceiling (heat stress) limit coronary artery bypass graft (surgery) FFM F102 FICO" FN FP fRV FVC xix .Abbreviations AACVPR American Association of Cardiovascular and ABI ACE ACGIH Pulmonary Rehabilitation ankle/brachial systolic CAD CDC CHF CHO CI COPD CPAP CPR CPK CRQ DBP DOMS ECG EF EIB EIH ERV ES FC FEV.

xxi supraventricular tachycardia target heart rate VMT 1iO.ABBREVIATIONS SVT THR TLC TN TP TPR TV VC \cO.R %IiO. \{)2max \iE VEmax Yo total lung capacity true negative true Positive total peripheral resistance tIdal volume vital capaCIty volume of carbon dioxIde per minute expired ventilatron per minute maxImal exercise ventilation inspired ventilatIon per minute V0 2peilk IiO.R VT WBGT WHR W-P-W YMCA YWCA ventilatory muscle training volume of oxygen consumed per minute maximal oxygen uptake peak oxygen uptake oxygen uptake reserve percentage of oxygen uptake reserve ventilatory threshold wet-bulb globe temperature waist·to·hip ratio Wolff·Parkinson·White Young Men's Christian Association Young Women's Christian Association .

PTCA PVC PVO RER RAO RAL RBBB rep RIMT l-RM RPE RQ RV RVG RVH S.xx ABBREVIATIONS GXT HAPE HOL HFD Hfl HR graded exercise test high-altitude pulmonary edema high-density lipoprotein P. and abilities left aXIs deviation left bundle-branch block lactate dehydrogenase low-denSity lIpoprotein Lown-Ganong-Levlne lower limit of normal left ventricle (left ventricular) mean corpuscular hemoglobin concentration metabolic equivalent myocardial infarction multigated acquisition (scan) maximal voluntary contractIon maXImal voluntary ventilation National Cholesterol Education Program non-InSUlin-depen dent dIabetes mellitus NatIonal InstItutes of Health National Institute for Occupational Safety and Health New York Heart Association HRmax HRR Pl max PNf Po.atlon of arterial oxygen systolic blood pressure standard error of estimate Single photon emission computed tomography HealthIFltness Director· HealthIFltness InstruetorSM heart rate maximal heart rate heart rate reserve resting heart rate Inspiratory capacity implantable cardioverter defibrillator insulin-dependent diabetes mellitus knowledge.P2 PAC PAR-Q PO PE max partial pressure of artenal oxygen premature atrial contraction PhySical Activity Readiness Questionnaire Program DlreetorsM maximal expIratory pressure maximal Inspiratory pressure proprioceptive neuromuscular facilitation partial pressure of oxygen percutaneous translumi· nal coronary angiopJasty premature ventricular contraction peripheral vascular disease respiratory exchange ratio nght aXIs deviation recommended alert limit right bundle-branch block repetition resistive inspiratory muscle training one repetition maximum rating of perceived exertion respiratory quotient reSidual volume radlonuclide ventriculography rrght ventricular hypertrophy percent satur. skills.)02 SBP SEE SPECT HR rest IC ICD 100M KSAs LAO LBBB LDH LDL L-G-L LLN LV MCHC MET MI MUGA MVC MW NCEP NIOOM NIH NIOSH NYHA .

and Safety of Exercise Chapter 1 Benefits and Risks Associated With Physical Activity Chapter 2 Preparticipation Health Screening and Risk Stratification .SECTION I Health AppraisaL Risk Assessment.

'ips «('.. and is eomprised skill·n'lat· ed. and :3) the risks associated with exercise. strm:tured. coordination.eral key terms dell ned e!<. halancf'.· lit ness difTers from he~llth-rf'lalcd fitness ill that il includes nonperformall<. Iw<tltll-relatcd.:isl'.i> (.g. and thell provides a review of: 1) the current public:: health reWl'llll1enrlatiolls for physical activity. Physical fiflless is a Illllltidilllellsional eoncept lilat lIas beell defined as a set of allribllips .llat people possess or achie\'<.'lopmenl of h)lx)kinclic disf'a. is dl'fllleJ as planned.."Omlx>nenls that relale to hiological systems iltnu· (. and Ixxl) composition. and rf'petitiw' hodily 1ll00f'Tllf'nt dOlle to illlprO\(' or Tllaintain onf' or mort' coltlponenls of pllysieal Iltness. IXldy fal l. Skill-related components of pll)'sical Illnpss inclllde agility."Onlent. alld reaction tillie. Physical Activity and Fitness Terminology It is important to SlItlllllari/(' s('\. Exercisl'. The chaplf'l" ctllH. power. ami phYSiologic eomponent.:! that are used throll!!.. lllu. ami the POss('ssion of" traits and eapaeities that an' assoeiatpd \\ith a low risk of prelllature lkH.:ludcs with a brief description of recommendations for redlll:illg tl1(--' incidence ami severil) of ('\('rdserelated eomplicalions ill prilll<tf) and secondary pn:>\('ntioll programs.elliar strength and endufiUlce. a t)lW of physieal aeti\ it). nexibilit). 2) tlw hC'alth and fitness benefits asso<:ia{l'd with regular physical activity aneVor l'xcn. and are associall'd ttlostly with sport and motor skills perfonnance.llout the text. Physical aclidry is dpfllwd a. Physiologic fitness incilldf's: or II II II II • • • ~Ietabolic fitness: Th(' "Ialll:' of melaoolie systems and variables predidi\I' the risk for diabetes and cardiovascular disease ~lorphologic fitness: The status of body wmp0l'oitioual fadoy <:irclIlllferencc. Physiologi<. and regional hody fat di" BOlle integrity: The st<1tus of bOllc mineral dellsity .' lhat relates to llle ability to ]1erf"orlrl pll)'sieal adivity'.CHAPTER Benefits and Risks Associated With Physical Activity TIJi~ 1 • •• chapter pro\'ides operational definitions for terminology used throughout Ihf' hook related to physical adi\'it)' allli fitness. P'\pf'nditnre.lIced by habilual activity.('WiJerc l .. those associaled with plJysical inacti\it~lllpalth-rpIaIPd COllllKlllellts of fllness Include cardio\"ilsclliar endurance.s Ixxlily TllO\'ement that is produced by tIle eontmetion of ~keletal muscle and tllilt stlbstantiall~ inereaSt's cner~. speed.2. Ilcalthrelal<'d physieal fitness is ilssociated with tlw ahility to perform daily adivities with Vigor.

To aid in the standard \lse of lenninology describing physical activity intensity.5 4. which represents the recommended session duration within most exercise prescriptions. 35 mL·kg I· mm I).6 2:8.~s Ie-vels at or abow that of sed(. • The theoretic basis for lhl' table is the lillk betwet'll the {/(ljrdir.\chit'H' the traditional physiol(l~ic training effect associated with exen:ise'. The intellt of these reporh is twofold: 1) to int'rease both professional alld publit' aWar('lleS$ of the health bellefits as~ociated with daily ph~~ieal acth.:'C(lltIIHCndatiolls·1 ':'i h<l\f' expanded thl' traditlollal emphaSiS on forlllall'xerciw' prescriptions to include a broader pllblic health perspectiw on physical aCtitily.0 3. Relati(.clne PosItion Stand The recommended quantity and quality of exerCise fex developing and maintaining card..4 SECTION II HEALTH APPRAISAL. brisk walkin~ at :3 to -l mpll still represellts lJIor/emti'-intensil) ph~'sical adi\it) for most healthyadlllts.8-4. and physical fitness. the physiologic intcnsity ranges have been expressed ill both relath'e and absolute tl:'rlllS.. with tlte rl:'lliainder of the (:ohlmm containing data to illustrate the concept that a giH'1l ~I ET \·"Ine {t>. 6-12.c and le.lt almost 40% of adults do not ell~ag:c in any leisuretime physical aclivit)')IO. '-1 .. Very light light Moderate Hard (vigorous) Very hard Maximal <20 20-39 40-S9 60-84 2:85 100 <SO SO-63 64-76 77-93 2:94 100 <3.ng ~I ET ran~e a. it should lw noted that the ranges ilre quite consistent for indi\iduals willi fllnc· tional capaciti('s less than or l'qual to JO .. tOlC.ax V0 2.md shorter total duration rl'qllircc! fur 1l10tT intcns(' activities. Two key factors~feasibility and emcat. Professionals should recognize that both the qnality and quantity of physical activity recommendations described in later chapters of this text relate to exercise recommendations and should not be viewed as incon::.9 2:7.' (e.e and the rda!ivl' physiologic rallg£'. VOlR. it was r('cogtliz(~d that health IWllcfits call be obtained from a rallge of activities.vcls t) pically round wit hin healthy adults (e. Became Americans are lrigldy scdC'lItar)' (111e I9'-J8 estill1alt'~ indicating tll:. and hard hav€' been associated with a \\ide range of physiologiC equi\'alents..8-S. oxygen uptake reserve. which can be acclllllulated to achieve health bCl\I'l"its.'1 or age)"~·tI. aerob.Jr!ce.'\er.\1 ETs) tYJlicalt~ represents a higher reLative illtetlsi~ I) for older eompared \\ ith ~Ollllgf'r in<lh·iduals.2 ~5.0 2. This issue has been problematic in that adjedh'es s\lch as tight..3 12 <2.cal actll/lty and health: A report of the Surgeon General. RISK ASSESSMENT.3 6 Adapted from United States Dep<lrtment of Hea. HRR.2-S.3 S.8 2.5 7.. AmenCdn College of Sports Med.2 2:10.ty recOtnllll'lldatiolls.6-6. moderate. vigorous.'.ces Phys..335364-5369 Abbreviations METs.4 2..g.4-8.7 3.'l1tary ~Oltllger adults.(~" :3-6 .sure versus OCcupa\lonal physical actll/lty Med SCi Sports Exerc 2001. Likewise. Public Health Perspective for Current Recommendations Au illlportant mission of the Allierican College of Sports ~lf'didne (ACSM) is to pronlole incrt'ased physical adi\ it~ and fitness to the puhlit. which has been modirled several times"'" and is sllllllllarized in Table 1-1.ximal oxygen uptake.7 10 <2.1-4...1-S. Ther<'forl'.r<'foH.wross the life . .4-7. tll<:.\h and Human Serv.ax VOl.6-10. and 2) to dn\\\ atlention 10 the altlotltlts and inh'llsities of physical aeti\ ity IH:'cl?ssary to achic\"(-' these helle-fits.il1tensity physical activity (e. Curn'llt l't.g.piralory and muscular fitness. a givcl1 ~1l:T vahl(.. which are 10\\\'1' thall Illose thought 11l'CeSSar~ to ... it should be re<:ogllized that pllysicall) adi\(' older individ'lals m<l) haH' f1ttW. 1l1()(leratc~..th regular participation in intermittent.30975-991.0-3.\1 ETs.(' il/tellsity is derlned using a percentage of an indhidllal's maximal oxygen uptake reser\{:. adults Me<! SCI Sports Ellerc 1998. HO\\l. metabolIC eqUIValent UnitS (I MET . whereas absoLllte illtellsity has heen defin('d using ~I ETs with values for each intensity categol)' pro\ided across a range of functional capacities..pan 7 .istent or contra!) to existing physical activity recommendations for the general puhlic3 6. -! ~I ETs} n. several of the aforementioned t('rms have been useo to describe quantities of physical acthit)' expressed in kilocalories expended per session or per week. The table contains an ordinal set of adjectivcs that are arl>itraril~ anchored to a set of physiologic intensity ranges. ax V0 2. In addition to definitions for physical activity. The ell~1 rL's~dt reprL'st'tlted all attempt to halance feasibility and ('mCaL: in de\t'loping public health n"commendations fllr physical acli\ ity. ewrds(' program professionals nlll~t be fall1iliar \\ ith existing public health statetllellls that t"elalt' to ph)sical activity alld tllllst stay abreast of'tlLe e\ohing scientific literalurc relatl'd to current ami future ph)sical acli\.or{".g...2 3.:pn. 1996. independent of fitnt'ss le\'(.. • f\lthough till' nll~. heart ral@ reserve .. exercise. A major thellle within tlK'se public health reports3-·j is that more traditiol1al excrc:ise recolnnlendatiollS' Ilavl' overlooked tile lllllllL'roUS Ilealtlt bt'nerlts associated \\.0 8 <2. Howley ET Type of actiVIty r('Stst. AND SAFETY OF EXERCISE CHAPTER 1/ 8ENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY 5 Both health-related and physiologic fitness IlleUSlires are c1osel) allied with health promotion antI disease prevention and can be modified through regular physical activity aml exercise.:y-w(>re important in the development of the recommendations that eillpilasizpl! IlllXlcmlt'-intcnsih phv~ical acti\ilv.2-6.0 4. of maxilllal aerobic power). such as metabolic equivalents (~I ETs) or percentagl's of Jll<'l.g. or heart rate reserve.g" light -20%--::3H9t \0 2 1{) is based on participation in acthities ranging from 20 to 60 mintltes.1 S.\1 ET'). with longer total duration required for less intense acthities. • ~1. <20 lIdllutes per session and <. the authors of the Surgeon Ceneral's report 3 pro\ided a c1a"silication scheme. there is a recognized need to standardize the lise of terms related to physkal activit)' intensitr·'.3 6.4-3. and fleXibility m heal1hy .ty. In fact. . In addition. persllading sedelltal~' iudi\ iduals to become physicall) active is I1l000e likely to be successful whell the largt't lewl of pll)'sical activit\ is Table 1-1. hI order to advance this mission.\1 ET<.Lx:imal aerohic capacity t~l)icall~ declines .50lff. Classification of Physical Activity Intensity Relative Intensity Intensity Absolute Intensity Ranges (METs) Across Fitness levels 12 MET 10 MET 8 MET 6 MET V0 2R ('Yo) HRR (%) Maximal HR (%) V0 2. The following points should be considered when interpreting the information within Table I-J: • The linking of adjectives to physiologic ranges (e.>sellts vary· ing rc/atirt' illtellsiti('s across tIl{: range of fillll'SS h-.~ociatl'd with modaate physical acti\-il)' f()IIml within Tahle 1·1 diff('rs from tilt' absolute range found in earlier \'ersions of this tnt (i.

it seems that greater amounts of . 30 minutes of brisk walking or raking leaves. more recent reports have made recommendations for greater volumes of physical activity6. Therefore. there was an attempt to define the lowest. rather than the traditional higher-intensity level. 111 the discussion of public health recommendations. It is also likely that the minimum dose and shape of the dose-response cUlve differs for various health conditions. and anxiety. that is likely necessary to: 1) prevent the onset of obesity. Besides the SCIentific value of these data. most Americans can improve their health and quality of life. osteoporotic fractures." • "Additional health benefits can be gained through greater amounts of physical activity. In 2001. some activity is better than none. Benefits of Regular Physical Activity and/or Exercise A large body of laboratory. The following year.. and that prevention of weight regain may require 60 to 90 minutes of moderate activity per day. This holds true from middle age to older age (forties to eighties). DIVERGENT PHYSICAL ACTIVITY RECOMMENDATIONS Although the Surgeon General's recommendation of30 minutes of light to moderate activity on most days of the week is a well-established public health recommendation. hypertensIon. several studies have examined the impact of change in physical actIVity or fItness m relation to developing coronary heart disease or dying prematurell6-32: These data indicate that individuals who change from a sedentary lifestyle to bemg phYSically active. 2) effect weight loss in overweight adults. these reports also acknowledge the myriad health benefIts assocJated with 30 minutes a day of moderate-intensity physical activity. and 3) prevent weight regam m formerly obese adults.e. and concluded that overweight adults should increase their activity to approximately 45 minutes of exercise per day (i. the answer is no. experience lower rates of disease and premature mortality compared \\'lth those who contmue to remain sedentary or unfit. days of the week. and their recommendations identified the higher volume of physical activity necessary to prevent weight gain and reduce weight regain follo~~ng weight reduction. Taken collectively.and population-based studies has documented the many health and fitness benefits associated with physical actl\'lty and endurance exercise training. the well-established relationship between physical activity and various health benefits clearly supports the need for professionals to encourage the public to engage in at least moderate amounts and intensities of daily physical activity. ACSM updated its Position Stand on weight loss and prevention of weight gain for adults 12. The health benefits of increasing physical activity \\~thin the general population are potentially enormous because of both the high prevalence of sedentary lifestyle lo and the impact of increased physical activity on lowering disease risk l l . the Institute of Medicine (10M) recommended 60 minutes a day of moderate-intensity physical activity to prevent weight gain and accrue additional weight-independent health benefits. Two conclusions from the Surgeon General's RepOlt. Through a modest increase in daily acti\~ty. People who can maintain a regular regimen of activity that is of longer duration or of more vigorous intensity are likely to derive greater benefit. The recommendations also agree that there is a dose-response relationship. most effective level of physical activity that could provide health benefits. remain prudent general guidelines for physical activity and public health: • "Significant health benefits can be obtained by including a moderate amount of physical activity (e.g. For example. with greater benefits occurring at higher duration andlor intensity of physical activity. colon and breast cancers. there has been much interest in the nature and shape of the doseresponse CUlve between physical activity and health W Although physical activity clearly has been documented to reduce the risk of the diseases listed pre\'lously (see Box 1-1). depression. 15 minutes of running.6 SECTION II HEALTH APPRAISAL. Physical Activity and Health 3 . as well as what fUlther lisk reductions occur with additional amouqts (duration andlor intensity) of physical activity. The clear focus of these recent reports was energy balance. and psychologiC parameters. which can I4 ls be accumulated in short bouts. obesity.ume of physical activity. 200-300 minutes/week) to facilitate weight loss and prevent weight regain. And finally. the data are far less clear regarding the minimal dose of phYSICal activity that is required. gallbladder disease. indicating that it is never too late to become physically active to 27 achieve health benefits DOSE-RESPONSE RELATIONSHIP In recent years. In other words. or who change from being physically unfit to physically fit. and more activity (up to a point) is better than less.12. or 45 minutes of playing volleyball) on most. Although the optimal dose of physical activity has yet to be defined." An impOltant component of the current recommendations·3-5 that has not been emphasized suffiCiently is the dose-response relationship between physical activity and health.associated ~th prevention of various diseases and health conditions and to clmity the shape of the dose-response cUlve... metabolic. ~dditionally.. However. compared with sedentary behavior . in a report on guidelines for healthy eating. above the 30 minutes cited ~thin the Surgeon General s report. such as improved physiologic. in 2003.n Are the recommendations found \vithin these reports in conflict with those found \vithin the Surgeon General's report? For the most part. these reports emphasize the additional vol.. Thus. as well as decreased risk of many chronic diseases and premature mortality (Box 1_1)3. if not all. type 2 diabetes mellitus. such information is also pertinent for public health recommendatIOns in order to balance the feasibility of the recommendations proposed \\~th their efficacy in preventing vmious diseases or health conditions.w Physical activity and exercise clearly prevent occurrences of cardiac events. fUlther research is needed to more clearly define the minimal dose of physical activity . the International Association for the Study of Obesity (IASO) concluded that 45 to 60 minutes of moderate physical activity per day is required to prevent the transition to overweight and obesity in adults. RISK ASSESSMENT. and delay mortaliti·19-2.. reduce the incidence of stroke. This consensus IS clearly supported by recent studies in men and women of different races. AND SAFETY OF EXERCISE CHAPTER 1 / BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY 7 moderate. showing risk reductions of some 20% to 50% in corona? heart dIsease and cardIOvascular disease incidence rates ~~th moderate-intenSity physical actl\'lty.

The clearest of these relationships is for all-cause mortality. quality of life. even though no randomized clinical trials on this topic have ever been conducted. interventions to prevent the initial occurrence) • Higher activity and/or fitness levels are associated with lower death rates from coronary artery disease Higher activity and/or fitness levels are associated with lower incidence rates for combined cardiovascular diseases. . Dose-response issues concerning physical activity and health: an evidence-based symposium. Danforth E Jr. cardiovascular and all-cause mortality are reduced in postmyocardial infarction patients who participate in cardiac rehabilitation exercise training. including data from randomized clinical tJials. Table 1-2 summarizes the available data on the inverse doseresponse relationship between physical activity and selected health outcomes W The categOlies use an evidence-based approach developed by the National Institutes of Health3. 1996. Table 1-2 summarizes results from a large body of observational studies. it is to be noted that cigarette smoking is clearly believed to cause lung cancer. type 2 diabetes. recreational. Reduction in coronary artery disease risk factors • • • • • Reduced resting systolic/diastolic pressures Increased serum high-density lipoprotein cholesterol and decreased serum triglycerides Reduced total body fat. AND SAFETY OF EXERCISE CHAPTER 1 I BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY 9 . angina pectoris. and gallbladder disease Secondary prevention (i. For example. et al. type 2 diabetes mellitus. Although randomized trails are considered the gold standard for clinical research. Physical activity and health: a report of the Surgeon General.33:5351-358. suggests the lack of an inverse dose-response for blood pressure and depression and anxiety. Jensen MD. which indicate an inverse dose-response relationship between physical activity and a variety of health conditions. continued Decreased anxiety and depression Enhanced physical function and independent living in older persons Enhanced feelings of well being Enhanced performance of work. ischemic ST-segment depression. Finally. I ~ Box 1-1. and in addition would be prohibitively expensive.g. and sport activities Other postulated benefits Improvement in Cardiovascular and Respiratory Function • • • • • • • Increased maximal oxygen uptake resulting from both central and peripheral adaptations Decreased minute ventilation at a given absolute submaximal intensity Decreased myocardial oxygen cost for a given absolute submaximal intensity Decreased heart rate and blood pressure at a given submaximal intensity Increased capillary density in skeletal muscle Increased exercise threshold for the accumulation of lactate in the blood Increased exercise threshold for the onset of disease signs or symptoms (e.involving postmyocardial infarction patients do not support a reduction In the rate of nonfatal reinfarction ~ • • • physical activity are required to prevent unhealthy weight gain compared with the amount needed to reduce the risk of cardiovascular disease. Whereas Box 1-1 contains a list of health related benefits attributed to a more active lifestyle.8 SECTION II HEALTH APPRAISAL. These exercise programs should be designed and supervised by qualified profeSSionals who possess training in exercise testing and prescription (see Appendix F for academic and experience prerequisites for ACSM certification). it is often impractical to conduct such studies. reduced intraabdominal fat Reduced insulin needs.. cancer of the colon and breast. When the knowledge of the additional health and fitness benefits associated with greater quantities and intensities of physical activity and/or exercise is combined with the fact that the list of chronic diseases favorably affected byexercise continues to grow. claudication) • • • • *Adapted from references 3. randomized clinical trials. and independent living in older persons. RISK ASSESSMENT. coronary artery disease.e.. espeCially as a component of multifactorial risk factor reduction Randomized controlled trials of cardiac rehabilitation exercise training . To emphasize this point. A smaller body of evidence also indicates likely inverse dose-response relations for weight and fat distribution. interventions after a cardiac event [to prevent another]) • Based on meta-analyses (pooled data across studies). stroke. there remains a clear need for medically and scientifically sound primary and secondmy prevention programs. 19: United States Department of Health and Human Services. colon cancer. More research is needed on certain health conditions to define the dose-response relationship for physical activity. .. improved glucose tolerance Reduced blood platelet adhesiveness and aggregation Decreased morbidity and mortality • Primary prevention (i. osteoporotic fractures. Med Sci Sports Exerc 2001 . Kesaniemi YK. studies of physical activity and the primary prevention of coronary heart disease would require many subjects (thousands to tens of thousands) followed for several years. and coronmy heart disease. a small body of data.1.e. cardiovascular disease. which places greater emphasis on data from large. It would be impossible to maintain good compliance with physical activity over this time.

Danforth E Jr. It requires substantial numbers of studies Involving substantial number of participants. Congenital cardiac abnormalities and nonatherosclerotic.27:641-647. Table 1-3. respectivell~. Category B pertains when few randomized tnals exist. Cardiac Causes of Death in High School and College Athletes* (N 100) = Disorder Men Women Risks Associated With Exercise Habitual physical activity reduces the incidence of atherosclerotic cardiovascular disease. For example. or meta-analysIs of RCTs. post hoc or subgroup analySIS of RCT. the lisk of exercise for any population depends on its prevalence of cardiac disease. All-cause mortality Cardiovascular and coronary heart disease Blood pressure and hypertension Blood lipids and lipoproteins Coagulation and hemostatic factors Overweight. 50 5 11 7 1 0 2 6 6 2 2 2 'Adapted from Van Camp Sp' Bloor CM. acquired myocardial disease are the primmy cause of exercise-related cardiac deaths in younger individuals.41. tlncludes anomalous lett coronary artery (LCA) from nght sinus of Valsalva (N = 4). The reason for lower rates of exercise-related cardiac death among women is unclear. Exercise does not provoke cardiac events in individuals with normal cardiovascular systems. AND SAFETY OF EXERCISE CHAPTER 1 / BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY 11 Table 1-2. Atherosclerotic coronmy artery disease is rare (Table 1_3)'J~--40 In the United States. . it does not indicate the absence of a favorable relationship. Neveltheless. and the tnal results are somewhat Inconsistent. Category B: EVidence IS from endpoints of intervention studies that Include only a limited number of RCTs. and fat distribution Type 2 diabetes mellitus Colon cancer Low back pain. RISK ASSESSMENT. Dose-response issues concerning physical activity and health: an evidence-based symposium. Consequently. Mueller FO. This category is used only in cases where the provision of some guidance was deemed valuable but an adequately compelling clinical literature addreSSing the subject of the recommendation was deemed InsuffiCient to Justify placement In one of the other categories (A through C). but is characteristic of most studies on this topic. and osteoporosis Quality of life and independent living in older persons Depression and anxiety Yes Yes Not C C B Insufficient data Insufficient data Yes Yes:j: Yes Insufficient data Yes Not C C C C B *From Kesaniemi YK. one had Wolff·Parkinson-White syndrome. Intramural left antenor descending (LAD) (N = 4). obesity.:J5 and acute myocardial infarction:J6 . and ostial ridge of the LCA (N = 2). These numbers overestimate the incidence of cardiac events because only 100 of the 136 deaths with identifiable causes of death in this report were caused by cardiac disease. et al.33:5351-358. they are small in size. Med Sci Sports Exerc 1995. vigorous physical exertion also acutely and transiently increases the risk of sudden cardiac death:J4 . Jensen MD. Med Sci Sports Exerc 2001. anomalous nght coronary artery (RCA) from left sinus (N ~ 2). Category C: Evidence IS from outcomes of uncontrolled or nonrandomized tnals or observational studies.000 men and 769. or the tnals were undertaken In a population that differs from the target populatIOn of the recommendation. This is not true for other populations. et al. Nontraumatlc sports death in high school and college tThree also had coronary anomalies. In general. anomalous LCA from pulmonary artery (N = 2). The absolute incidence of death during or within an hour of sports participation among United States high school and college athletes has been estimated as one death per year for evelY 133. tNo mdlcates a lack of eVidence for a "dose-response" for the relationship between the health outcome and physical activity. Category D: Expert Judgment is based on the panel's syntheSiS of eVidence from expenmental research deScribed in the literature and/or denved from the consensus of panel members based on clinical experience or knowledge that does not meet the listed criteria. the most common cause of exercise-related sudden cardiac death is hypeltrophic cardiomyopathy3s.10 SECTION 1/ HEALTH APPRAISAL.4o. the risk of sudden cardiac death during exercise is low because the prevalence of occult disease is low. Category definitions: Category A: Evidence IS from endpoints of well-designed randomized clinical trials (RCTs) (or trials that depart only minimally from randomization) that provide a consistent pattern of findings in the population for which the recommendation 15 made. i:lnverse dose-response for primary prevention. arrhythmogenic right ventricular cardiomyopathy is the most frequent cause of exercise-related sudden cardiac death in ItalyH Such observations suggest that the causes of exercise-related sudden death differ by both the age of the subjects and the population examined.000 women. hypoplastic RCA (N = 2). Three subjects With coronary anomalies also had hypertrophic cardiomyopathy and are tabulated with that group. whether diagnosed or occult. Hypertrophic cardiomyopathyt Probable hypertrophic cardiomyopathy Coronary artery anomalies:j: Myocarditis Aortic stenosis Cardiomyopathy Atherosclerotic coronary disease Aortic rupture Subaortic stenosis Coronary aneurysm Mitral prolapse Right ventricular cardiomyopathy Cerebral arteriovenous malformation Subarachnoid hemorrhage athletes. osteoarthritis. Evidence for Dose-Response Relationship Between Physical Activity and Health Outcome* Variable Evidence for Inverse Dose-Response Relationship Category of Evidence SUDDEN DEATH AMONG YOUNG INDIVIDUALS Among individuals younger than 35.:J7 It is impOltant to remember that exercise only provokes cardiovascular events in individuals with preexisting hemt disease. but not for improvement in blood glucose control in patients With diabetes.

FLllthermore. However. These results include exercise testing that is supcrvised by nonphysicians""'.37 are higher in individuals who exercise infrequently. which leads to platelet aggregation and subsequent acute coronary thrombosis.g. heat illness. Sickle cell trait is much more common in the African-American than the White population. whereas . ObViously.000 individuals. The o\'erall risk of exercise testing in a mixed subject population is approximately six cardiac events (e. In contrast.000 tests (Table 1-4). This is remarkably higher than the annual rate of exercise deaths among other populations of militmy age. Some expelts and organizations recommend routine exercise stress testing prior to initiating vigorous exercise programs in adults with risk hlctors. this approach is controversial and not presently recommended by all organizations. nonfatal myocardial infarction 36 . indi\'iduals \\'ith more than one coronaty disease risk factor. but both studies demonstrated that the rate of sudden cardiac death during or immediately after vigorous exertion was higher than that duTing more leisurely activities.000 to 18. In contrast. EXERCISE-RELATED CARDIAC EVENTS IN ADULTS The risks of exercise in adults are considerably higher than in younger subjects because of the increased prevalence of atherosclerotic cardiovascular disease. the paucity of exercise-related cardiac events makes it difficult to quantiJY the benefit of any routine screening procedures. Consequently.5). AND SAFETY OF EXERCISE CHAPTER 11 BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY 13 EXERCISE EVENTS IN THOSE WITH SICKLE CELL TRAIT In contrast to the overall low incidence of exercise-related deaths in young subjects. individuals with sickle cell trait have a remarkably higher incidence of exertionrelated death. and it has been estimated that vigorous exercise increases the risk of a cardiac event 100 times in this population'19. exercise testing in high-risk patients has a higher risk. The mechanism of sudden cardiac death and acute myocardial infarction in previously asymptomatic adults is probably acute coronary plaque rupture leading to coronmy thrombosis. Atherosclerosis decreases the flexibility of the coronary arteries. Some experts recommend extensive preparticipation screening of young subjects prior to sports participation using electrocardiographlO or echocanliographl'. Exercise also acutely increases the risk of acute. The ACSM recommends exercise stress testing prior to vigorous exercise for "moderate" or "high-lisk individuals" including men over 45 and women over . ventricular fibrillation. myocardial inf~lrction. Interventions cannot be proposed and tested because an enormous number of subjects would have to participate to document effectiveness. This is a low incidence of cardiovascular events. both acute plaque rupturc and ventricular dysrhythmias arising from previously infarcted myocardium contribute to cardiac events in patients with diagnosed coronal)' heart disease. Howe\'er. RISK ASSESSMENT. The most widely cited studies. estimated an incidence of sudden cardiac death dUling vigorous exertion in healthy adults as only one death per year for every 15. It is not possible to deCipher exactly how many of the exercise-related deaths were related to cardiac causes..37 Interestingly. Consequently.105 recruits. the risk of exercise stress testing also valies with the populations studied. the Tisk of exercise varies with the prevalence of underlying coronary artely disease in the population. As discussed. acute plaque disl'llption is the likely cause of most cardiac events in prcviously asymptomatic individuals. performed in Rhode Island44 and Seattle35 . Such atherosclerotic plaque disruption with acute thrombotic occlusion has been documented by angiography in individuals with exercise-induced cardiac events 45-47 PREVENTION OF EXERCISE-RElATED CARDIAC EVENTS The development and evaluation of strategies to reduce the risk of vigorous exercise have been negatively impacted by a low incidence of events. Most authorities agree \vith these recommendations for those \\'ith established coronal} altelY disease (CAD). nor are facilities for cardiac resuscitation readily available. 4 :3 examined deaths during basic training in 2 million U. and those \vith ].S.''. This approach also is controversial and not endorsed by all expeJi panels. Nevertheless. the relative risk of sudden unexplained death among AfJican-Americans with sickle cell trait was 27 times higher than in those without it. Nevertheless. both the incidences of exertion-related sudden cardiac death 35 and acute myocardial infarction 36.'10wn coronaI)' disease (see Chapter 2). other important dysrhythmia or death) per 10. or exertional rhabdomyolysis. RISKS OF CARDIAC EVENTS DURING CARDIAC REHABILITATION Individuals with diagnosed coronary artery disease are at the highest risk of experiencing a cardiac event during exercise.. with an annual rate of one death for evelY 478 to 660 recruits. An expelt panel from The Amelican Hemt Association recommends a prepmticipation physical examination of young athletes. studies of cardiac events during cardiac rehabilitation document that the risk of vigorons exercise ill such supervised populations is extremely low (Table 1-. All of the sudden. militalY recruits behveen 1977 and 1981. recommendations for strategies to reduce cardiac events are based primmily on common sense and expert opinion.12 SECTION II HEALTH APPRAISAL. The absolute death rate in African-Americans with sickle cell trait duTing 8 to 11 weeks of basic training can be estimated as one death for evelY 3. but does not recommend routine electrocardiography or echocardiograph/2 . This increased fleXing can produce cracking in the atherosclerotic plaque. Athletic trainers and others who supelvise young athletes during vigorous exertion should be aware of this potential problem in AfTican-American athletes. Exercise stress testing performed in previously healthy individuals has a low rate of cardiovascular events. "unexplained" deaths were related to physical exertion and attTibuted to cardiac events. these data cannot be extrapolated to vigorous exercise in cardiac patients who are not supervised because such patients are not monitored. a review of seven randomized and four nonrandomized tr1als of home-based cardiac rehabilitation indicated that there was no increase in cardiovascular complications of this approach versus formal center-based exercise programs 2. the American College of Cardiology and the AmeTican Hemt Association Guidelines for Exercise Testing considered the use- RISKS OF CARDIAC EVENTS DURING EXERCISE TESTING As noted.55 years of age. The increased frequency of cardiac contraction and the increased excursion of the coronary arteries during exercise produce increased bending and flexing of these arteries. Kark et a1.

.0 .364 81. unel..996 120. Abbreviation: MI. Public rlealth Rep 1985: I 00: 126-131. Ph)"sical activity and health: a report of the Surgeon General.14 SECTION 1/ HEALTH APPRAISAL. Research Digest.D M o IoU o o z{!!. United States Department of Health and Human Sen·ices. Average o c ".126 58.' ~ •Adapted from Franklin SA.ty. .669 .. c: E o u .o . and cardiac rehabilitation have not been evaluated rigorously. Gordon S. . Physical activity. Q) )( . :0 . Q . several Simple measures seem prudent.451 81.!:! "C III o (J) Lf) ...'pected dyspnea. Individuals with known cardiovascular disease should receive medical clearance prior to vigorous exercise training.418 219.101 120. and physical fitness: definitions and distinctions for health-related research..906 293. if young or older individuals develop exercise-induced symptoms such as chest discomfort.' ] 'Q. Individuals who seek to start an exercise program should be queried as to their reasons for initiating exercise.54 Such divergence of opinion leaves the decision about the necessity of a prepmticipation exercise test in healthy subjects largely to the clinician. Number of Participants for One Cardiac Event in Cardiac Rehabilitation Programs* Reference Cardiac Arrest MI Fatalities MI and Arrest Van Camp 61 Digenio 62 Vongvanich 63 Franklin 64 111. e i' U c. A recommendation from the Centers for Disease Control and Prevention and the American Colle"e of Sports Medicine. REfERENCES 1.254 752. Definitions: health. because the incidences of exercise-related sudden cardiac death amI acute myocardial inftuction are more frequent in physically unfit subjects. Cl CIl <t Z Z <t co 00 Lf) co Lf) <. '.970 783..503 97. Chest 1998.~ . <t o o co 00 Lf) o (J) o u "' '" o :. Sonzhelm K.. et a!. Physical activity and public health. Safety of medically supervised outpatient cardiac rehablll' tation exerCise therapy: a 16'year follow·up.!:! c: . et al. 0.: C CIl Q c: = c: ci ~ o R~ i' o o 00 00 ~ M M 00 6 No' Lf) CO' N ''. Caspersen C).:: III VI . RISK ASSESSMENT.J fulness of routine exercise testing prior to vigorous exercise in asymptomatic persons as less well established by evidence or opinion (Class IIB)'53. exercise stress testing. individuals initiating exercise programs should be encouraged to stalt slowly and progress gradually. Some victims of exercise-related cardiac events underestimated the importance of their symptoms prior to death H Finally. '6 E . exercise.0 o a:: \3 .503 292.127 116..000 67. Pate RR.000 268. Christenson GM.972 160. 1996.. President's Councll on Pbysical Fitness.. 2..990 268.501 146. It is also important that practitioners supervising vigorous exercise programs or testing have training in cardiac life support and established procedures for dealing with emergencies.. or syncope. AND SAFETY OF EXERCISE CHAPTER 1 / BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY 15 Table 1-5.. Pratt M. Nevertheless. z Q. ~ Q) c: ~ v ~ V1 ::Ci t!!! ~ a: . It is also impOltant that exercising adults know the prodromal symptoms of CAD. and physical acti\. they should be fully evaluated by a physician prior to retuming to vigorous activity. I (J) CO CO (J) (J) (J) U . Also.273:402-407. JAMA 1995. > z N o ~ Q) 'C:. E ~ (. Procedures for redUCing the risks of vigorous exercise during exercise training. .000 89. Blair SN.. 2000. because some patients with new symptoms of cardiovascular disease initiate exercise programs in an attempt to reassure themselves that they are well. 3.s:::: u E o '"C a V1 .~ Q ::i M is. Powell KE. fitness. myocardial infarction.. III Z :I: o a:: Z N 0Lf) a:: Z a:: Z a:: Z -0 g a oS o Cl * c: ..114:902-906. 4. These procedures should be reviewed and practiced at least several times yearly (see Appendix B)..~ g- o c 4.

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Oguma Y.:329:1617-168:3.orglclinicaVguidelines/exercise/dirindex. and litigation experience in approximately 170.. McHenry PL. Sereening for hypertrophic cardiomyopathy in young athletes. Shirani J. d al.1\ Press.3:3:S3. Re\l'ode K~1. . Scalld . 28. J Am Coli Cardio! 1986. In: Schottenl"ld D. Cook r\H. Schoenborn CA. Physical acti. Dose-response issues concerning plJ)'sical activity and health: ane. IIIortalil\.75:390-391. 1000. Body mass index. evaluatioll. il\ and risk of hip fracture in postmcnopausal wonlen.000 tests. Circulation 1997.276:199-204 .217:106J-I066. Hammoudeh AJ.341 :177-784.7:3:219-222.5G8-575.ent unllt'alth.716-72. Am J CardioI1994. Coronary·plaque rupture in acute coronary syndromes triggered by snow shoveling. t"\. Hisks of graded exercise testing.51.. Sorensen JI. Fraullleni JFJ. Smith LK. et al." of health. Kark JA.·. l<Xll. et a1. :32. JAM A 1971. and tn.52:7. Bloor CM. Black MM.94:850-856. demo· graphic. "an Baak ~1. ~Ied Sci Sports Exerc 1001 ::3:3:5:36·1--S:369. Barlow CE. 54. ous exercise. and quality of fell' . Hu 1'13. Thompson PD.erc 1001. Paffenharger HS J 1'.:650-658. et al. Sickle-cell trait as a risk factor for sudden death JIl physical training.5]-:3. 14. Triggering of acute myocardial infarction hy hea. 41. Hich·EdwarcIs J'\~ et al. Pafft'llhargl'r RS Jr. SpOlts·related and non·spurts·related sudden cardiac death in young adults.1' ExcrciS(" Te. et al. Roch-ille. and cardiO' as<:lIlar health.5. et aJ. Franklin BA. Lee I ~1. A prospeetiw st". Cochran Lihrarv. et ai.150: 11R9-1296. Institute of . Unill'd States. cigarette smoking. et a1.:317:781-787. 47. Williams P. Beasley J'V. Shaper AG. 9.<. A six'year follow· "l' in the Copenhagen IIlale study. Stern YIP. RISK ASSESSMENT. Department 01" 1I""lth and IIIIIIIan Sen·ices.5. :30. C""persen Cj. 6. Allicric:an Collegp of Sports J\ledicillt-'. Posey DM. 42. PI. et al.·it. N Engl J ~"'d 199:3::31~:5:31. . Lung. l't al.·oIllPn: is "no pain. 45.'If'-rf"ported.:39:93.

60. Ellestad MIl.80: 846-852. irving )13. Samuelsson B. The salety of m'Lxirnal exercise lestin~.. Cibbons L. Sim JC. cost effective. Blair SN. Bonzheim K. ~Iprz C:\.2. AND SAFETY OF EXERCISE 57. et al. Am J Cardiol 1977. \'ong-'anich P. Paul-Labrador :-IJ. Procedures range from self-administered questionnaires to sophisticated diagnostic tests.ximal exercise (treadmill) teslin~.980. pregnancy. and metabolic diseases. OeHotien TA. Cardiovascular CUlllrlications of outpatient cardiac rehabilitation programs. 61. el "I. when establishing program-specific policies for prepmticipation health screening and medical clearance. and time efficient. Am J Cardio! 1996. Jonsson B. 62. RISK ASSESSMENT. 63. Bruce HA. Safety of l1ledicaJly supervised outpatient cardiac rehabililation exercise therapy: a 16-year follow-up.. Exercise program profeSSionals should review these other documents. 59. Peterson HA. the Amelican College of Sports Medicine (ACSM) recognizes other published guidelines by the Ametican Hemt Association (AHA) and the Amelican Association of Cardiovascular and Pulmomu).17:94-97. Do\\'des\\'ell HJ. et al. pulmonalY.18 SECTION 1/ HEALTH APPRAISAL. Van Camp SP. 58.17:]:383-]:38. 64. Chest 1998. Circulation 1989. The pUl1Joses of the preparticipation health screening include the following: Identification and exclusion of individuals vvith medical contraindications to exercise • Identification of indi\~duals at increased risk for disease because of age.114:902-906 Preparticipation Health Screening and Risk Stratification • 2 ••• •• CHAPTER This chapter presents guidelines related to preparticipation health screening and lisk stratification for individuals initiating a self-guided physical activity regimen or those enteling plimary or secondary prevention exercise programs. S Afr ~Ied J 1991.to moderate-intensity (see 19 . JA:-IA 1986. Exercise tt'sting: a prospective study of complieation rates. The Johannesbur" experience. Nalional survey of pxercise strpss testin" f'. To provide guidance on the appropliate depth and breadth of prepmticipation health screening.98:512-579. Rehabilitation (AACVPR)I~5. The algOlithm defines three leuels of screening \vith the intent of presenting a logical sequence of assessment and decision making. ACSM offers the algOJithm presented in Table 2-1. as well as revisions to them. Exercise program profeSSionals should establish prepalticipat screening procedures appropdate for their clients or a facility's target population. .79: 188-191. Chest 1. Variations in and significance of systolic pressure during ma. as well as conditions (e. Kohl I IW. Stuart HJ Jr. Am Hearl J J979. Di"enio AG.g.5. Exercise-related cardiac arrest in cardiac rehabilitation. Atterhog JII. It is generally accepted that many sedentm)' individuals can safely begin a )ight.56: I I60-J 163. Safety of nwdicalh supe'Yised exercise in a cardiac rehabilitation center. To aid in the development of a safe and effective exercise prescription and optimize safety during exercise testing. it is important to screen potential participants for risk f~1ctors ancIJor symptoms of various cardiovascular. orthopedic injury) that may be aggravated by exercise.39:841-888. To this end. Franklin BA. and/or dsk hlctorS who should undergo a medical evaluation and exercise testing before stmting an exercise program • Identification of persons with clinically significant disease who should participate in a medically supel'\~sed exercise program • Identification of indi\~duals with other special needs • Preparticipation Screening Algorithm Prepmticipation screening procedures should be valid.cilities. symptoms. Cordon S.

regardless of the scope of prepalticipation screening employed.9 . it should bc noted that many exercise programs incorporate all three levels descJibed in Table 2-1 into their procedures regardless of the outcome from each level. This process requires identification of the presence of: • Coronary attery disease (CAD) lisk factors (Table 2-2) Signs or S)~llptoms of cardiovascular. 10 As self-administered surveys. Thus. RISK ASSSESSMENT. therefore. Levcl 1 screening ma)' be all that is necessary for most indi.1>-8.y. Finally. The modified AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire (Fig. minimal step. 2-1) and the Physical Activity Readiness Questionnaire (PAR-Q. many health/ (texl COnlill11f'S on page 27) . the prepalticipation screening recommcndations in Table 2-1 relate to both self~ and profeSSionally guided exercise regimens. because information gained in subsequent screening steps can enhance the safcty and effecti"eness of the exercise prescliption. This should not be ~ewed as inappropliate.or profeSSionally guided regimens. it is recommended that prospective exercisers complete a self-admillistered questionnaire that serves to alert those with elevated risk to consult their physician (or other appropriate health care provider) prior to participation 2 . FUlthermore. pulmona.uy andlor metabolic disease (Table 2-3) Known cardiovascular. or 3) ently procedures at health/fitness or clinical exercise program facilities. physicians and other allied health professionals counseling clients or patients to adopt a more active lifestyle should provide appropliate screening as palt of the physical activity counseling process.~ty promotional materials deSigned for the general public. information should 'he intell)reted by qualified profeSSionals and results should be documented 2 . and it identifies a broader scope of chronic diseases that might be aggravated hy exercise. such forms can be incorporated into: 1) physical aeti. Fig. Individuals recommended for medical clearance may further benefit from initial participation in a professionally guided program.~duals seeking to adopt a more active lifestyle. AND SAFETY OF EXERCISE CHAPTER 2 / PRE PARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION 21 Table 1-1) physical adi\~ty regimen . 2) routine paperwork completed within the scope of a physician office visit. andlor metabolic disease • . the AHA/ACSM questionnaire provides greater detail regarding cardiovascular disease risk factors and symptoms. pulmon. Although both surveys are effective in identifying individuals who would benefit from medical consultation prior to participation.20 SECTION 1/ HEALTH APPRAISAL. therefore. the AHA/ACSM questionnaire is more useful for identifying ACSM risk strata (Table 2-4). \Vhen medica] clearance is recommended from the questionnaire results. However. 2-2) II represent examples of self-administered surveys recommended for use at Level 1 screening for individuals seeking either self. Although the use of either questionnaire is acceptable at Level I screening. palticipants should be advised to obtain such clearance prior to participation.\~thout the need for extensive medical screening 2.N I Q) -= ell ~ As an initial. RISK STRATIFICATION AND MEDICAL CLEARANCE The initial screening step in Table 2-1 is deSigned to yield information regarding lisk stratification and the need for medical dearance plior to heginning or Significantly increasing physical actil~ty.

well-trained persons and during moderate exertion in healthy. syncope during exercise may result from cardiac disorders that prevent the normal rise (or an actual fall) in cardiac output.-. it should be regarded as abnormal. 035233.1 ) confirmed by measurements on at least two separate occasion Body mass index >30 kg'm. fingers in interscapular region • Provoking factors: Exercise or exertion. Both are symptoms of left ventricular dysfunction.26:3160-3167. and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). cheeks. However. or on lipid-lowering medication. in particular coronary artery disease Key features favoring an ischemic origin include: • Character: Constricting. If HDL is high. when it occurs at a level of exertion that is not expected to evoke this symptom in a given individual. Impaired FG threshold based on Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.1 ) Hypertension threshold based on National High Blood Pressure Education Program. Lipid thresholds based on National Cholesterol Education Program. neck. in left hemithorax • Provoking factors.1 (34 mmol·L-') or high-density lipoprotein (HDL) cholesterol 1 <40 mg·dL. NIH Publication No. stabbing.140 mm Hg or diastolic .03 mmol·L.' After completion of exercise.90 mm Hg.~NG Af. discomfort (or other anginal equivalent) in the chest.EA/H. 2002. and treatment of overweight and obesity in adults-the evidence report. in particular left ventricular dysfunction or chronic obstructive pulmonary disease.95 for men and . in forearms. evaluation. 2003. or on antihypertensive medication Low-density lipoprotein (LDL) cholesterol> 130 mg·dL. "jabs" aggravated by respiration • Location: In left submammary area. allied health profesSionals should use clinical judgment when evaluating this risk factor.86 for women Persons not participating in a regular exercise program or not meeting the minimal physical activity recommendations:t from the U. Obesityt 7. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection. or other areas that may result from ischemia Shortness of breath at rest or with mild exertion Negative Risk Factor Dizziness or syncope 1. Dyslipidemia 5. If total serum cholesterol is all that is available use >200 mg·dL. Abnormal exertional dyspnea suggests the presence of cardiopulmonary disorders. Paroxysmal nocturnal dyspnea refers to dyspnea. Detection. arms. Sedentary lifestyle Myocardial infarction.2 or Waist girth> 102 cm for men and >88 cm for women or Waist/hip ratio: . in particular. Evaluation.1 Fasting blood glucose .1 (1.6 mmol-L. Physical activity and health: a report of the Surgeon General.1 (5. 1996. Although nocturnal dyspnea may occur in persons with chronic obstructive pulmonary disease.:T~TTAT'ON 23 Table 2-2.6 mmol·L. National Institutes of Health. squeezing. jaw.. Dizziness and." sharp. because high HDL decreases CAD risk.1).-.100 mg·dL. Clinical guidelines on the identification. Hypertension 4. It commonly occurs during strenuous exertion in healthy. tProfessional opinions vary regarding the most appropriate markers and thresholds for obesity and therefore. hypertrophic cardiomyopathy. teeth. and Treatment of High Blood Pressure (JNCl).. "heaviness" or "heavy feeling" • Location: Substernal. Evaluation. in both arms.." ''"'0' /R'~ A~k's'" K AS'' S'M' '. or sudden death before 55 years of age in father or other male firstdegree relative. aortic stenosis. and malignant ventricular dysrhythmias. Impaired fasting glucose 6. High-serum HDL cholesterol l >60 mg·dL. shoulders. cold weather. burning. in neck. Arch Int Med 199B. Orthopnea refers to dyspnea occurring at rest in the recumbent position that is relieved promptly by sitting upright or standing..2 mmol-L.158:1855-1867. other forms of stress. subtract one risk factor from the sum of positive risk factors.S. Obesity thresholds based on Expert Panel on Detection Evaluation and Treatment of Overweight and Obesity in Adults. Surgeon General's Report Defining Criteria Pain. these symptoms may occur even in healthy persons as a result of a reduction in venous return to the heart.(1. confirmed by measurements on at least two separate occasions. occurrence after meals Key features against an ischemic origin include: • Character: Dull ache.. beginning usually 2 to 5 hours after the onset of sleep. or before 65 years of age in mother or other female first-degree relative Current cigarette smoker or those who quit within the previous 6 months Systolic blood pressure . *Accumulating 30 minutes or more of moderate physical activity on most days of the week INotes: It is common to sum risk factors in making clinical judgments. Such cardiac disorders are potentially life-threatening and include severe coronary artery disease. untrained persons. Orthopnea or paroxysmal nocturnal dyspnea One of the cardinal manifestations of cardiac disease. provoked by a specific body motion Dyspnea (defined as an abnormally uncomfortable awareness of breathing) is one of the principal symptoms of cardiac and pulmonary disease. Diabetes Care 2003. A'O "'m 0' mRC'" CHAPTER 2/ PREP7~iTI~. it differs in that it is usually relieved after the person relieves himself or herself of secretions rather than specifically by sitting up. Syncope (defined as a loss of consciousness) is most commonly caused by a reduced perfusion of the brain.1 (5.-'0. or Metabolic Disease*t Sign or Symptom Clarification/Significance Ma~ Sign~ 1. Followup report on the diagnosis of diabetes mellitus.-. The Seventh Report of the Joint National Committee on Prevention.-'0. excitement. "knifelike. Cigarette smoking 3. Family history 2. 02-5215.1) rather than low-density lipoprotein (LDL) >130 mg·dL. continued . across midthorax. Although dizziness or syncope shortly after cessation of exercise should not be ignored. which may be relieved by sitting on the side of the bed or getting out of bed. Pulmonary. or Symptoms SU9t:tive of Cardiovascular. Sedentary lifestyle thresholds based on United States Department of Health and Human Services.. coronh Artery Disease Risk Factor Thresholds for Use With ACSM Risk Stratification Positive Risk Factors Defining Criteria Table 2-3. anteriorly. coronary revascularization.

. you get <30 minutes of physical activity on at least 3 days per week). ACSMlAHA Joint Position *Modified from American College of Sports MediCine and Amellcan ~ n olicies at healthlfitness facili- ties. Known heart murmur Although some may be innocent. You take prescription medication(s). _ _ You smoke. = = Cardiovascular risk factors You are a man older than 45 years. practical and clinical knowledge. .. or blackouts.. Palpitations also often result from anxiety states and high cardiac output (or hyperkinetic) states. Diabetics are at increased risk for this condition.~~~~nFg. or metabolic dIsease.. You have concerns about the safety of exerCISe. skills.You have a close blood relative who had a heart attack or . . heart murmurs may indicate valvular or other cardiovascular disease From an exercise safety standpoint. compensatory pauses. and is often described as a cramp. or metabolic disease.heart surgery before age 55 (father or brother) or age 65 (mother or sister). Generalized edema (known as anasarca) OCcurs in persons with the nephrotic syndrome. Major Signs or Symptoms Suggestive of Cardiovascular. Coronary artery disease is more prevalent in persons with intermittent claudication. ACSM's resource manual for guidelines for exercise testing and prescription. . _ _ You experience unreasonable breathlessness. 1993:219-228... . fainting.. tThese signs or symptoms must be interpreted within the clinical context in which they appear because they are not all specific for cardiovascular. _ _ You are physically inactive (i.You take blood pressure medication. Ankle edema = __ __ __ __ Symptoms . You are >20 pounds overweight. _ _ You experience dizziness. You have burning or cramping sensation in your lower legs when walking short distances. Philadelphia: Lea & Febiger. staffing. The pain does not occur with standing or sitting. These include tachycardia. they also may signal the onset of. You should be able to exercise safely without consulting your physiCian or other appropriate health care provider in a self-guided program or almost any facility that meets your exercise program needs. and abllttles commensura e WI . and the so-called idiopathic hyperkinetic heart syndrome. Pulmonary. Mitchell as. . _ _ None of the above If you marked two or more of the statements in thiS section you should consult your physician or other appropriate health care provider before engaging in exercise. or are postmenopausal. Statement: Recommendations for cardIovascular screening. You may need to use a facility with a medically qualified staff. H rt Association.You do not know your cholesterol level. _ _ Your blood pressure is > 140/90 mm Hg. or quit smoking within the previous 6 months. and accentuated stroke volume resulting from valvular regurgitation. *Modified from Gordon S. it is especially important to exclude hypertrophic cardiomyopathy and aortic stenosis as underlying causes because these are among the more common causes of exertion-related sudden cardiac death. such as anemia. bradycardia of sudden onset. fever.. RISK ASSSESSMENT. . . You have musculoskeletal problems that limit your physical activity. or Metabolic Disease*t (continued) Sign or Symptom Clarification/Significance FIGURE 2-1.. which disappears within 1 or 2 minutes after stopping exercise. You are pregnant. . You do not know your blood pressure. If you marked any of these statements in this section.e.You have asthma or other lung disease. Other health issues You have diabetes. eds. Intermittent claudication Intermittent claudication refers to the pain that occurs in a muscle with an inadequate blood supply (usually as a result of atherosclerosis) that is stressed by exercise.hysterectomy. _ _ You experience chest discomfort With exertion. You might benefit from using a facility with a professionally qualified exercise staff t to guide your exercise program. or change in with usual activities the status of cardiovascular.Your blood cholesterol level is >200 mg/dL. Unusual fatigue or Although there may be benign origins for these sympshortness of breath toms. ectopic beats. arteriovenous fistula. severe heart failure. Painter PL. is reproducible from day to day. AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire* Assess your health status by marking all true statements History You have had: a heart attack _ _ heart surgery cardiac catheterization coronary angioplasty (PTCA) pacemaker/implantable cardiac defibrillator/rhythm disturbance heart valve disease heart failure heart transplantation congenital heart disease Bilateral ankle edema that is most evident at night is a characteristic sign of heart failure or bilateral chronic venous insufficiency. an emerge cy p . King AC. is more severe when walking upstairs or up a hill.24 SECTION 1/ HEALTH APPRAISAL.::~~i~~~:~~:~~~e:~~. Unilateral edema of a limb often results from venous thrombosis or lymphatic blockage in the limb. consult your physician or other appropriate health care provider before engaging in exercise.. 'Professionally qualified exercise staff refers to appropriately trai~ed i~~i~~deU:. or hepatic cirrhosis.You are a woman older than 55 years. Health appraisal in the non-medical setting. thyrotoxicosis. pulmonary. In: Durstine JL.. Palpitations or tachycardia Palpitations (defined as an unpleasant awareness of the forceful or rapid beating of the heart) may be induced by various disorders of cardiac rhythm. Med Sci Sports Exerc 1998:1018. AND SAFETY OF EXERCISE CHAPTER 2/ PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION 25 Table 2-3. have had a . _ _ You take heart medications. pulmonary. .

26 SECTION II HEALTH APPRAISAL.'ised2002) PAR-Q & YOU (A Questionnaire 'or People Aged 15 to 69) Regular physical activity is fun and healthy. along ~vith additional information 20 aid the clinician in the chuification and significance of each sign or symptom The presence of most of these factors can be identified using the AHNACSM Questionnaire. . however.. or • if you are or may be pregnant talk to your doctor before you start becoming more active. Pulmonary.or joint ~roblem (for example. AND SAFETY OF EXERCISE CHAPTER 21 PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION~ 27 FIGURE 2-2...and build up graduall'1 Or.we. knee or hip) that could be made worse b ya change In your phySical actiVity? ~~:~.e. and the level of supelvision for both exercise testing and exercise program patticipation. • Find out whICh communrty programs are safe and helpful for you.n.acianSooetyIorExerClSe~HealthCanada and this quesbomalf!.Q but only if you use the entire form. Ask whether you should change your physical activity plan.csep. or cystic fibrosis (see Reference 24: American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for pulmonary rehabilitation programs.asp. IL: Human KinetICS. also have been suggested as positive lisk factors in the plimary and secondalY prevention of CAD 17-19 may b! used for I!gaI or adminislrative pur~ I have read. asthma. or cerebrovascular disease.ca/forms. Champaign. candidates for exercise testing or training can be stratified based on the likelihood of untoward events . Talk with your doctor about the kinds of activIties you wish to participate in and foDow his/her advice.lrdet" ltll!ag!oI mapily)-VI'ITNESS _ Note: This csJII~ ~hysi~at. o o If you currently prescribing drugs (for example.e.. Olthopnea.. some people should check with their doctor before they start be<:oming much more physically active. a few (i. PLEASE NOTE: II your health changes SO thai you then answer YES to any of the above questions.rce: fPhysical A.flf:OFPARENT orGt. 'PJ may need to restrict 'PJr activities to t~ whICh are safe f~ 'PJ. consuh. 4. activity dearance is valid for a maximum of 1Z months from the date it is completed and be. thyroid disorders.Wil:lW'l (lor parl"""ntsl. 6. water pills) for your blood pressure or heart con- fltness and clinical exercise program facilities incorporate a more elaborate health/medical history questionnai re deSigned to provide additional detail regarding selected health habits and medical histOlY.. DELAY BECOMING MUCH MORE ACTIVE: • If you are not feeling wetl because of a temporary alness such as a cold or a fever wait until you feel better. 2. Sou. llis SKtIOfl ACSM lisk stratification is based. other variables.up I6..ny of the . the PAR-Q will teU you if you should check with your before you start. renal. Please read the questions carefully and answer each one honestly: check YES or NO. and Metabolic Disease Table 2-3 presents a listing of major signs or symptoms suggestive of cardiovasto cular. YES to .. SlGHATl. Has your doctor ever said that you have a heart condition and that you should only do phys' I t" recommended by a doctor? tea ac IVIIy Do you feel pain in your chest when you do physical activity? In the past month. talk with your doctor before you start becoming much more physically active.. YES o o o o o o 0 0 0 0 0 NO 1. ACSM Risk Categories Once symptom and risk factor information is known. Inlormedlkro!th(PAR·Q· TI'ltCar.. 1998:97-112. back. If you are between y ars 0 age.. • You may be able to do any activity you want as long as you start slowIy.at! PAR-Q questions. *Cardiac. 2nd ed. Moderate risk 3 High risk docto~ areno~~. t or metabolic oF disease ~ionnairt·PAR-Q (reo. • thelr agmts asSUI'll! no iahiIrty lor persons who und!flak! physical ~ and rll"llbJbt alter completmg No changes permitted.nge. interstitial lung disease. NIDDM). in part. because the intended use for the list in Table 2-2 is to aid in the identification of occult coronary attery disease.gns and symptoms listed in Table 2-3 or known cardiovascular. NOTE: If ttl! PAR-Q is bMg •. • take part in a fitness appraisal this is an excellent way to determine your basic fitness SO that you can plan the best way lor you to live actively.ty Readiness Questionnaire (PAR-Q) © 2002. Z. The lisk factors in Table 2-2 should not be viewed as an all-inclusive list. ~IJPE ©CanadianSooetyforExercistPhyslology Supported by: Health Canada Sante Canada continued on other side. and increasingly more people are starting 10 become more active every day. check with your doctor. Any questions I had were answered 10 my full satisfaction: NAME ~ Major Signs or Symptoms Suggestive of Cardiovascular. on the presence or absence of the CAD risk factors listed in Table 2_2 6 .. It is also highly recommended that you have your blood pressure evaluated. '0 th. answered If you answered NO honestly to. http://www. give'! to a person bdore h! or she participates ll\ a jXlyslcal aetlVlty program (If a fitn!ss apprarsaJ. should not be viewed as inconsistent ~vith other fisk factor lists that are intended for use in predicting coronalY events prospectively dUling long-term follow. * pulmonary.f you. 12. tDiabetes mellitus (IDDM.t you would .begin slO\l/ly aoo build up gradually This is the safest and easiest way to go. 3.. pulmonalY <mellor metabolic disease. ACSM Risk Stratification Categories 1. 7.on•. If your reading is over 144/94. doctor tChronic obstructive pulmonary dIsease. RISK ASSSESSMENT. have you had chest pain when you were not doing physical activity? Do you lose your balance because of dizziness or do you ever lose consciousness? Do you ~ave a bone . . o Do you know of any other reason why you should not do physical activity? Coronary Artery Disease Risk Factors YES to one or more questions Talk with your doctor by phone or in person BEFORE you start be<oming much more physically active or BEFORE you have a fitness appraisal Tell your doctor about the PAR·Q and which questions you answered YES. understood and completed this questionnaire. you can be reasonably sure that you can: • start becomlng much more physically active . the need for exercise testing plior to initiating patticipation. Low risk Men <45 years of age and women <55 years of age who are asymptomatic and meet no more than one risk factor threshold from Table 2-2 Men ~45 years and women ~55 years or those who meet the threshold to wo or more risk factors from Table 2-2 Individuals with one or ~.. If you are planning to become much more physically active than you are now start by answerin the seve ages of .Iod . peripheral vascular. but rather as a group with clinically relevant thresholds that should be considered collectively when making decisions about the level of medical clearance.h. such as major depression.. You are encouraged to photocopy the PAR.. However. tell your fitness or health professional.~. Being more active is very safe for most people. PhysicaiActivJty~adiness Table 2-4. 91f you very actIVe. Reprinted wtth permission from the Canadian S oCiety or Exerose Physiology. .15.n: In Ih~ box beldOw.15 and 69.ctiv. 'ond'tion . an you are not used to being ~he Common sense is your best guide when you answer these questions. The scope of the list. . healt murmur) require a more thorough medical histOlY anellor examination. yoor doctor prior 10 physical activity. PAR-Q form. 5. or liver disease. ankle edema. and the threshold for each fisk factor.ome. Furthermore.en quest. 0"'.

one or more staff should be cetiified in advanced cardiac life support (ACLS). little additional assessment is needed beyond the ACSM-AHA Questionnaire provided that one adheres to all medical clearance recommendations contained vvithin . However. \Vhenever possible. sitc personnel should at least be cetiified at a level of basic Ii fc suppOli. exercise profeSSionals should choose the most applicable definition (i. For low-lisk patients (see Table 2-4) with isolated stage 1 hypertension «160/100 mm Hg). The exercise testing recommendations found in Table 2-1 reflect the notion that the tisk of cardiovascular events increases as a function of physical activity intensity (i.e. symptom. prudent recommendations for prepatiicipation screening should be based on the severity of the hypertension (see Table 3-1 for JNC7 classifications) and the desired intensity of exercise. and Treatment of High Blood Pressure (JNC7)t3 recommends a thorough medical history. Inherent within the concept of tisk stratification is the impression that signs and symptoms (see Table 2-3) represent a higher-level concern for decision making as compared with risk factors (see Table 2-2). self. and the expelience of the laboratOlY staff. The degree of medical supelvision of exercise tests varies appropJiately from physician-supe'vised tests to situations in which there may be no physician present l The degree of physician supelvision may differ with local policies and circumstances. the health status of the patient. hypertension is the only presenting tisk factor from those in listed in Table 2-2). In all situations where exercise testing is performed. physical examination. and tisk factor information. Local circumstances and policies vary.or high-risk category as defined in Table 2-4. AND SAFETY OF EXERCISE CHAPTER 2/ PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION 29 during participation. preferably. EXERCISE TESTING AND TESTING SUPERVISION RECOMMENDATIONS No sct of guidelines for exercise testing and participation can cover all situations. if the patient has documented stage 2 hypertension. and any additional fitness and/or clinical assessments (including exercise testing) should follow procedures described in Chapters 3 through 5 for either clinical or nonclinical exercise settings. although it appears vvithin Table 2-2.. health status. and specific program procedures also are properly diverse. On the other hand. diabetes). categories A-2 and A-3). Evaluation.ssary for clearance to engage in up to moderate intensity exercise «60% of the V0 2 R). the requisite medical examination in Table 2-3 is consistent with the screening recommendations for hypertensive patients outlined in JNC7. further screening recommendations are provided in Table 2-l.or professionally guided) • Intended training intensity (i. approved consent forms for exercise testing and training should be completed (see Chapter 3 for examples of forms). dyslipidemia. Although the testing guidelincs are less rigorous for those individuals considered to be low risk. it is advisable for such patients to have physician clearance prior to participation. relative or absolute) for their setting when making decisions about the level of screening prior to exercise training and physician supervision during exercise testing. RISK ASSSESSMENT. obesity. testing should be performed by ACSM-credentialed personnel. Once risk strata are established. and physical activity level of thc person to be tested. The depth and breadth of these additional assessments vaty as a function of: • Type of program (i. It should be noted that the recommendations for medical examination and exercise testing for moderate risk individuals desiring vigorous exercise (Table 2-4) are consistent \vith those found within recent AHA Guidelines ( See Box 2-2. Using age. in cases of isolated hypertension (i. Detection. The appropriate protocol should be based on the age.e. However..e. For self-guided physical activity regimens of light to moderate intensity.e. For individuals seeking a profeSSionally guided excrcise regimen.e. special consideration should be given to hypertensive patients when screening for exercise testing or training. health status. For such individuals. Because hypertension is commonly clustered with other tisk factors associated with cardiovascular disease (i. moderate versus hard).. This stratification becomes progressively more important as disease prevalence increases in the population under consideration. hypertension represents a unique risk factor in that it may be aggravated by acute exercise. To providc somc general guidance on the need for a medical examination and exercise testing prior to participation in a moderate to vigorous exercise program. The Seventh Report of the Joint National Committee on Prevention. additional fitness and/or clinical assessments and procedures may be incorporated into the preparticipatiotl screening (Level 2 screening). Such regimens should incorporate the physical activity rccommendations from the U.e. Surgeon Gencral 6 A specific self-guided regimen suitable for previously sedentalY individuals can be found in the ACSM Fitness Book lo It should be noted that individuals in need of medical clearance as defined by the AHAlACSM Questionnaire wouldlikcly benefit from patiicipation in fUliher fitness assessment and a profeSSionally guided training regimen.28 SECTION 1/ HEALTH APPRAISAL. ACSM suggests the recommendations prescntcd in Level 3 of Table 2-1 for determining when a medical examination and diagnostic exercise test are appropriate and whcn physician supervision is recommended... prospective participants can be classified into one of three tisk strata (see Table 2-4) for triage to fUtiher screening ptior to participation. Although Table 1-1 provides both absolute and relative thresholds for moderate and hard intensity physical activity. an exercise assessment is recommended to quantify hemodynamic responses dUting exercise to aid in the establishment of prudent guidelines for exercise training 21 the form. the information gathered from an exercise test may be useful in establishing a safe and effective exercise prescription for these individuals. and other diagnostic procedures in the evaluation of patients with documented hypetiension. or a patient with stage 1 hypertension desires to engage in more intense exercise training (>60% of the V0 2 R). because these ADDITIONAL PREPARTICIPATION ASSESSMENTS Following risk stratification.. Therefore. exercise testing generally is not nece.S. However. moderate versus vigorous) (see Table 1-1) • Individual risk strata (see Table 2-4) . most hypetiensive patients presenting for exercise testing or training fall into the moderate. Physicians responsible for supervising exercise testing should meet or exceed the minimal competencies for supelvision and interpretation of results as established by the AHA (see Box 5-3) 22. routine laboratory tests.

. light-headedness. skills.7 METsJ) Mild to moderate level of silent ischemia during exercise testing or recovery (ST-segment depression <2 mm from baseline) Functional capacity <5 METs • • Nonexercise Testing Findings • Rest ejection fraction = 40%-49% HIGH RISK • I I • •• f • Characteristics of patients at high risk for exercise participation (anyone or combination of these findings places a patient at high risk) • Presence of complex ventricular dysrhythmias during exercise testing or recovery Risk Stratification Criteria for Cardiac Patients' • Presence of angina or other significant symptoms (e. Exercise program professionals should recognize that the AHA guidelines do not consider comorbidities (e.30 SECTION II HEALTH APPRAISAL. Risk stratification criteria from the AACVPR are presented in Box 2_13. The AHA guidelines provide recommendations for participant and/or patient monitOling and supelvision and for activity restliction.g.g. ~ Box 2-1. the dura~ion of monitored exercise training and/or educatIOn based on the nsk factor profile have now been suggested 23 . with permission from Elsevier. unusual shortness of breath. The AHA has developed a more extensive risk classification system for medical clearance of cardiac patients (Box 2-2)1... debilitating neurologic or orthopedic conditions) that could result in modification of the recommendations for monitOling and supelvision dUling exercise training.. chronotropic incompetence or flat or decreasing systolic BP with increasing workloads) or recovery (i. and abilities directly related to exercise testing. during exercise testing and recovery) Presence of normal hemodynamics during exercise testing and recovery (i. Cardiol Clin 2001. appropriate increases and decreases in heart rate and systolic blood pressure with increasing workloads and recovery) Functional capacity ?. severe postexercise hypotension) LOWEST RISK Characteristics of patients at lowest risk for exercise participation (all characteristics listed must be present for patients to remain at lowest risk) • • Absence of complex ventricular dysrhythmias during exercise testing and recovery Absence of angina or other significant symptoms (e. light-headedness. unusual shortness of breath. AND SAFETY OF EXERCISE CHAPTER 2/ PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION 31 credentials document the individual's knowledge. . morbid obesity. or dizziness occurring only at high levels of exertion [?. light-headedness.19:415-431.. Exercise testing in cardiac rehabilitation: exercise prescription and beyond.7 METs • • • • Nonexercise Testing Findings • Resting ejection fraction ?-50% • • • • • Uncomplicated myocardial infarction or revascularization procedure Absence of complicated ventricular dysrhythmias at rest Absence of congestive heart failure Absence of signs or symptoms of posteventlpostprocedure ischemia Absence of clinical depression ~ Nonexercise Testing Findings • Rest ejection fraction <40% • History of cardiac arrest or sudden death • Complex dysrhythmias at rest • Complicated myocardial infarction or revascularization procedure • Presence of congestive heart failure • Presence of signs or symptoms of posteventlpostprocedure ischemia • Presence of clinical depression *Reprinted from Williams MA..e.g. RISK ASSSESSMENT. or dizziness at low levels of exertion [<5 METs] or during recovery) High level of silent ischemia (ST-segment depression ?-2 mm from baseline) during exercise testing or recovery Presence of abnormal hemodynamics with exercise testing (i. or dizziness.e.e. Recommendations for.g.. unusual shortness of breath. severe pulmonal)' disease. MODERATE RISK Characteristics of patients at moderate risk for exercise participation (anyone or combination of these findings places a patient at moderate risk) • Presence of angina or other significant symptoms (e. continued Risk Stratification for Cardiac Patients Cardiac patients may be fUither stratified regarding safety during exercise using published guidelines. type 1 diabetes mellitus.

) 4. CAD (MI.32 SECTION 1/ HEALTH APPRAISAL. Congenital heart disease. Nonmedical personnel should be trained and certified in basic life support (which includes CPR). 3. Libby P. usually 6 to 12 sessions. abnormal exercise test. adolescents. Exercise test abnormalities that do not meet the criteria outlined in Class C. Complex ventricular arrhythmias not well controlled Clinical characteristics: 1. Clinical characteristics: 1. Ability to satisfactorily self-monitor intensity of activity Activity guidelines: Activity should be individualized. No evidence of congestive heart failure 4. Valvular heart disease.e. Class A: Apparently Healthy Individuals • Includes the following individuals 1. Congenital heart disease. ejection fraction ~30%. excluding 'severe valvular stenosis or regurgitation with the clinical characteristics outlined below 3. New York Heart Association class 1 or 2 2. Children. Exercise capacity ~6 METs 3. risk stratification should be guided by the 27th Bethesda Conference recommendations. No evidence of myocardial ischemia or angina at rest or on the exercise test at or below 6 METs 5. J Am Coli Cardiol 1996. Gotto AM. 2. includes stable patients with heart failure with any of the clinical characteristics as outlined below but not hypertrophic cardiomyopathy or recent myocarditis 5.27:964-976. Supervision by appropriate trained nonmedical personnel for other exercise sessions should occur until the individual understands how to monitor his or her activity. Men ~45 years and women ~55 years who have no symptoms or known presence of heart disease and with ~2 major cardiovascular risk factors. Absence of sustained or nonsustained ventricular tachycardia at rest or with exercise 7. continued 6. (Fuster V. CABGS. Activity guidelines: No restrictions other than basic guidelines ECG and blood pressure monitoring: Not required Supervision required: None. CAD with the clinical characteristics outlined below 2. with exercise prescription by qualified individuals and approved by primary health care provider Supervision required: Medical supervision during initial prescription session is beneficial. 3. but slightly greater than for apparently healthy individuals • Includes individuals with any of the following diagnoses: 1. Cardiomyopathy. risk stratification should be guided by the 27th Bethesda Conference recommendations 25 4. NYHA class 3 or 4 2. Previous episode of primary cardiac arrest (i. Although it is suggested that persons classified as Class A-2 and particularly Class A-3 undergo a medical examination and possibly a medically supervised exercise test before engaging in vigorous exercise. • • • • • • Class C: Those at moderate to high risk for cardiac complications during exercise and/or unable to self-regulate activity or understand recommended activity level • Includes individuals with any of the following diagnoses: 1.. Medical personnel should be trained and certified in advanced cardiac life support. Exercise test results: • Exercise capacity <6 METs • Angina or ischemia ST depression at workload <6 METs • Fall in systolic blood pressure below resting levels with exercise • Nonsustained ventricular tachycardia with exercise 3. includes stable patients with heart failure with any of the clinical characteristics as outlined below but not hypertrophic cardiomyopathy or recent myocarditis 5. ECG and blood pressure monitoring: Useful during the early prescription phase of training. RISK ASSSESSMENT. and abnormal coronary angiograms) whose condition is stable and who have the clinical characteristics outlined below. PTCA. AND SAFETY OF EXERCISE CHAPTER 2/ PRE PARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION 33 ~ Box 2-2. Appropriate rise in systolic blood pressure during exercise ~ • • . excluding severe valvular stenosis or regurgitation with the clinical characteristics outlined below. angina pectoris. cardiac arrest that did not occur in the presence of an acute myocardial infarction or during a cardiac procedure) Class B: Presence of known. stable cardiovascular disease with low risk for complications with vigorous exercise. and women <55 years who have no symptoms of or known presence of heart disease or major coronary risk factors 2. 27th Bethesda Conference: Matching the intensity of risk factor management with the hazard for coronary disease events. ejection fraction ~30%. Cardiomyopathy. Valvular heart disease. Men ~45 years and women ~55 years who have no symptoms or known presence of heart disease and with <2 major cardiovascular risk factors. men <age 45.

'. ) . Maron Bj. ". Attention should be directed to treating the patient and restoring the patient to class C or better. Fuster\'. National Cholcstcro "uca JOn .. Hodgers GP. .. • ECG and blood pressure monitoring: Continuous during exercise sessions until safety is established. Circulation 2001. I'D'. ' I" l~. I e CI I' I . ' . I ~' JA~IA 1995. " . ext' >. Puffer jC.ort of the American Co ege 0 .nc t'<. . 'k r -to _for coromuy artery disease III mell: ·1 DE Mead LA. et al. Ith . P I D t dion E\"uuallOll . Experi I cll1l' un ee. J tting In: Durstme JL. I I ' . . criteria for risk that would prohibit exercise conditioning should be guided by the 27th Bethesda Conference recommendations. among WOlllf'1I and rllf'n III t 1<. AND SAFETY OF EXERCISE CHAPTER 21 PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION 35 ~ Box 2-2..•\Ied Sci SPOltS Exerc 1998. 20.' K'I. Champ.. and cmergency policies at health/fitness facilities . IL: uman LO. et al. '['I S ' '" th Helmrt of the Joint National . __ . Other medical conditions that could be aggravated by exercise 200:3. lL: /luman Kinctics.' Cardiolol.ters athletes. Buc mel . betes Mellitus.n. .27:964-9i6.:. tion 9OO0'L02: 1726-1738.S. . [i 11 '11 Kinetics 199/. Painter PL. . 'uth/f'tness Eldlitv 9.'aluatJon. Ayaman -. . Balady Cj.Gxeluseaml .l '_ 25. A recommendation [rom the I . Fletcher CF.1998.. . corOllary artery (lse.. IT"'ltmcntoI'High BlonuCholestero Program (NCEp) £xpelt Panel on Deteellon... American Healt Association. 104:1694-1740.·ou.Ul( gUll e lOtS.F t·' .34 SECTION II HEALTH APPRAISAL.. .107:3109-:31 Hi.l996. C of CanJiology/American Heart . NI d S . I I . Ferketich AK. Exerc 2004:36:53. dlseasc.' "11 College of Sports Meuicine.lIll le. I O the diagnosis 0 1<1 ('tes me I us. '1 I' 's for exercise testing and prescription. Pratt M. IC'"0IL.. ...d 1998. ~Iitehe (~a "'. II BS H It I ·1 )pl"lis·\1 In the non-meu(. ' C II r Phvsicians-American SocIety () • 1-:1 -t Assochtlon/AmerJcan 0 ege 0 -. t' .."" 'Icti\'it)' in the [.112. \\'ilson P\V.78:613-6]1. m. 'In antecedent to healt chsease j A F·' I DJ et a DepreSSion "s .94:8. . I he'lit disease usillO' nsk factor CcltHi.. ~ I' . . . .273:402-407.t se . rehabilitation programs. ' .' I·' 998·18: LJ3-123. Araujo CC. National Hlg I 1 OO( HSSUIC .. pt a!. I. . the [Jrecllrsors stud).. /' I ... J996. on Clinical Competf>ll(.104: 1694-1740.ILeta. Guidelines f"r Cardiac Hehabilitation and Sccondar)' Prel'ention Programs.. '. . Thompson PO. ment 0 at College lerose elo IC (.<\ OJl clln<: . E\'a upatl. 6.'oronat. A statement f"r health professionals from the Sudden Death Committee (cliuical cardi%b')') and Congenital Cardiac Defects Committce (eardiO\'. et al. ~Iark DB. Gotto A.ltmen 0 I 1 f' 15. . Severe and symptomatic valvular stenosis or regurgitation.. Exercise standards (ur testing and training. POSition I ..97: 1837-1847.994. Chang pP.(' . r Association c. Uncontrolled arrhythmias 6. ~I "y . . I' " .. . I f.: um. staffing.). . I I '0 .stcll1t.cldar and Pulmonal)' Hehabilitation. Phi Amt'rican ColJf'ge of SPOlts ~led1(':lIle. I " fi I k "rd ed Champaign.. Physical actilih' and health: a report of the Surgeon Ceneral..1.I1d)1 I < . "p'ugn ~: um"" I ..158: 1422-1426.·. ~I' tehing the intensity of risk factor Illan'I I '11 I' 97th Bl'lhesda Con elence . dio\'asclilar rehahilitation sClyices in t 1e ung-terlll c II1l(.II tMedI998·158:1855-18ul." :'"0' ()9-5915 90<>9 ' P I III) 9009 NIH U. . American Assocmtion 0 ar<'lO\<lsCU'lI.' I ' . 1 .ho f' He . . agcment with the hazard for coron<Uy disease e\ <: nts. . < I '. A new 1ll0(C "1' .. • Activity gUidelines: No activity is recommended for conditioning purposes. . egories..lI cl -. E. Maron Bj. Arch Inteln I el ~. Le\')' 0. ._ 2nd • Supervision: Medical supervision during all exercise sessions until safety is established.up.IQ. . C' . Ie. IW.. J[ ed. overwl'lgllt al1<. · . . Ontario: Canadian Society Society fur Exel.1 for risk stratification and dehvelY 0 cal. Pn'( H. 1 . SN l' I Physic'll 'u:lIvltv Pate HR. . 9 I 1 CI·. Cordon S. DepreSSion IS a liS ac I " 18 1'01 ( . _ _ in Adnlts (Adult lreatment ane . with exercise prescription provided by qualified individuals and approved by primary health care provider. 'fi . RISK ASSSESSMENT. .epol 0 1 < < I 12. 200:3. M' 19000'160:1261-1268. A medical problem that the physician believes may be life threatening Activity guidelines: Activity should be individualized. Circulation 200/... I. am I PlI) I I'1(. e 111(. A .I..c •• lI~ue ACS~IIAHA . eds. II II . Hecommendations for prcpalticipalion screcuing and the assessment of cardiovascular disease in m. lI(. Circulatioll . IIANES I stlldv. 3. J Am Coil Caruiol. American College of Sports Medicine and American lIe'lIt Association.03-5233. 14. and PlIlnlOIl<lIV I'\t. . American Association of Cardiov". Exercise standards for testing and training.56. m I _ '. ' I ' C' '.:Iulica cOllljJe en l' c . Champaign.l . ACSM Itness '00 . .·k F -' . T Dnrnlller AM. I ""><ic. COlllmittee on Pre\"entioll. l . ACS~rs resource manlla 01 gU1(. Centers for Disease Control and PreventulIl clill t Ie mellc. 1 31 I 1" . arl( treat men 0 t f II Ith Clinic'l gUlue II1[>S on " cNationalnstitueso ea.la 31~fu' b 1ft· Dhhetes Glre 9003·2. Amellc"n 0 eo> > II f 22. et al. . _.1018. I' T' -. "t'.. joint Position Statement: Hecommendations for cardiovascular screening. Follow-up repOlt on Expert Committee on the Diagnosis anu ClaSSIlcatl~n ~ 31.50-8. Congenital heart disease. 1 I ' term mortality risk in patients with B'Ireroot JC (-[elms ~I I. '1" A jCa'diol1996. I. ."al Me( Icme "s OIC(. .:e. 2:3. . Ie. 25 4. .. .2003. 1I<':11 ell I . " . 3. KlIlg AC. I t c' shtelilent on stress ttS mg. A statement for health care professionals from the American Healt Association. .•1 I I . 1'I A . Class 0: Unstable disease with activity restrictiont • Includes individuals with 1. I. continued 4. ea 1 'I . usually Kinetics. 1. . r· ·'udio\'a5<. . " .. American College of Sporls Medicine. . United States Department of Health and Human Senices. . <lilt ~ 12 sessions. 1. 1 T' 'Itment of High Blood Pressure ON I . U )l'Slt) III cl( u s " .etics 1998:97-... Canadian "I' I I' t I' Ihe N'Itiol1'lJ Cholesterol Education fur Exercise ph\'siolog)'. IC 1 n I . SIO I I. ' " . et al. . IlIte.revention and Ireat8. 19.3:327-.:tlon 0 eOIOl1cll) c. Circulation 2001. . ' Iag.Llle. A/ch Intern ~I(.1 'D P' ·. else PI1). Heart failure that is not compensated 5. I 1 I I · L & Fehiuer [993·9[9-228.:ular (ISease. I It ·-the el'ldence report. Detection. . . tExercise for conditioning purposes is not recommended. Schwal1zhaum . Daily activities must be prescribed on the basis of individual assessment by the patient's personal physician *Modified from Fletcher GF. Sots a( e I' lla: . J .. C ld)I· I {' . D'Agostillo B.'. An"terdam EA. 1. . :. 4. Cardio\'ascular preparticipation screening of competitil'c athletes. I 'I't'ltioll Cliidelllles for pulmonu) . r-:. HOltman JL. Balady GJ. JZ B'lhd)' C et '". .""se in the )'oung). pAH-Q and _ .'~ REFERENCES 1.3-553.. Thompson PD. 1'1'012003. Thompson PD. Gloucester. ' t I' Ovenveight and Ohesity in Auu ts.( MecllclJ1e. .Ill. f' _ . I '" . . B atr 1. 21.. .cular dis. e ". American of Sports ACSl\I' _ l' S Ilee I • standards . lltll C-) 13.iAmertean eal . 24. DepreSSion ~ml ong17. A statement for health care professionals from the American Heart Association. et al. -. 'cise Hnd hypertension.. Education Program..oln. .5. 2. d ll1'1rngcment of patients Wit 1 (..334. 4th cd. Circulation J996. Amsterdam EA. I'.1 I' the identific'ltion evaluation.. . ' . 1< I • . Unstable ischemia 2. arterv Ccu<. I Ed r Prognm I llf( .

SECTION II Exercise Testing .

Appropriate components of the medica! hist01)' are presented in Box 3-1. medical history.. 39 . and the effect of certain medical therapies. but rather to provide a concise set of guidelines (or the pre-exercise test participant assessment.Pre-Exercise Evaluations • 3 •• •• CHAPTER This chapter contains information related to pre-exercise testing procedures and serves as a blidge between the risk. significant dysrhythmias. and Laboratory Tests The pre-exercise test medical hist01Y should be thorough and include both past and current information. identification of exercise contraindications. physical examination. For many persons. the fitness assessment (see Chapter 4). This evaluation provides greater assurance of exercise safety by identifying residual myocardial ischemia. Appropriate components of the physical examination specific to subsequent exercise testing are presented in Box 3-2. physical examination. stratification concepts presented in Chapter 2. Physical Examination.and high-risk subjects (see Table 2-4). and laboratory tests. however. Medical History. informed consent procedures) relate to both health and fitness and clinical exercise settings. A comprehensive pre-exercise test evaluation in the clinical setting generally includes a medical history. In today's health care environment. the lower-risk population typically encountered in the health and fitness setting generally justifies a less sophisticated approach to the pre-exercise test procedures. Although each of the chapter elements (e. andJor clinical exercise testing concepts (see Chapters 5 and 6). it is important to work with health care providers in understanding the importance of the baseline exercise evaluation. the exercise test and accomp<\l1)ing physical examination are critical to the development of a safe and effective exercise program. A preliminmy physical examination should be performed by a physician or other qualified personnel before exercise testing moderate. not all persons warrant extensive testing. abbreviated versions of the medical history and physical examination procedures described within this chapter are reasonable within the health and fitness setting. especially those with coronary artery disease (CAD) and other cardiovascular disorders. The extent of medical evaluation necessary before exercise testing depends on the assessment of risk as determined from the procedures outlined in Chapters 1 and 2. The goal of this chapter is not to be totally inclusive or to supplant more specific references on each subject. Therefore.g.

40

SECTION II/EXERCISE TESTING

CHAPTER 3/ PRE-EXERCISE EVALUATIONS

41

. I

Appropriate components of the medical history may include the following: Medical diagnosis. Cardiovascular disease including myocardial infarction; percutaneous coronary artery procedures including angioplasty, coronary stent(s), and atherectomy; coronary artery bypass surgery; valvular surgery(s) and valvular dysfunction (e.g., aortic stenosis/mitral valve disease); other cardiac surgeries such as left ventricular aneurysmectomy and cardiac transplantation; pacemaker and/or implantable cardioverter defibrillator; presence of aortic aneurysm; ablation procedures for dysrhythmias; symptoms of ischemic coronary syndrome (angina pectoris); peripheral vascular disease; hypertension; diabetes; obesity; pulmonary disease including asthma, emphysema, and bronchitis; cerebrovascular disease, including stroke and transient ischemic attacks; anemia and other blood dyscrasias (e.g., lupus erythematosus); phlebitis, deep vein thrombosis or emboli; cancer; pregnancy; osteoporosis; musculoskeletal disorders; emotional disorders; eating disorders. • Previous physical examination findings. Murmurs, clicks, gallop rhythms, other abnormal heart sounds, and other unusual cardiac and vascular findings; abnormal pulmonary findings (e.g., wheezes, rales, crackles); abnormal blood sugar, blood lipids and lipoproteins, or other significant laboratory abnormalities; high blood pressure; edema • History of symptoms. Discomfort (e.g., pressure, tingling, pain, heaviness, burning, tightness, squeezing, numbness) in the chest, Jaw, neck, back, or arms; light-headedness, dizziness, or fainting; temporary loss of visual acuity or speech, transient unilateral numbness or weakness; shortness of breath; rapid heart beats or palpitations, especially if associated with physical activity, eating a large meal, emotional upset, or exposure to cold (or any combination of these activities) • Recent illness, hospitalization, new medical diagnoses, or surgical procedures. • Orthopedic problems, including arthritis, joint swelling, and any condition that would make ambulation or use of certain test modalities difficult. • Medication use, drug allergies. • Other habits, including caffeine, alcohol, tobacco, or recreational (illicit) drug use. • Exercise history. Information on readiness for change and habitual level of activity: type of exercise, frequency, duration, and intensity. • Work history with emphasis on current or expected physical demands, noting upper and lower extremity requirements. • Family history of cardiac, pulmonary, or metabolic disease, stroke, or sudden death.
• For more detailed information see Bickley LS Bate's pocket guide to physical examination and history taking. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2003.

Appropriate components of the physical examination may include the following: • Body weight; in many instances, 'determination of body mass index (BMI), waist girth, and/or body composition (percent body fat) is desirable Apical pulse rate and rhythm Resting blood pressure, seated, supine, and standing Auscultation of the lungs with specific attention to uniformity of breath sounds in all areas (absence of rales, wheezes, and other breathing sounds) Palpation of the cardiac apical impulse, point of maximal impulse (PMI) Auscultation of the heart with specific attention to murmurs, gallops, clicks, and rubs Palpation and auscultation of carotid, abdominal, and femoral arteries Evaluation of the abdomen for bowel sounds, masses, visceromegaly, and tenderness Palpation and inspection of lower extremities for edema and presence of arterial pulses Absence or presence of tendon xanthon:a and skin xanthelasma Follow-up examination related to orthopedic or other medical conditions that would limit exercise testing Tests of neurologic function, including reflexes and cognition (as indicated) Inspection of the skin, especially of the lower extremities in known diabetics

• • •

• • • • • • • •

1t:t~11

'For more detailed information see Bickley LS Bate's pocket guide to physical examination and history taking. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2003.

'-'-=--11

~JI

Identification and risk stratification of persons with CAD and those at high risk of developing CAD are facilitated by review of previous test results, such as 1 coronary angiography or exercise nuclear or echocardiography studies Additional testing may include ambulatory ECG (Holter) monitoring and pharmacologiC stress testing to further clarify the need for and extent of intervention, assess response to treatment such as medical therapies and revascularization procedures, or determine the need for additional assessment. As outlined in Box 3-3, other laboratory tests may be warranted based on the level of risk and clinical status of the patient. These laboratOlY tests may include, but are not limited to, serum chemistries, complete blood count, comprehensive lipoprotein profile, and pulmonary function.

42

SECTION II/ EXERCISE TESTING

CHAPTER 3/ PRE-EXERCISE EVALUAT.IONS

43

BLOOD PRESSURE
Measurement of resting blood pressure (BP) is an integral component of the preexercise test evaluation. Suhsequent decisions should be based on the avcragc of two or more properly measured, seated BP readings recorded during each of two or more office visits:] SpeCific techniques for measuring BP are critical to accuracy and detection of high BP and are presented in Box 3-4. In addition to high BP readings, unusually low readings also should be evaluated for clinical significance. The Seventh RepOlt of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of lligh Blood Pressure (INCi) provides guidelines for hypertension detection and management3 . Table 3-1 summarizes the J1\Ci recommendations for the classification and management of BP for adults. The relationship between 'BP and risk for cardiovascular events is continuous, consistent, and independent of other risk factors. For individuals 40 to 70 years of age, each increment of 20 min Hg in systolic BP or 10 IlJIIl Hg in diastolic BP

Apparently healthy (low risk) or individuals at increased risk, but without known disease (moderate risk)
• • Fasting serum total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. Fasting blood glucose, especially in individuals ~45 years old and younger individuals who are overweight (BMI ~25 kg'm- 2 ) and have one or more of the following risk factors for type 2 diabetes: a firstdegree relative with diabetes, member of a high-risk ethnic population (e.g., Black, Hispanic American, Native American, Asian American, and Pacific Islander), delivered a baby weighing >9 Ibs or history of gestational diabetes, hypertension (BP ~ 140/90 mm Hg in adults), HDL cholesterol of :540 mg·dL- 1 and/or triglyceride level ~ 150 mg'dL- 1 , previously identified impaired glucose tolerance or impaired fasting glucose (fasting glucose ~ 100 mg'dL- 1 ), habitual physical inactivity, polycystic ovary disease, and history of vascular disease Thyroid function, as a screening evaluation especially if dyslipidemia is present

I

:

'"

Patients with known or suspected cardiovascular disease (high risk)
• Preceding tests plus pertinent previous cardiovascular laboratory tests (e.g., resting 12-lead ECG, Holter monitoring, coronary angiography, radionuclide or echocardiography studies, previous exercise tests) Carotid ultrasound and other peripheral vascular studies Consider measures of homocysteine, Lp(a), high sensitivity C-reactive protein, fibrinogen, LDL particle size, HDL subspecies, and number (especially in young persons with a strong family history of CAD and in those persons without traditional coronary risk factors) Chest radiograph, if congestive heart failure is present or suspected Comprehensive blood chemistry panel and complete blood count as indicated by history and physical examination (see Table 3-3)

• •

• •

Patients with pulmonary disease
• • • Chest radiograph Pulmonary function tests (see Tables 3-4 and 3-5) Other specialized pulmonary studies (e.g., oximetry or blood gas analysis)

Although a detailed descliption of all the physical examination procedures listed in Box 3-2 and the recommended laboratOlY tests listed in Box 3-3 are beyond the scope of this text, additional information related to assessment of blood pressure, cholesterol and lipoproteins, other blood chemistries, and pulmoll<lIY fimction are provided in the follOwing section. For more detailed descriptions of these assessments, the reader is referred to the work of Bickle/.

1. Patients should be seated quietly for at least 5 minutes in a chair with back support (rather than on an examination table) with their feet on the floor and their arm supported at heart level. Patients should refrain from smoking cigarettes or ingesting caffeine during the 30 minutes preceding the measurement. 2. Measuring supine and standing values may be indicated under special circumstances. 3. Wrap cuff firmly around upper arm at heart level; align cuff with brachial artery. 4. The appropriate cuff size must be used to ensure accurate measure ment. The bladder within the cuff should encircle at least 80% of the upper arm. Many adults require a large adult cuff. 5. Place stethoscope bell below the antecubital space over the brachial artery. 6 Quickly inflate cuff pressure to 20 mm Hg above first Korotkoff sound. 7. Slowly release pressure at rate equal to 2 to 5 mm Hg per second; 8. Systolic BP is the point at which the first of two or more Korotkoff sounds is heard (phase 1) and diastolic BP is the point before the disappearance of Korotkoff sounds (phase 5). 9. At least two measurements should be made (minimum of 1 minute apart). 10. Provide to patients, verbally and in writing, their specific BP numbers and BP goals.
'Modified from National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) 2003 03-5233.

44

SECTION II/ EXERCISE TESTING

CHAPTER 3 / PRE-EXERCISE EVALUATIONS

45

TABLE 3-1. Classification and Management of Blood Pressure for Adults*t
Initial Drug Therapy BP Classification Normal Prehypertension SBP mm Hg DPB mm Lifestyle Modification Encourage Yes No antihypertensive drug indicated Antihypertensive drug(s) indicated Drug(s) for compelling indications.* Drug(s) for compelling indications.* Other antihypertensive drugs, as needed. Without Compelling Indication With Compelling Indications

LIPIDS AND LIPOPROTEINS
The Third Report of the Expcrt Panel on Dctcction, Enllualion, and Trcatment of Hieth Blood Cholestcrol in Adults (Adult Treatment Panel Ill, or ATP lJ I) outlin~s the ational Cholesterol Education Program's (1\CEP's) recommendations for cholesterol testing and management (Table 3-2)~. ATP III identifies low-density lipoprotcin (LDL) cholesterol as the primary target ~or cholesterollowering therapy. This designation is bascd on a widc v,ariety oj eVidence IIlcbcating that elevated LDL cholesterol is a powerful risk factor [or CAD and that, lowerin et of LDL cholesterol results in a striking reductIOn In the lllCldence of CAD. T~lblc :3-2 summarizes the ATP III classifications of LDL, total, and IlDLcholesterol and triglycerides. According to ATP Ill, a low IIDL cholesterol leycl is strongly and imerseh associated with the risk for CAD. Clinical trials prm'ide snggesti\'e e\idence that raising HDL cholesterol levels reduces the risk for CAD. Howe\'er, it remains uncertain whcther raisinet IlDL cholesterol le\'els per se, independent of other b I' changes in lipid ancl!or nonlipid risk factors, reduces the risk for CAD. In \'icwo this, ATP III does not identif)1 a specific HDL cholesterol goallcvel to reach \\~th therapy. Bather, nondrug and drug therapics that raisc HDL c~lOlestcrol that also are part of the management of other lipid and nonlipid risk factors are encouraeted by ATP Ill. b There is growing evidencc for a strong association betwecn ele\'ated triglyceride leyels and CAD Jisk. Recent studies sug.,2;est that 'some species of triglyceridc-

H~

<120 120-139

And <80 Or 80-89

Stage 1 Hypertension

140-159

Or 90-99

Yes

Stage 2 Hypertension

;",160

Or ;",100

Yes

Antihypertensive drug(s) indicated. Two-drug combination for most.§

-From National High Blood Pressure Education Program. The Seventh Report of the JOint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNO). 2003. 03-5233. tTreatment determined by highest BP category. *Compelling IndICations Include heart failure, post myocardial infarction, high coronary heart dISease fisk, diabetes, chronic kIdney disease, and recurrent stroke prevention. Treat patients With chronIC kidney disease or diabetes to BP goal of < 130/80 mm Hg. §Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.

TABLE 3-2. ATP III Classification of LOL, Total, and HOL Cholesterol (mg'dL- 1 )*
LDL Cholesterol

<100 100-129 130-159 160-189 ;",190
Total Cholesterol

Optimal Near optimal/above optimal Borderline high High Very high Desirable Borderline high High /)
Low

doubles the risk of cardiovascular disease across the entire BP range from llsns to lSS/11S mm Hg. According to J C7, persons with a systolic BP of 120 to 139 mm Hg or a diastolic BP of SO to S9 mm Hg should be considered as prehlJpertensive and require health-promoting lifestyle modifications to prevent cardiovascular disease. Lifestyle modification, including phYSical activity, weight reduction (if needed), a DASH eating plan (i.e., a diet rich in fruits, vegetables, and low-fat daily products with a reduced content of saturated and total fat) (see Box 9-3), dietary sodium reduction (no more than 100 mmol or 2.4 g sodium/day), and moderation of alcohol consumption, remains the cornerstone of antihypertensive therapy. However, J C7 emphasizes the fact that most patients \vith hypertension who require drug therapy in addition to lifestyle modification require two or more antihypertensive medications to achieve the goal BP (i.e., <140/90 mm Hg, or <130/S0 mm Hg for patients with diabetes or chronic kidney disease).

<200 200-239 2:240
HDL Cholesterol

(C,coJ

,

etv l rs -reid
High

<40 2:60
Triglycerides

<150 150-199 200-499 >500

Normal Borderline high High Very high

*From National Cholesterol Education Program. Third Report of the National Cholesterol

Education Program (NCEP) Expert Panel on Detecllon, EvaluallOn, and Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). 2002. NIH PublicallOn No. 02-5215.

1 0. and total cholesterol-to-HDL cholesterol ratio are designated by ATP III as emerging lipid risk factors.0-4. diabetes. small LDL particles.. physical inactivity. whereas age. high sensitivity C-reactive protein). The root causes of the metabolic syndrome are overweight and obesity.3-14 mg-dL. Abdominal obesity.5-4. small LDL cholesterol particles.5 9 -dl. and bilirubin as well as to renal (k'idney) fimction tests such as creatinine. Indication of volume depletion and potassium abnormalities can *Certain variables must be interpreted in relation to the normal range of the tFasting blood glucose . SpnometlY IS a · I.1 3. lipoprotein (a). and reduced HDL cholesterol). chronic cough. thrombogenic and hemostatic factors..0-8. To accomplish this.. ATP III places emphasis on the metabolic syndrome as a risk enhancer. Additional guidelines for the plimary and secondmy prevention of cardiovascular diseases recently have been updated by the Americm1 Hemt Association 6 . Because these remnant lipoproteins appear to have atherogenic potential similar to that of LDL cholesterol. serum glutamic-pyruvic transaminase.100 is considered Impaired fasting glucose. Homocysteine.g. Typical Ranges of Normal Values for Selected Blood Variables in Adults* Variable Men Neutral Women Hemoglobin (g. and an atherogenic diet as modifiable nonlipid risk factors. The guiding plinciple of ATP III is that the intensity of LDL-lowering therapy should be adjusted to the individual's absolute risk for CAD. 5 The ATP III treatment guidelines are summmized in the ACSM Resource Manual.0-5. cigarette smoking. The metabolic syndrome is charactelized by a constellation of metabolic risk factors in one individual. apolipoproteins B and A-I. SGPT..5-5. derived from a variety of sources.5 15.1 4-24 mg-dL. total (jJ. and proinflammatOly state generally are accepted as being charactelistic of the metabolic syndrome. Follow-up report on the diagnoSiS of diabetes mellitus. insulin resistance. aspmtate transaminase (AST). One should pay particular attention to liver function tests such as alanine transaminase (ALT).0-5.5 g-dl. nonHDL cholesterol is calculated by subtracting HDL cholesterol from the total cholesterol level.1 6.1 2.1 1. ATP III recommends that they be added to LDL cholesterol to become a secondary target of therapy for persons with elevated triglycerides.5-10.1 4. HDL subspecies. These tests should be applied judiciously and not used as finite ranges of normal_ PULMONARY FUNCTION Pulmonary function testing with routine spirometJy is recommended for all sllloktl1e age of 45 and in any person presentmg WIth dyspnea (shortness of ~~ · · 8 · _ . atherogenic dyslipidemia (i. or excesstve mucus production. Many of these medications act in the liver to lower blood cholesterol and in the kidneys to lower blood pressure. notably.5 mg·dL. ion Phosphorus Protein. wheezing. male gender.5 11. AST. Abbreviations: SGOT.0 g-dl. inflammatory markers (e.5 40-52 4. BLOOD PROFILE ANALYSES Multiple analyses blood profiles are evaluated commonly in clinical exercise programs. breath). overweight and obesity.1 7-27 2.7 TABLE 3-3. Since publication of ATP III. b.8 135-150 mEq-dL.g-dL-1) Liver Function Tests Bilirubin (SGOT) (AST) (SGPT) (ALT) 13. blood urea nitrogen (BUN).0-8.26:3160-3167. Table 3-3 gives normal ranges for selected blood chemistries.1 98-110 mEq-dl.5 mEq-dl. elevated blood pressure.46 SECTION II/EXERCISE TESTING CHAPTER 3/ PRE-EXERCISE EVALUATIONS 47 rich lipoproteins.6 4-11 (x10 9/L) 150--450 (xl 09/L) 60-99 mg·dL.5-6.2 mg -dL.9-5. prothrombotic state. Such profiles may proVide useful information about an individual's overall health status and ability to exercise and may help to explain certain ECG abnormalities.1) Sodium Potassium Chloride Osmolality Calcium Calcium. an LDL goal of <70 mgidL appears to be appropriate for those in a categOlY of "velY high" lisk. physical inactivity. Reference 13: Expert ComiTlittee on the Diagnosis and Classification of Diabetes Mellitus. serum glutamic-oxaloacetic transaminase. Because of varied methods of assaying blood samples. Diabetes Care 2003. alanine transaminase (formerly SGPT). cholesterol-enriched remnant lipoproteins. ATP III designates hypertension.1 2.5 mg-dl" 8--46 wL-1 7--46 wL-1 ISSUing 4.dL -1) Hematocrit (%) Red cell count (Xl0 12/L) Mean cell hemoglobin concentration (MCHC) White blood cell count Platelet count Fasting glucoset Blood urea nitrogen (BUN) Creatinine BUN/creatinine ratio Uric acid (mg'dL. and family histOlY of premature CAD are nonmodifiable non lipid risk bctors for CAD. and genetic factors.5-17. Sl'mple and noninvasive test that can be performed easIly. elevated tliglycerides.1 3.3-7.9 35-180 7-34 wl-1 4-35 wl-1 laboratory. major clinical trials have been published that question the treatment thresholds for LDL.e.. aspartate transaminase (formerly SGOT). and impaired fasting glucose are designated by ATP III as emerging nonlipid risk factors. some caution is advised when comparing blood chemistries from different laboratories.0-22 40-190 <1. medications for dyslipidemia and hypertension are common. and BUN/creatinine ratio in patients on such medications. promote atherosclerosis and predispose to CAD.1 278-302 mOsm/kg 8. ALT. For many patients "vith CAD. When re Ia t lVe) . In pmticular.5 36-48 3. lipoprotein remnants. Triglycerides. Because the metabolic syndrome has emerged as an important contributor to CAD. seen in the sodium and potassium measurements. total Albumin Globulin A1G ratio Iron.5 mg·dL.

Lximal voluntal)' ventilation (MVV) also should be obtained during routine spirometric testing. 16: From Pauwels RA. et al. 30% to 49% of predicted FEV. would be most beneficial../FVC 2:70% With chronic symptoms: cough. enough information must be present in the informed consent process to ensure that the participant knows and understands the pUllJoses and risks associated with the test or exercise program. and mortality.g. This spirometric classification ~f lung disease has pro\'ed useful in preJicting health status. it should be emphasized that contraindications might not apply in certain specific clinical situations. the determination of the m. conditions exist that preclude reliable diagnostic ECG information from exercise testing (e. 2:80% of predicted FEV. Emergency departments are increasingly performing an exercise test on lowlisk patients who present with chest pain (i. Schema for Determining the Severity of Both Obstructive and Restrictive Lung Diseases from Pulmonary Function Tests* Severity of Obstructive Disease: This interpretation is based on the assessment of both the FEV" expressed as a percent of predicted. left bundle-branch block. dysrhythmias. Finally.. Table 3-5 is a quick reference source for serum concentrations of enzymes commonly used as indices of myocardial damage or necrosis. sputum production.d review of prior medical histOty. revascularization proceJure. additional evaluative techniques such as echocardiography or nuclear imaging can be added to the exercise test to improve sensitivity. In patients where spirometry indicates a restrictive pattern. specificity. Stage Characteristics 0: At risk I: Mild II: Moderate III: Severe FEV.e" within 4 to 8 hours) to rule out myocardial infarction ll . the forced e:-. Calverley PM. Aaron SD. TABLE 3-4. such as smoking cessation./FVC ratio./FVC <70% With or without chronic symptoms FEV.. or benefit of.~II! Severity of Restrictive Disease: This interpretation is based on the assessment of the FVC. 144'1202-1218. 30% to 79% of predicted IIA: FEV. the measurement of total lung capacity is needed to confirm a restrictive defect.). digitalis therapy). di'ug therapy. as described earlier in this chapter. <30% of predicted FEV. use of health care resources.1631256-1276.115:869-873 . heali attack and stroke and can be used to identifY patients in which interventions.piratory volume in 1 'seconJ (FEV. In these conditions. In addition to the preceding tests. Cardinal P How accurate IS spirometry at predicting restrictive pulmonary Impairment> Chest 1999. abnormal pnlmonarv hllldion test results can be indicatin' of an increascJ fisk for lung cancer. Generally. Je\'c1opment of exacerbations. and prevention of chroniC obstructive pulmonary disease NHLBIIVVHO Global InitIative for ChroniC Obstructive Lung Disease (GOLD) Workshop summary. exercise testing in this setting should be performed only as part of a carefully constructed patient management protocol and only after patients have been screened for high-risk features or other indicators for hospital admission. helps identify potential contraindications and increase the safety of the exercise test. IIm\'e\'er. standards for the performance of these tests should be followed 9 Although many spirometric tests are <1\'ailable. lung function testing: selection of reference values and interpretative strategies. and the FEV. 2:80% of predicted FEV. the most common\\.1 illustrates how these tests can be useJ to determine the se\'erity of'both obstructi\'e and restrictive lung diseases..related to s\'mptoms anJ should not be intell1reted in isolation. The exercise test may still provide useful information on exercise capacity.12.. 50% to 79% of predicted liB: FEV.48 SECTION III EXERCISE TESTING CHAPTER 31 PRE-EXERCISE EVALUATIONS 49 performing pulmonary function testing. Stage Characteristics Mild Moderate Moderately severe Severe Very severe FVC FVC FVC FVC FVC less than the lower limit of normal but 2: 70% of predicted 60% to 69% of predicted 50% to 59% of predicted 34% to 49% of predicted <34% of predicted Informed Consent Obtaining adequate informed consent hom paliicipants before exercise testing and participation in an exercise program is an important ethical and legal consideration. BUist AS. Patients with absolute contraindications should not perform exercise tests until such conditions are stabilized or adequately treated. Performing the preexercise test evaluation and the carefi.. expressed as a percent of predicted. or bypass surgelY or to determine the need for. Dales RE.identification of patients at risk for the de\'elopment of both restricti\'e and 'obstrudi\'e pulmonary disease before s~'mptoms developing. For these patients it is important to carefully assess risk versus benefit when deciding whether the exercise test should be performed./FVC <70% . it should be emphasized that pulmonary function test results prm'ide information that is close\\. Although the content and extent of consent forms may vary. and hemodynamic responses to exercise. Global strategy for the diagnOSIs. The consent form should be verbally explained and include a statement indicating that the patient has been given an oppoliunity to ask questions about the 'References 14. management. and the FEV. Am Rev Respl( DIS 1991. Box 3-5 outlines both absolute and relative contraindications to exercise testing". these patients include those who are no longer symptomatic and who have unremarkable ECGs and no change in serial cardiac enzymes. Amencan ThoracIC SOCIety. AJJitional\\-. Results from this test often can be used to help evaluate ventilatory responses obtained dUling graded exercise testing lO Contraindications to Exercise Testing For certain individuals the risks of exercise testing outweigh the potential benefits...used include the forced \ital capacity (FVC). and diagnostic capabilities. Patients with relative contraindications may be tested only after careful evaluation of the risklbenefit ratio. Table 3-. 15./F\'C ratio. dyspnea FEV./FVC <70% With or without chronic symptoms FEV. However. Results from these tests can be used in the ear\\. Additionally. Am J Resplr Cnt Care Med 2001. However. such as soon after acute myocardial infarction.

\Vlitten emergency policies and procedures should be in place.org/clinical/guidelineslexercise/dirlndex.. written instruction~ along \vith a descril. ACC/AHA 2002 gUidelme update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). facility legal counsel) to determine what is appropJiate for an acceptable informcd consent process... mononucleosis.e. If the palticipant is a minor. www. No sample form should be adopted for a specific program unless approved by local legal counsel. Also.L Males 25-90 U·L. American College of Cardiology web site.htm tRelative contraindications can be superseded if benefits outweigh risks of exercise.{. Absolute • TABLE 3-5. recent myocardial infarction (within 2 days). or rheumatoid disorders that are exacerbated by exercise High-degree atrioventricular block Ventricular aneurysm Uncontrolled metabolic disease (e. a legal guardian or parent must sign the consent form. Balady GJ. hypomagnesemia) Severe arterial hypertension (i. hepatitis.mL 1 Appears at 4-6 hours. returns to normal within 72 hours Appears within hours and peaks at about 24 hours without reperfusion. 2002.g. PARTICIPANT INSTRUCTIONS Explicit instructions for patticipants bcfore exercise testing increase test \'alidity and data accuracy. medical histOty. et al.:s Enzyme Normal Value' Time Course of Change (When Abnormally Elevated) A recent significant change in the resting ECG suggesting significant ischemia. the program must ensure that available personnel are appropriately trained and authorized to carry out emergency procedures that use such equipment.5 ng. The SGOT and LDH enzymes are no longer used as "cardiac enzymes" and have been replaced by the others. See Appendix B for more information on emergency management. diabetes. hypokalemia. A copy of the Policy on Human Subjects for Research is periodically published in ACSM's journal. hospital tisk management.g. vVhen the exercise test is for purposes other than diagnosis or prescription (i. It is advisable to check \vith autliOlitative bodies (e. procedure and has sufficient information to give informed consent. especially if they are asymptomatic at rest. peaks at 12-24 hours. test results) as described in the Health Insurance POttahilit)' and Accountability Act (HIPPA) of 1996. Because most consent forms include a statement that emergency procedures and equipment are available.g. this should be indicated duting the consent process and reflected on the Informed Comelli Form. institutional review boards. Bricker J. or swollen lymph glands CK myocardial band (CK-MB) Creatine phosphokinase (CPK or CK) <5% of total CK • • • • • • • • Females 10-70 U. The consent form must indicate that the patticipant is free to \\~thdraw from the procedure at any hme. all reasonable effOlts must be made to protect the plivacy of the patient's health information (e. accompanied by fever.1 1 Troponin I <0..acc. returns to normal within 2-4 days Appears about 4-6 hours. Note specific questions from the p<Uticipant on the form along with thc responses provided.g. AIDS) Mental or physical impairment leading to inability to exercise adequately 'Modified from Gibbons RJ. body aches. Relativet • • • • • • • • • • • • Left main coronary stenosis Moderate stenotic valvular heart disease Electrolyte abnormalities (e. Medicine and Science in Sports alld Exercise. for expetimental purposes).. and applicable policies for the testing of human subjects must be implemcnted.g. In some instances. peaks at 24 hours.tlon of the evaluation should be provided well in advance of the appointment so . thyrotoxicosis. or myxedema) Chronic infectious disease (e. or other acute cardiac event Unstable angina Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Suspected or known dissecting aneurysm Acute systemic infection. these individuals can be exercised with caution and/or using low-level end points. \Vhenever possible. A sample consent form for exercise testing is provided in Figure 3-1. musculoskeletal. Serum Enzymes (Myocardial Tissue Damage or Necrosis) Contraindications to Exercise Testing* .50 SECTION II/ EXERCISE TESTING CHAPTER 3/ PRE-EXERCISE EVALUATIONS 51 : .e... systolic BP of >200 mm Hg and/or a diastolic BP of > 11 0 mm Hg) at rest Tachydysrhythmia or bradydysrhythmia Hypertrophic cardiomyopathy and other forms of outflow tract obstruction Neuromuscular. remains elevated 5-10 days 'Normal values vary depending on the laboratory and the method used. and emergency dlills should be practiced at least once every 3 months or more often when there is a change in staff.

\Ve may stop the test at any time because of signs of fatigue or changes in your heali rate. hut only \\~th physician approval. ~ly permission to perfon. and/or arms) with physical effort may affect the safety of your exercise test.·oluntarily. . and I understand the test procedures that I will perform and the attendant Jisks and discomfolis. • Clothing should permit freedom of movement and include walking or running shoes. the information obtained may be used for statistical analysis or scientific purposes with your right to pJivacy retained.or high-dose l3-b1ocking agents may be asked to taper their medication over a 2. please ask us for further explanations. However. to the testing staff. • PaJiicipants should be rested for the assessment. or symptoms you may expeJience. Patients taking intermediate. Emergency equipment and trained personnel are available to deal with unusual situations that may arise. It is impOliant for you to realize that you may stop when you wish because of feelings of fatigue or any other discomfOli.52 SECTION II/EXERCISE TESTING CHAPTER 3/ PRE-EXERCISE EVALUATIONS 53 FIGURE 3-1. irregular. ECG. shortness of breath with low-level activity. It is not to be released or revealed to any person except your referring physician without your written consent. or death.to 4-day period to minimize hypcradrenergic withdrawal responses. heaviness in the chest. those taken today. You are also expected to report all medications (including nonprescription) taken recently and. and having had an 0ppOJiunit)' to ask questions that have been answered to mI' satisfaction. • . Responsibilities of the Participant Information you possess about your health status or previous experiences of heart-related symptoms (e. You are responsible for fully disclosing your medical histOlY. I consent to paJiicipate in this test. Use of Medical Records The information that is obtained duJing exercise testing will be treated as privileged and confidential as described in the Health Insurance Portability and Accountability Act of 1996. in evaluating the effect of your medications or in evaluating what type of physical activities you might do \vith low risk. pain. 5. neck. I understand that I am free to stop the test at any point if I so desire. specific instructlOns vaJ)' IV1th test type and PU'l)Osc. The exercise intensity will begin at a low level and will be advanced in stages depending on your fitness level. Sample of informed consent form for a symptom-limited exercise test. Every effOli will be made to minimize these risks by evaluation of preliminalY information relating to your health and fitness and by careful observations during testing. I have read this form. 3. avoiding significant exertion or exercise on the day of the assessment.l this exercise test is gil'en . heart attack. as well as symptoms that may occur during the test. Date Signature of Patient Date Signature of \Vitncss Datc Signature of Physician or Authorized Delegate the clien~ or patient can prepare adequately. tightness. Purpose and Explanation of the Test You will perform an exercise test on a cycle ergometer or a motor-dliven treadmill.. or caffeine or using tobacco products within 3 hours of testing. These include abnormal blood pressure. Thc followi'lg points should be conSidered for inclusion in such pre!iminaJ)' instructions. If you have any concerns or questions. it may be helpful for patients to discontinue prescribed cardiovascular medications. p<uiicipants should be made aware that the evaluation may be fatigUing and that they may wish to have someone accompany them to the assessment to drive home afterward. shOJi-sleeved blouse that buttons down the front and should avoid restrictive undergarments. 7. Inquiries Any questions about the procedures used in the exercise test or the results of your test are encouraged. Freedom of Consent I hereby consent to voluntarily engage in an exercise test to detcrminc 1111' exercise capacity and state of cardiovascular health. • If the test is for diagnostic purposes. . Benefits to Be Expected The results obtained from the exercise test may assist in the diagnosis of your illness. Knowing these Jisks and discomforts. continued Informed Consent for an Exercise Test 1. 6. 2. patients sT/lJIIld continue their medication regimen on their usual schedu Ie so that the exercise responses lvill be consistent \vith responses expected during exercise training. pressure. or blood pressure. • If the test is for functional purposes. • If the evaluation is on an outpatient basis. Attendant Risks and Discomforts There exists the possibility of celiain changes occurring during the test. in particular. back. 4. Your prompt reporting of these and any other unusual feelings with effort during the exercise test itself is velY important. however. Currcntly prescribed antianginal agents alter the hemodynamic response to exercise and Significantly reduce the sensitivity of ECG changes for ischemia. alcohol. jaw. FIGURE 3-1. fainting. stroke. and in rare instances. Women should bling a loose-fitting. Participants should refrain from ingesting food. fast or slow heali rhythm.g.

Smith SC Jr. Blair SN. and Treatment of High Blood Pressure ONC7). therefore. National Cholesterol Education Program. 02-5215. Braunwald E. orgiclinicaVguidelines/exercise/dirIndex. J Am Coli Cardiol 1996. I . to the assessment and should report the last actual dose taken. Pearson TA. American Thoracic Society and American College of Chest Physicians. A statement for healthcare professionals from the American Heart Association and the American College of Cardiology. http://www. American Thoracic Society. 1995. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segrnent elevation myocardial infarction: a report of the American College of Carlliology/American Heart Association task force on practice guidelines. September 14-15.- CHAPTER As evidence continues to evolve regarding the health benefits of phYSical activity and exercise. A fundamental goal of primaly and secondalY interv~ntion programs is promotion of health. Level 2 recommends an additional Pre-Palticipation Assessment that precedes the development of an exercise prescription. 27th Bethesda Conference: Matching the intensity of risk factor management with the hazard for coronmy disease events.J.144:1202-1218. Office spirometry for lung health assessment in adults: a consensus statement from the National Lung Health Education Program. Beasley J"V. et al. those associated with phYSical inactivity)l Both healthrelated and phYSiologiC fitness measures are closely allied with disease prevention and health promotion and can be modified through reguJar phYSical activity and exercise. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines.115:869-873. 14. ACC/AHA 2002 guideline update for exercise testing: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exercise Testing). Aaron SD. Antman EM. and Treatment of High Blood Cholesterol in Adults (Adult Treatment PanellII). Calverley PM. 6. Bate's pocket guide to phYSical examination and histOly taking. Grundy SM. are characterized by an ability to perform daily activities with vigor. 4th ed.104:1577-1579. Lung function testing: selection of reference values and inteqJretative strategies. Buist AS. Pauwels HA. 11.~v. 1994 Update. Bricker J. Am Hev Hespir Dis 1991. participants may wish to bring their medications with them for the exercise testing staff to record. The Seventh Report of the JOint National Committee on Prevention. 5. Fuster v. Am J Hespir Crit Care Med 2003. Follow-up report on the diagnosis of diabetes mellitus.54 SECTION III EXERCISE TESTING • Participants should bring a list of their medications. and demonstrate the traits and capacities associated with low risk of premature development of the hypokinetic diseases (e. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus panel guide to comprehensive risk reduction for adult patients \vithout coronary or other atherosclerotic vascular diseases. Bonow BO.163: 1256-]276. This chapter provides gUidelines for the Level 2 Pre-Participation Assessment through the measurement and evaluation of health-related phYSical fitness in presumably healthy adults. Evaluation. 2003. Am J Hespir Crit Care Med 2001. The purposes of health-related fitness testing in such programs include the follOwing: • • • • • Educating participants about their present health-related fitness status relative to health-related standards and age. Chest 2000. Cleeman JI. htm 12. 8. 03-5233. and prevention of chronic obstructive pulmonary disease. American College of Cardiology web site. Circulation 2002..152:!l07-!l36. the focus on health-related phYSical fitness. How accurate is spirometry at predicting restrictive pulmonary impairment? Chest 1999. Pearson TA. 2002. 4.106:388--391. 10. Am J Bespir Crit Care Med 1995. Purposes of Health-Related Fitness Testing Measurement of phYSical fitness is a common and appropJiate practice in preventive and rehabilitative exercise programs. management.acc. Blair SN. 15. 2002. Diabetes Care 2003. such programs should focus on enhancement of health-related and phYSiologiC components of phYSical fitness.44:720-732. et al. 3. Standardization of spirometry. \\~.pdf. et al. Ferguson GT. and physiologic fitness appear to supersede that of skill-related phYSical fitness. Cardinal P. 13. National High Blood Pressure Education Program. 2. American Thoracic Society. et al. including dosage and frequency of administration. et . Buist AS. Detection. 16. Global strategy for the diagnosis.orgiclinicaVguidelines/unstable/unstable. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection. Circulation 2001. J Am Coli Cardiol 2004.26:3160-3167. 2002. Health-Related Physical Fitness Testing and Interpretation 4 •• .and sex-matched norms Providing data that are helpful in development of exercise prescriptions to address all fitness components Collecting baseline and follow-up data that allow evaluation of progress by exercise program participants Motivating palticipants by establishing reasonable and attainable fitness goals StratifYing cardiovascular lisk 55 . Enright PL. Noel Bairey Merz C et al. As an alternative.2 See Chapter 1 for a detailed descliption of the aforementioned terms. Evaluation. ATS/ACCP Statement on cardiopulmonary exercise testing.l!7: l!46-1161.27: 957-1047. The health-related components of phYSical fitness have a strong relationship "vith good health. 2003. 7. Balady GJ. Dales HE. Daniels SR. NIH Publication No. Philadelphia: Lippincott Williams & Wilkins.g. AHA/ACC Scientillc Statement: AHA/ACC guidelines for preventing heart attack and death in patients \vith atherosclerotic cardiovascular disease: 2001 update. • Drink ample fluids over the 24-hour peliod preceding the test to ensure normal hydration before testing. et al.acc. BiclJey LS.167(2):2!l-277. As palt of the ACSM Pre-Participation Screening (Table 2-1). REFERENCES 1. Gibbons HJ. 9. NHLBI/\VHO Global Initiative (or Chronic Obstructive Lung Disease (GOLD) Workshop summary. Expert Committee on the Diagnosis and Classillcation of Diabetes Mellitus. American Heart Association Science Advisory and Coordinating Committee.

assessment of body composition should be emphaSized throughout the life span. height. • Pro\ide informed consent form (see Fig. test environment should be quiet and private. Testing procedures should not be rushed. Different assessment techniques are briefly reviewed in this section. metronome. bladder distention. ' 'Vhen multiple tests are to be administered. Body composition can be estimated with both laboratory and field techniques that vmy in terms of complexity. Although there is almost no difference in obesity levels of males based on race and ethnicity. dehydration rcsulting [rom CR endurance tests might influence body composition values if measured by bioelectJical impedance analysis (BIA). muscular fitness. • Calibrate all equipment a minimum of once each month to ensure accuracy (e. treadmill.. 15%. room tempera- . These seemingly minor tasks are accomplished easily and are important in achieving valid and reliable test results. Although skinfold measurements are more difficult than other anthropometJic procedures. All pretest instructions should be provided and adhered to plior to anival at the testing facility. The test should \ield results that are indicative of the current 'state of fitness. however. and accuracy. routinely practiced in the techniques. palticularly when tests using HR to predict aerobic fitness are used. emotional problems. Likewisc. and ''''hite women approXimately 30%4 Consequently. tables. is used by the health and fitness professional to help an indi\idual achieve specific fitness goals. and easv to administer. cost. These instructions may be modified to meet your needs. More detailed descliptions of each technique are available in Chapter 12 of the ACSM Resource Manllal~ for Guidelines for Exercise Testing and Prescription. ANTHROPOMETRIC METHODS Measurements of height. Experience can be accrued under the direct supelvision of a highly qualifled mentor in a controlled testi ng environment. score sheets. the test procedures should be explained adequately. circumferences. cycle ergometcr.3%. relati\'ely inexpensive. weight. blood pressure.9%. PRETEST INSTRUCTIONS ture and ventilation should be controlled as much as pOSSible. respectively. When all fitness components are assessed in a Single session. they provide a better estimate of body fatness than those based only on height. 23. and elsewhere. and flexibility. sphygmomanometer. the detail associated with obtaining measurements and calculating estimates of body fat for all of these techniques is beyond the scope of this text. Celtain steps should be takcn to ensure client safety and comfOlt before administeling a health-related fitness test.g. and circumferences. reflect changc frol. nesting measurements such as heart rate. the incidence of obesity of Black women is 50%. The demeanor of personnel should be one of relaxed confidence to put the subject at ease. Testing cn endurance after assessing muscular fltncss (which elevates healt rate) can produce inaccurate results about an individual's cn endurance status. The room should be eqUlpped WIth a comfortable seat and/or examination table to be used for resting blood pressure and heart rate and/or electrocardiographic (ECG) recordings. To minimize anxi~ty. A minimal recommendation is that individuals complete a questionnairc such as the ACSM-AHA form (see Fig. stroke. Basic body composition can be expressed as the relative percentage of body mass that is fat and fat-free tissue using a two-compaltment model. 2-1). graphs. 14. An ideal hcalth-related physical fitness test is reliable. resting measurements should be followed (in order) by tests of cardiorespiratOly (Cn) endurance.'-9 Before collecting data for body composition assessment. Mexican-Amelican women 40%. A listing of prelimimuy instl1Jctions for all clients can be found in Chapter 3 under Patient Instructions. and 30. and the. and be directly comparable to normativc data. and already have demonstrated reliability in his or her measurements. 1976 to 1980. 1971 to 1974. weight. depending on what physical fitness components are to be evaluated. and 1999 to 2000 the incidence of obeSity in the United States was 13. 3-1). 10 TEST ENVIRONMENT The test environment is important for test validity and reliability.4%. Test anxiety. type 2 diabetes. who displayed an increase from approXimately 4% in 1970 to 15% in 2000 5 . • Maintain room temperature of 68°F to 72°F (20°C-22°C) and humiditv of less than 60%. the technician must be trained. 1988 to 1994. weight. and body composition should be obtained first. 3 Approximately 65% of Americans are classified ovelweight (body mass index [BMI] >25) and almost 31 % classified as obese (BMI >30)4 In 1960 to 1962.56 SECTION II/EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 57 Basic Principles and Guidelines The information obtained from health-related physical fltncss testing. and skinfolds are used to estimate body compOSition. and other testing documents are organized and available for the test's administration. Body Composition It is well established that excess body fat is associated with hypertension. 5th ed. the organization of the testing session can be velY important. in combination with the individual's health and medical information. and all procedures must be explained clearly prior to initiating the process. food in the stomach.5%. and hyperlipidemia.l physical activih" or exercise intervention. skinfold calipers) • Organize equipment so that tests can follow in sequence without taxing the same muscle group repeatedly. TEST ORDER The follOWing should bc accomplished before thc p<uticipant anives at the test site: • Assure all forms. The twofold increase in adult obesity since 1980 coincides with an alarming trend in the incidence of ovelweight children in the United States. independent of the technique being used.6 This almost fourfold increase in 20 years shows no signs of abatement. coronalY healt disease. \'alid.

70-. . . IU. is used to assess weight relath'e to height and is calculated by w\iding body weight in kilograms b\· hCight in meters squared (kg'm-2). and cardiovascular disease. Heymsfleld 58.\ .12 A 13MI of less than 18. to risk (see Table 4e cll I'Olll'C dl'sease . Classification of Disease Risk Based on Body Mass Index (BMI) and Waist Circumference* Disease Riskt Relative to Normal Weight and Waist Circumference Men. the \VI-! H values are greater than 1. a new risk stratification scheme [or adults based on waist circumference has been proposed (Table 4-3). A cloth tape measure \\~th a spring-loaded handle (Gulick) reduces skin compression and improves consistency of measurement. 16. an increasedlisk of hypeliension.5 kg'm.58 SECTION II/EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 59 Body Mass Index The EMl. hypertension. and standards for risk vmy with age and sex.mate IS :!:S% for predICting percent body fat from 8MI (based on a four-compartment estimate of body fat percentage) Circumferences The pattem of body f~\t distribution is recognized as an impoliant predictor of the health risks of obeSity.2 for obesity Although.. conjunctIon .. The waist-to-hip ratio (\\'HR) is the circumference of the waist divided by the circumference of the hips (see Box 4-1. The use of specific 13M] \'alues to predict percentage body fat and health lisk is in the initial stages of cle\'e]opment (Table 4_2). WIt . t)1)e 2 diabetes.90 fOl women for the same risk classi fication.2 Cfable 4_]).9 25." Furthermore. For most people. or Quetelet index. Heo M. and premature death compared \\~th indi\'iduals who demonstrate g)110id obeSity (fat distlibuted in the hip and thigh). et al Healthy percentage body fat ranges: an . Increased waist CIrcumference can also be a marker for Increased risk even in persons of normal weight. coronary <\liery disease. Duplicate measUl ements are recommended at each site and should be obtained in a rotatlOnal IIlstead of a consecutin' order. I1 13Ml t 0 cv.1:3 Because of tbe relatively large standard error of estimating percent bt from BMI (::!::. BMI hlils to distinguish between body Elt. approach for developing gUidelines based on body mass index Am J Clin Nutr 2000.9 The tDisease risk for Type 2 diabetes. I 1Android obeSity which is charactelized by more f~\t on the trunk (abdominal f~lt).6-24.9 25. coronalY disease. *See Reference 11: Modified from Expert Panel.0 to 29. :588 em Men. muscle mass. Predicted Body Fat Percentage based on Body Mass Index (BMI) for African-American and White Adults*t BMI (kg'm ') Health Risk 20-39 yr Males 40-59 yr 60-79 yr <18.90) \\~th body composition determined by hydrodenSiometly.15 Gilih measurements may be used to predict body composition and equations are available for both genders and a range of age groups. Evaluation and Treatment of Overweight and Obesity in Adults prOVided a classification of disease risk based on both EMI and waist circumference as shown in Table 4-1.86.0 kg'm. >88 em Underweight Normal Overweight Obesity.9.10 other methods ofbocl)' composition assessment should he IIsed to predict hod\' fatness during a fitness assessment.2 also increases the lisk of cardiovascular disease and is responsible for the lower portion of the .6-24. and Treatment of Oven. Ewluation. but preferably both.5 nUll.17 The accuracv may he \\'ithin 2. and mOliality rate are associated with a 13MI greater thall :30 kg'm. and treatment of overweight and obeSity adults Arch Intern Med 1998.2 for overweight and a BMI of greater than or equal to 30. ExecutIVe summary of the clinical guidelines on the IdentIfication. and the Expert Panel on the Identification.veight and Obesity in Adults II lists a 13M! of 2. or bone. For people 60 to 69 years old.5 18. Adapted With permission by the American Journal of Chnlcal Nutrition. evalualion.5 185-249 250-299 300-349 350-39. The average of the two measures is used pro\~ded each measure is \\~thin . dyslipidemia.\ . TABLE 4-2. For example. aIone 1).5 and for young women when WHR is more th~\Jl 0. higll for young men when \'VHH is more than 0.9 kg'm. total cholesterolJlIDL cholesterol ratio.I-shaped curve of EM] \'ersus cardiovascular risk. obesity-related health problems increase beyond a EMI of 2. © Am J Clin Nutr Amencan SOCiety for (lln1(al Nutrition.s·lo The waist circumference can be used alone as an indicator of health risk because abdominal obesit\' is the issue.9 >30 Elevated Average Elevated High Elevated Average Elevated High <8% 8%-19% 20%-24% ~25% <11% 11%-21% 22%-27% ~28% <13% 13%-24% 25%-29% ~30% Females <21% 2'1 %-32% 33%-38% ~39% <23% 23%-33% 34%-39% ~40% <24% 24%-35% 36%-41 % ~42% 'See reference 13: From Gallagher D. Dashes (_) Indicate that no addItional risk at these levels of 8MI was assigned.694-701.5.5% bt). 158: 1855-1867 Skinfold Measurements Eody composition determined from skin[old measuremcnts correlates well (r = ..~3 for men and greater than 0. health risk is veri. for risk stratification.'9 This can be used · or In .9 ~40 Increased High Very high Extremely high In High Very high Very high Extremely high II III precise. >102 em Women.5 18. Box 4-1 contains a description of the common sites. prO\~des an increased lisk of h)pe'iension. tNote: Standard error of est. All assessm~nts should include a minimllll1 of either waist circumference or EMI. class I <18. buttocks and hip measure)and has been used as a simple method for determining body fat distribution 18 I-Ie<~th risk increases with WHH.0-29. :5102 em Women. The Expert Panel on the Identification.0-299 >30 <18.72.5.5% to 4% of the actual body COmposition if the subject possesses similar eharactelistics of the origimJ validation population and the gilih measurements are TABLE 4-1.

use video media that demonstrate proper technique. © Am J Clin Nutr American Society for Clinical Nutrition. feet together. The exact proportion of subcutaneous-to-totaJ fat varies with sex. regression equations used to convert sum of skinfolds to percent body fat must consider these variables for greatest accuracy. and ethnicity. C\bo lie With the subject standing and one foot on a bench so the knee is flexed at 90 degrees. usually at the level of the umbilicus With the subject standing erect and arms hanging freely at the sides with hands facing the thigh. Rotate through measuremenfsites or allow time for skin to regain normal texture. Don't throw the baby out with the bath water. a horizontal measure taken at the level of the maximum circumference between the knee and the ankle. Arm: Buttocks/Hips: Calf: Modified from Callaway CW. a horizontal measure midway between the acromion and olecranon processes. a measure is taken midway between the inguinal crease and the proximal border of the patella.1.60 SECTION II / EXERCISE TESTING CHAPTER 4 / HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 61 I I ~ Box 4. continued Procedures Abdomen: With the subject standing upright and relaxed. The tape should be placed on the skin surface without compressing the subcutaneous adipose tissue If a Gulick spring loaded handle is used. current formulae are not predicated on the NOTF suggested site. IL: Human Kinetics.0) > 11 0 (>43.. a horizontal measure is taken at the maximal circumference of buttocks. perpendicular to the long axis. With the subject standing erect and feet together. It is assumed that close to one-third of the total fat is located subcutaneously. arms at the sides. Refer to the ACSM Resource Manual. 1988. a horizontal measure is taken at the narrowest part of the torso (above the umbilicus and below the xiphoid process) The National Obesity Task Force (NOTF) suggests obtaining a horizontal measure directly above the iliac crest as a method to enhance standardization. an extremely obese or TABLE 4-3.5-350) 90-109 (355-43. just ~the gluteal fold. a horizontal measure taken at the greatest anterior extension of the abdomen. and accrue experience in a supervised practical environment.2o Therefore. age. Take duplicate measures at each site and retest if duplicate measurements are not within 5 mm. Forearm: HipSlThigh Mid-Thigh Waist: plinciple behind this technique is that the amount of subcutaneous fat is proportional to the total amount of body fat. et al. a measure perpendicular to the long axis at the maximal circumference. Anthropometric Standardization Reference Manual. Martorell R. a horizontal measure is taken at the maximal circumference of the hip/proximal thigh.5 in) 80-99 (315-390) 100-120 (395-470) >120 (470) 'See reference 19: From Bray GA. and abdomen relaxed. the handle should be extended to the same marking with each trial. Unfortunately. Champaign. Adapted with permission by the American Journal of Clinical Nutrition. Box 4-2 presents a standardized descliption of skinfold sites and procedures. This measure is used for the hip measure in a waisVhip measure. arms hanging downward but slightly away from the trunk and palms facing anteriorly. Circumferences: 39-80 In Lohman TG. New Criteria for Waist Circumference in Adults* Waist Circumference cm (in) Risk Category Females Males Very low Low High Very High <70 cm «285 in) 70-89 (28.5) <80 em (31. eds. for photographs of the skinfold sites. perpendicular to the long axis With the subject standing. With the subject standing. With the subject standing erect (feet apart ~20 cm). participate in workshops.5th ed. To improve the accuracy of the measurement. Am J Clin Nutr 2004. it is recommended that one train with a skiJJed technician. Roche AF. . .70(3):347-349. The accuracy of predicting percent fat from skinfoJds is approximately pJus or minus 3. With the subject standing. ~ • • • • • All measurements should be made with a flexible yet inelastic tape measure. legs slightly apart (~1 0 cm).5% assuming that appropriate techniques and equations have been used s Factors that may contlibute to measurement error vvithin skinf6Jd assessment include poor technique andlor an inexperienced evaluator.

62

SECTION II / EXERCISE TESTING

-rt rCMA 1e
SKINFOlD SITE
Abdominal Triceps

~~...;;..;...:...-.._-----_.I I

(Ylc( \e

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION

63

I

I

Vertical fold; 2 cm to the right side of the umbilicus Vertical fold; on the posterior midline of the upper arm,

~way between the acmrnioLLar.:u;Lole.aanon process~~ with the arm held freely to the side of the body
Biceps Vertical fold; on the anterior aspect of the arm over the belly of the biceps muscle, 1 cm above the level used to mark the triceps site Diagonal fold; one-half the distance between the anterior axillary line and the nipple (men), or one-third of the distance between the anterior axillary line and the nipple (women) Vertical fold; at the maximum circumference of the calf on the midline of its medial border Vertical fold; on the midaxillary line at the level of the xiphoid process of the sternum. An alternate method is a horizontal fold taken at the level of the xiphoid/sternal border in the midaxillary line. Diagonal fold (at a 45-degree angle); 1 to 2 cm below the inferior angle of the scapula Diagonal fold; in line with the natural angle of the iliac crest taken in the anterior axillary line immediately supenor to the iliac crest Vertical fold; on the anterior midline of the thigh, midway between the proximal border of the patella and the inguinal crease (hip)

extremely lean subject, and an improperly calibrated caliper (tension should be set at -12 g'mm -2).21 Vmious regression equations have been developed to predict body density or percent body fat from skinfold measurements. For example, Box 43 lists generalized equations that allow calculation of body density without a loss in prediCtion accuracy for a wide range of individuals. 2 1.22 However, if a populationspecific equation is needed, Heyward and Stolarczyk provide a qUick reference guide to match the client to the correct equation based on sex, age, ethnicity, fatness, and spOJi 8

I

I

Chest/Pectoral

MEN
• Seven-Site Formula (chest, midaxillary, triceps, subscapular, abdomen, supra iliac, thigh) Body density = 1.112 - 0.00043499 (sum of seven skinfolds) + 0.00000055 (sum of seven skinfolds)2 - 0.00028826 (age) [SEE 0.008 or -3.5% fat) Three-Site Formula (chest, abdomen, thigh) Body density = 1.10938 - 0.0008267 (sum of three skinfolds) . + 0.0000016 (sum of three skinfolds)2 - 0.0002574 (age) [SEE 0.008 or -3.4% fat) Three-Site Formula (chest, triceps, subscapular) Body density = 1.1125025 - 0.0013125 (sum of three skinfolds) + 0.0000055 (sum of three skinfolds)2 - 0.000244 (age) [SEE 0.008 or -3.6% fat)

Medial Calf Midaxillary

'*

Subscapular

_.

Suprailiac

WOMEN
Seven-Site Formula (chest, midaxillary, triceps, subscapular, abdomen, suprailiac, thigh) Body density = 1.097 - 0.00046971 (sum of seven skinfolds) + 0.00000056 (sum of seven skinfolds)2 - 0.00012828 (age) [SEE 0.008 or -3.8% fat) _ . Three-Site Formula (triceps, suprailiac, thigh) Body density = 1.099421 - 0.0009929 (sum of three skinfolds) + 0.0000023 (sum of three skinfolds)2 - 0.0001392 (age) ~, [SEE 0.009 or -3.9% fat) • Three-Site Formula (triceps, suprailiac, abdominal) Body density = 1.089733 - 0.0009245 (sum of three skinfolds) + 0.0000025 (sum of three skinfolds)2 - 0.0000979 (age) [SEE 0.009 or -3.9% fat) •

r Thigh

Procedures
• • All measurements should be made on the right side of the body with the subject standing upright Caliper should be placed directly on the skin surface, 1 cm away from the thumb and finger, perpendicular to the skinfold, and halfway between the crest and the base of the fold Pinch should be maintained while reading the caliper Walt 1 to 2 seconds (not longer) before reading caliper Take duplicate measures at each site and retest if duplicate measurements are not within 1 to 2 mm Rotate through measurement sites or allow time for skin to regain normal texture and thickness

• • • •

~ ~

'See reference 22: Adapted from Jackson AS, Pollock ML. Practical assessment of body composition. Phys Sport Med 1985;13:76-90; Pollock ML, Schmidt DH, Jackson AS. Measurement of cardiorespiratory fitness and body composition in the clinical setting. Comp Ther 1980;6:12-17.

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65

DENSITOMETRY
Body composition can be estimated [rom a measurcment of whole-body density, using the ratio of body mass to body volume. In this technique, which has been used as a reference or criterion standard for assessing body composition, the body is divided into two components: the hit mass (FM) and the fat-free mass (FFM). The limiting factor in the measurement of body density is the accuracy of the body volume measurement because body mass is measured simply as body weight. Body volume can be measured by hydrodensiometry (underwater) weighing and by plethysmography.
Hydrodensiometry (Underwater) Weighing

TABLE 4-4. Population-Specific Formulas for Conversion of Body Density (Db) to Percent Body Fat*
Population Age Gender
% Body Fatt

Race American Indian Black Hispanic Japanese Native

18-60 18-32 24-79 20-40 18-48 61-78

This technique of measuring body composition is based on Archimedes' principle, which states that when a body is immersed in water, it is buoyed by a counterforce equal to the weight of the water displaced. This loss of weight in water allows calculation of body volume. Bone and muscle tissue are denser than water, whereas fat tissue is less dense. Therefore, a person ,vith more FFM for the same total body mass weighs more in water and has a higher body density and lower percentage of body fat. Although hydrostatic weighing is a standard method for measuring body volume and hence, body compOSition, it requires special equipment, the accurate measurement of residual volume, and significant coop23 eration by the subject. For a more detailed explanation of the technique (see Chapter 12 of ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription, 5th ed.),
Plethysmography

White

7-12 13-16 17-19 20-80

Female Male Female Female Male Female Male Female Male Female Male Female Male Female Male Female Female Male

(481/Db)-4.34 (437/Db)-393 (485/Db)-439 (4.87/Db)-441 (497/Db)-452 (4 76/Db)-4.28 (487/Db)-441 (495/Db)-450 (530/Db)-489 (535/Db)-495 (507/Db)-464 (510/Db)-466 (499/Db)-455 (505/Db)-462 (495/Db)-450 (5,01/Db)-4.57 (5,26/Db)-4.83 (5.00/Db)-4.56

Levels of Body Fatness Anorexia Obese

15-30 17-62

'See reference 8: Adapted, with permission, from Heyward VH, Stolarczyk LM, Applied Body Composition Assessment. Champaign, IL: Human Kinetics, 1996; 12. tPercent body fat is obtained by multiplying the value calculated from the equation by 10O,

\+Conv~rsion ~ho~/D~nsity to Body Composition
prescr1(~~h

Body volume also can be measured by air rather than water displacement. One commercial system uses a dual-chamber plethysmograph that measures body volume by changes in pressure in a closed chamber. This technology shows promise and generally reduces the anxiety associated with the technique of hydrodensiometiy.lo,23,24 For a more detailed explanation of the technique, see Chapter 12 of ACSM's Resource Manual for Guidelines for Exercise Testing and

'sition provide a variety of new equations that should increase the accuracy of the estimate of percent fat when applied to different populations, These equatIOns (Table 4-4) are likely to improve over time as additional studies are done on larger samples within each population groups

eeJr

OTHER TECHNIQUES
Additional assessment techniques of dual energy x-ray absorptiometry (DEXA) and total body electrical conductivity (TOBEC) are reliable and accurate measures of body composition, but these techniques are not popular for general health fitness testing because of cost and the need for highly trained personnel. 9 Techniques of bioelectrical impedance analysis (BrA) and near-infrared intercadence are used for general health fitness testing, Generally, the accuracy of BIA is similar to skinfolds, as long as a stringent protocol is followed and the equatIons programmed into the analyzer are valid and accurate for the populations being tested,27 Near-infrared intercadence requires additional research to substantIate the validity and accuracy for body composition assessment. 28 Detailed explanations of these techniques are found in Chapter 12 of ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription, 5th ed,

Percent body fat can be estimated once body density has been determined. Two of the most common prediction equations llsed to estimate percent body fat from body density are derived [rom the two-component model of body composition: 2.5.26
% fat = Body ~:nsity - 4142 % fat =
495 , - 450 Body Density

Each method assumes a slightly different density of both fat and fat free mass. Ongoing research, using the three- and [our-component models of body compo-

66

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67

BODY COMPOSITION NORMS
There are no unh-ersaJly accepted norms for body composition; however, Tables 4-5 and 4-6, which arc based on selected populations, provide percentile values for percent body fat in men and women, respectively. A consensus opinion for an exact percentage body fat value associated ,vith optimal health lisk has vet to be defined; however, a range 10% to 22% and 20% to .32% for men and' women, respecti,-ely, is considered satisfactory for health. 29

TABLE 4-6. Body Composition (% Body Fat) for Women*
Age Percentile

20-29

30-39

40-49

50-59

60+

Cardiorespiratory Fitness
Cardiorespiratory fitness is related to the ability to perform large muscle, dynamic, moderate-to-high intensity exercise for prolonged periods. Performance of such exercise depends on the functional state of the respiratory, cardiovascular, and skeletal muscle systems. CardiorespiratOl)' fitness is considered health-related because: 1) low levels of CR fitness have been associated \\ith a marked'" increased lisk of premature death from all causes and specifically from cardi~­ vascular disease, 2) increases in cn fitness arc associated ,vith a reduction in death from all causes, and3) high levels of cn fltness arc associated ,vith higher levels of habitual physical activity, which in turn are associated \\ith many health benefits. 3 (h32 The assessment of cn fitness is an important pali of a plimary or seconda!y intervention program.

90 80 70 60 50 40 30 20 10

14.5 17.1 19.0 20.6 22.1 237 25.4 27.7 32.1

15.5 18.0 20.0 21.6 23.1 24.9 27.0 29.3 32.8

18.5 21.3 23.5 24.9 26.4 28.1 30.1 32.1 35.0

216 25.0 26.6 28.5 30.1 31.6 33.5 35.6 37.9

21.1 25.1 27.5 29.3 30.9 32.5 34.3 36.6 39.3

'Data proVided by the Institute for AerobiCS Research, Dallas, TX (1994). Study population for the data set was predominantly White and college educated. The follOWing may be used as desCflptors for the percentile rankings: well above average (90), above average (70), average (50), below average (30), and well below average (10).

THE CONCEPT OF MAXIMAL OXYGEN UPTAKE
Maximal oxygen uptake (V0 2m "J is accepted as the critelion measure of CR fitness. Maximal oxygen uptake is the product of thc maximal cardiac output (L blood'min- 1 ) and alierial-venous oxygen difference (mL O 2 per L blood). Significant variation in V0 2""., (L'min- l ) across populations and fitness levels results plimarily from differences in maximal cardiac output; therefore, \'0 201"" is closely related to the functional capacity of the heari_

TABLE 4-5. Body Composition (% Body Fat) for Men*
Age Percentile

Open-circuit spirometty is used to measure V0 2011 ",. In this procedure, the subject breathes through a low-resistance valve (,vith nose occluded) while pulmomu)' ventilation and expired fractions of O 2 and CO 2 are measured. Modern automated systems pro,ide ease of use and a detailed p,intout of test results that save time and effort.3-3 However, attention to detail relative to calibration is still essential to obtain accurate results. Administration of the test and interpretation of results should be reserved for profeSSional personnel with a thorough understanding of exercise science, Because of the costs associated with the equipment, space, and personnel needed to carry out these tests, direct measurement of \10 2,mL\ generally is reserved for research or clinical settings. \\Then direct measurement of V0 201,,,, is not feasible or desirable, a valiety of submaximal and maximal exercise tests can be used to estimate \'0201m" These tests have been validated by examining: 1.) the correlation between directly measured V0 201m' and the V0 2",,,, estimated from physiologic responses to submaximal exercise (e.g., heart rate at a speCified power output); or 2) the correlation between directly measured V0 2011 ,,, and test performance (e.g_, time to run 101' 1.5 miles, or time to volitional fatigue using a standard graded exercise test protocol).

20-29

30-39

40-49

50-59

60+

90 80 70 60 50 40 30 20 10

7.1 9.4 118 14.1 159 17.4 19.5 22.4 25.9

11.3 13.9 15.9 17.5 19.0 20.5 223 24.2 27.3

13.6 16.3 18.1 19.6 21.1 22.5 24.1 26.1 28.9

15.3 179 19.8 21.3 227 24.1 25.7 27.5 30.3

15.3 18.4 20.3 220 23.5 25.0 26.7 28.5 312

MAXIMAL VERSUS SUBMAXIMAL EXERCISE TESTING
The decision to use a maximal or subm,vdmal exercise test depends largely on the reasons for the test and the availability of appropriate equipment and personnel. V0 2011 ,., can be estimated using conventional exercise te~t protocols, by considering test duration at a given workload on an ergometer and using the prediction equations found in Appendix D. The user would need to consider the population being tested and the standard error of the associated equation, Maximal tests have the disadvantage of requiring participants to exercise to the point of volitional fatigue and might require medical supervision (see Chapter 2) and emergency equipment. However, maximal exercise testing offers increased sensitivity in the diagnosis of eoronmy artely disease in asymptomatic individuals and

'Dala provided by the lnslitute of Aerobics Research, Dallas, TX (1994). Sludy population for the data set was predominantly White and college educated. The followin9 may be used as descriptors for the percentile rankings' well above average (90), above average (70), average (50), below average (30), and well below average (10).

• Mechanically braked cycle ergometers are excellcnt test modalities for sub maximal and maximal testing..."v Practitioners commonly rely on submaximal exercise tests to assess CR fitness because maximal exercise testing is not always feasible in the health and fitness setting. The Rockport One-Mile Fitness Walking Test has gained \\~de popularity as an effective means for estimating CR fitness. and subjects tend to be least anxious using this device. (see Ch. The main disadvantage is that cycling is a less f~lIniliar mode of exercise for many Americans.. Some Single stage step tests require an energy cost of 7 to 9 metabolic equivalents (METs). Step tests require little or no equipment. Treadmills must be calibrated to ensure the accuracy of the test.:36 The workload must be appropriate to the fitness level of the client.:35 SpeCial precautions might be needed for those who have balance problems or are extremely deconditioned.". \10 2. Estimates of \102max from the HR response to submaxllnal exercise tests are based on several assumptions: • A steady-state heart rate is obtained for each exercise work rate and is consis• • • • • tent each day... an~ by their nature. These all-out run tests may be inappropriate for sedentmy individuals or individuals at increased risk for cardiovascular and musculoskeletal complications. holding on to the support rail should not be permitted to ensure accuracy of the metabolic work. preferably on a track or a level surface. inadequate compliance to the step cadence and excessive fatigue in the lead limb may diminish the value of a step test. MODES OF TESTING Commonly used modes for exercise testing include field tests. and for the 1.st has traditionally been to predict \102max from the HR-workload relatIOnship. Cycle ergometers provide a non-weight-bearing test modality in which work rates are easily adjusted in smaJl work-rate increments. The basic aim of submaximal exercise testing is to determine the heart rate (HR) response to one or more submaximal work rates and usethe results to predict \102max' Although the primmy purpose of the te. • Motor driven treadmills can be used for submaximal and maximal testmg and often are used for diagnOStic testing. and other subjective indices as valuable information regarding one's ~unctional response to exercise.5-mile test it is to run thc distance in the shortest period of time.:31 Postexercise (recovery) heart rates decrease with improved CR fitness and test results arc easy to explain to partieipants. which may exceed the maximal capacity of the participant. . ..ts. Tevertheless.apter 5). The advantages of field tests are that they are easy to administer to large numbers of individuals at one time and little equipment (e. Mechanical efficiency (i. workload. On the other hand. In this test. often resulting in limiting localized muscle fatigue.. This information can be used to evalua:e submaxlmal exercise responses over time in a controlled environment and to fine-tune an exercise prescription. However. can be estimated from test resul. cycle ergometry tests.and 6-minute walk test). steps are easily transportable.g.e. The subject is not on medications that alter heart rate. and stepping is advantageous for mass testing. Note: The most accurate estimate of \102'mLX is achieved if all of the preceding assumptions are met.ws for the accurate assessment of anaerobic threshold and the measurement of V0 2 . In addition. An mdlvidual's level of motivation and pacing ability also can have a profound Impact on test results.. the use of open circuit spirometry during maximal exercise testmg allo. an indi\~dual walks 1 mile as fast as possible. blood pressure. not easily transpOliable. are unmonitored for blood pressure and heart rate. Medical supervision may be reqmred for moderate or high-risk individuals for each of these modes.68 SECTION II/EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION.5-mile test for time. a stopwatch) is needed. They provide a common form of exercise (i. The disadvantages are that they all potentially could be maximal tests. and hemi rate is obtained . treadmill tests. The practItIOner should use the various submaximal measures of heart rate. treadmills usually are expensive. and make some measurements (e.e.5-mile run tests.. The maximal work load is indicative of the maximal V0 2 · The maximal heart rate for a given age is uniform. Field Tests Two of tbe most widely used running tests for assessing CR fitness are tbe Cooper 12-minute test and the l.e. Additionally.. There are advantages and disadvantages of each mode: • Field tests consist of walking or running a certain distance in a given time (i. Some electronic fitness cycles cannot be calibrated and should not be used for testing. They are relatively inexpensive. and the 1. .. and allow blood pressure and the electrocardiogram (if appropriate) to be mcasured easily. but calibration might require speCial equipment not available in most laboratories. • Step testing is an inexpensi. Most tests are unmonitored because of the difficulty of measuring heart rate and blood pressure during a step test. the test usually is of short duration. easily transportable.. 12-minute and 1. stepping skill requires little practice. Electronic cycle ergometers can deLiver the same work rate across a range of pedal rates. a practice session might be necessarv in some cases to permit habituation and reduce anxiety. Thc objcctive in the 12minute test is to cover the greatest distance in the allotted time period. blood pressure) more difficult.. It IS ll~portant to obtam additional indices of the client's response to exercise. and step tests. RPE."e modality for predicting CR fitness by measuring the hemi rate response to stepping at a fixed rate andlor a fixed step height or by measuring postexercise recovery heart rates.. walking) and can accommodate the least fit to the fittest individuals across the continuum of walking to running speeds. In addition. A linear relationship exists between heart rate and work rate..g. The cycle ergometer must be calibrated and the subject must maintain the proper pedal rate because most tests require that hemi rate be measurcd at specific work rates. 69 provides a better estimate of \'0 2 .". Refer to Table 2-1 for exercise testing and supervision guidelines. \10 2 at a given work rate) is the same for evelyone. V0 2m 'L' can be estimated from the equations in Appendix D.

sex.. it may result in near maximal performance for those with low fitness levels or disease. hands in proper position on handlebars). signs and symptoms) should be continued for at least 5 minutes of recovery unless abnormal responses occur. The client should be familiarized with the ergometer. The exercise test should begin with a 2.g.. cm = centimeter.e.g.e.. If heart rate > 11 0 beats'min-\ steady-state heart rate (i. Client appearance and symptoms should be monitored and recorded regularly. In addition. An alternative is to measure a lO-second heart rate immediatelyon completion of the I-mile walk. The use of a relatively inexpensive hemt rate monitor can reduce a significant source of error in the test. Several multivmiate equations are available to predict peak oxygen consumption from the 6-minute walk.5 L'min -[ and her HR was 1.. or experiences an emergency situation.. An appropriate cool-down/recovery period should be initiated consisting of either: a. Standardized procedures for submaximal testing are presented in Box 4-4. near the end of the second and third minutes of each stage. smoking. persons \\rith congestive hemt failure or pulmonary disease). Even though the test is considered submaximal. 5-degree bend in the knee at maximal leg extension. age. RPP = rate pressure product (HR X systolic blood pressure in mm Hg) • n2 = 0. 2. 37 In addition to independently predicting morbidity and mortality3. b. treadmill. 10. two heart rates within 5 beats'min-') should be reached before the workload is increased. heat ancllor humidity. Cycle Ergometer Tests The Astrand-Rhyming cycle ergometer test is a Single-stage test lasting 6 minutes 40 For the population studied. the test mode (e. heart rate. 9 The test should be terminated when the subject reaches 70% heart rate reserve (85% of age-predicted maximal heart rate). Preexercise test instructions were presented in Chapter 3. The sublmLximal heart rate response is easily altered by a number of environmental (e. or. a passive cool-down if the subject experiences signs of discomfort or an emergency situation occurs 11..45 o m = distance in meters. These vmiables must be controlled to have a valid estimate that can be used as a reference point in a person's Fitness program. several stages from any of the treadmill protocols found in Chapter 5 can be used to assess subm. A specific protocol should consist of 2.. 39 Submaximal Exercise Tests • I • I Both Single-stage and multistage submaximal exercise tests are available to estimate \102m". .L'Cimal exercise responses. time since last meal).65 SEE = 2.[0. requests to stop. 5. caffeine. blood pressure.~ the 6-minute walk test has been used to evaluate cn Fitness ""rithin some clinical patient populations (e. and beha\rioral (e. 7. anxiety. these researchers observed that at 50% of \10 2 . is estimated from a regression equation (found in Appendix D) based on weight.26 X npp (x 10-')] + 2. from simple heart rate measurements. Obtain resting HR and BP immediately prior to exercise in the exercise posture. respectively. cycle. kg = kilogram.70 SECTION II/EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 71 in the final minute. It is recommended that an electrocardiograph. 3. which would warrant a longer posttest surveillance period.. If a woman was working at a \10 2 of 1. Continue low-level exercise until HR and blood pressure stabilize.07 X weight (kg)] + [0.02 X distance (m)] . All physiologic observations (e. but this may overestimate the \10 2m ". but not necessarily until they reach preexercise levels. demonstrate a limited short-term survival. pre\rious acti\rity) factors. dietary (e..191 X age (yr)] . upright posture. however. Blood pressure should be monitored in the last minute of each stage and repeated (verified) in the event of a hypotensive or hypertensive response.to 3-min warm-up to acquaint the client with the cycle ergometer and prepare him or her for the exercise intensity in the first stage'of the test 4. If using a cycle ergometer properly position the client on the ergometer (i.68 Patients completing less than 300 meters during the 6-minute walk.g. or a stethoscope be used to determine heart rate. or step) should be consistent \\rith the primary acti\rity used by the pmticipant to address specificity of training issues.or 3-minute stages with appropriate increments in work rate.g. \102m.g. 8. fails to conform to the exercise test protocol. and heart rate. compared to when hemt rate is measured dUling the walk. the accuracy of this method depends on the experience and technique of the evaluator. experiences adverse signs or symptoms.. Although there are no specific submaximal protocols for treadmill testing.m" the average heart rate was 128 and 138 beats' min -I for men and women. continued exercise at a work rate equivalent to that of the first stage of the exercise test protocol or lower. the follo\\ring equation requires minimal clinical information ::39 • Peak \10 2 = V0 2 mL·kg-1·min. see Appendix E). Accurate measurement of hemt rate is critical for valid testing.09 X height (cm)] + [0. 6. Perceived exertion and additional rating scales should be monitored near the end of the last minute of each stage using either the 6-20 or 0-10 scale (see Table 4-8). Heart rate should be monitored at least two times during each stage. yr = year.g.l = [0. Although hemt rate obtained by palpation is used commonly.[0. walk time. heart rate monitor.

The test administrator should recognize the error associated with age-predicted maximal HR and monitor the subject throughout the test to ensure the test remains submaximal. V0 2 ".. The goal is to obtain HR values between 125 and 170 beats'min..I (loa or 1.87 0.83 0. The test is deSigned to raise the steady-state HR of the subject to between 110 beats' min -1 and 70% HRR (85% of the age-predicted maximal I-l~) for at least two consecutive stages.71 0.1 3... unconditioned: women.8 0.200 1. and the YMCA test is a good example. A nomogram for calculation of aerobic capacity [physical fitness] from pulse rate during submaximal work. The two lines noted as ::': 1 SD in Figure 4-3 show what the estimated V0 2 """ would be if the 2.3 1. t 1e work rate should be maintained for an additional minute. 220-age).500 1.. This has become one of the most popular assessment techniques to estimate V0 2 ". This value must then be adjusted for age (because maximal HR decreases \\~th age) by multipl)~ng the V0 2 """ value by the following correction factors: 36 Age 15 25 35 40 45 50 55 60 \/ 65 Correction Factor 1.7 2.I .0.I. and a perpendicular line is dropped to the x-axis to estimate the work rate that would have been achieved if the person had worked to maximum (Fig. Ryhming I.7:218-221.0 "'-- 750 750 0.g.3 3.7 70 60 600 600 1:8 1. conditioned: women.. 300 The pedal rate is set at 50 rpm.72 SECTION II/EXERCISE TESTING CHAPTER 4 / HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 73 138 beats'min-I..e second and third minutes.0 1. 4-3).75 '1:5 1. (Reprinted with permission from Astrand P-O.50 watts) kg'm'min. kg) Work load (kg/min) Women Men . each wor' i'ate IS per onne or at least 3 mimi es an 1eart rates are l'ecorded durin t 1e 111" to 30 seconds of th.0 L·min.10 170 166 162 158 154 150 146 142 138 134 130 126 122 172 168 164 160 156 152 148 144 140 136 132 128 124 120 IV0 40 2max .9 100 3.4 0 60 50 450 300 .8 2...I (50 or 75 watts) kg'm'min. and HR is measured during the fifth and sixth minute of work. unconditioned: men..1 900 900 / In contrast to the single-stage test.3 2..2 3. therefore cantion must be used if extrapolating to workloads outside of this range.6 1. Modified Astrand-Ryhming nomogram.68 0. The suggested work rate is based on sex and an individual's fitness status as follows: men.I (75 or 100 watts) Step test 33 em 40 em Women Men (weight. conditioned: 300 or 600 600 or 900 300 or 450 450 or 600 kg'm'min.. LI 1. 4-2).. The average of the two beart rates is then used to estimate V0 2 ".It a series of submaximal work rates and extrapolated the response to the subject's age-predicted maximal heart rate. The line generated from the plotted points is then extrapolated to the age-predicted maximal heart rate (e.2 40 50 1.6 450 100 0..I (50 or 100 watts) kg'm'min .65 80 70 90 80 2.. J Appl Physiol 1954.9 1.. can be estimated from the work rate using the formula in Appendix D.4 3.6 90 2.1 1.. 4-1)..) . 3-minute stages of continuous exercise (Fig. If these two heart rates ValY by more t 1an 5 eats'min .5 1. Mantz et al 41 measured HR . The heali rate measured during the last minute of each steady-state stage is plotted against work rate.". from a nomogram (Fig.2 2. It is im oliant to remember that two consecutive HR measurements must be obtained within this HR ranae to Jredict V0 2 "". These eqllations are valid to estimate oxygen consumption at submaximal steady state workloads from 300 to 1.5 2.4 2..0 3.78 0. then her V0 2 "1<" was estimated to be 3. In t 1e YMCA rotoco .050 FIGURE 4-1. 42 The YMCA protocol uses two to four.200 kg'm'min -I.9 2.

0 kg) 1050 kgm/min (3. V0 " can be estimated from the formula [or stepping in AppendL'X D. . 10 oco s see lapter 5) can be e s lOU e elt 1 east 3 mmutes.{]mal I-IR I b .m.m:i:~~i:. y-s a e lemt rates.dl ~ ~ III lU Q) I4thl .0 kg) 190 180 170 160 150 140 130 120 110 150 300 450 600 750 120C HR<80 HR: 80-90 600 kgm/min (2. .5 kg at 50 rpm) 2 If the HR In the third minute of the stage is' <80. .. . Step Tests 22.. s common treadmtll p' t . . .. .5 mL. . .' d -IR response at each staae TI HR I b 0 enSUle a stea y-state I va ues are e xt..5 steps'min. (''''0 . maximal HR and YO ' b . ec maxIma R) is used.CHAPTER 4/ HEALTH-RELATED PHYSICAL FITNESS TESTING AND INTERPRETATION 75 74 SECTION III EXERCISE TESTING Q.III Appendix .J stage 200 150 kgm/min (0. Heart rate responses to three submaximal work rates for a 40-year old. In contrast.0 Q) lU .0 kg) . a wide variety of step tests have been developed to categorize cardiovascular fitness on the basis of a person's recovery HR [ollowing a J6 Step tests have also been used to estunate YOo used a smgle-step heIght of 33.aae) can p"d 2m. b 10Vl eon yan estimate of maximal HR In '1dditioll" .2 L·min.0 kg) 700 kgm/min (2.. responses occurs because the ~o lInu . t I 0 maCCl1late pedalmg cadence . lU Q) ::I: Directions: 1 Set the 1st work rate at 150 kgm/min (0.. sedentary woman weighing 64 kg VOzmax was estimated by extrapolating the heart 1 rate (HR) response to the age-predicted maximal HR of 180 beats·min. The other two lines estimate what the VOzmax would have been if the subject's true maximal HR 1 was:. The Canadian Home Fitness Test has demonstrated that such testing can be performed on a large scale and at low cost. min -1) FIGURE 4-3.. and V0 'L' is estimated frolll the nomogram (see Fig. A steady-state HR was measured for each step rate and a line formed from these HI\ values was extrapolated to age-predicted maximal HR. 41 used a single-step height (30... d '11 1 el Clse testmg tradltlOnal1y has b .t. IH and the stages of the test I ld b 3 . f. 2m. set the 2nd stage at 750 kgm/min (2 5 k 3 S~~~h~oT~~~~~:~~S:~:~u~~e~a~~COrding to the work rates in ~!~~~:.5 kg) 900 kgm/min (3.4~:3 Instead o[ estimating V0 2max from I-H\ responses to several submaximal work rates.:.. These tests require oxygen uptakes of about 25.5 kg) 600 kgm/min (2.5 kg) 600 kgm/min (2. The same endpOint (709\ HRR .5 kg)' 900 kgm/min (3. s lOU e mmutes or lOll"er t ..el. bee d'[ I D from the worked to maximum Mo t . l ( CI used. .. YMCA cycle ergometry protocol R .5 kg) 'E i: r-. appropriate for an ergometer with a flywheel ~:I~t:~:~e. n use m many settings.8 and 29. FIGURE 4-2.....5 kg) HR: 90-100 450 kgm/min (1. Heart rate is measured as described for the cycle test.value. o 01 10 0 age-predict I . been the cycle eraometer altll It ..:'. but the duration of each stag I Id b . . Maritz 2m et al.5 kg) HR>100 300 kgm/min (1. Treadmill Tests The primary exercise modality [or submaximal ex . respectively.Partoftheerrorl'llvo] d' .. . .. ell ors can e attn buted t . estimated using the I formula in Appendix D and expressed in L'min~l.. 4-1).I . o u g 1 lea ml s nve bee d . ' . 10m su ma. ~I beats'min-J.nMV Astrand and Ryhming cm OJ women and 40 cm for men at a rate of .:35-'J7.0 kg) 750 kgm/min (2..5 cm) and four-step rates to systematically increase the work rate. e~ts'mm . IS estllnated usin a the f· I' highest speed andlor grade tllcl .(based on 220-age). was 2. ~ ~ 750 kgm/min (2. I. Such step 2rm tests should be modified to suit the population being tested.. the maximal work rate was determined as described for the YMCA cycle test. t WOU Id Ilave b OImu I a . rather than 180 ve l1l esllmatmg VO f· b .n ac lleve L t le person had . The work rate that would have been achieved at that HR was determined by dropping a line from that HR value to the x-axis.:1 SD from the 180 beats' min.tIngs shown here are subject's true maximal HR were 168 or 192 b . .:~o~{g:r~~(~i{ig~J&~) 900 1050 Work rate (kg. (workload) and imprecise stead . VOzmax.. 85(J1 [ .L.kg-I'min. '.le lapo ltd a e to age-predicted .0 kg) 450 kgm/min (1.

'. [ 1 0 Btl RPE '70 "Ild the reviseu or category-ratlO scale 0 0 to . [r' fatigue. Heart rate values are used to obtain a qualitative rating of fitness from published normative tables. Borg's Perceived Exertion and Pain ca es. After exercise is completed. Heart rate can be determined using several techniques. which rates cxerclse In ensl y I are WI eyuse.k I".. obtain blood pressure in the exercise position. . the bell of the stethoscope should be placed to the left of the sternum just above the level of the nipple. I I' . In addition.01y-ratio scale. perceived exertion ratings corre ate Wit 1 exel clse leal I...1 e 0 f 6 to ~ . one should not press too hard with the palpating fingers because this could produce a marked bradycardia in the presence of a hypersensitive carotid sinus reflex..·1 factors mood states environmental conlhtlOns. b f 'st fourth and fifth Korotkoff sounds. di Cf . tNole: ON the Category-Ratio Scale. . For correct usage • S I follow the administration and instructions gIven In Borg G.... [ . Hemt rate telemetry monitors ("heart rate watches") .7 9 Very light 10 11 Fairly light 12 13 Somewhat hard 14 1 Very weak 1. however.rogress t~ward maxim:' exertion during exercise testing. Reproduced With permISSion. ' I" Iate lIS or b b I r' 1." I II R'PE 'be '1 v'lluable indicator for monitoring an indl\'ldual s exerCise to " ] . a: stron Cf ) on the catc. 42 CARDIORESPIRATORY TEST SEQUENCE AND MEASURES A minimum of heart rate. This test uses a 12-inch (30. auscultation with a stethoscope... the use of an appropriate-sized blood pressure cuff is important. . ' elall c . Blood pressure should be measured at heart level with the subject's arm relaxed and not grasping a handrail (treadmill) or handlebar (cycle ergometer).3 "No I" Just noticeable 7 Very. Although the carotid pulse might be easier to obtain. Blood pressure measurements should be taken with a mercury sphygmomanometer adjusted to eye level or a recently calibrated aneroid manometer.les exelCI . t" f tl e well as cardiac patients mandates caution in the ulllversa ap~ Ica Ion ~. the subject immediately sits down and heart rate is counted [or 1 minute.' . To obtain accurate blood pressure measures during exercise. very light 8 0. . The pulse is typically counted for 15 seconds.I . ivlost apparentl)' healthy subjects reach their subjective lin~lt 0 atl~~l:l~t RPE of 18 to 19 (very very hard) 011 the category Borg scale 01 9 to ] 0 . selected baseline measurements should be obtained prior to the start of the exercise test.5 2 Weak 2. prOvided there is no outside electrical interference (e. emissions from the display consoles of computerized exercise equipment). b' . Counting must start within .. : . SystoliC and diastolic blood pressure measurements can be used as indicators for stopping an exercise test (see next section).5 Light 3 4 Moderate Heavy 15 Hard 16 17 Very Hard 18 5 Strong 6 7 Very strong 8 9 19 Very. a normal-size adult cuff . t ·t· Cf tIle RPE c'm be used as an indication 0 Illlpen n"" Dunn Cf exel clse es I11 b.ctlve 00. and rating of perceived exertion (RPE) should be measured during exercise tests. I~r [eelinCfs durin Cf exercise. I . This method is most accurate when the heart sounds are clearly audible and the subject's torso is relatively stable. . . After the initial screening process.44 Many electronic cycles and treadmills have embedded this HR technology into the equipment. Category and Category-Ratio Scales for Ratings of Perceived Exertion* Category Scale Category-Ratio Sealet 6 o Nothing at all 0. with a stepping rate of 24 steps'min 1 (estimated oxygen cost of2S. taking into account persona 1 ness . if the fourth Korotkoff sound can not be discerned. SC'l Ies are s1 lown III "±.5 Extremely weak 0. b" t I . blood pressure. '[able '_7 Either scale is a[J[Jropnate as a su Je. d b inOuence Y psyc I101 OgIC" . therefore.5 seconds of the end of exercise. .S-cm) bench. 'se Illolles and aCfe which reduce its utility.. RPE can be used to Illomtor ly . For the auscultation method.vith chest electrodes have proved to be accurate and reliable. including radial or carotid pulse palpation. and then multiplied by 4. The rubber bladder of the blood pressure cuff should encircle at least 80% of the subject's upper arm. 1 . very hard 20 10 11 Extremely strong Absolute maximum "Strongest I" Highest possible *Copynght Gunnar Borg.I ). follow the guidelines in Chapter 3 (Box 3-4) for resting blood pressure. Cnrrently. 0 1 a sca. Champaign. I 16 R1tillCfS C'1Jl be '.g.. " . and genera atlgue eve s. thus resulting in an erroneous elevated reading (the converse is also true).8mL'kg I'min. to determine the per-minute HR. or the use of heart rate monitors.."".76 SECTION II/EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 77 standardized step test. I. It is important to TABLE 4-7. If the subject's ann is large. The sequence of measures is listed in Box 4-4. and when apparently healthy individuals are being tested \vith submaximal tests. "I" represenls IntenSily of the Borg scales It 15 necessary to . the fifth 'f d 1 Id be obt-:tined DurinCf e. it is alh-isable to obtain the Korot k0 f soun s lOU .·t "Ites can " 1 'e Although. IL: Human Kinellcs. 45 B ·Cf'S RPE sC'lle was de\'eloIJed to allow the exelTlsel to subJectl\ elv SC'lIes 01 ' 1ft ... level environmental conditions.ercise. The pulse palpation technique involves "feeling" the pulse by plaCing the first and second fingers over an mtery (usually the radial artery located near the thumb side of the wrist or the carotid mtery located in the neck near the larynx).tes ]'Irge interindividual variability in RPE with both healthy as anc WOl " " . ' c . To help ensure accurate readings..ill be too small. two RPE sC. The 3-Minute YivlCA Step Test is a good example of such a test. 1998. t 't 01 'd I . d· tIle origill"ll or category scale. 1 .. . An ECG is not necessary when diagnostic testing is not being done. Taking a resting ECG prior to exercise testing assumes that trained personnel are available to interpret the ECG and provide medical guidance.' . ' .

.4 37.0 37.9 28.4 29.2 41.4 44.1 ·min-') in women.6 33.1 )* Percentile values for maximal oxygen uptake (mL'kg "min-') in men.0 39. The study population for the data set was predominantly White and college educated.4 29. Box specific termination criteria. Percentile values for maximal oxygen uptake (mL·kg. and well below average (10).0 47.0 31. MaXimal oxygen uptake was estimated from the final treadmill speed and grade using the current ACSM equations found in this edition of the Guidelines.2 42.6 39.4 28.6 31. 50% to 70% HRR or 70% to 85% age-predicted maximal HR).8 34.3 26.2 41.1 23.7 '" I.6 31. This feeling should reflect your total amount of exertion and fatigue. Dallas.895) 40-49 (N = 4.0 44..0 39. with speciflc reference to age and sex. Because of the individual variation in maximal heart rate. but try to concentrate on you r total.6 47. volitional hltiglle.0 314 29.234) 30-39 (N = 11.9 20.032) 60+ (N = 465) 90 80 70 60 50 40 30 20 10 49.4 49. or claudication Signs of poor perfusion: light-headedness. and well below average (10).3 25. 1970 to 2002.641) 60+ (N = 1. The following may be used as descriptors for the percentile rankings: well above average (90).8 36.6 33.2 41. *Data were obtaIned from the Initial examination of apparently healthy men enrolled In the AerobICS Center longitudinal Study (AClS).0 31.4 36. PrinCipal Investigator. pallor. The AClS IS supported 10 part by a grant from the National Institute on Aging (AG06945). nausea.4 283 45.8 44. Dallas. More speciflc termination critelia for clinical or diagnostic testing are prOvided in Chapter 5. confusion.1 37. The Cooper Institute.6 33. for safety reasons. Maximal oxygen uptake was estimated from the hnal treadmill speed and grade uSing the current ACSM equations found in thiS edition of the Guidelines.2 34.1 219 34. and fatigue. The data are provided courtesy of the AClS investigators.0 31. For clinical testing.9 26.001) (N 50-59 = 2.erestimate your feelings of exertion.8 34.2 33. inner feeling of exertion.4 44. above average (70). the test may have to be terminated prior to the subject reaching a measured \70 201 ".78 SECTION II / EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 79 use standardized instructions to reduce problems of misinteqJretation of RPE. effort.4 37.0 37. whether maximal or submaximal. The Cooper Institute.4 29. Occasionally.0 45.8 36. below average (30). 1970 to 2002.109) 50-59 (N = 5.0 31.6 52. ataxia.8 410 394 36.0 39.1 ·min. below the 20th percentile for age and sex. leg cramps.244) 90 80 70 60 50 40 30 20 10 55. wheezing.2 34.4 36. INTERPRETATION OF RESULTS Table 4-8 prOvides normative values for \102m.e.7 25. The study population for the data set was predominantly White and college educated. Age (yr) TEST TERMINATION CRITERIA Graded exercise testing.2 34. cyanosis.9 44.7 25. The follOWing may be used as descriptors for the percentile rankings: well above average (gO).5 21. SN Blair. Maximal treadmill exerCIse tests were administered using a modified Balke protocol. General indications-those that do not rely on physician involvement or ECG monitOlingfor stopping an exercise test are outlined in Box 4-5. Research suggests that a \702m". .3 26.. TX. below average (30).1 52. is a safe procedure when subject screening and testing guidelines (see Chapter 2) are adhered to..2 41.2 33.6 41. Don't concern youn-elf Leith anyone factor such as leg pain.8 36.4 36.0 39. shortness of breath or exercise intensity.4 28.223) 30-39 (N = 3. TX. Percentile 20-29 (N = 2. Maximal treadmill exerCIse tests were administered usrng a modifIed Balke protocol.9 28. combining all sensations and feelings of physical stress. • • • • • • • • • • Onset of angina or angina-like symptoms Drop in systolic blood pressure of > 10 mm Hg from baseline blood pressure despite an increase in workload Excessive rise in blood pressure: systolic pressure >250 mm Hg or diastolic pressure> 115 mm Hg Shortness of breath.1 50.3 * Assumes involvement or ECG monitoring. SN Blair. Try not to underestimate or or. The following are recommended instructions for using the RPE scale during exercise testing AS During the exercise test tee want you to pay close attention to how hard you feel the exercise tcork rate is.1 49.6 41.0 31. be as accurate as you can.3 26.0 50. Principal Investigator.30 In a compmison of the fitness status of TABLE 4-8. 5-2 provides more definitive and *Data were obtained from the initial examination of apparently healthy women enrolled in the Aerobics Center longitudinal Study (ACLS).6 49. The AClS is supported In part by a grant from the National Institute on Aging (AG06945)..158) 40-49 (N = 13. the upper limit of 85% of an estimated maximal heart rate may result in a maximal effort [or some individuals. or a predetermined endpoint (i. average (50). is associated with an increased Iisk of death from all causes.2 42. (mL·kg-l·min -I). average (50).6 33.6 33..2 34. above average (70). Percentile Values for Maximal Aerobic Power (mL.7 42. which is often indicative of a sedentmy lifestyle.0 44. kg. or cold and clammy skin Failure of heart rate to increase with increased exercise intensity Noticeable change in heart rhythm Subject requests to stop Physical or verbal manifestations of severe fatigue Failure of the testing equipment that testing is nondiagnostic and is being performed without direct physician Age (yr) Percentile 20-29 (N = 1. The data are proVided courtesy of the ACLS Investigators.2 34.

the performance of a 6 RM to momentary muscular fatigue would provide an index of strength changes over time. Peak force development in such tests is commonly referred to as the maximum voluntalY contraction (MVC). Muscle function tests are velY specific to the muscle group tested. whereas those in which numerous repetitions (> 12) are performed prior to momentary muscular fatigue were considered measures of muscular endmance. prediction. 50 •51 However. thus results are • • • A change in one's muscular fitness over time can be based on the absolute value of the external load or resistance (e. Individnals should participate in huniliarizationJpractice sessions with the equipment. caution must be used in the interpretation of the scores because the norms may not include a representative sample of the individual being measured. Traditionally. and adhere to a specific protocol (including a predetermined repetition duration and range of 1lI0tion) ill order to obtain a reliable score that can be used to track true physiologic adaptations over time. which is related to type 2 diabetes Musculotendinous integrity. "'hen an individual is given repeated submaximaJ exercise tests over a period of weeks or months and the heart rate response to a fixed work rate decreases over time.. as a measure of muscular strength. the values should be expressed as relative values (per kilogram of body weight [kg/kg]).. Although submaximal exercise testing is not as precise as ma. such as 4. However. leg press versus bench press) varies tremendously. J Traditionally. it is likely that the indiddual's CR fitness has improved. newtons.. the I-repetition maximum (l-RM). which is related to a lower risk of injUly. measures of static strength are specific to both the muscle group and joint angle involved in testing. Estimatillg a l-RM from such tests is problematic. including cable tensiometers and handgrip dynamometers. a standardized protocol may be absent. MUSCULAR STRENGTH Although muscular strength refers to the external force (properly expressed in newtons.or 8-RM. which is related to sel f-esteem • The fat-free mass and resting metabolic rate. which may allow the participant to integrate evaluation into their training program. has been the standard for dynamic strength assessment.~9 Muscular strength refers to the abilily of the muscle to exert force. the type of equipment. whereas others (e. a multiple RM can be used.. estimated maximal hl'alt rate) introduce unknown errors into the prediction of \'0 1 """. or the exact test being used (free weight versus machine weight) may differ. which are related to weight management The ACSM has melded the terms muscular strength and muscular endurance into a category termed "muscular fitness" and included it as an integral portion of total health-related fitness in a position stand on the quantity and quality of exercise to achieve and maintain fitness. Some of the assumptions inherent in a subm'L~imal test are more easil\' met (e. in which the muscle changes length). steady-state healt rate can be verified). the type of contraction. difficult to interpret. etc. few muscle endurance or strength tests control for repetition duration (speed of movement) or range of motion. However. 8) also can be used to assess strength.' Muscular endurance is the muscle's ability to continue to perform for successive exertions or many repel itions. including low-back pain • The ability to cany out the activities of daily living. Strength can be assessed either statically (no overt muscular movement or limb movement) or dynamically (movement of an external load or body pmt. and requires less time and effort on the part of the subject. the velocity of muscle mO\'ement. Static or isometric strength can be measured conveniently using a variety of devices. In both cases. The standardized conditions or protocol should include: • • • • • • Strict postu re Consistent repetition duration (movement speed) Full range of motion Use of spotters (when necess'lIy) Equipment familiarization Proper warm-up Muscular Strength and Muscular Endurance Muscular strength and endurance arc health-related fitness components that mav improve or maintain the follO\\ing: Bone mass. the accuracy of the classification is dependent on the similarities between the populations and methodology (estimated vs measmed \'Olm"" ma. but when comparisons are made between individuals. 4. if one were training with 6 to 8 RM. Corresponding indices of lower body strength include l-RM values for leg . independent of the accuracy of the \'Olm. and the joint range of motion.e.g.g. their utility in describing overall muscular strength is limited. kilograms [kg]. or pounds [lb]).g.). independent of the true l-RM. Results of anyone test are specific to the procedures Ilscd.ximal exercise testing. and generally not necessaly. UnfOltunately. virtually all evaluations can establish a baseline and be used to track relative progress.ximal \'ersus subm'Lximal. . the performance of a maximal repetition range (i.. although kilograms and pounds are commonly used as well) that can be generated by a specific muscle or muscle group.·51 Valid measures of general upper body strength include the l-RM values for bench press or militmy press. 6. which is related to osteoporosis Glucose tolerance. tests allowing few «3) repetitions of a task prior to reaching momentary muscular fatigue have been considered strength measures. it is commonly expressed in terms of resistance lifted... therefore. the greatest resistance that can be moved through the full range of motion in a controlled manner with good posture. The number of lifts one can perform at a fixed percent of a l-RM for different muscle groups (e. it pro\ides a reasonably accurate reflcction of an individual's fitness at a lower cost and reduced lisk. and no single test exists for evaluating total body muscular endurance or muscular strength. Unfortunately. thus rendering an estimate of l-RM impractiea1. For example. Despite differences in test accuracy and methodology.g. the true l-RM is still a popular measure.80 SECTION II/EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 81 anyone individllal to published norms.

80 076 0. 70%) is used both pre.57 0.10 1.74 1.38 0.61 1.52 0.70 0.48 30-39 1.84 0. hip.88 0.13 1.33 1.00 0.65 1.g.99 0.62 0.42 40-49 1.27 1.78 60+ 1. shoulder.63 0.63 1. Although "'One repetition maximum bench press. Hesistance is progressively increased by 2. 10 Women 90 80 70 60 50 40 30 20 10 second).58 1.83 1.65 0.5~ or the maximum number of pushups that can be performed without rest5~ may be used to evaluate the endurance of the abdominal muscle groups ancl upper body muscles.27 213 205 197 191 1. average (50).90 0.22 1. but an impOttant drawback is that this equipment is extremely expensive compared to other strength-testing modalities. Isokinetic testing involves the assessment of maximal muscle tension throughout a range of joint motion set at a constant angular velocity (e. above average (70).62 1.68 1.82 1.51 1.39 0.61 0.85 0.32 1. below average (30). If the total number of repetitions at a given amount of resistance is measured.94 50-59 1.37 1. respectively.g.51 0.83 0. 2. A Universal DVR machine was used to measure the l-RM The follOWing may be used as desCflptors for the percentile ranklngs: well above average (90).71 1.63 0.92 1.33 Men 90 80 70 60 50 40 30 20 tAdapted from Institute for AerobICS Research.72 0. Upper Body Strength*t Age Percentile 'One repetition maximum leg press With leg press weight ratio = weight pushedlbody weight. above average (70).13 1.74 070 0.40 0.99 0.68 1. The subject should warm-up by completing a number of submaximal repeti ti on s.93 088 0.14 1.76 0.80 1. 5. 3..59 1.71 0. and well below average (10).23 1. based on resistance lifted divided by body mass for the bench press and leg press are provided in Tables 4-9 and 4-10. Such de\~ces measure peak rotational force or torque.57 0.90 0. the result is termed absolute muscular endlll'ance. with bench press weight ratio = weight pushed/body weight tAdapted from Institute for AerobiCS Research.78 071 0.68 0.44 135 148 1. The following represents the basic steps in l-RM (or any multiple RM) testing 52 follo\\~ng familiarizationJpracti<:e sessions:· 1.64 0.18 1.84 079 0. the result is termed relative muscular endurance.59 0. and well below average (10).71 0.54 0.51 047 0.95 0.14 30-39 207 1. respectively.74 1.52 143 1..46 044 042 0.52 1.47 1.82 SECTION II / EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 83 press or leg extension. Select an initial weight that is \\~thin the subject's perceived capacity (-50%-70% of capacity).71 1.62 1.97 0.57 1.50 047 043 038 50-59 0.21 115 1.04 0. Dallas.93 1.93 0.27 1.39 1.18 1.64 1.60 0.80 0.73 1.50 1.16 132 1.80 0.63 0. knee.09 1.17 1.82 1.45 043 0.57 0.32 1.24 1. used as desCflptors for the percentile rankings.08 1. The final weight lifted successfully is recorded as the absolute loR or multiple RM.51 1.93 0..88 0.98 0.00 40-49 1. Study population for the data set was predominantly White and college educated A Universal DVR machine was used to measure the l-RM. Simple field tests such as a curl-up (crunch) test5. Equipment that allows control of the speed of joint rotation (degrees/sec) as well as the ability to test movement around various joints (e. If the number of repetitions performed at a percentage of the l-RM (e. Dallas. Leg Strength*t Age Percentile 20-29 2.51 0.77 1. Study population for the data set was predominantly White and college educated.99 0. 1994.52 0.22 137 125 1.46 1.06 0.04 0.66 0.and posttesting. average (50).58 1. All repetitions should be performed at the same speed of movement and range of motion to instill consistency between trials.88 0.44 137 1.54 0.53 0.56 0.5 to 20 kg until the subject cannot complete the selected repetition(s). Determine the 1 HM (or any multiple HM) within four trials with rest periods of 3 to 5 minutes between trials. 20-29 148 1.75 0.88 0.05 0.1.93 0. The follOWing may b.39 1. 1994.10 1.57 0.22 1. .47 0. 4.55 0.g.''» MUSCULAR ENDURANCE Muscular endurance is the ability of a muscle group to execute repeated contractions over a period of time sufficient to cause muscular fatigue.29 1.65 0.56 149 143 138 130 125 1. well above average (90). or to maintain a specific percentage of the maximum voluntary contraction for a prolonged period of time.02 0.48 0.72 Men 90 80 70 60 50 40 30 20 10 Women 90 80 70 60 50 40 30 20 10 TABLE 4-9. Norms.53 0.37 60+ 089 082 077 072 0.68 0.85 1. below average (30).12 1. elbow) is available from commercial sources. 60 angles per TABLE 4-10.

using the toes as the pivotal point) and female subjects in the modified "knee push-up" position (legs together. The test is done for 1 minute. The low back should be flattened before curling up. Reprinted With permission from the Canadian Society for Exercise Physiology. respectively. Fitness Categories by Age Groups and Gender for Push-ups* Age Category Gender Excellent Very good Good Fair Needs Improvement 20-29 M 30-39 M F 40-49 M F 50-59 M 60-69 M t Alternatives include: 1) having the hands held across the chest.' PUSH-UP CURL-UP (CRUNCH) . Individual assumes a supine position on a mat with the knees at 90 degrees. with the head activating a counter when the trunk reaches a 3D-degree position 55 and placing the hands on the thighs and curling up until the hands reach the knee capsS6 Elevation of the trunk to 30 degrees is the important aspect of the movement.56 Procedures for conducting the push-up and curl-up (crunch) muscular endurance tests are given in Box 4-6. Resistance training equipment also can be adaptcd to measure muscular endurance by selecting an appropriate submaximal Icvel of resistance and measuring the number of repetitions or thc duration of static contraction before fatigue. 3 For both men and women. and muscle viscosity. 4. Subjects are scored by the number of successful repetitions conlpleted. The subject must raise the body by straightening the elbows and return to the "down" position. tissue damagc can occur. The stomach should not touch the mat. *An alternative includes doing as many curl-ups as possible in 1 minute 36 35 29 28 22 21 17 16 30 29 21 20 15 14 10 9 30 29 22 21 17 16 12 11 27 26 20 19 13 12 8 7 25 24 17 16 13 12 10 9 24 23 15 14 11 10 5 4 21 20 13 12 10 9 7 6 21 20 11 10 7 6 2 1 18 17 11 10 8 7 5 4 17 16 12 11 5 4 2 1 'See reference 54: The Canadian Physical Activity. A second piece of masking tape is placed 10 cm apart. Flexibility depends on a number of specific vmiables. 2003. adequate warm-up. Canadian Society for Exercise Physiology. 3rd ed. in contrast. . maintaining flexibility of all joints bcilitates movement. . Normative data for the YMCA bench press test are presented in Table 4-13. Consequently. Additionally. therefore.84 SECTION II / EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 85 . poor abdominal strength or endurance is com5 monly thought to contlibute to muscular low back pain s . For example. scientiHc data to support a cause-effect relationship betwecn abdominal strength and low back pain are lacking. The push-up test is administered with male subjects starting in the standard "down" position (hands pointing forward and under the shoulder. when an activity moves thc structures of a joint beyond a joint's shOitened range of motion. The arms are at the side. back straight. 2003. t Shoes remain on during the test.:1: 'See reference 54: Canadian Society for Exercise Physiology.5-pound barbell. 1. 2. A metronome is set to 50 beats·min. compliance ("tightness") of vmious other tissues such as ligaments and tendons affects the range of motion. 3rd ed. The maximal number of push-ups performed consecutively without rest is counted as the score. lower leg in contact with mat with ankles plantar-flexed. hands shoulder width apart. Just as muscular strength is specific to the muscles involved. to a maximum of 25. head up. controlled curl-ups to lift the shoulder blades off the mat (trunk makes a 30-degree angle with the mat) in time with the metronome at a rate of 25 per minute. back straight. head up. including distensibility of the joint capsule. The test is stopped when the client strains forcibly or unable to maintain the appropriate technique within two repetitions.1 and the individual does slow. until the chin touches the mat.. TABLE 4-11. Fitness & Lifestyle Approach: CSEP-Health & Fitness Program's Health-Related Appraisal & Counseling Strategy. using the knees as the pivotal point) 2.. Fitness & lifestyle Approach: CSEP-Health & Fitness Program's Health-Related Appraisal and Counseling Strategy. gymnastics) and in the ability to carry out the activities of daily living. the YMCA bench press test involves performing standardized repetitions at a rate of 30 lifts or reps min -1 Men arc tested using an SO-pound barbell and women using a 3. 42 The YMCA test is an excellent example of a test that attempts to control for repetition duration and posturc alignment. no single flexibility test can be used to evaluate total body flexibility. Individual performs as many curl-ups as possible without pausing.. palms facing down with the middle fingers touching a piece of masking tape. The Canadian Physical Activity. ballet. the subject's back must be straight at all times and the subject must push up to a straight arm position. It is important in athletic performance (e. 3. and fltness categories are provided in Tables 4-11 and 4-12. flexibility is joint specific. Flexibility Flexibility is the ability to move a joint through its complete range of motion. thus possessing high reliability. 5.g. LaboratOlY tests usually quantify flexibility in terms of range 1.

e). hip flexibility. the Leighton flexometer. lower extremity flexibility. Accurate measurements require in-depth knowledge of bone. IL 60606. One limb is held straight while the knee of the other limb is flexed and the plantar surface of the foot on the flexed limb is placed on the floor adjacent to the medial surface of the knee of t11e straight limb. Common devices for this purpose include vatious goniometers. Table 4-14 provides normative range of motion values for select anatomic joints.86 SECTION II / EXERCISE TESTING CHAPTER 4 / HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 87 TABLE 4-12.:pressed in degrees. TABLE 4-14. however. Philadelphia: FA Davis. its relationship to predict the incidence oflow back pain is limited S9 The sit-and-reach test is suggested to be a better measure of hamshing flexibility than low-back flexibility60 However.62 The back saver unilateral sit and reach test measures each limb independently as opposed to the standard simultaneous measurement of both limbs. 1992. and joint anatomy. . shoulder flexibility. 2nd Ed. the relative impOttance of hamstring flexibility to activities of daily living and sports performance requires the inclusion of the sit-and-reach test for health-related fitness testing until a criterion measure evaluation of low back flexibility is available.ring shict procedures 57.57 . Range of Motion of Select Single Joint Movements (degrees)* Shoulder Girdle Flexion Abduction Horizontal Abduction Medial Rotation Elbow Flexion Supination Trunk Flexion Lateral Flexion Hip Flexion Abduction Medial Rotation Knee Flexion Ankle Dorsiflexion Inversion 90-120 80-100 30-45 70-90 135-160 75-90 120-150 10-35 90-135 30-50 30--45 130-140 15-20 10-30 Extension Horizontal Adduction Lateral Rotation 20-60 90-135 70-90 Pronation Extension Rotation Extension Adduction Lateral Rotation Extension Plantarflexion Eversion 75-90 20-45 20-40 10-30 10-30 45-60 5-10 30-50 10-20 *Reprinted with Permission from Norkin C. and postural assessment. A more precise measurement of joint range of motion can be assessed at most anatomic joints follov. muscle. The sit-and-reach test has been used commonly to assess low back and hipjoint fleXibility. The back saver test is purpOtted to reduce excessive disk compression. 3rd ed. Joint Structure and Function: A Comprehensive Approach. Chicago. as well as expetience in administeting t11e evaluation. 30 18 16 12 10 8 7 5 4 3 2 0 0 N.58 and the proper use of a goniometer. inclinometers. electrogoniometers. Levangie P.58 Visual estimates of range of motion can be useful in fitness screening. Fitness Categories by Age Groups and Gender for Partial Curl-up* Age Category Gender TABLE 4-13. Although limb and torso length disparity may impact on the sit-and-reach scoring. posterior ligament tension. of motion. Reprinted with permission from the Canadian Society for Exercise Physiology. but are inaccurate relative to directly measured range of motion. 101 Wacker Drive. and tape measures. 64 66 61 62 55 57 47 50 41 42 36 Excellent 44 42 41 40 36 33 28 29 24 24 20 16 41 38 37 34 32 30 25 24 21 21 Good 34 30 30 29 26 26 21 20 17 17 12 33 28 29 28 25 24 20 18 14 14 10 Above average 9 16 14 12 12 29 25 26 24 22 21 8 10 28 22 24 22 21 20 14 13 11 Average 7 9 8 18 '18 16 12 10 24 20 21 6 6 8 9 22 18 20 17 17 14 11 Below average 4 5 7 5 9 20 16 17 14 14 12 4 3 4 6 8 17 13 16 13 12 10 Poor 2 2 2 2 5 6 9 9 13 9 12 1 1 1 1 4 2 6 6 9 <10 6 Very poor *Reprinted from YMCA Fitness Testing and Assessment Manual with permission of the YMCA of the USA. YMCA Bench Press Test: Total Lifts* Age Category 18 25 M 26-35 M 36-45 M 46-55 M 56-65 M >65 M 20-29 M 30-39 M F 40-49 M F 50-59 M 60-69 M F Gender Excellent Very good 25 25 25 25 25 25 25 25 25 25 24 24 24 24 24 24 24 24 24 24 21 18 19 18 19 17 19 16 18 17 18 17 18 16 18 15 17 20 17 16 Good 11 15 13 11 10 11 16 14 10 8 14 12 10 10 9 10 Fair 15 13 9 7 11 4 8 6 11 5 6 6 6 3 5 7 5 Needs Improvement 10 4 10 5 3 5 2 *See reference S4: The Canadian Physical Activity. Fitness & lifestyle Approach: CSEP-Health & Fitness Program's Health-Related Appraisal and Counseling Strategy. Comprehensive instmctions are available for the evaluation of flexibility of most anatomic joints. These estimates can include neck and tmnk flexibility. modified testing that establishes an individual zero point for each participant has not enhanced the predictive index for low back flexibility or low back pain 61 . and erector spinae muscle strain. 2003. Additional information can be found in the ACSM Resource Manual.

however. fitness & lifestyle Approach: CSEP-Health & fitness Program's Health-Related Appraisal & Counseling Strategy. subtract 3 em from each value in this table. The participant's shoes should be removed. YMCA of the USA.55 Methods for administeling the sit-and-reach test are presented in Box 4-7Normative data for two sit-and-reach tests are presented in Tables 4-15 and 4-16. a yardstick is placed on the floor and tape is placed across it at a right angle to the 15-inch mark The participant sits with the yardstick between the legs. IL 60606. Poor lower back and hip flexibility may. ECG (if appropJiate) • Body composition o Waist circumference Skin fold assessment • CardiorespiratOlY Fitness Submaximal YMCA cycle ergometer test • Muscular Strength 1-. height. body mass. Wacker Drive. BP. 3rd ed. The participant should slowly reach forward with both hands as far as possible. Fingertips can be overlapped and should be in contact with the measuring portion or yardstick of the sit-and-reach box. Canadian Society for Exercise Physiology. TABLE 4-15. AComprehensive Health Fitness Evaluation A typical fitness assessment includes the follOWing: • Prescreeninglrisk stratification • Resting HR. however. 35 34 31 30 27 26 23 22 tNote: These norms are based on a sit-and-reach box In which the "zero" point is set at 26 em.6-. which may increase the possibility of an injury. The data accrued from the evaluation should be . the client sits without shoes and the soles of the feet flat against the flexometer (sit-and-reach box) at the 26-cm mark. Fitness & Lifestyle Approach: CSEP-Health & Fitness Program's Health-Related Appraisal & Counseling Strategy. The Canadian Physical Activity. subtract 3 cm from each value in this table. 3rd ed. however.. in conjunction with poor abdominal strength/endurance or other causative factors..J Although asymmetJic stretching is appropriate for flexibility training. the participant should exhale and drop the head between the arms when reaching. Fitnessgram). Note that these norms use a sit-and-reach box in which the "zero" point is set at the 26-cm mark If you are using a box in which the zero point is set at 23 cm (e. Heels of the feet should touch the edge of the taped line and be about 10 to 12 inches apart. with legs extended at right angles to the taped line on the floor. Fitness Categories by Age Groups for Trunk Forward Flexion Using a Sit-and-Reach Box (cm)*t Age Category Gender Excellent Very Good 20-29 30-39 M F 40-49 M F 50-59 M 60-69 M M • I Pretest: Participant should perform a short warm-up prior to this test and include some stretches (e. Myers CR. contJibute to development of muscular low back pain.6. The best of two trials should be recorded.88 SECTION" / EXERCISE TESTING CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 89 while permitting the assessment of limb asymmctlyfi. the participant's knees should not be pressed down. 4th ed.) 2. For the YMCA sit-and-reach test. For the Canadian Trunk Forward Flexion test. the aforementioned components of a fitness evaluation represent a comprehensive assessment that can be performed within 1 hour. holding this position approximately 2 seconds. The norms for the YMCA test are presented in Table 4-16.g. or 8-RM upper body (bench press) and lower body (leg press) • Muscular Endurance o Curl-up test o Push-up test • Flexibility Sit-and-reach test or goniometlic measures of isolated anatomic joints Additional evaluations may be administered. Canadian Society for Exercise Physiology. 1. Be sure that the participant keeps the hands parallel and does not lead with one hand. a lack of nonnative data for adults precludes the inclusion of the back saver unilateral sit and reach test at this time. Norms for the Canadian test are presented in Table 4-15. 3. Repnnted with permiSSion from the Canadian Society for Exercise Physiology. *Diagrams of these procedures are available from Golding LA. 2003. (Note the zero point at the fooVbox interface and use the appropriate norms. Sinning WE. this hypothesis remains to be substantiated. modified hurdler's stretch) It is also recommended that the participant refrain from fast. Jerky movements. Inner edges of the soles are placed within 2 cm of the measuring scale. 101 N.4-. To assist with the best attempt.1 A comp<lIison of the two versions of the sit and reach test found no difference in mO\'ement in the sit and reach and in Cailliefs protective-hamstJing stretch. When using a box in which the zero point is set at 23 em. Testers should ensure that the knees of the participant stay extended. YMCA Fitness Testing and Assessment Manual. The score is the most distant point (in centimeters or inches) reached with the fingertips.g. 2003 41 40 38 41 35 38 35 39 33 40 37 34 39 40 34 37 32 38 34 37 33 36 29 34 28 33 25 33 36 32 35 28 33 27 32 24 Good 33 28 32 24 30 24 30 20 30 Fair 29 32 27 31 23 29 23 29 19 28 23 27 18 25 16 25 15 25 Needs Improvement 24 27 22 26 17 24 15 24 14 -The Canadian Physical ActIVity. The participant should breathe normally during the test and should not hold his or her breath at any time. Chicago.

Bray GA. Don't throw the haby out with the bath water. Ohesity. Brozek J.51. Paffenharger RS Jr. et al. Giovanllllcci E. Med Sci Sports Exerc IfJ87. Univ Calif Donner Lab Med Phys Rep. alld demographics. Stolarczyk LM. The Canadian Home Fitness Test as a predictor lor aerohic capacity. Validity of Futrex-.49(suppl):4. 12. 1. Martorell H. Cahalin LP. vVeincr DH. Ovelweight children and adolescents: description.npaign. Kaminsky LA. Hoehe AF. Champaign. Pathogenesis. Prediction of mortality and morbidity with a (i-minute walk test in patients with left ventricular dvsl'unction. et '-11. et al. Phys Sport Med 1988. 1996. Troiano HI'. stahilitv and functionality. IL 60606. ('cl. Blair SN.270: 1702-1707.5.27.288: 1723-1727. Hilllm EB.110:325-.3-2. et al. 16:14. et al. exercise. Bray GA. 8. 18.luman Kinetics. 19R8.8:28.3-1077.34.5. Van Hallie TB. Gallagher D. eds. Going SB.30. JO. Folsom AB.I.102:975-980.149:429-441 19. Body fat distrihution and5-year risk of death in older women. Chclll1pajgn. 'Reprinted from YMCA Fitness Testing and Assessment Manual with permission of the YMCA of the USA. Flegal KM. Wacker Drive. Hyhming 1.3. Densitometry. Lee 1M. ed. .1:3(. 1996::3-23. YMCA Fitness Testing and Assessment Manual. . Physiological Assessment of Human Fitness. and physical fitness: definitions and distinctions lor health-relatcd research. \fJ91 update. Yusuf S. J Appl Physiol 19. Anthropomet.10:47-. Med Sci Sports ExelT 1992. 41. McConnell TR CardiorespiratOlv assessment of apparently healthy populations. Estimation of \10 2111 <1X frorn a one-mile track walk. In: Maud PJ. et al. Applied Body Composition Assessment. as well as forming the basis for the initial exercise prescription and subsequent evaluations to monitor progress. epidemiolo1(".5 11 Panel E. d al. 1(I ):. National Institutes of Ilealth. JAMA 1989. Cotfredsen A.5. Baltimore: Lippincott Williams & Wilkins. and physical activity. 200.3. This information is central to the development of a client's short.110: 11. 1989. 1999-2000. 1. 189.y' and ultrasound. 17. 4th eel. ACSM Hesource Manual lor Guidelines for Exercise Testing and Prescription.100:126-1. ed.5. Ogden CL.11:. ed.16. Ogden CL. 25. Percentiles by Age Groups and Gender for YMCA Sit-andReach Test (Inches)* Age Percentile Gender M 1.32. Int J Sport Nutr 1998. 44.31. Body I"t measuremcnt goes high-tech. Astrand P-O. Flegal KM. Grade F.101:497~504.58:18. Public Health Hcp 198. Carroll MD. Hescarch Digest. adults. West J Med 1988. 24. The Canadian 110me Fitness Test. Kline eM.3. Aerobic work capacit.5000 for body composition determination. A new air displacement lllethod for the detf'rmination orhuman body composition. Shephard HJ. 22. I-Ieymsl'ield SB. eds. Champaign. Bittner V.59. 36. age. fLo Human Kinetics. \Veltman A. cds. Golding LA. . Maritz JS. Phys Sport Med 198.'-I in men and women with special reference to agc.3-140. Caspersen C.7:218-22]. Tn: Roitman JL. ct al. I-Iojgaard L. Thivierge M. Physical activity. A prospective study of healthy and unhealthy men.332. Hendel 11\1'. ITcalth implications of obcsity. ACSM's Hesourc:e Manual for Guidelines [or Exercise Testing and Prescription. HUIll Biol 18-25 F M 26-35 M 36-45 M 46-55 M 56 65 M >65 90 80 70 60 50 40 30 20 10 22 24 22 20 19 18 17 15 14 13 11 21 20 19 18 17 16 14 21 19 17 17 15 14 13 11 9 23 21 20 20 19 17 16 15 13 21 19 17 16 15 13 13 22 11 7 21 19 18 17 16 15 14 12 19 17 15 14 13 11 10 9 6 21 20 18 17 16 14 14 12 10 17 15 13 13 11 9 9 7 5 20 19 17 16 15 14 13 11 9 17 15 13 12 10 9 8 7 4 20 18 17 17 15 14 13 11 9 1988. lAMA 1993. 40.'ard VH.90 SECTION III EXERCISE TESTING CHAPTER 41 HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 91 TABLE 4-16.5. below average (30). 38. 1L: 1. Davis JA. \Veltman A.58. President's Coul1ciJ on Physie<J Fitness. IL: Human Kinetics. Sports Mecl 1991. Topography of body fat: relationship to risk of cardiovascular and other diseases.114:680-682. Christenson GM.58. A practical method of estimating an individllal's maximal oxygen uptake. 14.24:2. . 39. Jette M.58-366. Prevalence and trcnds in ovenvcight among US children and adolescents.288: 1728-17. Mclean KP. Lohman TG.307. Ileymsfield SB. Baltimore: Williams & Wilkins: Baltimore.26H:483-487 16. Healthy percentage hody fat ranges: an approach (or developing guidelines based on hody mass index. H nman Body Composition. Annals of Internal Medicine 198.5. Anlhropometric Standardization Hden::'nce Manual. eds.and long-term goals. 20.19:2. Lohman TG. gendcr. Executive SllllllllaJY of the clinical guidelines 011 the identification. Physical fitness and all-cause mortality. The following may be used as deSCriptors for the percentile ran kings: well above average (90).3: 107.Hoche AF'.3. Cha. Acta Physiol Seand 1960. Kohl 11\1' 3rd. In: Hoehe AF. eds.3.5-. IL: Iinman Kinetics. Blair SN. Circulation 2000. JAMA 1fJ95. average (50). et al. He). 12.54. 19f)6: 167-18H. Stampfer MJ.72:694-701.141:1117-] 127. Body composition methodolob'v in sports medicine. Body composition from nuid spaces and denSity. JAMA 2002.5:3-2. 2000. Human Body Composition. Ileymsfieid SB. Flegal KM.262:2395-2401 .5-60 37.347-349. Going BS.e six minnte walk tcst predicts peak oxygen uptake arrd survival in patients with advancecl heart Elilure. . 23. and well below average (10) interpreted by a competent professional and conveyed to the client. Mongeon J. Dcnnitiolls: health. .31.32. Sesso HD. Aitkens S. Prevalenee and trends in obesity among US adnlts. Leger L.3) :76-90. Direct determination of aero hie power. et al. Chest ]996.60:167-1/. Kohl IIW . Tran ZV. Am J Clin Nutr 2004.5. Foster C. 9. IL: Iluman Kinetics. Am J Epidemiol 199. In: Lohman TG. Gray DS. Can Med Assoc J 1976. 26. 101 N. Med Sci Sports Exerc 199. Tran ZV. IL: Human Kinetics. 19. Pediatrics 1998. Arch rntern Med 1998. 21: Heyward VH.3-1.5. Semigran MI. Anderson J. Densitornetric analysis 01" body composition: revision of some I1 llan titative assumptions.27:J692-1697. Physical activity and coronary heart disease in men: The Halvard Alumni Health Study.3rd. Changes in physical fitness and all-cause mortaht)'.3. eds. Jackson AS. PowelJ KE. T'. Budy size and rat dislribution as predictors of coronalY heart discase among middle-aged and older US men.56:671-67'). Change in hlt-free mass sed by hioelectrical impedance. Astrand P-O. Chicago. 6. 4. . Ergonomics 1961. Hoche AF. 4. Practical hody composition assessment lor children. Carroll MD. above average (70).Lximal work. 1999-2000 JAMA 2002.5. Campbell J. Siri . et al. IL: Human Kinetics. Phys SportsmedI982. Am J Clin NutI' 2000. Hcart rate monitors: validity.21:101-104. Dernpstcr P. and older adults. . Kaye SA. Houtkooper L.4:97-122. and body weight. A prospective study ol'healthy men and women. 1996.3: 1093-1098. 2. I-lintenneister H.55-1867.\IE. Champaign. REFERENCES 1.5. Til: Boehe AF. ACSNl's Health Fitness J 1997. Ann NY Acad Sci 1%. Hnman Body Composition.5. JAMA 1993. and treatment of overweight and obesity in adults. Porcari Jr. 42. Champaign. Lohman TG. Palfenbarger HS Jr. Champaign. Ileymsfieid SB..5:9-17.37. A nomogram for calcnlation of aerohic capacity (physical fitness) I'rom pulse rate during suhm. Weller 1. 29. fitness.30-. Pollock ML Practical assessment of body composition. total body potassiurn and dual energy X-ray absOllltiometJy dnring prolonged weight loss. evaluation.79:. Part I. Lohman TG. Skinner JS. ct a1.56 27. Med Sci Sports Exerc 1989. 28.5.3. . Thomas S. Barlow CE. Lohman TG. Morrison JF. Mathier MA. Scand J Clin Lab Invest 1996. 2001:361-. Sellers TA. lleo M. Ceneralized equation for predicting body density of worllf'11 from girth measnrements.33. Predkting body curnpositiun of lllcn from girth me'-lSnrell1ents. Peter J. 7.

et a!' A categOly-ratio perceived exertion scale: relationship to hlood and muscle lactates and heart rate.. 63. Logan P. in those whom preoperative risk is indeterminate. . and applications Exerc Sport Sci Hev 1997.ll' Cuidelines for Exercise Testing and Prescription. Borg GA.56. Pollock ML. ACSM's I". et a!' V. Joint Bange of Motion and ManuaJ Muscle Strength. Blyant CX. and symptomatic responses are monitored for manifestations of myocardial ischemia. and f1exibilit~t in healthy adults. Sharpe GL. 54. Baltimore' Li!J!'incott Williallls & Wilkins 9001. 2001 :376-:380.58. Clarkson H. 50. typical angina. '~ . mediators. Assessmcnt of mllScnlar strength and endurance. Fitness & Lilestvle Approach:. CanadIan SOCIety lor ExerCIse PhYSiology. eds. Faulkner RA..57(3): 18. prognostic. A comparison of the sit and reach and the modi lied sit and reach in the measurement of flexibility in women. 1988:17. Helationship hetween repetitions and selected percentages of one repetitIon IncLXllllUTn: a comparison between untrained and trained males and females. 64. opu e a I 46. \IVasserman JF. Philadelphia: FA Davis. Fundamentals of Musculoskeletal Assessment Techniques.4(2):47-54 . DIAGNOSTIC EXERCISE TESTING Diagnostic exercise testing is best used in patients with an intermediate probability of angiographically significant coronmy altery disease (CAD) as determined by age. Kaminsky LA. or in patients with known or suspected pulmonary limitations.5-119. Hale DR. pmticularly in patients with chronic heart failure. ed. patients with a high probability of disease (e. Patterson P. In: Hoitman IL.5-141. Brubaker PH. ed. and symptoms (Table . Low Back Pain Syndrome. 47. The validity of' the modified sit-and-reach test in college-age students. Cailliet H." It also may be indicated in those who are about to start a vigorous exercise program (see Chapter 2). Med Sci Sports Exerc 19R3.3 9 0 . 2nd ed. lL: Human Kinetics. Canadian Society for Exercise Physiology. In. 55. J Cardi I R h· b'l 1997. electrical instability. Mental Health and Emotional Aspects of Sports. ed.Hopkms DH. Res Q Exerc Sport 1986. Nelson T.e. Noble BJ. 2000: 200-221.(. Morgan W. Clinical Exercise Testing • 5 •• •• CHAPTER Standard graded exercise tests are used in clinical applications to assess a patient's ability to tolerate increasing intcnsities of exercise while clectrocardiographiC (ECG). the standard exercise test is considered the initial diagnostic evaluation of choice regardless of gender. gender. Jacohs T. 48.:. ed. Hopkins DR. The Canadian Physical Activity. 19:2127-2 1:30. Helationship hetweeo repetition and selected percentages of one repetltlon m'LXImum. Diener MH.5-179. ed. Spine l(J94.92 SECTION II/EXERCISE TESTING 45. Validity and rcliahilitv of a onc-minute half sit-up test of abdomlllal muscle strength and endurance. American College of SPOlts Medicine. Lumhosacral movement in the sit-and-reach and in Culhet s protective-bamstring stretch. Fore CJ. Graves JE. I indicating at least a moderate risk of experiencing a serious cardiovascular event within .5:.5-991. Fomasiero D. 53. 2003.52R. Sports Med Training Hehah 199.5: 189-192. Diener D. Gas exchange and ventilatory responses also are commonly assessed during the exercise test. In general. Barette SL.3-11\6. Baltimore: Llpplllcott Williams & Wilkins. eds. espeCially in regard to exercise prescription (see Chapters 7 and 8).5.3: 191-19.523-.5-1). Golding LA.. Exercise electrocardiography for diagnostic purposes is less accurate in women largely because of a greater number of false-positive responses. Chicago: American Medical Associ'ltion 1976:126--129.27:22-26. ' . lies Q Exerc SPOlt 1994:6. Morrow JH Jr. 60. . However.. Champaign. 62.5 years. Epler ME. Hoeger WW. or those involved in occupations in which cardiovascular events may affect public safety. Perception of effort in the prescription of phvsical activity. Abernathy P..]4: 13. Can J Sport Sci 1989.30:97.6. Protocols for the assessment of isoinertial strength. <10%) of Significant CAD. Minkler S. 51.somcc Manual for Guidelines for Exercise Testing and Prcscription.n' adults hased on an analYSIS 01 two procedures. Position Stand: The recommended quantitv and qualitv of exerCIse for developmg and maintaining cardiorespiratOlY and nlUSClllar fltness. Baltlmore: Lippincott Williams & Wilkins.52.5:407--452. Protas EJ. Res Q Exerc Sport 1992. hemodynamic.1. Palmer ML. 49.57. Borg GA. In: HOitman JL.17:261-267. Brill PA. 61. :3rd ed. Sprigings EJ. prior coronary revascularization or myocardial infarction [MI]) are tested to assess residual myocardial ischemia and prognosis rather than for diagnostic purposes. ACSM's Hesource Manual I. Noble BI· Perception of physicaJ exertion: methods. Hobertson HJ. 1998. The relationship of the sit and reach test to criterion measures of hamstring anel back fleXIiJihty JJ1 young females. among postmyocardial infarction (post-MI) patients who wish to return to moderate heavy occupations.59. and therapeutic applications. 4th ed. Diagnostic exercise testing in asymptomatic individuals gcnerally is not indicated. . Med Sci Sports Exerc 1998. McQuarrie A. Musculoskeletal Assessment. PhiladelphIa: Llpplllcott-Baven. Flexibility and range of' motion. JAIJ I p Sport Sci Hes 1990. J Appl SPOlt Sci Hes W87. Hoeger WVV. WhaJeyMH. Asymptomatic individuals generally represent those with a low likelihood (i. J Orthop Sports Phys Ther 1998.P. Jackson AW. Indications and Applications The exercise test may he used for diagnostic. Hoeger WW. Baker AA. Although differences in test accuracy between men and women may be in the order of 10% on average. 3 8 1 . et aI.Jidity of rating of perceived exertion during graded exercise testlllg III apparently healthy adults and cardiac paticnts.g. PhYSlOloglcaJ tests for elite athletes. . eds. .5. Bareete SL. et a!' A partial curl-up protocol f. . CSEP-HeaJth ~ Fitness Program's Health-Belated Appraisal & Counseling Stratei\". Jackson AW. exercise testing may be useful in asymptomatic persons whcn multiple risk factors are present. et aJ. 1 93 65. Belations of sit-up and sit-and-reach tests to low back palll III adults. ~i~J~o~n \V.2. 1999. eds. .1(1):lJ-13. or other exertionrelated abnormalities.

and whether exercise capacity was measured directly or estimated should be considered. Committee on ExerCise Testing. and the duration of ST-segment depreSSion in recovely. exercise prescliption. In contrast. return to work evaluations. Pretest Likelihood of Coronary Artery Disease*t Age Gender Typical Definite Angina Pectoris Atypical/Probable Angina Pectoris Nonanginal Chest Pain Asymptomatic 30-39 40-49 50-59 60-69 Men Women Men Women Men Women Men Women Intermediate Intermediate High Intermediate High Intermediate High High Intermediate Very low Intermediate Low Intermediate Intermediate Intermediate Intermediate Low Very low Intermediate Very low Intermediate Low Intermediate Intermediate Very low Very low Low Very low Low Very low Low Low *See reference 1: Reprinted with permission from Gibbons RJ. Another studl 2 repOlted on 3. and evaluatIOn of medical therapy. Data derived from the exercise test are most useful when considered in context with other clinical data.7 METs over the average follow-up of 6. functional capaCity. Bricker JT. The magnitude of ischemia caused by a coronal)' leSIOn generally is proportional to the degree of ST-segment depresSIOn. the number of electrocardiographic (ECG) leads involved.:pected METs for age using a nomogram (Fig. the use of exercise testing in the evaluation of prognosis has changed. It is inversely propOltional to the ST slope. 5 . Duling an average follow-up of 6.] As contemporal)' therapies have led to dramatic reductions in mOltality after MI. that is. Other indicators of adverse prognosis in the post-MI patient include ischemic STsegment depreSSion at a low level of exercise (particularly if accompanied by reduced left ventricular systolic function). immediate exercise testing of selected low-nsk patients presenting to the emergency department with chest pain is now. Exercise capacity also may be reported as tlle percentage of e}.2 METs. Similarly. 5-1). Previous studies in persons \vithout known coronal)' altel)' disease have identified a low level of aerobic fitness as an independent risk factor for all-cause and cardiovascular mortali ty B. Several numeric indices of prognosis have been published and are discussed in Chapter 6. but it can be assumed that prevalence of CAD increases with age. there were no deaths among patients who averaged 2::9.94 SECTION II/EXERCISE TESTING CHAPTER 5/ CLINICAL EXERCISE TESTING 95 TABLE 5-1.g. Figure 5-2 shows the inverse relationship between peak oxygen uptake and subsequent mOltality. and to help estimate prognOsiS. (N = 215). and those with unremarkable ECGs and normal selial cardiac enzyme assays (e. Those \vith an exercise capacity of :::. and metabolic equivalent (MET) level achteved.4. \\~th 100% being normal (separate nomograms are provided for referred men \vith suspected CAD and in healthy men). systolic blood pressure. symptoms. In a few cases. I! Oxygen uptake at peak exercise on a cycle ergometer was directly measured 13 weeks after acute myocardial infarction (N = 312) or coronary mtel)' bypass surgel). Balady GJ. EXERCISE TESTING FOR DISEASE SEVERITY AND PROGNOSIS Exercise testing is useful for the evaluation of disease severity among persons with known or suspected CAD. and myocardial ischemia dming the exercise test must be considered together.1 years.4 METs. Submaximal tests may be used before .9 METs had a relative risk of death of 4. increasingly employed to "rule out myocardial infarction. Patients who have not undergone coronary revasculmization and are unable to undergo exercise testing appear to have the worst prognosis. low.' Normal standards for exercise capacity based on directly measured \10 2 .679 men with coronal)' disease who were referred for treadmill exercise testing for clinical reasons. the double product at which the ST-segment depreSSion occurs.1 compared to those \vith a fitness level 2::10.harge (as early as 4 days after MI) for prognostiC assessment. disability assessment. et al. Symptom-limited tests are usually performed at more than 14 days after MI. patients with ages at the extremes of the decades listed may have probabilities slightly outSide the high or low range. 4 Generally. High Indicates >90%. findings from the National Exercise and Heatt Disease Project among post-MI patients demonstrated that evel)' I-MET increase after the training The use of maximal or sign/symptom-limited exercise testing has expanded greatly to help guide decisions regarding medical management and surgical therapy 111 a broad spectrum of patients. respectively. For eve I)' 1MET increase in exercise capacity there was a 12% improvement in survival. Information related to lisk factors. All tests were terminated at a comparable endpoint. intermediate.acc.htm tNo data eXISt for patients who are <30 or >69 years. Low-level exercise testing provides sufficient data to make recommendations about the patient's ability to safely perform activities of daily living and serves as a guide for early ambulatOl)' exercise therapy. hospital discharge at 4 to 6 days after acute MI.2 years. and a hypotensive blood pressure response to exercise. 2002. exercise mode. functional capacity of less than 5 METs. <5%. American College of Cardiology web site: www.4.6 EXERCISE TESTING AFTER MYOCARDIAL INFARCTION Exercise testing after MI can be performed before or soon after hospital disc. 10%-90%."3 and help make deCISions regarding which patients require hospital admission.. 33 and 20 patients died of cardiovascular and noncardiovascular cases. and very low. Those with the highest cardiovascular and allcause mOltality averaged :::. This information can be valuable for activity counseling. no appreCiable rise in the level of troponin).mLx are also available for women and by ageS When using a pmticular regression equation for estimating percentage of normal exercise capacity achieved. investigators extended these analyses to 527 men with cardiovascular disease who were referred to an outpatient cardiac rehabilitation program. For example. Functional capacity can be evaluated based on percentile ranking (based on apparently healthy men and women) as presented in Table 4-8. a report of the American College of Cardlologyl American Heart Association Task Force on Practice GUidelines.orglcllnlcaVguldellneslexerciseldirlndex. and the maximal healt rate. volitional fatigue. ACCIAHA 2002 GUideline Update for Exercise Testing. FUNCTIONAL EXERCISE TESTING Exercise testing is useful to determine functional capacity. factors such as population speCifiCity. <10%.lO Recently. patients who may be safely discharged include those who are no longer symptomatiC. activity prescliption.

Treadmill testing provides a more common form of physiologic stress (e. higher oxygen consumption (\10 2 ) and peak heart rate than during cycle ergometer testing 14 . Froelicher VF. walking) in which subjects are more likely to attain a slightly . and should be discouraged. et al. J Am Coli CardioI1993. Nomogram based on metabolic equivalents and age for assessing aerobic exerci'se capacity in men. regardless of the study group assignment. but holding the handrails can reduce the accuracy of estimated exercise capacity and the quality of the ECG recording.96 SECTION II/EXERCISE TESTING CHAPTER 5/ CLINICAL EXERCISE TESTING 97 Exercise Capacity (% of Normal in Referred Men) 20 25 30 35 40 45 50 CIl Cl Exercise Capacity (% of Normal in Healthy Men) o 20 25 0 2 3 Sedentary 4 30 35 40 45 Active 50 50 60 2 3 4 5 6 7 8 lJ) 5 60 70 80 90 100 80 110 90 120 130 100 140 110 150 120 130 140 150 Active 6 7 ~ 8 9 10 « :: w CIl Cl 50 55 60 65 70 75 80 55 60 65 70 75 80 85 90 « 70 60 70 80 90 80 90 00 10 110 110 120 120 Sedentary 130 130 140 140 150 150 ~ 9 w 10 11 12 13 14 15 16 17 18 :: 11 12 13 14 15 85 90 (FIGURE 5-1. Myers J. (continued) See reference 7: Reprinted from Morris CK. with permission from the American College of Cardiology Foundation.15 The treadmill should have handrails for patients to steady themselves.. Nomograms of percent normal exercise capacity in men with suspected coronary artery disease who were referred for clinical exercise testing (this page) and in healthy men (page 97) period conferred an approximate 10% reduction in mortality [i·om any cause. 11 FIGURE 5-1. However. it may be necessary for some individuals to hold the handrails Exercise Test Modalities The treadmill and cycle ergometer are the most commonly used devices for clinical exercise testing.g. over a 19-year follow-up.22:175-182.

1) less movement of the patient's arms and thorax during cycling.. 1 MET per stage or lower). © 1994 American College of Cardiology Foundation. 40 Peak 02 uptake (mL·kg-1.. However. Arm ergometer tests can be used for activity counseling and exercise prescription for certain disabled populations (e.... but increases in ramp r~lshion. ..... An emergency stop button should be readily available to supervising staff.. such as Naughton or Balke-Ware (i.. 30 """"'.20 have been used.. because of localized leg fatigue) before a cardiopulmonary endpOint has been achieved. ~ Exercise Protocols The protocol employed for an exercise test should consider the purpose of the test. however.: 10 0 .......30 .e.... ~ :'::: I1l >. in which the work rate increases in a constant and continuous manner. lightly for balance... it employs relatively large increments (i. and individuals who perform primarily dynamiC upper body work during occupational or leisme-time activities..min... 40 Peak 02 uptake (mL·kg. 10 """"" 20 .19... and the characteristics of the individual bein a tested.... such as the BSU/Bruce ramp. require less space..98 SECTION II I EXERCISE TESTING CHAPTER 5 I CLINICAL EXERCISE TESTING 99 40 __... and make less noise than treadmills. Shaded area represents 95% confidence limits. Incremental work rates on an electronically hraked cycle ergometer are more sensitive than mechanically braked ergometers hecause the work rate can be maintained over a wide range of pedal rates. Lower \'alues for \'02m'" during cycle ergometer testing (versus treadmill testing) can range from 5% to 25%.g.. it is easier to obtain better quality ECG recordings and blood pressure measurements . the specific outcomes desired. METs per stage) evelY 3 minutes. Both individualized 19 and standardized ramp tests. Protocols with larger increments (e. 40 __. the test may end prematurely (i.. Fagard R.e..... Consequently.... Advantages of the ramp approach include the follOWing: 15 • Avoidance of large anclunequal increments in workload • Uniform increase in hemodynamic and phYSiologic responses • More accurate estimates of exercise capacity and ventilatOly threshold • Indi\~dualizing the test protocol (individualized ramp rate) • Targeted test duration (applies only to individualized ramp protocols) :'::: 30 m ... changes in phYSiologic responses tend to be less uniform and exercise capacity may be markedly overestimated when it is predicted from exercise time or workload. many of the major treadmill manufacturers recently developed controllers that ramp speed and grade. 20 en ~ o 10 U 0... stationalY cycling is an unfamiliar method of exercise for many and is highly dependent on patient motivation.. ThiJs L.20 Although ramp testing using a cycle ergometer has been available for many years.. spinal cord injUly)........ 20 -... et al Prognostic significance of peak exercise capacity in patients with coronary artery disease...1 ·min.lb it has been largely replaced by the nonexercise pharmacologic stress techniques that are described later in this chapter. Cycle ergometers are less expensive. See reference 11: Modified from Journal of the American College of Cardiology.. The former test individualizes the rate of increase in intensity based on the 'suhject.e.... whereas protocols with smaller increments. depending on the participant's conditioning and leg strength...... Ellestad) are better suited for screening younger and/or phYSically active individuals..... Vanhees L.. Some of the most common exercise protocols and the predicted \10 2 fo~ each stage are illustrated in Figure .. V0 2max during ann exercise is generally 20% to 30% lower than that obtained during treadmill testing J7 Although this test has diagnostic utility. 1-1-16 Arm ergometry is an alternative method of exercise testing for patients who cannot perform leg exercise. o E u j ~ I1l >- ~ .. 10 . Because a smaller muscle mass is used during arm ergometry. Thus..........1 ) FIGURE 5-2. Relation between peak oxygen uptake with all cause mortality (top) and cardiovascular mortality (bottom) in patients with coronary artery disease. Because there is .g. 30 . o j E 20 Ql en I1l ~ :..-... The ramp protocol is an alternative approach to incremental exercise testing that has gained popularity in recent years.... are preferable for older or deconditioned individuals and patients with chronic diseases. 23(2) 358-363. and the latter matches work rates to equivalent time periods on the commonly used Bmce protocol.- ..15. The Bl'1lce treadmill test remains the most commonly used protocol.... Bruce.5-3.

0 5 3.0 3.0 MPH/%GR 3.0 7.0 3.0 0 2. NAUGHTON (CHF) METS .0 3.3 5 2 I I I 3.5 0 0 3.0 0 0 2 III :.0 15 10 3.0 3.0 6.0 24.0 3.0 14.0 !:i c( >J: 13 12 12 11 10 10 9 3.0 2.0 3.5 *2 . '-- I- w 10 14. en c - ~3 .0 3.0 2.1 2 3.1 =lt6 I - I 20 f----- 19 19 f----- 18 f----- 18 " z c( uf 0 ~Ol 4..1 I I 16 15 I 25 I 22.0 25.0 RAMP - FUNCTIONAL CLASS CLINICAL STATUS O2 COST METS ml/kg/min I~I r TREADMILL PROTOCOLS BALKEWARE USAFSAM "SLOW" USAFSAM MODIFIED BALKE ACIP MOD.0 14.0 5.0 3.3 MPH 18 18 17 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 MPH/%GR 3.0 3.5 1.l.1 24.0 10.5 3.0 3.J.0 10.0 3.5 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 150 (24) 900 (148) 750 (123) 1350 (221) 1200 (197) 1050 (172) 1500 (246) I 20 %GRADE AT 3.0 3.0 17.0 MPH/%GR 3. FIGURE 5-3.5 I 20 I 15 I 10 I 7.0 3.0 0 1.0 3.0 3.0 3.5 7.0 24.5 I I 0 0 4 f----- .0 10.4 24.0 MPH/%GR 2 25 22.0 3.0 3.0 8.0 3.7 300 (49) 12 '"I I 7 f----- II w c w i5 z I.0 3.3 25 MPH/%GR 3.5 0 2.0 3.0 9.0 2.0 16.1 8 2.5 f----8 3.0 3. 12 ll.0 22.0 3.5 t::n UT ~? 2 3.Rue.5 FOR 70 KG BODY WEIGHT Kpm/min (WATTS) 5.0 2.5 600 (98) 450 (74) 1.5 1.0 3.0 3.0 4.3 15 I 17.0 2.0 3.0 11.0 I I I I 10..0 3.0 7.0 112.5 21.2 I 16 !:i c( J: J: &= • ~ 35.0 I 0 1 .5 I 7.5 49.3 10 2 12."iI 2.0 3.0 3.4 I 3.0 21.0 1 MIN STAGES 21 f----- I 20 :> () c( >I- 63 59.5 w ll.0 3.--"1 100 SECTION II / EXERCISE TESTING CHAPTER 5/ CLINICAL EXERCISE TESTING 101 I BICYCLE ERGOMETER BRUCE 3MIN STAGES MPH/%AGR 5.0 15.3 2.0 17.0 0 3.0 18.0 0 2.5 56.0 0.n IDI L- IV - ~31 5 3 1.0 3.0 52.0 f----- >ex: ~"- j.5 28.5 21.0 45. • I 1. Common exercise protocols and associated metabolic costs of each stage.0 31.0 17.0 3. >en I 3.0 20.5 10 7.8 17 f----- I 16 f----- NORMAL AND I I PER 30 SEC MPH/%GR 3.0 3. RAMP 1ERMIN ?H/%GR 5.5 5 2.0 3.0 20 17.51 16 4. w z w c z c >=" w >-- I- 15 f----- I 4.5 15 3.0 3.0 3.0 23.0 3.5 11 f----- I I I I 14 10 f---- I I I 25 3.0 38.0 3.0 12.0 1..0 13.0 19.0 2 f----- """'" IIIl.0 6 f----- 5 f----- :E ~ :::i :.5 14 f----- 13 f----- 12 f----- 14 3.5 42.5 20 3.0 3.0 3.5 2.0 2.4 I I I 14 +1 .0 3.8 f----- 73.0 3.5 70 66.5 i= -1 .0 0 0 0.5 () 3.3 20 3.

I pI b .Ol ' mos ' . crlll'1Y be considered. " WI'tl1 type of cardiac event or interventional procedure. have been applied to a broad spectrum of patients. t "sk for serious arrhythnm1s or bl d ' of s'1fety. .~..dlninistered a Tests 'Slmu atmg . cular contJactJOn. For pattents a I I . t Y EC e mOll!'t" olln b ' 0 ischemia am 'uIf a 01 I t'. 'J III 'd'Ica tes t le recommen .. b d Irst. increments of 10 to 15 watts (1 \V == 6. preferably before hospital discharge. d Illg. t of the patIent s JO 0 . Blood pressure can be measured with the individual dropping one arm and continuing to arm crank witb the other. r' b d d ell'fr . may benefit from fUliber unctlOna es Balbi ' t'ents \\'1'tb borderline IJbysical d 'I tI eXT especr y p. or modified from an eXisting stationaIy cycle ergometer by replaCing the pedals \vith handles and mounting the unit on a table at shoulder height. may help establish reasonable return-to-work expectations./ can measured or estImate pe. However. ' t ' 'b'l'ty to resume work \vithin a . leisp~ltlseand decrease in stroke volume ' " .. 'f aerobIC reqUlremen s I ' I de I. Increases in grade of 1% to 3% per minute. or other adverse signs or symptoms. to work involving a static musologic responses include a greaterpressoj. informatlOn IS aval a e o . \vith about 15% to 20% of patients failing to resume work.emen t'ave I. . ts ~n return-to-work status is well test (eXT) in evaluating and co~nse mg pa le~lln IlelIJ '1ssess IJrocrnosis. /' b of work not evaluate \\'1t 1 a ' . " b . d >~ F' tl ' tient s responses c. as we. subst-lntialJ)1 ' I i ' J t f lcr i JO eman s IIel . Most job 0 scribed for a home exercIse proglam e. 2-t Measurements During Exercise Testing " linical exercise testing include beart rate and Common variables assessed dUllllg c" 11 as signs 'md symIJtoms.l ( .12 kg'm' min -I) per minute can be used on the cycle ergometer for elderly persons. However . 'I. . work capacity III re atJOns IIp ' I ' those concerned about resuming a pbySitant left ventriclJ lar dysfunctiOn .2~ Both medical and nonmedical factors contribute to tbis loss of employment. or during brief rest periods between stages. Although no longer \videly used.1 1 from that evaluate \\'1t 1 le '" d' b deillands those \\~th concomi" l' I' to tbe 'lIltlclpate JO . teness for returning to occuwork and is t)lJically performed to assess appl OP! 1'1 pational activities. work sllllUlators e. nses 'llso are common yev. I . e blood pressure. . le pa _ 'h' be comIJared to the estimate establishe . some pattents return-to-wor status t O I l .tl e m'lJonty 0 cm lac p a . EC c langes.2~ The appropriate time to return HEART RATE AND BLOOD PRESSURE cr .g" a 1m I ' t 't '11 be set UIJ to evaluate t)'P >6 I I I' Ie ineA-pensl"e es s c. .' d 'lk MEl capacI.b 'tt e'1VY work' 24 r T)mical physl' tu ' t'ess an d IIltelml en t I 1. . Work rates are adjusted by altering the cranking rates and/or resistance against the flywheel. Testing for Return to Work The decision to return to work after a cardiac event is a complex one.. associated to wor k valles I' t' and IJrocrnosis d ' comp Ica Ions. su . SIJecw!Jze 'b b I. 1 bl'edlve ratmgs. . tasks require less than 5 METfs. such as a heart rate of 120 beats'min -lor a MET level of5. Ideally.. . IS le on. to 5 '/0 . \Vork rate increments of 10 \V evelY 2 to 3 minutes.it should be individualized so that the treadmill speed and increments in grade are based on the subject's capability. I . increments in work rate should be chosen so that the total test time ranges between 8 and 12 minutes. ~ re durin the Heart rate and blood pressure should be measlUle ded fl'equency graded exercise test. . d "d '11 or c Icle ergometer grade exercise The value of a symptom-limIte t. gen deman 'b when insufficient ' s \\'1t l ' 1 IIItl ellt' I k(s) in questIOn can e . d b eo. and for patients who may be at high risk for serious rhythm disturbances.g" om \\~thin UPPER BODY EXERCISE TESTING An arm cycle ergometer can be purchased as such. 1 'llmted during the . llallds are considered appropnate I d >5 F ' t IYltients p lyslca deman S. . disease patients. " . d reason a e eglee. can be used for treadmill tests for these same populations.a t 10Ug 1 sImp. 'k' b'lleel \\~th light dynamiC C j' Itt 1 '1VY St'ltlC WOl com I evaluate tolerance lor Igl Ole.I. ane~od 'd' 'oIJortionate m)locardial demands d ' 'b 0 Job tasks tllat pi 0 uce ISPI k cally deman ' ' . 'ocrreSSlve nse m leal Ia e . Expired gases and venti atOly lespo " uch 'lS heart failure and pulmonaty exercise test. ' t t leeeled to IJro\~de realistic advice on I eXT ' tI I)' hlJe 0 exercIse es I . "1ges less than or equal.. but this may vary based on the patient and clinical judgment. Id \T'11IJar work simulators) also ' on the. _>4 A 'I t c'11'l'Vin test can be used to cr d ' I ' eXl welg 1 -. ' requlJ . Early discussion of work-related issues \vitb patients.lea m~. and 4) determine speCial work-related needs orjob contacts. at a cranking rate of 50 to 60 IFm. wor' lOse requlJ Illcr Statl'c . .22 Arm ergometiy is best performed in the seated position with the fulcrum of the handle adjusted to shoulder height. Discussion \\~th the patient could include a job histOJY analysis to: 1) ascertain job demands and concerns. b t assess eXIJected relative energy . s .5 to 2. and patients \·\~th cardiovascular or pulmonmy disease. adjusting the medical regimen. and after and .I de t1 '" muscular contraction. . . l bl t detenmne a patlen s a I I . \~Tork assessment and counseling are useful in optimiZing return-to-work decisions. 2) establish tentative time lines for work evaluation and return. deconditioned individuals. These tests are stopped frequently at a predetermined level. \\~th constant belt speeds of 1. When performed in this manner.102 SECTION" / EXERCISE TESTING CHAPTER 5/ CLINICAL EXERCISE TESTING 103 Whichever exercise protocol is chosen. submaximal tests have been useful in risk stratifying post-MI patients. Second. these can be braked either mechanically or electrically.le as . Electrocardiographic leads should be placed to minimize muscle artifact from upper body movement. B 0 'e T lerapeu IC al . . Ta bI e 5 -:.2:3 Blood pressures can also be measmed at the thigb dming arm ergometlY testing.5 mph. es are available.deman ~ e. Similar to leg cycle ergometers.2J For example. .l eXT compare to' a IIlC ' .. post-iVfI evaluations. combined \\'lth tempera me s I . abnormal blood pressure responses. ane a su e d 'I' t 'n'ttent hem')' work. particularly III certalll glOupS.g(" 809f IJeak METs or lower). . submaximal testing can be an appropriate choice for predischarge. and identifying the need for further interventions. Submaximal tests can be useful for making activit} recommendations.. d len increase in myocardIal OAyover time for work in a hot ell\'1ronment.'.5--45 minutes) are guidelmes prepeak METs and peak Job . eneltture the 8-hour enelg) exp 'd ( . 3) individualize rehabilitation according to job demands. systolic blood pressures taken by the standard cuff metbod immediately after arm crank ergomet!y are likely to underestimate "true" physiologic responses.} " f 'd'" tl'ellts T le k C .

Gas exchange Baseline reading to assure proper operational status Obtain peak exercise value then not measured in recovery Generally not needed in recovery ELECTROCARDIOGRAPHIC MONITORING A high-quality ECC is of paramount importance in an exercise test. SP. Signal processing techniques have made it possible to average ECG waveforms and remove noise. and then every 2 min thereafter Inaccurate sphygmomanometer Improper cuff size Al. recorded as observed for blood pressure assessment at rest and potential sources of error during exercise. The general areas for electrode placement should be shaved. the test should be stopped. . ~. but caution is urged because signal averaging can actually distort 'See Reference 44: Adapted. if hair is present. ratings of perceived exertion. IL: Human Kinetics 20(J2:182. representing the inferior. recorded as observed Recorded during the last 5 sec of each minute Measured continuously Monitored continuously. without corresponding signs and symptoms. heart rate. each JaboratOlY so that baseline measures can be assessed more acc <. Whaley MH. (See Box 5-2 for test termination criteria. xes .. Monitored continuously. recorded during the last 5 sec of each minute Measured and recorded during the last 45 sec of each stage (interval protocol) or the last 45 sec of each 2 min time period (ramp protocols) Monitored continuously. three leads.Iditory acuity of technician Rate of inflation or deflation of cuff pressure Experience of technician Reaction time of technician Faulty equipment Improper stethoscope placement or pressure Background noise Allowing patient to hold trea'dmill handrails or flex elbow Certain physiologic abnormalities (e. arteriovenous fistula) *. respectively. It is important to lower the resistance at the skin-electrode interface and thereby improve the signal-to-noise ratio. ' y plone 0 <utI act. Twelve leads are available. The superfiCial layer of skin then should be removed using light abrasion '""ith finegrain emery paper or gauze. or if it drops below the value obtained in the same position before testing.104 SECTION" / EXERCISE TESTING CHAPTER 5/ CLINICAL EXERCISE TESTING 105 TABl~ 5-2. < lila e y w len Although numerous devices have been devc10IJed to 'lUtOlll'lte blood me'lS' t d " < < pressu re < 1II emen s unng exerCise. recorded as observed Explain scale Monitored continuously. by permISSion from Brubaker PH K . recorded during the last 15 sec of each stage (interval protocol) or the last 15 sec of each 2 min time period (ramp protocols) Monitored continuously. anterior. • • ~. it should be retaken immediately. . seconds sequence of these measures. subclavian steal syndrome. t II et I 01 repeat testing is performed. they arc genenlJ .g. recorded during the last 5 sec of each minute • Measured and recorded immediately postexercise and then every 2 min thereafter Signs and symptoms RPE Monitored continuously. ' amlns y LA. 'f' h . recorded supine position and posture of exercise Measured and recorded in supine position and posture of exercise Monitored continuously. use of torso leads should be noted on the ECG. ECG • Monitored continuously.an . t . recorded supine position and posture of exercise HR:I: BPH Monitored continuously.suggest methods . the limb electrodes commonly are affixed to the torso at the base of the limbs for exercise testing.commended Monitoring Intervals Associated with Exercise Testmg* Variable Before Exercise Test During the Test A fter Exercise Test : I Potential Sources of Error in Blood 'Jf1. The electrodes then are placed according to standardized anatomic landmarks (see Appendix C). do not warrant test termination. .. If systolic blood pressure appears to be decreasing with increasing exercise intensity. t us manual medSUl ements remalll the preferred method Bo 34 d51 . sec. damaged brachial artery. and cleansed with an alcohol-saturated gauze pad. and lateral distribution are routinely monitored throughout the test. Coronary Artery tNotes An unchanged or decreaSing s t I bl d verified Immediately) ys 0 JC 00 pressure with increasing workloads should be retaken (I e tin addition BP and HR should be a d d OCcur ssesse an recorded whenever adverse symptoms or abnormal ECG changes Abbreviations: HR. however. 23 Substantial breast tissue or abdominal adiposity may warrant modification of standard electrode placement to minimize movement artifact. 28 Because torso leads may give a slightly different ECG configuration when compared with the standard 12-lead resting ECG. during the last 15 sec of first minute of recovery. Because electrodes placed on wrists and ankles obstruct exercise and cause artibet. blood pressure. RPE.27 If a drop in systolic blood pressure of 10 mm Hg or more occurs with an increase in work rate. Proper skin preparation is essential for recording the electrocardiogram..) Anxious patients who demonstrate a drop in systolic blood pressure during the onset of exercise. k Disease: Champaign. recorded immediately post-exercise. particularly if accompanied by adverse signs or symptoms. A standardized procedure should be 'ldo Jt If. Re.

the patient should be given clear and concise instructions for use of the selected scale. Bricker JT. 4..g. degree of chest pain.. et al ACCIAHA 2002 Guideline Update for Exercise Testing. Excruciating and unbearable Dyspnea 1. Generic instructions for explaining either scale are provided in Chapter 4. Mild. leg cramps. In general. claudication. scale or the 0-10 categOl)'-ratio scale (see Chapter 4) mav be used to assess RPE during exercise testing. However. 4. using filtered data to aid in the interpretation if no distOltion is obvious. 2. in the absence of other evidence of ischemia • ST or QRS changes such as excessive ST depression (>2 mm horizontal or downsloping ST-segment depression) or marked axis shift • Arrhythmias other than sustained ventricular tachycardia. discomfort. by conversation) 3. or claudication • Development of bundle-branch block or intraventricular conduction delay that cannot be distinguished from ventricular tachycardia • Increasing chest pain • Hypertensive response (systolic blood pressure of >250 mm Hg and/or a diastolic blood pressure of > 115 mm Hg). Use of alternative rating scales that are specific to subjective symptoms are recommended when subjects become symptomatic during exercise testing. 'See reference 1: Modified from Gibbons RJ. Definite discomfort or pain. 2002. Patients are asked to provide subjective estimates during the last 15 seconds of each exercise stage (or every 2 minutes during Hamp protocols) eithcr verbaJly or manually..g. Somatic ratings of perceived exertion (RPE) and/or . burning. Either the 6-20 categOl). Frequently used scales for assessing the patients' level of angina. wheezing. but on'" of initial or modest levels (established. 2H Moreover. the individual can provide a number verbally or point to a number if a mouthpiece or face mask is being used. 2.0 mm) in leads without diagnostic Q-waves (other than V. when accompanied by other evidence of ischemia • Moderately severe angina (defined as 3 on standard scale) • Increasing nervous system symptoms (e. including multifocal PVCs.:JO GAS EXCHANGE AND VENTILATORY RESPONSES Because of the inaccmacies associated \\~th estimating o>. leg discomfort/pain) should be assessed routinely dming clinical exercise tests. from which the patients attention can be divert4) from which the patients attention cannot be pain Light..g. a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Committee on Exercise Testing.5 Before the start of the exercise test.orglclinical/guidelineslexercise/dirlndex. or aVR) RELATIVE INDICATIONS • Drop in systolic blood pressure of > 10 mm Hg from baselinet blood pressure despite an increase in workload. Therefore. Moderate discomfort or pain ed (e. dizziness. very uncomfortable Most severe or intense dyspnea ever experienced the signal.htm tBaseline refers to a measurement obtained immediately before the test and in the same posture as the test is being performed. shortness of breath. many laboratories directly measure expired gases. barely noticeable Moderate. For example. treadmill speed and grade). but minimal) 2. 2. specific symptomatic complaints (e.acc. it is important to consider the "real timc" ECG data first. reaching a rating of 3 on the angina scale or a degree of chest discomfort that would cause the patient to stop normal daily activities. ataxia. supraventricular tachycardia. The exercise technician should state the number out lond to confirm the correct rating. Intense pain (short of grade diverted 4. andlor dyspnea are as follows: Angina ]. bothersome Moderately severe. triplets of PVCs. Balady GJ. The direct measurement of \'0 2 has been shown to be more reliable and reprod"cible than estimated values from treadmill or cycle SUBJECTIVE RATINGS AND SYMPTOMS The measurement of perceptual responses during exercise testing can provide useful clinical information. very uncomfortable Most severe or intense pain ever experienced Claudication 1. are reasons to terminate thc exercise test. or near syncope) • Signs of poor perfusion (cyanosis or pallor) • Technical difficulties monitoring the ECG or systolic blood pressure • Subject's desire to stop • Sustained ventricular tachycardia • ST elevation (+ 1. higher levels of dyspnea or claudication may be acceptable during the exercise test.e. 3. bothersome Moderately severe. or bradyarrhythmias • Fatigue. barely noticeable Moderate. heart block. most manufacturers do not specify how such procedures modify the ECC.ygen consumption and METs from work rate (i. 3. American College of Cardiology web site: www. dyspnea.106 SECTION II/EXERCISE TESTING CHAPTER 5/ CLINICAL EXERCISE TESTING 107 ABSOLUTE INDICATIONS • Drop in systolic blood pressure of > 10 mm Hg from baseline t blood pressure despite an increase in workload.

whereas relative indications sometimes may be superseded by clinical judgment.:3:3 and most oximeters are inaccurate at an S.:Jl Carboxyhemoglobin (COHb) levels greater than 4% and black skin may adversely affect the accuracy of pulse oximeters.108 SECTION II/EXERCISE TESTING CHAPTER 5/ CLINICAL EXERCISE TESTING 109 ergometer work rate.. Ha\1ng the patient perform a cool-down walk after the test may decrease the risk of hypotension but can attenuate the magnitude of ST-segment depression.02) from oximetty at rest correlate reasonably well \~th S. hemodynamics. Peak \10 2 is the most accurate measurement of functional capacity and IS a !Iseful index of overall cardiopulmonmy health S In addition. In patients who are severely dyspneic. including proper lead placement and skin preparation Knowledge of endpoints of exercise testing and indications to terminate exercise testing BLOOD GASES Pulmonary disease should be considered in patients who exhibit \\~th dyspnea on exertIOn. The measurement of mmute ventilation also should be collected whene\'er gas exchange responses are measured. patients should be placed supme dunng the postexercise period. the supine posture may exacerbate the condition. measurements of m. 102: 1726-1738. and sitting may be a more appropriate posture. \!\Thcn the test is being performed for nondiagnostic purposes. an active cool-down usually is preferable. STsegment changes that occur only during the postexercise period are currently 15 recognized to be an important diagnostic part of the test. risks. As such. an integrated analysis of these measures can be useful for differential diagnosis S F11Ithennore. Postexercise Period If maximal sensiti~ity is to be achieved with an exercise test.re and specIfic substrate contribution during physical acti\1ty.0-1.: . Ayanian JZ.:14 although it is advantageous to record about 10 seconds o[ ECG data while the patient is in the upright position immediately after exercise [or ECG clarity at peak exercise heart rate. but the additional information can provide useful physiologIC data. Circulation 2000.5 mi·h -I) or continued cycling against minimal resistance. It IS also ImpOltant to measure gas pmtial pressures in these pattents because oxygen desaturation may occur during exertion. the rate in which heart rate recovers from exercise recently has been demonstrated to be 36 3 an important prognostic marker and is discllssed in Chapter 6. Absolute indications are unambiguous. and risk assessment of testing Knowledge to promptly recognize and treat complications of exercise testing Competence in cardiopulmonary resuscitation and successful completion of an American Heart Association-sponsored course in advance cardiovascular life support and renewal on a regular basis Knowledge of various exercise protocols and indications for each Knowledge of basic cardiovascular and exercise physiology. slow walking (1. 'See reference 35: Adapted from Rodgers GP.. Balady GJ. . Measurement of gas exchange and ventilation is not necessmy for all c1l11lcal exerCise testmg. for example. Because h~art and hll1g diseases frequently manifest as ventilatory or gas exchange abnormahttes dunng exercise. Although measurement of P. et al American College of Cardiology/American Heart Association c1il1lcal competance statement on stress testing.. Situations in which gas exchange and ventilatlOn measurements are appropriate include the following: I • \"!hen a precise cardiopulmonmy response to a specific therapeutic intervention is required • When the etiology of exercise limitation or dyspnea is uncertain • When evaluation of exercise capacity in patients with heart failure is used to assist in the estimation of prognosis and assess the need for transplantation • \"!hen a precise cardiopulmonary response is needed within a research context • When assisting in the development of an appropliate exercise prescription for cardiaC and/or pulmonaty rehabilitation • • • • • • • • • • • • • I' • Knowledge of appropriate indications for exercise testing Knowledge of alternative physiologic cardiovascular tests Knowledge of appropriate contraindications.ygen saturation (S. collection of gas exchange and ventilatOlY responses arc increasingly being lIsed in clinical tlials to objectively assess the response to specific interventions..02 measured from mterial blood (95% confidence limits are ± 3% to 5% saturation). AlteJial blood gases may be obtained if clinically warranted. the measurement ofV0 2 carbon dioxide (VC0 2) and the subsequent calculation of the respiratory exc!1ange ratio (RER) can be used to determine total energy expenditu.:l2. including hemodynamic response to exercise Knowledge of cardiac arrhythmia and the ability to recognize and treat serious arrhythmias Knowledge of cardiovascular drugs and how they can affect exercise performance.02 and P"C02 from arteJial blood has been the standard in the past. . Monitoring should continue for at least 5 minutes after exercise or until ECG changes return to baseline and significant signs and symptoms resolve. INDICATIONS FOR EXERCISE TEST TERMINATION The absolute and relative indications for termination of an exercise test are listed in Box 5-3.02 of 85% or less. and the electrocardiogram Knowledge of the effects of age and disease on hemodynamic and the electrocardiographic response to exercise Knowledge of principles and details of exercise testing. Hemodynamic variables (heart rate and blood pressure) also should return to ncar-baseline levels berore discontinuation of monitoring. In patients \~th pulmonary disease.: In addition. the avmlablhty of oximetry has replaced the need to routinely draw mterial blood in most patlents.

Technetium-99m permits higher dosing v. As a result. Perfusion defects that are present during exercise and persist at rest suggest previous MI or scar. multiple myocardial segments can be \iewed individually.ith a relatively increased flow to normal arteries and a relatively decreased flow to stenotic arteries. Thns.:J9 Perfusion defects that are present during exercise but not ELECTRON BEAM COMPUTED TOMOGRAPHY Although not an exercise test per se. It is infused intravenously and the dose is increased gradually until the masimal dose or an endpOint is achieved. and echocardiographic images are obtained throughout the infusion. it is important to quantify the extent and distribution of myocardial ischemia. ECG. as well as to determine the extent of myocardium at risk as a result of ischemia. among whom it is most often noted. angina. or akinetic wall motion to develop or worsen in the affected segments. PHARMACOLOGIC STRESS TESTING Patients unable to undergo exercise stress testing tor reasons such as deconditioning. Although EBCT has been highly promoted in the .ith pharmacologic infusion. Indications for these tests include establishing a diagnosis of CAD. \\ithout the overlap of segments that occurs \·vith planar imaging. serious arrhythmias. orthopediC disabilities. and the presence and extent of calcium is closely related to atherosclerosis. particularly in elderly people. The two most commonly used pharmacolOgiC tests are dobutamine stress echocardiography and dipyridamole or adenosine stress nuclear SCintigraphy. Echocardiographic images at rest are compared with those obtained during cycle ergometry or immediately after treadmill exercise.ith less radiation exposure than thallium and results in improved images that are sharper and have less artifact and attenuation. A common protocol with technetium is to perform rest images 30 to 60 minutes after intravenous administration of technetium followed by exercise (or pharmacologic stress) 1 to 3 hours later. There are several different imaging protocols using only technetium (Tc)-99m or thallous (thallium) chloride-20l. Hemt rate. blood pressure. Stress images are obtained 30 to 60 minutes after injecting technetium approximately 1 minute before completion of peak exercise. Nuclear perfusion imaging under resting conditions is then compared v. Myocardial contractility normally increases with exercise. whereas ischemia causes hypokinetic. Rest and stress images are compared side-by-side in a cine-loop display that is gated during systole f)'om the QRS complex. but not in stenotic segments. determining myocardial viability before revascularization. calcium also may stabilize plaque. The limitations of nuclear imaging inclnde the exposure to low-level ionizing radiation.:J8 Advantages of exercise echocardiography over nuclear testing include a lower cost. technetium is the preferred imaging agent when performing tomographiC images of the heart using single photon emission computed tomography (SPECT). Furthermore. and concomitant illness often benefit from pharmacologic stress testing.110 SECTION II/EXERCISE TESTING CHAPTER 5/ CLINICAL EXERCISE TESTING 111 Exercise Testing With Imaging Modalities Cardiac imaging modalities are indicated when ECG changes from standard exercise testing are non diagnostic. Dipyridamole and adenosine cause maximal coronmy vasodilation in normal epicardial arteries. approximately 5% of patients have inadequate echocardiographic windows secondary to body habitns or lung interference. and a Significant increase or decrease in blood pressure. timely images. intolerable side effects.ith imaging obtained after coronmy vasodilation 4o Interpretation is similar to that for exercise nuclear testing. stopping at preset angles to record the image.ith a nuclear imaging agent. However. a coronary steal phenomenon occurs.. and a physician trained in nuclear medicine to reconstruct and interpret the images. Cardiac images then are displayed in slices frolll three different axes to allow visualization of the heart in three dimensions. Consequently. SPECT images are obtained with a gamma camera. EndpOints may include new or worsening wall-motion abnormalities. electron beam computed tomography (EBCT) is being used increasingly to screen asymptomatic and high-risk individuals to detect CAD. Significant ST depression. EBCT is highly sensitive for detecting coronmy artery calcium. additional equipment and personnel are required for image acquisition and interpretation. Dobutamine elicits wall motion abnormalities by increasing hemt rate and therefore myocardial oxygen demand. seen at rest suggest myocardial ischemia. Images must be obtained within 1 to 2 minutes after exercise because abnorrmJ wall motion begins to normalize after this point. neurologic disease. Some protocols include light exercise in combination v. Limitations include dependence on the operator for obtaining adequate. EXERCISE ECHOCARDIOGRAPHY Imaging modalities such as echocardiography can be combined with exercise ECG in an attempt to increase the sensitivity and specificity of stress testing. Atropine may be given if an adequate heart rate is not achieved or other endpOints have not been reached at peak dobutamine dose. The extent and distribution of ischemic myocardium can be identified in this manner.:J~ although sonicated contrast agents can be helpful to enhance endocardial detlnition in these conditions. including a nuclear technician to administer the radioactive isotope and acquire the images. EXERCISE NUCLEAR IMAGING Exercise tests with nuclear imaging are performed with ECG monitoring. v. Comparison of the rest and stress images permit differentiation of thed versus transient perfusion abnormalities. which rotates 180 degrees around the patient. and a shorter amount of time for testing. an adequate heart rate response. Echocardiographic images are obtained similar to exercise echocardiography. the absence of exposure to low-level ionizing radiation. peripheral vascular disease. In addition. dyskinetic. or a positive or negative exercise ECG needs to be confirmed. A new or worsening wall motion abnormality constitutes a positive test for ischemia 40 Vasodilators such as dipyridamole and adenosine commonly are used to assess coronary perfusion in conjunction v. and evaluating cardiac risk preoperatively. assessing prognosis after MI or in chronic angina.

et al.500 tests. J Am Coli Cardioll\)\)1:17:1:3:34-I:342. A prospect in' . physical therapists. both acute MI and cardiac arrest have been reported and can be expected to occur at a combined rate of up to ] per 2.3. 27 Dubach P.5~ I h2. Compendium of physieal acti\'ities: an update of aetivity eodes and MET intensities.-948. Abrahamson D. Interll Med 1\)96. Because of this. I)alrl'nbar~er HS Jr. Ailisterdalll EA.Am J Careliol 1\)\)0:6. et ai. Ashley E. Perception of clwst pain during exercise testing in patients with coronary artery disease.6. Am J CardioI1990.30. Weiner DA.. . 5. Cibbons HJ. Froeheher VF. et a!. . Dou~he. et al. 18. Bur!(!(raf G\\'. Kohl 1111' :3rd. et al. 24 Sheldalll L\I.ia.:J·5 i. :\ En~1 J ~Ied 1\)\)1:. the physician should be physically present in the exercise testing room to personally supervise the test. Abdollall H.\'aluation of the patiellt with 'rule out myocardial inEtrction.3.156:41-45. lndh'idualized ramp treadmill. 15.35. \Ied Exerc NlItr Health 1995:4: 27.:ise scorp in olilpatit:'nh with suspected eoronary arten disease. it has not been shO\\~l to produce test results that are superior to existina modalities.tl infarction patiellts: the National Exercise and Ileart Disease Supervision of Exercise Testing Although exercise testing generally is considercd a safe procedure. Am J CardioI19805. In most cases.tud\ of health\ and nnhealth\ men. Am Heart J 1966. Myers IN. American Heart Association. Kohl 1111' :3rd. Value of arm exercise testinl( in detectinl( coronary artelY disease.:3-5 Several studies ha\'e demonstrated that the incidence of cardiovascular comI)lications durina b exercise testing is no higher with experienced paramedical personnel" than with direct physician supervision 42.5.' Arch . SPOltS Med 19805. Kaminsh' LA. 1. Hose L. J Am Coli Cardiol 2002:40:251-2.. availahle at: \\'\\'\v. Kirk JD.'J" V. N Enl(1 J "it'd 2002::346:79.erc 2002. 17 Franklin BA. J Am Coli Cardiol 1\)\)4:2:3::3. et al. II'ilmore J II. Comparison of the ramp \'ersus slandard exercise protocols.4~ EBCT had an overall predictive accuracy (percentage of subjects correctly classified) of approximately 70% for detecting CAD. Accuracy of Iwo t'ur oxitl1eters at rest and during t::'xerdse in pulmonaIy patients.3H--444.58-1. Such cases include. l't al. Med Sci Sports Exerc l!J>J4:26:J082-108fi. Ilambrel'hi HI'.5: 1.37-1847.3-801. 26.ties in patients after a Inajol' cardiae event.acc. 6. Exereise-indueed hypotension in a male population. \\'ilson P\\'. Fo. Criteria. S.3\)8.3. severe left ventricular dysfunction.3--289. \I. pi al. 11." and all-cause mortalit. II'hitt MC.3205:849-8. 16. Accllrac.3. Circulation ]\)\)8. McCabe CH. Am t. 29. Barlow CL cl al. Bricker J.. IllIlIlewatt-' eM:rcise testing to ('valuak low-risk patients presenting to the elllergt:'Jl(:) depmtlllent with chest pain..ty SM.56. J Am Coil Cardiol 1990:16: 1. Lcwis \VH.97: 18. 1 Accordingly. 4. et al. Milliken JA. Lehmann KG. Ilarrell FE Jr.. Klein J. n. Balady GJ. \\'hale\ ~I H. :\i\on PA. Circnlali'on I999. JA\IA 1995:27:3: I09:3--1 O\)i>. Vanhees I. t:'t al.74:41\)-424.70: 141-146.sil'al Ihne. Sheldahl LM. and bypo. Smith D. F. Am He\' Ht'spir Dis l!J91:144:1240-1244. t:'t al.5-3.10U. American Thoracic Socie-h al1<1 AIlH.orgidinicaVguiJelineslt-'\erdsl'/dirJ 11(1<:. Myers J. or medical technicians who are worhing under the direct supenision of a physician. Froeliclwr \'. FroelidH. eauses. "Iyers J. and prol(nosis. and American College of Physicians with broad involvement from other professional organizations involved with exercise testing (including the American College of Sports Medicine) have outlined those cognitive skills needed to competently supervise exercise tests 35 These are presented in Box . The American College of Cardiology. Mason HE. 19.3.39.32. O'Agostino R B. Ilaskell II'L. Progllostie value of a treadmill c\en.:an College of Cardiolog)-JAmerican Ileart Association Task F'oJ"{:e on Practice Guitlclines (Committee un E\('ITise Testing).. Pollock ML.ol1ar. the panel did not recommend the routine use of E BCT [or screening individuals who are as\'mptomatic or suspected to be at risk for CAD. Am J Cardiol J992. Ries AL. ACC/AIIA 2002 l(uideune update for exercise testinl(: a report of the Anleric. ~Inth T. False-positi\e treadmill exereise tests due to computer signal averagin!(. 2002. Farrow JT. 112:11-16. E\. J Ikspir Crit Carl' "led 2003:167:211-277. Buchfuhrer \\ J. Buchanan ~. :'\olllogralli ha\cd Oil Illt'tahoJjc eqlli\alellts and age I()I' assessing aerohic exercist:' capacity in llleli.5:\)4(.>t-' Testing.-I:J In situations where the patient is deemed to be at increased risk for an adverse event during exercise testing. Dum J. that is. Prt'diction of coronary heart disease using risk Eldur catel(ories. Balady CJ. et al. Cireulation l!J88:78:l:380-1.36S-24I S.505: 1. 14. !\aughtoll J. \\'eisman J\-\.37-.sicialls Slaknwnl on Can. Am He\' Hespir Dis 1\)85. 11ll<lJlwra and long-tcrlll survival in lllvoci:lnJi<. Blair S:\. et al. 2. Hehahilit\ of 1I0nil1\'asi\'e oximetry in black subjects durinl( exercise REFERENCES I. 20.:'rican Collt'gt> of Cllest Ph.5. \Iorris CK. Chest 199:3: 104: 11i>7-1190. Med Sei Sports E. Fagan} R. Optimizinl( the exereise protocol for cardiopulmonary assessment. Hansen JE. Orenstein D~I. "led Sei Spnrts Exere 2000. nurses. . 28. 2. V. 21. E\·aluation of a new standardized ramp protoeol: the BS UlBruee Ramp protocol~J Cardiopul:n HehabiI19\)8.\. of treadmill versus eyele exercise testinl( of asymplomatic men with (1)ron". Wilke NA.e.5-2~O I. Hobinson TE. Arch Phys Med Hehabil 199. Uk"r 1. 10. et ill.l1l College oj' Chest _Ph~.34: 1:391-1. Observations on a new protocol.i1uation and traininl( for resumption 01 oc<:Upational and leisure-tillle physical acti\.i1icuty of ann erl(ometer blood pressures immediately after exercise. Cbesl 1992. t-'t al. Alllcrican Thoracic Society/Allwric<. lark DB. Prognostic si~nificance of peak t:'xerc. Clausen JL. SM. . AlIlcrican Collegt' of Canliology \n"h site. Diercks DB.358-1. JAMA 1%\):262:2:3>J. et al. :3. l3alady GJ. Thij') L. Hnllinl(swOlth V. exercise tests can be supervised by properly trained exercise physiologists. J Am Coli Cardinl HJ9:3::2:2: 11. et al.)' al1l'l) disease. Curtis SE. Myers J.55:. 1I . 22. J Appl Physioll!J8.564.g" aortic stenosis). physician assistants.36:" Prak~\s" ~l. .stic fibrosis. Schuler CC. 34.:ise capacit~ in patients with coronalyarten diseas". 31. 1990.hll11 2. et al. Results of a 1l111lticenter randomized dinic:al trial of exercise 1. Blair SN.3. Exercise in Health and Disease: Evaluation and Prescription for Prevention and Hehabililation.1:32:685-689. Froelicher \'F. Tristani FE. acute coronary syndrome or myocardial infarction \\ithin 7-] 0 days). or known complex arrhythmias. Myers exercise testinl(.30-1. of three plll"it::' u\imeters during exercise and hypoxemia in patients with c. Exereisp testing SCOrt-'S as an example of hetter dt-'cisions through scienee.J8:4. patients undergOing symptom limited testing follo\\iug recent acute events (i. 9.32:S4\)8-So5 I (1.3.360. Buchanan K Il'alsh D..387. lraininl( and ann ergometry.112 SECTION II / EXERCISE TESTING CHAPTER S / CLINICAL EXERCISE TESTING 113 media. E\t'rcise capacity and mortc~ity among men referred for 12. "RecO\'e!)' only" ST-seglllt'nt depression and the predietive accuracy of the exercise test.£\)' 0. Bendiek P. et al. Franklin 13.. Project ('iF: II DP).. Lachterrnan B.lOO: i/64-176\). Philadelphia: \\'B Saunders.5. 71:196-20.sidans. individuals who supervise exercise tests must have the cognitive and technical skills necessary to be competent to do so. A new S\'stem of multiple-lead exercise electrocanuography. but arc not limited to. Weiner DA.. liopultl. Exercise testin~.ers J. In studies reviewed by a recent AIIA consensus writing panel. !'h.. Baltimore Therapeutic Equipment work simulator: eneriO' expendilure of work activities in eardiac patiellts. which is no better than standard exercise testing. E\er<:i. Physiolo~ic responses to arm ergometry exercise relative to a~e and l(ender. Greater diagnostic sensitisit. d <11.5i>-.5. et al. Shaw L. Ainsworth BE. Chanl(l's in ph\sieal f1tne" and all-eausl' mortality.. Amsknlalll EA. severe valvular stenosis (e.2:100-119. the physician must be in the immediate vicinity and available for emergencies. Zeb"lIos HJ. A I'rospecti\'e Stllli: of health\ men and \\()llll'n. \\'ilke 1\A. Ann Intern Med 19\)0.

Jil}.3.5. Bayes theorem states that the posttest probability of a patient hal1ng disease is determined by the disease probability before the test and the probability that the test \\111 provide a true result. Timlllis et a!.. :37. Forster T. F'iorctti PM. with spccific reference to screening for corOll<U)' aliel)' diseasc (CAD). .50(}-1.111:262-26. et . Report ()(' tJle Anll'rican College of Cardioloh'y/Alnerk'all Ileart A~sociation Task Forct' on AsseSSllH'llt Diagnostic and Therapeutic Cardim"ascular Procedures (Collllllittee Oil Radiolluclide Imaging.'rican College of Cardiology/AIllPriC<ln Heart AssociationlAmerican College of P!Iysic. The probability of a patient ha\1ng disease before the test is related. Froelidwr \'F. Exercise Testing As aScreening Tool for Coronary Artery Disease The probability of a patient having CAD cannot he estimated accurately from the exercise test result and the diagnostic characteristics of the test alone. hemodynamic electrocardiographic (ECG) gas cxchange and ventilatOlY responses. Stress t'chocardiograpliy. It also depends on the likelihood of the patient having disease before the test is administered. FrankJin BA. to the patient's chest pain characteristics. Circldatiun 1993.:an Heart Association Clinical Competence Statclllcnt on Stress Testing: A Heport urthe Alll<.102: 1:?(i-140..I:?.. 4. even among symptom-free men and women more than 60 years old (see Table 5-1). Poldenllans D.2(X12:1S2. Lauhach CA Jr. A~ani. den~luped in conjunction with the American Socipt: of ::\udear CardioloL. 36.:hcr VF'. lIeart-raIP recmery immediatel} alier csercise as a preuictoror mwt. 44. Hodgt'rs GP. ed. Cole CH.' is problematic in view of the low to velY low pretest likelihood of CAD.5. American College ofCardiolog:IAnlericall Ileart Asso<. Atypical angina (chest discomfort that lacks one of the mentioned charactelistics of typical angina) generally indicates an intermediate pretest likelihood of CAD in men more than :30 years old and women more than .')-1 ). Kalllinsky LA. The use of exercise testing in screening as}1nptomatie indi\1duals. 40. :3H. However. ~larcO\'itz PA. the description of symptoms can be most helpful among individuals in whom the diagnosis is in question. Corol1<u-:' Artt'l-: Disei:L"iP. I Such testing can have potential adverse consequences (e. Dohutarnine stress echocardiograph:' ICll' aSSeSSIIll'llt of perioperative cardiac risk in patiellts lIndc:rgoing major vascular sllrgery.57.J. l't al. Challlpai~n.in) makes the pretest probability so high that the test result docs not dramatically change the probability of underlying CAD. :\ Engl J ~Ied HJ99:341:1:3. p<uiicularIy among individuals \vithout diabetes or other lisk factors fell' coroll<l1Y <uteI')' disease.:3IU%O-19b7. jaw.52 1-5-17. most importantly. Testing in asymptomatic persons with multiple risk factors may provide 115 ce. I L: I(ulllan Kinetics. I99:3:i-IO. Alll J Cardiol 1995.')l J AnI Coll Cardiol J995:. Ritchie JI '.g. :3g. Heart rate rec(wt'ry: \"aJidatioll and lIIl'thodologic issues. Balady C.. et al.-lIl JZ. 1 a"Bourke HA.:ialls-Anwrican Society of' InIPrnal l\leuicin(' Task Force WI Clinical Competence. Brundage BU. In: BraulI\vald E.:an College of Cardio)oh')/AIIlt'I·ic. Pashko\\' FJ.. psychological. Typical or definite angina (substernal chest discomfOli that may radiate to the back. Allwric.rcise phssiologists.-1 738. Exercise testing as a pmt of routine health screening in apparently healthy individuals is not recommended. anel/or prior coronmy revascularization) is not regularly used for diagnostic purposes. . Interpretation of Clinical Exercise Test Data • 6 •• • • CHAPTER or This chapter addresses the interpretation and clinical significance of exercise test results. Brubaker PH. d a1.:iation Expert Consensus document on e1ectron-heam computed tomograph: Ic)r the diagnosis and prognosis of coronary arter: dise"Lse. work and insurance status. Knight JA.'sling hy "". Buteher HJ. Cuidelint-'s for clinical use of cardiac radiolllldide inwgillg. Froeli<. angiographically documented coronary stenoses. Supel"ision of clinical exercise I. S)1nptoms provoked by exeliion or emotional stress and relieved by rest <mel/or nitroglyce. Is direct physician SllpefYision of' exercise stress tf'sting routinel} llecess'll)'? Chest 1997. \\'haley ~t H. as well as the diagnostic and prognostic value of the exercise test.51-1:3. J Am Coli CaruioI2(X11. Anllslrong \r. gcnder. but also to the patient's age.1>7: I.. Circulation :?000. 102: 172(}. Plliladelphia: \\'B Saunders.512.50 years old (see Table .114 SECTION II / EXERCISE TESTING :3. and the presence of major lisk factors for cardiovascular disease. ileaI'I Disease Updates. Shetler K. or arms. Cordon S. Batt'lllclll T\L BOllow RO. Circulation 2000. Exercise testing in individuals \\1th known CAD (plioI' myocardial infarction.75::)!J(h391. . \Ian:u'l H. Blackstone Ell. et al. t't al. costs for subsequent testing) by misclassifying a large percentage of those \vithout CAD as having disease.

X> i) Supraventricular dysrhythmias Ventricular dysrhythmias Heart rate (HR) HEART RATE RESPONSE Maximal heart rate (HRmaJ may be predicted from age using any of several published equations 4 The relationship between age and HR max {or a large sample of subjects is well established. left ventricular ejection fraction does not correlate well with exercise tolerance. Isolated atrial ectopic beats or short runs of 5VT commonly occur during exercise testing and do not appear to have any diagnostic or prognostic significance for CAD. especially resting STsegment changes secondary to conduction defects. complexity.116 SECTION II / EXERCISE TESTING CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA 117 some useful information. exercise-induced myocardial ischemia may cause left ventricular dysfunction. I It is likewise difficult to choose a chronological age beyond which exercise testing becomes valuable as a screening tool prior to beginning an exercise program because physiologic age often differs from chronological age. or valvular heart disease Frequent ventricular ectopy during recovery has been found to be a better predictor of mortality than ventricular ectopy that occurs only during exercise. A peak exercise HR that is >2 5D (>20 beats'min. Although the severity of symptomatic ischemia is inversely related to exercise capacity. the relationship between these variables can be altered by exercise training. cardiomyopathy. Chronotropic incompetence may be signified by: 1. anthropometric measures such as height and weight. or in patients with a history of sudden cardiac death.. corresponding to 10 ± 2 beats·MEr' for inactive subjects. The normal HR response to progressive exercise is a relatively linear increase. PVCs that increase in frequency. and other factors that may contlibute to spuriOUS ST-segment depression. drugs. In general.g. at 80 msec beyond the J point. Although total body and myocardial oxygen consumption are directly related.g. For example. and hody composition do not indepcndently influence HRm.8. it is impOltant to consider the purpose of the test (e. • Variable ST-segment depression (ST J. neurologic disorders. pulmonary disease. exercise intolerance.1 ) below the age-predicted maximal HR for subjects who are limited by volitional fatigue and are not taking l3-blockers Interpretation of Responses to Graded Exercise Testing Before interpreting clinical test data. although this practice cannot be strongly recommended based on available data. and a hypotensive blood pressure response. 2. As a result. Medication effects (see Appendix A) and resting ECG abnormalities also must be considered. V0 2ma VEl Responses to exercise tests are useful in evaluating the need for and effectiveness of various types of therapeutic interventions.l ). conversely. The suppression of resting ventricular dysrhythmias during exercise does not exclude the presence of underlying CAD. and significant deconditioning. 10-12 beats' min. there is potential for considerable error in the lise of methods that extrapolate sllhmaximal test data to an age-predicted HR nmx • Aerobic capacity. Complex ventricular ectopy. and runs of ventricular tachycardia (23 successive beats). interindividual variahility is high (standard deviation. and disease. suggesting myocardial ischemia ST i in leads displaying a previous Q-wave MI almost always reflects an aneurysm or wall motion abnormality. the guidelines presented in Table 2-1 are recommended if the exercise is more strenuous than brisk walking. left ventricular hypertrophy.) ST-segment elevation (ST Clinical Significance An abnormal ECG response is defined as 21.39 where CI is calculated as the percent of heart rate reserve to percent metabolic reserve achieved at any test stage ~ . Medical conditions influencing test interpretation include orthopediC limitations. Test results should be considered as prohability statements and not as absolutes.3 The objective of exercise testing is to evaluate quantitatively and accurately the follOwing variables. Each is described in the following sections and summarized in Box 6-1: • • • • • HemodynamiCS: assessed by the heart rate (HR) and systolic/diastolic blood pressure (SBP/DBP) responses ECG waveforms: especially ST-segment displacement and supraventricular and ventricular dysrhythmias Limiting clinical signs or symptoms Gas exchange and ventilatory responses (e. diagnostic or prognostiC) and patient conditions that may influence the exercise test or its interpretation. exerciseinduced 5T i often is associated with a fixed highgrade coronary stenosis. obeSity. or both do not necessarily signify underlying ischemic heart disease.lX' The inabil- 2 A chronotropic index (CI) <0. however.0 mm of horizontal or downsloping ST J. The potential ramifications resulting from mass screening must be considered and the results of such testing must be applied using the predictive model and Bayesian analyses. including paired or multiform PVCs. In the abser:ce of significant Q waves. are likely to be associated with significant CAD and/or a poor prognosis if they occur in conjunction with signs and/or symptoms of myocardial ischemia..

expected in healthy sedentary men and women can be predicted from the following regressions Ao Men = (57. electrocardiographic. SBP may remain below pretest resting values for several hours after the test. A DBP of > 115 mm Hg is considered an endpoint for exercise testing. LV. PVC. supraventricular tachycardia. Abbreviations: EC G. The normal response to exercise is no change or a decrease in DBP. SVT. and (X. is considered an abnormal test response. l l Signs and symptoms of ischemia generally occur at a reprodUCible double product. Women = (41.' Achievement of age-predicted maximal heart rate should not be used as an absolute test endpoint or as an indication that effort has been maximal. metabolic equivalent. left ventricular dysfunction. coronary artery disease. VO'm". with a possible plateau at peak exercise. exertional hypotension has been shown to correlate with myocardial ischemia. see Table 4-8 for age-specific Systolic blood pressure (SBP) The normal blood pressure response to dynamic upright exercise consists of a progressive increase in SBP. CAD. left ventricular. Exertional hypotension (SBP that fails to rise or falls [> 10 mm Hg]) may signify myocardial ischemia and/or LV dysfunction. standard deviation.118 SECTION II/EXERCISE TESTING CHAPTER 6 / INTERPRETATION OF CLINICAL EXERCISE TEST DATA 119 BLOOD PRESSURE RESPONSE ~ Box 6-1.e demonstrate exertional hypotension caused by antihypertensive thcrapy. Exercise testingshould be discontinued with SBP values of >250 mm Hg. • Although maximal heart rates are comparable for men and women. MI. DBP also may drop dUJing the postexercise period. men generally have higher systolic blood pressures (~20 ::':: 5 mm Hg) dUJing maximal treadmill testing. • In patients on vasodilators. no change or a slight decrease in DBP. A rating of 3 (moderately severe) generally should be used as an endpoint for exercise testing. Also. maximal oxygen uptake. respectively. typically 10 ::':: 2 mm Hg'MEr 1 . patients without clinically signiflcant heart discas. ELECTROCARDIOGRAPH WAVEFORMS ity to appropliately increase heart rate during exercise (chronotropic incompetence) is associated with the presence of heart disease and increased mortality. the gender difference is no longer apparent after 70 years of age. and serious dysrhythmias. because of its high intersubject variability.343 [age])/35. SBP. angiotensin-converting enzyme inhibitors. cardiomyopathies. systolic blood pressure. corresponding to perceptible but mild.and f3-adrenergic blockers. Can be graded on a scale of 1 to 4. valvular heart disease.5. and vasovagal responses.6 A delayed decrease in the heart rate during the first minute of recovery « 12 bpm decrease) after a symptom-limited maximal exercise test is also a powerful predictor of overall mortality. • The rate-pressure product or double product (SBP X HR) is an indicator of myocardial oxygen demand. premature ventricular contraction. and a widening of the pulse pressure. SD. heart rate.8-0445 [age])/35. Average values of V0 2max . expressed as METs. ventricular tachycardia. calcium channel blockers. SBP may decrease abruptly because of peripheral pooling (and usually normalizes on resuming the supine position). continued The normal response to exercise is a progressive increase in SBP. Diastolic blood pressure (DBP) Anginal symptoms Aerobic fitness V0 2max norms. or failure of SBP to increase with increased workload. Maximal exercise SBP of < 140 mm Hg suggests a poor prognosis. Good judgment on the part of the physician andlor supervising staff remains the most important criteria for terminating an exercise test. The following are key points concerning interpretation of the blood pressure response to progressive dynamic exercise: • A drop in SBP (> 10 mm Hg from baseline SBP despite an increase in workload). During passive recovelY in an upright posture. Occasionally. VT. moderately severe. Additional information is provided here with respect to cOlTIlTIon exercise-induced changes in ECG variables. HR. moderate.10 • The normal postexercise response is a progressive decline in SBP. The normal ECG response to exercise includes the follOwing: • • • • • • Minor and insignificant changes in P wave morphology SuperimpOSition of the P and T waves of successive beats Increases in septal Q wave amplitude Slight decreases in R wave amplitude Increases in T wave amplitude (although wide vmiability exists among subjects) Minimal shortening of the QRS duration . diastolic blood pressure. MET. The clinical indications for stopping an exercise test are presented in Box 5-2. prolonged strenuous exercise. and severe. DBP.9 In some cases this response is improved after coronalY bypass surgely.2-0. the blood pressure response to exercise is variably attenuated and cannot be accurately predicted in the absence of clinical test data. However. AppendiX C provides information to aid in the interpretation of resting and exercise electrocardiograms. and an increased risk of subsequent cardiac events S . A systolic blood pressure >250 mm Hg or a diastolic blood pressure> 115 mm Hg should result in test termination. myocardial infarction. However. Exercise-induced decreases in SBP (exertional hypotension) may occur in patients with CAD.

There may bc I-point depression and tall pcaked T-waves at high exercise intensities and during recovelY in normal subjccts.) may be indicative of ischemia even in the presence of this conduction abnormality."L:. Ii In right bunule-branch block.0 mm (1 mV) of horizontal or downsloping ST segment 80 msec after the I point.0 4..-. some changes in EGG wave mOI1Jhology may be indicative of For example. such changcs during cxercisc 'havc no independent predictivc power.. and V(. Many factors affcct R-wave amplitudc.g. bundle-branch blocks.120 SECTION II/EXERCISE TESTING CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA 121 • Dcprcssion of the J point Hatc-rclated shortening of the Q1' interval ST-Segment Elevation • Howe\'er.. An ST/HR slope of >2.. consequently. Depression of the I point that leads to marked ST-scgmcnt upsloping is causcd by competition between normal repolarization and delayeu tcrminal depolarization forces rather than to ischemia. it may increase in patients with either angina or left vcntricular dysfunction. • 10 E • 5 :iE 80 msec o. . 18-20 but . !*-'.-. an acute transmural infarction) when followed by the evolution of significant Q-waves.'-.e. 14 • Exercise-induced ST-segment elevation on an othenvise normal EGG (except in aVR or V I ... left ventricular hypelirophy) and pharmacologic agents (e. ST-segment depression does not localize ischemia to a specific area of myocardium.5.. . 13 Exercise-induceu myocardial ischemia may be manifesteu by different types of ST-segment changes on the EGG.I--t7"-2. Thc ST/HR index is the ratio of the maximal ST segment change to the maximal change in HR from rest to peak exercise. Significant ST-segment depression occurring only in recovery likely represents a true positive response.. however. In patients \\~th left bunule-branch block. An ST/HR index of 2:1..:·~--. ST segment changes during exercise.0 mm • Classic Upsloping FIGURE 6-1. --------.. The more leads \'lith (apparent) ischemic ST-segment shifts. \1.2) generally indicates significant myocardial ischemia...2. Slowly upsloping 5T-segment depression (second complex) should be considered a borderline response.. ST-Segment Depression • • • • 20 Normal Abnormal • • 15 l/l Q) Q) .-~--~ . Exercise-induced P wavc changes are rarely scen and arc of questionable significancc.6 is defined as abnormal. Slowly upsloping ST-segment depression should be considered a borderline response. Ii Adjustment of the ST segment relative to the HR may pro~ue additional diagnostic information. The ST/HR slope evaluates the maximal slope relating the amount of the ST segment depression to HR duling exercise. ST-Segment Displacement S1'-scgment changes are \\~dely accepted criteria for myocardial ischemia and injury. The interprctation of ST segments may be affected by the resting ECG configuration (e.---_J_. The standard critelion for a positive test is 2:1. additional ST segment depression dUling exercise is less specific for myocardial ischemia..4 mVlbeatimin is defined as abnormal..-- .. and local15 izes the ischemia to a speciflc area of myocardium • ST-segment elevation indicates myocardial injUly (i. the more severe the disease.. l2 underl)~ng pathology... Several studies have addressed the diagnostic value of these ST/H R vaJiables.J..0 .g.. ...__jI__J. ST-segment abnormalities that develop dUling exercise are uninte'1Jretable \vith respect to e\~dence of myocardial ischemia. V2.... as shown in Figurc 6-1. Increasing HR may cause these elevated ST segments to return to the isoelectric line. . • Exercise-induced ST-segment elevation in leads displaying a pre~ous Q wave infarction may be indicative of wall motion abnormalities or ventiicular aneurysm. and added emphasis should be placed on other clinical and exercise variables. although QRS duration tends to decrease slightly \\~th exercise (and increasing HR) in normal subjects. and added emphasis should be placed on other clinical and exercise variables. exercise-induced STsegment depression in the antelior precordial leads (VI. and Vl) should not be used to uiagnose ischemia. S1'-segment changes in the lateralleads (V4.. L. . Classic ST segment depression (first complex) is defined as a horizontal of downsloping ST segment that is 2: 1 mm below the baseline at 80 msec past the J point. digitalis therapy). HOIizontal or downsloping ST-segment depression is more indicative of myocardial ischemia than is ups loping depression. ST-segment elevation (early repolaJization) may be seen in the normal resting EGG. and should be considered an impOliant diagnostic finding. ST-segment depression (depression of the I point and the slope at 80 msec past the I point) is the most common manifestation of exercise-induced myocardial ischemia... l6 In the presence of baseline S1' abnormalities on the resting EGG.

Among 29. or drug efrects. and a reduced capaCity to perform work. including T-wa\'(:. 28 Whichever method is used. it should be remembered that the usc of any of these methods prO\~des only an estimation and the use of these methods is eontroversiaJ. and activity status. metabolic. whereas in others it reduces their occurrence. 2. sometimes referred to as the lactate or anaerobic threshold. Frequent isolated PVCs were obselved in 3%. Gas exchange and ventiiatOlY responses often are used in clinical settings as an estimation of the point where lactate accumulation in the blood ocelli'S. Sustained supraventricular tach)'cardia occasionally is induced by cxercise and may require pharmacologic treatment or electroconversion if discontinuation of exercise fails to abolish the rh)thm. Maximal or peak oxygen uptake (V02peak) provides important information about cardiovascular fitness and prognosis. Various objcetive and subjective indicators can be used to confirm that a maximal effort has been elicited during graded exercise testing: • Failure of HR to increase \~th further increases in exercise intensity. Jn the absence of untoward signs or symptoms. and triplets of PVCs. and oXYgen tension contribute to disturbances in myocardial and conducting tissue automaticity and reentlY. angina pectOJis lcithollt ischemic ECG changes may be as predictive of CAD as ST-segment changes alone. when concomitant angina occurs. ECG abnormalities at rest.'smal atrial tachycardia may be evaluated by repeating the exercise test after appropliate treatment. ma\' return to normal dming anginal S\'lllptOIllS and dming exercise in some patients. there is considerahle interindi\~dua] variability in this response. hyperventilation. which are major mechanisms of dysrhythmias. and sustained ventricular tachycardia (>30 seconds in duration) in 0. 3% had frequent ventricular ectopy (>7 PVCs/minute) only during exercise. ventricular bigeminy in ] %. however. Population-specific nomograms (see Fig. Criteria for terminating exercise' te'sts based on ventricular ectopy include sustained ventricular tachycardia. as well as multiloeal PVCs. 29 . couplets and triplet in <J %.27 and the V slope method. however. Several different methods using ?oth gas exchange and ventilatOlY responses have been proposed for the estimation of this point. Increased sympathetic drive and changes in extracellular and intracellular electrolytes. Atrial flutter or atlial fibrillation may occur in organic heart disease' or may reflect endocrine.244 patients.50 mL·min 1) \~th increased workload. and 2% only during recovely. The presence of ventlicular ectopy during exercisc testing was observed in a large series of patients undergOing exercise testing in a Single clinicallaboratory.5-2).5-1) and/or population norms (see Table 4-8) may be Ilsed to compare \10 21"'ak with the expected value fiJI' a given age. The decision to terminate an exercise test should also he influenced I)\' simultaneous e\~dence of myocardial ischemia andlOl' adverse signs or symptom's (see Box . . Ventricular Dysrhythmias Isolated premature vcntlicular complexes or contractions (PVCs) occur during exercise in 30% to 40% of healthy subjects and in . there is great interindi~dua] vmiability in this response. gender. graded exercise induces PVCs. Patients who experience parox. • A postexercise venous lactic acid concentration of >8 mmol also has been used.s • A respiratOly exchange ratio> ] . • A plateau in oxygen uptake (or failure to increase oxygen uptake by 1. • A rating of perceivecl exertion> 17 on the 6 to 20 scale or >9 on the 0 to 10 scale. its estimation has evolved into a useful phYSiolOgiC measurement when evaluating interventions in patients \\~th heatt and puJmonmy disease as well as studying the limits of performance in healthy individuals.122 SECTION II / EXERCISE TESTING CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA 123 the findings have been inconsistent and preclude a strong recommendation regarding their utility. especially when a reduction in maximal exercise capaCity is suspected.50% to 60% of patients \\~th CAD. LIMITING SIGNS AND SYMPTOMS Although patients \~th exercise-induced ST-segment depreSSion can he asymptomatic.:>·21 GAS EXCHANGE AND VENTILATORY RESPONSES Gas exchange and ventilatory responses should be used to assess patient effOlt during an exercise test.01 %24 In some individuals. patients should be encouraged to give their best effort so that maximal exercise tolerancc can be determined. inversion and ST-segment depression. pH. cach of ventricular trigeminy. the likelihood that the ECG changes result from CAD is Significantly increased.6%.. 22 In addition. Supraventricular Dysrhythmias Isolated premature atrial contractions are common and require no special precautions. Submaximal efforts from the patient can interfere \~th the interpretation of the test results and subsequent patient management. ST-Segment Normalization or Absence of Change • Ischemia may be manifested by normalization of resting ST segments. 2~ This criterion has f~lllen into some disfavor because a plateau is inconsistently seen during continuous graded exercise tests and is confused by vatious definitions and how data are sampled during exercise. .30 Because exercise beyond the lactate threshold is associated with metabolic acidosis. These includc the ventiJatOlY equivalents method 26.1. nonsustained vcntrieular tachycardia «30 seconds in duration) in 0. 2% dllring exercise and rccoveJY. Dysrhythmias Exercise-associated dysrhythmias occur in healthy subjects as well as patients \\~th cardiac disease. 23 Both are currently considered independent vmiables that identify patients at increased lisk for subsequent coronary events.

. the pooled results show a sensitivity of 68% and a speciflcity of 77% I Sensitivity = TP/(TP + FN) have a positive test = the percentage of patients with CAD who Specificity = TN/(TN + FP) = the percentage of patients without CAD who have a negative test Predictive Value (positive test) = TP/(TP + FP) with a positive test result who have CAD = the percentage of patients Predictive Value (negative test) = TN/(TN + FN) = the percentage of patients with a negative test who do not have CAD PREDICTIVE VALUE The predictive value of exercisc testing is a measure of how accurately a test result (positive or negative) correct!v identifies the presence or absence of CAD in tested patients. Mam' conditions mav cause abnormal exercise ECG responses in the absence of significant obstructive coronary aIielY disease (Box 6-4). Disease prevalence is an impOliant determinant of the predictive value of the test. FN.e. the predictive value of a positive test is the percentage of those persons with an abnormal test who hm'e CAD. duration of exercise or maximal MET level. test protocols. ECG criteria for a positive test. and the angiographic def'inition of CAD. limit the ability to intel1Jret exercise-induced STsegment changes as ischemic ECG responses. exertional hypotension) Angiographically significant CAD compensated by collateral circulation Musculoskeletal limitations to exercise preceding cardiac abnormalities Technical or observer error Diagnostic Value of Exercise Testing The diagnostic value of conventional exercise testing for the detection of CAD is influenced by the principles of conditional probability (Box 6-2).uy because of differences in patient selection. Prcexisting ECG changes.g. indicative of a reduced ventilatOlY reserve and a possible pulmonary limitation to exercise. Tcst sensitivity is decreased by inadequate myocardial stress. A comparison between the VE n"" and the MVV can be used when evaluating responses to a graded exercise test. Common factors that contribute to r~tlse-negative exercise tests are summaJized in Box 6-3.5%.5%.. symptoms of angina or dyspnea) should be considered in the overall interpretation of exercise test results. drugs that attenuate cardiac demands to exercise or reduce myocardial ischemia (e. .. Moreover.. true positive (positive exercise test and coronary artery disease [CAD]). Reported valucs for the speCifiCity and sensitivity of exercise ECG testing v. TN. true negative (negative exercise test and no CAD). left bundle-branch block. positive) changes. respectively. A true negative test correctly identifies a person \\1thont CAD.. FP. • • • • • • Failure to reach an ischemic threshold Monitoring an insufficient number of leads to detect ECG changes Failure to recognize non-ECG signs and symptoms that may be associated with underlying coronary artery disease (CAD) (e. The relationship between these measures. Exercise ECG sensitivity for the detection of CAD usually is based on subsequent angiographically SPECIFICITY The specificity of exercise tests refers to the percentage of patients \\1thout CAD who demonstrate nonsignificant (i. nitrates..g. typically referred to as the ventilatOlY reserve. In most normal subjects this ratio ranges from 50% to 8.3\ Patients with pulmonary disease typically have values >8. a test should not be classiHed as "negative" unless the patient has attained an ade- Abbreviations: TP. For examplc. :--1e\'elthcless. f3-blockers. the VEm<"/MVV ratio). False-negativc test results show no or nondiagnostic ECG changes and f~lils to identify patients with underlying CAD. false positive (positive exercise test and no CAD). determined coronary artery stenosis of 70% or more in at least one vessel.e. Sensitivity and specificity determine how effective the test is in making correct diagnoses in individuals with and without disease. SENSITIVITY Sensitivity refers to the percentage of patients tested with known CAD who demonstrate significant ST segment (i. or the preexcitation S)llllrome (WolffParkinson-White syndrome). The use of right precordial leads along with the standard six left precordial leads during exercise electrocardiography may improve thc sensitivity of exercise testing in the detection of CAD.:J2 although this has not been demonstrated consistently. In studies that controlled for these variables.e. traditionally has been defined as the percentage of the MVV achieved at maximal exercise (i. I.0 mm or more and correctly identifies a patient with CAD. maximal minute ventilation (VEmaJ can be used in conjunction with the maximal voluntaIy ventilation (MVV) to determine if there is a ventilatory limitation to maximal exercise. calcium channel blocking agents). negative) ST segment changes. and insufficient ECG lead monitoring.g.. non-ECG criteria (e. The factors that determine the predictive outcome of exercise testing (and other diagnostic tests) are the sensitivity and specificity of the test procedure and the prevalence of CAD in the population tested. hemodynamiC responses. such as left ventricular hype'irophy. A true positive exercise tcst reveals ST-segment depression of 1. false negative (negative exercise test and CAD).124 SECTION III EXERCISE TESTING CHAPTER 61 INTERPRETATION OF CLINICAL EXERCISE TEST DATA 125 In addition to estimating when blood lactate values begin to increase.

and these two points are connected. an exercise test should be performed in persons with known or susassist in subsequent t d CAD to assess lisk of future cardiac events. left bundle-branch block) Cardiac hypertrophy Accelerated conduction defects (e. Fourth. compared \vith 83% and 88% for thallium agents. In addition. 6-2) can be helpful when applied appropIiately.126 SECTION II/EXERCISE TESTING CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA 127 • • • • • • • • • • • • • • I' Resting repolarization abnormalities (e. Pa~ents who recently have suffered an acute myocardial mfarcbon and receiVed tlliombolytic 'Selected variables simply may be associated with rather than be causes of abnormal test results.96 0. Duke Nomogram uses five steps to estimate prognosis for a given individual from the parameters of the Duke score. Third. ImpOltant prognostic vaJiables that can be de lived from the exercise test are summarized in Box 6-1.an 75 years old.t e exelclse test are most useful when considered in the context of other chl1lcalmformatlOn.55 3mm 4mm PROGNOSTIC APPLICATIONS OF THE EXERCISE TEST Risk or prognostic evaluation is an impOltant activity in medical practice on which many patient management decisions are based. respectively. For planar imaging.5% 2% ~% 20 17 13 10 7 5 0 Nonlimiting 1 mm COMPARISON WITH IMAGING STRESS TESTS The overall senSitivity and specificity of exercise echocardiography ranges from 74% to 97% and 64% to 94%. reversible. . Wolff-Parkinson-White syndrome) Digitalis Nonischemic cardiomyopathy Hypokalemia Vasoregulatory abnormalities Mitral valve prolapse Pericardial disorders Technical or observer error Coronary spasm in the absence of significant coronary artery disease Anemia Female gender clinical factors contlibute to patient outcome. In Single photon emission computed tomography (SPECT) imaging. data denve .s Duke nomogram does not appear to be valid in patients more th. including severity and stability of symptoms. the observed amount of ST-depresslon IS marked on the ST-segment deviation line. angiographic extent and seventy of CAD. the sensitivity and specificity of technetium agents have been measured at 84% and 83%.85 0. and nonreversible segments scanned with technetium and thallium agents are compared.33 Exercise with concomitant nuclear imaging using technetium (Tc99m) agents has shown similar accuracy to those using thallous (thallium) chloride-20l agents in the detection of myocardial ischemia.93 0. Finally.4% 1% 1. and the estimated 5-year survival or average annual mortality rate is read from the pOint at which this line intersects the prognosis scale. the mark on the ischemia reading line is connected to the mark on the exercise capacity line. 34 . Second.80 0. Th. left ventricular function. the sensitivities and specificities were 90% and 93% for technetium agents. compared with 89% and 76% for thallium agents.95 0.' management decisions.90 0. including women) (Fig. the observed degree of angina IS marked on the line for angina.35 2mm Exerciselimiting 8~8 g~ 9% % 0. First.99 0.g.. there is 88% agreement "vith planar and 92% agreement \vith SPECT imaging. Omm None 0. generally defined as having achieved 85% or more of predicted maximal heart rate during the test. Predictive value cannot be estimated directly from a test's specificity or sensitivity because it depends on the prevalence of disease in the population being tested. ST-Segment deviation during exercise IPrognosis I survival IExercise I Exercise METs 5-year Average mortality annual quate level of myocardial stress.g. electlical stability of the myocardium.r~m . As stated in Chapter 5. several FIGURE 6-2. and to pece 'df' h . Use of the Veteran's Administration score36 (validated for the male veteran population) and the Duke nomogram 37 (validated for the general population. Unless cardiac cathetelization and immediate coronmy revasculanzatlOn are indicated. In patients with CAD.2% 0. the observed exercise tolerance is marked on the line for exercise capacity... The sensitivity and specificity are similar for planar and tomographic nuclear imaging. and the presence of other comorbld conditions. when normal. the POll1t where this line intersects the ischemia reading line is noted. \vith higher sensitivities observed in patients with multivessel disease.

128

SECTION II/EXERCISE TESTING

CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA

129

therapy and/or have undergone coronary revasculatization generally have a low subsequent cardiac event rate. Exercise testing still can provide prognostic information in this population, as well as assist in activity counseling and exercise presCliption.
REFERENCES
Gibbous HJ, Balach- GJ, Blicker J, et a1. ACC/AIIA 2002 guideline update for exercise testing: a repOlt of the Amelican College ofCard..iolog;JAmer;can Ile<111 Association Task Force on Practice Cuidelines (Committee on Exercise Testing). 2002. Ameliean College of Cardiology weh site. a\ailahle at: \\'\\'\v.at'C.orWc1i n icaVgu idelineslexercise/di r1ndex. ht 111. ~Iyers J, Froelicher "F. Hemodynamic determinants of" t''\en..'ise eapadty in chronic hemi failure. Ann Intem ~Icd 1991; 115:31'1--386. ~IcKimau ~I D, Sulli'>ln .\1, Jensen D, et a1. Treadmill perfonllanc~' and carchac functiou in selected patients "oth coron<ll)' heart disease. J Am Coli Cardiol J9f;..l;3:25J-261. Londeree BH, ~Ioeschberger ~,I L. Influence of age and other factors on maximal healt rate. J Cardiac Hchab J984;(4)44-49. Ellestad M II. Chronotropic incompetence. TIle ilnplications of heali rate response to exercise (COlllpens,'tOl)' parasympathetic h)1)eracti\oty?). Circlilation 19%;93: 1-18.5-1487. Laller MS, Francis CS, Okin PM, et al. Impaired chronotropic respollse to exercise stress testing as a predictor of mortality. JAMA 1999;281:.524-,529. Cole CH, Blackstone EH, Pashkow F.I, et al. Heart-rail' recovel)' immecliately after exercise as a predictor of' mortality. N Engl.l Mcd 1999;341: 13.51-13.57. Cnmess KA, Fenster PE. Clinical implications of' tl", blood prcssure response to exercise. Carruolog)' 1981;68:233-244. Irving JB, Bnlce RA, DeRouen TA. Variations in and significance of systolic pressure during IIl,LXimal exercise (treadmill) testing. Am J CardioI1917:39:841-848. Weiner DA, Mc-Cabe CII, Cutler SS, et al. Decrease in s),stolic blood pressure dUliug excreise testing: reproducibility, response to coronary bypass surgel)' and prognostic significance. Am J Cardinl 1982;49: 1627-1631. Kitamura K, Jorgensen CR, Gobel FL, et a!. Hemocl)llamic correlates of m),ocardial O\')'gen consumption dllling uplight exercisc. J Appl Ph)'siol 1972;32:516-522. Myers J, Ahn\'e S, Froelicher \', et al. Spatial R wmoe amplitude changes dllling exercise: relation with left ventricular ischemia and function. J Am Coli Cardiol 1985;6:603-608. Mil"is D~I, Hamanathan KB, Wilson JL. Hegional blood flow correlates ofST segment depreSSion in tachycardia-induced mvocanlial ischemia. Circulation 1986;7,3:36.5-.373. Bruce HA, Fisher LD, Pettinger ~I, et al. ST segment ele\'ation "oth exercise: a marker for poor \'entIicular function and poor prognosis. Coron",,, AI1er)' SurgeI')' Study (CASS) connrmation of Seattle Ilel1lt Watch results. Circulation 1988;17:897-90.5. :-Jostratian F, Froelicher "F. ST ele""tinn dllling exercise testing: a re\iew. Am J Carchol 1989; 63:986-988. Lachterman B, Lehmann KG, Detrano H, et aL Comparison of ST segment/hemt rate index to standanl ST cJiteJia for analysis of exercise electrocardiogram. Circulation 1990;82:44--.50. WhinnelY JE, Froelicher VF Jr, Longo ~IH Jr, et al. The electroearcliographie responsc to IIl'Lxilllal treadmill exereixe of asymptomatic men with light bundle branch block. Chest 1917;71 :33.5--340. Froelicher VF, Fearon WF, Ferguson CM, et al. Lessons learned from studies of the stanclard ex!'l'cise ECG test. Chest 1999;116:1442-14.51. Okin PM, Klignelcl P. lIel1lt rate adjustmcnt ofST segmc'nt depression and pcrformance of'the exercise electrocardiogram: a critiC'll1 evaluation . .1 Am Coli Cardiol 1995;25:1726-]73.5. Morise AP. Accuracy of healt rate-adjusted ST segments in populations with and without postlest rcferral bias. Am Ileart J I997;l::>4(4):647-6S.5. Lavie Cj, Oh JK, Mankin HT, ct a!. Signillcance ofT-wave pseudouonnalization during exercisl'. A rachonuclidl' angiographie study. Chest 1988;94:.512-.516. Weiner DA, Byan Tj, McCahe CIl, ct ,J. Exercise stress testing Correlations among histon' of a"gina, ST-segment r(-'sponse and prevalence coronary-artery disease in the Coronary Altery Surgery Study (CASS). :-J Engl J Med 1979;301:23(}-2:}5

23. Cole JP, Ellestad MH. Signincance of chest ["tin during treadmill exercise: eorrelation with eoronal)' events. Am .I CarruoI1978;41:227-232. 24. Taylor HI., Buskirk ER, Hensehel A. Maximal oxygen uptake as an objective measure of carruorespiratory performance. J Appl Physiol 1955;8:73-80. 25. :-Joakes TO. Challenging beliefs: ex Africa semper aliquid nO\o. Med Sci Sports Exere 1997; 29;5/1-590. 26. Wasserman K, Whipp BJ, Ko)'1 SN, et aJ. Anaerobic threshold and respiratOl)' gas exchange during exercise. J App! Physiol 1973;35:236-243. 27. Cai07,z0 Yj, Davis JA, Ellis .IF, et al. A comparison of gas exehange inruees osed to detect the anaerobic threshold. J Appl Ph)siol 1982;53:118+-1189. 28. Beaver WL, Wasserman K, Whipp B.I. A new method for detecting anaerobic threshold by gas exchange. J Appl Physiol 1986;60;2020-2027. 29. Brooks GA. Anaerobic threshold: review of the concept and cbrections for future research. Med Sei Sports Exerc 198.5;17:22-34. 30. Sue DY, Wasserman K, Moricca RB, et pJ. Metabolic aeidosis during exereise in patients with duonic obstructive pulmonary rusease. Use of the V-slope method for anaerobic threshold determination. Chest 1988;94:931-938. 31. American Thoracic Society and American College of Chest Physicians. ATS/ACCP Statement on cardiopulmonal)' exercise testing. Am J Respir Crit Care Med 2003;167:211-277. 32. Michaelidcs AI', Psomadaki ZD, Dilaveris PE, et al. Improved deteetion of coronal)' artel)' rusease by exercise electrocarruography with the use of right preeordial leads. N Engl J Med 1999;340: 340--345 33. Chetlin MD, Alpert IS, Armstrong WF. ACC/AHA gUidelines lor the dinieal application of echocardiography: a rcport of the American College ofCardiology/Ameriean Heart Association Task Foree on Practice Guidelines (Committee on Clinical Applieation of Eehocarruography). J Am Coil Cardiol 1.997;29;862-S79. 34. Berman OS, Kiat H, Leppo J. Technetium-99m myoeardial perfUSion imaging agents. In: Marcus ML, Schelbert HR, Skorton OJ, eds. Carchac Imaging: A Companion to Baunwald's Heart Disease. Philadelphia; WB Saunders, 1997:1097-1109. 35. Ritchie .IL, Bateman TM, Bonow RO. Guidelines for dinical use of carruac raruonudide imaging. HepOlt of the American College of CarruologylAmelican Heart Association Task Force on Assessment of Diagnostie and Therapeutic Carruovascular Procedures (Committee on Raruonoclide Imaging). J Am Coli Carruol 1995;2.5(2):521-554. 36. ~IOITOW K, Morris CK, Froelicher VF, et aJ. Precliction of eardiovascular death in men undergOing noninvasive evaluation for eoronary artel} rusease. Ann Intem Med 1993;118:689-695. 37. Mark DB, Hlatky MA, Harrell FE J 1', et a!. Exercise treadmill score for preructing prognOSiS in coronary artel)' rusease. Ann Intem ~Ied 1987;106:793-S00. 38. Kwok .1M, Miller TO, Hodge DO, et al. PrognostiC value of the Duke treadmill score in the elderIv. J Am Coil Carruol 2002;39:1475-1481. 39. \Vilkoff B, Miller R. Exercise testing for chronotropiC assessment. Cardiol Clin 1992;10:705-717. 40. Bruce RA, Kusumi F, Hosmer D. M'Lximal oxygen intake and nomographiC assessment of functional aerobic impairment in cardiovascular disease. Am Heart .11973;85:546-562.

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II. 12. 13. 14.

15. 16. 17. 18. 19.

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or

SECTION

III
Exercise Prescription

CHAPTER

General Principles of Exercise Prescription

7

The prin1alY focus on achic\'ing health-related goals has been on prescribing exercise for improvements in cardiorespiratory (CH) fitness, body composition, and muscular fitness. To hlcilitate change, the Centers for Disease Control (CDC) and American College of Sports \ledicine (ACSM) recommended that all adults in the United States should accumulate 30 minutes or more of moderateintensity physical activity on most, and preferably all, days of the week I The success of exercise implementation is predicated on a willingness and readiness to change behavior. See the latter section of this chapter and Section 12 of the ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription (5th ed,) for additional information on behavior modification. [n 1996, the United States Office of the Surgeon General (SGH) issued the first report on physical activity and health. This report concurred \\~th the CDC/ACSM recommendations and concluded that people of all ages benefit from regular physical activit)', I The SGH indicated that although health benefits improve \vith moderate amounts of physical activity (1.5 minutes of running, 30 minutes of blisk walking, or 45 minutes of pla)ing volleyball), greater benefits are obtaincd with greater amounts of ph)'sical activity." [n October 2000, an international consensus committee conducted an evidence-based symposium that examined the doseresponse of phvsical acti\~ty and health. The proceedings for this symposium indicate ample e\~dence to suppOJi the beneficial effects of regular physical activity on more than a dozen health outcomes.3 See Table 1-2 for a summary of the dose-response evidence, The panel suggested that, when assessing dose-response, consideration be given to not only the dose that induces the greatest health benefit, but also the potential risk in a particular population, They noted that the greater intensity and volume of exercise, the greater the risk of injUly, especially musculoskeletal injury in general, and cardiovascular injul)' for those \\~th disease 4 Hegular physical acti\~ty to enhance health benefits for all popillations is supported by numerous organizations and research. The Physical Activity Pyramid has been suggested as one way to facilitate this objective (Fig. 7-1). Some fitness profeSSionals \~ewed this recommendation as a major departure from the traditional ACSM exercise programming recommendations published in earlier editions of this text and various ACSM position stands. Others saw the new recommendation as part of a continuum of physical activity recommendations that meets the needs of almost all individuals to improve health status, The lower end of the moderate intensity scale (40%-59% of heart rate reserve) can
133

intensity.) improve fitness for many sedentary.w . if the goal is to improve one specific acti\~­ ty. however. a fitness program that involves a wide variet)' of exercises and recruits most of the m. .S.. or low-fitness indi\~duals.. specific outcomes identified for a particular person should be the ultimate target of the exercise prescription. blood pressnre (BP).134 SECTION III / EXERCISE PRESCRIPTION CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 135 SIT SPARINGLY • watch TV • play computer THE ACTIVITY PYRAMID " games 12-3 TIMESIWEEK I '\. Minneapolis. adopting a moderately active lifestyle (i. duration. For example. the exercise prescription should be developed with carcful consideration of the individual's health status (including medications). The essential components of a systematic. the physical acti~ty should focus on that acti~ty.. Move more.-_. The combined ACSM/CDC and traditional ACSM recommendations represent a true continuum for one of the primary variables in exercise prescription. muscular endurance. Overview of the Exercise Prescription FIGURE 7-1. Improvements in the final four components follow the two major principles of training progression: overload and specificity. and ensure safety during exercise participation. promote health by reducing risk factors for chronic disease (e. health needs. is exemplified bv different modes of aerobic exercise that produce different outcomes.A.:. whenever possible.e . An exercise prescription specifies the mode. this results in limited carryover for s\\~m performance. regardless of the individual health status. including observations of heart rate (HH).. The optimal exercise prescription for an individual is determined fr9m an objective evaluation of that person's response to exercise.g. and VO Zmax measured directly or estimated during a graded exercise test. despite exercising at the same percentage of VOZIll"x or rating of percei\'ed exeltion (RPE)' Consequently. The Activity Pyramid. Repeated exposure is associated \\~th an adaptation by the tissue or organ that leads to improved functional capacity and/or efficienc).l. Reprinted with permission. the intensity of exercise. a health/medical screening helps determine the necessary or recommended evaluation before beginning a physical conditioning program.. electrocardiogram (ECG) when applicable. " ENJOY LEISURE STRETCH! ACTIVITIES STRENGTHEN • golf • curl-ups • bowling • push-ups • . The individual rate of progression in response to similar stimuli can val)' significantlyS Gcnetic characteristics and hcalth status are responsible for the different response rates. and progression of physical acti~ty. and flexibility. has been suggested as a model to facilitate public and patient education for the adoption of a progressively more active lifestyle. 5 AJthough numerous modes of aerobic exercise can prO\~de a general adaptation of the myocardium. risk factor profile. However. the ACSM/CDC recommendation) may prO\~de important health benefits mld represent a more attainable goal than achievement of a high VO Z •mv However. In all cases. analogous to the USDA's Food Guide Pyramid. intensity.~or muscle groups increases the likelihood that the training effect may transfer to vocational and recreational acti~ties. frequency. Conversely.. U. specific to the muscles recruited.ya"Trd_w_o_rk _ _. (The Activity Pyramid © 2003 Park Nicollet Health Innovations. beha\~oral characteristics. and clinical status. indi~dualized exercise prescription include the appropriate mode(s).e. The principle of specificity states that training effects derived from an exercise program are specific to the exercise performed and muscles involved. Principles of Training The health-related physical fitness components identified and evaluated in Chapter 4 included body composition. These five components apply when developing exercise prescriptions for people of all ages and fitness levels. This chapter describes how to structure exercise prescriptions to achieve and maintain health and fitness goals. Based on individual interests. Those who follow the more recent recommendation L eX1Jerience many of the health-related benefits of physical acti~ty. and if they are interested in achieving higher levels of fitness. Enhance your fitness by choosing other activities on the pyramid. and exercise preferences.. enhancing physical fitness. it must be exposed to a stimulus greater than it is normally accustomed to. and frequency of training. the interaction of these variables results in the cumulative overload to which the tissue or organ must adapt. duration. they \\~Il be ready to do so. sit less. glucose intolerance).. changes in oxygen extraction and delivel)' at the muscle site are specific to the muscle recruited and intensity of exercise 6 The training effect. subjective response to exercise (RPE). The principle of progressive overload states that for a tissue or organ to improve its function. overweight. Some individuals may be classified as responders verslls nonresponders based on different changes to similar stimuli. that is. high blood pressure. For the sedentm)' person at risk for premature chronic disease. running improves VOZm"x through both central circulation and peripheral muscle adaptations. personal goals. 1-888-637-2675.). As discussed in Chapter 2.. CR fitness (VO Zm ". . Exercise prescriptions are designed to enhance physical fitness. ig.g _ 13-5 TIMESIWEEK DO AEROBIC ACTIVITIES • long walks • biking • swimming I \ ENJOY RECREATIONAL SPORTS • tennis • racquetball • basketball I EVERYDAY I • take extra steps in your day • walk the dog • take the stairs instead ot the elevator • park your car farther away and walk Start your weekly activity plan with the daily activities at the base of the pyramid. is a desirable feature of exercise prescriptions.hrt_Iift_in. these common purposes do not carry equal or consistent weight.:. muscular strength.

5 of the ACSM's Resource Manllal for Gllidelinesfor Exercise Testing and Prescription (. studies in healthy subjects and postmyocardial infarction patients who were taking l3-blockers have failed to confirm these cardiovascular abnormalities during sudden strenuous exercise. a stimulus or conditioningphase (CR.. abilities. The redoml1lendatiolls presented should be used \\~th carcful attention to the goals of the individual. Excrcise prcscriptions recluirc modification in accordanc:e \I~th observed individual respouses and adaptations because of thc following: amona indi\'iduPhysiologic and perc:eptwJ resjJonses to acute exercise l'aJY / b als and within an indi\idual performing differcnt t\1Jes of exercise.)9 200 .cti\'~ e:o..5th eel. As such. whcre appropri. I I 1 180 CO . frequency (how often). these guidelines cannot he implemented in an overly rigid f~lshion by simply applying mathematical calculations to test data. and cool-down phases along with a representative heart rate response. At the conclusion of warm-up.ercise prescription presented in this book are based on a solid foundation of scientific information. Similarly. Format of a typical aerobic exercise session illustrating the warm-up. participants who use brisk walking during the endurance phase might conclude the warm-up period with slow walking. All tmining (p. • Desired outcomes based on individual nced(s) may be achieved with exercise programs that vary considerably in structure.1 beats. or undertakcn at a separate time. so onc should address individual interests. ane! a cool-down period (5 to 10 minutcs) (Fig. duration (how long).min. Although an abllndance of Iitemture exists on this topic. elevates body temperature.. resistance. Thus.~te. stretches postural muscles. flexibility) should be prescribed in speCific terms of in~cnsity (how difflcnlt). WARM-UP Warm-up facilitates the transition from rest to exercise.ll A preliminary warm-up also may have preventive value.'s when endurance tminina is not' however both h" acti\ities can be combined into the same workout. and resistance training should be integral parts of a comprehensi\'e tr:aining pra'gram. The art ofexercise prescription is the slicces. and are dependent on health status and genetic potential. and limitations in the deSign of thc program.ljlll integration ofexercise science leith behal)ioral techniqlles that resliit in long-term program compliance and attainment of the indil)idllal's goals. endurance. an optional rccreatlonal game (proVides variety).lo. Maximum = 170 HRR 85% = 155 beats·min. dissociates more oxygen. There is a need to adjust the intensit\' and duration of exercise and monitor lIR BP HPE. CO J: y Start exercise 10 20 30 40 50 Stop exercise Minutes of exercise FIGURE 7-2.e warm-up or cool-do\\~l. and transient global left ventricular dysfunction follo\~ng sudden strenuous exertion 14 .ideal warm-up to for participants who jog slowly dUJing the endurance phase. The sequence of performing endurance or resistance training is a personal preference \\~thout a scientific mandate. impro~ng joint range of motion and flmction.g" CR. corresponding to 70% to 85% of the peak heart rate reserve achieved during maximal exercise testing.1 . resistance tmining) (20 to 60 minutcs). 12. For example. The stretching acti~ties may be Components of the Training Session Once the exercise prescription has been fonnniated. III Q) Q) Resting : Warm-up . Resistance training often IS performed on aitelllate da. knowledgc of methods to change hcalth behaviors is essential and is addressed later in this chapter. 7-2). it is integrated into a comprehenSl\'e phYSical conditioning program. • Adaptations to exercise training vary in terms of magnitude and rate of development. brisk walking serves as an .(10-20 min). augments blood flow.136 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 137 The Art of Exercise Prescription The guidelines for e:o.15 However. and enhanCing muscular performance. and increases the metabolic rate from the resting level (1 MET) to the aerobic requirements for endurance training lO A warm-up may reduce the susceptibility to musculoskeletal injury by increasing connective tissue extenSibility. ~ . which generally is complemented by an m'erall health impro\'ement plan. and. Progress sl~ould be monitored by checking HH and HPE responses to allow finc-tuning of the exerc:ise stimulus.~ FleXibility training can be included as part of th. Oexibilitv. Oexibility. l'l:.5 to 10 minutes). The format for the exercise scssion should include a warm-up period (approximatcly .~:Cooldown: Recovery 1(5-10 min). heart rate approached the lower limit of the target zone for training. I . an excellcnt source is Section .n The exercise session should begin with 5 to 10 minutes of low-intensity large muscle activity (10% to 30% \'02R) and progress to an intensity at the lower limit prescribed for endurance training.1.3 threatening ventricular dysrhythmias.0 CO ""Q) l::: E 160 140 120 100 80 60 . Cardiorespiratory. Gi\'en the di\'erse nature and health needs of the population. the most appropriate exercise prescription for a particular indi\idual is the onc that is most helpful in achie\ing this behmioral change. • A fundamental objecti\'e of excrcise prescription is to bring about a change in personal health behmior to include habitual phYSical acti\'ity. and t:1Je of acti\ities.ercise stimulus.. decreasing the occurrence of ischemic ST-segment depression.f---I Endurance (20-60 min) ----l. ECG responses to achie\'e a safe and eH.

have definite recreational value. or cardiovascular endmance refers to the ability to persist or continue in strenuous activity reqlliring large-muscle groups for prolonged time. pro. playing volleyball while allowing one bounce of the ball per side facilitates longer rallies.J ·min. machine-based stair climbing. safe program for both healthy participants. Cardiorespiratory Exercise Prescription This phase develops CR and local muscle fltness. or all program areas can be included. aerobic endurance training below a minimal threshold (20% HRR or . However. Cool-down is a critical ingredient of a comprehensive. or combinations thereof. duration. which is related to a minimal threshold of frequency. the sudden termination of exercise results in a transient decrease in venous return. walking.m1x. aerobic endurance.ZI Because of heterogeneity in the response to an exercise stimulus. and in some cases. generally demonstrate the greatest percent increase in VO Zon ". alternate activities (e. Ma. Stlldies to confirm this hypothesis are lacking. dizziness. Using a constant mode (type) of exercise for both testing and training provides ideal speCifiCity. and flexibility training. IH COOL-DOWN The cool-down period provides a gradual recovery from the endurance/games phase and includes exercises of diminishing intensities. relaxation training). Indi\~duals \\~th low initial levels of fitness. A comprehensive program shollld include all three conditioning components.. competition. intermittent rest periods. CardiorespiratOlY fitness. Stretching (flexibility) exercises performed as part of the warm-up may primarily have an acute effect. thereby reducing the potential for postexercise hypotension and.. These terms refer to the maximal capacity to produce energy aerobically and usually are expressed in METs or mL Oz·kg.1 CardiorespiratOlY endurance. cycling and approximately . Omission of a cool-down in the immediate postexercise period theoretically increases the opportunity for cardiovascular complications. may be proportional to the quality of the stimulus above the minimal threshold. and combat the potential.vides additional fun. 18 Because of a potential discordance between RPE and IIR dnring game activities. and adjusted scoring. Game modifications should maxlImze the experience of successful participation. such as cardiac patients and those experiencing concomitant reductions in ?ody weight and fat stores. and flexibility programming. Later sections of this chapter focus on exercise programming by CR conditioning. more modest increases occur in healthy individuals V\~th high initial levels of fitness and in those whose body weight remains unchanged.ygen (Oz) to the working muscles and in the muscle's ability to generate energy with Oz result in increased CR fitness. STIMULUS OR CONDITIONING PHASE The stimulus (conditioning) phase includes CR (endnrance). tai chi. yoga. catecholamine response. and cardiovascular fltness are used synonymously. diffuse ann pain. especially in patients with heart disease. elliptical activity. energy cost.J 'min. V0 2m "" aerobic capacity. possibly reducing coronary blood flow when HR and myocardial oxygen demands still may be high. and reduces the skill required to play the game sllccessllllly. who have a low V0 2m "x «30 mL'kg. but are enjoyable. Genetics also influence the magnitude and rate of change. may reducc the likelihood of threatening ventricular dysrhythmias. the latter should be monitored periodically to adjust the intensity of play. serious ventricular dysrhythmias.5 minutes of stretching exercises. 18 The attenuation of the MODE OF EXERCISE Exercises for the endurance phase employ large muscle groups in activities that ate rhythmiC or dynamiC in nature. which are potential harbingers of sudden cardiac death.50% max HR) may be sufflcient for developing aerobic fitness in healthy adults. lowered net height. deleteriolls effects of the postexercise rise in plasma catecholamines. Conseqnences may include ischemic ST-segment depreSSIOn. running.5 minutes of slower walking or jogging. I I RECREATIONAL ACTIVITIES Activities like golf are unlikely to elicit a cardiovascular training effect for flt individuals. hlCilitate the dissipation of body heat. The cool-down is critical to attenuate the exercise-induced circulatOlY responses and return HR and BP to near resting values. one. two. For example. and basketball also have aerobic conditioning potential if they are pursued for a sufficient duration and intensity. In contrast. throat pain). Figure 7-2 depicts a typical exercise training session with the CR phase exemplified. with or without anginal symptoms (e.. resistance training. hiking. Improvements in the ability of the heart to deliver (J}. and heart rate responses to play. and may yield health-related benefits. The inclusion of enjoyable recreational activities dming (or immediately after) the endurance phase may enhance adherence. minor rule changes. as well as patients with disease. Dynamic stretching or modified proprioceptive neuromuscular bcilitation techniqlles or combinations thereof also can be incorporated into the latter portion of the warm-1lpIl Generally low-intensity stretching is preferred before vigorous endurance activity. swimming. . whereas flexibility performed during the cool-down may provide a more longterm benefit. Depending on the individual's goals or outcomes.J )2Z The training-induced increase in VO Z . racquetball. and volume of exercise.H. handball. intensity. approximately. for example. cycling.g. maintain adequate venous return. The imaginative exercise leader may suggest a smaller court Size.ZO. winning or losing should be of lesser importance. The greatest improvement in V0 2n "" occurs when exercise involves the use of large muscle groups over prolonged periods in activities that are rhythmic and aerobic in nature (e.. Presumably. freqllent player-position rotation. promote more rapid removal 01 lactic acid than stationaJy recovely.IlY other team games and individual sports can be modified in a similar fashion. Sports such as tennis.g.g. back pain.138 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 139 conducted after the initial large muscle warm-up and should stretch the major muscle groups using static techniques. which generally ranges from . game rules may be modified to decrease skill requirements. Alteration in CR fitness is measured by assessing the change in VO Zn "". resistance.5% to 30%. and is the most a~curate measure of change in oxygen consll1nption.

but does not alter the current methods of calculating target heart rates.. The ACSY[ recommends an intensity of exercise corresponding to 40% and 50% (40%/50%) to 850/< of' Q. Examples of these activities are walking and cycling. a mini mal int. habitual walkers can elicit an aerobic training stimulus comparable to 50% IlRR or 70% HR max in oldcr adults (>50 \'ears of age). factors that influence compliance to the exercise program and thus desired outcomes. imprm'ements in health related benefits may be achieved by a low-intensity. he desirable to ha\'e the indi\'idual cross train (engage in se\'eral different acti\'ities) to reduce repetith'e orthopediC stresses and involve the greatest nu mber of' muscle groups. I BOX 7-1 Grouping!of ~ :·il' Group 1 Activities that can be readily maintained at a constant intensity and interindividual variation in energy expenditure is relatively low.. middle-aged men.27.· In contrast. skating. but individual skill levels must be considered. it is important to consider uniquc \'oeational or recreational objecti\'es of the exercise program when recommending activities. Similarly.:30 Consequently.creased with the latter. 24 Variations of conventional walking training. or both. if' pOSSible.\'\'gen uptake reserve (\'02R) or heart rate reserve (I-IHR).140 SECTION III / EXERCISE PRESCRIPTION CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 141 rowing. The intensity range to increase and maintain CH fitness is intentionally broad and reflects the fact that low-fit or deconditioned indi\~duals may demonstrate increases in CH fitness with exercise intensities of only 40% to 49% I-lRR or 64% to 70% HR m . dancing.9 mph)." Improvements in \10 2ma. '. however. offers tolerable exercise intensity. Walking may be the activity of choice for many individuals because it is readily acceSSible. especially for the o\'crweiaht or no\'ice exerciser. Such activities can be very useful to provide group interaction and variety in exercise. ' 1'\1e or 64% and 70% (64%170%) to 94% of maxunum heart rate ( I-IR) VO.H is the diff'erence between V0 2""" and resting V02. the percent values are apprOXimately equal to the percent values for the HRR. Because impro\'ement in muscular function is largeh.. .\ can occur with a high-intensity stimulus and low duration «10 minutes).speCific to the muscles in\uh-ed in exercise. or 77% to 90% HHn"C\ are sufficient to achieve improvements in CR fitness when combined \\~th an appropriate frequency and duration of training. In the development of the exercise prescription for the novice exerciser. crosscountry skiing. adaptation. the HHR is the-difference between HR ma\ and resting HI\.. improve CR fitness.:ll ·:33 . it may be useful to begin with group 1 activities and progress depending on the individual's interest..a\ in participants in primaly and secondmy prevention programs. The risk of injury associated with high-impact activities or highly repetitive training also must be considered when prescribing exercise modalities. but must be employed cautiously for high-risk. ':li . . ma\ .2" Manv indi\'iduals might logically progress through walking and jogging programs before engaging in group 2 and 3 activities.. Such activities also may be useful in the early stages of conditioning. shorter-duration program.. Finally. and is an easily regulated exercise for improving health outcomes and CR fitness. especially treadmill and cycle ergometry. apparently healthy.ercise program. 11.. Examples of these activities are racquet sports and basketball. this wide range of activities provides for individual variability relative to skill and enjoyment.. Even extremely slow walking «2 mph) approximates 2 METs and may impose metabolic loads sufficient for exercise training in lower-fit subjects. Desirable for more precise control of exercise intensity. Group 3 Activities where both skill and intensity of exercise are highly variable. and highly motivated individuals. Brisk walking (2. below 40 mL' kg "min ~ I. Examples include swimming and cross-country skiing. longer-duration regimen. \Vhen exercise intensities arc set according to \10 2R. 22 Those who are already physically active (in aerobic actiVity) require exercise intensities at the high end of the continuum to further augment their CR fitness. as in the early stages of a rehabilitation program. For most indi\~duals.. intensities \\~thin the range of 60% to 80% HRH. combined upper and lower body ergometry. Clearly. 1129 . Group 2 Activities in which the rate of energy expenditure is highly related to skill. It m<l\' o . indi\iduals with greater CH fltness (>40 mL'kg I 'min-I) require a minimal threshold of 45% V0 2R. Box 7-1 groups commonly prescribed activities by the consistency of the exercise intensity. whereas improvemcnts in CR fitness (\10 2maJ are associated with a higherintensity. which can be attained by healthy.ample. but can provide a constant intensity for a given individual. especially for low-fit clients. low-fit.to 6-kg backpack load 25 and swimming pool walkini 6 offer additional options for those who wish to reduce body weight and fat stores. EXERCISE INTENSITY Intensity and duration of exercise determine the total caloric expenditure during a training session. ancl are inversely related. the e. one should deSign programs to eliminate or attenuate barriers that might decrease the likelihood of compliance with. 23 Brisk walk training programs proVide an activity intense enough to increase aerobic capacity and decrease body weight and fat stores in previously sedentary. programs emphaSizing moderate to \~g­ orous exercise with a longer training duration (>20 minutes) are recommended for most individuals.. For inchiduals with \'0 2m . or lldherence to. for e. and/or symptomatic individuals. including walking with a 3.20 21 but this training should be reserved for asymptomatic. and clinical status.ensity of 30% \10 2R can elicit impro\'ement in \'0 2m . These ranges of exercise intensities have been successful for increasing \'02". 12 The risk of orthopediC injury is purported to be il. endurance games).9 to 3. use of the V0 2H improves the accuracy of calculating a target V0 2 from a HRH prescription. Competitive factors also must be considered and minimized.

.6 + 3. the exercise intensity has been expressed as a percentage of oxygen uptake reserve (%\102R)..34 However. Med Sci Sports Exerc 1992. Higher fit individuals need to work at the higher end of the intensity continuum to improve and maintain their fitness.'min. • • • Heart Rate Methods Heart rate is used as a guide to set exercise intensity because of the relatively linear relationship between HR and V0 2.. such as musculoskeletal disorders. the prescribed intensity could be set at 24 to 32 mL'kg-"min. (Reproduced with permission from Whaley MH. Medications (see Appendix A) that may influence HR require special attention when defining the initial target HR range and when the dose or timing of medication is changed. 1::: 'E .1 = Target V0 2 mL'kg. level of hydration. perceived exertion. It is best to measure maximal HR (HR.. the range of exercise training intensities (mL'kg.est) (exercise intensity) + V0 2 . Medical conditions..l . of 40 mL'kg-1'min -I. The ability of individuals to undertake exercise successfully at a given absolute intensity is directly related to their relative effort as reflected by HR and RPE.- . a corresponding work rate may be calculated through the use of metabolic equations (see Appendix 0) or by selecting an activity with a corresponding MET level from published tables. the following equation is used: Target .24(10):1173-1179.7..'min. In the ACSM position stand. Risk of cardiovascular and orthopedic injuries is higher and adherence is lower with higher-intensity exercise programs. II To calculate the target \10 2 based on V0 2R. all Intensity Prescription by \/0 2 Traditionally. but the load should be titrated depending on the physiologic responses. Individual preferences for exercise must be considered to improve the likelihood that the individual will adhere to the exercise program. sedentary. longer-duration exercise sessions.1 Once a V0 2 (MET) target level is identified. pollution). Dwyer GB. 7-3).142 SECTION III / EXERCISE PRESCRIPTION CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 143 Factors to consider before determining the level of exercise intensity include the following: • Low-fit.1 = Target V0 2 mL'kg.0001.35) (040) (140) (040) 5. asthma.. lower body fatness. P <.ell This equation has the same form as the heart rate reserve (HRR) calculation of target heart rate (see the fo]]owing). Athletes may frequently train at intensities in excess of 90% V0 2 R to achieve improvements in performance..6-0789 (age). ell Q) J: (ij V0 2 mL'kg. Q) 220 210 200 190 180 170 160 150 140 130 120 10 20 30 40 50 80 V0 2 = (V0 2max . increased V02mnJ help define the characteristics of the exercise prescription. For example.(l MET) and the exercise intensity is 50% to 85% (or as low as 40% for velY deconditioned individuals).1 mL'kg. altitude.g" estimated HR ma. Individual program objectives (lower BP.ell . Intensity is expressed as a fraction in the equation.and underachievement of age-predicted maximal heart rate. Note: y = 213. humidity. the most comm~n methods of setting the intensity of exercise to improve or maintain CR fitness use HR and RPE.5 E >< ell :2E 0 0 0 9. and other variables that can alter the HR and RPE responses to exercise.V0 2 . The relationship between age and maximal heart rate for men demonstrates a high SEE.5 + 3.I 'min. = 220-age) and the vanance for any glVen age is considerable (1 SO :±: 10-12 beats'min. Kaminsky LA. SEE = 10.. and symptoms.1 'min.0 Q) . • • • The caloric cost of activities can provide a starting point for prescribing exercise intensity for individuals with cardiac andlor pulmonary disease.es! III .. Consequently.1 = Target I 1 r (175 . Currently.5 + 3.g" heat.1) (Fig.r 'min. Predictions of over.) .603. and clinical populations can improve fitness with lowerintensity. r =-0. corresponding to 60% and 80% of V02mm" respectively. what is the target \10 2 at 40% of V0 2R for a person with a \102n"" of 17. Age (years) FIGURE 7-3.) dUling a progressive maximal exercise test whenever possible because HR max declines with age (e. there are limitations to the use of \10 2 iu prescribing exercise: • The caloric cost for activities in groups 2 and 3 (see Box 7-1) are quite variable and depend on the skill of the participant andlor the level of competition. In the target \10 2 equation. • The caloric cost of an activity does not take into consideration the effect of environment (e. or metabolic conditions.mc.= Target V0 2 mL'kg. V0 2 "es( is 3. which is similar for women.5 mL'kg-r'min -1 (5 METs)? . and for individuals with low functional capacities.J 'min -J or in METs) has been based on a straight percentage of V0 2mn" For example.5 1 mL·kg-1·min. if an individual had a measured \10 2ma.

.~ eu ::I: m110 100 90 5 10 15 20 25 30 35 40 The direct method of obtaining the target FIR range im'oh-es plotting measured HR against either measured \'0 2 (Fig. 120 . The target HR range for the %HH.. if the resting HR is 60 and the maximal The HHH method yields a target HR range of 132 to 1.56 beats' min -1 for.) to obtain EBR. prescribing a cool dO\\~l intensity of' 30% IIR""" for an indi\~dl!CtI \\~th a maximal EB of ISO yields a target HH 01'.7 ..1 . empirically based.:)'> and prO\ides the stimulus needed to imprO\'e or maintain \'02m".ation..80) + 60 = 156 beats-min. the traditional..I One then takes 60% andSO% of the HHH and adds each of these values to resting HR to obtain the target HR range: Target HR range = One of the oldest methods of setting the target HR range uses a straight percentage of the I-IH""".this subject.. obese..60) + 60 = .. in reality (and celtainly dming discontinllOus exercise) IIR is likeh. those with cardiovascnlar anellor pulmonary disease.1 .1 'min. If' an indi\~dual's HH".144 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 145 prediction fOrl1l1llae for ma"imal heart rate contain large standard errors of estimate. which are population specific (e. the assumption is that the indi\idual \\~11 achie\'e a steady-state HR response in the prescribed range. This range of' exercise intensities approximates .1 = 120 beats'min. For example..1 The HR reserve (HHR) method is also known as the Karvonen method.:). then: ISO beats'min. and those taking medications (e. This method is appropriate for setting exercise intensity for persons \\~th low fitness levels.. A target heart rate range was determined by finding the heart rates that correspond to 50% and 85% of V0 2max ... If BPE data are available.60] x 0. Forthis individual. is ISO beats'min -I. Early researchers and clinicians used 70% to S.g" l3-blockers) that affect the EH rcsponse to exercise. There are several approaches to determining a teu'get HR range for prescriptive pU!1)oses.1 -min. Sixty to eighty percent of the EHR is equal to about60% to 80% ofV02'~"lX for most fit individuals.g..:l5 Prediction equations. i -4) or exercise intensity (as discllssed in Chapter 4).. The latter point is most impOitant when working with lowfit clients. but is more closely linked to the %V0 2H across the entire range of fitness levels. those with elevated resting HR). obtaining the actual maximal HR through a maximal exercise test is preferred.1 'min. The systematic difference between the hvo HR methods is reduced as the mtensity increases.. RPE. Percent of HRmax (Zero to Peak Method) V0 2 (mL·kg-1 ·min-1) FIGURE 7-4..50% to iO% \'0 2". Either method can be used to approximate the range of exercise .54 (. the target HB range is 126 to 153 beats' min-I. easy-to-use (220-age) is stiJi ~able.1 and maXimal heart rate was 184 bpm. 130 .to be both above and below the prescribed intensity.g" smokers.1 Target HR range of 60% intensity Target HR range of 80% intensity = ([180 = ([180 ..30 X ISO = . resting heart rate (IIRr~\() is subtracted from the maximal heart rate (HR"".60] x 0.. aged. which is often below the resting lIIt HR Reserve Method (Karvonen) ([HRmarHRrestl x percent intensity) + HR re51 132 beats-min. in individuals exercising in clinical and adnlt fitness settings.54). Specific medications (l3-bloekcrs) preclude the use of a predicted maximal HR.5% of an indi\~d­ ual's HH". and 85% of V0 2max was approximately 32 mL'kg. The goal slHJIlld be to maintain an average IJR close to the midpoint of the prescribed range. ~lETs). which is helpful in monitoring the exercise intensity. the IIH-\f0 2 relationship can be evaJnated further in relation to the individual's RPE. The corresponding target heart rates are approximately 130 and 168 beats-min.1 .1 . In the absence of a tnle determination of maximal IIR. A line of best fit has been drawn through the data points on this plot of heart rate and oxygen consumption data observed during a hypothetical maximal exercise test in which \102max was observed to be 38 mL'kg. The actual maximal HR is specific to the mode of exercise and may differ \\~th­ in populations of the same age and sex. similar to the target HR range calculated by the percent of maximal HR method. Until a multivariate regression equation is developed that accurately predicts maximal HR.1 ..:)I-:J:J It is also simple to compute.use different resting heart rates are used in the target HH calcul. which ma\' result in inaccurac\' when applied to general populations. Ul . thus other methods of monitoring intensity are necessary (e. For example. The direct method allows one to prescribe an appropriate training HR range below the point of ackerse signs or symptoms experienced b\' the inclividual during exercise testing. HH is ISO.. Direct Method 180 ~ 170 160 150 m 140 . This is a conservative approach that is vel)' inaccurate at low intensity target zones. despite the large standard error. as the preselibed exercise intensih'.0 -.·l~ In this method..mx and the HHR methods are diffel:ent bec. 50% of \102max was approximately 19 mL-kg. may prO\~de more accurate estimates of maximal 1B HIt· .1 minus 60 beats-min. Dnring an exercise session.

Consistent with the manner in which the intensity of a session is gradually increased over wecks of training."aJ 21 have demonstrated improvements in \10 2IlHL\. and achieves the desired caloric output aiven the time constraints of' the exercise session. an exercise frequency of 3 d'wk.5 MET capacities.' . and should be reserved for the performance oriented individuals or competitive athletes. For those exercising at 60% to 80% IIRR or 77% to 90% HIl.01l<L\ utes or le~s.' is sufficient to improve or maintain \'02m<L\' For those exercising at the lower end of the intensity continuum. 01m .' Although deconditioned persons may improve CH fitness with only twiceweekly exercise.PE is considered an adjunct to monitoring HR because RPE determined during a gradeo exercise test may not consistently translate to the same intensity during an exercise session or for different modes of exercise.7% \102m<L\':'~ • If an estimate of HR max (e. b 60 minutes of continuous or intermittent activity (lO-minute bouts accumulated throughout the day).:lu Rating of Perceived Exertion • Commonly useo RPE scales are found iu Chapter 4. the IIRR method more accurately depicts the intensity relative to oxygen consumption. although the e\idence is weak to suggest that a longer omation further enhances \'02ma" As the duration increases the opportunity for cardiOl'ascular drift (e. 77o/c Exercise Frequency EXERCISE DURATION The duration of an exercise session interacts \lith the intensity to result in the expenditure of a sufficient number of calories to achieve health and fitness goals such as improved body composition.. one should suit the Il. however. 110wever. the target IlR range is only a guideline used in setting the exercise intensity: Some individuals prefer to exercise at the low end of the target HR range and focus on long dmation (>40 minutes) to accomplish fitness goals. high -intensity exercise.I . The ACS~1 position stand recommends a minimum of 20 minutes of cardiOl'ascular exercise f'or improvement in aerobic capacity.PE has prol'ed to be a valuable aid in prescribing exercise for indi\iduals who have difficulty with H R palpation. .. and three to five sessions per week are recommended for individuals \lith a functional capacity of >5 METs. 30 minutes) can begin with as little as multiple (4 to 10).R. an indi\idual's perception of effort \Iill vary among exercise modes when exercising at exactly the same lIB.AoAI Howel'er. moderate duration (20 to 30 minutes) cxercisc is recommended for improving aerobic capacity (\T0 2IlJaxl of most adults. 2-to 5-minute bouts with rest pCliods between bouts for those \\ith low levels of CR fitness. a reduction in the \\'orkioad may maintain the target HR range. and lower compliance. Patients with functional capacities of fewer than 3 MEl's may benefit f'rom multiple brief daily exercise sessions. one to two shOlt sessions per day are appropliate for those with 3 to . Consequently. the appropriate exercise intensity is one that is safe. thus. limited data on short bouts (12 minutes at high intensity)20 or interval training (six to seven bouts of 20 seconds at > 170% \'02. Use of Il. exercising at 60% to 80% HRR or for 20 to 30 minutes. however. 30 minutes or more of moderate intensity physical activity is preferable on most days of the week for . the Il.146 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 147 intensities kno\\'n to increase or maintain \10 2011 <. a rise in HR over time from increased core temperature. High-intensity exercise is associatcd with an increased risk of orthopedic injury.PE to the individual on a specific mode of exercise and not expect an exact matching of the RPE to a %HR 01 "" or %lIIl.1-l5 People training at low intensity should conduct the exercise sessions O\'er a longer period of time (30 minutes or more). response to exercise may hm'e b~en altered because of a change in medication. because of significant interindil'idual variability in the psychophysiologic relationship. 4(i Thcrefore. This must be considereo when an individual begins an exercise program. It is important to establish the target HPE within the training environment.I appear to be minimal. In the final analysis. moderate intensity. 7 • Conversion of a %HR 01 "" value to a %\'0 201 "" value carries with it a stanoard error of esti mate of ± .. eOl1\'erselv. enhances aerobic capacity (\10 2ma \). the duration (e. indiliduals training at higher le\'els of intensitv m<1\' train for 20 minto 90% I-Tl'l. The duration of the exercise bout can be extended until the goal is achieved. conlpatiblc with a long-term active lifestyle for that individual.') ehvk. the error inherent in that estimate is carried over to the calculated target HR range (see Fig.. Although fitness may improve through short duration. and blood redistribution) is increased.' may be needed to achicvc the caloric expenditure associated with weight loss and fitness goals. The RPE can be helpful in adjusting the exercise intensity in such situations.g. The average RPE range a~soeiated \lith physiologic adaptation to exercise is 12 to 16 (in the range of "somewhat hard" to "hard") on the Borg scale (see Chapter 4). enables most indi\iduals to fulfill their goals.1 is not recommendcd.5. Vigorous training 7 d'wk.. and in cases where the HIl. Duration is inversely related to the intensity of the activity. 4. exercising more than 3 chvk. 7-3). dehnlration. greater improvement is achieved with a frefluency of three to five sessions per week. scientific evidence to support the health benefits of short duration exercise is lacking. 220-age) is used in the preceding calculations rather than measured HR. Increases in cxercise duration should be made as the indi\idual adapts to training \lithout e\idence of undue fatigue or injlll)'.g. As "the art of exercise prescription" suggested earlier. Lowcrintensity activity should be done for a longer period of time (30 minute's or more). The risk of musculoskeletal injllry increases abruptly with increased frequency of training beyond 6 d ·wk. the RPE should be used as a guideline in setting the exercise intensity.Lximal heart rate is oifferent for different modes of exercise. and. ' • Because of the specificity of training and the fact that measu red m.1 frequency47 Additional bcnefits of training 6 or more chvk. excluding time spent warming up and cooling down.g. The CH phase usuallv includes 20 to The ACSlvI recommends an exercise frequency of 3 to. cardiovascular incidence. hut improvements generally plateau within the 3 to 5 d'wk. 4 Tn addition. 42 Consequently. I I Significant improvcment in \'0 2011 <1\ has been demonstrated \lith multiple shOlt bouts (l0 minutes) of exercise equivalent to the total duration of a single long bout (:30 minutes) of exereise.

the endurance aspect of the exercise prescription has three stages of progression: initial. the lIet calOlic expenditure from the exercise is 6 kcal'min -I. see Ainsworth et al.e exerClse program has been set at a net caloric expenditure of 1.000 kcal'wk.5 MEl's because 1 MET of the activit)' represents resting metabolic rate. Any attempt to quantify energy expenditure by accelerometly must be viewed cautiouslyS5 Another useful method to approximate the caloric cost of exercise is by using the follO\ving equation based on the MET level of the activity: (METs x 3. the net calolic expenditure from the exercise is. which is associated with a significant 20% to 30% reduction in risk of all-cause mortality. duration. and maintenance (Table 7-1). and limitations imposed by the participant's lifestyle.2. 300 to 400 kcal'day-l from activity) as their fitness levels improve during the training program.l ). . participant preferences. and the MET level of the prescribed activity is 6 MEl's. Accelerometers have been used to estimate calO1ic expenditure during v.and long-term weight control.48.000 kilocalories for an individual who weighs 70 kg.1.'Irs Resource .\[an//a! for Exercise Testing and Prescription (.I ) for weight loss and weight loss maintenance may be insufficient for effective control. individualized exercise prescriptions should be deSigned with energy expenditure goals in mind. Training Progression for the Sedentary Low-Risk* Participants Program Stage Week Exercise Frequency (sessions'wk ') Exercise Intensity (%HRR) Exercise Duration (min) Initial stage 1 2 3 4 Improvement stage 5-7 8-10 11-13 14-16 17-20 21-24 24+ 3 3-4 3-4 3-4 3-4 3-4 3-4 3-5 3-5 3-5 3-5 40-50 40-50 50-60 50-60 60-70 60-70 65-75 65-75 70-85 70-85 70-85 15-20 20-25 20-25 25-30 25-30 30-35 30-35 30-35 35-40 35-40 20-60 Maintenance Staget 'Defined as the lowest risk categones In Table 2-4 and Boxes 2-1 and 2-2 tDepending on long-term goals of program.uious recreational and household activities. The energy expenditure associated with walking can be predicted with reasonable accuracy.000 kcal threshold (150 kcal'day-I X 7 d'wk. or a reduced risk of premature chronic disease may be different. Based on the dose-response relationships between physical activity and health and fitness. The ACSM recommends a target range of 150 to 400 kcal of physical activity and/or exercise energy expenditure per day. If the goal was a more aggressive 2.48 The lower end of this range represents a minimal calO1ic threshold of ~1. age. and exercise economy (the V0 2 at a given submaximal work rate) and the variable intensities within each available activity strongly influence estimation of caloric eX1Jenditure during exercise. the caloric thresholds necessmy to elicit significant improvements in V02m.2. and duration may vary. which is double the current recommendation for healthrelated physical activity. For information on ~IET values for over 500 physical activities. kcal'min. 50 . Energy Expenditure Goals The interaction of physical activity intensity. post-) comparison within the same individual.50-52 Physical activity and/or exercise energy expenditure in excess of 2. It is recommended that low-risk cardIac patients train at the lower end of these ranges. The weekly goal of th. coordination. which requires 167 minutes per week to attain the 1. 5 d·wk.5th ed.1 Abbreviations: HRR. medical and health status.4 8 However.I program. Clearly. weight loss.1 from physical activity. Interindividual differences in skill..). 53 Estimating caloric expenditure dUling exercise has been problematic for exercise profeSSionals. Therefore. Working back'ward from the caloric goal to determine the volume ?f exercise needed to reach the goal is useful in determining the appropriate exercise prescription components. and tolerance to the current le\'el of training.2. The application of the 1. frequency. Consider the follO\\ing example. individuals should be encouraged to move toward attainment of the upper end of the recommended range (e.4 9 and this should be the initial goal for previously sedentmy individuals. In this example. the IntenSity. Therefore.5 x body weight in kg)/200 = This formula helps an indi\idual understand the components of the exercise prescription and the \'olume of exercise necessary to achieve the caloric goalsof the program. and frequency determines net caloric expenditure from the activity.000 kcal goal (or 33 minutes per day.g. heart rate reserve.L would require 333 minutes per week or ~48 minutes per day on all days of the week. such as golf and household activities may be underestimated by 30% to 60%.148 SECTION III I EXERCISE PRESCRIPTION CHAPTER 7 I GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 149 health-related benefits.51 Recent reports suggest that 60 minutes or more per day may be necessary for weight loss and maintenance.54 Accelerometers provide a general estimate of caloric expenditure and may be more valuable on a relative (pre-. improvement. the net caloric expenditure of 6 kcaJ'min . For healthy adults. but other activities. the number of exercise sessions per week varies depending on the caloric goals.000 kilocalorie threshold.:34 or the ACS. Exercise profeSSionals should TABLE 7-1.000 kcahvk. It is generally accepted that many of the health benefits and training adaptations associated with increased physical activity are related to the total amount of work (volume) accomplished during training.1 for long-term weight control. the individual would require approximatel~' 42 minutes per day to achieve the 1. The optimal training frequency is still elusive.000 kcal'wk. and developing an exercise plan based on caloric thresholds should not be viewed as an exact science. Rate of Progression The recommended rate of progreSSion in an exercise program depends on functional capacity. Gi\'en a -l chvk.~x.l have been successful for both short. indi\idual activit)' preferences and goals.

thus confirming the specificity of training. and vice versa (Fig. Although some apparently healthy but sedentm)' indi\~duals may not be able to attain this initial level of activity. moderate intensity aerobic activities (40% to 60% of HRR) in an intelval format.~x or reduced submaximal heart rate \\ith untrained limbs. such programs usually are associated \. group 3 activities) that the individual finds enjoyable. cardiac patients with left ventlicular dysFunction. The improvement stage of the conditioning program differs from the initial stage in that the palticipant is progressed at a more rapid rate. discomfort.~th increased exercise duration. an exercise prescliption should incollJorate an intensity. \-~th a system of rewards. Duration is increased consistently. The duration of the exercise session during the initial stage may begin with approximately 15 minutes of the cardiovascular stimulus phase and progress to 30 minutes. This initial conditioning stage should prepare the palticipant for the novel activities and develop an OIthopedic tolerance to the exercise stress. Exercise adherence may decrease if the program is initiated too aggreSSively.57 Similar differences in muscle-speCific adaptations have been shown for blood lactate 58 and pulmonm)' ventilation S9 The use of arm training during a detraining phase failed to maintain the gains accrued during leg training. For example. To maintain CR fitness. experience suggests that adaptation to conditioning may take longer in older individuals. frequency. DUling this stage. upper extremity or lower extremity training resulted in only minor improvements in subma. the goals of the program should be reviewed and new goals set. lowintensity muscular fitness exercises that are compatible \~th minimal muscle soreness. but continuing the same workout routine enables indi~duals to maintain their fitness levels. It is important to include exercises and recreational activities (see Box 7-1. Some transfer-oftraining effects have been repOlted.150 SECTION 1111 EXERCISE PRESCRIPTION CHAPTER 7 I GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 151 recognize that recent physical acti\~ty recommendations from the ACSM/CDC 1 and the Surgeon General 2 include 30 minutes of moderate intensity physical acti\~ty on most. At this point. FUlther improvement may bc minimal. including increased V02m. 55 Although the conditions under which the interchangeability of arm and leg training effects may val)'. Increases of duration andlor frequency usually precede increases in intensity. The progression of intensity also can be achieved through intelval training incorporating extended higher-intensity work intervals or by adding one higher-intensity exercise session each week until the target intensity is achieved. speCifically alterations in trained skeletal muscle 64 However. frequency. adjustments in intensity of no more th. for example.63 It has been suggested that approximately half of the increase in trained limb performance results from a centralized training effect and half from peripheral adaptations. GO These findings suggest that a substantial pOltion of the training effect derives from peripheral rather than central changes. subjects trained by lower extremity exercise failed to demonstrate a conditioning bradycardia during upper extremity work. If there is the need for fmther weight loss dUling this phase of the program. Individual goals should be established early in the exercise program and must be realistic. during which intensity is progressively increased \~thin the upper portion of the target range of 50% to 85% of HRR.ximal and maximal lower extremity or upper extremity exercise responses. and an extended cool-down (10 to 15 minutes) \~th the majority of cool-down time devoted to stretching. The goal of each pmticipant should be to reach a minimum of the 50th percentile in all health-related fitness parameters. days of the week for health-related benefits. I I . and duration consistent \~th the palticipant's long-term goals.an 5% of HRR evel)' sixth exercise session are well tolerated. Once the target duration and frequ ncy are achieved. thus providing e~d~nce for central circulatOl)' adaptations to chronic endurance exercise 62 . Thus. or both. the lxuticipant may no longer be interested in further increasing the conditioning stimulus. It is recommended that individuals who are starting a moderate-intensity conditioning program should exercise three to four times per week. \~th increments of no more than 20% each week until palticipants are able to exercise at a moderate to ~gorous intensity continuously for 20 to 30 minutes. Deconditioned indi~duals should be permitted more time for adaptation at each stage of conditioning. This stage may last 1 to 6 weeks. This stage of the exercise program usually begins after the pmticipant has reached preestablished fitness goals. and injm)'. 7_5). they should be encouraged to progress to this goal dUting the first few weeks of the training program. However. respectively. Age also should be taken into consideration when progressions are recommended. and should also meet. It is also helpful to pro~de valiety \~thin and between each exercise session to mai ntain pmticipant interest. if not all. but the length depends on the adaptation of the indi~dual to the exercise program. the minimal calOlic thresholds identified earlier in the chapter. including cellular and enzymatic adaptations that increase the oxidative capacity of chronically exercised skeletal muscle 61 . This stage typically lasts 4 to 8 months. the pelipheral adaptations may predominate in some patient subsets. MAINTENANCE STAGE The goal of this stage of training is the long-term maintenance of CR fitness developed dUling the improvement stage. a calOlic restJiction combined \~th a moderate intensity exercise program that results in a significant negative calOlic balance (500 to 800 kcal . The frequency and magnitude of the increments are dictated by the rate at which the participant adapts to the conditioning program. and preferably exceed. Training Specificity Tumerous studies have investigated the CR and metabolic responses of trained versus untrained muscles to chronic aerobic conditioning. INITIAL CONDITIONING STAGE The initial stage should include an extended warm-up (10 to 15 minutes).day -I) is recommended. there is evidence to suggest that the initial fitness of the subjects as well as the IMPROVEMENT STAGE The goal of this stage of training is to provide a gradual increase in the overall exercise stimulus to allow for significant improvements and adaptations in CR fitness.

Consequently. greater improvement is achieved "vith a frequency of 3 to 5 d'wk. who have a low\T0 2llULx «30 mL·kg-1·min.Leg work ~ . C1l ca 0 Low High Low High • The goal of each palticipant should be to reach a minimum of the 50th percentile in all health-related fitness parameters. ca .-10 C1l c: ca C1l ~ VI lrl Cl 0 Low High Low High Workloads FIGURE 7-5. 66 The limited degree of cardiovascular and metabolic crossover benefits of training from one set of limbs to another appears to discredit the general practice of limiting exercise training to the lower extremity alone. Importance of peripheral adaptation to training of the arms (top) and legs (bottom). • Athletes may frequently train at intensities in excess of 90% V0 2R to achieve improvements in performance. • The CR phase usually includes 20 to 60 minutes of continuous or intermittent (lO-minute bouts accumulated throughout the day) activity. Trap-Jensen J.Leg work ~ . with increments of no more than 20% each week until participants are able to exercise at a moderate to vigorous intensity for 20 to 30 minutes continuously. The effects of training on the heart rate during arm and leg exercise. Arm training on the cycle ergometer reduced the heart rate during arm work but not during leg work. leg training was associated with a lower heart rate response during leg exercise but not during arm exercise. individuals who rely on their upper extremities should be advised to train the upper as well as the lower extremities. frequency. Increases of duration and/or frequency usually precede increases in intensity. • Although deconditioned persons may improve CR fitness with only twiceweekly exercise. Such programs should serve to maximize the conditioning response through increased crossover of training benefits to reallife situations. intensities within the range of 60% to 80% HRR or 77 to 90% HRIll'LX are sufficient to achieve improvements in CR fitness. • The HRR method is recommended for prescIibing exercise intensity rather tl1an the HRIll'LX method because the HRR method more accurately depicts the intensity relative to oll. • Aerobic endurance training below a minimal threshold (20% HRR or 50% HRm'LJ may be sufficient for developing aerobic fitness in healthy adults.152 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 153 ~ Arm Training VI C: -40 E ca r . Lassen NA.I r---. with the expectation of improved CR. • Progression of the CR stimulus: Duration is increased consistently.0 C1l ~ ~ -30 _ -20 ca C1l . • The ACSM recommends an intensity of exercise corresponding to 40% and 50% (40%/50%) to 85% of oxygen uptake reserve (V0 2R) or hemt rate reserve (HRR). when combined witl1 an approptiate frequency and duration of training.. and duration of training may be impOltant variables in determining the extent of cross-training benefits. Scand J Clin Lab Invest 1970.1). but improvements generally plateau within the 3 to 5 d'wk.r. Similarly. Once the target duration and frequency are achieved.r. and hemodynamic and perceived exertion responses to both forms of effort. (Adapted from Clausen JP.1 frequency.26:295-301. adjustments in intensity of no more ilian 5% of HRR evelY sixth exercise session are well tolerated.-10 VI ~ c: C1l intensity.1.Arm work----.Arm work-----. Many recreational and occupational activities require sustained arm work to a greater extent than leg work. or 64% and 70% (64%170%) to 94% of maximum healt rate..I r---.) .ygen consumption. HRR and V0 2R can be used interchangeably. lrl Cl SUMMARY OF GUIDELINES FOR CARDIOVASCULAR STIMULUS PHASE Workloads ~ Leg Training m VI 'E C: -40 r . .0 C1l ~ ~ C1l -30 _ -20 ca ca C1l . • For people with \10 2max below 40 mL·kg-1·min-\ a minimal intensityof30% V0 2R can provide for improvement in V0 21llax ' • For most individuals.

Resistance training (i. the somewhat limited for the general population ability to increase LBM is linked to genetic factors.2.70 In addition. bone density. accounts for a net caloric expenditure of 60 to 150 kcal.". with little rest between exercises) results in an average improvement in \IO? . These adaptations are beneficial for all ages.3 to 2.) would typicaJl)' demonstrate a net caloric expenditure of 338 kcal.g. of which 1.. At this point.holamine responses. S7 Responses to resistance training may be subjcct to indi\~dual heterogeneity&7 similar to responses to cardiovascular exercise training. until a maximal voluntarv contraction is achieved.I • have been successful for both short.g. s".I while engaged in actual resistance training. Thus. Improving muscular function t~1rough resistance training (weight training) may accrue health-related benefits 6 ' A reduction in the risk of osteoporosis.: r~nge from 4 to ]Q kcahnin .7. For example. hypertension. \\~th the greatest improvement in males ·sfi Increases in LBM that were similar between resistance training programs lasting 12 to 24 weeks. the progressive recruitmcnt of muscle fiber motor units has occurred and the muscle is at high intensityml \Vith each repetition.5 This does not include rest intervals and is proportional to the amount of muscle mass involved. Thus. il The use of resistance training as a primary mode for weight and bod\' fat loss is controversial. For ~:~~~~_ pie.7-1 Circuit weight training (a series of resistance exercises. 8 to 12) \~~th a lighter resistance.i) does not change. Resistance training does little to increase the \TO? . The HM indicates that the muscle has reached a point of fatigue or failure in which the force-generating capacity falls below the required forcc to shorten thc muscle against the imposed resistance.82 however. high intensity can he reached by performing a f~w repetitions (e. and 15 RM result in a similar intensity as defined hy the repetition maximum.'>-1 One study even revealed no alteration of sleeping metabolic rate despite a 1. .0 mph I (161 m'min.154 SECTION III / EXERCISE PRESCRIPTION CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 155 • A target range of 1. postmenopausal women who may expelience a more rapid loss of bone mineral density. The common use of a percentage of the 1 RM (repetition maximum) to estimate intensity does not portray a true intensity and is only used as a general guideline.. Physical aeti\~ty and/or exercise energy expenditure in excess of 2000 kcal'wk. when cardiovascular endurance is dcfined as the length of time a person can walk on a trcadmill during a graded exercise test protocol.~.000 kcahvk .0 kg. Resistance Exercise Prescription Muscular strength and muscular endurance directly impact on activities of daily lh~ng (ADLs) because daily Ii\~ng activity rcquires a given percentage of one's muscular capacity to perform common tasks.77 Reports of elevations in resting metabolic rate (HMR) following a bout o[ resistance training have generally accounted for less than 100 net calories over 24 hours.~ \vith several studies repOlting a net expenditure of only 19 to .and long-term weight control. . The enhancement of muscular strength and endurance enables an individual to pcrform such tasks \vith less phYSiologic stress and aids in maintaining functional independence throughout the life span. and the increase or maintcnance of lean body weight also may occur..ygen consumption.e. A 3 HM. and. A resting muscle represents minimal intensity. 7fi. Although successful fat loss is associated with a caloric deIlcit achieved through a combination of dietary restriction and caloric expcnditure. and diabctes are associated with resistance training 6S. the heart rate is disproportionate to m. A small increase in caloric expenditme occurs dUling recovelY [rom both aerobic and resistance training but it is transient and usually dissipatcs \vithin 2 hours postexercise. sufficient to develop and maintain muscular fitness and fat-free mass or reduce the normal decrease in fat-free mass associated \vith aging) should be an integral palt of prima. Even the cardiovascular stress of lifting or holding a given wCight (objcet) is proportional to the percentage of maximal strength invoked. .50 kcal in the 2-hour postexercise period.5 minutes is lifting and 15 minutes is recovelY. Unlike cardiovascular activity.>-3 Heart rate should not be used as a measure of intensity dUling resistance training. performed one after another.. resistance training may permit one to extend the duration of the exercisc because of increased muscular strength and muscular endurance \\~thout increasing V0 2". suggest that additional increase in LBM after 12 weeks of training may be g6 Although not well studied. All other levels of muscle activity arc somewhere between these two extremes.I. 71 Although resistance training may ele\·ate healt rate because of sympathetic acth'it)' and ca_te. 10 RM. of about 6%.'....I from physical acti\~t)' is recommended. whereas a half hour resistance training session. there is a progreSSive increase in active musclc mass. 78-ii1 Resting metabolic rate may be influenced by a greater amount of fat-free mass.g.. more calories can be expended in aerobic exercise compared to resistance training. The number of repetitions performed at a given percentage of 1 HM differs between muscle groups (e. in particular. the benefits of increased muscular strength and endurance. for a given length o[ time. resistance training per se expends only moderate amounts of calories.1-kg increase in fat-free mass after 12 weeks of resistance training. H The ability to demonstrate large increases in LBM appears limited in the general population. low back pain. bench press versus leg curl) as well as between individualsg&·'>H This variability in the number of repetitions performed at a percentage of 1 RM precludes its use as an accurate measure of intensity. a 70-kg person jogging [or 30 minutes at 6. Typical increases in Ican body mass (LBM) in up to 6 months of resistance training range gJ from 0.5 To raise the resting metabolic rate through resistance training requi res increases in the quantity of lean tissue. it is not generally recommended as an activity for in~'.H. Moderate aerobic exercise exceeds the energy expenditure of resistance exercise and a cardiovascular stimulus can be maintained for a longer duration.50 to 400 kcal of physical activity and/or exercise energy e~penditure per day or a minimal caloric threshold of approximately 1.y and seconchuy prevention programs. resistance training studies suggest that the relative metabolic rate (kcal'kg FFM. Energy expenditure estima!. 70 although resistance training may improve cardiovascular endurance. enhanced strength of connective tissue. intensity for resistance cxercise is not easily determined. including middle-aged and older adults. whereas moment<Uy muscular fatigue (failure) in the concentlic pOltion of an exercise performed in strict form represents high intensity..'~ving CR endurance. Intensity can be defined as the effort or how difficult the training stimulus or exercise is.'. Thus. three to six) \vith a heavier resistance or several repetitions (e.

performcd at a moderate repetition duration (-3 seconds concentJic. asymptomatic population. Caution is advised for training that emphasizes accentuated lengthening (eccentIic) muscle actions. performing a bench prcss exercise on a flat bench versus a stability ball is different. To elicit improvement in both muscular strength and endurance. and not interfere with normal breathing.9. slower speed of movement).106 This may provide insight for training indiVIduals prone to osteopenia or osteoporosis. Although each type of training has advantages and limitations. the exercise activity has been changed. . A higher-intensity effort at or near maximal effort produces the grcatcst sti. bench press. involve a full range of motion. but may not produce any greater adaptation.99-103 If the resistance training stimulus is generally less than 90 seconds to fatigue per exercise.)69. All muscle groups can be trained through a variety of exercises.122 In addition. Some exercises may be more difficult to perform (stability ball activity) because of increased neuromuscular com'dination or balance.94 Submaximal training can occur by terminating the exercise when the participant demonstrates an obvious unintentional increase in concenbic repetition duration (e. and muscular endurance between single and multiple set resistance training programs. militcuy prcss. Develop a menu of exercises for each muscle group and choose one for cach exercise session. leg press. dynamic resistance exercises are recommended for most adults.mulus.g" standing curl versus machinc curl) can change thc difficulty of the exercise. 8 to 12 repetitions at a high intensity (approximate momentaly muscular fatigue) is recommended for healthy populations. . or absolute muscular endurance. or few versus several repetitions. hypertrophy. whether by small versus large muscle groups. while keeping all the other variablcs constant: • The weight (resistance) • The numbcr of repetitions • Rcducing momentum by increasing the repetition duration (reducing specd of movement) • Maintaining muscular tcnsion versus "locking out" the joint when performing multiple joint exercise (e. The soreness may discourage exercise participation. A few researchers repmt a supelior response {i'om multiple set resistance trainingJ07-111 However.102. High-intensity exercise . The initial repetition is typically least difficult and cach subsequent repetition progresses in intensity until the terminal repetition..112-12. A variety of exercises for cach muscle group also may maintain participant adhercnce and interest in the exercise program. Individuals with hypertension. or when one to three more repetitions could still be performed or by using the RPE scale as an index of intensity.93. Moditlcations such as a change in the length of the external moment arm (e... without a fear of muscular hypertrophy.5-97 A target of 19 to 20 on the RPE scale is synonymous with high-intensity strength stimuli for healthy populations. not the absolute force of contraction Hl . etc. the brief exposure to these high blood pressures is considered inconsequential. stability ball) or other variables (e. Successful resistance training typically increases strength and absolute muscular endurance. by terminating lifting before fatigue. but not necessmily to the same degree.92 The magnitude of the blood pressure response depends on the degree of effOlt (intensity). Although undefined. squat) An overload or progression can occur with any exercise by requiring an increased intensity with controlled repetition duration (movement speed).lOo . The theory of a strength-endurance continuum producing specific adaptabons related to the number of repetitions has limited scientiHc support.5-97. diabetes. However improvements in bone mineral density have ~een associated with lower (7 t~ 10) repetitions versus higher (14 to 18) repe68 tI. hypettrophy. Any overload beyond a minimal thrcshokl results in strength development. If high intensity is achieved (momentmy muscular fatigue).g.11. -3 seconds eccentric). both muscular strength and absolute muscular endurance (number of repetitions performed at a specific amount of resistance) increase. . at risk for stroke.and post-training) remains stable 86. compared to shOltening (concentlic) or isometlic muscle actions. the preponderance of evidence reports similar responses of muscular strength. There is no evidence to show one form of bench press is superior to the other.g" bicep curl move from a position of the upper arm vertical to a preacher curl position) or the basc of support (e. or at other medical lisk from exposure to high blood pressures should avoid high-intensity resistance training.g. The elevation in blood pressure associated with this high intensity is extreme even when recruiting a small 92 muscle mass. They arc simply different. 104 Thus. An initial goal of 12 to 13 and a Hnal goal of 15 to 16 on the RPE scale has been recommended {or submaximal train9 ing. Muscular strength and endurance can be developed by means of static or dynamic exercises.) there is little evidence to suggest a specific number of repetitions will provide a superior response relative to muscular strength. but cach is specific in its purposc. Women who may have a predisposltlOn to osteoporosis should be advised to resistance train with higher resistance with fewer repetitions and a variety of exercises to benefit from sitespecific bone improvement. therefore. For a healthy. 6 to 10.3 Single set programs require less time and are eftlcient. For example. 10 to 12. 10 to 12.tlOns 111 older populations. but there is no evidence to indicate these activities are better in terms of muscle strcngth or endurance. regardless of the size of the muscle mass involved Hl . etc. the results are similar. a threshold for improvements in muscle strength and endurance is evident below momentary muscular fatigue (high intensity)69. the muscle has been stimulated to a high degree. which can prOl'ide novel or different stimuli to the muscle and bone.u'97. For example. for any common range of repetitions (3 to 6.94. yet relative muscular endurance (a speciHc percentage of the 1 RM adjusted {or both pre. Resistance training for the average pmticipant should be rhythmic.g. doubling the number of repetitions performed at a given resistance does not mandate the performance of twice the resistance for 1 RM. There is no evidence to suggest there is an absolute best exercise for any specific muscle group. 6 to 10. an effective resistance training program conducted \\rithin a limited time commitment may improve exercise compliance. They can engage in lowerintensity resistance training. Thc increase 01 intensity ot resistance training can be manipulated by valying any onc of the follo\ving variables. .156 SECTION III / EXERCISE PRESCRIPTION CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 157 The progressive increase in muscle fiber recruitment parallels increases in blood pressure. 98 Muscular strength and endurance can be developed simultaneously within a reasonable range of repetitions (3 to 6.92 A similar blood pressure is evident at the same relative degree of effOlt despite significant differences in absolute force pro9l 92 duction. because the potential for acute delayed onset of muscle soreness is accentuated and the outcome is similar.

and motivation. elasticity indicates that length changes are directly proportional to the applied force. For example. Properly performed stretching exercises can aid in improving and maintaining range of motion in a joint or selies of joints. Reductions in flexibility often are evident by the third decade of life and progress 'Nith aging. perform a different exercise for the muscle group every two to three sessions. exercise with a training partner who can provide feedback. there is a lack of scientific evidence as to how long the effect may last. exercise programs for elderly persons. The strain in the muscle has a fast onset and tlle muscle tension reaches relatively high values. 'f'lcan t 11llprOVemen . Many experts recommend frequent (daily) stretching because flexibility is believed to be transient. assistance. PNF typically requires a partner trained in tlle technique. Exercise each muscle group 2 to 3 nonconsecutive days per week and if possible. Therefore. choose a range of repetitions between 3 and 20 (e. arthlitis)124 Stretching can be defined as the systematic elongation of musculotendinous units to create a persistent length of the muscle and a decrease in passive tension. speciHcity of training) may warrant their use for specific populations. 125 Muscles have viscoelastic properties. that is. as well as other populations. the participant relaxes the hamstling and allows the paItner to passively stretch the hamstring to a greater range of motion by flexing the hip. shoulders. requires little time and assistance.158 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 159 combined with the Valsalva maneuver (forced expiration against a closed glottis) can cause a dramatic. Musculotendinous units are considered the limiting structures preventing greater ranges of motion about the joint. The palticipant then actively extends the hip against the pmtner's resistance. PNF stretching involves a combination of alternating contraction and relaxation of both agonist and antagonist muscles through a designated series of motions.128 15 secon d s 0 f· a stretcI 1 WIt The optimal number of stretches per muscle group is two to four. specific goals. -3 sec eccentric).g. The greatest change in flexibility has been shown in the !irs~ ' I1 no slgm . carpal tunnel syndrome. certain circumstances (e. 3 to 5. controlled manner with a gradual progression to greater ranges • • • • • • Flexibility Exercise Prescription Optimal musculoskeletal function requires that an adequate range of motion be maintained in all joints.. Dynamic stretching uses the momentum created by repetitive bouncing movements to produce muscle stretch. Total exercise training programs lasting longer than 1 hour per session are associated with higher dropout rates. breath-holding can induce excessive increases in blood pressure. Although flexibility can improve acutely. and is quite effective. and abdomen. however. or machines) that is comfortable throughout the full pain free range of motion. static. Static stretching involves slowly stretching a muscle to the end of the range of motion (point of tightness without invoking discomfort) and then holding that position for an extended peliod of time (usually 15 to 30 seconds). t aft er 30 secon d s. The attenuation of muscular tension over time is termed stress relaxation. acute increase in both systolic and diastolic blood pres91 92 sures.. should emphasize proper stretching for all the major joints. 12 to 15) that can be performed at a moderate repetition duration (~3 sec concentric. The follOwing two types of stretching techniques are not recommended for the general population. 121. Accordingly. back. thigh. while maintaining good form.g. Finally. . 126 The risk of injury is low.g. Different types of stretching techniques (e. legs. past histOly. PNF can be applied to a hamstJing stretch by allowing a paltner to flex the hip with the knee straight until the pmticipant reports muscle tightness. • • • individual. especially for areas affected by a reduction in range of motion. For these reasons.. specific to each joint. The following resistance training guidelines are recommended: • • Choose a mode of exercise (hee weights. including muscular strength and disease (e. While the traditional recommendation of 8 to 12 repetitions is still appropriate. Currently there is little scientific evidence to indicate that the stimulus for improving muscular strensrth and muscular endurance in resistance-trained populations is different than for the untrained healthy adult populations. A lack of flexibility combined with a reduced musculoskeletal strength in elderly persons often contributes to a reduced ability to perform activities of daily living. and is more time consuming than alternative methods. Perform both the lifting (concentric phase) and lowering (eccentric phase) pOltion of the resistance exercises in a controlled manner. For people with high cardiovascular risk or those with chronic disease (hypertension. bands. terminate each exercise as the concentric portion of the exercise becomes difficult (RPE 15 to 16) while maintaining good form. Flexibility exercises should be performed in a slow. because no significant additional improvement in muscle elongation is evident in repeated stretching of five to ten repetitions.. Adhere as closely as possible to the specific techniques for performing a given exercise. Maintain a normal breathing pattern. and affected by many factors. and viscous properties indicate that the rate of muscle deformation is directly proportional to the applied force. Perform a minimum of 8 to 10 separate exercises that train the major muscles of the hips. chest. If possible. The muscle's viscoelastic propelty permits a gradual decrease in tension or force within the muscle at a given length. dynamic. Allow enough time between exercises to perform the next exercise in proper form. static stretching is recommended. diabetes). This type of stretch can result in muscle soreness or injUly if the forces generated by the dynamic movements are too great. which is commonly known as improved fleXibility. may cause some degree of muscle soreness.g.8 to 10. Flexibility is highly . 126 The application of stretching can resul~ in a continued deformation (longer length) of the muscle at a lower tension. anm. preventive and rehabilitative exercise programs should include activities that promote the maintenance of flexibility. A plimary goal of the program should be to develop total body strength and endurance in a relatively time-efficient manner. proprioceptive neuromuscular facilitation [PNFJ) can be performed. There is a greater risk of strain injUly because the muscle is not held at the higher tension to allow the time-dependent stress relaxation response to occur. Perform one set of each exercise to the point of volitional fatigue for healthy individuals.

Although research concerning the risks of speCific exercises is lacking. skill. Exercise profeSSionals should recognize that most individuals can exercise safely at a moderate intensity without supervision. The preservation of resistance training effects also has been examined relative to a reduced exercise frequency. Similarly. and exercise testing a]]o\V the exercise profeSSional to determine those individuals for whom supervised exercise programs are suggested. or position the joint in a range of motion that stretches ligaments or nerves are not recommended. it appears that a reduced training frequency or duration does not adversely affect V0 211l 'LX or muscular strength if the training intensity is maintained. determine the level of supervision Maintenance of the Training Effect Numerous studics have investigated the phYSiologic consequenccs of a reduced exercise dosage or complete cessation of training in phYSically conditioned people. decreasing the frequency or duration of training had little influence on the postconditioning V0 2111ax> prOVided that the intensity was maintained. the follOWing is a list of high-risk stretches (danger to the joint) and safer alternativcs. age.' Stretch to the end of the range of motion at a point of tightness. those activities that require substantial flexibility. \\~th a total reduction of only 16% after 12 weeks of detraining. Additional evidence. 137 In contrast. restricted walk training resulted in rapid deconditioning in cardiac patients who had been jogging. followed by 15 weeks of reduced training at one-third and two-third reductions in the frequency. 129 High-Risk Stretch Standing toe touch Alternative Stretch Seated toe touch or modified hurdlcr's stretch Scated toc touch or modified hurdler's stretch Modified hurdler's stretch on-twisting directional stretch Kneeling hip and thigh stretch Seated toe touch Barre stretch Hurdler's stretch Neck circles Knee h)1Jerflexion Yoga plow fitness in apprOXimately 10 weeks 132 to 8 months of detraining 133 or decrease their gains by half after only 4 to 12 weeks Of134 complete cessation of training. refer to thc ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription (5th ed. For cxample. 140 prOvided that the resistance training loads remained constant.160 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 161 of motion. A gcneral exercise prcscription for achieving and maintaining flexibility should adhere to the following gUidclines: 12H • • • • • • Precede stretching with a warm-up to ele\'atc muscle temperature Do a static stretching routine that exercises the major muscle tendon units that (ocuses on muscle groups (joints) that havc reduced range of motion Perform a minimum of 2 to 3 chvk. or other conditions. or intensity of training. For additional information on the topiC. tai chi. ideally 5 to 7 chvk. strength gains were maintained for 12 weeks vvith one training session per week '39 and only one training session evelY 2 to 4 weeks. and in conjunction ~th the palticipants' functional capaCity. A significant reduction of 5% to 10% in 'i'02. tions that can provide the basis for a prudent flexibility program. suggests that upper body training per se has little influence on the retention of lower body training effects. duration. joint insufHciency. despite an unchanged exercise frequency and duration.36 or intensiti37 on the maintenance of V0 2m 'LX during a period of reduced training. However. Only when the intensity of training was reduced was there a significant decrease in V0 2max . determine the health status of the participant through risk stratification. All three studies trained young men and women for 40 minutes. In these studies. 1 and Pilatcs movements also may be used to improve flexibilitv when appropliate.30 seconds Two to four repetitions for each stretch A series of easy-to-understand stretchcs are available from various publica:lO Yoga. Stretching exercises can be effecti\'ck included in the warm-up and/or cool-down periods that precede and follow the aerobic conditioning phase of an exercise session. intervening illness or injury. Some com monly employed stretching exerciscs may not be appropriate for some pmticipants who may be at greatcr risk for musculoskeletal injuries bccause of plioI' injul)'. '38 Collectively. The rapid reduction in maximal ox)'gen consumption plateaus relatively soon. 131 that is. relevant to the maintenance of training effects.I.1 for 10 weeks at a moderate to high exercise intenSity. To use this table. 13] Participants may return to pretraining levels of aerobic . Thus. medical evaluation. moreover.141 further reinforcing the principle of training specificity. and speCific conditioning practices. 1:31 \\~th most of the reduction attJibuted to dccreased blood volume. without inducing discomfOlt Hold each stretch for 15 to . these findings indicate that exercise intensity is the most impOltant exercise prescription variable to maintain a cardiovascular training response.I . an alternate training modality augments energy expenditure and serves to maintain health benefits. the longer one remains in a trained state the longer it takes to return to baseline levels. However. Program Supervision Information from health screening. Table 7-3 provides general guidelines for exercise program supervision.).135 duration. and may be modulated by the level of fitness. 6 d'wk. most of the reduction occurred within the first 5 weeks of reduced training. for those who \\~sh to maintain or increase their fitness levels by follo~ng the exercise prescliption guidelines \vithin this chapter. Table 7-3 represents a hierarchy of supervision. A related series of studies examined the relative effects of decreased exercise frequency.mL' has been reported within 3 weeks of stopping intense endurance training. Jt is recommended that an active warm-up precede stretching exerciscs. Maintenance of the training effect generally shows a direct relationship to the length of time in training.

For cxample. <7 METs§ Intensity 40%/50%-85% HRR or V0 2 R 55%/65%90% HR max 12-16 RPE Duration 20-60 min Activity Large muscle groups Dynamic activity 8-10 exercises Include all major muscle groups Health Status Low risk (from Table 2-4) Resistance 2-3 d'wk. heart rate reserve. and either at or Flexibility Minimal 2-3 d·wk. 14. then a professional (Table 7-3) should supervise the exercise program. momentary muscular fatigue Methods for Changing Exercise Behaviors recommended.5 METs. ACSM Exercise SpeCialist.. 19-20 RPE) Or Stop 2-3 reps before volitional fatigue (e. if a pcrson's health status is classified as modcrate risk.g. Fitness and cardiac exercise programs have typically reported dropout rates ranging from 9% to 87% (mean. an alternative approach involves the . skills. To understand why people sometimes lack the motivation for regular physical activity.. 8-10.5 In another study.7 METs IS well below the 10th percentile for apparently healthy men. but has a functional capacity of <7 METs. Thus. and/or metabolic disease Abbreviations: HRR. patients undergoing gymnasium-based exercise training spent more time in their cars going to amI from the programs than paticnts in a hometraining comparison group spent on their cycle ergometers. skills. 16 RPE) Stretch to tlghtness at the end of the range of motion but not to pain 1 set of 3-20 repetitions (e. General Guidelines for Exercise Program Supervision TABLE 7-2. and either at or bclow the 10th percentile [or most apparently bealthy women from the Acrobics Center Longitudinal Study (see Tahle 4-8). direct supervision of each scssion by a physician is not necessarily rcquired to ensure safcty. maximal oxygen uptake reserve. therefore.144 Dropout rates are generally high in the first 3 mouths.1 Ideal 5-7 d-wk. If a person is of low risk. then the clinical professional should supervise the excrcise program. pulmonary. It should be notcd that a functional capacity of ~7 METs is wcll below the 10th pcrcentile for apparently healthy men.inically supeIVised means supervision by appropriately trained personnel who possess academic training and practical/clinical knowledge. Supervised exercise programs are recommended for patients \vith symptoms and cardiorespiratOlY disease who are considcrcd by their physicians to bc clinically stable and who bave been medically clem'ed for participation in such programs. new members of fitness centers typically use these facilities less than t\\ice a month.g. Summary of General Exercise Programming Level of Supervision Components of Training Program Cardiorespiratory Unsupervised Frequency (sessions'wk ') 3-5 d·wk1 Professionally Supervised* Moderate risk (from Table 2-4) Or Clinically Supervisedt High risk (from Table 2-4) with recent onset of CPM that have been cleared by a physician for participation in exercise regimen. Apparently healthy individuals within the ACLS cohort would be inclusive of individuals within the ACSM Low and Moderate Risk categOlics (see Table 2-4). According to one recent repmi. irrespective of initial health status or type of program.. but he or she has a functional capacity of. However. one clinical staff member for every five to eight patients) also is recommended Abbreviation: (PM. and an ACSM-certified Program Director.e" ACSM Health/Fitness Instructor. Apparently healthy indiViduals within the ACLS cohort would be inclUSive of indiViduals within the ACSM Low and Moderate Risk categones (see Table 2·4). >A functional capacity of. increasing to approximately . or the ACSM Program Director. the ACSM Program Director.1 Volitional fatigue (MMF) (e. a small staff-to-patient ratio (I. or ACSM Registered Clinical Exercise Physiologist (see Appendix F).. 3-5.50% within 1 year. 4. smoking cessation. it appears that exercise is not unlike other health-related behaviors (e. §For functional capacity of <5 METs. For some participants.142 These programs can be useful for those who need instruction in proper exercisc techniqucs." structmed exercise programs have been only marginally effective in getting people to be more phYSically active. stable CPM disease > 7 METs *Professionally supervised means supervision by appropriately trained personnel who possess academic training and practical/clinical knowledge.g.n Appendix F.CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 163 162 SECTION III/EXERCISE PRESCRIPTION TABLE 7-3..12-15) Functional:l: capacity >7 METs High risk (from Table 2-4) but with well-controlled. appropriatc nursing staff. MMF. ACSM Exercise Specialist. ACSM RCEP). However. It is recommended tbat supervised exercise programs for sucb individuals be under the combined overall guidance of a physician. one must acknowledge a simple yet important fact: Exercise is voluntary and time consuming.g.1 15-30 seconds 2-4 x/stretch Static stretch all major muscle groups below the 10th percentile for most apparently healthy women from the AerobiCS Center Longitudinal Study (see Table 4·8). it may cxtend the day or compcte \\ith other valued interests and responsibilities of daily life. Despite nearly three decades of the so-called "exercise revolution. and abilities commensurate With the ACSM Exercise Specialist or ACSM RCEP credentials defined ..e. medication compliance. cardiovascular. or ACSM Health/Fitness Director tC. highlighting the compliance problem among those who initiate phYSical conditioning programsI4:3. J46 The traditional approach to the exercise compliance problem has involved attempting to persuadc dropouts to become reinvolved. and abilities c~mmensurate with any of the three credentials defined in Appendix F (I. direct supclvision may enhance compliance \\ith an exercise program. weight reduction) in that typically half or less of those who initiate the behavior will continue.5%). V0 2 R.

Box 7-2 describes each of these stages. Stage-specific interventions using varied approaches (e. researchers have re-evaluated the scientific evidence linking physical inactivity \vith a variety of chronic diseases..147 Readiness for change theory has received \vide acceptance by health care practitioners in assisting individuals to make permanent lifestyle changes. video recording. 3. 149. The lower the self-motivation score. completion of activity logs). 4. 5 432 1 1 234 5 I don't work any harder than I have to.lt . Transtheoretical therapy. Morgan WP. A score ~ 24 suggests dropout-prone behavior. and transtelephonic ECG monitoring. the fen'or of the primary physicians' recommendatlOn appears to be one of the most powerful predictors of the patient's participation In exercise/ 5 [ espeCially if a baseline fitncss assessment and an exercise prescnptlon are prOvided at the point of care. competing priorities [w~rk deadlines]).. toward a more IIltegratlve model of change. Reproduced by permission of the copyright holders. 1980:Appendix A-B. 7-7). somewhat characteJistic of me." and essentiaJly discontinue their sporadic activity patterns. D.l1lI( ~ FIGURE 7-7. I'm good at keeping promises. The alternatives are: A. Dishman RK. and counseled that these behavlOrs are not necessarily tantamount to failure.'~I . STRATEGIES FOR INCREASING EXERCISE ADHERENCE umerous inter\'entions aimed at increasing phYSical acti\ity levels using behav.g. extremely characteristic of me. and stage of readiness for change (Fig. lOr cIlange counse " . Snch indi\~duals should be taught to deal WIth InactIve lapses 01 Ielapses. These analyses suggest . Dishman RK. I get discouraged easily. social support systems. extremely uncharacteristic of me. belief systems and values. Self-motivation and adherence to habitual physical activity. From Falls HB. re-entered at the appropriate stage. I have a very hard-driving.52 Research and cmpmc expenence suggests tl1.14~ including regular exercise. . 7. I don't impose much structure on my activities. it should be viewed as an incentive to remain active. Other persons in the "action" stage also may stop exercisin a for a variet\' of reasons (e. (Adapted from Prochaska J. some individuals may "exit" from the "preparation phase. fax. coping techniques/defense mechanisms. \.. The latter may include regular telephone contact.\ ~ eXit ermanent ~ Relapse Maintenance Directions: Circle the number beneath the letter corresponding to the alternative that best describes how characteristic the statement is when applied to you. \vith an aim toward preventing recidivism. Self-motivation assessment scale to determine likelihood of exercise compliance. Scoring: Add together the seven numbers you circled. perso~al convenience bctors. 7_6). 6. 10: 115-132. (Copyright 1978. structured group programs versus home-based exercise). Illail (e. 2. b Nevertheless.g. Ickes W. somewhat uncharacteristic of me. Progressive stages of readiness for behavior change. to predict male and female dropout-prone behavior (Fig. Baylor AM.. eXit . I'In a 11'lve l)ee[l described preViously \vith mixed results. especiaJly the ones I make myself. intercurrent illness or i~jl1tY. ENCOURAGE LIFESTYLE PHYSICAL ACTIVITY Over the last decade.. t'JOna It· a'es m'l)' enlnnce l)artlclcertain program modi fications ant1 motlva s 1 a tebl . 19:276-288. E. . J Appl Social Psychol 1980.. Philadelphia: Saunders College. I seldom if ever let myself down. job change andlor move. neither characteristic nor uncharacteristic of me. DiClemente C.1. C.) identification and subsequent monitOling of "dropout-prone" individuals. If the score suggests dropout proneness. B.g. I'm just not the goal-setting type.. Psych Theory Res Prac 1982. the greater the likelihood toward exercise noncompliance. Unfortunately.) Action Precontemplation ~ Contemplation Preparation - Enter Temp"". FIGURE 7-6. and serial monitoring andlor communication should be employed. rather than a selffulfilling prophecy to quit exercising. aggressive personality.164 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 165 5 5 1 5 1 ABCDE 432 1 432 1 234 5 432 1 234 5 1. Essentials of fitness. 5. . pant interest and compliance.. A brief questionnaire designed to assess "self-motivation" can be used along with measures of intention and self-efficacy.50 A preliminmy interview/orientation provides an opportunity to identify the client's expectations (realistic or unrealistic). as shown in Box 7-3. with specific reference to temporary and permanent exits and relapse. Internet. community resources.

these findings have important implications for public health.. 3.g.. body composition. 5. Collectively. in reducing the incidence of type 2 diabetes. realistic goals. . Establish regularity of exercise sessions. and modes of training that are associated with structured programs. Provide qualified. 5.166 SECTION III/EXERCISE PRESCRIPTION CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 167 . Thus. benefits. Contemplation: Patients are "thinking" about making a desired change. Brainstorm opportunities to increase physical activity in daily living (e. household chores. gardening. To assist with this objective. them to increase physical activity in daily living.9 and facilitate exercise adherence. intensity. *From Dunn AL. Emphasize the short. Encourage group participation Emphasize variety and enjoyment in the exercise program. and bike paths). Provide clients with a traditional exercise prescription.. • • • • • • • • • • • • • • Recruit physician support of the exercise program. Kampert JB. Accordingly. accelerometers or pedometer use may assist clients in tracking their daily activities 158. including at least ]50 minutes of physical activity per week. was even more effective than pharmacologic treatment. brisk walking. Action: Patients are meeting the referenced (preparation) criteria on a consistent basis but they have not maintained the behavior for 6 months.26:883-892. Moving patients through this stage involves use of multiple resources to stress the importance of the desired change. tModified for physical activity interventions. Precontemplation: Patients express lack of interest in making change. Comparison of lifestyle and structured interventions to increase physical activity and cardiorespiratory fitness: a randomized trial. This stage can be influenced by helping patients define the risks and benefits of making or not making the desired change (e. Plan regular follow-up contact to reinforce efforts and devise ways to overcome barriers to regular physical activity. and enthusiastic exercise professionals. JAMA 1999.1 of vigorous intensity activity for 20 minutes. 4. Ask clients about their current structured excrcise and activity habits to deter- mine whether those activities are sufficient to confer health andlor fitness 2. 2. 3. Clarify individual needs to establish the motive to exercise. Use progress charts to record exercise achievements. et al. frequent bouts of moderate-intensity activity (e. Marcus BH. it provides an effective complement to any health and fitness regimen. increase routine activity by taking the stairs rather than the elevator. that is. hIking trails.1. Preparation: Patients are doing some physical activity but not meeting the recommended criteria. Minimize injuries and/or complications with a light to moderate exercise prescription.. 30 minutes of moderate intensity physical activity 5 d·wk. personable.. Kampert JB. Employ periodic fitness testing to assess the client's response to the training program.g. Emphasize short-term. educational classes.0. 1. 15. starting an exercise program). increase transportation-related physical activity by walking or cycling versus automobile. This can be achieved through written materials. Prev Med 1997. physician and family persuasion. Provide exercise facilities and changing facilities that are appropriately maintained. Recognize participant accomplishments through a system of rewards. and coronary risk factors as compared with a traditional structnred exercise program. a five-step counseling plan has been suggested to help clients initiate and maintain that the intensity of exercise needed to achieve health-related benefits is probably less than that required to improve CR fitness.and long-term benefits of these varied approaches. despite a lack of scientific evidence. recreational activities) may serve as an alternative to vigorous exercise. Reduction in cardiovascular disease risk factors: 6-month results from Project Active. and other means. and find more convenient forms of leisure physical acti\~ty in parks. Recruit support of the program among family and friends Include an optional recreational game to the conditioning program format. 4. et al.281327-334. Marcus BH. 7_1). by encouraging a more physically active lifestyle: 1. provided that the total energy expenditure is comparable.. Maintenance: Patients have been in action for 6 months or more.g. The Activity Pyramid has been suggested as one way to facilitate these objectives (see Fig. duration.1 or 3 to 5 d·wk.157 In addition.154 Another recent study showed that lifestyle intervention. • I' I •• 1. exercise profeSSionals should consider broadening their client's recommendations beyond the frequency. Dunn AL. 15:) Recent randomized trials have shown that a lifestyle approach to physical activity among previously sedentary adults is feasible and has similar effects on aerobic fitness. 156 Although lifestyle exercise is not being suggested to replace traditional structured exercise programs.

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IdentiflcatlOn. inhospital exercise programs after acute MI appear to offer little additional phYSiOlOgiC or behavioral (self-efficacy) benefits over routine medical care.. to independent ambulation on the unit. such as intermittent sitting or standing during hospital convalescence.2 Outcome analysis is an important part of thIS evolut1On and includes not only clinical parameters and quality of life. patients hospitalized after a cardiac event or procedure should be prOvided with a program consisting of early mobihzatlon. a baseline assessment should be conducted by a health care provider who possesses the skills and competencies necessary to assess and document heart and lung sounds. ~he benefits of early mobilization and the other components of the mpatlent cardrac rehabilitation program include: • Offsetting the deleterious psychological and physiologic effects of bed rest during hospitalization • Providing additional medical surveillance of patients • IdentifYing patients with significant cardiovascular. The optimal dosage of exercise for inpatients depends in pari on their medical history. formalized. shorter than exercise bout duration. to walking sholi-to-moderate distances (50--500 feet) start with minimal or no assistance. the criteria for terminating an inpatient exercise session are similar to or slightly more conservative than those for terminating a low-level exercise test.1 (arbitrmy upper limit) • PostsurgelY: HR res ! + 30 beats'min. The AACVPR or ACP risk stratification models (see Chapter 2) are useful because they are based on overall prognosis 1 Furthermore.l or HR res ! + 20 beatS'min. functional.6 Patients may progress from self-care activities. however. In many instances. uncomplicated patients are now seen for only 3 to 4 days before hospital discharge. clinical status. appropnately prescribed exercise therapy remains the cornerstone of these programs. as tolerated • Rest periods can be a slower walk or complete rest at patient's discretion. However. including baseline patient assessment. as well as musculoskeletal strength and flexibility. and phase IV (no ECe monitoring. Simple eA'P0sure to orthostatic or gravitational stress. recent data on the safety of exercise. and pressures in the era of managed. phase III (variable length program of intermittent or no ECe monitoring under clinical supervis1On). attempt to achieve 2:1 exercise/rest ratio 174 . professional supervision). Intensity • RPE <13 (6-20 scale) • Post-MI: HR <120 beats'min. There is now movement toward a continuum wherein patients follow a regimen of exercise specific to their vocational and recreational needs. may reduce much of the detelioration in exercise performance that generally follows an acute cardiac event 4 Structured.CHAPTER 8 • • Exercise Prescription e•• • Modifications for Cardiac Patients CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 175 • Enabling patients to more safely return to activities of daily liVing within the limits imposed by their disease • Preparing the patient and support system at home to optimize recovery follo""ring hospital discharge Contemporary cardiac rehabilitation programs provide several important core components. In general. Recommendations for inpatient exercise programming include the follOWing. Box 8-2 lists potential adverse responses that should result in cliscontinuation of an inpatient exercise session. degree of Ece mOl1ltoru~g. and symptoms. New theories of risk stratification. capitated health care have contributed to a shortening and acceleratlOn of these phases. J Initiation and progression of phYSical activity depends on the findings of the initial assessment and varies with level of risk. and postural change. and level of clinical supelvision. arm and leg range of motion. nutrition counseling. with more individualization of the length of program. exceptions should be considered based on clinical judgment. the clinical indications and contraindications for cardiac rehabilitation (inpatient or outpatient) are listed in Box 8-1. and education of cardiovascular disease risk factors' assessme~t of the patient's level of readiness for phYSical activity. peripheral pulses. CardIaC rehabilItation programs traditionally have been categorized as phase I (mpatient). but also recurrent cardiac events as well as physiologic. or cognitive impairments that may influence prognOSis Before beginning formal phYSical activity in the inpatient setting. psychosocial management. three to four times per day. and compre~ hensl~e dIscharge planning that includes referral to an outpatient cardiac rehablhtatIOn program. 5 . physical. phase II (up to 12 weeks of electrocardiographic [ECe] monitored exercise and/or education following hospital discharge). Activities during the first 48 hours following myocardial infarction (MI) and/or car'diac surgery should be restlicted to self-care activities. and health outcomes. risk factor management. thus inpatients should be risk-stratified as early as pOSSible follov-ring their acute cardiac event. The rating of perceived exertion (RPE) provides a useful and complementary gUide to hemi rate (HR) to gauge exercise intensity.3 Inpatient Rehabilitation Programs FollOWing a documented physician referral. Traditional inpatient programs with multiple steps for increasing activity are no longer feasible because of the decreased length of hospital stay for most cardiac patients.I (arbitrmy upper limit) • To tolerance if asymptomatic Duration • Begin ""rith intermittent bouts lasting 3 to 5 minutes. and activity counseling..

etc._I.. by permission. Until the patient is evaluated with a submaximal or maximal exercise test. • • Severe orthopedic conditions that would prohibit exercise Other metabolic conditions.. Selected moderate. The patient also should be apprised of outpatient exercise program options and proVided with information regarding the use of home exercise equipment. the patient should demonstrate an understanding of phYSical activities that may be inappropriate or excessive. (Champaign. including angina. be counseled to identify abnormal signs and symptoms. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. f t . including risk factor assessment. 4th ed. Although not all patients may be suitable candidates for inpatient exercise. • Other patients who may benefit from structured exercise and/or patient education (based on physician referral and consensus of the rehabilitation team) • • • • 177 I. and electrocardiogram changes suggestive of ischemia See reference 1: Reprinted. the goals for outpatient programs are as follows: • Provide appropriate patient monitoring and supervision to detect deterioration in clinical status and provide ongoing surveillance data to the referring phySICIan to enhance medical management. virtually all benefit from some level of inpatient intervention..75 cm 2 in an average size adult) Acute systemic illness or fever Uncontrolled atrial or ventricular dysrhythmias Uncontrolled sinus tachycardia (> 120 beats'min. 2004. Moreover. • • • • • Diastolic BP 2: 11 0 mm Hg Decrease in systolic BP > 10 mm Hg Significant ventricular or atrial dysrhythmias Second. 36 and 119 Frequency • • Early mobilization: three to four times per day (days 1-3) Later mobilization: two times per day (beginning on day 4) with increased duration of exercise bouts Progression • When continuous exercise duration reaches 10 to 15 minutes increase intensity as tolerated By hospital discharge.1 ) Uncompensated congestive heart failure 3-degree AV block (without pacemaker) Active pericarditis or myocarditis Recent embolism Thrombophlebitis Resting ST segment displacement (>2 mm) Uncontrolled diabetes (resting blood glucose of >300 mg·dL -1) or >250 mg'dL -1 with ketones present • • • • • Outpatient Exercise Programs Presuming that the goals for inpatient cardiac rehabilitation are met.. '. a safe.~~~ Indications Medically stable postmyocardial infarction Stable angina Coronary artery bypass graft surgery Percutaneous transluminal coronary angioplasty (PTCA) or other transcatheter procedure • Compensated congestive heart failure • Cardiomyopathy • Heart or other organ transplantation • Other cardiac surgery including valvular and pacemaker insertion (including implantable cardioverter defibrillator) • Peripheral arterial disease • High-risk cardiovascular disease ineligible for surgical intervention • Sudden cardiac death syndrome • End-stage renal disease • At risk for coronary artery disease. hypertension. Contra indications • • • • • • • • • Unstable angina Resting systolic blood pressure of >200 mm Hg or resting diastolic blood pressure of > 110 mm Hg should be evaluated on a case-by-case basis Orthostatic blood pressure drop of >20 mm Hg with symptoms Critical aortic stenosis (peak systolic pressure gradient of >50 mm Hg with an aortic valve orifice area of <0. progressive plan of exercise should be formulated before they leave the hospital. dyslipidemia. marked dyspnea.''"I:~.to high-risk patients should be encouraged strongly to participate in clinically supervised outpatient rehabilitation programs and. activity counseling" and patient and family education. hypokalemia or hyperkalemia.. etc.. at a minimum. with diagnoses of diabetes mellitus.176 SECTION III/EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS . .or third-degree heart block Signs/symptoms of exercise intolerance. from the American Association of Cardiovascular and Pulmonary Rehabilitation. the upper limit of exercise should not exceed levels observed during the inpatient program. such as acute thyroiditis. suggesting exercise intolerance and the need for medical review.. IL: Human Kinetics). hypovolemia.

and duration) for the general population are detailed in Chapter 7.g. exercise training is relatively safe for the vast majority of appropriately assessed cardiac patients. high). the guidelines for appropriate exercise duration and frequency described in Chapter 7 can be applied safely to most Jow.2 allow categorization to a single risk class (e. lisk stratification. Patients at moderate risk for exercise participation .1." yet below the metabolic load that evokes abnormal clinical signs or symptoms 7 . there should be no development of abnormal signs and symptoms either within or away from the exerCIse program. beginning with continuous ECG monitoring and decreaSing to intermittent ECG monitoring as appropriate (e.xercise program.178 SECTION "' / EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 179 • Contingent on patient clinical status. and adberence to established recom1 mendations. . Such patients may receive a more cautious approach to risk stratification at program entry and a more conservative exercise prescription. risk stratification should be only one factor to consider when making recommendations for outpatient medical supervision and the need for continuous or instantaneous ECG monitoring during exercise. there should be no development of abnormal signs and symptoms either within or away from the exerCise program. return the patient to premorbid vocational and/or recreational activities. and should be established in order to prevent the signs and symptoms listed in Box 8-4. For most deconditioned cardiac patients. all cardiac patients should be stratified based on their risk for a cardiovascular event during exercise (see Chapter 2).9 Setting the safe upper limit for exercise intensity should be a foremost consideration. beginning with continuous ECG monitoring and decreasing to intermittent ECG monitoring as appropriate (e. © 2001. . premorbid and current activities. orthopedic limitations. The remainder of this chapter considers specific modifications of the exercise prescription for cardiac patients participating in an outpatient rehabilitation setting. intensity. or significant limitations In the patient's ability to participate in the exercise regimen may resultm discontinuation of the exercise program until appropriate evaluation.to moderate-risk cardiac patients. regardless of the methods employed. CI"!nICS 0 f Noth America See reference 94: Reprinted from Cardiology r.. low. 24. . Prescriptive techniques for determining the exercise dosage (i. can take place. with permission from Elsevier. .g. at 12-18 sessions) For a patient to move to the lowest-risk category. As presented in Chapter 1. For a patient to remain at lowest risk. ECG and hemodynamiC findings should remain normal. • • • EXERCISE INTENSITY FOR THE CARDIAC PATIENT The prescribed exercise intensity for a cardiac patient should be above a minimal level required to induce a "training effect. or the need to severely decrease exerCISe levels may result in the patient remaining in the moderate-risk category or even moving to the high-risk category. 415-431. patient education. • Direct staff supervision of exercise should occur for a minimum of 6 to 18 exercise sessions or 30 days postevent or postprocedure. there should be no development of abnormal signs and symptoms either within or away from the exerCise program. Generally. at 6-12 sessions) . • • • ... . the development of abnormal signs and symptoms either within or away from the exercise program. frequency. V19(3) Williams.A. Abnormal ECG or hemodynamic findings dUring exerCise.. However. I • '. Recommendations for the intensity of supervision and monitoring related to the risk of exercise participation are described in Box 8-3. 0 • • Patients at highest risk for exercise participation . and progression of the exercise regimen should be appropriate. Provide patient and family education about comprehensive cardiovascular risk reduction therapies and serial outcome assessments to maximize secondalY prevention. beginning with continuous ECG monitoring and decreasing to Intermittent ECG monitoring as appropriate (e. M. modify these activities as necessaJy. . Current risk stratification models for cardiac patients... .e. ' Patients at lowest risk for exercise participation • . at 18. the development of abnormal signs and symptoms either within or away from the !. Abnormal ECG or hemodynamic findings dUring exerCIse. For a patient to move to the moderate-risk category. • Direct staff supervision of exercise should occur for a minimum of 12 to 24 exercise sessions or 60 days postevent or postprocedure. ECG and hemodynamic findings should remain normal. Exercise testing in cardiac rehabilitation: Exercise prescription and beyond. Develop and help the patient implement a safe and effective formal exercise and lifestyle activity program. and intervention where necessary. the minimal effective intensity for improving cardiorespiratOlY fitness approximates 45% of the Direct staff supervision of exercise should occur for a minimum of 18 t 36 exercise sessions or 90 days postevent or postprocedure. I I . the risk of exercise-induced events can be reduced through appropriate assessment. and progression of the exercise regimen should be appropriate.g. Althougb not completely preventable. Patients who have not undergone exercise testing before entering a program or those with nondiagnostic exercise tests may be inadequately categorized using this approach. Prior to starting outpatient exercise rehabilitation. or find alternate activities. The formation of exercise intervention plans for cardiac patients must not only consider safety but also should consider as the patients' vocational and avocational requirements. witb particular emphasis on intensity because this may be the most critical variable with regard to the safety and effectiveness of exercise training. moderate.g.. ECG and hemodynamic findings should remain normal. or 30 sessions). and progression of the exercise regimen should be appropriate. as well as personal health and fitness goals of the patient. sucb as the ones presented in Chapter 2 (see Boxes 2-1 and 2_2).

nds to the upper limit of presclibed training healt rates during the early stagesof outpatient cardiac rehabilitation. 28 . to those under which the subject will be exercising. or both. maximum o>. hemodynamic abnormalities. patients taking a single moming dose of a (3-blocker are more likely to e>'1Jelience tachycardia and ischemic ST-segment depression during late afternoon than during morning exercise bouts. For example. even in patients taking (3-blockers. treadmills. angina symptoms. dysrhythmlas.g.. atrial fibrillation.. ratl11g of perceived exeltion of 14 to 16 may be appropliate provided there are no signs or symptoms of ischemia or serious dysrhythmias.l~~ same percentage of the oxygen uptake reserve (%V0 2R) m cardiac patients.. prescribed healt rates for training should be based on an exercise test conducted under conditions as similar as possible.3 and diabetics with and \\~thout autonOlnlC neuropath y14 However. Such patients may wish to consider using a healt rate monitor that is highly accurate and offers the advantage of alarms for the upper and lower limits of training. .e. 25. also should be considered when establishing exercise intensity. provided there are no contraindications. etc. there is considerable intelindividuaJ variation among patients with regard to the relationship between RPE and heatt rate or oxygen consumption 17 One stud/" using cardiac patients in an early outpatient program.1 mm 5T-segment depression. Although perceived exertion generally correlates well with exercise intensity. stlive for the goal of more vigorous exercise. supraventricular tachycardia.16 ischemic ST-scgment depression and selious ventricular dysrhythmias can occur at low heart rates and/or ratings of perceived effort.g. It is also impoltant to consider medication effects (see Appendix A). especially (3-blockers. Generally. and moderate versus light intensities. PerceIved exeltion is pmticularly valuable when patients enter an exercise-based rehablhtation program without a preliminm')' exercise test. can provide a useful anduTIpor15 tant adjunct to hemt rate as an intensity guide for exercisc training. one cannot simply rely on these metabolic or healt rate formulas when prescribing exercise intensity for clinical populatIOns because other variables (e. no evidence of ischemia. • • • • • • Onset of angina or other symptoms of cardiovascular insufficiency Plateau or decrease in systolic blood pressure..g." correspo. training at higher intensities resulted in greater percentage improvements in aerobic capacity than training at lower intensities.e. with lightto-moderate training intensities suggests that a decrease m thc mtenslty may be paltially or totally compensated for by increases in the exercIse duration or frequency. 2o Accordingly. Other variables (e. frequency.29 MODES OF EXERCISE FOR CARDIAC PATIENTS Whenever possible.) Other signs/symptoms of intolerance to exercise • 'The peak exercise heart rate generally should be at least 10 beats'min-' below the heart rate associated with any of the referenced criteria. blood pressure responses. It is impOltant to know when myocardial ischemia occurs for cardiac patients with exercise-induced ischemia. ischemic ST-segment depression.. significant dysrhythmia.. patients should be encouraged to engage in multiple activities to promote total physical conditioning (i. becal. if possible.')'gen consumption are linearly related dUling dynamic exercIse I1lvolvmg large muscle groups.lse healt rate and o>.. when properly explained and practiced.or 3-degree atrioventricular block. at a fixed extema! work load.::. clinicians using RPE exclusively to regulate exercise intensity in cardiac patients should be aware of the intersubject vmiability of this approach.g.24 several welJ-designed intelventions have come to a similar conclusion. For higher-intensity levels of exercIse tral11mg. even when the lower-intensity activity was compensated for by an increased exercise duration. systolic blood pressure of >250 mm Hg or diastolic blood pressure of >115 mm Hg .1 or more below the threshold has been suggested. Consequently. observed a wide range in actual physiologic demand (39%-92% of V0 2R) during an exercise session when patients were instructed to use an RPE of 11 to 13 to regulate exercise training intensity. between "fairly light" and "somewhat hard. however. perceived exeltion) also should be consIdered. thereby potentiaJJy increasing the safety and effectiveness of exercise. with respect to the timing of medications. mcludmg cardiac patients 8 The heart rate reselve method appears to closely approx. complex ventrIcular ectopy. these data suggest that physicians and allied health professionals should encourage their patients with coronalY disease to improve their exercise capacity by initiating a moderate-intensity physical conditioning program and. or symptoms) workload achieved on an exercise test. 21 In two analyses. the corresponding systolic blood pressure response and perceived exertion).')'gen uptake reserve (V0 2R). This finding is clinically relevant in view of epidemiologic data showing lower all-cause mortality for those exercising at vigorous versus moderate intensities. so that patients can exercise below the angina or ischemic ECG threshold. or when clinical status or medical therapy changes. to accomplish the same total amount of work.10.180 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 181 I' . exercisc rated as 11 to 13 (6-20 scale). RPE. including those taking (3-blockers 1.10 Improvement in V0 2m. a one-time assessment of exercise habits and/or failure to control for the total caJOIic expenditure).imatel. a predetermined training or target healt rate (THR) has become WIdely used as an index of exercise intensity in a valiety of clinical populatIOns. because silent myocardial ischemia has been identiBed as a link between lack of premonitOling symptoms and increased lisk of cardiac arrest dUling physical stress 19 An altemative is to use heart rate obselved at the highest "safe" (i. However. horizontal or downsloping Radionuclide evidence of left ventricular dysfunction or onset of moderate to severe wall motion abnormalities during exertion Increased frequency of ventricular dysrhythmias Other significant ECG disturbances (e. A peak exercise training hemt rate 10 beats'min. . 2. 2:3 Although some studies suppOlting the added cardioprotective effect of vigorous activity were plagued by methodologic limitations (e.22 including individuals with and \vithout hemt disease..27 Collectively. or both u As desClibed in Chapter 7. cycle and arm .

and duration over the first month. to maximize the carryover of training benefits to real-life activities. or stationary cycle ergometry at -150 to 300 kg'm'min. using stairs. the training work rate must be subtly increased over time to maintain the presclibed heart rate range. comorbid conditions (e. which includes months 2 through 6.5. may require an intermittent format of exercise and should be progressed according to symptoms and clinical status. intensity. if medically appropliate. For the low-risk cardiac patient. the duration may be lengthened to 60 minutes or Jonger. recurrent infarction. One study sought to determine if men and women \\lith coronary artery disease could achieve an exercise intensity during a brisk I-mile walk on a flat track sufficient to induce a training heart rate (THR).. the rate of energy expenditure) establish it as an appropriate mode of activity for early-unsupervised exercise for coronary patients.4 METs Min Exercise 3-5 2-3 Optional Optional Min Rest 3-4 3 2 2 Reps 1 2 3 4 5 6 40-50 10-15 3-5 40-50 12-20 5-7 50-60 15-25 7-10 50-60 10-15 20-30 60-70 25-40 12-20 Continue with two repetitions of continuous exercise.. The improvement stage. diabetes). An example of a progression from intermittent to continuous exercise is presented in Table 8-1. as velified by a conditioning bradycardia. begins with three to four exercise sessions per week. during the maintenance stage.g. 5 to 6 hours a week was suggested for optimal benefits. walking breaks at work. tl1ere are systematic increases in the frequency (up to five sessions per week). arbitrarily defined as ~70% of measured HR max . moderate. intensity (up to 85% heart rate reserve or V0 2R). household chores). Nevertheless. duration. For most previously sedentmy patients. frequency.30 The CR adaptations to walking are well documented in persons \vith and \vithout coronary mtery disease. Even extremely slow walking «2 mph) approximates 2 METs and may impose metabolic loads sufficient for exercise training in lower-fit subjects. and maintenance (refer to Table 7-1). Olthopedic and musculoskeletal status. including the individual's functional capacity. Intensity should be kept low until a continuous duration of 10 to 15 minutes is achieved. improvement.g.32 Vmiations of conventional walking training. or both. middle-aged men. However.35 These findings suggest that brisk walking is of a sufficient intensity to elicit a THR in all but the most highly fit patients with coronary disease. and rowing machines). Depending on the individual's progress.to 6-kg bach 'Pack load 33 and swimming pool walking34 offer additional options for those who \\Iish to reduce body weight and fat stores.31 RECOMMENDED TOTAL DOSE OR VOLUME OF EXERCISE FOR CARDIAC PATIENTS As desclibed in Chapter 7. including range-of-motion exercises and resistance training. such as those with congestive heart failure. the initial intensity might range from 2 to 4 METs. 25 to 30 minutes per session (excluding warm-up or cool-down peliods). TABLE 8-1. improve cardiorespiratory fitness. garde?ing.to 3. A scientific statement on preventing hemt attack and death in patients with atherosclerotic cardiovascular disease extolled the importance of a minimum of 30 to 60 minutes of moderate-intensity activity three or four times weekly supplemented by an increase in daily lifestyle activities (e. at a moderate to hard exercise intensity.182 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 183 ergometers. the total dose or volume of exercise can be quantified and subsequently prescribed to target a specific level of energy expenditure. 31 Coronary patients undergoing a walking program demonstrated decreases in the rate-pressure product and somatic oxygen requirements at a fixed submaximal work load.. As the patient becomes more fit. without increasing the risk of death.5-mph pace. corresponding to walking on level ground at a 1. The initial phase of structured exercise training should begin with a low total volume of exercise and include only modest increases in frequency. Physical activity programs initiated early can enhance self-confidence of cardiac patients.. Thereafter. stair-climbers. Blisk walking programs provide an activity intense enough to increase aerobic capacity and decrease body weight and fat stores in previously sedentary. or combinations thereof. period or progress to a single continuous bout 3-5 3-5 3-5 2-3 2 with one rest 3-4 3 3 2 2 .to high-lisk cardiac patients may require more gradual increases in exercise dosage over time. the endurance component of the exercise prescription generally has tllree stages of progression: initial.1 (25-50 W). The inherent neuromuscular limitations to the speed of walking (and. The first week of training might include three sessions at a moderate intensity for only 15 to 20 minutes of continuous or intermittent activity (minimum of 10-minute bouts accumulated throughout the day). For PROGRESSION OF EXERCISE FOR THE CARDIAC PATIENT The recommended rate of progression in a physical conditioning program depends on several variables. suggesting increased mechanical efficiency. therefore. Example of Exercise Progression using Intermittent Exercise Wk Functional Capacity (FC) >4 METs Total Min Min Min Rest at %FC Exercise %FC Reps 1 2 3 4 Wk 50-60 50-60 60-70 60-70 %FC 15-20 15-20 20-30 30-40 Total Min at %FC 3-5 7-10 10-15 15-20 FC. and duration (up to 40 minutes per session) of training at 6 months. and additional lifestyle activities may be used to complement the conditioning regimen. Clinically stable higher-risk patients. physical activity progression can be facilitated by gradual increases in the presclibed intensity. depending on body weight.36 especiaJly if weight management is a primmy objective. or other complications. Using a presclibed THR provides a built-in regulator for improvements in cardiorespiratOlY fitness. including walking \\lith a 3. obesity. and their activity goals and preferences.

Abbreviations: ROM. such as the Duke Activity Status Index (Fig. ECG-telemetry. low-level calisthenics (ROM) Muscular fitness Resistance exercise: * all major muscle groups Cardiorespiratory fitness Frequency Durationt Intensity:t: Type of activities§ 5-10 minutes 10-20 minutes. respectively38 These goals would require walking approximately 24 and 32 km (15 and 20 miles) per week for most patients. drug therapy). these tests may prOvide insufficient data to formulate a traditional exercise prescliption. including those with extreme deconditioning. MacDougall AS.1 above standing rest.5 to 1. or those with left ventricular dysfunction who are limited by shortness of breath 41 An initial exercise prescription for patients with no preliminaly exercise stress test is shown in Table 8-2. arm ergometer.000 kcal'wk. et al. 2 d-wk. Guidelines for Exercise Prescription for Cardiac Patients Without an Entry Exercise Stress Test Component Initial Recommendations Warm-up Stretching. <25 W. Furthermore. symptoms. 8_1)42 can be used to estimate an individual's activity status and functional capaCity in the absence of a preliminaly exercise stress test. symptomlimited exercise testing may be inappropriate for some patients at or soon after hospital discharge.5 mph.1 1-2 bouts per day. In some instances.500 to 2. ROM. 0% grade. The patient should be observed closely for signs and symptoms of exercise intolerance. dobutamine testing may evoke a considerable rise in heart rate.600 kcal'wk -I.24: 178-186).533 ± 122 and 2. 1 to 2. Patient questionnaires. Exercise prescrrption using heart rate plus 20 or perceived exertion in cardiac rehabilitation. range of motion exercise. initial exercise intensities usually range from 2 to 3 METs. one set of 8 to 10 exercises.2 The THR can be set at an arbitraly level of approximately 20 beats'min. 0% grade on the treadmill.I because activity below this level was associated with coronary artely progression in one study.4o Fmthermore. Brubaker PH. leg ergometer.0 M'ETs as tolerated.. arm ergometer. To maximize the potential for coronmy artery disease stability and/or regression. however. there was Significant behveen-subject variability.1 RPE: 11-13 Treadmill. Several investigations have observed that the estimated phYSical activity energy expenditure of a typical cardiac maintenance program palticipant is <300 kcal per session 39 . MI. coronary artery bypass graft surgery. stretching *Resistance training consisting of 10 to 15 repetitions per set. threatening ventricular dysrhythmias.'38 Higher levels of physical activity and/or exercise energy expenditure. with a standard deviation of 846 kcal'wk. Exercise programs for such patients should be implemented conservatively \vith close medical surveillance.CHAPTER 8 / EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 185 184 SECTION III/EXERCISE PRESCRIPTION stable cardiac patients generally it is prudent to progress over a 3. orthopedic limitations. If ECGtelemetry monitOJing suggests new-onset ST-segment depression.557 kcal'wk.204 ± 237 kcal'wk-1.1.to 6-month peliod to a total dose or volume of physical activity energy expenditure of more than 1. and exercise blood pressure measurements should be obtained regularly. before initiating an exercise training program.1 MI: 30-45 minutes CABG: 30-45 minutes RHR +20 beats'min. associated signs and symptoms). Because these test results may not necessarily define the ischemic ECG threshold. allow up to 10 minutes on each exercise device for a cumulative exercise duration of 30 to 45 minutes. depending on body weight. or both. RPE.140 Although weekly amounts of phYSical activity of these cardiac rehabilitation pmticipants in one study averaged 1. because there is Significant intersubjective vmiability . myocardial infarction. Initial exercise intensities can be determined according to the length of time from the acute cardiac event and associated complications. Nevertheless. more aggressive medical management (e. respectively. §Treadmill. This is particularly true if atropine is infused at the end of the dobutamine infusion protocol. a pharmacologic stress test may have been recently performed. Use of arbitrarily determined heart rate levels and/or subjective ratings of exertion should be done with caution. and gradually increased using perceived exertion in the absence of symptoms. J Cardlopulm Rehabil 2004. other complementmy methods (e. *Use of these techniques may result in significant intersubject variability in exercise intensity as defined by percent of actual HRR or VO. a period of continuous ECG-telemetry monitoring is highly recommended. an abnormal test may signify the need for coronary revascularization. corresponding to 1 to 3 mph. with gradual increments of 0. abnormal hemodynamiCS. this should be confirmed with 12-lead electrocardiography during a simulated exercise session.R (Joo KC. the highest healt rate obtained may be used as a guide to determine the presclibed THR.. RHR. 2 d'wk tFor patients who tolerate more than 5 minutes. corresponding to 1. heart rate monitor [watches)) should be used in conjunction with conservative healt rate guidelines to determine the exercise intensity. CABG. duration since hospital discharge. only 43% and 19% of participants achieved the target levels of 1.g.g. stairs 5-10 minutes 1 Cool-down Low-level aerobic exercise. depending on the patient's body weight). 5 d'wk. If the echocardiogram or myocardial perfusion imaging results are negative for ischemia. were associated with either no change or a reversal of coronary atherosclerotic lesions. Exercise Prescription Without aPreliminary Exercise Test In patients with known or suspected coronary disease.500 and 2. or ECG changes Signifying myocardial ischemia. current home walking program. or 100 to 300 kg'm'min. Holter monitoring.g" activities of daily living. rating of perceived exertion.100 kcal'wk -1.140 Consequently.5-50 W) on the cycle ergometer. patients should focus on achieving a total volume of physical activity of 1.100 kcal 'wk-138 Clinicians need to recognize and convey to program participants that three traditional (30--40 minutes of moderate-intensity exercise) sessions per week will fall short of these goals and that phYSical activity outside of the center-based program is necessaly40 TABLE 8-2. leg ergometer (25-50 W. and the information obtained during the patient's preliminary outpatient assessment (e. resting heart rate. physical activity energy expenditure on "nonprogram days" for cardiac rehabilitation pmticipants averaged <200 kcal·d. moreover.1 and a range of 397 to 4.1 (or 12. However.

and the availability of direct medical surveillance and emergency suppmt. that is. IS Nonetheless. The program lasted 12 weeks.ith increasing work load) and recovery • Appropriate ECG response at peak exercise with normal or unchanged conduction..1 ·min 1) = 0. home exercise rehabilitation should be promulgated as an alternative. The decisiqn to progress a patient from a clinically ancIJor profeSSionally supenised program to a nonsupervised environment is best made by the physician with input from the rehabilitation team. in the absence of abnormal signs/symptoms..00 2. l Movement along this continuum should be individualized to the patients' medical and psychosocial needs and not Simply hased on length of participation..00 4... football.' .75 1. and all patients underwent continuous ECG telemetry monitming for the first 3 to 6 wceks. Sum the weights for each "yes" reply and enter into the following equation: V0 2 peak (mL·kg. such as around your house? Walk a block or two on level ground? 4. recreational opportunities. increased access to varied training modalities. profeSSional feedback and monitOJing.... and potential to promote independence and sclf-responsibility4. or carrying groceries? moving heavy furniture? 8. or skiing? for some pcriod of time to facilitate both exercise and lifestyle management changes..50 Walk indoors..e.75 5. basketball. 4fi A variety of techniques may be used to facilitate monitoring ancIJor communication hetween patients managed at home and rehabilitation staff.Do heavy work around the house like scrubbing floors or lifting or 9- Do yard work like raking leaves.50 8. Advantages to cxercising in a structured program include group suppoli.5 For low-risk patients. In the current era.Take 23- care of yourself. eat. medically directed. and there were no cardiovascular events in either group.25 6. medication use. or throwing a baseball or football? 12.. and nondiagnostic ischemic response (i.. convenience..50 8. Outpatient cardiac rehabilitation programs traditionally havc been divided into phases II and III.Participate in strenuous sports like swimming. whereas the latter group initiated training at approximately 2 to 3 METs and. home-based rehabilitation and supervised group programs have shown comparable safety and efficacy.. Types of Outpatient Exercise Programs Although traditional supervised group programs are associated with increased cost and extended travel time.. doubles tennis. abnormal signs and symptoms. Not all patients are able to... most cardiac patients should participate in a supenised rehabilitation program Estimated functional capacity of 2:7 METs (or measured 2:5 METs) or twice the level of occupational demand • Appropliate hemodynamiC response to exercise (increase in systolic blood pressure v. • • II • • I . FIGURE 8-1. stable or benign dysrhythmias..Have sexual relations? 11· Participate in moderate recreational activities like golf. weeding.. or those whose adherence depends heavily on group support. often scparated arbitrarily based on length of participation or number of exercise sessions attended.Run a short distance? 67- Do light work around the house like dusting or washing dishes? Do moderate house work around the house like vacuuming. participate in a supervised rehabilitation program.3 considerable data are available regarding the safety.00 7. singles tennis. 44 Such programs also are more appropriate for the growing medical complexity of candidates who may be at increased risk for future cardiac events. bathe. one study compared the rehabilitation outcomes in 229 post-MI and coronalY artely bypass patients who had undergone prelimimuy symptom-limited exercise testing with 271 matched patients who did not 4 :3 Program prescliption and progression for the fonner group involved conventional intensities (70%---85% HR m "" HPE 11-14). with these approaches. or wish to. efficacy. Gcneral criteria for such decisions are presentcd in Box 8-05.75 2.43 x DASI + 9. as well as those unable to selfregulate. the outpatient rehabilitation process is viewed more on a continuum from carly outpatient to long-term (lifelong) maintenance.Climb a flight of stairs or walk up a hill? 5. bowling.. progressed using heart rate and perceived exeltion. Guidelines for the intensity of supervision and dcgree of monitoring arc described in Box 8-3..186 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 187 Can you: .. sweeping floors. and cost effectiveness of this model. Duke Activity Status Index (QASI).. or use the toilet? 2. dress.Weight 1. hecause of its lowcr cost. dancing. or pushing a power mower? 10. Both groups showed similar physiologic improvements. and side effects ... Smoking cessation programs and dyslipidemia managcment also can be successfully achieved in a home-based rehabilitation setting.50 5. <1 mm ST-segment depression) • Cardiac symptoms stable or absent • Stable ancIJor controlled baseline heart rate and blood pressure • Adequate management of Jisk factor intervention strategy and safe exercise paliicipation such that the patient demonstrates independent and effective management of lisk factors with favorable changes in those lisk factors • Demonstrated knowledge of the disease process..70 3. Accordingly. Ideally.

Resistance training provides an effective method for improving muscular strength and endurance. 54 The beneficial effects of exercise training on myocardial perfusion and/or indices of myocardial ischemia include less ST-segment depression dming exercise testing. mail (e.. and transtelephonic ECG monitoring.imal workload. or unstable symptoms) have not been well studied.. recent cross-sectional studies have reported an inverse relationship benveen C-reactive protein. General absolute and relative contraindications to resistance training are similar to those used for the aerobic component of cardiac exercise programs (see Box 8-1) and should be evaluated in each patient. blood pressure (particularly among hypertensive individuals)."9 also may help to reduce infarct size and/or the potential for threatening venllicular dysrhythmias 60 Although endurance exercise training has been shown to increase baroreflex sensitivity and heart rate variability in patients with coronary artely disease. these patient subsets may require more careful evaluation.g. Internet. higher intensity regimens 48 Considerable data now strongly SUpp01t the role of aerobic fitness and regular physical activity in improving both glucose and insulin homeostasis 49. while simultaneously increasing endurance capaci ty 63 Potential Cardioprotective Effects of Regular Physical Activity Improved lipids BPs Depression Stress Platelet adhesiveness Fibrinolysis Myocardial 02 demand Vagal tone ELIGIBILITY AND EXCLUSION CRITERIA FOR RESISTANCE TRAINING Many low.. and simultaneously elevating red blood cell transport efflciency. *Moderate to vigorous exercise intensities (i. preventing and managing a variety of chronic medical conditions. fax. is seen most clearly with higher amount. 55 . 8-2). 44 Accordingly. those with severe left ventricular dysfunction. during exercise and in recovely. severe valvular disease.56 Additionally. . and resolution of reversible myocardial perfusion abnormalities. independent of changes in body weight.e. it has been suggested that exercise training improves hemostatidfiblinolytic parameters in patients with and without coronary altery disease. 57 Finally. short-term aerobic exercise training has now been shown to improve endothelium-dependent vasodilation both in epicardial coronmy vessels and in resistance vessels in patients with asymptomatic coronmy atherosclerosis. and enhancing functional independence 62 Resistance training also appears to decrease cardiac demands (i. total blood cholesterol. Benefits of Endurance Exercise Training in Cardiac Patients There are multiple physiologic and psychosocial mechanisms by which moderate to vigorous physical activity may decrease morbidity and mOttality rates associated with the secondary prevention of cardiovascular disease (Fig. bliefperiods of myocardial ischemia before coronmy occlusioh. even when low to moderate exercise training intensities are used. and CR fitness in men 5l and women S2 The effects of chronic exercise training on the autonomic nervous system act to reduce heart rate at rest. and increases in the "antiatherogenic" high density lipoprotein subfraction 47 The beneficial effect of exercise on a variety oflipid and lipoprotein variables. A structured endurance exercise program sufficient to maintain and enhance cardiorespiratory fitness may provide multiple mechanisms to reduce nonfatal and fatal cardiovascular events.58 Ischemic preconditioning. The safety and effectiveness of resistance training in higher risk cat:diac patients (i. completion of activity logs). HR. reduced rate pressure product) during daily activities like carrying groceries or lifting moderate to heavy objects. 2':55% HR max. whereas sympathetic drive (circulating catecholamines. Aerobic exercise training programs can reduce stress and depression and promote decreases in body weight and fat stores. Coronary flow I Adrenergic t activity HR variabilit) t Adiposity Insulin t sensitivity Endothelial t Social support t Fibrinogen tI dysfunction t Blood viscosity t Inflammation FIGURE 8-2. a marker of inflammation.50 Moreover.3 Vagal tone appears to be increased at rest. and progression. uncontrolled dysrhythmias. Box 8-6 lists criteria and time course recommendations for resistance training in low to moderate risk cardiac patients. Palticipation in resistance training ultimately should be contingent on approval of the medical director and/or the patients' personal physician. that is. video recording. Abbreviations: SP. particularly norepinephline) is decreased dming exercise. and low-density lipoprotein cholesterol.e. heart rate.. Box 8-6 lists the general guidelines of resistance training for cardiac patients.188 SECTION III/EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 189 including regular telephone contact. especially those who rely on their upper extremities for work or recreational pursuits. modifying coronmy risk factors. blood pressure. reduced anginal symptoms. 2': 12-13 rating of perceived exertion (6-20 scale). sel1lm triglycerides..e. initial monitOling. uncontrolled hypertension.61 reports that described changes in venllicular dysrhythmias related to exercise-based cardiac rehabilitation have yielded inconsistent results 44 Resistance Training for Cardiac Patients Many cardiac patients lack the physical strength and/or self-confidence to perform common activities of daily living. The result is a reduction in the healt rate-blood pressure product and myocardial aerobic requirements at any given oxygen uptake or submax. reducing the potential for thrombosis and plaque expansion.to moderate-risk patients should be encouraged to incorporate resistance training into their physical conditioning program.

Monitoring the physiologic responses to a simulated work environment also may be helpful in this regard. poor prognosis. TIME COURSE FOR RESISTANCE TRAINING Many patients can safely perform static-dynamic activity equivalent to carrying up to 30 pounds by 3 weeks after acute MI. although these values are not absolute contraindications for participation in a resistance training program o Unstable symptoms should not exceed that during prescribed endurance exercise. (Champaign. light free weights. A more comprehensive deSCription of exercise testing and training protocols for these patient subsets is available elsewhere 67 A brief description of each population and specific modifications to the exercise prescription is provided. it is possible that resistance exercise could be initiated sooner if a continuum of modalities is employed. 44 In addition to enhancing work capacity. including 2 weeks of consistent participation in a supervised CR endurance training program:j: No evidence of the following conditions: o Congestive heart failure o Uncontrolled dysrhythmias o Severe valvular disease o Uncontrolled hypertension. Patients who plan to resume work combined \vith environmental heat stress should consider a gradual exposure to an outdoor exercise program during convalescence rather than restticting all exercise to an air-conditioned environment. exhale during the exertion phase of the lift.. 'Reprinted. The rate-pressure product MYOCARDIAL ISCHEMIA Ischemia generally occurs when clinicaJIy significant lesions (i. avoid straining and the Valsalva maneuver. 1 RM)l However. and perceived exertion should range from 11 to 13 ("light" to "somewhat hard") on the Borg categOlY scale. Guidelines for Cardiac Rehabilitatoin and Secondary Prevention Programs. Patients with moderate hypertension (systolic BP > 160 mm Hg or diastolic BP > 100) should be referred for appropriate management. and/or implanted cardioverter defibrillators (ICDs). RESISTANCE TRAINING PRESCRIPTION FOR CARDIAC PATIENTS The cardiac patient should start at a low weight and perform one set of 10 to 15 repetitions to moderate fatigue using 8 to 10 different exercises. Weight is increased slowly as the patient adapts to the program (approximately 2 to 5 Ibs'wk. controlled movements to full extension. and stop exercise in the event of warning signs and symptoms. Nevertheless. light (1.190 SECTION III/EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 191 •• t I • • • Minimum of 5 weeks after date of MI or cardiac surgery. congestive heali failure. 70% or more of the vessel's cross-sectional area) result in blood flow inadequate to meet . and economic incentives. 4th ed. Special Cardiac Patient Populations Cardiac patients who have specific needs to consider when formulating the exercise prescription include those with history of myocardial ischemia. 1.I for legs).or employment status. 65 Exercise training may enhance the return to work decision and long-term employment by helping selected patients to improve their work capacity and self-efficacy for physical work. The use of elastic bands.. the use of elastic bands. it appears that exercise-based cardiac rehabilitation exelis less of an influence on the rates of return to work than many nonexercise variables. in tum. and wall pulleys may be initiated in a progressive fashion at immediate outpatient program entty (i. Exercise Training for Return to Work Failure to return to work after a cardiac event can stem from a variety of factors. A traditional resistance training program has been defined as one in which patients lift weights corresponding to 50% or more of the maximum weight that could be used to complete one repetition (i. with permission. 2004. including employer attitudes.! Tight gl. other).pping of the weight handles or bar should be avoided to prevent an excessive blood pressure response to lifting. including 4 weeks of consistent participation in a supervised CR endurance training program:j: Minimum of 3 weeks following transcatheter procedure (PTCA. Enhanced self-efficacy. *Entry should be a staff decision with approval of the medical director and surgeon as appropriate. phase II) in the absence of contraindications. 66 Refer to Appendix E for further discussion of the impact of environmental factors on vocational requirements. 64 Thus. or inappropl. can lower the cm'diovascular demand of work combined with heat stress.' for arms and 5 to 10 Ibs'wk.e. 1 repetition maximum.e. patients should be counseled to raise weights with slow. IL: Human Kinetics). 65 A few days of relatively short periods of mild to moderate exercise in a warm environment can enhance thermoregulation that.to 5-lb) cuff and hand weights. in tum. pl. exercise training may help patients gain a better appreciation of their ability to perform physical work within reasonable levels of safety. pacemakers. 36 and 119.ate perceptions of actual job demands. reduced self-efficacy. from the American Association of Cardiovascular and Pulmonary Rehabilitation. as well as revascularization or valve surgelY. provided no other contraindications exist.e. 15 AdditionaJIy. a resistance exercise program is defined as one in which patients lift weights 50% or greater of 1 RM. including low functional capacity. cardiac transplantation.. tin this box.to 3-lb hand weights. and light free weights may be initiated in a progressive fashion at phase II program entry. may lead to a greater \villingness on the pmi of patients to resume work and/or more wiJIingness to remain employed long-term follO\ving a cardiac event.

vith heart failure and moderate to severe left ventricular dysfunction results in improved functional capacity and quality of life. the patient should be transported to the nearest hospital emergency center. jaw.vith stable angina may. funded by the ational Institutes of Health.19 the THR for endurance exercise should be set safely below (~1O beatS'min -I) the ischemic ECG or anginal threshold. or lower neck pain or discomfort.. Exercise Prescription and Training Considerations for Heart Failure Patients • • • • • • • • • • Exercise may be inappropriate for those who e:l:perience exeliional angina at aerobic requirements of <3 METs. Two randomized controlled trials in patients with anterior Q-wave MI and decreased ejection fraction showed no significant difference in left ventlicular dysfunction between exercise training and contro I patients . stretching. now have been resolved.xlImillevels of exertion by reducing heart rate.1 . This trial proposes to randomize patients with CHF to a formal exercise training program (12 weeks).CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 193 192 SECTION III/ EXERCISE PRESCRIPTION myocardial oxygen demands. or stomach. unstable angina may be charactelized by an abrupt increase in the frequency of angina. both of which may have an antianginal effect. the upper heali level can be set as the highest "nonischemic" workload from the GXT. • If anginal symptoms are not relieved by termination of exercise or by the use of three sublingual nitroglycerin tablets (one taken every 5 minutes). In addition to the reduction in myocardial demand. • CHF patients who are selected for exercise training should be stable on medical therapy without absolute contraindications (particularly obstruction to left ventricular outflow. Patients should be taught to recognize the symptoms that may represent classic angina pectOlis. selves as a contraindication to exerCIse.vith 5 to 10 minutes per session and two or three sessions per day)68 may be useful. Patients . Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION). . 75 Peripheral adaptations (increased skeletal muscle oxidative enzymes and improved mitochondrial size and density) are largely responsible for the increase in exercise tolerance. is underway currently. secondary to impairment in cardiac output. transient myocardial perfusion abnormalities. >2 on 1--4 scale) level.'" Exercise Prescription and Training Considerations for the Angina Patient • Intermittent. or at least decreased in intensity. Exercise training can decrease the sevelity of angina at subm<1. . Impaired left ventricular systolic function ancl!or diastolic dysfunction can result in abnormalities in skeletal muscle metabolism and morphology. Because symptomatic or silent ischemia may be arrhythmogenic. The plimary goal for persons with angina is to increase the anginal and ischemic ECG threshold by decreasing the rate-pressure product at any gwen level of submaximal exeliion. also benefit from prophylactic (preexercise) nitroglycerin. . The goal of the warm-up is to gradually raise the heali rate response within 10 to 20 beats'min. The exercise session should be discontinued. neurohormonal responses. in selected cases. However. 7o Whether these physiological adaptations will ultimately decrease fatal and nonfatal cardiovascular events is yet to be determined by a large prospective trial.. systolic blood pressure and subsequent myocardial oxygen consumption (MV0 2 ). This acceleration of symptoms may herald an impending cardiovascular event. 73 Physical conditioning in patients . . causing significant ST-segment depression. • Any increase or change in anginal symptoms should be recorded and receive immediate medical attention as it may reflect a change in coronary status. exercise can be safe and beneficial for those with chronic heart failure 70 Previous concerns 71 regarding the potential deleterious effects of early exercise training in patients recovering from large anterior wall MI. or usual care. stable angina predictably occurs with progressive exercise at approximately the same rate-pressure product. vVhen ischemic ECG changes occur in the absence of symptoms It IS referred to as silent ischemia. Blood pressure should be checked routinely before and after the administration of nitroglycerin to reduce the potential for hypotensive sequelae.In contrast. vascular function. or threatening dysrhythmias) and have an exercise capacity of more than 3 METs. For a given patient. Upper body exercises may precipitate angina more readily than lower body exercises because of a higher pressor response. Alternatively. or pulmonary function 69 Although treatment with bed rest and restricted physical activity is still appropriate for acute or unstable conditions. ancllow-level aerobic activities. decompensated CHF. exercise training may improve myocardial blo<:? supply through changes in endothelial function and vascular smooth muscle. such as substernal pressure radiating across the chest and/or down the left arm. angina pectoris. and requires immediate medical attention.g.'2. or combinations thereof.vith the primary endpoints of all-cause mortality or all-cause hospitalizations. CONGESTIVE HEART FAILURE Congestive heart failure (CHF) is characterized by the inability of the heart to adequately deliver oxygenated blood to metabolizing tissue. The exercise session should include a prolonged warm-up and cool down (~10 minutes). 4-6 d'wk. the lise of prophylactic nitroglycelin should be cleared \vith the supelvising physician ancl!or refening physician.e. although there is at least one small trial that showed a reduction in hospital admissions and improved I-year sUlvival 74 A large prospective randomized trial.1 of the lower limit presclibed for endurance training. angina at rest. causing abnormal ventricular remodeling and infarct expansion. back. when the discomfOli reaches a moderate level (i. or both. shOlier duration-type exercise on a more frequent basis (e.vith stable angina should be counseled regarding the potential exacerbation of symptoms while exercising in the cold. and consist of 68 range of motion. followed by home-based exercise (-3 years). Patients . and reduced symptoms 74 .

. AAI. disease who are heart rater~sponsive. gas analysis) may be helpful when formulating the exercise intensity to avoid work rates that produce ischemic wall motion abnormalities. Training sessions initially should be brief (e.82 Exercise prescription and training considerations for patients \\~th ftxed rate pacemakers include the follOwing: • Because of the nonlinear relationship between oxygen consllmption and heart rate.g. f3-blockers. exercise echocardiogram. ACE inhibitors. These moderate-intensity activities may be safely and effectively complemented by a resistance training program in patients \vi!~ stable CHF to improve symptoms of fatigue. b bolic demand.'>l However.est where TSBP equals training systolic blood pressure. Serial ECG and blood pressure monitOling may be helpful in this regard. Other individuals vvith WI pacemakers may have little or no chronotropic reserve. the patient demonstrate~ an attenuated rise in cardiac output during physical activity. 20 to 40 minutes per session fi9 If possible. radionuclide studies. WIR. hypokalemia commonly results from chronic diuretic therapy. Considerations for Patients with Fixed Rate Pacemakers • • For many patients. there is a blief period (-2--3 weeks) following pacemaker imIJlantation dUlin a which the . I Moreover.. the safety and effectiveness of exercise training in this hO patient subset now has been demonstrated Because some upper body movements may clislodge implanted leads.9 The NOtth American Society of Pacing and Electrophysiology (NASPE)/British Pacing and Electrophysiology Group (BPEG) have developed a standard international five-letter code to provide a universal description of pacemaker characteristics (Table 8-3). including ann exercise training. DDD. and progressively lengthened as the patient's tolerance improves. worsethan-usual dyspnea or shOttness of breath or angina on exeltion. Perceived exertion ratings of 11 to 14 (on the 6-20 scale) are useful guides. The fourth letter represents rate-responsive propelties. limitations of WI pacing include the lack of AV s)'llchronization. stationary cycling. as follows (modified Karvonen formula): TSBP = PACEMAKERS AND IMPLANTABLE CARDIOVERTER DEFIBRILLATORS Patients with a histOly of resuscitated sudden cardiac death. using a THR range corresponding to approximately 40% to 75% V0 2"""" 3 to 7 d'wk. and quality of life. Consequently. in patients without rate-adaptive pacemakers. . sudden weight gain. the pacemaker is programmed in WI to manage ventricular bradycardias effectively. Particularly impOttant is maintenance of the proper emergency and resuscitation equipl~lent. and AATOP). edema. Pacemakers are categOtized by these codes (e. and functional capacity may be severely compromised.SBP." Because the chronotropic response may be impaired. absence of an atrial contribution to end-diastolic volume and intermittent valvular regurgitation. Thereafter. and other aerobic activities. b patient should avoid raising the ann on the affected side above the shoulder.est) (50% to 80%) + SBP. including a cardioverter/defibrillator v\~th R-wave synchronizing capability. supe/visol)' staff should be especially vigilant of worsening signs and!or symptoms (e.ticnts traditionally werc cautioned to avoid vigorous physical activity because of the pacemaker's ILxed rate.194 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 195 • If possible. peak oxygen consumption should be determined by direct gas exchange measurements because aerobic capacity may be markedly overestimated from treadmill exercise time in this patient subset. Although vigorous upper body activities and contact sports are not advised for patients with pacemakers. 19 a drop in ejection fraction. threatening vcntlicular dysrhythmias. Interval exercise training has been used in patients with chronic CHF.. \vith good clinical results and accelerated rehabilitation outcomes'6 \Valking. patients may participate in physical activities that are compatible with their functional capacity. Initial ECG telemetlY monitoring may be useful to ensure proper functioning of the pacemaker dUling progressive physical activity. VVI. adjunctive target MET levels and perceived exertion limits should be provided • Exercise intensity can be determined by modifying the Karvonen 8:J equation from heart rate to systolic blood pressure (SBP). Although previously it was believed that exercise training programs were ineffective for patients \\~th a fixed heart rate response. Moreover.g. most physicians permit routine acti~ties involving the upper extremities. ancillaty study data (e. increasing fatigue.l . advances in (SBP max . it appears that these patients adapt to physical conditioning in a manner similar to patients \\~th coronary artet). including exercise for intervals of 2 to 6 minutes separated by 1 to 2 minutes of rest. or a response exceeding the ventilatOty threshold 69 Warm-up and cool-down peliods should be lengthened to a minimum of 10 to 15 minutes each. or disease of the sinus node or conduction system vvith permanent pacemakers or an lCD. .6'J Many of these patients also may be taking multiple medications.g. are being increasinaly referred to exercise-based cardiac rehabilitation programs'S Although these p. a pulmonaJy wedge pressure greater than 20 mm Hg. or malignant ventricular dysrhythmias) that mav suggest detelioration in clinical status. and the third letter position signifies the response of the pacemaker to a sensed event. 10-20 minutes). dyspnea.g. perceived exertion and dyspnea may be used preferentially over heart rate or workload targets. the second letter position describes the chamber(s) sensed. • • • • • • technology now enable dual chamber pacing with atrioventricular (AV) synchrony as well as dynamic adjustment of the hemt rate to match increasin a levels of meta~ .. including digoxin. and the fifth position denotes any antitachyarrhythmia function of the pacemaker. which have the potential to influence the ECG and hemodym{mic response to exercise. generally are recommended. and antiarrlwthmics. vasodilators. applying shOtt bouts of intense muscular loading. Because malignant ventticular dysrhythmias are the most common cause of sudden cardiac death in CHF patients. The first letter position represents the chamber(s) paced. diuretics. and patients should be advised to avoid isomettic exertion. Exercise intensity should be based on a symptom-limited treadmill or cycle ergometer evaluation.

the DDDR pacemaker most closely resembles the normal heart's conduction system because it provides AV synchrony and uses sinus rhythm for the sensordriven heart rate. despite comparable aerobic requirements. Nevertheless. The unit is designed to recognize rapid rhythms and respond in a tiered fashion. • Extended warm-up and cool-down periods are recommended. and the absence (complete or partial) of autonomic cardiac innervation. Reprogramming of maximum heart rate below the ischemic threshold also should be considered. If signs or symptoms of myocardial ischemia occur during exercise.and lower-rate limits of the pacemaker device. For example. associated skeletal muscle derangements. NASPE/BPEG Generic Pacemaker Code IV Position Category Chamber(s) Paced II Chambers Sensed V Antitachyarrhythmia Functioning III Response to Sensing Programmability and Modulation 0= A= V= D= None Atrium Ventricular Dual (A and V) 0= A= V= D= None Atrium VentrcularDual (A and V) 0= None T = Triggered I = Inhibited D = Dual (T and I) 0= None P = Simple programmable M = Multiprogram C = Communicating R = Rate modulation 0= P= S= D= None Pacing (antitachyarrhythmia) Shock Dual (P and S) • Systolic blood pressure should be monitored throughout exercise to ensure safe and effective exercise intensity. 1. to titrate a safe and effective exercise dose. Exercise intensity for pacemaker patients should approximate 50% to 85% of HRR. Because the device is programmed to detect dysrhythmias using heart rate and intervals as the main criteria. A magnet should be readily available to override or inactivate the device should it malfunction. stationary cycle ergometry may not produce sufficient motion of the thorax to yield an adequate rise in heart rate. such as a motion sensitive piezoelectric crystal device or accelerometer. consideration should be given to the upper.and 3-year survival rates for transplant recipients now approximate 86% and 80%. • Maxi mal hemt rate reserve method of Karvonen S:1 • A fixed percentage of the maximal heart rate 9 • Rating of perceived exertion 15 • METs If either of the heart rate methods is used. hypertension.'s For this reason. and diabetes. Similarly. CARDIAC TRANSPLANT RECIPIENT Cardiqc transplantation represents a therapeutic alternative for nearly 3. it should be emphasized that without rate adaptive pacing. pulse palpation. such as dyslipidemia.CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 196 SECTION III/EXERCISE PRESCRIPTION 197 TABLE 8-3. Pacing in the WIR mode provides rate responsiveness to activity. the upper limit for prescribed heart rate in DDD and WIR pacemakers should be set at 10 beats'min. obesity.Sl • Finally. The R in the pacemaker coding system indicates that physiologic or nonphysiologic sensors are used for rate modulation. The pacing rate for these modalities is determined by physiologic variables or atrial tracking. Persons with ICDs are at risk of receiving inappropriate shocks during exercise if the sinus heart rate exceeds the programmed threshold or the patient develops an exercise-induced supraventricular tachycardia. cardiac transplant patients continue to experience exercise intolerance because of extended inactivity and convalescence. it should augment cardiac output during activity in appropriately selected patients. An ICD consists of a cardioverter device and a lead system.I or more below the person's ischemic threshold. Moreover. • Such patients also should work at a markedly reduced intensity for the first few minutes of exercise to avoid dyspnea or premature fatigue. Considerations for Patients with Rate Responsive Pacemakers Rate responsiveness to exercise can be achieved in patients with chronotropic incompetence with WIR or DDD pacing. should be designed carefully with respect to the type and intensity of activity. the functional capacity of WI-paced patients may be greatly reduced when compared with those with rate modulation and AV synchrony. or both.'s Exercise intensity for patients with rate-modulating pacemakers can be prescribed using the follo\ving methods. it is critical to know the cutoff rate. alone or in combination: Sl Considerations for Patients with Antitachycardia Pacemakers and Implanted Cardioverter Defibrillators Antitachycardia pacemakers and ICDs are commonly used to manage tachydysrhythmias (usually with burst pacing or shock). the DDD pacemaker offers the advantage of AV synchrony as well as rate responsiveness during activity via atrial tracking. Because of the adverse side effects of immunosuppressive drug therapy (cyclosporine and prednisone). loss of muscle mass and strength. treadmill exercise should use speed increments more than gradient changes because these units may respond at an inappropriately slower rate during uphill walking. these individuals are at . Various rate-responsive sensors have relative advantages and disadvantages. but without AV synchrony.000 patients each year with end-stage heart failure. patients with ICDs should be closely monitored using continuous or instantaneous ECG telemetry monitOling. 4 to 7 d'wk-l. 20 to 60 minutes per session. Exercise recommendations for patients with nonphysiologic sensors. Finally. respectivelyS4 Despite surgelY. A combined <Hm-leg ergometer that uses the levers and pedals simultaneously may elicit a more appropriate chronotropic response 81 For patients with adequate sinus node function but high-grade AV block.

to 3-pounds) hand weights. Cardiac transplant recipients should perform aerobic exercises 4 to 6 d 'wk-1 while progressively increasing the duration of training from 15 to 60 minutes per session 84 Low. as outlined in Box 8-7. in stroke volume. particularly for aortic and mitral valve disease. and neuroendocrine responses at rest and during exercise when comparing transplant recipients with age. glucose intolerance andlor diabetes mellitus. increased appetite. 90 Valve replacements/repairs are also commonly pelformed. 1. there are numerous differences in the cardiorespiratory. Exercise Prescription and Training Considerations for Cardiac Transplant Patients Because the initial heart rate response is attenuated and may not correspond with exercise intensity. and. the effects of immunosuppressive medications. fat redistribution from the extremities to the torso' gastric irritation. osteoporosis. knowledge of the most recent cardiac biopsy score is important because rejection exacerbates exercise intolerance. 91 Generally. to a lesser extent. loss of muscle mass.to moderate-intensity resistance training and range-of-motion activities performed 2 to 3 d'wk. Resting sinus tachycardia (90-110 beats'min -1) is common. respectively. In the denervated heart. • Exercise intensity in cardiac transplant recipients can be established using the following methods: o 50% to 75% V02pcak o Rating of perceived exertion (11-15 on the 6-20 scale) o Ventilatory threshold o Dyspnea . prednisone therapy may result in numerous side effects. generally there is an absence of anginal symptoms because of partial or complete denervation. 6 months of resistance training prevents glucocorticoid-induced myopathy in heart transplant recipients and restores fat-free mass to levels greater than before transplantation surgely 89 Surveillance of the transplant patient during exercise training should focus on resting and exercise blood pressures.. more than 519. including sodium and fluid retention. possible adverse effects of immunosuppressive drug therapy. using perceived exertion and dyspnea ratings as adjunctive guides for training.and gender-matched healthy individuals. two separate P waves may be apparent). the uncomplicated PTCI patient is discharged in 24 hours. However. 8. Moreover. the increase in cardiac output during exercise is elicited by a significant increase in heart rate. large interindividual variations in RPE at a given oxygen uptake have been reported in this patient population 88 With continued exercise it is not uncommon for cardiac transplant patients to approach or exceed the maximal heart rate achieved on a previous exercise test. coronary s risk factors. although some evidence for partial reinnervation exists 86 As a result of the denervation. increasing numbers of patients are being referred to exercise rehabilitation early after cardiac transplantation to improve functional capacity. and quality of life. altered baroreceptor sensitivity. In the normally innervated heart.000 PTCIs were performed in 2000. Moreover. at higher work rates the myocardium responds with tachycardia to humoral adrenergic stimulation. However. However. hemodynamic. as well as mobilization are initiated while in the hospital or in the early outpatient setting. Consequently. CARDIAC SURGERY AND PERCUTANEOUS TRANSLUMINAL CORONARY INTERVENTION The two most common approaches to revascularize occluded coronaty arteries are coronmy artery bypass graft surgelY (CABGS) and percutaneous transluminal coronalY interventions (PTCIs) which include angioplasty (PTCA) andlor intracoronary stenting. If evidence of rejection is present. whereas cardiac surgelY patients (CABGs or valvular) are hospitalized for 4 to 6 days. predetermined work rates or MET loads may be preferred. Blood pressure should be monitored carefully because hypertension is a common side effect of cyclosporin. ECG (e.000 CABGS and 561. the prescribed exercise regimen should be discontinued until this is reversed. postsurgery patients should avoid traditional resistance training exercises (with moderate to heavy weights).1 may be used to complement this regimen.198 SECTION III/EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 199 increased risk of developing coronary atherosclerosis of the donor heart. 84 Longer periods of warmup and cool-down are indicated because the physiologic responses to exercise and recovery take longer. largely to rising plasma norepinephrine levels 87 Postexercise heart rates often rise or remain elevated longer than normal because of the continued presence of norepinephrine andlor the lack of parasympathetic innervation. Patients may be seen once daily and perform 10 to 15 repetitions of each exercise. predis~ position to peptic ulcers. generally by 62 3 months Surgery patients who experience sternal movement or wound compli- • The exercise prescription for the cardiac transplant recipient should be based on data derived from exercise testing to volitional fatigue. Stretching or flexibility activities can begin as early as 24 and 48 hours after bypass surgery or uncomplicated MI. As a result. increased susceptibility to infection. the transplanted heart essentially is denervated. Peak oxygen consumption in untrained cardiac transplant recipients generally is 50% of normal and ranges from 10 to 22 mL'kg~1'min-184 Collectively. the cardioacceleratory response to exercise is delayed. To counteract the deleterious eff~:ts of bed rest and complications associated with the cardiac surgelY. using "graded" protocols with 1 to 2 MET increments per 3-minute stage 84 • Although isolated cases of chest pain have been reported in cardiac transplant recipients. and systolic and diastolic hypertension may result from elevated catecholamine levels. In the United States alone. Finally. • The sensitivity of the exercise ECG in this patient subset is extremely low relative to the detection of myocardial ischemia.e. Because of the surgical procedure. yet cardiac output increases to support the metabolic demand. until the sternum has healed suffiCiently.g. Studies in cardiac transplant recipients have shown that the initial increase in cardiac output with submaximal exercise is achieved by an increase in stroke volume via the FrankStarling mechanism because immediate cardioacceleratory stimulation is lacking. and evidence of rejection. range-ofmotIon activities and velY light (i. and increased potassium excretion. or combinations thereof. radionuclide testing or exercise echocardiography may be more appropriate in assessing atherosclerotic heart disease. these data indicate an earlier onset of anaerobiosis in transplant recipients than in healthy individuals..

13. Exercise prescription: role of the physiatrist and allied he. Champaign. 182 . Wilmore JH.104:1694-1740. Low-risk-stratified. Silent myocardial ischemia as a potential link between lack of premonitoring symptoms and increased risk of can. Effect of orthostatic stress on exercise performance after bed rest: relation to in-hospit. Exercise testing and training of individuals with heart disease or at high risk for its development: a handbook for physicians. Valve surgery patients generally can follow the same exercise prescription guidelines as the CABGs patient. If a 1 RM pretest is used. Swain DR. Aerobic exercise training for the postsurgical inpatient can be guided initially using resting HR + 30 beats' min ~ I (or other techniques described in the inpatient section of this chapter) until more objective data from a symptomlimited exercise test is generated. Hogowski BL. 21. Almes Mf. Fletcher GF. J1. et al. o Exhale (blowout) during the exertion phase of the lift (e. 17. Schuler G. Circulation 2001. Gordon S. Med Sci Sports Exerc 1998. Acute and chronic responses to exercise in patients treated with beta-blockers.. 8. Reprinted. 2. The exercise prescription for PTCIs is similar to other cardiac patients although these patients may be able to progress more rapidly if there was no myocardial damage and less inactivity preprocedure and postprocedure. 16. Franklin BA. Whaley MH. Franklin BA. 4. Brubaker PH. The relationship of heart rate rese. Vinik AI. the initial load should allow 12 to 15 repetitions comfortably. [s there a threshold intensity for aerobic training in cardiac patients? Med Sci Sports Exerc 2002.liac arrest during physical stress. Hall L. or anginal discomfort 7.34:1071-J075. significant soft-tissue and bone damage of the chest wall can occur during surgery. et al. 5. The resulting low functional capacity. Sivarajan ES. If this area does not receive range-of-motion exercise. Lowenthal DT. Implications for exercise testing and prescription of exercise and training heart rates.IJ :132-144. Med Sci Sports Exerc 2002. The recommended quantity and quality of exercise for developing and maintaining caruiorespiratory and muscular fitness. et al. Nevertheless.305:357-362. 4tb ed. o An RPE of 11 to 13 may be used as a subjective guide to effort o Stop exercise if warning signs or symptoms occur. Swain DP. Timmis Gc.6: 118-1. Joyner MJ. Some specific considerations are as follows: o Exercise large muscle groups before small muscle groups. adhesions may develop and the musculature can become weaker and shorten. In-hospital exercise after myocardial infarction does not improve treadmill performance. J Cardiac Rehab 1983. IL: Human Kinetics). especially dizziness.g. Arch Phys Med Hehabil 1976. Kunze B. 1998. Butcher JD. 108:253-257. Am J Cardiol 1990. Brawner CA. Pollock ML. Foster C. (Champaign. Balauy Gf. IL: Human Kinetics. Dallas. J Cardiopulm Rehabill991. Cordon S. as well as advanced age. Franklin BA. o Avoid straining. Swain DP. Contempora. aerobic and resistance training can begin almost immediately as long as the catheter access site has healed properly. unusual shortness of breath. New insights on the threshold intensity for improving cardiorespiratory fitness. Hoberg E. Champaign. • • • cations should perform lower extremity exercises only. J Cardiopulm Rehabil 1997. Acute response to submaxin"u and maximal exercise consequent to beta-adrenergic blockacle: implications for the prescription of exercise.55:135D(141D. et al. Use of heart rate reserve and rating of perceived exertion to prescribe exercise intensity in diabetic autonomic neuropathy.26:886-990. Chest 1886. 18. Wilmore JI-!. I' To prevent soreness and minimize the risk of injury. Freund BJ. However. Am J Carcliol 1992.u rehabilitation.66:362~365. Pollock MI. well-trained patients may progress to higher relative loads depending on program goals. Am J Cardiol 1997. accentuating postural problems and hindering strength gains.200 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 201 .30:975-991.24:178-186.21. Diurnal variation of ischemic response to exercise in patients receiving a once-daily dose of beta-blockers. 1975. Alilerican Association of Cardiovascular and Pulmonary Rehabilitation. II.79:1075~1077. Borg's Perceiveu Exertion and Pain Scales. o Increase loads by 5 % when the patient can comfortably lift 12 to 15 repetitions. Tillllllis ce.y caruiac rehabilitation services. An additional set may be added. and flexibility in healthy adults. Keteyian SJ. which may evoke an excessive BP response to lifting. An10unt of exercise necessary for the patient with coronal)' artely disease. Amsteruam EA. Timrnis ce. et al. dysrhythmias. from the American Association of Cardiovascular and Pulmonary Rehabilitation. Gaesser GA. 4th ed. Validity of rating of perceived exertion during graded exercise testing in apparently healthy adults and cardiac patients. 3. Prev Cardiol 2003. 9..3:660-663. emphasize complete extension of the limbs when lifting. Franklin BA. 12.65:583-589. In the current era of stenting and aggressive pharmacotherapy. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 6.: Human Kinetics. Oldridge NB. Diabetes Care 2003. Am J Cardiol 1985. 2004.92 For PTCI patients. Exercise Standards lor testing and training: a statement for healthcare professionals from the American Heart Association.'.57:315-319. Colberg SH. American Heart Association.ve to V02 reserve in patients with heart disease. Brubaker PH. although these patients may have had greater activity restrictions and/or longer periods of symptoms prior to surgery. controlled movements. Bruce RA. this load would be approximately 30% to 40% 1RM for the upper body and 50% to 60% for hips and legs. but additional gains are not proportionate.t rate plus 20 or perceived exertion in cardiac rehabilitation. 2003. Kaminsky LA. may require valve surgery patients to start and progress at a slower rate. Ehrman JK. Am J Cardiol 1990. et al. 15. J Cardiopulm Rehabil2004. Convertino VA. N Engl J MedI981.uth professional. SeH~efficacy anu in-patient cardiac rehabilitation. 20. the risk for restenosis in PTCI patient is reduced considerably from early experiences with PTCA alone. Perform one set of 8 to 10 exercises (major muscle groups) 2 to 3 days/week. Franklin BA. tight gripping. 10. MacDougall AS.69:1426-1432.17:261-267. 14. Exercise prescription using hea. Borg GAV. exhale when pushing a weight stack overhead and inhale when lowering it) o Avoid sustained. 19. o Raise weights with slow. Guidelines for Cardiac Hehabilitation and Secondary Prevention Programs. 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Impact of a home-based walking and resistance training program on quality of life in patients with heart failure. IL: Human Kinetics. Kavanagh T. Durstine JL. Kaye OM. c'ontrolled trial of long-term moderate exercise training in chronic heart failure: effeds un fundional capacity. 78. 85. Clinical Cardiac Rehabilitation: A Cardiologist's Guide. Pashkow FJ. If modil'ications of exercise testll1g and exercise prescriptions are not noted. Schweikert HA. et al. Schepers 0. individuals with either inflammatory or degenerative JOll1t dIsease g. and bones. American College of Sports Medicine's Exercise Management for Persons with Chronic Diseases and Disabilities. Other Clinical Conditions Influencing Exercise Prescription A~though :~thout chromc • •• 9 •• CHAPTER ~Ied Sci 77. In: Pashkow FJ. and decrease joint swelllllg and pain. 205 .87:712-715. Br J Sports Med 1996. immunologic disorders. and defibrillators.3:561-568. fatigue.33. Rheu~nat01d arthntls lS a chronic.hat typically impacts the knees. Heidbuchel H. TI~~. 2nd eel. Friedman D. 86. EAM l--exercise training in anterior myucanlial infarction: an ongoing multicenter randomized study. Cbampaign. Am Heali J 2002. Meyer K. However.18:421-431. 83. Vanhees L. Burgess JJ. enhance functional status.nerally are able to engage in regular exercise to improve their health status: fhe goals for many ~rthritis patients are to engage in normal everyday actIVItIes w1thout undue fatigue and pain. eds.123: 2104-2111. IL: Human Kinetics. hypeltenslOn. Hesponses of the cardiac transplant patient to exercise and training. and pregnancy. Hesistance exercise prevents glucowrticoid-induced myopathy in heart transplant recipients. Functional and neuralchemical evidence for paliial cardiac sympathetic reinnervation after cardiac transplantation in humans. Refer to the ACSM Resource Manual (Section 4) for a comprehensive and detailed analysis of each condition. Arthritis Arthritis and rheumatoid disease typically affect almost 14% of Americans and cause muscle weakness. 2003 Update. This chapter extends the general exercise prescription guidelines presented in Chapter 7 for pers~ns \\~th. Roberts SO. Cardiac transplant. heart transplant. and for chronic heart failure. et al. Exercise prescription for patients with pacemakers. 81. penpheral arterial disease. Med Sci Sports Exerc 1998. 87. et aI. Am J CardioI2001. eds. American College of Sports Medicine's Exercise Management for Persons with Chronic Diseases and Disabilities. Sharp CT. and swelling in joints and other supportmg structures of the body such as muscles. feet. eds. Brawner C. and pain. Effects of exercise training in patients with heart failure. Esler M. or more of the follo>\~ng conditions: arthritis. West NI. 2003:52-57. Chest 2003.7:297--320. 84. Preliminary results on left: ventricular function and remodeling. IL: Human Kinetics. 2003:58-63.30:483--489. 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Aquatic. cycle testing or combined arm and leg ergometry may provide a more accurate measurement of cardiopulmonary function if the patient is less limited by pain. Approximately 90% to 95% of all diabetics are type 2. or both. machines. and flexibility exercise stimuli (see summary in Table 9-1). and continuing pain that lasts more than 1 hour after exercise.. Although treadmill and cycle ergometer protocols can be tolerated. 19-20 RPE) Or 1 set of 3-20 repetitions (e. • Diabetes Mellitus Diabetes mellitus is a group of metabolic diseases resulting from defects in insulin secretion. EXERCISE PRESCRIPTION • Tbe recommended mode. • In a single exercise session. 8-10. and morning exercise \vith rheumatoid arthritis because of significant morning stiffness. and overload generally are consistent with those in Chapter 7 for cardiorespiratOly. some patients may benefit from the enhanced circulation. momentary muscular fatigue.1 j Intensity Duration Activity Cardiorespiratory 3-5 d·wk.1 40%/50%-85% HRR or V0 2 R 55%/65%90% HR max 12-16 RPE 20-60 min Large muscle groups Dynamic activity 8-10 exercises Include all major muscle groups Perform flexibility exercise one to two times daily. to aerobic activities (weight-bearing and/or non-weight bearing). and cycling activities are preferred J • Perform resistance training (free weights. • Choose a mode of exercise based on the most pain-free method for exercise. However. decreased range of motion. • Morning exercise often is avoided for rheumatoid arthritis patients. isometrics) of two to three repetitions progressing to 10 to 12 repetitions. Use low-intensity and low-duration during the initial phase of programming. highly repetitive exercise \vith unstable joints. duration. • Modifications of traditional protocols may be warranted depending on functionallimitations and an early onset of fatigue. 2 to 3 d'wk. 3-5. the types of diabetes have been classified by the etiologic origins. Since 1997. In contrast to type 1 diabetes.. 16 RPE) Flexibility Minimal 2-3 d·wk. • Focus on improvement of both functional status as well as physical fitness..g. insulin action. V0 2 R. walking. overstretching and bypennobility. maximal oxygen uptake reserve. intensity. • Conditions for exercise termination include unusual or persistent fatigue. Type 2 diabetes (NIDDM) is caused by msulm resistance with an insulin secretory defect.g. sit to stand) should be performed daily. resistance. heart rate reserve. increased joint swelling. I • Perform cardiovascular exercise initially in short bouts (~1O minutes).g. elastic bands.1 Stretch to tightness at the end of the range of motion but not to pain 15-30 seconds 2-4 xlstretch Static stretch all major muscle groups SPECIAL CONSIDERATIONS Hydrotherapy may attenuate pain and stiffness and reduce reliance on nonsteroidal antiinflammatOly drugs (NSAIDs). progress from flexibility exercises (affected joints). Add 5 minutes per session up to 30 minutes and progress with duration versus intensity. . Type 1 diabetes is caused by the autoimmune destruction of the insulin producing f3 cells of the pancreas.206 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 207 TABLE 9-1. • Avoid exercise during a1ibritic flare-up. MMF. neuromuscular status. to neuromuscular muscle function exercises (strength and endurance). Summary of Exercise Programming Components of Training Program Frequency (sessions'wk. • Alternate exercise modes or cross-training should be incOlvorated in the program. • Most patients are able to perform a symptom-limited graded exercise test. increased weakness. • • Resistance 2-3 d·wk.1 using pain thresbold as an index of intensity. 2 Although type 2 diabetes is associated with excess body fat.1 • Functional activities (e. Discontinuous exercise bouts of 5 to 10 minutes may be necessary with deconditioned patients. the primary feature is an upper body fat distribution regardless of the amount of total body fat. • Abbreviations: HRR. and fleXibility. who have significant morning stiffness. • Contraindications to exercise include vigorous. EXERCISE TESTING Assessment of physiologic function should inc:lude cardiopulmonary capacity. type 2 diabetes often is associated with elevated insulin concentrations.12-15) Stop 2-3 reps before volitional fatigue (e. Absolute insulin defiCiency and a high propensity for ketoacidosis are the common characteristics of type 1 diabetic patients.g. • Regular use of NSAIDs may cause anemia because of gastrointestinal bleeding and mask the musculoskeletal pain. using the pain-free range of motion as an index of intensity.1 Ideal 5-7 d'wk. climbing stairs.1 Volitional fatigue (MMF) (e.. frequency.

1mmol·L.6 mmo]' L -I) • Cutpoint between non-diabetic and diabetic is fasting plasma glucose 2:126 mg. with at least 48 hours behveen sessions. 8 Additional benefits of exercise for diabetic patients include improved lipid profiles.0 mmol. 6 • EXERCISE TESTING • Prior to beginning an exercise program. and visual systems because they are related to diabetic complications • Some patients. Intensive treatment to control blood glucose has been documented to reduce the risk of progression of diabetic complications 50% to 75% in type 1 diabetic adults:l and has been considered to be of similar efficacy in type 2 diabetic adults. Hypoglycemia. lower resistance (40%-60% of one repetition ma'\imum [RMJ).L 1) • Fasting plasma glucose "alues between 100 and 125 mg'dL . nervous. medications.' • Simple cardiovascular tests of resting heart rate (tachycardia) as well as heart rate and blood pressure response to orthostatic challenge. blood pressure reduction. associated with exercise.I indicate impaired fasting glucose (IFG) • 2-Hour plasma glucose level in an oral glucose tolerance test (OGTI) <200 mg. the risk of hypoglycemia exists during and after exercise.I of physical activity. and decreased insulin rcquirements. progress to 15 to 20. 14 To prevent postexercise hypoglycemia. Because of the increase of glucose uptake during exercise. diabetic patients should undergo an extensive medical evaluation particularly for the cardiovascular. may be required if weight loss is a goal. who exhibit nonspecific electrocardiographic (ECG) changes in response to exercise or who have nonspecific ST and T wave changes on resting ECG. Hyperglycemia during exercise is a risk.dL -I (7. particularly for type 1 diabetics. which includes diet. usually considered <80 mg'dL -1 is relative. amounts of caloric expenditure (2:2000 kcal 'wk -1). including minimizing sustained gripping. • Proper technique. 6 renal. • For resistance training. Rapid drops in blood glucose also can cause the signs and symptoms of hypoglycemia in elevated glycemic states.000 kcahvk. exercise that produces high arterial pressures may increase the risk of retinal detachment and vitreous hemorrhage. who are not in glycemic control. weight management. For diabetic patients with retinopathy. See Table 9-2 for common symptoms associated with hyperglycemia. • The minimum frequency is hvo per week. • Outcomes of exercise treatment in diabetes include improved glucose tolerance.\~th diabetes. scant urination Decreased appetite Nausea Vomiting Abdominal tenderness Acetone breath Kussmaul respirations Crying Drowsy Fainting or feeling faint Hand tremors Sweat Dizziness Excessive hunger Fatigue Irritability Unsteady gait Apathy Blurred vision Confusion Delusion Double vision Loss of Consciousness Convulsions Headache Inability to concentrate Nervousness Slurred speech Somnolence Poor coordination . deep breathing.CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 209 208 SECTION III/ EXERCISE PRESCRIPTION The treatment goal for diabetes is glucose control.8 Greater 1 Hyperglycemia Hypoglycemia (>300 mg'dL -1) «80 mg'dL -1 or a rapid drop in glucose) Weakness Increased thirst Dry mouth Soft eyeballs Frequent. including daily exercise. may require additional radionuclide stress testing to rule out atherosclerotic hemt disease. and lower intensity (avoiding MMF) is recommended.~ • • • TABLE 9-2. '0-12 • The basic elements of a cardiorespiratory exercise prescription' • Frequency: 3-4 d'wk• Duration: 20-60 minutes • Intensity: 50%-80% \T02R or heart rate reserve (HRR) Within this recommended prescription. See Table 9-2 for common symptoms associated . and improved well-being.~th hypoglycemia. monitor plasma glucose levels and ingest carbohydrates as needed. patients with type 2 diabetes should strive to accumulate a minimum of 1. and excrcise. static work and Valsalva are essential to prevent a hypertensive response 13 • • Hypoglycemia is the most common problem for diabetics who exercise. increased physical work capacity. may last as long as 48 hours after exercise. decreased glycosylated hemoglobin.dL I (11. • One set of exercises for the major muscle groups with 10 to 15 repetitions. increased insulin sensitivity.~ The 2003 report from the ADA Expert Panel on Diagnosis of 5 Diabetes :Vlellitus includes the following: • ~onnal fasting plasma glucose <100 mg·dL -1 (5. Hypoglycemia.1) • The use of HbA Ic as a diagnostic test for diabetes is not recommended because of a lack of standardizcd methodologies ACSM makes the following recommendations rcgarding exercise testing aud training for patients . 15 Diabetic patients with ovelt nephropathy often have a reduced capacity for exercise 6 Peripheral neuropathy may result in balance and gait abnormalities during exercise 16 as well as foot ulceration and fracture. Signs and Symptoms of Hyperglycemia and Hypoglycemia EXERCISE PRESCRIPTION • Exercise is effective in glucose control because exercise has an insulin-like effect that enhances the uptake of glucose even in the presence of insulin defiCiency. and Valsalva can provide information on the extent of autonomic neuropathy.

26 1 ' (: Ip~nts revea ed that aerobic exercise training has varying influences on blood hplds and hpopr~teins. and treatment guidelines for dyslipidemla are avaIlable '\~thin the NCEP ATP rn report. because this measure provides information on long-term glycemic control. 19 Use precautions for poor thermoregulation in both hot and cold environments. 9 As mentioned.19 • Sudden death and silent ischemia during exercise also are associated with autonomic neuropathyfi The incidence of silent myocardial infarction is six to seven times greater in the diabetic population. avoid exercise that increases systolic blood prcssure > 170 mm Hg. avoid activities that dramatically elc\'ate blood pressure. especiaJly when beginning or modifying the exercise program.7 Exercise with a partner or under supervision to reduce the risk of problems associated with hypoglycemiC events.5 • For moderate nonproliferative diabetic retinopathy.5 The ATP III repOlt recogn~es the impOltance of lifestyle modification in the treatment of dyslipidemIa. • A late-onset hypoglycemia can OCCllr up to 48 hours follOWing exercise. The most common lipoprotein adaptation. Valsalva maneuvers.5 The National Cholesterol Education Program's classifications for cholesterol and TG measurements are presented in Table . which occurred in both . blunted systolic blood pressure response.g. • • • • • • Dyslipidemia Dyslipidemia. weight loss (sometimes with polyphagia). • Tlllcllse resistance exercise often produces an acute hyperglycemic effect. • For severe nonproliferative diabetic retinopathy. 49% of adult men and 43% of adult women in the Unitcd States have elevated low-denSity lipoprotein cholesterol (LDL-C) concentrations (e. • For proliferative diabetic retinopathy avoid strcnuous activities.2:3 • Limit weight-bearing exercise for patients \vith significant peripheral neuropathy.19 • Monitor for signs and symptoms of h\1Joglycemia because of the inability of the patient to recognize them. Current dctection. Brittle diabetic patients must be in glycemic control before starting an exercise program to prevent hypoglycemiC and hyperglycemic events.2.22 avoid injecting insulin into exercising limbs. an increased consumption of carbohydrates may be required to minimize the risk of nocturnal h)1Joglycemia. • For the patient \\~th peripheral neuropathy:" • Take proper care of the feet to prevent foot ulcers. Twenty to thirty grams of additional carbohydrates should be ingested if preexercise blood glucose is <100 mg'dL-I.50 mg'dL-I and ketosis are present.::130 mg·dL -1). • For the patient \vith nephropathy:6 • Limit exercise to low to moderate intensities and discourage strenuous intensities when physical work capacity is low. 19 Cardiac patients reported angina during exercise approximately 50% more often than diabetic cardiac patients with similar thallium scintigraphy. if needed. HbAJ(. Monitor blood glucose to prevent hypoglycemia or hyperglycemia associated \vith exercise. or activities of pounding or jarring • For diabetic patients \\~th autonomic neuropathy:6. espeCially when beginning or modifYing the exercise program.210 SECTION III / EXERCISE PRESCRIPTION CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 211 Autonomic neuropathy may cause chronotropic incompetence.IR Consequently. • Monitor for signs and symptoms of silent ischemia becausc of the inability to perceive angina. is not recommended as a screening tool for diabetes.6% increase in IIDL-C. common to diabetes may cause polyuria. blunted oxygen uptake kinetics. prevent retinal detachment and vitreous hemorrhage associated with exercise: 1.. 2. • Monitor blood prcssure follmving exercise to manage hypotension and hypertenSion associated \\~th \~gorous exercise J9 • Understand that the hemt rate and blood pressure response to exercise may be blunted and that the use of perceived exeltion may help guide exercise intensity. These recommendations include increased physical acti\~tv and weight reduction. • See Table 9-2 for signs and symptoms of hyperglycemia and hypoglycemia. whereas postexercise hypoglycemia in the hours follOWing basic resistance training is an increased risk for patients on insulin or oral hypoglycemiC agents. observed in 40% of the studIes. . especially if taking insulin or oral hypoglycemic agents that increase insulin production. or abnormalities in blood lipid and lipoprotein concentrations. • vVhen exercising late in the evening. 1:3 For diabetic patients 'vith retinopathy. • To lower the risk of hypoglycemia associated with exercise.20 Sudden death during exercise may be attributed to sympathetic imbalance and prolonged QT interval. and blurred vision. 18.3-2.17. polydipsia. evaluation. A recent review of 28 randomized clinical trials involving over 4 700 [J'lrtic. and use caution if glucose >300 mg·dL-I and no ketosis is present. and an hydroSiS fi . Hyperglycemia. • Monitor blood glucose prior to exercise and follOWing exercise. an abdominal injection site is preferred. • Dehydration resulting from polyuria contributes to compromised thennoregulation. RPE may be needed to regulate exercise intensity. • Avoid physical activity if fasting gillcose >2.' • Adjust carbohydrate intake or insulin injections prior to exercisc based on blood glucose and exercise intensity to prevent h)1Joglycemia associated \vith exercise. For example. 21 • SPECIAL CONSIDERATIONS • Glycosylated hemoglobin (HbAld should be an additional blood chemistry test.24 Elevated blood LDL-C and triglyceride (TG) concentratIOns and low high-denSity lipoprotcin cholesterol (HDL-C) concentrations are all independent risk factors for CHD.. was a 4. is a major modifiable cause of coronmy heart disease (CHD) and a \videspread problem.

pelipheral vascular disease. However.e..:J·5 With respect to training protocols. respecttvely. fibric acid) that have the potential to cause muscle damage. and control of hypettension have taken place over the past few decades..000 stroke deaths annually in the United States and is a major factor contributing to the more than 1 million heatt attacks and 500. respectively. and total cholesterol (-1. such as obesity and hypertension. and overload generally are consistent with those in Chapter 7 for cardiorespiratory. triglycerides (-3. frequency. with changes in body and fat mass.33 Recent meta-analyses 34 .·1 ! Therefore.212 CHAPTER 9 / OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION SECTION III/ EXERCISE PRESCRIPTION 213 men and women and across all age groups. • Improvement in blood lipids/lipoproteins with aerobic exercise training may take several weeks or months.0%). 200 to 300 min'wk-t. 29 The goal of hypettension prevention and management is to reduce morbidity andmOltality by the least intrusive means possible.600 subjects indicate that aerobic exercise training vvilJ elicit average reductions of 3 to 4 mm Hg and 2 to 3 mm Hg for systolic and diastolic pressure. control rates (SBP <140 mm Hg and DBP <90 mm Hg) are still well below the Healthy People 2010 goal of 50%. or in combination with pharmacologic treatment by JNC 7. hypertension) that may require modifications to standard exercise testing protocols and modalities.000 strokes and 280. the risk of many of these diseases increases at levels of blood pressure well below the diagnostic threshold of 140/90 mm Hg. The Seventh Report of the Joint National Committee on Prevention. lowering blood pressure may benefit individuals with any elevation above optimal levels. and approximately 30% of hypettensive individuals remain undiagnosed. • Standard exercise testing methods and protocols are approptiate for use with dyslipidemic patients cleared for exercise testing. HMG CoA reductase inhibitors.4 and -5. 26 . while controlling other cardiovascular disease tisk factors. 29.g.:J7 EXERCISE TESTING • Individuals with dyslipidemia should be screened and stratified prior to exercise testing (see Table 2-4).. the reductions subsequent to aerobic training appear to be more pronounced in hypertensive subjects (i. In addition. and kidney failure.:J5 Reductions in blood pressure follOWing aerobic exercise training appear to be independent of both baseline obesity status and weight loss during training. and flexibility exercise stimuli (see summary in Table 9-1).000 heart attack deaths annualJy.7%). Changes in HDL-C were inversely related to the baseline concentrations. the association between obesity and hypertension is well established. ACSM makes the following recommendations regarding exercise testing and training of persons with dyslipidemia. • Exercise intensity between 40% to 70% of V0 2R or HRR • Frequency of training: 5 or more days per week to maximize caloric expenditure • Duration of training session: 40 to 60 minutes (or two sessions per day of 20 to 30 minutes) • This prescription is consistent with recommendations for long-term weight control (e. and for training durations of 30 to 60 minutes.:J4 ACSM makes the following recommendations regarding exercise testing and training of persons with hypeltension.0%. and Treatment of I-Iypettension (JNC7) classification system for hypertension is presented in Table 3_1. Changes in LDL-C (-5. • Alternative testing modes may be required if the individual has xanthomas that cause biomechanical problems. resistance.24 Hypertension is also an impOltant lisk factor for congestive heart failure. The available studies that evaluated a doseresponse relationship between training intensity and lipid changes provide conflicting results. -7. This may be accomplished by achieving and maintaining blood pressure <140/90 mm Hg or lower if tolerated. Risk estimates from the Framingham Heart Study suggest that approximately 75% and 65% of the cases of hypertension in men and women. 29 Table 9-3 presents lifestyle modifications recommended alone. in part. changes in blood pressure follOwing aerobic training appear to be similar with training intensities between 40% and 70% of V0 2Illax> for training frequencies 3 to 5 d'wk-t. 27 .35 from over 54 randomized clinical trials. 29 Regular physical activity and weight control are at the core of current recommendations for both the primaty prevention and treatment of high blood pressure.g. nonsignificant) occurred less consistently than the changes in HDL-C. treatment.8 mm Hg for systolic and diastolic pressure).g.27 HYPERTENSION Hypeltension is defined clinically as an elevation in <utcrial blood pressurc equal to or exceeding a systolic blood prcssure of 140 mm Hg and/or a diastolic blood pressure of 90 mm I-Ig. which may necessitate modification in the exercise prescription (see relevant sections in this chapter). 29 The prevalence of hypertension increases with advanCing age and is higher in men than women and in blacks than in whites 30 Hypeltension is the major contributor to the more than 700. intensity. Special consideration should be given to the presence of other conditions (e. duration. • Consideration should be given if the individual takes lipid-lowering medications (e. • Primary mode should be large muscle group aerobic activities. Detection. Based on the known therapeutic effects of habitual physical activity. 29 Persons ~ith systoliC blood pressure 120 to 139 mm Hg and/or diastolic blood pressure of 80 to 89 mm Hg are classified prehypeltensive and should also engage in lifestyle modifications to prevent cardiovascular disease. depending on the blood lipid/lipoprotein of interest and the weekly caloric expenditure. EXERCISE PRESCRIPTION • The recommended mode. and were associated. are directly attributable to overweight and obesity.:J6 . 29 Hypertension is one of the most prevalent forms of cardiovascular disease affecting approximately 50 milJion Americans and approximately 1 billion individuals worldwidc.28 SPECIAL CONSIDERATIONS • Consideration should be given to the presence of other conditions.:J2 Although advances in the detection.1 ). ~2.000 kcal·wk. obesity. 24 Furthermore. Evaluation.. involVing more than 2.

H~wever.. Standard exercise testing methods and protocols are appropliate for use \vith hypettensive patients cleared for exercise testing. Hypertensive patients taking these medications s~ould be well informed about signs and symptoms of heat intolerance. Carefully monitor blood pressure for exaggerated response (systolic >260 mm Hg or diastolic> 115 mm Hg are indications for test termination).e. potentially leading to cardiac dyslhytllmlas and a false positive exercise ECG (see Appendix A). (X2-blockers. and overload are consistent \villi those in Chapter 7 for cardiovascular. most days of the week) Limit consumption to no more than 2 drinks (1 02 or 30 mL ethanol. Evaluation. such as the elderly and obese. • I3-Blockers and diuretics may impair thermoregulation during exercise in hot and/or humid environments.9 kg m.38 Duration of aerobic training session: 30 to 60 minutes Resistance training is not recommended as the primary form of exercise training for hypeltensive individuals. advanced age) may dictate modifications to the testing procedures. • (XrBlockers. systolic blood pressure. body mass index. g. resistance. Department of Health and Human Services. Mass exercise testing is not advocated to determine those individuals at high risk for developing hypertension in the future as a result of an exaggerated exercise blood pressure response. Medication changes may be appropliate in certain instances. • I3-BJockers attenuate heart rate response dUling submaximal and maximal exercise and may decrease exercise capacity. duration. SBP. gram. OZ. • Exercise intensity 40% to 70% \T02R or HRR appears to reduce blood pressure as much as. Dietary Approaches to Stop Hypertension. calcium channel blockers. exercise at higher intensities. ounce. e. vegetables. Detection.. • ?iuretics may cause a decrease in [K+j.e. Lifestyle Modifications to Manage Hypertension* Modification Recommendation Approximate SBP Reduction (range) necessity for appropliate lifestyle counseling to ameliorate this increase. patticularly in patients without myocardial ischemia (see Appendix A).2 ) Consume a diet risk in fruits. 2402 beer. However. if exercise test results are available and an individual has a hypertensive response to exercise. National Heart..g. • Plimary mode should be large muscle group aerobic activities. 10 02 wine.3 7 : Avo.ld Valsalv~ maneuvers dUling resistance training. Resistance training regimens should incorporate lower resistance \vith higher repetitions. 03-S233. allow tllem to decrease tlleir antihypeltensive medications and attenuate their lisk for premature mortality. obesity) or concerns (e. • 'See reference 29: Reprinted with permission from National High Blood Pressure Education Program. and vasodilators may provok~ postexettion hypotension so emphasize a gradual cool-dovm peliod follOWing the exercise session. Weight reduction Adopt DASH eating plan Dietary sodium restriction Physical activity Moderation of alcohol consumption Maintain normal body weight (BMI 18. EXERCISE TESTING • • Medical clearance of hypertensive persons is advised before maximal exercise testing or plioI' to tlleir palticipation in vigorous exercise (see Table 2-1). and low-fat dairy products with a reduced content of saturated fat Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride) Engage in regular aerobic physical activity such as brisk walking (at least 30 min per day. • Frequency of aerobic training: 3 to 7 d'wk. along Willi prudent modifications in the exercise routine to prevent heat illness (see Appendix E). The Seventh Report of the Joint National Committee on Prevention. I 07) 2-8 mm Hg (106-108) 4-9 mm Hg (34.. and Blood Institute U. daily exercise may provide more optimal control of BP. 2003.. because of the acute reduction in BP that may last many hours after a slllgle bout of aerobic exercise.1 are effective in reducing BP.g.g. IndiVlduals With more marked elevations in BP (i. this information does provide some indication of risk stratification for that patient and the • • • . >220/105 mm Hg).214 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 215 TABLE 9-3. and Treatment of High Blood Pressure (JNC7).105) 8-14 mm Hg (106. ~160/100) should add endurance exercise training to their treatment regimen only after initiating pharmacologic therapy37 Exercise may reduce their BP further ·and. and flexibility exercise stimuli (see summalY in Table 9-1).S. Lung. or 3 02 80-proof whiskey) per day in most men and to no more than one drink per day in women and lighter-weight persons 5-20 mm Hg per 10 kg weight loss (104. Other comorbidities (e. • Altllough BP termination clitelia for exercise testing are established at >250/115 mm Hg. EXERCISE PRESCRIPTION • The recommended mode. If not more than. Medications should be taken at the usual time relative to the exercise bout. lower BP thresholds for termination of an exercise training ~ession may be prudent (i.5-24. 37. BMI. tllus.109) 2-4 mm Hg (110) • • SPECIAL CONSIDERATIONS Do not exercise if resting systolic BP >200 mm Hg or diastolic BP > 110 mm Hg (see Box 3-5). but should be combined with aerobic training. Abbreviations: DASH. 35 This may be espeCIally Important for specific hypertensive populations.

'9 An excess accumulation of fat. S16 weeks) in which suhjects consumed an isocalOlic diet revealed that physical activity was associated with reductions in total body fat in a dose-response manner... modifications should be made to encourage greater overall energy eJ\'Penditure \vitl1in the program for the obese individual... • Other comorbidities (e. For example.. the initial stage may need to be extended. and many have had negative eX'Periences with exercise in the past. health care providers.06 kg'wk . According to the most recent ational Health and utJition Examination SlIIvey (NHANES II!). the test restarted.I \vith exercise and one of these individuals reduces their activity dming the remainder of the day by 1.43 However. \vith an average weight loss of 0.I reduction in body weight and total ht). exercise prescriptions should be designed to aid in accomplishing this objective. physical activity and sound nutJition fonn the basis of obesity prevention and treatment.50 kcal) then the difference in weight loss between these individuals over time could be considerable (i. • Medications should be taken at usual time relative to the exercise bout. hypertension other chronic diseases) or concerns (e..1 Longer duration studies repOlted a smaller effect (i. the above results were delived from studies that: 1) incor1)orated isocaloric diets to isolate the "exercise effect. 28 . ACSM makes the follOWing recommendations regarding exercise testing and training of overweight and obese persons. and type 2 diabetes and reduced life eJ\'Pcctancy and early mOltality40Ar In tum. whereas others eJ\'Pelience dramatic weight loss.e. and the locations where exercise might be performed (e.42 therefore. ar1d improvements in lipid and lipoproteins concentrations. This could selve to discourage health care providers from making physical activity recommendations to their obese patients. This may increase adherence to an agreed-on exercise program. The modem environment is dliving the current obesity epidemic by favoling sedentmy behavior and overconsumption. the thermic effect of food. approximately 30 lbs versus 1. Obesity is caused by a complex interplay between genetic and ell\~ronmental factors." and 2) reported an average energy expenditure typically less than 1. perceived barriers to exercise palticipation. 28 The prevention of fUtther weight gain should be the first primity for obese individuals. increases in insulin sensitivity.500 kcal of energy (1 kg is approximately equal to 7. EXERCISE PRESCRIPTION • The recommended mode. and overload are consistent \vith those in Chapter 7 for cardiovascular. One pound of fat is equivalent to approximately 3. However. • For those who have difficulty adjusting to the exercise equipment. coronal)' healt disease. is associated with an increased lisk of a number of chronic diseases including h)1)eltension. and flexibility exercise stimuli (see summary in Table 9-1).g. or track).216 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 9 / OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 217 Obesity Obesity is a serious and common public health problem in the United States and other indushialized countlies.. sports club. DUling the past dccade the number of overweight (BMI ~2.. have low physical work capacities. school gym.50 kilocalOlies (or consumes an additional 1. Obesity often canies a negative social stigma and obese individuals are almost invariably sedentmy. However. olthopedic limitations or elderly) may dictate modifications to the testing procedures. 28 .' and fat loss of 0. Subsequently. street. particularly in the intraabdominal region. a cumulative positive energy balance causes obesity. in some cases. improving cardiorespiratory fitness and reducing overall cardiovascular disease risk. • Special attention to proper cuff size is necessary for accurate blood pressure measurements. Some individuals actually may gain small amounts of weight. the obese patient should be encouraged to focus on gradual but permanent weight loss. Energy balance is determined by the difference between energy intake (calmies consumed) and energy eJ\'Penditure (calories eJ\'Pended through resting energy metabolism. weight gain occurs when energy intake exceeds energy eJ\'Penditure (i. Results from recent meta-analysis 43 of short-term exercisc intervention studies (i.26 kg'wk. In this regard.g. Therefore. reductions in body weight and fat resulting from increased cxercise appear to be propOltional to the amount of aerobic exercise performed. because reduction in adiposity is often a goal and need of many obese exercise program participants. In addition.e.5 to 1.5 Ibs in 1 year). it is impOttant to emphasize that it is not necessary to achieve an optimal body weight to eJ\'PeJience health benefits. 28 Overall. or the test repeated.5% of Americans are overweight and 31% are obese. resistance. if two individuals eJ\'Pend 300 kcal·d . -6. 0.0 METs).5 kg'wk.e.5 to <30 kg·m -2) and obese (EMI ~30 kg·m. Even modest levels of weight loss (. . Therefore. • Use of leg or arm ergometry may enhance testing performance.2) indi\~dllals has increased dramatically. Intervention programs that incorporate dietary modification and greater energy expenditure would likely produce greater weight and hlt losses.2. 41 Ultimately. and physical activity).700 kcaI). normalization of body weight and composition is not a realistic goal for most obese clients.e..500 kcal ·wk. The exercise profeSSional should interview the obese palticipant to determine goals. negative energy balance). duration.r. The degree to which an individual compcnsates with changes in energy intake anclJor physical activity dming the remaining nonexercise pmuons of the day is an impOltant determinant of the degree of weight loss experienced \vith exercise. A failure to fully appreciate the eJ\'Pected weight loss following exercise training has led to disappointment on the palt of many palticipants and. positive energy balance) and body weight is lost when the opposite occurs (i. home. past exercise histOty. intensity...44 EXERCISE TESTING • Although standard exercise testing methods and protocols are generally appropriate with obese patients cleared for exercise testing.e. it is impOttant to emphasize the concept of energy balance in both causing and treating obeSity. obesity places a significant burden on the economy by increasing rates of health care usage and associated costs.g. However.5% to 10% reduction in body weight) are associated \vith clinically significant reductions in blood pressure. it is important to emphasize that there is considerable intelindi\~dual valiability in the magnitude of weight loss produced by exercise. the level of deconditioning typically obselved \vithin this population \viII necessitate a low initial workload (2 to 3 metabolic equivalents [METsJ) and small workload increments per test stage (0.

'> The lisk factors associated \\~th this syndrome act synergistically to increase cardiovascular disease morbidity and mortality. and lean sources of protein • Includes foods that are acceptable in terms of sociocultural background. and this may require that the intensity of exercise be maintained at or below the intensity recommended [or improvement of CR fitness.218 SECTION III/EXERCISE PRESCRIPTION CHAPTER 9 / OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 219 • The needs and goals of the obese subject must be indiVidually matched with the proper exercise program to achieve long-term weight management. Eventual progression to higher exercise intensities (50% to 75% \10 zR or HRR) allows for further increases in \/OZm. • Primmy mode should be large muscle group aerobic activities. as assessed by waist circumference. 4. insulin resistance.uy (i.000 kcahl. However..g. • Equipment modifications may be necess. h)1)erinsulinemia.. thereby increasing non-esterified fatty acid (NEFA) flux to the liver so Increased hepatiC NEFA uptake may lead to hyperglycemia. focusing on attainment of 150 minutes of moderate intensity exercise weekly.' (l kg approXimately equal to 7. there is little evidence that exercise alone or in combination \vith dietaly energy restriction produces magnitudes of weight loss achieved \vith dietmy energy restriction alone..g. 40% to 60% VOzR or HRR) with more emphaSiS placed on increased duration and frequency. desc:ibes a c. • lon-weight-bearing activities (.]. 4 ' The prevalence of the metabolic syndrome has been estimated to be approXimately 22% in the United States. IL-6.5% to 10% • Includes the exercise recommendations outlined in the preceding section • Includes a reduction in dietary fat intake to <30% of total energy intakc and emphaSizes fruits. waist circumference should be used as the plimary anthropometriC marker of the metabolic syndrome. T F-ct). elevated blood pressure. attainment of goal energy expenditure in reasonable amount of time).5 to 1 kg'wk.I (200-300 minutes per week [or most). the balance between intensity and duration of exercise should be manipulated to promote a high total calOlic eX'Penditure.I • Duration of training session: 45 to 60 minutes ZIl. is more highly correlated \\~th metabolic lisk factors than is an elevated body mass index (BMI).. and ease in acquisition and preparation • Provides in a negative energy balance of . • The initial exercise training intensity should be moderate (e. preferences.49 Several mechanisms havc been proposed to explain how \~sceral obeSity might lead to insulin resistance and the other abnormalities associated vvith the syndrome.5 However.g. and hypeliliglyce. whole grains.500 to 1. • Obese individuals have an increased Jisk of hyperihermia during exercise. Some male patients exhibit metabolic Jisk factors \vith lower levels of abdominal obesity (e. is highly lipolytically active. ACSM makes the foIlO\\~ng recommendations for weight loss programs: z'> • Targets a long-term reduction in body weight of at least .2.700 kcal) • Includes the use of behavior modification techniques including relapse prcvention • Pro\~des phYSical acti\~ty and dietaly habits that can be continued for life to maintain the achieved lower body wCight Metabolic Syndrome The metabolic svndrome also referred to as syndrome X or the insulin resistance syndrome.. waist circumference 01'94-102 cm [37-40 in.e." which in tum allows for a more efficient exercise session (i. costs.44 • Volume of training: Initial training volume should follow the progressions outlined in Table 7-1.mcl!or rotation of exercise modalities) may be necessary.44 • Obese individuals benefit from additional resistance exercise training in a manner similar to othenvise healthy adults. visceral adipose tissue. z. which corresponds to about 47 million adults. obesity and phYSical inactivity). However..\ resulting in gradual weight loss of 0. wide seats on cycle ergometel's and rowers)4.ndition in which several coronary hemi disease (CHD) risk factors (e.g.Z5 Therefore.g.g. the optimal maintenance dose of phYSical activity is 2:2. a walking or other moderate-intensity exercise program may be all they desire. Visceral adipose tissue secretes factors including PAl-I. and chronic low-grade inflammation) are clustered together 46 Visceral obesity (e. for some (espeCially older) obese subjects. • Obese individuals are at an increased Jisk for olihopedic injUly. • Physical activity is the best predictor of long-term weight maintenance 40 RECOMMENDED WEIGHT LOSS PROGRAMS UnfOliunately. the initial treatment SPECIAL CONSIDERATIONS • vVhen the exercise component of a weight loss program is deSigned.. • Frequency of training: 5 to 7 d'wk.. impaired fibrinolYSiS.000 kcahvk. abdominal obeSity.'lo However. the optimal approach to weight loss . can reduce the risk of cardiovascular disease in obese subjects. increased intra-abdominal adipose tissue) appears to be a central feature of this syndrome.e. and 2) treat the associated lisk factors.zI> is one that combines a mild caloric restJiction \vith regular endurance exercise. dyslipidemia. which is drained by the portal vein.idemia so Diagnosis of the mctabolic syndrome is made when threc or more of the risk determinants shown in Table 9-4 are present. the addition of resistance exercise to endurance exercise and diet modification does not appear to minimize the loss of fat-free mass or resting energy expenditure compared to that observed with diet modification alone. and angiotensinogen that are associated \vith one or more features of this syndrome so In addition. and frequent modifications in frequency and duration also may be required. cven in the absence of weight loss. cytokines (e. z5 Thus.z5 These 5 patients are thought to have strong genetic contribution to insulin resistance. There are two major objectives for the clinical management of the metabolic syndrome: 1) reduce underlying causes of the disorder (e. vegetables.ZI>. and movement toward a more intense program may not be warranted. or the combination of diet modification and endurance exercise training.5 • It should be emphaSized that increases in phYSical acti\~ty..44 However.

g. Such persons may have a strong genetic contribution to insulin resistance.) ~150 mg·dL. as the syndrome represents a clustering of metabolic disorders. Exercise. However. and if necessary. Thus.Sl the eventual exercise progression should incorporate an increased training intensity (50% to 75% V0 2R or maximal HR reselve) to provide the stimulus to improve cardiorespiratOlY fitness and allow for more efficient exercise sessions (i.S8 Moderate exercise training (e. and obesity).1 EXERCISE AND UPPER RESPIRATORY TRACT INFECTIONS The generally accepted 'J' cUlve model proposes a relationship between the amount and intensity of exercise and susceptibility to URTI (Fig. this section focuses on the relationship between exercise and URTI symptomatology and on basic immune responses to exercise. which may necessitate alterations in standardized testing methods (see appropriate sections of this chapter for testing considerations).g.g. For more detailed information on exercise immunology. They should benefit from changes in life habits. Epidemiologic studies have demonstrated a higher incidence of self-reported symptoms of URTI in endurance athletes after both competition (e.) a: i= o a: ~ III Average Below average Sedentary Moderate Very high Amount and intensity of exercise FIGURE 9-1. plasma insulin). Med Sci Sports Exerc 1994..g" hypertension. e. high-sensitivity C-reactive protein). or prothrombotic state (e. whereas the risk rises to above-average levels after intense exercise.. pmticularly as it relates to cancer patients/survivors and people infected with a human immunodeficiency virus (HIV). Because obesity is at the core of the metabolic syndrome. 2002. hypeltension. common cold or influenza [flu)).g. diabetes.) .. upper respiratory tract infection. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection. 25 Above average EXERCISE TESTING AND PRESCRIPTION Standard exercise testing methods and protocols are recommended for individuals with the metabolic syndrome. the exercise guidelines related to the other components of the syndrome (i.g.g..1 <40 mg·dL. Furthermore..e.26: 128-139. 02-S215.]). diabetes) also should be taken into consideration. approach is weight reduction and increased physical activity.. *Some males can develop multiple metabolic risk factors when the waist circumference is only marginally increased (e.t Risk Factor Defining level Immunology The majOlity ofhuman research in exercise immunology has focused on the influence of exercise on susceptibility to upper respiratOly tract infections (URTls.220 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 221 TABLE 9-4.1 ~ 130/~85 ~110 mm Hg mg·dL. Even a modest 5% to 10% reduction in body weight results in significant improvements in metabolic risk factors 47 Treatment of risk factors also may involve treatment of hypertension. and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II!). (Reprinted with permission from Nieman DC. from which recommendations for exercise testing and prescription are delived.56-.'s2-. consult other publications.y person.. NIH Publication No.. tThe ATP III panel did not find adequate evidence to recommend routine measurement of insulin resistance (e. Proposed relationship between the amount and intensity of exercise and susceptibility to upper respiratory tract infections. proinflammatory state (e. fibrinogen or PAI-1) in the diagnosis of the metabolic syndrome.s and low CR fitness. However. similar to men with categorical increases in waist circumference. may reduce the incidence and/or the duration of URTI 'See reference 2S: From the National Cholesterol Education Program. consideration should be given to specific elements of the syndrome (e. as the metabolic syndrome has been associated with both sedentary Iifestyle 2 . exercise prescription guidelines should be based on those for obese patients (see preceding section on obesity). Evaluation.55 Abdominal obesity Men Women Triglycerides High-density lipoprotein cholesterol Men Women Blood pressure Fasting glucose Waist circumference:j: >102 cm (>40 in. marathon) and intensified training relative to the gcneral public. and the immune system. Clinical Identification of the Metabolic Syndrome*.1 <50 mg·dL. and the treatment of elevated TG and low HDL-C concentrations.g. dyslipidemia..-56 This model proposes that moderate cxercise training reduces the risk of developing URTI below that of a sedenta. brisk walking) in untrained healthy individuals on the other hanu. 9_1). aspitin use in patients with CHD. attainment of goal energy expenditure in reasonable amount of time)44 ::. 94-' 02 cm [37-39 in.) >88 cm (>35 in.e.

fever. • Resumption of training after URTI should begin at a modest level and the progression should be gradual.52 EXERCISE TESTING • It is probably safe to test clients at a submaximal intensity. the overall health status of the client must be taken into account when assessing the impact of exercise on immunity. and myalgia).61 However..~tllout symptoms) or a clinical (i.g. socioeconomic factors.g.. 53 . then exercise should be postponed until the symptoms have resolved. • Exercise testing should be postponed in clients who demonstrate symptoms of systemic involvement (e. 50 .66 Thus. and minimize psychological stress. • Clients should be encouraged to consult "vith their physician on the appropriateness and timing of receiving a flu vaccine. and throat (above the neck) exercise could be performed. • Clients should minimize their exposure to individuals \vith a URTI because URTI is spread from person to person plimaIily through coughing and sneezing of infected persons. underlying disease. nutrition. anellor sore throat). and people of any age \vith chronic medical conditions are more likely to e>:pelience secondary complications (e. • Closely monitor exercise tolerance to avoid overtraining and chronic fatigue. 55. smoking. it is prudent to delay maximal testing until tlle symptoms have resolved. paIticularly those at high risk for developing secondary complications from the flu (persons aged 65 years and older.. and myalgia) until the symptoms have resolved (generally 1 to 2 weeks). HIV-infected individuals.. EXERCISE PRESCRIPTION • Healthy individuals mth symptoms of a URTI could follow the above the neck 53 rule. tiredness. HIV-infected individuals.g.52 Clinicians who have frequent contact mth these high-risk populations should obtain a flu vaccine. myocarditis) from tlle flu s2 • Prescribed or over-the-counter medications should be taken into account because they may affect cardiovascular responses to testing and exercise per~ formance. fever. allergies.g. such that fractures occur \vith minimal .52 Larger long-term prospective studies are needed to confirm the 'T' curve model and the "open mndow" hypothesis. Exercise should be discontinued if symptoms worsen. SPECIAL CONSIDERATIONS • Encourage clients to get adequate rest.i mal exercise responses. diarrhea.54 .65. Maximal testing of subjects exllibiting URTI symptoms does not elicit diminished performance. encourage clients to wash hands with warm soapy water and minimize hand-to-eye and hand-to-nose contact. aging. paIticularly dUling tlle cold and flu season.g. Changes in URTI symptomatology may occur in the absence of exercise.e. ingest ample fluids. lead to severe dehydration. sneezing. 53 . intensity exercise may increase the probability of developing a subclinical (i. Exercising with a systemic Osteoporosis Osteoporosis is defined as a systemic skeletal disease characterized by low bone mass and microarchitectural detelioration of bone tissue \villi a consequent increase in generalized skeletal fragility. weight loss. bronchitis.51 IMMUNE RESPONSES TO EXERCISE Reductions in selected measures of immune function dming recovery from endurance exercise may provide an "open window" for viruses and bacteria to gain a foothold. Persons aged 65 years and older.. medications. including psychological stress.59 Shmt-term 00 days) moderate exercise training (55% of HRR) does not appear to increase the severity of mild symptoms associated with a rhinovirus-induced URTI (-50% of URTI are caused by rhinoviruses) nor negatively affect resting pulmonalY function. common cold symptoms of a runny or congested nose. Changes in immune function after a Single bout of intense endurance exercise or after intense training does not appear to chronically enhance nor suppress immunity in the resting state. cancer patients/survivors... chronic fatigue syndrome. particularly dUling peliods of intense training. whose symptoms are mild and limited to the upper respiratOly tract (e. and exacerbations of cardiopulmonary conditions).6.. and tllUS it is not necessaIy to postpone testing 60 . exacerbate existing conditions (e.g. and environmental conditions. In addition to exercise. Because clinical populations (e.J Thus. for the comfOlt of the patient and because of a lack of information regarding long-term effects.222 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 223 symptomatology. and elderly people) exhibit mallY of the aforementioned factors. . pregnant women. nose. Similarly. pneumonia. \\~th symptoms) infection 1 to 4 days after the exercise.54 In addition.\~ng recommendations regarding exercise testing and training for patients \vith URTI. and people of any age "vith chronic medical conditions).g. That is. ACSM makes the follo. • To reduce viral self-inoculation...5s. the immune response to exercise may be different from the responses observed in healthy or younger individuals.54. no studies have demonstrated that endurance athletes during intensified training are clinically immune deficient. clinicians should not confuse the apparent association between acute and chronic exercise and altered susceptibility to URTI with causation. >80% HRR). subma.g.56 Vigorous (e..e. alcohol consumption.. infection could increase the virulence of some viruses..63. tiredness.. maintain a well-balanced diet. albeit at a lower intensity and volume. obesity.. • Clients "vith a mild URTI should be encouraged not to exercise in a group exercise setting to prevent the spread of their infection to other clients. If the symptoms are moderate to severe anellor indicate a systemic involvement (e. pregnant women. 53. diaIThea. cardiovascular diseased. if the symptoms of a URTI are mild and limited to the mouth..·55. the immune system is influenced by many factors. or maximal exercise performance.. pulmonaIy or cardiovascular disease). and increase the risk of developing secondaIY complications (e. moderate endurance training and resistance training in healthy individuals does not appear to chronically influence immune function in the resting state:53 . but not moderate.

Claudication is the primaly symptom of PAD and is charactetized as walking-induced pain in one or both legs that does not go away with continued walking and is relieved by rest. exercise training. . by pain. Peripheral Arterial Disease Peripheral artetial disease (PAD) is a manifestation of systemic atherosclerosis that affects approximately 8 to 10 million people in the United States. exercise programming should be presented to optimize bone health and to safely prescribe exercise for individuals with existing low BMD. elastic bands) with the load directed over the long axis of the bone." Osteoporosis has a debilitating effect on independence and quality of life.'t Nutrition. 2 d 'wk-t for 8 to 10 repetitions at a submaximal intensity (HPE 13-15) for one to two sets 69 Avoid exercises with spinal flexion and pelform all exercises in an upright posture. aerobic weight bearing activity (4 d'wk. The goals of treatment for patients with claudication are to relieve their exertional symptoms. Sit-ups).169 • Perform functional exercise activities (chair exercise. bone-mineral density. Exercise can positively affect peak bone mass in children and adolescents. • Specific exercises focusing on improving balance and modifYing activities of daily living are recommended. calisthenics. prolonged use of corticosteroids.osteo. may result in compromised ventilatory capacity and a fOlward shift in center of gravity. Therefore.5 standard deviation units below average and places the individual at greater lisk for osteoporosis. improve their walking capacity and quality of life. and body composition all playa key role in bone density. A cycle ergometer protocol is preferred. Premature termination may occur from osteoporotic pain. paliicularly resistance-based and weight-bearing activity may increase bone material and modify several tisk factors for osteoporotic fracture.. patients with claudication alter their gait by decreasing their ambulatOlY pace and distance. excessive trunk flexion. as any SOli of spinal flexion is contraindicated. smoking. and gait biomechanics. walking. chair sit and stand. including muscle strength. Patients are treated initially with cardiovascular dIsease risk factor modification. 7Z. such as jumping. the physician should be consulted prior to exercise pmiicipation. Claudication ptimarily affects the calves but may begin in the buttock region and radiate down the leg. Hisk factors for osteoporosis are family histolY.73 PAD diminishes blood flow to the lower extremities. which leads to a mismatch of oxygen delively and metabolic demand dUring physical activity. • Perform flexibility exercise 5 to 7 d'wk. and twisting movements can be dangerous. Osteopenia is dcfined as a bone density between 1 and 2. or jogging 68 • Dynamic abdominal exercises (e. or cramping.org). ~erform cardiovascular exercise (aquatic. 67 Osteoporosis involves reductions in both bone mineral density (BMD) and bone quality.'5 In more advanced cases. machines.g. ACSM makes the following recommendations regarding exercise testing and training for patients 'vith osteoporosis. running. dietmy factors.t 69 • SPECIAL CONSIDERATIONS • Contraindicated exercises include explOSive movement and high-impact loading activities to the skeleton. '4 To avoid leg discomfOli.I ) and resistance training (2-3 d'wk.ight posture at all times. Many affected patients are so deconditioned that they become housebound or dependent on others. cycling) at 40% to 70% of VOzH or HHR 69 • Perform resistance exercise (free weights. searing.'o • ImprOving muscle strength helps to conserve bone mass and enhance dynamic balance.'o Wben prescribing exercise for patients who are severely limited °NationaJ Institutes of Health. Care must be taken to ensure the patient does not trip or fall if a traditional treadmill exercise test is performed.I ) is recommended. Osteoporosis and Related Bone Diseases National Resource Center (\\~\~v. ischemic limb symptoms can occur at rest ("critical limb ischemia") and often requires surgery or amputation. and assist in minimizing age-related bone loss in older adults. The patient should maintain an up.A~SM makes the following recommendations regarding exercise testing and trammg for patients with PAD.224 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 9 / OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 225 trauma. maintain or even modestly increase bone density in adulthood. female gender. and reduce their atherosclerosis tisk burden. Daily activities such as sitting and bending to pick up objects can cause vertebral fracture. EXERCISE TESTING • • • • Physician approval is warranted plior to graded exercise testing to determine the risk! benefit ratio of testing. estrogen deficiency. low weight. and physical inactivity69 Exercise therapy. which can exist as a functional limitation imposed by multiple veliebral fractures. Additional testing may include balance. An estimated 44 million Amelicans are at risk of osteoporosis./(.7o Bone mass attained early in life is perhaps the most important determinant of lifelong skeletal health. exercise. aching. Severe kyphosis. Claudication is present in 15% to 40% of persons with PAD. . vigorous walking) 2 to 5 d'wk. with 10 million displaying the disease and 34 million having low bone mass. and dynamic balance. The symptoms commonly are desctibed as burning. If the patient is relatively pain-free. Exercises that require bending forward at the waist or excessive twisting at the waist (golf swing) produce high compressive forces in the spinal area and increase the vulnerability to fracture. Daily physical activity and maximal oxygen uptake are reduced by 50% in those with claudication compared to healthy subjects of similar age. tigh!ness. and medications. muscular strength. The goals for rIsk factor modification in patients with petipheral alierial disease are similar to those in patients with coronaty aliery disease. 68. 6B The risk of fracture increases with age for the osteopenia patient. • EXERCISE PRESCRIPTION • Consider pain status of patient.

an increase in leg blood flow is not a common response to exercise training. Graded treadmill protocol at 2 mph with modest increases in grade of 3. frequency. or dysrhythmias may be IdentIfied.30 . dry. exercise testing with ECG monitoring should be performed so that ischemic symptoms.'n to be an effective intervention that can break this cycle and prevent disability and functional impairment.5 minutes of intermittent walking. Individuals suffering from acute asthma should not exercise until symptoms have subsided. chemicals.90 • Severe PAD: 0. duration. Restrictive lung dysfunction is an abnormal reduction in pulmonary ventilation that may be the result of many different diseases. S:.81 • The recommended mode. resistance. . Unless this vicious cycle can be broken.5% every 3 minutes or 2% eveI)' 2 minutes or a gradual ramp protocols may be used. Pulmonary Diseases Pulmonal)' diseases typically result in dyspnea or shOltness of breath with exertion. In contrast. • Time to onset of intermittent claudication on exercise test is valuable outcome measure. ST-T wave changes. chronic obstructive pulmonary disease (COPD) is defined as a permanent diminution of airflow. • Although serial measurements of ABI are used for assessing progression in disease severity. pulmonal)' patients experience even greater dyspnea with even lower levels of physical exertion.00 to 0. However. and duration) generally can be applied to patients with pulmonat)' diseases. • The exercise-rest-exercise pattern is repeated throughout the exercise session.80. Ultimately. • SPECIAL CONSIDERATIONS • The most common procedure for assessing the pelipheral circulation is the ratio of ankle to arm systolic blood pressure (ankle-hrachial index [ABI]) • Normal: 0.S4 Pulmonal)' function abnormalities often are divided into restrictive and obstructive dysfunction.CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 227 226 SECTION III/EXERCISE PRESCRIPTION EXERCISE TESTING • • Patients with PAD generally are classified as high risk. However. The initial duration is a total of 3. . pulmonal)' function and determination of arterial blood gases and/or arterial oxygen saturation (5. • Exercise testing may be terminated because of atterial oxygen desaturation. usually associated with chronic bronchitis. ABI is not useful for assessing the efficacy of intervention.'S. thus.'>r. • Resistance training and/or upper body ergometry is complementary to but not a substitute for walking. emphysema.. pulmonary patients limit their physical activity. particularly those with exerciseinduced asthma (EIA). and overload generally arc consistent with those in Chapter 7 for cardiorespiratory. Hence.. • Initial enrollment in a medically supcrvised program with ECG. and increased by 5 minutes each session until 50 minutes of intermittent walking can be completed. frequency. and flexibility exercise stimuli (see summaI)' in Table 9-1).. Consequentially.41 to 0.02)' • Modifications of traditional protocols (extended stages. or certain drugs. dusty air and/or inhaled pollutants.. Because of the high Iisk of cardiovascular disease in this population. 35 to 50 minutes of continuous walking is desired. trauma. • Treadmill and track walking are the most effective approaches to reduce clau1s2 clication and should be performed 3 to 5 d·wk• Initial treadmill workload is set to elicit claudication symptoms within 3 to 5 minutes.5. • Cardiac signs and symptoms may appear as patients increase their exercise capacity and reach higher heart rates and blood pressure. exercise testing should be conducted in the presence of a physician. and asthma." Record time or distance to the onset of claudication pain (see Chapter 5 for claudication scale) and the maximal walking time or distance. This is followed by a brief peliod of standing or sitting to allow symptoms to resolve. and blood pressure monitoring is encouraged (see Table 7-3). the pulmonat)' patient eventually becomes disabled and functionally impaired. Patients walk at this workload until they reach claudication of moderate sevelity (level 3). the majority of published data on exercise testing and prescription in this population have been obtained from those with COPD b . ACSM makes the follOWing recommendations regarding exercise testing and training for patients with pulmonar)' disease. smaller increments. Current evidence suggests that standard principles of exercise prescription (mode. Individuals with wellcontrolled asthma can exercise follOWing the general guidelines presented in Chapter 7. • \"!arm-up and cool down period of 5 to 10 minutes each. healt rate. calcified vessel: >] . radiation.) • • Ankle systolic BP and ABI are further reduced after exercise because blood flow is shunted into the proximal leg musculature at the expense of the periphe. As a result of this dyspnea.91 to 1. • • EXERCISE PRESCRIPTION77.40 • oncompressible. should pay special attention to avoiding environmental "triggers" such as cold. slower progression) may be warranted depending on functional limitations and the early onset of dyspnea..5. EXERCISE TESTING Assessment of physiologic function should include cardiopulmonaty capacity. Exercise has been shov.)' and distal circulation in the leg. Questionnaires are ': u:~£ul adjunct to exercise testing to assess commumtybased activity levels. and deconditioning results. Arm ergometry or pharmacologic stress testing can be used in patients who cannot perform leg exercise to assess cardiovascular status. intensity.30 • Mild to moderate PAD: 0. patients with asthma.

5. may be necessary for the initial training sessions until the patient can achieve sustained higher intensities. exertion at altitude greater than 6. 94-96 • Because respiratory disease patients can experience greater dyspnea while performing activities of daily living involving the upper extremities. not only affect the lungs but skeletal muscle as well. either the partial pressure of arterial oxygen (P. WI Generally. In addition.P2). Individuals with a reduced functional capacity may require more frequent (i.9& As such. 92 .ning of these muscles has the potential to reduce dyspnea and improve exercise capacity. the exercise professional should closely monitor initial exercise sessions and be ready to adjust intensity andlor duration according to patient responses. moderate-intensity physical activity to reap the healthrelated benefits associated with exercise. resistance. If the aforementioned contraindications do not preclude .99 • Guidelines for inspiratOly muscle training for individual patients include: a minimum frequency of 4 to 5 chvk-\ an intensity of 30% of maximal inspiratory pressure measured at functional residual capacity. However. and a duration of 30 minutes a day or hvo I5-minute sessions per day.000 feet. duration. upper extremity aerobic exercise training can result in increased levels of dyspnea.228 SECTION III/EXERCISE PRESCRIPTION CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 229 • The exercise testing mode is typically walking or stationary cycling. • Walking is recommended strongly as the mode of exercise because it is involved in most activities of daily living. These same guidelines apply when considering supplemental m. • The traditional method for monitoring the training intensity has been heart rate.P2 of 88% or less while breathing room air. oximetry is recommended for the initial exercise training sessions to evaluate possible exercise-induced O 2 desaturation. and overload generally are consistent with those in Chapter 7 for cardiorespiratory. activities that have a high potential for contact. some patients may be able to exercise only at a speCified intensity for a few minutes. current studies indicate that healthy women with uncomplicated pregnancy do not need to limit their exercise for fear of adverse effects. during pregnancy refrain from activItIes with a risk of abdominal trauma. that is. or an S. An alternative approach is to use a dyspnea rating obtained from a GXT as a "target" for exercise training. daily) exercise training for optimal improvement. or activities vvith a high rIsk of falling should be avoided.S7 it may be beneficial for these patients to focus on the muscles of the shoulder girdle when performing resistance exercises. Although positive benefits from inspiratory muscle training have not been demonstrated conclusively. SPECIAL CONSIDERATIONS Unlike healthy individuals and heart disease patients. and flexibility exercise stimuli (see summary in Table 9-1). particularly dyspnealbreathlessness supersedes objective methods of exercise prescription. RespiratOlY muscle strength andlor endurance can be speCifically increased with inspiratOly muscle training. • The recommended minimal goal for exercise frequency is 3 to 5 d·wk.. • At present. • Based on the recommendations of the Nocturnal Oxygen Therapy Trial/ oo supplemental O2 is indicated for patients with a P. should be made during the initial GXT. the benefits of chronic exercise reside with the mother. some measure of the blood oxygenation. As with testing. • It is now recognized that respiratory diseases. As such. Intermittent exercise.. The American College of Obstetricians and Gynecologists (ACOG)WI have established relative and absolute contraindications (Box 9-1) for exercise during pregnancy. COPD in particular.02) or percent saturation of arterial oxygen (S. there is emerging evidence to suggest that inspiratory muscle training does have positive effects in those patients presenting with inspiratOly muscle weakness 8 . lOi Interestingly.ygen desaturation with exercise. resistance training of skeletal muscle should be an integral part of pulmonary rehabilitation programs. 2) hypothermia-induced fetal distress or birth abnormalities. participation in a wide range of recreational activities appears safe during and after pregnancy. Therefore. and scuba diving.89 • 0 matter what the prescribed intensity. \Vomen should be encouraged to engage in a consistent. Most patients with COPD can accurately and reliably produce a desired exercise intensity using a dyspnea target of 2 to 3 (on 4-point scale) or between 3 and 5 ("moderate to severe") on the 0 to 10 category-ratio scale during submaximal exercise of 10 to 30 minutes' duration. there is no consensus as to the "optimal" intensity of exercise training for pulmonary patients. pulmonmy disease patients may exhibit arterial m.imester. trai. If anTI ergometry is to be used.1. 90 •9i It is probably unrealistic for most patients vvith a chronic respiratOly disease to perform 20 to 30 minutes of continuous exercise at the start of a physical training program. Overly vigorous activity in the third tr.e. the presence of symptoms.88. it is important to remember that upper extremity aerobic-type exercise can result in increased dyspnea that can limit the duration of the activity87 EXERCISE PRESCRIPTION • The recommended mode. repetitive exercise-rest periods. Concerns regarding the possible adverse effects of exercise participation have focused on: 1) inadequate availability of oxygen or substrate for mother and fetus. Two major approaches that have been evaluated are to exercise at 50% of peak \10 2 or at maximal limits as tolerated by symptoms84. frequency. Therefore. Stationary cycling may be used as an alternate mode of training.94 The exercise prescription for resistance training with pulmonary patients should follow the same principles as those with older healthy adults. • InspiratOlY muscle weakness has been identified as a contributor to exercise intolerance and dyspnea 97. In many cases.. • Pregnancy The physiologic changes associated with pregnancy warrant evaluation of obstetric and medical risks prior to engaging in regular physical exercise. andlor 3) increased uterine contractions.ygen during exercise training. whereas the risks of overexercise predominantly affect the fetus.02 of 55 mm Hg or less. In addition.

many active women modify their program based on symptoms. Although there is no evidence that a rapid return to training is associ- SPECIAL CONSIDERATIONS Pregnancy requires an additional 300 kcal·d. so it should be avoided. 103 Attenuate the • . humid weather or when you have a fever. • EXERCISE PRESCRIPTION • The recommended mode. ACSM makes the following recommendations regarding exercise testing and training during and follov. such as walking and swimming. resistance. Caesarean section) and physical symptoms. exercise has no detrimental effects on lactation for milk composition.1 ) is preferable to intermittent activity. low.e. • Submaximal testing can be performed vvith an endpoint of <75% heart rate reserve. • He~t dissipation is impotiant throughout pregnancy. it is not recommended for pregnant women. and overload generally are consistent with those in Chapter 7 for cardiorespiratOlY. Prepregnancy exercise programs should be resumed gradually depending on birth complications (i. 267. and adequate hydration should be priorities dunng the exercise program to prevent the possibility of hyperthermia and the corresponding risk to the fetus. ACOG Committee Opinion No. Avoid brisk exercise in hot. Drink ample water to prevent dehydratIon. at least 3 d'wk. cold.1 to maintain metabolic homeostasis. However.. ingest additional calories to meet the needs of exercise and pregnancy. discomfort. milk volume. 30 to 40 minutes or more of moderate physical activity on most. the rate of return to prepregnancy levels dif102 Moderate weight reduction while nursing is safe and fers among individuals. participation. EXERCISE TESTING Unless a clinical condition dictates ma"imal exercise testing. en~ronmental considerations. however. • In the absence of either medical or obstetric complications. decreased maternal liver glycogen stores. guidelines for safe exercise participation for women with no risk factors for adverse maternal or perinatal outcomes are suggested. Exercise during pregnancy and the postpartum period. Many of the physiologic changes associated with pregnancy persist 4 to 6 weeks postpartum. rather than heart rate. Lactation is an energy-demanding physiologic process. • Women who were sedentary or relatively inactive prior to pregnancy should begin v. • Motionless standing results in venous blood pooling. • • • • • • • • • • Heavy smoker Hemodynamically significant heart disease Restrictive lung disease Incompetent cervix/cerclage Multiple gestation at risk for premature labor Persistent second. or maternal health. From American College of Obstetricians and Gynecologists. Women who currently participate in exercise can continue their exercise program without major moditlcations. Appropriate clothing. or reduced maternal liver glycogenolysis. Exercising indoors may provide more environmental control to avoid excess heat. if not all. Obstet GynecoI2002. • Monitor exercise intensity by use of ratings of perceived exertion (RPE 11-13) (light to somewhat hard). and risk associated 'Nith joint laxity and body mass gain. L03 Therefore.g. • Regular exercise (e.ring pregnancy. Precautions may include using a treadmill or track for walking or running instead of exercising along the sidewalks or roadways. days of the week is recommended. duration. frequency.99:171-173.230 SECTION III / EXERCISE PRESCRIPTION CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 231 Contraindications for Exercis~ng During Pregnancl* Relative • Severe anemia • • • • • • • • • • • Unevaluated maternal cardiac dysrhythmia Chronic bronchitis Poorly controlled type I diabetes Extreme morbid obesity Extreme underweight (BMI < 12) History of extremely sedentary lifestyle Intrauterine growth restriction in current pregnancy Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism ated with maternal complications.or third-trimester bleeding Placenta previa after 26 weeks of gestation Premature labor during the current pregnancy Ruptured membranes Preeclampsia/pregnancy-induced hypertension Absolute *See reference 101. • Women who were less active or sedentmy prior to pregnancy should seek the approval of a physician prior to engaging in physical activity. • Avoid exercise in the supine position after the first trimester because mild obstruction of venous return attenuates cardiac output and may facilitate orthostatic hypotension. or air pollution.. and only under the supervision of a physician.rith light-intensity (20%-39% HRR). and flexibility exercise stimuli (see summary in Table 9-1). • Matet:nal hypoglycemia may be associated vvith strenuous exercise during the last tnmester of pregnancy. does not compromise neonatal weight gain.(or non-) impact activities. The reduction in blood glucose lllay result from mcreased glucose uptake by the fetus and mother.

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Ch"sl 1990. I. Lotters F.9. Progrt'ssive resistallce exercise and resting hlood pressur. chest pain. it is important that these features be considered when performing clinical exercise testing or physic<J fitness testing in children as well as in designing exercise programs for young subjects. including: 1) recognition of the role of regular exercise in the present and future health of youth. Clwst 1988.. Brin~l T. rate increases with complete heart block). ed. Semin Perinatol 1996:20:217-284. Nex:. Resistance versus (-'IHluranct' training in patients with musclt' wt'akness. Matt'rnal ext'rcist'. These have provided evidence that.93:580~586. Effects of controlled inspiratory musclt' training in pati"nts with capo: a meta-analysis. A number of issues have prompted specific interest in physical actil'ity and fitness in the pediatric population. He J. 95. Long-krm effects of "'t'ight loss and di"tary sodium reduction on incidence ofhYl)ertension. 3) identifying myocardial ischemia (most commonly in patients with aortic valve stenosis or Kawasaki disease). S"etkey L. syncope. Xin X.'" ana European Hespirato. 102.35:858-863. Arch lnt Med 1997.1 L. and Blood [nstitutt' \ I'orkshop on Sodium and Blood Pressure: A critical review of the current scientific eyiden<:e. et al. So(.167:211-277. especially childhood obesity.r rating dyspnea. Exercise dllring pregnanc). Clin Chest Med 1988. 98. Frontini MG.sports or physical activity. Mahler DA. 110. a number of particular featmes need to be appreciated when dealing with this age group.35:831>-843. :"Jocturnal Oxygen Therapy Trial Croup. \lilne L. He J. 96. controlled trials. :'oJ. use o[ the treadmill is more appropl'iate when testing very young 237 lO9. Continuous or nocturnal o\"ygen therapy in h:poxemic chronic obstrudive lung disease: a dinical trial. 104. Am J Ht'spir Crit Car" \tt'd 2(Xl:3. The growing body of research information surrounding these issues has identified a number of biological responses to exercise that are unique to physically immature individuals (Table 10-1). Am J Ht'spir Crit Cart' \It'd 1999:\. Hale m\·.236 SECTION III/ EXERCISE PRESCRIPTION 92.'iet. E. 9.657-667.35:5"[4-~9. Kwakkel G. and 5) assessing response to cardiac and pulmonaty rehabilitation programs. Kt'lley KS. I Most importantly. However. American College of Ohstetricians and C:l1ecologists. Mottola MF.·. Exercise Testing and Prescription for Children and Elderly People Children • 10 •• •• CHAPTER <\1. The Trials of Hypertension Prevention Collaborative Research Group. DASH-Sodium Collaborati"e Researcb Group. Hill M. Whelton P. National Heart. App. Sacks F. ATS/ACCP Statement on cardiopulmonary t'wrcise tt'sting. Hespiratnry nluscles and dyspnt'a.>t'. and the postpartum pt'riod. tolerance. Experience in pediatric exercise testing laboratories indicates that tests are most commonly performed [or: 1) evaluating individuals who experience symptoms (e. American Thoracic Societ) and America!l College of (~he~t PII. phYSiologically. letal wcll-bringand pr"gnancyoutcome. 99.:tunlal O'\ygen Therapy Trial Croup. children are emotionally immature and need encouragement and positive support by an experienced testing staff to achieve an adequate exercise effort. d ai. Sacks F. Eur Respir J 2<Xl2:20:570-51fi. \\'t'lis CK. Hl1)ertensioll 2001:38:1ll2-1117. 103. Br"nnt'r JK. 106. Ann Intern \·Ied 2oo1. Simpson K. 1994: 145-194. et aI. Eur Ht'spir J 2002. ACOG Committee Opinion :\0. Exercise & Sports Scienct's neviews. Effects or diet and sodium intake on blood pressure: Subgroup analysis of the DASH-sodium trial. 2) assessing cardiopulmonmy functional capacity. satisfactory testing of children can be conducted equally well as in adults. 4) examining responses of heart rate. 'an Tol B.'.237-248. with high-normal blood pressure.19:1012-1071>. Jont's N L.'~i<:i<llIS.: a meta-analysis of randomized controlled trials. Skeletal muscle dysfunction in chronic obstructi.1. In gencral.70-7. and 3) a growing awareness of the role of exercise testing and intervention in children and adolescents with chronic diseases. Effeds 01' weight loss and sodium redudion intervention on blood pressure and hypertension incidence in overweight people 105. Kefley GA. The elite athlete and t'xt'rcise in pregnancy. T!lorcL\ 1992. McCarliw. pt ai. Gosst-'Iin H. t>t capo and peripheral 100. palpitations) during. Handomiwd "ontrolled trial of\\'t'ightlif\ing exercist' in patients with chronic airflow limitation. In: Holloszy JO. Chobanian A. The indications for exercise testing of children and adolescents are more diverse than for adults.J35: 1019-1028. 107. Vollmer \1'. I-Iendersoll K. Both cycle and treadmill protocols have been used for exercise testing of children. Killian K. .t' pulmOl"uY dist'a.157. 9:3. Ann lntern ~led 1980:9:3::391-:398. children are not simply smaJl adults..59:S1-S~0. Troosters T. \'ollmer \1'.344:3-10. and rhythm (changes in ventricular ectopy. However. Obstet CY11t'col 2002. Effeds or alcohol reduction on blood pressur<e: a meta-analysis or randomized.ung. 97.:.g.. \1'011' LA. Lake FH. Ard J. Effects on blood pressure of redoced dietary sodium and the DietHl}' Approach"s to Stop Hypert"nsion (DASH) dit't. Baltimort': Williams & \l'ilkins.Juation of clinical methods li. Uppt'r-lilllh alld (mer-limh t''Xercist' training in patit'l1b with chronic airflow ohstruction. 2) the growing number of children participating in elite-level sports competition. shortness of breath.47. 267.5. 1-I:11ertension 2000.97: 1017-101>2.99: l71-173. et al. Killian KJ. 108. Spruit MA. :\ Engl J ~Ied 2001. Hypertension 2000. lOt. ct al. even in subjects as young as 3 to 4 years. and cardiopulmonaty responses to high-intensity exercise in a controlled setting.. "t al. American Thoracic Societ. CLINICAL LABORATORY TESTING The basic prcmise for treadmill or cycle testing of young persons is not different than that for adults-to assess symptoms. Hypertt'nsion 2000.

238

SECTION III/EXERCISE PRESCRIPTION

CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

239

TABLE 10-1. Unique Physiologic Responses of Children Relative to Adults*t
Variable Submaximal Exercise:!: Maximal Exercise

TABLE 10-2. Cycle Ergometer Protocols for Children*
Protocol Cadence (RPM) Body Size Initial Load Increment per Stage Stage Duration (min)

1;0 2 (L·min- 1) 1;0 2 (mL'kg- 1 'min- 1) Heart rate Cardiac output Stroke volume Lactate concentration Tidal volume Ventilation

RER

I; E/I; 0 2

Lower Higher Higher Lower Lower Lower Lower Lower Lower Higher

Lower Higher or equal Higher Lower Lower Lower Lower Lower Lower Higher

McMaster

50

Height (cm)

Watts

Watts

<120 120-140 140-160 >160
James

12.5 12.5 25 25
kg·m·min- 1

12.5 25 25 25 (female) 50 (male)
kg·m·min- 1

2 2 2 2

60-70

Body Surface Area (m 2 )

*See references 1, 31. 32, and 33: Developed from Rowland TW Aerobic exercise tes\lng protocols In Rowland TW, ed. Pediatnc Laboratory ExerCISe Testing: Clinical GUidelines. Champaign, IL: Human Kinetics, 199319-42; BarOr 0 Pediatric Sports MediCine for the Practitioner. New York: Springer-Verlag, 1983:315-338; Rowland TW, Straub JS, Unnlthan VB, et al. Mechanical efficiency during cycling In prepubertal and adult males Int J Sports Med 1990; 11 :452-455; Washington RL. Measurement of cardiac output. In: Rowland TW, ed. Pediatric Laboratory Exercise Testing: Clinical GUidelines. Champaign, IL: Human Kinetics, 1993: 133. tComparisons are based on exercise responses in a male child between 8 and 12 years of age compared with an apparently healthy young adult male. *Submaximal exercise responses are referenced to the same absolute work rate.

<10 1.0-1.2 >1.2

200 200 200

100 200 300

3 3 3

*See references 31 and 34: Adapted from Bar-Or O. Pediatric Sports Medicine for the Practitioner. New York: Springer-Verlag, 1983:315-338; James f, Kaplan S, Glueck C, et al. Responses of normal children and young adults to controlled bicycle exercise. Circulation 1980;61 :902-912 Abbreviations: RPM, revolutions per minute; em, centimeters; min, minute.

children, because this modality requires that the subject maintain the pace of the belt rather than provide the volitional effort to maintain a cycling cadence with increased workloads. Electronically braked cycle ergometers reduce the dependence on a specific cadence by allowing a range of cadence to achieve the same workload. However, appropriate small size cycle ergometers are not available in most laboratories. Seat height, handlebar height and position, and pedal crank length may have to be modified for cycle ergometer testing to accommodate children. Most children who are 125 cm (50 in.) tall or taller can be tested on a standard cycle ergometer. The greater potential for accidental falls on the treadmill requires greater attention by the testing staff. Regardless of the mode or protocol, children must be familiarized vvith all testing procedures to ensure the opportunity for a successful evaluation. Because of the wide ranges of ages and testing indications, no Single standard testing protocol has been used for children (Table 10-2). Most laboratories use the Bruce treadmill protocol for pediatric subjects, often modified to 2-minute work stages. In addition, various modifications of the Balke protocol commonly are employed in pediatric research studies and in some clinical laboratories. This protocol allows a constant comfortable speed (usually walking 3.0-3.5 mph or running at 5.0 mph), minimal slope elevation (2% per stage), and appropriate test duration (about 8-10 minutes). Its disadvantage is that, in contrast to the Bruce protocol, this protocol provides no standard norms for test duration to age as an indicator of phYSical fitness. Adjustments to the protocol speed may be necessary to accommodate for differences in stature and fitness levels. A number of different cycle testing protocols have been lISed for young subjects, most commonly the McMaster and James protocols. These are outlined in Table 10-2.

Certain phYSiologiC features can be anticipated during exercise testing of children. 2 The heart rate at rest, and both submaximal and maximal exercise are higher in young subjects compared with adults. Although the heart rate at rest and at a given workload progressively decreases as a child grows, maximal heart rate does not change. Heart rate at exhaustion in a progressive test remains stable for both boys and girls during the growing years, and does not begin to decline until about age] 6 years. Consequently, formulae for estimating maximal heart rate (e.g., 220-age) are inappropriate for children and young adolescents. The achievable peak heart rate in young subjects depends on testing modality and protocol. During treadmill running the maximal rate is typically 200 bpm, whereas walking or cycling protocols usually elicit a peak rate of approximately 195 bpm. However, it should be recognized that vvide interindividual variability exists in such values, and peak rates of ] 85 to 225 bpm are consistent with exhaustive exercise efforts in individual subjects. Blood pressures at rest and during exercise are lower in children compared with adults. 3 At maximal exercise, a child 'with a body surface area (BSA) of 1.25 2 m demonstrates a systolic blood pressure of about 140 mm Hg, whereas 160 mm Hg i,s expected in a subject with a BSA of 1.75 m 2 . Endurance time with a given exercise testing protocol progreSSively improves as a child ages. Mean duration times for males are greater than for females. Age-related norms for subjects during treadmill testing with the Bruce protocol have been published and used to assess cardiopulmonary fitness in children (Table 10_3)4,.5 However, it should be recognized that endurance time during exercise testing in children might differ between laboratories, even with the same protocol, because it is influenced by factors such as testing experience and level of encouragement by the testing staff.

240

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CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

241

TABLE 10-3. Endurance Time (Minutesl by Gender and Age Group with the Bruce Treadmill Protocol*
Percentiles
10

TABLE 10-4. Field Tests for Children
Health Fitness Component Field Test

50

90

Cardiorespiratory fitness Muscular fitness Flexibility Body composition

Males Age (years)

4-5 6-7

8.6 7.9

10.1 11.0

127

l-mile walk/run Curl-up test Pull-up/push-up test Sit and reach test Body mass index or skin folds

8-9
10-12 13-15 16-18
Females Age (years)

8.9
9.5 99
10.7

11.2 118 132 132

123 14.6 14.4 14.6 14.9

4-5
6~7

8-9
10-12 13-15 16-18

5.9 8.2 8.6 92 8.2
81

9.5 10.2
10.5

11.2

120 136
13.8

110
10.8

Typically, a battely of simple field tests (generally four to six tests) are administered to evaluate different components of fitness ancl!or health7~\J Two of the most commonly administered test batteries are the FITNESSGRAM' and the President's Challenge Test.~ Each provides criterion-referenced standards for interpretation of results. Table 10-4 provides a list of common field tests of physical fitness for children, with specific reference to the five components of physical fitness. Some communities, schools, and SUlyeys develop their own battery of tests and standards of performance.\! Questionnaires also have been used to assess physical activity patterns of young people. 1o

10.0

130 11.4

EXERCISE PRESCRIPTION
Regular exercise in children and adolescents can pay immediate health benefits (e.g., reduction of body fat, diminished mental stress), and, if persistent, can reduce the risk of future adult disorders such as atherosclerotic disease, osteoporosis, and systemic hypertension. For this reason, promotion of exercise in youth should be designed to introduce exercise habits that will serve as the basis for a long-term life style of regular physical activity. Although children are the most physically active age group, a significant minority is considered to have inadequate levels of regular exercise. Survey data suggest that only about 50% of American youth aged 12 to 21 are vigorously active on a regular basis. Daily enrollment in physical education classes also has declined in high school students from 42% in 1991 to 25% in 1995. 11 Physical acti\~ty typically declines through pubelt)', especially for girls, and the development of appropriate intervention strategies is impOltant. Current research data do not allow recognition of a certain minimal level of daily physical activity in children necessary for long-term health benefits. However, a number of consensus groups have considered this issue and have concluded that a reasonable goal is for each child to engage in at least a moderate level of physical activity 30 to 60 minutes on most days of the week. 12.1.3 Such activity should include blief periods of rest and recovelY as needed. Recently, the National Association for SPOlt and Physical Education released a position statement for children ages 5 to 12 that includes the following guidelines: 14 • Children should accumulate at least 60 minutes, and up to several hours, of age-appropriate physical acti\~ty on all or most days of the week. This daily accumulation should include moderate and vigorous physical activity \\~th the majority of the time being spent in activity that is intermittent in nature. • Children should participate in several bouts of physical activity lasting 15 minutes or more each day.

"Treadmill tImes represent the average for a given gender-age group across two studles. 4.5 Data were derived from two pediatric cohorts referred for clinICal exerCIse testing. Subjects were not allowed to use handrail support dUring the exercise test.

Electrocardiographic changes during exercise testing in children are similar to those observed in adults. An increase in R-wave voltage has been considered a marker of myocardial ischemia in adults but often is observed in health\' children. The traditional ST-segment indicators of myocardial ischemia in adults with coronary artery disease have been interpreted similarly in pediatric subjects. However, thc v"lidity of these changes as markers of coronmy insufficiency in immature subjects is not certain. Other physiologic features in children may not have a direct influence on clinical exercise testing but need to be appreciated by the testing staff. Children exhibit a much more rapid recovelY of healt rate, blood pressure, and other physiologic vmiables after exercise testing compared with adults. The sweating rate of children is less than adults because of a dccreased capacity per gland fi Young subjects have lower exercise economy dnring walking or running than adults, such that oxygen uptake (and heat production) per kg body mass at a given treadmill work rate is greater in children. Compensating for this, children have a larger ratio of body surface area to mass than adults. As a result, heat loss in a thermoneutral environment is comparable in the two populations. However, heat loss by the rclativcly greater body surf~lce area of the child may be impaired at velY high ambient temperatures.

FITNESS TESTING
Measurement of physical fitness and health in children and adolescents is a common practice in school-based physical education. Such testing also has been used in recreational programs, public health assessments, and clinical settings.

242

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CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

243

• Children should participate in a variety of age-appropriate physical activities designed to achieve optimal health, weJlness, fitness, and performance benefits. • Extended periods (periods of 2 hours or more) of inactivity are discouraged for children, especially during the daytime hours. Counseling efforts to improve level of activity have bcen applied to young persons who are identified as having a sedentary lifestyle. In addition, there are specific disease entities in which exercise intervention is considered an important component in management, including patients with familial hypercholesterolemia, type 2 diabetes, obesity, and essential h)1)crtension. As in adults, the emphasis has shifted from improving physical fitness in youth to encouraging an increase in levels of habitual physical activity. Such activities should be well rounded, inclu<.ling those that t,1-",( the cardiovascular system (swimming, cycling), provide weight-bearing stress to bones (jumping, running), and improve muscle strength (calisthenics, lifting). Promotional efforts to maintain or improve habits of physical activity in children are most effective if multifactorial, including school physical education classes, commllnity recreation programs, family-based activities, and counseling by health professionals. Little research has been performed in the pediatric population to determine the most effective means of stimulating regular physical activity. For instance, it is not clear if psychosocial constructs used in programs designed to alter exercise behavior in adults, such as the transtheoretical model and social cognitive theory, are applicable to children. Studies examining the effect of physical activity interventions on youth in school and community settings indicate that motivational factors for exercise are likely to vary according to a child's developmental age. 1.5 However, certain components of a successful exercise intervention program for children seem evident, including the necessity for fim, lack of embarrassment, limited competition, peer and family support, and recognition of success. Unsafe neighborhoods, lack of proximity to playgrounds, and inability of parents to transport represent environmental barIiers that also may modify the plan. The use of school recess and after school activities such as intralllllrais and activity-based latch-key programs may permit children to enhance physical activity. At the present time there exists no evidence-based standard approach to improving the physical activity habits of children. The development of sucb standards is hampered by variations in age, motivation, and degree of parental suppOli, as well as tbe vmying influences of geographic location, socioeconomic level, and availability of recreational facilities. A number of different activity counseling models can be considered because no single exercise plan is likely to fit all children.
The Adult Prescription Model

becomes inclement, the activity can be moved indoors (e.g., exercising on a stationary cycle while watching television). This model has ceriain advantages for youth. It does not necessitate any athletic skill or special equipment, it requires no transpOliation by parents, it can be performed \vith or \vithout company, and it is not physically taxing to the point of becoming uncomfortable. On the other hanel, it might be expected to ultimately prove boring for an unmotivated child over an extended period of time.
The Exercise "Menu"

In this model, the child is presented \\~th a list of possible acti\~ties to begin, which he or she can help compile, based on those feasible in a paliicular community. This widens the possibilities of exercise interventions to those invoh~ng team spolis, recreational programs, and activity clubs. It offers the possibility of more social interaction and allows the child to select activities that are individually attractive; and, imporiantly, it permits the child a greater degree of autonomy in de\~sing the exercise program. An exercise menu is only limited by one's imagination and resources, and may include acti\~ties such as soccer, dance,.i u mp rope, karate, broom ball, skateboarding, hide and go seek, and pick-up basketball.
Increasing Lifestyle Activities

This approach does away \vith structured activities altogether and attempts to increase the child's ca101ic expenditure in his or her usual daily activities. This may be more attractive than a more formal schedule of regular exercise for young persons who are pmiicularly sedentary or obese. The child can be instructed on specific ways of accomplishing this: Use stairs instead of the escalator, walk instead of riding in the car, do specific chores around the home, stand while talking on the telephone, don't stand still, or use a rocking chair while watching television. Acti\~ty lists can be checked as they arc accomplished and signed by the parents, with a small reward (e.g., sports tickets, t-shirt) for a certain total.
Decreasing Sedentary Time

By this traditional approach, a particular activity (usually walking) is recommended, to be performed by the child for a certain number of minutes (beginning at 15 minutes), three to five times per week, and then increasing duration and frequency to eventually reach the activity guidelines described pre\~ously. ',Valking can be done in interesting places to avoid boredom (e.g., at a zoo, museum, or maJl) and in the company of family, friends, or pets. If the weather

Recognizing the impOliance of regular exercise for the physical and emotional health of children has been coincident \\~th concern that youth are spending an increasing amount of time in sedentary pursuits. In fact, sedentmy habits may track or persist more as a child grows into adulthood than levels of physical acti\"lty. For this reason, reducing time spent watching tele\~sion, in front of a computer, or playing video games can be a p,ui of any prescription for sedentary 16 Because physical activity experiences in childhood may be pivotal in youth terms qf adult activity, health agencies have stepped up their efforts to encourage schools, families, and communities to promote positive childhood and youth physical activity expetiences. 17- 20 Schools are encouraged to: • • • • Offer daily physical education classes at each grade. Increase time being physically active in physical education classes. Discuss health benefits of physical activitv. Eliminate or shalply decrease exemption~ for physical education.

Resistance or weight should be increased only when the child can perform the desired number of repetitions \vith good form. .' play (instead of exercise) and othcr activities of intermittent houts of pln'sical activitv. tics of the pediatric age group.l~ In older children. Get involved in school and/or community activity programs. • Avoid overly intense or maximal (IRM) resistance training. Still. Guidelines for resistance training in children are similar to those for adults (sec Chapter 7). and encouragement. cycling. 30-60 minutes) and frequency (i.Ieen young boys and girls. . Resistance Training Cardiorespiratory Training Sustained cardiorespiratory endurance activities such as distance running.. and duratIOn typically demonstrates an improvement in \10 2m "" of approximately 15% to 30%. improve performance in strength-related spOlis. howevcr. specific guidelines are noted: 13 • The intcrmittent nature of resistance training is compatible \vith a child's natural physical activity pattems. Provide opportunities for all skill levels. the relative magnitudc of these increases in strength has been similar to that obselved in training programs in adult subjects. 20 to 30 minutes of vigorous exercise at least::3 d'wk. 2 A previously sedentalY adult placed in a progra. Little difference is seen in \l02max betv. are unlikely to increase their V0 2m "x in similar programs by more than 10%.The V0 2m "x of a prepubeltal child does not increase with endurance training to the same degree as IS observed in young adults. Moreover. Encourage children to be active around the home. lifetime physical activities.. on the other hand.and 111 some repOlts no change at all is observed. strength. No gender differences have been obselved in aerobic trainability in the pediatric age group. b~t values 111 girls dechne 1 during childhood to ~40 mL·kg-1·min -I by age 16 years. it is more likely that biological factors. emphasis should be directed at acti\'(. and s\vimming are not typical of the normal activity patterns of children. Offer praise. supen~sed resistance training programs can he conducted safely in children. Children have higher levels of maximal oxygen uptake (V0 2m ". or have a long-term saluta.5 repetitions per exercise. However. possibly related to hormonal changes at puberty.1 In tact.-. :0 .yhether strength improvements in children and adolescents can serve to protect against athletic injUlY.. which remains constant over the growing years . It appears that any aerobic training adaptations that occur in children can be elicited by the same frequency and duration training cliteria as those recommended in adult programs. This observation has lent credence to the concept that neural adaptations can playa key role in the development of muscle strength with resistance training. Provide safe facilities outside school hours. the resistance is too heavy and should be reduced. • Resistance training should be carefully supervised by a competent instructor. but may result from a high innate level of activity anellor less effective training regimens. 6-7 d'wk. The mean value of increase in m~imal aerobic power in a meta-analysis of training programs in children was 5%.m of endurance exercise of sufficient intensity. Children do not generally require heart rate monitoring because of their low cardiac risk and their ability to adjust exercise through rating of perceived exertion and/or tolerance. and degree of maturity of the child.244 SECTION 1111 EXERCISE PRESCRIPTION CHAPTER 10 I EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY 245 Schools and communities should: • • • • • • Provide enjoyable.. issues of athletic training and responses to cardiac and pulmonalY rehabIlItation programs in youth have stimulated an interest in the aerobic charactens' . Promote self-efficacy and skill development.' is I~ecommend­ ed 13 Increased duration (i. which may discourage young subjects. • Focus on participation and proper technique rather than the amount of resistance. Parents should: • • • • • Set a good example by being physically active. interest. A typical V0 2max value in boysls -52 mL·kg-l·min -1.e. Meet diverse ethnic and gender activity interests. It is currently not clear if the dampened response of phySIOlogIC aerobIC trainability in children also reflects a blunted improvement with training in performance in endu rance events. Most studies have demonstrated that improvements in strength from resistance training in children are not accompanied by increascs in muscle bulk. Not limit activities exclusively to team-oriented sports.)' influence on infirmities such as back disease and osteoporosis currently is being studied. • A repetition range below eight should be reselved for adolescents (Tanner stage 5) of sufficient matlllity. these repOlis indicate that age-appropliate. However. The explanation for the limited rise in maxima] aerohic power in children following endurance training is not known. • If a prepubescent child cannot perform a minimum of eight repetitions in good form. frequency. improve \l 0 2max. a selies of' recent studies has indicated clearly that strength can be effectively increased \\~th training in both boys and girls before the age of puberty. are responSIble. Gradual progression is impOliant to avoid excessively demanding programs.xl relatIVe to their body mass than at any other time in life.e. Previously it was assumed that muscular strength could not be improved \\~th resistance training in prepubelial subjects because of their lack of circulating testosterone. The role of resistance training in young subjects remains to be clHlified.' ) of exercise are recommended to reduce overweight and obeSity. • Training equipment should be v<uied and appropliate to the size. 2. • Training should be a comprehensive program to increase motor skill and fitness level. training intensity in children should produce a healt rate of 1/0 to 180 bpm. • The child should perform 8 to 1. Provide needed transpOltation. Children. In young children.

it is not satisfactOty to define "elderly" by any specific chronologie age or set of ages. • For those who have difficulty adjusting to the exercise equipment. Therefore. or fear. However. 27 EXERCISE TESTING The prevalence of coronaJy healt disease increases with advancing age. There are no specific exercise test termination criteria that are necessalY for the elderly population beyond those previously presented (see Box . Effects of the Aging Process on Selected Physiologic and Health-Related Variables Variable Change Resting heart rate Maximal heart rate Maximal cardiac output Resting and exercise blood pressures Maximal \. and fleXibility. ImpOttantly. To avoid. There is a \\~de selection of test protocols using a variety of modalities that have been used for testing the elderly population. • Added treadmill handrail support may be required because of reduced balance. poor neuromuscular coordination. and even reversible \\~th. The safe and effective performance of exercise testing and the development of a sound exercise prescription requires a thorough knowledge of the effects of aging on physiologic function at rest and during graded exercise. Although aging is inevitable. poor neuromuscular coordination. • The exercise electrocardiogram has higher sensitivity (~84%) and lower specificity (~70%) than in younger age groups... resistance training. In addition. Protocols are available for those who are highly deconditioned or phys!cally limited. The . However. Naughton protocol) for those with expected low work capacities.25 It should be noted that exercise training may attenuate some of the observed changes in aging.2~. . underestimating the level of stress imposed during graded exercIse testmg. Individuals of the same chronologie age can differ dramatically in their physiologic age and response to an exercise stimulus. TABLE 10-5. The follo~ng are special considerations for testing elderly people:. both the rate and magnitude of decline in physiologic function may be amenable to. and dosage than that used for younger and middle-aged persons. the justification for exercise testing in elderly people may be even greater than that of the general adult population. The assessment of cardiorespiratOty function for elderly adults may require subtle differences in protocol. low functional capacity. Unfortunately. medical clearance of older adults is advised before maximal exercise testing or prior to their participation in vigorous exercise. • Presclibed medications are common and may influence the electrocardiographic and hemodynamic responses to exercise.6 • The initial workload should be low (2-3 metabolic equivalents [METs]) and workload increments should be small (0. • A cycle ergometer may be preferable to a treadmill for those \\~th poor balance.1 and mL·kg. either in their standard form or with slight modifications. impaired vision. welght-beanng lnmtatlOns. it is difficult to distinguish the effects of aging per se on physiologic function from that resulting from deconditioning and/or disease.246 SECTION III/EXERCISE PRESCRIPTION CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY 247 Elderly People There is increasing recognition that the term "elderly" is an inadequate generalization that obscures the variability of a broad age group. It should be understood that many elderly subjects exceed the maXimal heart rate predicted from the 220-age formula during a maximal exercise test.relative adaptations to exercise also are similar to other age groups. handrail SUppOlt for gait abnormalities can reduce the accuracy of estnnatll1g peak MET capacity based on exercise duration or peak workload achieved. or the test repeated.g. The higher rate offalse-positIve outcomes may be related to tile greater frequency occurrence of left ventricular hypertrophy and the presence of conduction disturbances. 17 T!le pa~lcularl~ Important components of the exercise prescription include cardIOrespiratory fItness.0 2 (L'min. and orthopedic problems 25 in elderly pe~ple often leads to an earlier test termination than in the young adult populatIOn. metabolic. thus.1 ) Residual volume Vital capacity Reaction time Muscular strength Flexibility Bone mass Fat-free body mass Percent body fat Glucose tolerance Recovery time Unchanged Lower Lower Higher Lower Higher Lower Slower Lower Lower Lower Lower Higher Lower Longer EXERCISE PRESCRIPTION The'general principles of exercise prescription (see Chapter 7) apply to adults of all ages. Physiologic aging does not occur uniformly across the population. the initial stage may need to be extended.1 ·min. and deconditioning are more common in elderly persons than in any other age group and can contribute to loss of independence in advanced age. decreased muscular strength.5-2). the test restaJted. the possibility that an active or latent disease process may be present in the elderly individual always should be considered. A list of key changes is provided in Table 10-5. • Exercise-induced dysrhythmias are more frequent in elderly people than in people in other age groups. 26 In accordance ~th Tables 2-1 and 2-4. • Treadmill speed may need to be adapted according to walking ability. senile gait patterns. The percent Improvement in V0 2Jn 'LX in elderly persons can be comparable to that reported m younger populations. the probable attainment of a lower peak V0 2 and/or the increased prevalence of cardiovascular. and/or foot problems.5-1. muscle weakness.0 METs) (e. methodology. exercise/activity intervention.

Mode in persons more than 6. • A group setting may prOvide impOltant social reinforcement to adherence. Initiating a program at less than 40% \I0 2 R or HRR is not unusual.I . such as work capacity. • A measured peak hemt rate is preferable to an age-predicted peak hemt rate when prescribing aerobic exercise because of the variability in peak heart rate Muscular strength declines \vith advanCing age at least in palt because of reductions in muscle mass. • The activity should be accessible. additional benefits may be obtained with longer-duration. convenient. power. • Longer-duration or higher-aerobic intensity offers additional health and fitness benefits. • Exercise need not be vigorous and continuous to be bcneficial. those who have difficulty sustaining exercise for 30 minutes or who prefer shorter bouts of exercise can be advised to exercise for lO-minute periods at different times throughout the day. moderate-intensity phYSical activity or by substituting moderatewith higber-intensity phYSical activity. 25 . dignified manner. with exercise and no exercise or (Iow. Importantly. • When returning from a layoff of more than 3 weeks. Elderly people should consult a physician before progressing to a vigorous exercise program. thus. a conservative approach to increasing exercise intensity may be warranted initially. housework. to llleet tbe population-wide recOlllmendation to accumulate at least 30 minutes of moderate-intensity physical activity on most and preferably all days of tbe week. and then gradually increase the resIstance. and then by increasing the resistance. The optimal mode of exercise for elderly persons can be influenced by phYSiologiC and psychosocial variables. and enjoyable to the pmticipant. it should be performed at least 2 to 3 d'wk.CHAPTER 101 EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY 248 SECTION 1111 EXERCISE PRESCRIPTION 249 Cardiorespiratory Fitness Elderh. • As a training effect occurs. II Intensity • Physical activity performed at a moderate intensity should be performed most days of the week.28. • Many older persons suffer from a valiety of medical conditions. achieve an overload initially by increasing the number of repetitions. resistance training should be an impOltant focus of any exercise program. although it can lead to greater lisk of cardiovascular and musculoskeletal problems and lower compliance to a long-term exercise plan. and active recreational pursuits (see Fig. The major goal of the resistance-training program is to develop . • Begin (the first 8 weeks) \vith minimal resistance to allow for adaptations of tl?e connective tissue elements. poor balance. 7-1. some comll1on sense guidelines are specific to elderly people: 30 • The first several resistance training sessions should be closely superVised and monitored by trained personnel who are sensitive to the speCial needs and capabilities of elderly people. • If exercise is undeltaken at a vigorous level. ImpOltantly. older individuals should initially increase exercise duration rather than intensity. • Walking is an excellent mode of exercise for many elderly people. Duration • Exercise duration need not be continuous to produce benefits. however. fre(luency.2H The reduction in muscle strength contIibutes to a decline in functional capacity. yard work. gardening. This can be aceomplisbed with activities sucb as brisk walking. a daily accumulation of 30 minutes of modcrate-intensity phYSical activity can prOvide health benefits. Resistance Training • The intensity gUidelines and precautions establishcd for adults (see Chapter 7) for aerobic exercise training generally apply to elderly people. • To minimize medical problems and promote long-term compliance. and endurance (muscular fitness) in elderly individuals25. Resistance training increases muscular strength. exercise intensity for inactive elderly people should start low and indiVidually progress according to tolerance and preference.people sbould be encouraged. • A set should involve 10 to 15 repetitions that elicit a perceived exertion rating of 12 to 13 (somewhat hard). • Perform one set of 8 to 10 exercises that use all the major muscle groups. Frequency • Tbc exercise modality should be one that does not impose excessive orthopedic stress. • Aquatic exercise and stationary cycle cxercise may be especially advantageous for tbose with reduced ability to tolerate weight-bearing activity.to moderate-intensity) exercise days alternated. and duration into an exercise plan. • To avoid injury and ensure safety. Therefore. cli mbing stairs. all factors directly related to exercise adherence. For those achieving this level.29 and in turn has the potential to deter the untoward effects of frailty by improving 'mobili~ and preventing falls and fi-actures. • The wide range of health and fitness levels observed among older adults may require special considerations in terms of integrating intensity. and travel limitations. thus. improved muscular fitness may allow the elderly adult to perform activities of daily living with less effort28 and extend their functional independence by living the latter years in a self-sufficient. whene\'er possible.5 years of age and their greater lisk of underlying coronary mtely disease. OIthopedic problems. Tbe guidelines for resistance training for adults found in Chapter 7 generally apply to the older adult. The Activity Pyramid). patticularly for elderly people. start \vith resistances of 50% or less of previous training intenSity. • Elderly persons are more likely than young persons to be taki ng medications that can influence hemt rate. activities performed at a given MET value represent greater relative effOlt in elderly than young people because of the decrease in peak METs with age (Table 1-1).

Med Sci Sports Exerc 1998. DC: United States Deparlmcnt of Health alld Uuman Selvices. nnithan VB.150:. President's COllncil on Ph). should follow the recommendations for flexibility training found in Chapter 7. M D: United States Departmellt of Ilealth and Human Selvices. 2nd ed. Must A. S201-205. N Engl J Med J994. 17. 21. O' 'eill EF. Am J Cardiol 1979. New York: Oxford University Press. et al. A well-rounded program of strctching can counteract thc usual decline in flexibility of elderly people and may improve balance and agility. Tek'. Pediatric SPOltS Medicine for the Practitioner. 2004. upper trunk.3. Straub JS.27:3:402-407. James F. Consider devoting an entire exercise session to fleXibility for deconditioned older adults who are beginning an exercise program. low back problems.. Cavill N. Mechanical efflcienc). TL: Iluman Kinetics. Armstrong N. Int J SPOltS Med 1990: II :4. UK: Oxford niversitv Press. In: lIandbook ofPh).:30:975-99 I: . Champaign. IL: Human Kinetics. They also protect the back by stabilizing the user's body position. 6. 1.5:681. Physical activit" and health. Position Stand: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratOly and mllscular ntness. 5. Glueck C. Therefore. 32. A meta-analysis. Flexibility An adequate range of motion in all body joints is impOitant to maintaining an acceptable level of musculoskeletal function. Routine activities (e. Developmental Exercise Ph)'siology. 199:3: 1. Masoro E. Hockville.61 :902-912. eds. Hesponses of normal children and yoong adnlts to controlled bicycle exercise. Bruce treadmill test in children: norlllal values in a clinic population. 14. Monahan KD. Centers for Diseasc Control ancl Prevention. Oxford. 1989. Pratt ~I. Pereira MA.g. COli maker SL. Howland n\!. and agility in older adults. Pediatr Exerc Sei 2001:1. Washington. et al. Blicker J..1mum range of motion that does not elicit pain or discomfOlt). 1998. and neck regions) in the body. Stress that all exercises should be performed in a manner in which the momentum is controlled. In: Assessing Physical Fitness and Physical Activit. What is almost universally accepted. Position Stand: Exercise and phYSical activity for older adults. Aerobic cxercise tcsting protocols.30:J 769-1775. . during c"cling in prepllbertal and adult males. ~Ied Sci Sports Exerc 1998:.172. 28. it is clitical that a sound stretching program be included as pmt of each exercise session for older adults. Blood pressurc.5. 199:3: 19-42. Washington. 1996. and flexibility in healthy adults. The effectiveness of' resistance training in children.e. ACC/AlIA 2002 gUideline update for exercise testing: a reporl of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Exereise Testing).46: 1-46. walking) may help to maintain muscular strength. 25. Circulation 1980. New York: Splingcr-Verlag. MMWR 2000.250 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY 251 • • • • • • • • • sufficicnt muscular fitness to cnhance an individual's ahility to live a physically independent lifestyle. Wessel HU.5_31.'ss and Sports.5. lu: Howland n\!.1991. Blair SN. Hiopel DA. Temperature regulation. ~Ied Sci Sports Exerc 1997. 29. Paediatric Exercise Scienee and ~Iedicine.'" in Population-based Surveys. Youth risk beha. United States Department of Health and Human Selvices.l. risk of muscle strains. Avoid explosive movements. 1999 8. Washington RL. Sareopenia and its implications for the elderly.55. Cumming CH.3-1.3.g. Instruct pmticipants to maintain their normal breathing pattern while exercising. Sallis JF. Everatt 0.64:. 22. Van Mechelen W. Biddle S. the Imu. as opposed to free weights. Howland n\'. bending and ffi~sting) and reduces injUly potential (e. IL: Human Kinetics. shoulder. American College of SPOltS Medicine. Gregg EW. The Cooper Institute for Aerobics Hesearch. 2. 24. Falk B. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. Fitzgerald SJ. Champaign. 2000:22:3-2. 10.3. . Pedialr Exerc Sei 200]: 1:3:12-2. Holin AH. Ilastm<ln L. Aerobic /Itness. Physical activity and publiC health.ity guidelines for adolescents: consensus statement.39.41:69-7.22: 17&--]86. 16: 1:39. 2002. 26.34.997. Tenenbaulll C. ed. . DC: DHHS Publication (PHS) 91-50212.. PI"'sical acti.31.3:3. A repOlt of the Surgeon Ceneral. Strashurger JF. 9. back. although not documented. 19.29:S170-189.30.3):S40-47. Patrick K. knee. and falls) palticularly for aged people. Mitclicll BM. et al. IL: I luman Kinetics. 11. J Am Coli Cardiol 2001. Annn Hev Nul'S Res 1998. Arch Pediatr Adolesc ~Ied 1996. Eur J Clin NutI' 2000:. Health)' People 2000: National Health Promotion and Disease Prevention Objectives. Weisman JE. 19B. 1997. Payne VG. Pender NJ.356-362. Cibhons HJ.3. Engage in a year-round resistance-training program.3:.3. pressure-rail' product and electrocardiographiC changes in healthy children during treadmill exercise. Washington.52-4. Discourage palticipation in strength training exercises during active periods of pain or inflammation for aJthritic patients. Exercise training and nutritional supplementation for phYSical frailty in vel)' elderly people. Pnblic Health Service. SalliS JF. et al. American PhYSiological Society. 20. 199. Cliampaign.sical Fitness and Sports. Pediatr Exerc Sci 199-1:6::302-:314. Measurement of cardiac oulput.3.37:15. Ross Je. hearl rate. New standards for the Bruce treadmill protocol in children and adolescents. In: Howland n\'.49: 1-94 12. American College of Sports Medicine. Res Q Exerc Sport 199.3-182. domestic work.30:992-1008. Aging. 7. Champaign. American College of Cardiology.. Statement of the United Kingdom Expert Cons('nsus Confcrenee.3. DC: President's Council on Physical Fit". PI"'sical aethit)' for children: A statement of guidelincs. Older adults. Cuidelines for school and community programs to promote hfelong phYSical actiVit)' among young people. Tador AB. 2000:17. Cet Fit: A Handbook for Youth Ages &--17. Seals DR Age-predicted maximal heart rate revisited.g. 1999. Perform the exercises in a range of motion that is within a "pain-free arc" (i.siology. UK: Oxford Uni"ersit" Press. Sobol A~L et al. 30. 16. Heston. National Association for SPOlt and Physical Education."ision vie\\~ng as a cause of increasing obeSity among children in the United States: 198&--1990.56. balance. MMWR 1.3:.. Fiatarone MA. and allow the user to more easily control the exercise range of motion. The effect of ph. In: Armstrong N. JA~IA 1995. A collection of ph)'sical actiVity qllestionnaires for health-related research. Paediatric Exercise Science and Medicine. Evaluating fitness and aClivity assessments from the National Children and Youth Fitnf"ss Studies J and U. Ryan ND. 23.54(suppl . Masoro E. l\·lorrow JR. Yoga and tai chi movements may be helpful in this regard. Roubenoff R.3H. I'ITNESSCRAM. is the fact that maintaining adequate levels of fle:dbility enhances an indi\~dual's functional capabilities (e. use machines to resistance train. In: Armstrong :"1. .. Allow participants ample time to adjust to postmal changes antI balance during the transition between resistance training exercises. REFERENCES 1.392-401. 18. et al. Kaplan S.htm 27. Baladv CJ. Hcalth enhanCing physical activity for young people. Pediatric Lahoratory Exercise Testing: Clinical Guidelines.ior sUlyeiliance: nited States. Howland TW. ed. Falk B. gardening. Bar-Or O.-14:697-70-1. Tanaka 11. Motivation for phYSical activity among childrcn and adolescents."sical training on prelJtlbescent V02rnax: a meta-analysis. Oxford.orgidinicaVguidelineslcxercise/djr[ndex. VA: NASPE. Exercises should be presc'ibed for evelY major joint (hip.acc. Pate HR. Pediatric LaboralOlY Exercise Tesling: Clinical Cuidelines. Sports Med 1996. et al. eds. ed.31:h. 4. vall ~1e<:hclcn \V. Machines generally require less skill to use. Given a choice. Website available at: www. Am J Cardiol 1978. Perform multi-joint (as opposed to single-joint) exercises. 15.

SECTION IV Appendices Appendix Appendix Appendix Appendix Appendix Appendix A B C 0 E F Common Medications Emergency Management Electrocardiogram (ECG) Interpretation Metabolic Calculations Environmental Considerations American College of Sports Medicine Certifications .

Catapres-TIS (patch) Tenex Aldomet Serpasil Aldoril Diupres Hydropres Carvedilol Labetalol OIt-Adrenergic Blocking Agents Doxazosin Prazosin Terazosin Clonidine Guanfacine Methyldopa Reserpine Methyldopa + hydrochlorothiazide Reserpine + chlorothiazide Reserpine + hydrochlorothiazide Central 0I2-Agonists and Other Centrally Acting Drugs Central 0I2-Agonists in Combination With Diuretics continued 255 . Trandate Cardura Minipress.and {J-Adrenergic Blocking Agents Tenoretic Ziac Inderide Lopressor HCT Corzide Timolide Coreg Normodyne. Generic and Brand Names of Common Drugs by Class GENERIC NAME {J-Blockers BRAND NAME* Acebutolol* * Atenolol Betaxolol Bisoprolol Esmolol Metoprolol Nadolol Penbutolol * * Pindolol** Propranolol Sotalol Timolol **f3-Blockers with intrinsic sympathomimetic activity. Minizide Hytrin Catapres. Toprol XL Corgard Levatol* * Visken** Inderal Betapace Blocadren {J-Blockers in Combination With Diuretics Atenolol + chlorthalidone Bisoprolol + hydrochlorothiazide Propranolol LA + hydrochlorothiazide Metoprolol + hydrochlorothiazide Nadolol + bendroflumethiazide Timolol + hydrochlorothiazide a.Common Medications • •• A APPENDIX •• TABLE A-1. Sectral** Tenormin Kerlone Zebeta Brevibloc Lopressor SR.

Verelan PM Verapamil-Coer Calcium Channel Blockers (Dihydropyridines) Amlodipine Felodipine Isradipine Nicardipine Sustained Release Nifedipine Long-Acting Nimodipine Nisoldipine Cardiac Glycosides Norvasc Plendil DynaCirc CR Cardene SR Adalat. transmucosal Nitroglycerin. Procardia XL Nimotop Sular Lanoxin. Isoptin SR. Deponit. Nltrol Benazepril +hydrochlorothiazide Captopril + hydrochlorothiazide Enalapril + hydrochlorothiazide Lisinopril + hydrochlorothiazide Moexipril + hydrochlorothiazide Quinapril + hydrochlorothiazide Lotensin HCT Capozide Vaseretic Prinzide. Dilacor XR. Nitroglyn. Dilatrate Nitrostat. Nitrocine. transdermal Nitroglycerin. continued GENERIC NAME BRAND NAME> Nitrates and Nitroglycerin ACE Inhibitors in Combination With Diuretic Amyl nitrite Isosorbide mononitrate Isosorbide dinitrate Nitroglycerin. Nitro-Dur. Verapamli Long Acting Covera HS. Nitrodisc. topical Amyl nitrite Ismo. Transderm-Nitro. Oretic Renese Lozol Mykron. Monoket. Tiazac Calan. Isoptin Verapamil Immediate Release Calan SR. sustained release Nitroglycerin. Cardizem LA. sublingual Nitroglycerin. Nitro-Bid Minitran. Sorbitrate. Nitro-Derm Nitro-Bid.256 SECTION IV / APPENDICES APPENDIX A / COMMON MEDICATIONS 257 TABLE A-1. HydroDiuril. Zaroxolyn Bumex Edecrin Lasix Demadex Midamor Dyrenium Inspra Aldactone Bumetanide Ethacrynic Acid Furosemide Torsemide Potassium-Sparing Diuretics Amiloride Triamterene Aldosterone Receptor Blockers continued Eplerenone Spironolactone continued . Prinivil Univasc Aceon Accupril Altace Mavik Benazepril Captopril Cilazapril Enalapril Fosinoprli Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril Chlorothiazide Hydrochlorothiazide (HCTZ) Polythiazide Indapamide Metolazone "Loop" Diuretics Diuril Microzide. Zestoretic Uniretic Accuretic Lotrel Lexxel Tarka ACE Inhibitors in Combination With Calcium Channel Blockers Benazepril + Amlodipine Enalaprli + felodipine Trandolapril + verapamil Angiotensin II Receptor Antagonists C~/cium Channel Blockers (Nondihydropyridines) Diltiazem Extended Release Cardizem CD. translingual Nitroglycerin. continued GENERIC NAME BRAND NAME> TABLE A-l. NitroQuick Nitrolingual Nitrogard Nitrong. Lanoxicaps Candesartan Eprosartan Irbesartan Losartan Olmesartan Telmisartan Valsartan Atacand Tevetan Avapro Cozaar Benicar Micardis Diovan Atacand HCT Teveten HCT Avalide Hyzaar Micardis HCT Diovan HCT Diuretics Angiotensin II Receptor Antagonists in Combination With Diuretics Candesartan + hydrochlorothiazide Eprosartan + hydrochlorothiazide Irbesartan + hydrochlorothiazide Losartan + hydrochlorothiazide Telmisartan + hydrochlorothiazide Valsartan + hydrochlorothiazide Digoxin Direct Peripheral Vasodilators Thiazides Hydralazine Minoxidil Angiotensin-Converting Enzyme (ACE) Inhibitors Apresoline Loniten Lotensin Capoten Inhibace Vasotec Monopril Zestril. Imdur Isordil.

Cardioquin HMG-CoA Reductase Inhibitors Atorvastatin Fluvastatin Lovastatin Pravastatin Simvastatin Rosuvastatin Lovastatin + Niacin Nicotinic Acid Niacin Cholesterol Absorption Inhibitor Ezetimibe Ezetimibe + Simvasatin Blood Modifiers (Anticoagulant or Antiplatelet) Clopidogrel Dipyridamole Pentoxifylline Ticlopidine Cilostazol Warfarin Lipitor Lescol Mevacor Pravachol Zocor Crestor Advicor Niaspan. Maxzide Moduretic Antiarrhythmic Agents Class I IA Disopyramide Moricizine Procainamide Quinidine Class I IB Lidocaine Mexiletine Phenytoin Tocainide IC Flecainide Propafenone Class /I I3-Blockers Class 11/ Amiodarone Bretylium Sotalol Dofetilide Class IV Calcium channel blockers Norpace Ethmozine Pronestyl. Quinidex. continued GENERIC NAME BRAND NAME' TABLE A-1. Quinaglute. Uniphyl continued . continued GENERIC NAME BRAND NAME' Diuretic Combined With Diuretic Triamterene + hydrochlorothiazide Amiloride + hydrochlorothiazide Dyazide. Pacerone Bretylol Betapace Tikosyn see page 256 Respiratory Agents Steroidal Antiinflammatory Agents Flunisolide Triamcinolone Beclomethasone Fluticasone Fluticasone and salmeterol (132 receptor agonist) Budesonide Bronchodilators Antilipemic Agents AeroBid Azmacort Beclovent. Procan SR Quinora.-Receptor Agonists) Salmeterol Metaproterenol Terbutaline Pirbuterol Albuterol Salmeterol and Fluticasone (steroid) Xanthine Derivatives Theophyline Questran. Ventolin Advair Theo-Dur. Cholybar. Prevalite Welchol Colestid Atromid Lopid Tricor. Sio-Niacin Zeta Vytorin Plavix Persantine Trental Ticlid Pletal Coumadin Xylocaine. Lofibra continued Serevent Alupent Brethine Maxair Proventil.-Receptor Agonists) Ipratropium and Albuterol Combivent Sympathomimetics (f3. Quinalan. Nicobid. Xylocard Mexitil Dilantin Tonocard Tambocor Rythmol see page 255 Cordarone. Qvar Flovent Advair Diskus Pulmicort Bile Acid Sequestrants Cholestyramine Colesevelam Colestipol Fibric Acid Derivatives Clofibrate Gemfibrozil Fenofibrate Anticholinergics (Acetylcholine Receptor Antagonist) Ipratropium Atrovent Anticholinergics with Sympathomimetics (f3.258 SECTION IV / APPENDICES APPENDIX A / COMMON MEDICATIONS 259 TABLE A-1.

. continued GENERIC NAME BRAND NAME· t m c m Q) Q) -'= Leukotriene Antagonists and Formation Inhibitors Zafirlukast Montelukast Zileuton Mast Cell Stabilizers Accolate Singulair Zyflo Intal Tilade Xolair Antidiabetic Agents '(3 ell ell ell > C. . ""Represent selected brands... Q)~ O-~ o c c 0 C ell '" 'v Qi x w 0- c Biguanides (Decrease hepatic glucose production and intestinal glucose absorption) a t '... c:c ::!: ci: L. Riomet Glucovance Glyset t~ ~ o ~. .:0 > fu- :.. tJ ell E +- ell C ell .~ .~ 0- V1 +-' Q) c C Q) .= tJ en c ell "D c m 2::. Glynase. 'v 'Co " u '" 11I ~ s 01 u fu.. '" :0 11I ::i: v ..~ ---7---7 .... Gluconorm DiaBeta..U ~ C Q) .~ c-'= U Cromolyn Inhaled Nedocromil Omalizumab .6'l.i en en ell 0.+-' C C V1 m L..~ m:r: LL ~o ""D ".c c m '01 +-' f' '~ f' C ~ +-' '!! c f' '~ m 0 -'= +-' '~ V1 C :J V1 .. tJ .. Micronase Glucotrol Diamicron Amaryl Tolinase Orinase Diabinese c:c a:: Glyburide Glipizide Gliclazide Glimepiride Tolazamide Tolbutamide Chlorpropamide Thiazolidinediones (Increase insulin sensitivity) 1: a.~ 2::..::.and rapid-acting combination Long-Acting Humalog Humulin R Novolin R lIetin II R Humulin L Humulin N lIetin II Lente lIetin II NPH Novolin L Nivalin N Humalog Mix Humalog 50/50 Humalog 70130 Novolin 70/30 Humulin U Lantus Injection W .::. ---7 t Pioglitazone Rosiglitazone Actos Avandia Obesity Management :c ell :E tJ • C' en Appetite Suppressants Sibutramine Lipase Inhibitors Meridia Xenical N = ell L.. 0 V1 m 01 C fu.-+: Glucosidase Inhibitors (Inhibit intestinal glucose absorption) ~ Intermediate.~ V1 Q) c 0 01 . . these are not necessarily all inclusIVe.~ .260 SECTION IV I APPENDICES APPENDIX A I COMMON MEDICATIONS 261 TABLE A-1..U c: '" o '. ell )( '.:0 m 00- c ~ C t ~ :J ~---7 Metformin Metformin and Glyburide Miglitol Insulins Rapid-acting Intermediate-acting Glucophage. a.D ~ >:-= E o. C C ell Meglitinides (Stimulate pancreatic islet {3 cells) ~ Nateglinide Repaglinide Sulfonylureas (Stimulate pancreatic islet {3 cells) Starlix Prandin.c : :l ell e tJ ell ..i ell ell t :::c c C C .U Orlistat ..E • Q) u \:l w I <>::-0 .

1 or H (R) H(E) iorHHR(R) May prolong QRS and QT intervals (R) Quinidine may result in "false-negative" test results (E) H Class I Quinidine Disopyramide continued Procainamide H (R and E) H (R and E) Phenytoin Tocainide Mexiletine Moricizine } May prolong QRS and QT intervals (R) May result in "falsepositive" test results (E) H (R and E) May prolong QRS and QT intervals (R) H(E) .) Class 1/1 Amiodarone Sotalol .1orH(E) H (R and E) H Class /I i3-Blockers (see I. except i or H in patients with CHF H (R and E) . continued Medications Heart Rate Blood Pressure ECG Exercise Capacity Ql N N V. except i or H in patients with CHF H.1 HR (R) H(E) H X :t> n o " m " Z :t> Class IV Calcium channel blockers (see 111. except possibly in patients with CHF V> m Cl o z <: -:t> " m " Z n m V> o VI.) S S o z S m 12 n :t> -i V> o o Z N Ql CAl .1 HR (R) .1 or H HR (R and E) H H All antiarrhythmic agents may cause new or worsened arrhythmias (proarrhythmic effect) i or H (R and E) .1 (R and E) H or PVCs (R) May cause PVCs and " fa Ise-positive" test results if hypokalemia occurs May cause PVCs if hypomagnesemia occurs (E) i or H HR (R and E) H (R and E) H.1 (R and E) H (R and E) . Vasodilators.1 (R) .1 (R and E) H (R and E) . Diuretics H (R and E) H or .1 (R and E) .1 (R and E) .1 or H HR (E) H H (R and E) H (R and E) H (R and E) H (R and E) H H Propafenone .TABLE A-2.1 or H (R and E) .1 (R and E) H. Antiarrhythmic agents i or H (R and E) H (R and E) . nonadrenergic ACE inhibitors and Angiotensin II receptor blockers a-Adrenergic blockers Antiadrenergic agents without selective blockade VII.

arrhythmias (R and E) XII. Cold medications with sympathomimetic agents H (R and E) H (R and E) H (R and E) H H Effects similar to those described in sympathomimetic agents. Bronchodilators Anticholinergic agents Xanthine derivatives Sympathomimetic agents Cromolyn sodium Steroidal Anti-inflamatory Agents IX. BP All other hyperlipidemic agents have no effect on HR. or 1. H HR and BP by controlling anxiety. or H in patients with angina May provoke ischemia. 6 z N (R and E) Chronic use may have role in i BP (R and E) H VI UI a> . angina in patients with prior myocardial infarction Nicotinic acid may 1. no other effects (R and E) 1. or H HR May produce PVCs (R and E) i or H HR (R and E) H (R and E) H (R and E) H H " <: :t> m " Z H ~ n m VI Clofibrate may provoke arrhythmias. Nicotine i or H (R and E) i (R and E) i or H HR H. Psychotropic medications Minor tranquilizers Antidepressants 1. Thyroid medications i (R and E) i (R and E) i Only levothyroxine XV. BP. (R and E) H (R and E) H (R and E) H. unless angina worsened o z m S (') o ::. except 1. Antilipemic agents H Heart Rate (R and E) or H (R and E) H Blood Pressure (R and E) H ECG (R and E) Exercise Capacity VI Bronchodilators i exercise capacity in patients limited by bronchospasm m C1 6 z i i H i H or H (R and E) (R and E) H (R and E) i. or H (R and E) Variable (R) May result in "falsepositive" or "falsenegative" test results (E) continued Lithium H (R and E) H (R and E) May result in T wave changes and arrhythmias (R and E) XI. Antihistamines XIII.N a> ~ TABLE A-2. and ECG May i or H X. continued Medications VIII. Alcohol H HR May provoke arrhythmias i ischemia (R and E) May provoke arrhythmias (R and E) H. although magnitude of effects is usually smaller " m " Z o n :t> X :t> o S S XIV. or H (R and E) Variable (R) May result in "falsepositive" test results (E) (R and E) Major tranquilizers i or H 1.

. ~ '" u· '" 3 E '" Q If a problem occurs during exercise testing. E ~ tJ C ru ~ 'x a... expiration dates for pharmacologic agents and other suppOltive supplies (e. Emergency communication devices must be readily available and working properly. and preferably two trained ACLS personnel and a physician immediately available at all times when maximal sign... '" m .' GJ GJ GJ GJ u iii 0 0 es t c ru u es t c ru u es t c ru u es t c ru "II u *~ '" it --> ~ ! g a: t '" '" :I: <II 2! GJ GJ GJ GJ u es t c ru u es t c ru u es t c ru u es t >. ~ a VI <II ".. In addition.~ . the nearest available physician or other licensed and trained ACLS provider (paramedic or code team) should be summoned immediately.2 . '" ~ .0 ~ .g. Only those personnel c!J.l '" C Q) 01 +-" Q) '" c 01 u c ru '" c . n." -"! '" EO '" '" a '" ~ I E g' ~ 8 0 'il "t.!!! ::J 01 '" a. c 0 '" ~ ..D <t 267 . o A specific person or persons should be assigned to the regular maintenance of the emergency equipment and regular surveillance of all pharmacologic substances.£ 13 g. :r: c Q) u W . c Q) N et v c >.' ~ '" I ~- 'u '" w ~ ~ • There should be at least one." c ~ .. o Records should be kept documenting function of emergency equipment such as defiblillator.... ...266 SECTION IV / APPENDICES APPENDIX +-" ..9 c 0 Q1 Q) co c <t +-" ~ ru U 'x Q) c <t ~ ~ Q. EqUipment and drugs that should be available in any area where maximal exercise testing is performed are listed in Table B-1.ygen supply. Emergency plans should be established and posted. <II < :::i: I- <L 0 ~ ru ~ ru ~ 0 v (i . 5: c v. 0 ~ iii :> x :> x > x x x x x x X ~ " (. • . -0 <U ~ Col ru E0 c: 0 .c·~ - ~ § t t o ..£ ".. u c ru U \:1 w es t u c ru :r: cr: t es t t o t- t 1ii . Regular rehearsal of emergency plans and scenalios should be conducted and documented. • Telephone numbers for emergency assistance should be posted clearly on all telephones. and suction.:.~ VI ru v ru ~ U '" '" OJ c +-" . = C c Q a.~ u c Q) :v .~ ~ c . c >. ru e. • Regular drills should be conducted at least qualterly for all personnel. then emergency transportation to the closest hospital should be summoned immediately.D U c Emergency Management E >. intravenous equipment and intravenous fluids) should be kept." U c 0 i:> 3.<t 0 ~ is Q) E +-" ru v .or symptom-limited exercise testing is performed.. ~ Vi c ru * S II ~ <- ~ ~ '? ~ '" 1( C ~ c '" 0 c 0 "C ''.i. B . . o Hospital emergency departments (or code teams) and other sources of support such as paramedics (if exercise testing is performed outside of a hospital setting) should be advised as to the exercise testing laboratOly location as well as the usual ti mes of operation. If a physician is not available and any question exists as to the status of the patient. m. The physician should decide whether to call for evacuation to the nearest hospital if testing is not carried ant in the hospital.. ::J .-ro~ <L V t'!!-g t- t u c ru cr: The following key points are essential components of all emergency medical plans: • All personnel involved with exercise testing and supervision should be trained in basic cardiopulmonary resuscitation (CPR) and preferably advanced cardiac life support (ACLS).

oxygen. battery-operated defibrillator-monitor with hardcopy printout or memory. prOViding pOSltlve-pressure. including oral. CirculatIon.Anisoylated plasminogen activator complex (APSAC): Eminase . nitroglycerin. An automated external defibrillator (AED) is an acceptable alternative to a manual defibrillator in most settings.Reteplase: Retavase o Glycoprotein lib/Ilia receptor inhibitors . ventilations. aspirin) greets all patients o I3-Adrenergic blockers (see Appendix A for list) o Heparin continued . • Sphygmomanometer. opening and maintaining the airway. metoprolol) o CalCium channel blockers (diltiazem. cardioversion capability. continued Drugs (IV Form Unless Otherwise Indicated) o o • Portable. Breathing. verapamil) o Digoxin o Procainamide o Amiodarone o Lidocaine o Ibutilide o Magnesium sulfate Less commonly used: o Flecainide o Propafenone o Sotalol (not approved for use in United States) *Drugs in parentheses are used most frequently for taChycardias Within a class of agents The reader is encouraged to review ACLS algorithms. where the pharmacologic agents descnbed In this table are used In the context of the ABCDs (Airway.Tissue plasminogen activator (tPA): Alteplase . available by nasal cannula and mask • AMBU bag with pressure release valve • Suction equipment • Intravenous fluids and stand • Intravenous access equipment in varying sizes including butterfly intravenous supplies • Syringes and needles in multiple sizes • Tourniquets • Adhesive tape. direct-current capability in case of battery failure (equipment must have battery low-light indicator). Defibrrllatlon. gauze pads • Emergency documentation forms (incidenVaccident form or code charting form) Drugs (IV Form Unless Otherwise Indicated) ACE inhibitors (see Appendix A for list) Fibrinolytic agents . Defibrillator should be able to perform hard wire monitoring in case of exercise testing monitor failure. transcutaneous eledrical paCing or synchronized cardloverslon). and/or intubation equipment (only in situations where licensed and trained personnel are available for use) • Oxygen.Streptokinase . Emergency Equipment and Drugs Equipment TABLE B-1.MONA (morphine. 2001' • Pharmacologic agents used to treat ventricular fibrillation/pulseless ventricular Tachycardia o Epinephrine o Vasopressin • Antiarrhythmics o Amiodarone o Lidocaine o Magnesium o Procainamide • Pharmacologic agents used to treat pulseless electrical activity and asystole o Epinephrine o Atropine • Pharmacologic agents used to treat acute coronary syndromes: acute ischemia chest pain o Oxygen (mask or nasal cannula) o Aspirin (oral) o Nitroglycerin (oral or IV) o Morphine (if pain not relieved with nitroglycerin) . nasopharyngeal.268 SECTION IV / APPENDICES APPENDIX B / EMERGENCY MANAGEMENT 269 TABLE B-1. including aneroid cuff and stethoscope • Airway supplies. atenolol.TNKase: Tenecteplase • Pharmacologic agents used to treat bradycardias o Atropine o Dopamine o Epinephrine o Isoproterenol • Pharmacologic agents used to treat unstable and stable tachycardias Most commonly used: o Adenosine o I3-Adrenergic blockers (esmolol. chest compressions. ' • American Heart Association ACLS. alcohol wipes.

CC '" <II .:. +-' (lJ QJ E tJ c -0 v.. Automated External Defibrillators Early defibrillation continues to be the critical element for successful resuscitation of a life-threatening cardiac arrest. These plans are provided only as examples.0 .APPENDIX B / EMERGENCY MANAGEMENT 270 SECTION IV / APPENDICES 271 authorized by law to use certain equipment (e.. syringes.:..' ~ u .:. Q... ..:.:.:.:. E .:. . ~~ -.0 0:: n « V1 eO -'= ~ +-' E 0 .:.... There is growing use and support for automated external defibrillators (AEDs) in medical and nonmedical settings (e. casinos)..9 . III . Q.V1 u QJ u QJ :.r: .....:. Recent guidelines from the American Heart Association! indicate that for a witnessed cardiac arrest...:..:. . E LLJ 0 0:: .~ u C E OJ E~ > QJ .. . immediate bystander CPR and early use of an AED can achieve outcomes equivalent to those achieved with the full ACLS armamentarium... 0 ~ 2 u +-' E ..9 V1 E .. ''. Special conditions that may change how you use the AED are: • • • Do not use AED on child less than 8 years of age Do not use on victim in standing water Do not place AED electrode directly over implanted cardioverter defibrillator (ICD) • Do not place AED electrode over transdermal medication patch (nicotine.:.:. Q e l» = ca +-' . -0 OJ OJ -0 . u .2 QJ QJ >. <II VI '" ~ . Q. u: > l!! ..g. the reader is encouraged to obtain the American Heart Association's 2000 Handbook of Emergency Cardiovascular Care (ECC) and/or Advanced Cardiovascular Life Support textbook. OJ ~ 0 c QJ V1 > QJ E Q:i > .. Tables B-2 through B-4 provide sample plans for nonemergency situations (see Table B-2) and emergency situations (see Tables B-3 and B-4)...0 QJ V1 ~ E QJ' c CJ) OJ ~ ...9 .::: Q) -0 QJ CJ) ~ > ::r OJ Q:i E QJ '" cr: <II ... nitroglycerin) For more detailed explanations on the expanding role of AEDs and management of various cardiovascular emergencies.:.~ 0 ~ Z' E . c u OJ ''. and specific plans must be tailored to individual program needs and local standards. '. 0. ..0 ~ V1 -0 ~ 0 QJ ~ 0 . u OJ 0 cc c W ..9- E ~ rr QJ u >. needles) and dispense drugs can lawfully do so. airports.. ..:. 0 .::: ~ > ~ :.g. It is mandatory that such personnel be immediately available during maximal exercise testing of persons with known coronmy artery disease.: = ca = Cii Q III >tJ = l» c::n . .2 ..9 +-' c QJ t: N m «i . .. defibrillators. c E 0 G. during flights.9 ru Q. .. l» Q .r: >. OJ 0 (5 'iii Qi v Q. u 'iii v III Qi v 0 :s: -0 '6 c -0 V1 '6 QJ E -"" QJ q . ..:... OJ u = ii: N I -"" c QJ ~ +-' Q. c' QJ V1 'u ~ .~ V1 OJ ..

intubation. Call nurse on ward 2. Establish responsiveness a. Notify primary physician as soon as possible m m . Take vital signs every 1 to 5 minutes 5. 1 to 5 Also may adapt/add: 1.» m Gl Z n -< ~ :t> z :t> Gl m ~ m Z -l N w -. intravenous TABLE B-3.e.. intravenous drug administration. Call nurse if physician is off ward 3. Note time. nitroglycerin) Take pulse Same as Basic Level Nos. Document vital signs and rhythm. Responsive: Instruct victim to sit Activate EMS Direct second rescuer to call EMS Stay with victim until EMS team arrives Note time of incident Apply pressure to any bleeding Note if victim takes any medication (i. and suctioning Victim may be inpatient or outpatient High First Rescuer :t> "1) "1) level: Basic First Rescuer Intermediate First Rescuer o Z m X ~ OJ 1. IV. Apply monitor to victim and record rhythm (or apply AED). and victim signs and symptoms Same as Intermediate Level Nos.. pool. 1 and 2 Add: 3. drawing arterial blood gas samples.J . Plan for Potentially Life-Threatening Situations level: Basic Intermediate High At a field. 1 to 3 Abbreviations: ECG. drive victim to ER or physician's office. or park without emergency equipment At a gymnasium or outside facility with basic equipment plus manual defibrillator (or AED) and possibly a small "start-up" kit with drugs Hospital or hospital adjunct with all the equipment of intermediate level plus a "code cart" containing emergency drugs and equipment for oxygen.J N Vl m -l n <5 z <: m :t> "1) -"1) TABLE B-2. emergency room. if necessary Same as Basic Level No. electrocardiogram: ER.N -. continued Level: Basic Second Rescuer Intermediate Second Rescuer High Second Rescuer n m o Z Vl 1.. Assist first rescuer. Monitor continuously 4. Bring blood pressure cuff and ECG monitor to site 3. Assist with taking and monitoring vital signs Same as Intermediate Level Nos. Add: 2.

Run ECG rhythm strips (or Same as Intermediate Level Nos. 1 to 3 Add: 4.I Ul . continued Level: Basic Second Rescuer Intermediate Second Rescuer High Second Rescuer 1. continue to monitor respiration and pulse 2. Direct emergency team to scene or 2. Assist first rescuer ECG. place something under head if possible d. compress area to decrease/stop bleeding b. Return to scene to assist Same as Basic Level Nos. Wait to direct emergency team to scene 3. If absent. EMS. Turn victim on side. Other considerations a. to help drain secretions C1 z (5 -» " m " Z n m VI <: o TABLE B-3. continued b. electrocardiogram. 1 to 4 apply AEDL HIGH THIRD RESCUER c.N -.I ~ m VI TABLE B-3. do not hyperextend neck c. Unresponsive: Activate EMS Place victim supine Open airway Check respiration. Suspected neck fracture: open airway with a jaw-thrust maneuver. If absent follow directions in Table B-4 Direct second rescuer to call EMS Stay with victim. Take vital signs LEVEL: BASIC THIRD RESCUER INTERMEDIATE THIRD RESCUER " m " Z Same as Basic Level m » o X ro ~ 1. If seizing: prevent injury by removing harmful objects. If bleeding. follow directions in Table B-4 Maintain open airway Check pulse. Same as Basic Level m ::>J m G) () Z -< ~ » z » G) m m ~ --i Z N -. emergency medical services. Bring all emergency equipment and a. Place victim on monitor b.once seizure activity stops. Call EMS 2.

intubation. Administer 15:2 compression/ventilation if no pulse 7. Assist with two-person CPR or 2. Return to scene. drawing arterial blood gas samples. emergency medical services High Third Rescuer m m ~ » z » CI ~ Same as Basic Level Same as Basic Level -. determine unresponsiveness 2. Open oxygen equipment and use AMBU bag with oxygen at 10 Umin (i. Open airway. 1 to 6 » -0 m -0 o X OJ Z m m m ~ CI ~ n Z -< level: Basic Third Rescuer 1.e. en m '" TABLE B-4.. Continue ventilation if no respiration Step Nos. pool. 1 to 3 Add: 4. Check pulse (carotid artery) 6... Locate nearest phone and call EMS 2. and feel for the air 4. or park without emergency equipment At a gymnasium or outside facility with basic equipment plus manual defibrillator (or AED) and possibly a small "start-up" kit with drugs Hospital or hospital adjunct with all the equipment of intermediate level plus a "code cart" containing emergency drugs and equipment for intravenous drug administration. bringing defibrillator: take "quick look" at rhythm Document rhythm (do not defibrillate unless certified to do so and this activity is part of your clinical privileges for the facility in which the work is being completed) (or apply AED) 5. Return to scene and help with twoperson CPR. Open drug kit and prepare intravenous line and drug administration (must only be done by trained. look. Bring emergency drug kit if available a. Place monitor leads on patient and monitor rhythm during CPR 6. Z . and suctioning Victim may be inpatient or outpatient High First Rescuer Q <5 z <: » -0 --0 m n m o Z '" level: Basic First Rescuer Intermediate First Rescuer 1.. Give two ventilations if no respirations 5. licensed professionals) c. Help clear area EMS.. 1 to 7 for Basic Level Step Nos...N . oxygenation. .. Remain at designated area and direct emergency team to location Step Basic Level Nos. or 3. Call for help (911 or local EMS number) 3. Keep equipment at scene for use by emergency personnel Intermediate Third Rescuer Step Intermediate Level Nos... 1 to 7 for Basic Level TABLE B-4.. 100%)2 (if trained to do so) b. listen.. Help direct emergency team to site 3. Position victim (pull from pool if necessary) and place supine. continued level: Basic Second Rescuer Intermediate Second Rescuer High Second Rescuer 1.. Plan for Life-Threatening Situations level: Basic Intermediate High At a field. N .

infarction. He·tith Colre Providers . TABLE C-1. QRS. 2001. . Check for correct calibration (1 mV = 10 mm) and paper speed (25 mmlsec) Calculate the heart rate and determine the heart rhythm Measure intervals (PR. . Greem·ille . ST segments. 2001.278 SECTION IV I APPENDICES REFERENCES 1. Greem. Electrocardiogram Interpretation Steps 1. QRS complex. Interpret the present electrocardiogram (ECG) 7. Compare the present ECG with previous available ECGs 8. 5. 4. conduction delays. repolarization changes) 6..lIe. 2. TX: American Heart AssocIatIOn. 3. Precordial (Chest Lead) Electrode Placement Lead Electrode Placement 4th intercostal space just to the right of the sternal border 4th intercostal space just to the left of the sternal border At the midpoint of a straight line between V2 and V4 On the midclavicular line in the 5th intercostal space On the anterior axillary line and horizontal to V4 On the midaxillary line and horizontal to V4 and Vs TABLE C-2. TX: American Healt Association. Each of these tables should be used as part of the overall clinical picture when making diagnostic decisions about an individual. clinical correlation. 2. chamber enlargement. QT) Determine the mean QRS axis and mean T wave axis in the limb leads Look for morphologic abnormalities of the P wave. . T waves and U waves (e. Conclusion. ACLS Provider Manual. and recommendations 279 .g. L'lIe c SUppOI·t co' II I (( BaSlC Electrocardiogram (ECG) Interpretation • •• C •• APPENDIX The tables in this Appendix provide a quick reference source for electrocardiogram (ECG) recording and interpretation.

where K = 0.e.20 sec If 2':0.e. Abbreviations: bpm. <0../\ QT interval Rate dependent Normal QT = K".e.04 sec and/or >25% of R wave amplitude except lead III (the lead of exceptions) and V.12-0.>J s: m () :l> Transition zone *If supported by other electrocardiograms (ECGs) and related clinical criteria. continued Parameter Normal Limits m Z -0 -0 o Abnormal If Possible Interpretation(s)* X () Taxis Generally same direction as QR5 axis The T axis (vector) is typically deviated away from the area of "mischief" (i. WPW. OTc.>J o Q waves o Z --l m ..>J --l (5 C) . pulmonary disease. WPW. incomplete or complete bundle branch block. Resting 12-Lead Electrocardiogram: Normal Limits Parameter Normal Limits Cl z Abnormal If 1 possible Interpretation(s)* (5 Heart rate PR interval QR5 duration 60-100 beats·min0.e. pericarditis. chronic obstructive pulmonary disease. bundle branch block. COPD. normal variant Injury. Infarction or pseudoinfarction (as from chamber enlargement. chronic obstructive pulmonary disease. hypercalcemia Left axis deviation (ie. electrolyte abnormality. (5 ~ z m --l . normal variant. Before V 2 After V4 Chamber enlargement. infarction) All limb leads transitional <: :l> m -0 -0 Z o .30 to + 11 0 degrees QTc long QTc short <-30 degrees >+110 degree Indeterminate QR5 axis (continued) :l> TABLE C-3. WPW.l0sec <60 >100 <0. ischemia.. LGL) First-degree AV block Conduction abnormality (i.>J -0 N CO ~ . drug effects. infarction) Right axis deviation (i. cardiomyopathy) Counterclockwise rotation Clockwise rotation :l> ..04 sec and <25% of R wave amplitude (exceptions lead III and V.20 sec UptoO. m \. WPW.11 sec Bradycardia Tachycardia Preexcitation (i.12 sec >0.>J . hypertrophy) Elevation of 5T segment Depression of 5T segment >0. hemiblock. conduction abnormalities. RVH. aberrant conduction) Drug effects. ischemia.-V4 . electrolyte abnormalities. drug effects. OT corrected for heart rate. electrolyte abnormality. ischemia./RR. chamber enlargement. LGL. beats per minute./\ m TABLE C-3. electrolyte disturbances m r m () 5T segments Generally at isoelectric line (PR segment) or within 1 mm. Lown-Ganong-Levine syndrome. The 5T may be elevated up to 3 mm in leads V. ischemia Digitalis effect. ischemia. Wolff-Parkinson-White syndrome.37 for men and children and 0.N co o \.) Usually between Vr V4 o () Injury.40 for women .=.

In other words. I. U.37 0..:. r::c ~ cD OJ x ~ 1IJ a.c S o~ C OJ Vl 0 ..l c CI. III 0E u Vl E ~ 0 OJ <1J > a 0::: :s: .g :::J :::J ~ c CI.l ~ Cil *Based on abnormal Q waves except for true posterior myocardial infarction. III..+:0 o c (lI 0'.-V l VI.39 041 042 045 030 033 035 036 039 037 039 041 043 045 0. if you bisect the RR interval.~ B u a 50-60 U L L ~ c > OJ <1J . which is reflected by abnormal R .l > (lI ~ o u 0 C Co CI) :! w .c <' 0 >0::: E "- ....l . c. Abbreviations: l. -= Cil CI.. lower limit in seconds. aVL V.. Localization of Transmurallnfarcts* Infarct Location Typical ECG Leads Cil * r::c o ( lI CI. c >- ~ >-' 0- OJ C (.. upper limit in seconds."t: a 0::: et OJ :s: S OJ ~ Vl :::J <1J <1J :::J Vl u 0 0- ::::J 'Adapted from Simonson E. Co c. V4R waves.32 0.34 036 0.63:747. Reproduced from Chou TC Electrocardi09raphy in Clinical Practice.l c. E Vl 115-84 83-72 71-63 62-56 55-45 0. 1996:16...39 037 0.:: . Normal OT Interval as a Function of Heart Rate*t Age (Y) 4~9 .. t A good rule of thumb for the QT interval is that at normal heart rates between 60 and 100 bpm. Cady LD. V 3R . Philadelphia: WB Saunders. the T wave should be completely finished being inscribed before you get half way between the previous and subsequent R waves.~ W ~ ~ '.-V 6 I.31 033 035 037 039 037 040 041 043 046 031 033 035 0.. Anteroseptal Localized anterior Anterolateral Extensive anterior High lateral Inferior True posterior (RlS>l) Right ventricular . Woodbury M.c Ci aJ > -0 Vl <1J C 0 0 :s: c C OJ . by permission of CV Mosby. aVF V.~ "-0 <1J Vl S <1J Vl ~ £m <1J :::J Vl-O -0 OJ E (.. ..37 040 042 043 046 'S c: v > 1IJ c:i AI ~~ 0:::-0 :::J-o Vl OJ :::J .APPENDIX C I ELECTROCARDIOGRAM (ECG) INTERPRETATION 283 282 SECTION IV I APPENDICES <'0 TABLE C-4. TABLE C-5.+:0 18-29 Heart Rate L 30-39 U L U U ~ :.:: > .30 0. > . The normal QT interval. '. the T wave should end before you get to that bisecting line.. III u OJ Vl a c 0:::_ V1 :~ <1J d.l ~ g . 9:::J.. aVL II.l V 1-V 3 Vr V4 V4 -V 6 . Am Heart J 1962.39 0.

An example of this IS sinus rhythm With complete AV block. » ~ <5 z N UI CO . The causes of AV dissoCIation are "block" and "Interference. P waves and QRS complexes In the ECG are unrelated AV dissociation may be complete or incomplete. and AV diSSOCIation results. tranSient or permanent.» C) o ("\ o AV dissociation by usurpation Sinus rhythm with either AV junctional or ventricular tachycardia Atrial fibrillation with accelerated AV junctional pacemaker and block below this pacemaker Physiologic <5 » . their contractions are "dissociated" and AV diSSOCIation exists. Atrioventricular Block P Wave Relationship to QRS R-R Interval Q <5 z <: » -u -m -u o PR Interval {"\ Z Interpretation m VI 1 degree Atrioventricular (AV) block 2 degree AV block: Mobitz I (Wenckebach) 2 degree AV block: Mobitz II 3 degree AV block 1:1 >0. pause less than two other cycles Regular except for pause. This table descnbes the four types of AV dissoCiation. A clear distinction must be made between block and Interference. PP interval is longer than RR interval. Unrelated P wave and QRS complexes.20 sec Progressively lengthens until a P-wave fails to conduct Constant but with sudden dropping of QRS Variable but P-P interval constant Regular or follows P-P interval Progressively shortens.» ~ *What IS meant by "AV dissociation") When the atria and ventricles beat independently.N ~ m VI TABLE C-7. The lower chamber's impulse "interferes" with conduction by producing physiologic refractori- . Thus. "Interference" results from slOWing of the primary pacemaker or acceleration of a subsidiary pacemaker. PP interval is longer than RR interval Unrelated P wave and QRS complexes X {"\ m r m Slowing of the primary or dominant pacemaker with escape of a subsidiary pacemaker Acceleration of a subsidiary pacemaker usurping control of the ventricles AV block and interference Physiologic Q . PP interval is shorter than RR interval Unrelated P wave and QRS complexes.» s: m ("\ Combination Pathologic . preventing the primary pacemaker's Impulse from reaching the lower chamber.» » ." and both may be present In the same ECG. "Block" IS assoCiated With a pathologiC state of refractonness. An example of this is sinus rhythm with AV junctional or ventricular tachycardia and no retrograde conduction into the atria. Atrioventricular Dissociation* Type of Atrioventricular (A V) Dissociation Electrophysiology Example Significance Comment » -u m -u o Z AV dissociation resulting from complete AV block AV dissociation by default causing interference AV block Sinus rhythm with complete AV block Sinus bradycardia with junctional escape rhythm Pathologic Unrelated P wave and QRS complexes. which usually equals two other cycles Usually regular (escape rhythm) >1:1 >1:1 None TABLE C-8.» -u m ~ ness.9 z m .

However. the equations work well if tracking the same subject over time but are less accurate for comparing \10 2 among different individuals and should be used v.g. the \10 2 at the same exercise intensity for the same individual is velY similar evelY time he or she exercises.individuals who vmy in body mass. variables that change the mechanical effiCiency (e. for exercise prescIiption pUlposes.9 kJ. V0 2 (mL·min. the value of 5. In this form. and is calculated by di\riding the absolute V0 2 (mL'min -I) by the individual's body weight (kg). 1 L \10 2 = 5 kcal 'min -I). sand) result in a loss of accuracy. .05 kcal' L -I \'0 2 when RQ is 1.I • The net V0 2 is calculated by subtracting the resting \10 2 from the gross \10 2 . 1 kcal = 4. these equations may be used to determine the reqUired exercise intensity associated \\rith a desired level of energy expenditure.. that is. such as the cliterion measure of cardiorespiratory fitness (\10 2maJ. the intersubject variability (vmiability between different subjects) in measured \10 2 may have a standard error of estimate (SEE) as high as 7%. fats are the pIimmy fuel source for energy metabolism and the kcal equivalent of a lL \10 2 is approximately 4. • Although the accuracy of these equations is unaffected by most environmental influences (heat and cold). expressed as either L'min. reasonable estimates of the \10 2 dming exercise can be made from regression equations delived from measured \10 2 dming steady-state exercise on ergometric devices and while walking and mnning.1 In some instances.2 kj) of energy (i.I • The net rate of ox')'gen uptake is the \10 2 associated \vith only the amount of exercise being performed exclusive of resting oxygen uptake.APPENDIX • • Metabolic Calculations D •• APPENDIX D / METABOLIC CALCULATIONS 287 f1 he relative rate of \10 2 (relative to body mass) is typically expressed by the units.J Subsequently. gait abnormalities. to square meters of surface area."ygen consumption (\10 2 ).69. When it is not possible or feasible to measure \10 2 . \10 2 provides a measure of the energy cost of exercise (kcal) and in combination with \1C0 2 can provide information about the fuels for exercise. Under steady-state conditions. When the RQ. 286 Estimation of Energy Expenditure: Metabolic Calculations MeasUling \10 2 requires equipment that is expensive and sophisticated and trained profeSSional staff that can pelform the test as well as intelpret the data. they are only appropIiate for predicting \10 2 during steadystate submaximal aerobic exercise. For the greatest accuracy. that is.rith caution.0 and the plimary fuel source for energy metabolism is carbohydrates.0 kcal' L -I \10 2 is used. it does not lend itself to large numbers of subjects or patients.I ). 20. \10 2 provides useful information for exercise professionals.rind. therefore.l or mL·kg-1·min. Moreover. • The energy expenditure associated v. oxygen consumption (\10 2 ) and carbon dioxide output (\[C0 2 ) are calculated. • These equations were derived during steady-state submaximal aerobic exercise. measUling \10 2 is impractical in most nonlaboratOJ')' or fitness situations. milliliters per kilograms of body mass per minute (mL·kg-l·min. snow. In this notation for \10 2 : • the V stands for volume • the O 2 for m.I ) . This increases to 5. which directs the expired air to an integrated metabolic system and computer interface that measures the volume and percentage of O 2 and CO 2 of the expired air.e. several cautionmy notes about the use of these "metabolic equations" are in order: • The measured \10 2 at a given work rate is highly reprodUcible for a given individual. The \10 2 is overestimated during non-steady-state exercise conditions.e. is 0.. when the contlibution from anaerobic metabolism is large. Net V0 2 = Gross V0 2 - resting V0 2 Measurement of V0 2 The actual measurement of \10 2 typically is performed in exercise laboratories or clinical settings using a procedure called open-circuit spirometry. DUling opencircuit spirometry the subject or patient uses a mouthpiece and nose clip (or mask). Therefore.rith a given level of \10 2 varies slightly \vith the respiratOly quotient (RQ). expressed as either L·min.1 ·min. The energy requirements of physical activity are calculated by measuring or estimating the oxygen requirements of the amount of exercise or activity being performed. v. the volume of ox)'gen per unit of time. or to other indices of body size.70. commonly called the m. \10 2 can be converted to the overall rate of energy expenditure (kcal): • The consumption of 1 L of O2 results in the liberation of approximately 5 kcal (i. l--.. The relative rate is used when compaling the \10 2 of.1) 7 kg body mass = mL·kg. Subsequently. • The gross rate of oxygen uptake is the total \10 2 including the resting ox')'gen requirements. "'hen HQ is not k'l1own."ygen • the dot above the V denotes a rate. typically per minute Vmious expressions of \10 2 are used depending on the pUlpose for its measurement: • The absolute rate of \10 2 is typically expressed by the unit liters per minute (I·min. one may eX1Jress \10 2 relative to kg of fat-free mass. which is the ratio of \1C0 2!\102 .I or mL·kg-1·min.

APPENDIX D I METABOLIC CALCULATIONS 289 288 SECTION IV I APPENDICES TABLE 0-1.1 mL O 2 is needed for transporting each kg of body mass a horizontal distance of 1 meter (m).1 + 3.1 ·min.2 mL·kg. These speeds (3.9·5·G) + 3.5 mL·kg-l·min. such as how much m.ygen demand of raising one's body mass against gravity at sea level for walking on the treadmill or ground is approx.1 ·min.1) (body mass in kg) + 3. min.1 ) (body mass in kg) + 3.1) (1.1 ·min. no rail holding during treadmill exercise).05) .5 mL·kg.1 ·meter. Horizontal Component (Running): The oxygen demand of running the same distance (1m) is twice as great (0.1).1 ·min.1 Stepping • • • • • Horizontal Component (Walking): During walking. work rate (kg·m·mll1.1 .1 Running V0 2 (mL·kg. II Besting \10 2 = 3.8·H·f) + 3.5 mL·kg.9 mL·kg.1 ·min.ygen cost of walking.0 mph) are in the range of" the transition from a walking to running motion.8 mL·kg.&--lo Veltical Component (Bunning): DUling running on a treadmill or over ground.8 (work rate)/(BM) + 3.1 ·min. • \10 2 (n~.33·1. For each prediction equation.kg-l.8 mL per kg of body mass for each meter (m) of veltical distance (1.1 ) = 0.~.1) = (1.1 ·meter.1 ) = [0.ygen is required to move the body hOlizontally (walking on the flat) and veltically (walking up a grade or hill) or the oxygen costs of pedaling at no resistance.1 ·min.1 (speed = = 0.1) = (3 mL·kg. The degree of transition varies depending on the individual's size..1 ·meter. the proper and judiCiOUS use of metabolic calculations prOVides valuable inf"ormation to the exercise professional.1 ) + (1.5 mL·kg. Metabolic Equations for Gross • The use of" the prediction equations presupposes that ergometers are calibrated properly and used appropliately (e.7 mph) I 5% grade is 0.8 mL·kg.50 to ]00 m·min.5 mL·kg. 7 . (O.1 (speed) + 1. apprOXimately 0.1 f ractlonal ' m·mln grade is in decimal form. therefore.1 ·meter.5 mL·kg.8·S·G) + V0 2 (mL·kg.1 ·min. BM is body mass (kg). leg length.1 ·5 (m·min.(\.1 ·S (m·min.5 mL·kg.5 mL·kg. G IS the percent grade expressed as a fraction.. 5 is speed in m·min.1 Arm Cycling V0 2 (mL·kg.1 ·min.1 ·min. and stepping. 1 mph = 268 .1 ·min.1) = 3 (work rate)/(BM) + 3.' = ] MET (metabolic equivalent) V0 2 (mL·kg.I ):.1 V0 2 (mL·kg.1 ·min. leg ergomctry.1 V0 2 (mL·kg.1 ·min.1 ·min.1) = (O.1 ·S (m·min.1 ·meter. there are some essential known phYSiologic constants. • The equations are most accurate at the stated speeds and power outputs.g.8 mL·kg.5 mL·kg.1 ·min.2 mL·kg.imately 1.7 Bunning on a level surbee is more costly than walking because of the greater veltical displacement that occurs between each step and the greater need to overcome ineltia to maintain the greater speed.2·f) + (1.5 mL·kg.1 ·min.1 V0 2 (mL·kg.1) x (step height in meters) (steps·min.1 ) = (O.kg.1 ·min.9-3.1 ·min.8 m·min1 • Most accurate f"or speeds of.5.ygen cost of vertical ascent is half that of walking or 0.1) = (0. interindividual variability in \10 2 is very wide within this speed range.1 ) + 3.1 ·min.1)] + [1. • Conversion: 1 mph = 26.' )fi. arm ergometly.l ·meter.1 ·min.1 ) = 1.min-l) mL·kg ·min.1 ·5 (m·min.1 ·min.. There is a range of" walking speeds for which neither the walking nor the running equations are applicable.5 mL·kg. f is stepping frequency in minutes.1 )] + [0.9 mL. and normal walking pace.1 V0 2 (mL·kg.2·5) + (O.8 (speed) (fractional grade) + 3. Veltical Component (Walking): The m.5 mL·kg.1) X (work rate in kg·m·min.l·S) + (l.lmL·kg-l·min.1 ·min.1 Walking and Running Constants V0 2 (mL·kg.5 mL·kg. V0 2 (mL·kg.' .1 ·min.8 mL·kg-1·min-1). running.1 + 3.1 V0 2 is gross oxygen consumption in mL·kg. ' .1 ·meter. Walking V0 2 in Metric Units* 3.5 Walking Equation m·min-1.'1 Despite these caveats.1 ·min.1)·G] + 3.7-.2 (steps·min.1)·G) + 3. the m. stlide length.1 mL·kg.1) = [0.' ·min. H is step height in meters.1 Leg Cycling DERIVATION OF METABOLIC EQUATIONS Table D-l presents the metabolic equations f"or the gross or total o).33 mL·kg.I .1 .1) x (work rate in kg·m·min.

1H • Conversion: 1 inch = 0. 12-14 • The cost of cycling against the external load (resistance) is approximately 1.m -min -I for the leg and arm ergometer equations. most likely because of the recruitment of accessory muscles needed to stabilize the torso.8 mL-kg-l-min.9 (speed) (fractional grade) + 3.kg.6 to 15.5. 2) the external load (amount of resistance). and an additional one-third of this (1.1 perkg-m-min.I (50' d ~ • V0 2 (~~L-k(:-min-l) = 1.33-1.1. Use the walking equation if the individual assumes a walking patte111.1 and step l~eights 0.I) = R (kg)-D (m)-f(revolutions per minute) R = resistance setting in kg.ygen cost against the external load during arm ergometry is greater than that of leg ergometIy. The total oxygen demand of leg ergometry includes: 1) unloaded cycling (i.5 2 mL-kg-J-min.ive to restmg values .33) must be added to account for the O 2 cost of stepping down. Leg and Arm Ergometry • ~~ Most accurate for power outputs between 300 and 1. I·a te d f"10111 tI ' . hxed bench. as well as up and down.I \Vatts = kg-m-min.APPENDIX D / METABOLIC CALCULATIONS 291 290 SECTION IV / APPENDICES Leg Cycling Equation Running Equation • Most accurate for speeds> 134 m -min-I (.8 m-min 1 fractional grade is in decimal form. and stepping do:vn with the first and then second leg in a repetitIve fashlOn.8 mL-kg-l-min. the arms arc less efficient than the legs dUling cycling. 8M = body mass [kg]) Stepping Ergometry Constants Constants Power is ex-pressed in kg. the movement of the legs). 1 mph = 26.. and 3) the resting oxygen uptake_ • At 50 to 60 rpm.I (25 and 125 W) V0 2 (mL'kg I-min-I) 3 (work rate)/(BM) + Resting (3. D-6 were C<I le equations as a practIcal reference for the gross V0 2 for the respective types of steady-state exercise..7 in.0 mph) observations of the individuals gait pattern determine which equation (walh'ing or running) may be most accurate. Use the running equation if thc individual has to assume a running gait.12.4 m for Monark arm crgometers r= • the pedaling frequency (revolutions per minute).An ox . • Therefore.I. D = distance in meters (m) the flywheel travels for each pedal revolution is performed traditionally in a four-part process of lifting one leg onto a box.15-1.5 mL-kg-I-min.l .2 (stepping rate) + 1.5 mL-kg-I'min. In the scientific literature.0254 meters (m).04 to 0.I divided hy 6 [or more accu- rately 6.1 . the ox)"gen cost of unloaded cycling is approximately 3.e.min -1 (3. 5% grade is 0. pushing with this leg to raise the body.8 (work rate)/(BM) + Resting \10 2 (3. The \700 in each of the Tables are presented in METs. the deceleration against gravity6 Stepping Equation Step~ing • • 6 m for Monark leg ergometers • 3 m for Tunturi and BodyGuard ergometers • 2.l ) (work rate = kg-m-min. approximately 3 mL.8 (step height) (steppmg rate) + 3.5 mL-kg -mm ) + Unloaded cycling (3. The oxy?en cost of stepping has horizontal and vertical components because one moves forward and backward horizontally. or step. To determine the power output during leg or arm ergometry: • Power (kg-m-min.5 mL-kg-1-min.2 mL. • Vertical Component: The O 2 demand of vertical ascent is 1.ygen up t·a ke 0 I' 8 MET < s means t Ilat the m.' -min I) = 0. .0 mph) but appropriate for speeds as low as 80 m-min.2 mL O 2 per four-cycle step (stepping up and down) per kg of body mass (0. METs express oxygen uptake rela.40 m (1.kg I). Practical Use of the Metabolic Calculations Tables D-2 thru .5 mL-kg-I'min I (Stepping rate = steps'min. • V0 (mL-kg-I-min-l) = 0.200 kg-m-min.) • V0 2 (mL..1 above rest.1 speed = m-min 1. Icu . placing the other leg on tl~e box.kg-I-min -I per kg' m -min -1. • Most accurate for stepping rates between 12 and 30 steps-min. Horizontal Component: The oxygen demand of the horizontal movement is approximately 0.ygen require- . step height = meters) However.05 For speeds between 100 m. the m.7 mph) and 134 m-min -I (5.I (3 mph) if the individual is truly jogging or running. BM = body mass [kg]) Arm Cycling Equation • • pu Most accurate for 110weI' au t tsl1etween 150 an d 750 kg-m-min. power is most commonly expressed in watts [\V] as opposed to kg-m-min.l ) (work rate = kg-m-min.2 (speed) + 0.

7 4.7 8.e.8 9.4 9.3 9.6 12.1 6.5 10.4 13.8 5.3 10.7 7.5 5.5 4.5 3.1 15.1 12.5 25.2 3.2 112 12.9 11.6 9.3 5.5 42 49 5.3 9.0 3.5].4 11 .6 4.8 14.5 8.6 3.3 7.457 3.0 10.6 5.4 5.0 17.4 7.8 7.8 10.0 6.8 2.356 0.0 12.4 10.6 8.9 11.1 17.0 19. Approximate Energy Requirements in METs for Horizontal and Grade Jogging/Running mph % Grade m'min1 5 134 6 161 7 188 7. when there are two unknown variables (i.6 5.9 43 5. and then solve for thc fractional grade.3 7.2 3.5 15.6 8.7 8.6 9.9 3. Once the net V0 2 is determined.2 15. Approximate Energy Requirements in METs for Horizontal and Grade Walking mph %Grade m'min-' 1.7 8.5 10.0 53.5 7. TABLE 0-4.3 4.1 4.7 10.6 2.0 12.6 2.2 12.9 5.5 10.3 14.7 12.l ·min.2 6.6 5.5 6.3 18.4 11.3 2.7 45.9 14.9 11.9 3.8 6.1 10.8 8.2 6.7 19.3 11 .2 8.6 4.2 3.5 20.0 12.4 5.4 17.4 8.5 3.0 22.9 120 10.6 8.1 9. Convert V0 2 (mL·kg-J·min.000 b. Approximate Energy Requirements in METs During Leg Cycle Ergometry Power Output (kg'm'min.3 8.3 6.8 6.6 4. kg Ib 150 25 300 50 450 75 600 100 750 125 900 (kg'm'min ') 150 (W) 0 2.2 4 6 8 10 12 14 16 18 0.7 9.3 8.8 15.200 (kg'm'min.6 5.7 6.6 3.5 6.9 3.1 .0 8.5 7. Approximate Energy Requirements in METs During Arm Ergometry Power Output (kg'm'min ' and W) 80dy Wt.6 8. If starting from mL· kg-I.0 14.4 4.5 10.4 91.305 0.3 9.5 9.4 38 4.1 2.7 18.0 4. Metabolic equivalents (METS) are calculated as METs = V0 2 (mL·kg.0 80.3 4. Multiply the mL·kg-l·min.6 12.e.3 16.5 TABLE 0-5.9 4.2 15.6 13.3 15.5 16.2 3.7 ment of the task is cight timcs that of rest.7 8.7 6.1 4.102 0152 0203 0254 0. 1.1 8.5 5.4 9.5 6.9 5.9 9.6 7.5 17.3 12.4 6.1 13. For purposcs of prescribing exercise.5 67.9 14.8 5.1 8.9 4.9 5. kg TABLE 0-6.9 12.0 7.4 2.5 5.0 7.I )/3.2 2. min -1: a.1 6.1 or METs) into the absolute unit ofL'min.9 8. another utility of the metabolic equations is to estimate a target work rate that will elicit a desired level of oxygen uptake or energy expenditure.5 6.3 17.5 13.4 82 90 9.6 83 7.4 6.6 2.0 7.2 7.OOO (i. Method #]: 1.9 7. the V0 2 should first be expressed in net terms (gross V0 2 minus resting V0 2 ).75 100.7 12.0 79 88 9.0 13. In the case of treadmill exercise. convert the value to caloric expenditllre per minute using either of the following methods.6 6.5 5.4 14.1 7.1 16.5 15.292 SECTION IV I APPENDICES APPENDIX D I METABOLIC CALCULATIONS 293 TABLE 0-2. Approximate Energy Requirements in METs During Stair Stepping Step Height in m 20 22 Stepping Rate per Minute 24 26 28 30 Ib 300 50 450 75 600 100 750 125 900 150 1. If knowledge of the caloric cost of exercise is desired.5 10.6 11.1) 200 (W) 50 60 70 80 90 100 110 132 154 176 198 220 5.9 3.1 6.8 11.8 4.5 11.4 18. speed and fractional grade).000 mL per Liter).3 4.050 175 1.8 16.8 5.4 16.6 4.9 79 9.5 7.0 9..4 3.9 13. mL·kg-l·min -1 kg body mass/I.406 0.7 TABLE 0-3.0 8.. it is best to select an appropriate speed based on the ability and comfort of the client.8 6.6 78 7.2 5.8 9.6 5.2 90 8.1 5.0 11.3 4.8 50 60 70 80 90 100 110 132 154 176 198 220 3.9 19.1 by the kg body mass and divide by 1.4 23 6.3 14.3 6.7 3.4 6.3 3.3 13.6 11.1 4.8 10.4 16.7 16.0 2.4 16. The equations are solved for the unknown variable on the workload side of the equation.3 5.4 7.0 7.1 7.1 and W) 80dy Wt.1 2.7 10.0 7.9 5.7 8.5 201 8 214 9 241 10 268 0 2.4 7.4 11.8 13.

1 = 1.8 (93. Convert the \'0 2 in METs directly to caloric expenditure using the equation below from Chapter 7.70) (44. use the leg cycling equation and solve for the unknown work rate.8 = 168.l) Target V0 2 (mL'kg.8 (fractional grade) 0.5 mp/l X 26. a maximal heart rate of 190 bpm.0 mL'kg. of 48 mL· kg-I'min . weighs 180 lb. reserve (\102.I He \\~shes to begin an exercise program including treadmill walking and leg cycling on a Monark ergometer..259 (kg'm'min.1 34.and then complete step 2a.7 = 0. what resistance setting would be required? A: Work rate (kg'm'min.l ) by multiplying by 5 (i.5 mL'kg. V0 2 (mL'kg. Using feedback fi'Olll the subject.259 kg'm'min.129 = fractional grade = 12.1 (speed) + 3.1 ) = (0.5 mph.8 m'min.e.1) = (resistance setting) 360 If using a straight percentage of V0 2 Target V0 2 (mL'kg.1 'min.1 'min.5 kcal per L O2 during steady-state exercise) Method #2: 1.1 as the target V0 2 (i.8 kg 2266 = 18 (work rate) x (V0 2 R) + V0 2fe51 Target V0 2 (mL'kg.I 'min.7 mL'kg-I'min.1 + 1.6 mL'kg.8 m'min.t ) = 7.1) 31..5 mph.2 = 9.1 'min. If starting from METs: 1 a.1 (938 m'min.1) "'(lX as the target V0 2 : 3.I ) to caloric expenditnre (kcahnin.1 'min.e.'min- 1 Q: If he is comfortable pedaling at 60 rpm on a Monark cycle.I ) on the Monark bike') A: First determine his body mass: 180 Ib/2.5 mL'kg.38 + 1.1) = (resistance setting) (6) (60) 1.. Kcahnin .') A: First calculate the \10 2011 ".1 ) = (resistance setting) (distance) (pedal cadence) 1.294 SECTION IV / APPENDICES APPENDIX D / METABOLIC CALCULATIONS 295 3.259 (kg'm'min.8 (fractional grade) 21.1 ) + 1.1 'minl ) 1.8 kg Then.5 kg = resistance setting = (exercise intensity) x (V0 2011ax ) / .8 (938 m'min. Convert \10 2 (L'min.8 kg V0 2 R = 44.8 m'lIIin.5 31.. 70% of his V0 2R) Q: If he is walking at 3.8 (speed) (fractional grade) 34. a.1 = 70 + 1.1 = work rate t + 3.I = (METs X 3.1 'min.1) = 0.8 (work rate) / (body mass) + 1..1 'min.1 ) = (exercise intensity as a decimal) 27.R) V0 2011ax = 48 mL'kg.m. V0 2 (mL'kg.5 X body weight in kg)/200 Target V02 = 33.5 to obtain mL·kg-l·min. Answer the following questions: Q: What is his target \10 2 using his \102R and a straight percentage of \10 2011 ".I ) (fractional grade) + 168.1 CASE STUDY EXAMPLE A 30-year-old man has a resting hemi rate of 60 bpm.1 ) (fractional grade) + 3.1 A: Use the walking equation and solve for the unknown fractional grade.1 ·min. and has a \10 2011 .7 mL·kg.1 Then calculate the Target \10 2 (mL'kg-I'min.1 'min.9% grade Q: What is the target work rate (kg'm'min.1 'mil1. approximately .8 = 93. 4.1 'min.1 (93. 7 mL'kg. how steep should the treadmill grade be to elicit a \10 2 of34. you select 70% \10 2m "x as his initial training intensity. you estimate that a comfortable walking speed for him is 3.5 mL'kg.8 (work rate) / 81.2 = 81.1 The remainder ofthe questions will use 34.1 'min. Based on his physical acti~ty history and aerobic capacity.I 'min.8 (work rate) / 81.5 mL'kg.2 = 0.7 mL'kg.' ') Remember: 3. Multiply the MET value by 3.

2 mL·kg I·min.000 Net caloric expenditure in kcal'min 1 2. on level ground. \oVhat is his average net VOz (in mL·kg-l·min.1 All of the aforementioned treadmill prediction equations assume that the patient does not use handrail support. 7.1 'min.8 .55 L'min 1 x 5 = 12.35 mL'kg. If this same man exercised at this intensity five times per week for 30 minutes each session. 6. The available equations are either generalized equations that can be used across gender.I V0 2 in L'min 1 = ANSWERS 1. If an indi\ridual reduces his or her dictary intakc by 1.m. One such commonly used equation is based on the Bruce protocol:l.5 mL·kg-1·min.l B V0 2max (mL'kg.HR. What is his estimated gross VOz? 2. can be predicted using the following equation that adjusts for the use of a ramping treadmill protocol: 19 V0 2max (mL'kg. 4.282 (time in min) + 8.1 PRACTICE METABOLIC CALCULATIONS (WITH ANSWERS) I.1 'min.1 .4 mL'kg- (x is the predicted V0 2 calculated for the peak speecl!grade using the ACSM walking equation) Another validated equation for use \\rith a Ramp Blllce Treadmill Protocol is: 2o V0 2max (mL'kg. such as peak or maximal levels of exercise.1) = 2.012 (time 3 ) + SEE = 3.kg-"min l). then at 450 kg·m·min I for 15 minutes. non-handrail-supported exercise may be impossible or result in early test termination because of anxiety on the I?art of the patient.0 SEE = 3.4 mL'kg. For such instances.5 mph and a 1.9 kg (or kp) About 20 weeks 12.1 14.' 10. how much wcight (in Ib) would he or she lose in 6 months (26 weeks)'? 6.1) (body mass) /1.1 'min.1 'min. how long would it take him to lose 12 Ib (assuming all calOlies expended in this exercise are in excess of food intake)') Hint: Use the net VOz to calculate the exercise energy expenditure. age. what would her gross \10 z be (in mL.1) 0.750 kcahvk.1 'min. A 198-lb cardiac patient \\rishes to use an arm ergometer for part of his rehabilitation program.92 mL'kg.296 SECTION IV / APPENDICES APPENDIX D / METABOLIC CALCULATIONS 297 Q: What will be his net caloric expenditure dUling 30 minutes of exercise') A: :\let VOz = 34.379 (time in min) 0.1. V0 2 .9 (time in min) -7.67 SEE = 4. If an 18-year-old girl steps up and down on a 12-inch step at a rate 01'20 steps (complete up and dO\\~l cycles) per minute.l ) over this session'? 5. or they are protocol specific and are a function of the time of exercise completed for that specific protocol.70) (130) Target HR = 91 + 60 + 60 + 60 The metabolic equations presented in Table D-1 were derived during steady-state exercise and are not applicable for estimating non-steady-state conditions.1 'min. 3. 7. A 71-year-old man weighing 180 Ib walks on a motor-driven treadmill at 3. Other prediction equations have been deJived for use dming peak or maximal exercise. He works at a power output of 300 kg'm'min.1 (V0 2 in mL·kg-1·min..) + HR"est Target HR = (070) (190-60) Target HR = (0. for patients who may be unsteady or have difficulty walking on a motorized treadmill.I for ]5 minutes. Using equations derived during steady-state exercise overestimates the V0 2 during non-steady-state conditions and should not be used.12x 'min.55 L'min 1 = 2.l . 39. what setting (kg) would you use at a pedaling rate of 60 rpm'? 3.? 7.451 (time 2) = - Target HR = 151 beats'min. 4. ModifYing the protocol invalidates the equation.1) = 1 0. and for different protocols.1 + 3.".9 METs Net caloric expenditure for 30 minutes = 128 kcal·min x 30 min = 384 kcal ESTIMATING V0 2MAX Q: What is an appropriate target heart rate according to the heart rate reserve method? A: Target HR = (exercise intensity as a decimal) (HR n" " .1 = (312) (818) /1.2 mL·kg-'·min.3.000 = V0 2 in L'min.7 mL·kg-l·min 1 . However.545 SEE = 4.5% grade..5 mL·kg I·min-I = 31. 5. A man weighing 176 Ib nills at a pace of 9 minutes per mile outdoors.i ·min. What is his gross MET level'? Ramp treadmill protocols are discussed in Chapter 5.1 'min-') = 3.8 kcal'min.1mL·kg.1 1 2. there is a validated equation for predicting V0 2m "x dUJing handrail suppOlied treadmill exercise using the Bruce protocol: 21 V0 2max (mL'kg.J 131b 22. To match this exercise intensity (from #] above) on a Tunturi cyclc ergometer.

Estimatioll of \f0 2111 . SEtorer T\V. years = age) Females: 20. .~( uati Sports Ex~re 1992.\lIna o. Latin R\I'. Porcari JP." < b ' cl. gender. Agh~mo P. . ~I~d Sci Sports Ex~r(' 19117. et al. I ) .3.'\'de erl1ometr\'.:tiollal aerohic iinpairlllt. elllO( ynalllll' response to work with difkrent Illuscle groups. 19:253-259. t'1O )1(: reqLllrelllcnh of O\'ervround fUllmng. Evaluation of a llew standardized ramI' lJrotol'ol: I 3 plotocol. 't' I' .t1. .·11 T.' 1(( Ie Ion 0 ma.LD. Buehanan 1\. Validation of the Rockport Fitness Walking Test in college males and females. R~hahiJ 1998. The aeeurac)' of the ACS\I c\de ~r"ometl . ~Ied Sel Sports Eserc 199-1.18:-138--144. Workman jM.A.. Dolgener FA.l:99-J 24. mg. I'r~dicting Jim('tional • .65:152-158. Tesls nf nl<tsimnm osyg~n uplak~. and body weight. ca )acit .· . ~e~'l'gard ~'.5-mile run are given in Table D-7. ' . .5 + 483/ (time in minutes) *See references 23 and 24: From Kline GM.2 I :37-46. . .J A' I' tI B RepOlt.0. kg = body mass.'. Oxyg~n eost of hmiLOntal and grad~ walking and running on th~ tr~admili.3:6:3-66. IB:253-2.11 jA I 0 .J--712.7:. s ep lesls V0 2max (mL·kg.1) = 10.. I • ' .s)'gen uptake r~sponses.II'. . ACl'uratp prediction of \'0211l.. ' ". or body weight for enhanced predictive accuracy. I 1~ I SUlEruce Ramp 21. .5: 152-1. 8.88 (years) + 136. df . et a1.1692 (body mass in kg) . such as age. Porcari JP.1. during cycle ergometlY using 15 W per min increments.0. Gradational st~p tesls for ass~ssing \\ork capacity. j Canilopullll Behahi' 19117.1049 (years) 1 + 5193 18. Commonly used field test equations for the I-mile walk and 1.58. . 196. ~IcConnell TB Chrk BA p. . 12 or 15 minutes).1 ·min. Kc.l9:4. ( .. March JJ. Bruce HA. J Appl physiol 1963. and hod)' weight.1) = 3.g. ' . ObSelY'lIions 01' " SEE = 212 mL'min- ' " nc\\ (\\1 = final power output completed in watts. S1ttrng and SUPll1~. Pollock M L.7 SEE = 147 mL'min- 22. A eritieal re.1) = 132. l.liking. years = age) FIELD TEST EQUATIONS Field tests are an efficient and economically feasible option for predicting V0 2".\)gcn consumption of cycle eraOllle!" IS nonltn.7 (kg) 1 5.5-Mile Run Test 11. J Appl \'f:'I"SliS ph)'siol (gender = 0 for female. llenseh. Compatihilitv of proaressi"e tw.L\ in t. An exp~rlln~ntal sludv of "pll\'sieal fitlless" of 'Ii' l' '. Giese ~ID N'l"l~ Fj et·1 A . Shephard Bj. • . Oxygen eosl of Irea.' <. 4.1 ·min.5:17:477--481. (V" = final power output completed in watts. '. ~ . Hintermeister R. Hensely LD. ag~.L\ from a one-Ill ill' track walk (fendel. gender.51 (W) + 635 (kg) .18:367-370. Baptista G.0 mL·kg. A". Maximal oxygen intake and 1100lH>graphic asseSSlnent of fUIH.298 SECTION IV / APPENDICES APPENDIX D / METABOLIC CALCULATIONS 299 TABLE 0-7.oma City. \ ~'Ilal(:y J\I J I.al~s. heart rate (HR) is taken at end of walk) 1. kg = body mass. 1 or 1. 107: I 229-123~.. \Iarch . 1971. 1_ leg(' lIIalt's and f~". A simplified field test lor 'L"essm~nl nf pl1\·sie·t1 fltlw" C' .1 ·min. Berg KE. .22:61-70. 11 V0 2max (mL'min. Ch~sl 1992. Balke B. Estimation of V02max from a onemile track walk. M~d Sci Sport.3877 years) + 6315 (gender) . Common Field Test Equations to Estimate Rockport Walking Test (1-Mile Walk) V0 2max * 6. et a. Ie. et al..1.39 (W) + 7.22 Males: V0 2max (mL·min. Dolgen~r FA. 1 for male. t 1'10 0- tr~admill.10:67.g. j Appl Physiol 1963.85:546-562. 3.324-:331. Exercise tesling wilh gas ~xehang~ analysis.5-780 b • 15.-' 0111 . ('t al. age.26:642-646. . Stenherg j Astr'rnd PO Ekhi B t· I H I ' '. Field equations may incorporate other independent variables. ' . Armed Nagle 1'. 18:798-803. 23. Ill's Q Ex~re Sport 1994. 17. ~Iofntt-G~rst~nher"~r j p. ' . Bassett DB jr. . Cerrel.lJnmg '111( arm ergomelr)'. . Armstrong B\\'. j Cardll1puJ". ~s~arch Institnlt' Margaria R.2649 (time in minutes) ~ 0 1565 (HR).3~149~154.6. S"'ith D.20: 19-22. Kli:W GJ\I. (age in 9. Cardiol Clin 2001.co 2. M)'ers j. \'alidatiou of th" Bock1~orl Fitn~ss Walking Test in . 7. .. Kusumi 17... " ) 1 on. Okl.5 miles) as qUickly as possible or cover the greatest distance possible in a fixed period of time (e. Individualized ra"'p col. b treadmill 12.59 '" 24.'ts 'x. when large numbers of individuals are being tested or the use of standard ergomctlY is not possible. . 19. I ()Ice p~lsoone. jackson AS. Gen('rajiz~d e'luations lor f.dmill bic' l i t bascd on o.om treadlllil' perronnan('e.-'nt in cardiovascular disease. Circulatory adaptation to ann and leg (:"xen:ise in 'supine anJ Slttlllg po"tlOn. I01:2.\led Sci SIJO. ~ladha"'111 B. ~~~2~'j7-1~~:8B. Lang PB. (SEE = 5. Dill DB.24:272-276..HiJ1terlllt'istt"r H. Sporls ~Ied 19114. reyschuss U. <. H""rt j 1984. et al.3:J-445. Franklm BA Esercise I"st' t . g 14.. ~t al. II "Iom~.e <I. I . Med Sci Sports Exerc 1987.\de ergollletrv equation for \Olll) women. . " .2: 100-JJ9 16.1 ) 10. . Caiozzo \'J. Latin HW ' B~r" KE • The < 'WClll"IC\' I' tl ACS~I 1 ~. Res Q Exerc Sport 1994. Ware R\I.. Med Sci Sports Exere 1997'29:77. I" . ~I~d Sei V0 2max (mL·kg. REFERENCES I.5. 5. My~rs J.. Naughton . These tests involve walking or running over level terrain to either cover a fixed distance (e. .-688. \c ~ an. I US Forces ~Ied j J959. j Appl Physiol 1966. Foster C. Hoslller D.\)'gen consumption Juring handrail su J JOlted tre"dmilleselc"e.·i~w.Ole !' allt a new c.uly r~Jat('d to work rate and p~dal rate. Med $<:1 SPOIis Exert:: 19H.1 ) = 9.'... Da~is JA.elli 1'. J Appi Physiol 1965. Balke B.hnill w.. j Appl Ph)'siol 1967. . For predicting V0 2um.1Il1insky I . Sports \Ied 19S. Lond~rcc BR.36S-2-11S. Aill Heart J 1973. ~t al.853 . et al. c l l( t .. Balke B. I.0. 13. Strallch..'rc 1990:22. Energy cost of running.

Approximate risk of heatstroke or heat exhaustion during competitive distance running. fitness profeSSionals and clinicians can use industrial standards. Figure E-l illustrates categories of risk for heat illness.28:i-x... also may be applied to exercise environments. >. exercise intensity.3 T9 300 The first use ofWBGT occurred in the 1950s at militmy bases. Reprinted with permission from Armstrong LE. Epstein Y. cold.. or competitive activities (and the clinicians and trainers advising them). which is measured by placing a wet wick over a thermometer bulb eX}Josed to natural air movement.0 .2 T9 + 01 Tb Indoors. air movement (i. heat cramps. Ql 100 35 90 30 80 25 70 20 E Co The human body constantly responds to changes in the surrounding environment to maintain health and performance. established by the National Institute for Occupational Safety and Health (NIOSH).. the American College of Sports Medicine (ACSM) has published guidelines regarding competitive exercise in heat 1 For example.. American College of Sports Medicine position stand. The exertional heat illnesses (i. + 0.. WBGT is calculated as follows: WBGT = 0. if not. Greenleaf JE. and solar radiation from the sun. The WBGT is determined vvith specialized instruments that are commercially available. heat exhaustion. with the goals of quantifying heat stress and preventing heat illness. heat.. body core temperature is affected by air temperature.7 Twb + 0. Other guidelines. et al. Heat and cold illnesses during distance running.. the temperature measured inside a 15-cm diameter copper globe painted flat black. For example. no single standard defines safe upper limits for temperature and humidity during exercise. 2 as a convenient starting point. based on air temperature and humidity.. age. WBGT is calculated using this formula: WBGT = 0. Outdoors.'v1 position stand that focuses on competitive distance running. These ~teps include limiting the maximum duration of continuous exercise and requirmg rest breaks between exercise periods. ::3 I II . NIOSH standards denne WBGT levels at which the risk of heat injury is II1creased. In a hot environment.. but exercise can be performed if preventive steps are taken. and high altitude comprise the greatest concerns for people engaged in recreational. humidity.7 Twb 0 20 40 60 80 100 --dry . These environmental conditions exacerbate the physiologic strain of exercise.wet~ Relative humidity ('Yo) FIGURE E-1. the temperature of internal organs increases. and illness that modify the physiologic strain imposed by a given environment.3 These guidelines can help to prevent dangerous elevations in body temperature during exercise and mitigate the deleterious effects of dehydration. eventually reaching dangerous levels. C 60 Heat and Humidity Muscular contractions generate heat that must be released to the environment. Med Sci Sports Exerc 1996.. Table E-l prO\~des recommended exercise-rest intervals derived from NIOSH standards for moderate and vigorous exercise based on WBGT measurements.. UnfOltunately. fitness. The wet-bulb globe temperature (WBGT) integrates the effects of all these factors into a single value.APPENDIX APPENDIX E / ENVIRONMENTAL CONSIDERATIONS 301 E Environmental Considerations OF 110 °C 40 . High ambient temperature and humidity impede heat dissipation. when relative humidity is high (>70%). fitness. and heat syncope) are described in an ACS. the WBGT tends to underestimate the risk of heat illness 4 Further.4 However. ..e. Subsequently. wind speed).0 ::3 Ql Ql .. for industrial and military populations.. The WBGT index combines dry-bulb air temperature (T b).e. 2 . '''''BGT does not account for factors such as clothing insulation. natural wetbulb temperature (Twb). and globe temperature (Tg )... heatstroke. I For noncompetitive exercise.. For example. acclimatization. the 'VBGT index has limitations.. However. other organizations promulgated similar 'VGBT guidelines 1--3 that have successfully reduced the incidence of heat illness during hot weather physical activity.

• Relocate exercise to a shady. . The first exercise session in the heat may last as little as 10 to 15 minutes for safety reasons. Most healthy people become fully acclimatized to the heat in 10 to 14 days. a-agonists. A prior history of heat illness or difficulty acclimatizing to heat also may fc.:. A . at a rate of 16 oz of fluid for each pound of weight lost. water is the replacement drink of choice. sodium and chloride) concentration decreases. Those who eat a low-salt diet should visit their physician to discuss the effects of exercise on their salt balance. sodium. although illness or alcoholldrug abuse may slow this process. HEAT ACCLIMATIZATION This process involves a series of physiologic adaptations that decrease the risk of heat illness and improve exercise performance in the heat. not maximi.. Ob~sity also impairs h~at dissipation.e~ast future problems. Generalized drinking r~commendations are difficult to make. 1986. diabetes-associated neuropathies. followed by a rest period for coolIng. Following heat acclimatization. cardiovascular disease. rugs (e. f3-blockers. calcium) usually are small during brief exercise sessions (20.e. athletes who exercise for more than 3 hours continuously ought to realize that drinking too much flUId can lead to a serious medical condition known as hyponatremia. breezy site or indoors with fans and air conditioning.g. drinking alleviates thirst sensations well before sufficient fluid is consumed to replace sweat losses. exacerbate dehydration.0-81. a person's water requirement increases but the salt requirement decreases. in hot or humid weather. Guidelines for Safe Exercise Duration: Rest Periods for Healthy Unacclimatized Persons* Moderate Exercise Work/Rest Periods (min·h-') Vigorous Exercise Work/Rest Periods (min·h-') DEHYDRATION Maintaining proper hydration is a key to preventing heat illness and optimizing performance. Fluids should be chilled (59°F-72°F) and palatable to encourage consumptIon. potassium. Thus.g. d ~ . and after physical activity. Their goal ought to be to optimi. 70. The best method of inducing heat acclimatization is to exercise in the heat. even though the work of the heart (myocardial oxygen uptake) remains unchanged. andmcreases the risk of heat iIl8 ness Clinicians and exercise profeSSionals should consider these limitations when recommending exercise programs for hot weather. Other strategies to alleviate heat stress include: • \Vear clothing that allows heat loss and sweat evaporation. Notes: Times indicate recommended maximum duratIon of Intermittent exercise.:. For the vast majority of workout sessions.e. progressively higher exercise intensity is tolerated and required to elicit the THR.9 73. Also. Occupational exposure to hot environments. Profuse sweating can lead to serious dehydration unless adequate fluid is consumed. body temperature. hypertension. Unless the exercise bout lasts more than 50 to 60 minutes. For example.e.0-76. For example. the heart rate. DHHS NIOSH Pub!. diuretics.. FItness facilities and organizations that offer exercise programs must fonnulate a standardIzed heat stress management plan for hot or humid weather. rating of perceived exertion. before beginning another exercise bout. a reduced speed or resistance achieves the THR. Cnteria for a recommended standard. and ~gmg may impair cardiovas:ular. progressively increasing the duration and/or intensity of exercise for 10 to 14 days. I Drug therapies for these and other disorders vasodilators) as well as licit recreation'~1 (e. during. As acclimatization occurs. fluid consumption. Resl means minimal physical activity (slt1lng or standing) in a shaded area If possible. a simple suggestIOn mvolves dnnkmg two cups of fluid 2 hours before exercise. but exercise duration can be increased gradually to its usual length. . 86-113. sweating rate increases and the sweat salt (i. • Reschedule exercise for a cooler time of day. exacerbating P ySlOloglC strain dunng exerCIse-heat stress. there is little advantage in supplementing carbohydrates 6 Electrolyte losses (e. Individuals whose exercise prescription specifies a target heart rate (THR) should maintain the same exercise heart rate in the heat. because of an excessive dilution of body fluids. This approach reduces the risk of heat illness while allO\ving acclimatization to develop. No. However. • Reduce exercise intensity and add rest breaks to maintain the same target heart rate as normally prescribed.9 820-839 84.0-86.5 However..g..0 No limitation 40/20 30/30 20/40 10/50 No work should be performed 45/15 30/30 20/40 10/50 No work should be performed No work should be performed 'See reference 2: Adapted from National Institute for Occupational Safety and Health. or sweating responses and Impair temperature regulation.9 770-799 80. skin blood flow. Even mild dehydration i:npairs temperature regulation and compromises performance during exercise:' The scientific literature indicates that endurance performance begins to decline at approximately 3% body weight loss and strength/power performance begins to decline at about 5% body weight loss. can alter blood flow and cardiovascular responses to heat stress.to 40-minute duration) and persons consuming a normal diet easily replenish electrolytes when their next meal is eaten. In most people. and interfere with the body's ability to dissipate heat. Program participants should be reminded to drink before.0-72.7 Exercise program organizers and leaders should ensure that replacement fluids are available and easily accessible.302 SECTION IV 1 APPENDICES APPENDIX E 1 ENVIRONMENTAL CONSIDERATIONS 303 TABLE E-1. alcohol). and drinking during exercise at a rate that matches sweat losses s Active individuals can weigh themselves before and after each exercise session to determine the amount of water that must be replaced. INCREASED RISK OF HEAT ILLNESS Disease and the effects of some drugs may increase the 11sk of heat illness. and physiologic strain decrease for a given exercise intensity.. especially those older than 60 years.

e. and cardiac work at rest and during exercise. two cold illnesses are caused hv excessive boclv heat loss dUling prolonged e>q10sure to cold. the resulting airway congestion may impair pulmonmy mechanics during exercise. Third.304 SECTION IV / APPENDICES APPENDIX E / ENVIRONMENTAL CONSIDERATIONS 305 comprehensive heat stress management plan should establish procedures for the following: • • • • • • Screening and surveillance of at-risk participants Environmental assessment using the \\'BGT index WBGT criteria for modifying or canceling cxercise Heat accli matization of participants Prmidina easv acccss to fluids Increasil~g <I\~'areness of the signs and symptoms of heatstroke. 2003. if weather conditions are \'el. frostbite may occur in 5 minutes or less. TABLE E-2. Although the \VCI provides useful guidance concerning the condnct or cancellation of outdoor activities.. fall substantially when extremely cold air (1°F-25°F) is breathed during strenuous exercise. it has inhcrent limitations. The reader should note that the color of each rectangle tells you the amount of time required for frostbite to occurin exposed skin (i. Active indi\iduals should avoid restrictivc garments because tight clothing restricts blood flow to the skin. which purports to integrate the potenti'al stress <uising from both factors. the temperature of the lower respiratory tract and the body's core are unaffected 13 Pulmonary function during exercise is unaffected by breathing cold air. During water immersion. red. o Color key: = Little risk of frostbite = FrostbIte occurs Within 30 minutes = Frostbite occurs Within 10 minutes = FrostbIte occurs WithIn 5 minutes Body heat production during moderate or strenuous exercise is sufficiently high to prevent hypothermia in air temperatures as low as -25°F.g. and fishermen or hunters who wade in streams can lose considerable amounts of body heat and become hypothermic. has achieved popular acceptance 9 and is presented in Table E-2. long-distance swimmers. which in turn increases the risk of frostbite. In contrast. Those who exercise in windproof clothing are at less risk of frostbite than the \\ind chill tables suggest. Both fatigue and hypothermia negatively affect human performance in the follo\\ing ways. 10 For example. because these tasks exacerbate blood pressure responses greatly. \\ind chill tables provide no meaningful estimate of the risk of hypothermia. arterial pressure. this bronchospasm is triggered by facial cooling rather than cooling of respiratory passages. breathing cold air during heavy exercise may cause bronchospasm. J5 In allergy-prone athletes. and wetting of the skin facilitates heat loss. 12 First. Cold e>q)osure. prolonged exercise leads to substrate (i. little lisk. Fortunately. Thus. Health and fitness profeSSionals are often asked. unshaded. hypothermia (core body temperature below 95°F [normal is 98.18 Fatalities resulting from coronmy artely disease increase in winter. until body temperature falls into a hypothermic state. the \VCI estimates the lisk of tissue freezing for sedentary persons only. when chronic underfeeding results in significant loss of subcutaneous adipose tissue. stimulates the sympathetic nervous system and elevates total peripheral resistance. rnyocardial contractility. 1b This likely explains why patients with coromuy arteJy disease experience angina pectoris and ST-segment depression at low exercise intensities in cold weather 18 Particular caution should be ad\ised for chopping wood and snow shoveling. Indeed. 17 Older adults and persons who have cardiovascular and circulatolY disorders may need to use greater caution. and Rain Although many people avoid cold e>q)OSllre by exercising indoors during winter. triathletes. conductive and convective heat transfer can be 70-fOld greater than in air of the same temperature. FOUlth.4 depending on the water depth and amount of body surface immersed. Revised Wind chili chart. "Is it too cold to ~xercise?" Indeed. and heat syncope • Integrating heat illness into emergency procedures Cold. dark pmk. fatigue that does not deplete muscle glycogen still may impair constriction of skin blood vessels. chronic fatigue that lasts many weeks may delay the onset of shiveIing at rest. Second. muscle glycogen) depletion that compromises further exercise and reduces the rate of heat production. but the extent that this reflects the effects of cold exposure on untrained older adults remains unclear 1 & . Interestingly. 30 minutes. heat cramps. proper clothing can reduce the risk of frostbite markedly. hcat exhaustion. those who choose to exercise outdoors usually are not at great risk becallSe exercise aenerates heat.e. Also.. Once exercise stops and metabolic heat production declines. 5 minutes). 16 Chronic inhalation of cold air also can increase respiratOly passage secretions and decrease mucociliary clearance. Upper airway temperatures. these effects are usually negligible. allowing increased heat loss. 12 Health and fitness professionals also should consider the possible consequences of inhaling cold air during exercise. Wind. 75°F-80°F). either wet clothing must be replaced or the indi\idual must return indoors to maintain core body temperature.. which remain unchanged during exercise under temperate conditions. body insulation may be compromised and the risk of hypothermia may increase.6°F]) and frostbite (freezing of skin and body tissues). 10 mmutes.l9.' se\'ere. even when water temperatures are relatively mild (e. in healthy athletes l4 and nonathletes. even when mild. Both cold air and \\ind favor body heat loss4 The \\ind chill index (WCI). Thus. light gray. The Wind Chillindex* Wind Speed (mph) Air Temperature (OF) 40 30 20 10 0 -10 -20 -30 40 0 10 20 30 40 50 60 40 34 30 28 27 26 25 30 21 17 15 13 12 10 20 9 4 1 -1 -3 -4 10 -4 -9 -12 -15 -17 -19 0 -16 -22 -26 -29 -31 -33 -10 -28 -35 -39 -43 -45 -48 "'See reference 11 From National Oceanic and Atmosphenc Administration. The insulation value of wet clothing is compromised.20 which require significant npper body use.

and S.~I~t~I:~~~~~~: ~l~. tlnng CJstance runnlllg. Descent The ~ J] . St. a t s .. Furthermore."ygen in the atmosphere (F 10 2) remains constant at 0. severe weakness. . cough producing 'pink frothy sputum. \V1t 1 t 1e c e\'eJop 1 t f· l' d . l e e per ay.'. and insomnia.000 to 8. A chronic body weigbt loss of 1 to 3 pounds per week is common at extreme altitude and results from factors such as loss of appetite and increased energy expenditure. combined with the reduced \T02m'L' at higb altitude.r~ e~erEset:~. ' - . Less common. 86-113. Epst~in Y.' . . sleep Very rapid breathing and heart rate breathlessness.1~X. 1986. acetazolamide dexamethasone as a preventIve measure. After 5 to 10 days of acclimatization at higb altitude. uue a adjustment in the 101 some mdl\1duals. • dehydration • . particularly during exercise \ This accounts for the common sensation of breathlessness at high altitude. increase thc likelihood that the ill 1 . . tachycardia abates conSiderably. C. C"t . ~Ied Sci Sports Exerc 1996·:). 22 These facts empbasize the importance of wholesome nutrition in maintaining \igor and performance. this response becomes more pronounced after several days of residence at high altitude... ' e 1111 Ive tleatl11ent for these three illnesses o OWlJ1g SIX recommcndations 22 r d 1 .. ese tesponses can mduce angina ancIJor ischemic ST-' H . t to hIgh altItude).' (1lCan Colleg(> of Sports ~ledieine positioll sland. d ownwarcl ' prescIibed TI-IR r _. indigestion. Further. . . heavy clothing. C ' HIGH ALTITUDE ILLNESSES When unacclimatized persons ascend rapidly to ele\'alions abo\'e 8. Armstrong LE. at least in the case of REFERENCES I. . the wind. \Vhen low-altitude residents ascend to high altitude. J" xel clse I mlts carc lac stnin bec'lUse it .02) usually falls when low-altitude residents ascend to 5. and rain fre(luently contribute to cold stress..000 feet. \/0 2""" is lower at higb altitude than at sea level.. ashen skin color: confusion. which is achieved by tachycardia. • Kit a high-carbohydrate diet to reduce the symptoms of AMS. This adaptation is not equivalent to full recovery to sea level performance.g. mental Impairment. ])1/1/5 . In: Auerbach PS.' [1101'. blue-colored skin because of low blood oxygen content Staggering gait.g.e. 2. sU. flatulence ' constipation. pulmonaJy edema. however. coma disturban~e High-altitude cerebral edema (HAC E) See reference 24: From Hackett PH. Heat and eold illnesses d ' I'. I . many experience high-altitude illnesses (Table £-3) and reduced exercise capacity2:1 The most common of thesc is acute mountain sickness (AMS). Thus. and increased solar radiation can contribute to heat stress.eXCI 1ennia. ' ow .000 feet above sea level or higher. enabling some improvement in endurance and work capacity. bmlt your rate . vomiting. the decreasing barometric pressure with increasing altitudc is associated with a decreasing pressure of oxygen in the inspired air (P\02). the increased cardiovascular strain of exercise.")·" . LOUIS: Mosby. commercial airline passengers are exposed to barometric pressures that arc equivalent to altitudes of 5. Washin Ion D '. increased urine production and increased water loss during breathing. which is characterized by severe headache. f . '. These impairments usually become noticeable at an elevation of about 5. f .'pelience a dis ro or'. fatigue. loss of upper body coordination. at lower exercise intensities than at se' 1 1 \8 ypeltenslve patIents mav eJl. . . High-altitude medicine. P. Air temperature decreases lOF per elevation increase of 300 feet and body water losses may be misjudged by climbers because tbe air temperature is cool on bigh peaks. Roach RC. Despitc increased ventilation.000 fcet. Although highly variable between individuals. as pI escll Jcd for sea level e' . ." e·'1)oslll( to hot ell\·lronments. myocard · I .). . Because the fractional concentration of m. TABLE E-3. However. . Wilderness Medicine. the possibility of acute dehydration increases because of inadequate drinking. In susceptible people these symptoms arise after 6 to 12 hours at altitude and usually abate after 3 to 7 days of residence. compromise work capacity and endurance. IHigh-altitude exposure increases cardiac output cardiac work and 1a oxygen recJu' t ] " ..ltlOnal In511111te for Oecup"lional Safety and Ilealth. . _:>. cardiovascular adjustments lessen the physiologic strain of exercise. loss of consciousness. • Climb with an experienced g:lide or team. 11en 0 a t1tU e acclimatization (e. altitude illnesses: e uce t 1e Ilsk of expeliencing high• Ascend slowly • Conduct a climb in stages. hypoxia (i. they notice an increased 2 pulmonary ventilation. irritability. 21 The resulting dccrease in blood oxygen content necessitates an increased cardiac ontpnt. drowsiness. Ask )<1 phySICian to prescribc medications (e. . ed..I tel \.PI/~S~ . are high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema (UACE). Publ. Even in pressurized cabins.306 SECTION IV / APPENDICES APPENDIX E / ENVIRONMENTAL CONSIDERATIONS 307 High-Altitude Exposure In mountainous areas. ~n ellcl 01 a recommended standard. snow.. . ' J I '] . cise intensitv H . .od. 0('<:11 ) . 1995:1-37. This I e acc llnatlzatlOn may req '. nausea. at high altitude. effect of aJtitl d .000 feet (or lower for some very fit athletes) and worsen with increasing elevation.. 1':. of ascent to 1 000 C t db' leet 01 higher.\10511 g . No. a eve. arterial oxygenation (i. . longer tban a 3-d'l visi . . but much more serious and even life threatening.y .. segment depl ess\on.2093. Gr~enleaf JE et al Am>·'·· '. nausea loss of appetite.. If mo\'ina to 10 000 C . an dl1ypot1 • <. gastrointestinal disturbances. Exercise at altitude usually exacerbates the symptoms of tbese illnesses and may. ~ nemen s. 'J]] 1 to a lower altitude constitutes the d f T ' tess \V1 C eve op.e.. • Avoid over ' t'lOn. neceSSttates a reduction in exer. Three High-Altitude Illnesses Condition Symptoms Acute mountain sickness (AMS) High-altitude pulmonary edema (HAPE) Severe headache..g both rest and Y sea eveJ resIdents ascend to high altitude use of the S'lme THR" . .02. durit. low oxygen content of inspired air) is the unique physiologic stressor encountered at high altitudes. whereas strenuous activity. ' . anc necessitates an increase in coron'uy blood 11 Ie atlve to sea level exercise IH Th _. owevel..

Amellc"n 5 Com'ertino \'A. d d I \ I . Gon~lez RR. ld' It Avi.. Since 1975. . . ACSM Certifications and The Public The first of the ACSM clinical celtifkations was initiated nearly 30 years ago in conjunction with publication of the first edition of the Guidelines for Exercise Testing and Prescription. . Siple PA. Hoach HC. ld C 11. ' \ . 1 t: . I . I f d healthy subjects. Alhtu e an co~: n: 1995'309-396 . . ' . I '. d 11 'd' I·· ent Med SCI SPOltS xelc stand. pi 'SIO ccup l)SI . A. Exerctse-lIle uce I runners. I 23. . . Saw a I I . J 1995·8·2088-2093. Exerc Sport Sci 7.5. 'li"n IL' Human Kinetics. Armstrong LE. d Environmental Medicine at Terrestna Gonzalez RR. accessible and affordable credentials and continuing education programs for health and exercise profeSSionals who are responsible for preventive and rehabilitative programs that influence the health and wcll-bcing of all individuals. 3. H k PB Medical problems re atee 0 a I .Department of the 'e\'eI1tl'on.545-563.1. Per tormmg 111 x I I t .B un 0 Rev 1\. . Orl1l'U subJ'ects following exercise at cold et TT Pulmonary unchon 10 n . Over the past 30 years. skills.. 10 Danilesson U. fon 'md esophageal temperature in exerD ·u EC J' Roberts DE. Malkonian M K. as 11l1M ' .1 un . . e s. Tikkanen HO. Measur:~"ents of dry atmosp lenc coo m Am Philosoph Soc 1945. Over the past several years. Heart Disease and 18. Thus. Biochem Physiol A Mol IntegI' P 'YSIO ~ C' ld . 1995.. Tukiainen H . F acm co . Haahtela T. Chung NK. The development of the health/fitness certifications in the 1980s reflected ACSM's intent to increase the availability of qualified profeSSionals to provide scientificaHy sound advice and supervision regarding appropliate physicaJ activities for health maintenance in the apparently heaJthy adult population. Body Fluid Balance: XelClse an 1996:259-282.u . demands of heavy snow s lOve mg.. clinical practice. M 1 stIiction' a studv in ast 1111a Ie an . In: I C\l d Fluid rep acemen c u n n . In addition.d·. eSI . . I t I . Public HeaJth Service and the U. d d 'n" exercise in healthy older adults.. .'hgue an 1 oung . eels. . Puhl SM. .:tt Sp'lce Environ l ec 17. 9003 Revised \vind chill chart.25:41-76 fl. 16 Koskela H. f'" freezing.-' . ' . anu abilities (KSAs) that comprise the foundations of these celtification anu registry examinations.. Wind dull and thensk 0 tIss . 6. d thermoregulation in the co. The mission of the ACSI\[ Committee on Certification and RegistlY Boarus is to develop and prOVide high quality. treatment and control of heat injury. exercise has gained Widespread favor as an impOltant component in programs of rehabilitative care or heaJth maintenance for an ex-panding list of chronic diseases and disabling conditions.l.. ' -. at lac T • 1995. Biophysics of heat exchange an cot ung. aw a tion and sud d en coronmy e.'. PI Arn1\'. 24. . k MN · . et al. Hogan P.' . . .4:290-30. tl' g of cold air induces bronchocon. Pandolf KB. Helenius IJ. ue .308 SECTiON IV I APPENDICES wI' "ton DC. lamp.'_... .. ( ( American College of Sports Medicine Certifications • F •• •• APPENDIX This appendix details information about American College of Sports I\[euicine (ACSM) Certification and Registry Programs. E trerne EnVIronments.S. . d I I' . . as well as a complete listing of the currcnt knowleuge. . ' . 1 . \Ied SCI SPOltS E . I oling but not nasa Ie. g exercise 'lI1d recoyelV from exerCIse. ' \ .e. Schmidt DH.. High-altitude mediCll1e.ltIzatlOn to ~ . 19. e. xerc 1980. That era was marked by rapid ue\'elopment of exercise programs for patients with stable coronalY cutely disease (CAD). BonzIlem1 .161:739-742.60. ThermoregulatIOn at rest d. Armstrong < " '.273:880--882.I . 'gn IL' Human Kmetlcs. Y AJ c-lStellani ]\\'. 0 all 1111<1" I .' CI. th Am J Cardiol 1996. d SpOlt. 20. Ciesbre~ht The respiratory system in a co enVlfonmel.1 PS eel Wilderness Me cme. I l' JAMA 1 c.. I At sphenc Adnul1lstr" t lOn.51:628-629. 21. Mil Med 1996._. J A I ambient temperatures.89:111-199. In: Pandolf KB. I di Terrestrial Extremes. federal government poliCY makers have revisited questions of medical efficacy and financing for exercise selvices in rehabilitative care of selected patients. Hackett PH. . I . applications to sports physiology. National Oceal1lc anc 1110 . IncIlanapo IS: ' . P' 10C 9. . BOl1zhell1l K. Young AJ. . The growth of public interest in the role of exercise in health promotion has been equally impressivc. . 15. A11 en LJ . Franklin HA. eds. cising humans. 309 . Thorax 1990. T T Louis: Mosby. College of Sports Medicine position Exerc NutI' Health 1995. E' .000 celtificates have been awarded. Human acdlln. Snow 5 'love m .97. 1980. recommendations from the U. Young PM. LE Coyle EF et a. more than 30. . eds. Human Perlonnance lYS~O 0 ' I'" Benchmark 1988:491-543. \0 PI .1 I g' '1 trigger [or acute myocardial infarc· K Gordon S et al.' hi h terrestrial altitude.. . It'tude IIr Pandolf KB. Human Performance P 1)'S10 og) "n · I' Benchmark 1988:.. . E UI pp 1) lb' .S. S k '. Boca Raton. Med 4. \\'ith this consistent CG. oc' . ExerCise an U1 lep acem . .' d f:' . eds. FL: CRC Press. 22. Chal)man KR. E' " 1996·98·i-vii . Kennev \VL.. ExeltlOn-lI1duce . 1995:1-37. J Appl PhysioI1996.') .998--232.espll .85" -858 d . I. Franklin BA..' I gy 'lI1d Environmental Medicine at MN Gonzalez RH. Surgeon General have acknowledged the central role for regular phYSical activity in the prevention of disease anu promotion ofheaJth. ..81:2666--2673. CI . Armstrong LE. 2000. CH Ob 'ty 'lnd the occurrence 0 8. Jaeger jJ.t disorders. di' St Extremes. . db 'onchospasm at low temperature 10 ehte 14. TB Med 507. Passel CR. RehabilitatIOn.. Buskirk ER. UI .12:365-369. 13.66:890-902. . '01 1990. Young AJ. these early clinical certifications were viewed as an aid to the establishment of safe and scientifically based exercise services within the framework of cardiac rehabilitation. 'l<lmp< M ' . I' g in subfreezing temperatures. ~Iares 1 .' 19001'128'769-776. In: uel )<lC 1 . . omp 9_. . Rom . et a. and education. E' I' . Pollock ML. PII1 . . t . I .. n anapO IS. . ACSM sought a means to disseminate accurate information on this health care initiative through expression of consensus from its members in basic science.

risk factor identification and lifestyle management selvices to individuals \vith or at risk for cardiovascular. design. leading and demonstrating safe and effective methods of exercise. The ACSM Exercise Specialist® is. the Personal Trainer is proficient in leading and demonstrating safe and effective methods of exercise by applying the fundamental principles of exercise science. the HFI level of celtification incorporates the KSAs associated with the ACSM certified Personal Trainer™ certification. Other examples include publishing a periodical addressing professional practice issues targeted to those who are celtified. How to Obtain Information and Application Materials The celtification programs of ACSM are subject to continuous review and revision. also competent to provide exercise-related consulting for research. and program management. rehabilitation. and examination test sites and dates may be made to ACSM Celtification Resource Center 1-800-486-5643 Website: www. Continuing education credits can be accrued through ACSMsponsored educational programs such as ACSM workshops (Health/Fitness Instructor® and Exercise SpeciaIist®). phySICIans offJces or medical fitness centers. Using a variety of teaching techniques. and implement individual and group exercise and fitness programs for low risk individuals and individuals \vith controlled disease. or other celtifications. The College has formally organized its volunteer committee structure and national office staff to give added emphasis to informing the public.org. and fitness assessments. The ACSM Exercise Specialist® (ES) is a is a healthcare professional certifIed by ACSM to deliver a variety of exercise assessment. The ACSM certified Personal Trainer'" is proficient in writing appropriate exercise recommendations. as illustrated in Figure F-l. These selvices are typica. and prescribes exercise and physical actI\!Jty ~nm~U1Jy in hospitals or other health provider settings. The ACSM certified Personal Trainer'" is familiar with forms of exercise used to improve. values. ACSM also acknowledges the e'\''Pectation from successful candidates that the public \vill be informed of the high standards. Because the standards and guidelines refer to the KSAs that follow. and professionalism implicit in meeting these celtification requirements. as a founder member of the multi-organizational Committee on Accreditation for the Exercise Sciences (CoAES). since 2002 ACSM has provided guidelines to assist colleges and universities with establishing standardized curricula that are focused on the knowledge. and other educational programs approved by the ACSM Professional Education Committee. E'\''Peltis. and specific information regarding the standards and guidelines can be obtained by visiting www.caahep. ph~s~cal a:tl\!Jty. conducting fitness assessments. and motivating individuals to modIfy negative health habits and maintain positive lifestyle behaviors for health promotion. CeltlfICatlOn at a given level requires the candidate to have a knowledge and skills base commensurate with that specific level of certification. and motivating individuals to begin and to continue with their healthy behaviors.org. medicine. and the ES level of certification incorporates the KSAs associated \vith the HFI certification. application reqUIrements. programmatic accreditation can be obtained by visiting www. . The ACSM Registered Clinical Exercise Physiologist® (RCEP) is an allied health professional who works with persons with chronic diseases and conditions in w~1ich exercise has been shown to be beneficial. and government agencies about issues of critical importance to ACSM. the ACSM University Connection Endorsement Program is designed to recognize institutions with educational programs that meet all of the KSAs specified by the ACSM Committee on Certification and Registry Boards (CCRB). maintain. In addItIon. Inquiries concerning celtifications. Administration of celtification is the responsibility of the ACSM NatIOnal Center.coaes.lIy delivered in cardiovascular/pulmonalY rehabilitation programs. The RCEP performs health. pulmonaJy.com/acsmcrc E-mail: certification@acsm.org ACSM Certification Programs The ACSM certified Personal Trainer'" is a fitness professional involved in developing and implementing an individualized approach to exercise leadership in healthy populations andlor those individuals with medical clearance to exercise. and metabolic disease(s). andlor optimize health-related components of physical fitness and performance. . writing appropriate exercise prescriptions. publIc health.310 SECTION IV I APPENDICES APPENDIX F I AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 311 growth. .e in design and procedures for competency assessment is also represented on tl1lS commIttee. Recently. In addition. and other clinical and non-clinical selvices and programs.lww. For example. skills. ACSM has taken steps to ensure that its competency-based celtifications will continue to be regarded as the premier program in the exercise field. training. ACSM Exercise Specialist® and ACSM Registered Clinical Exercise Physiologist@ Additionally. assisted '""ith the development of Standards and Guidelines for educational programs seeking accreditation under the auspices of the Commission on Accreditation of Allied Health Education Programs (CAAHEP). and abilities (KSAs) requisite in the examinations for the ACSM HealthlFitness Instructor®. each level of ceItification has minimum requirements for experience. The ACSM Health/Fitness Instructor® (HFI) is a professional qualified to assess. Additional information on outcomesbased. ACSM's Certified News. regional chapter and annual meetings. reference to specific KSAs as they relate to given sets of standards and guidelines \vill be noted when appropriate. fees. The HFI is skilled in evaluating health behaviors and risk factors. Informing these constituencies about the meaning and value of ACSM certification is one important pliOlity that \vill be given attention in this initiative. and oversight of continuing education requirements for maintenance of celtification is another. level of educatIon. professionals. ACSM. Content development is entrusted to a diverse committee of professional volunteers WIth expeltise in exercise science. These enhancements are intended to SUppOlt the continued professional growth of those who have made a commitment to service in this rapidly growing health and fitness field.

as listed in the current edition of ACSM's Guidelines for Exercise Testing and Prescription. patient counseling. ACSM Registered Clinical Exercise Physiologist® Demonstrate competence in the KSAs required of the ACSM Registered Clinical Exercise Physiologist® Exercise Specialist® and Health/Fitness Instructor® as listed in the current edition of ACSM's Guidelines for Exercise Testing and Prescription. risk factor and health status identification.g. * Master's Degree in exercise science. AND *Minimum of 600 hours of practical experience in a clinical exercise program (e. * Ability to demonstrate extensive knowledge of functional anatomy. exercise physiology. and emergency management). and exercise prescription * Demonstrate ability to incorporate suitable and innovative activities that will improve an individual's functional capacity *Demonstrate the ability to effectively educate and/or counsel individuals regarding lifestyle modification *Knowledge of exercise science including kinesiology. and injury prevention ACSM Exercise Specialist® ACSM Health/Fitness Instructor@ * An Associate's Degree or a Bachelor's degree in a health-related field from a regionally accredited college/university (one is eligible to sit for the exa m if the candidate is in the last term of their degree program). exercise physiology. and emergency procedures related to exercise testing and training situations. pathophysiology. graded exercise testing for healthy and diseased populations. and skill in. Health/Fitness Instructor®. fitness appraisal and exercise prescription *Demonstrate ability to incorporate suitable and innovative activities that will improve an individual's functional capacity Demonstrate the ability to effectively educate and/or communicate with individuals regarding lifestyle modification *Demonstrate competence in the KSAs required of the ACSM Health/Fitness Instructor® as listed in the current edition of the ACSM's Guidelines for Exercise Testing and Prescription *Work-related experience within the health and fitness field * Adequate knowledge of. electrocardiography. The RCEP is an allied health professional who uses exercise and physical activity to assess and treat patients at risk of or with chronic diseases or conditions where exercise has been shown continues . *Demonstrate competence in the KSAs required of the ACSM certified Personal Trainer™ as listed in the current edition of the ACSM's Guidelines for Exercise Testing and Prescription *Adequate knowledge of and skill in risk factor and health status identification. exercise supervision/leadership. psychology. and metabolic diseases. human behavior/psychology.APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 313 312 SECTION IV / APPENDICES FIGURE F-1: continued FIGURE F-1: Level Level Requirements Recommended Competencies Requirements Recommended Competencies ACSM certified Personal Trainer'" * 18 years of age or older *high school diploma or equivalent (GED) *Possess current Adult CPR certification that has a practical skills examination component (such as the American Heart Association or the American Red Cross). * A Bachelor's Degree in an allied health field from a regionally accredited college of university (one is eligible to sit for the exam if the candidate is in the last term of their degree program). pulmonary. *Demonstrate competence in the KSAs required of the ACSM Exercise Specialist®. electrocardiography. exercise prescription. nutrition. patient education and counseling. cardiac/pulmonary rehabilitation programs. disease management of cardiac. program administration. functional anatomy. exercise physiology or kinesiology from a regionally accredited college or university * Current certification as a Basic Life Support Provider or CPR for the Professional Rescuer (available through the American Heart Association or the American Red Cross). gerontology. AND *Current certification as a Basic Life Support Provider or CPR for the Professional Rescuer (available through the American Heart Association or the American Red Cross). AND * Possess current Adult CPR certification that has a practical skills examination component (such as the American Heart Association or the American Red Cross). fitness appraisal. exercise testing.

1.ll. time spent working with a patient who has Coronary Heart Disease and Parkinson's Disease may be counted in two practice areas IF you were providing exercise evaluation or programming specific to each of the conditions. Fitness and Clinical Exercise Testing x. and evaluation of exercise and physical activity outcome measures. metabolic-120. where all the KSAs for a given certification/credential are listed in their entirety across a given Practice area aneVor Content f\latter area for each level of celtification.x Nutrition and Weight Management x. exercise and physical activity counseling. and this KSA is the tenth KSA within this content matter area. community. Skills.12.x Neuromuscular 7.2.x Medical and Surgical f\lanagement x.x Health Appraisal. It is designed to be easier to use for cettification candidates. but are not limited to. cancerous.x Exercise Physiology and related Exercise Science x.x Human Behavior and Counseling x. Injury Prevention.3.x.x x.4. which may be completed as part of a formal degree program in exercise physiology.x Cardiovascular 3. Celtifieation examinations are constructed based upon these KSAs. and ACSM's Certification Rez.x General Population/Core 2. pulmonary. .ieu. Patients for whom RCEP services are appropriate may include.x. exercise testing. Two companion ACSM publications. and Outcome Assessment x. Knowledge. Quality Assurance. orthopedic.x Safety. and Emergency Procedures x. The practice of clinical exercise physiology is restricted to patients who are referred by and are under the care of a licensed physician. neuromuscular-40.10 Knowledge to describe the normal acute responses to cardiovascular exercise.lO. *Minimum of 600 clinical hours are required with hours in each of the clinical practice areas. exercise and health education/ promotion.7.5. evidence-based primary and secondary preventive and rehabilitative exercise and physical activity services to populations ranging from children to older adults. and obstetrical diseases and conditions.x Pathophysiology and Risk Factors x. These hours may be obtained with patients with co-morbid conditions.x Clinical and Medical Considerations (ACSf\1 certified Personal Trainer™ only) EXAMPLES by Level of Certification/Credential: ACSM celtified Personal Trainers~1 KSAs: 1. neither the Guidelines for Exercise Testing and Prescription nor either of the ahove mentioned Resource Manuals provides all of the information upon which the ACSM Celtiflcation exam ina- In this example. SKILLS.x. \\~thin each Content Area The Practice Areas (the first number) are numhered as follows: 1. and applicable state and federal regulations. fifth edition. The practice and supervision of the RC EP is guided by published professional guidelines. ACSM's Resource Manual for Guidelines for Exercise Testing and Prescription. The RC EP provides scientific. CLASSIFICATION/NUMBERING SYSTEM FOR KNOWLEDGE. and Abilities (KSAsl Underlining ACSM Certifications Minimal competencies for each certification level are outlined below. pulmonary-l00 .x Program Administration. \\'ithin each certification's/ credential's KSA set.1. Book.x Pulmonarv Metabolic 4.x.x. The RCEP performs exercise screening.x. For example. cardiovascular-200.6. the practice area is General Population/Core. exercise supervision.x) Second number~denotes Content Area (x. Each may prove to be beneficial as a review of specific topics and as a general outline of many of the integral concepts to be mastered by those seeking certification.I).x.9. musculoskeletal.x Orthopedic/M useuloskeletal 6. neuromuscular. gynecological. inflammatory.x. persons with cardiovascular. orthopediclmusculoskel etal-l00.x Electrocardiography and Diagnostic Techniques Patient Management and Medications x.8. Lx) Third number-denotes the sequential number of each KSA (x. AND ABILITIES (KSAS) The system fill' classifYing and numhering KSAs has been changed. and public health settings. to provide therapeutic and/or functional benefit. The RCEP works individually and as part of an interdisciplinary team in clinical. may also be used to gain further insight pertaining to the topics identified here. the numbeJing of individual KSAs uses a three-pm1: number as follows: First number-denotes Practice Area (1.314 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 315 FIGURE F-l: continued Level Requirements Scope of Practice tions arc based. exercise prescription. immunologic. metabolic. second edition.x Exercise Prescription and Programming x. standards.x Immunologic The Content Matter Areas (the second number) are numbered as follows: x. the content matter area is Exercise Physiology and Related Exercise Science. However.x 5.x. immunological/ hematological-40.

17 Design strength and flexibility programs for individuals with cardiovascular.1. adductors.1.19 1. When reviewing these KSAs.1. plyometrics. gluteus maximus. Furthermore.20 1. latissimus dorsi. cardiovascular.316 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 317 ACSM HealthlFitness Instructor® KSAs: 1. internal and external obliques. because this specific KSA appears in bold. pulmonary and metabolic practice areas.16 1.1 "List the drug classifications commonly used in the treatment of patients with a National Institutes of Health (NIT-I) disease. a number of them describe a specific topic with respect to both exercise testing and training. rotation. Knowledge of the following curvatures of the spine: lordosis. Knowledge of the physiological principles involved in promoting gains in muscular strength and endurance. jogging.1. and stabilizer. then it applies equally to each of the general population.7 1. ACSM Exercise Specialist® KSAso: 1. the content matter area is Exercise Prescliption and Programming. major side effects. the practice area is General Population/Core. where appropliate. and this KSA is the seventeenth KSA within this content matter area. stability. For example. including changes in body position.5 1. balance.1. the practice area is General Population/Core. or a combination of K. blood pressure. adduction. supination. pectoralis major. practice area). Knowledge of how the principle of specificity relates to the components of fitness. running. Each KSA desclibes either a Single or multiple knowledge (K).9 11. the content matter area is Health AppraisaL Fitness and Clinical Exercise Testing. skeletal muscle. flexion. and gastrocnemius. However. Knowledge of the basic anatomy of the cardiovascular system and respiratory system. Knowledge of the concept of detraining or reversibility of conditioning and its implications in fitness programs. cycling. Knowledge to describe the myotatic stretch reflex. Skills.8 Skill in accurately measuring heart rate. Knowledge of the basic structures of bone. 7.15 11. Knowledge of the biomechanical principles for the performance of the following activities: walking. and obtaining rating of perceived exertion (RPE) at rest and during exercise according to established guidelines. and Abilities (KSAs): EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE In this example.113 1. medial. ACSM Registered Clinical Exercise Physiologist KSAs: 7.1. name common genelic and brand names drugs within each class.1.1. Knowledge of the normal chronic physiological adaptations associated with cardiovascular exercise. as stated previously.1. hyperextension. pronation. lateral. please note that KSAs in bold text cover multiple content areas. Ability to identify the major bones and muscles. indications. eccentric..3 11. °A special note about ACSM Exercise Specialist® KSAs: Like the other celufications presented thus far. Knowledge of the physiological adaptations that occur at rest and during submaximal and maximal exercise following chronic aerobic and anaerobic exercise training. Knowledge of blood pressure responses associated with acute exercise.18 1.23 The practice area is Immunologic. swimming. ACSM certified Personal Trainer SM Knowledge. skill (S). some KSAs mention specific patient populations (i. If a specific practice area is not mentioned within a given KSA. weight lifting. metabolic syndrome. diabetes (type I or II). repetitions. 1. hamstrings.1. isotonic/isometric. that an individual should have mastely of to be considered a competent ACSM Exercise Specialist@ Finally.4 1. Knowledge of the following terms: progressive resistance.1. Knowledge of the interrelationships among center of gravity. biceps. Note that "metabolic patients" are defined as those with at least one of the folloWing: overweight or obese. if any. However. and carrying or moving objects Ability to define aerobic and anaerobic metabolism. and this KSA is the second KSA \vithin this content matter area.14 1. the ACSM Exercise Specialist® KSAs are categOlized by content area. the following: trapezius. and explain the purposes. it covers multiple practice areas and content areas.1.8 In this example.1 1. abductors. Each ES KSA begins 'vvith a '1' as the practice area. and children. rectus abdominis. S or A. base of support. scoliosis. and proper spinal alignment. circumduction. superior. but are not limited to. or ability (A).3.122 1.1. Knowledge to describe the normal acute responses to resistance training. . Knowledge of the normal chronic physiological adaptations associated with resistance training.1. erector spinae. and kyphosis. agonist antagonist. Knowledge of the physical and psychological signs of overtraining and to provide recommendations for these problems. pulmonary and/or metabolic diseases. on the exercising individual.6 1. and this KSA is the eighth KSA within this content matter area. abduction.12 1. Rather than wlite out each separately (which would have greatly expanded the KSA list length) they have been listed under a Single content area.2 1. and the effects.6. Valsalva maneuver. elderly.1. quadriceps. hypertrophy. the ACSM Exercise Specialist® candidate is also responsible for the mastely of both the ACSM HealthlFitness Instmctor® and the ACSM celtified Personal Trainer™ KSAs. triceps.17 1. atrophy. which are two distinct content areas. concentric. Major muscles include.e. Knowledge to describe the normal acute responses to cardiovascular exercise.10 1.1." 1. Knowledge of the plane in which each muscle action occurs. Knowledge of the common theories of muscle fatigue and delayed onset muscle soreness (DOMS). the content matter area is Medical and Surgical Management.21 1. some ES KSAs cover multiple practices areas within each area of content. sets. extension. and connective tissues.1.111 1. Knowledge of the definition of the following terms: inferior. Knowledge of the physiological principles related to warm-up and cooldown.

7. specificity.7. aerobic stimulus phase. Knowledge of the components incorporated into an exercise session and the proper sequence (i. and progression and how they relate to exercise programming. and body composition.8 1. hydrostatic weighing. resistance bars and water exercise equipment. aerobiC stimulus phase.7. muscular strength. and flexibility).11 1.17 1.22 1.3. stairclimbers.3. but are not limited to the clavicle.10 1.7.6 1.3. Ability to identify appropriate criteria for terminating a fitness evaluation and demonstrate proper procedures to be followed after discontinuing such a test.20 1.3.11 1. Skill in accurately measuring heart rate. and type of phySical activity necessary for development of cardiorespiratory fitness in an apparently healthy population. Ability to locate the anatomic landmarks for palpation of peripheral pulses.8 1.125 1.3. humerus.3.26 1313 1.3. Knowledge of and ability to apply methods used to monitor exercise intensity.7.19 1. Knowledge of Progressive Adaptation in resistance training and it's implications on program deSign and periodization Understanding of personal training client's "personal space" and how it plays Into a trainer's interaction with their client..7. tibia.1 1.5 1.12 1.27 1. musculilr strength and/or endurance.126 1.10 1.7. Ability to locate common sites for measurement of skinfold thicknesses and circumferences (for determination of body composition and waist-hip ratio). treadmills.2 1.4 1. Knowledgeof the recommended intensity. Ability to obtain a basic health history and risk appraisal and to stratify risk in accordance with ACSM Guidelines.1. Knowledge of the benefits and precautions associated with resistance and endurance training in older adults. plethysmography.7.7.7. preexercise evaluation. strernum. frequency. and METs.9 1. HEALTH APPRAISAL. including assessments of cardiovascular fitness. Ability to instruct participants in the use of equipment and test procedures Knowledge of the purpose and implementation of pre-activity fitness testing.7.18 1.g. Major bones include. Knowledge of the categories of participants who should receive medical clearance prior to administration of an exercise test or participation in an exercise program. Knowledge of the primary action and joint range of motion for each major muscle group.3.3 1. and flexibility. Knowledge of the concept of "Activities of Daily Living" (ADLs) and its Importance In the overall health of the individual.7.7.31 Knowledge of and ability to discuss the physiological basis of the major components of physical fitness: flexibility.14 1. Skill in the use of various methods for establishing and monitoring levels of exerCise Intensity. ' Ability to identify proper and improper technique in the use of cardiovascular conditioning equipment (e. pregnant and postnatal women. ulna. including heart rate and rating of perceived exertion. FITNESS AND CLINICAL EXERCISE TESTING 1. Knowledge.3. radius. carpals. and body composition. Knowledge of the value of a medical clearance prior to exercise participation. EXERCISE PRESCRIPTION AND PROGRAMMING 1. different ambient temperatures. elliptical trainers). cardiovascular fitness. Ability to teach a progression of exercises for all major muscle groups to Improve muscular strength and endurance. 1.7.16 1. warm-up.APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 319 318 SECTION IV / APPENDICES 1. Knowledge of common orthopedic and cardiovascular considerations for older participants and the ability to describe modifications in exercise prescription that are indicated. stationary cycles. cool-down. Knowledge of special precautions and modifications of exercise programming for participation at altitude.3. Knowledge of the advantages and disadvantages of implementation of Interval. Including heart rate. Knowledge of the limitations of informed consent and medical clearance prior to exercise testing. Bod Pod. muscular endurance.. Knowledge of how to modify cardiovascular and resistance exercises based on age and physical condition. 1.9 1. duration. Knowledge of the advantages/disadvantages and limitations of the various body composition techniques including. muscular strength/endurance flexibility).3 1.7. humidity. scapula. Skill to teach and demonstrate appropriate exercises for improving range of motion of all major joints.21 1. cool-down. Knowledge of relative and absolute contraindications to exercise testing or participation.3.15 1. muscular strength. fibia. weights. warm-up. Knowledge of specific leadership techniques appropriate for working with participants of all ages. Knowledge of and ability to describe the unique adaptations to exercise training with regard to strength.7. ' Skill to teach and demonstrate appropriate modifications in specific exercises for the following groups: older adults. and persons with low back pain.14 1.6 Knowledge of the benefits and risks associated with exercise training in prepubescent and postpubescent youth. obese persons. exercises designed to enhance muscular strength and/or endurance of specific major muscle groups. bioelectrical impedence. and obtaining rating of perceived exertion (RPE) at rest and during exercise according to established guidelines. continuous.27 1. Ability to Identify proper and improper technique in the use of resistive equipment such as stability balls.7. functional capacity.7. Knowledge of the importance of a health/medical history. Skill to teach and demonstrate the components of an exercise session (i. muscular endurance. bands.728 .7.13 1. RPE. Ability to determine training heart rates using two methods: percent of agepredicted maximum heart rate and heart rate reserve (Karvonen).24 1. and circuit training programs.7.3.e.7. Knowledge of the importance and ability to record exercise sessions and performing periodic evaluations to assess changes in fitness status. and the ability to demonstrate (such as technique and breathing). to describe. Knowledge of the principles of overload.7.12 1..4 1.25 1.124 Ability to identify the major bones. Ability to explain and obtain informed consent. but not limited to: air displacement.2 1. Ability to describe modifications in exercise prescriptions for individuals with functional disabilities and musculoskeletal injuries Ability to differentiate between the amount of physical activity required for health benefits and the amount of exercise required for fitness development.7.5 1. and motor skills.7. and enVIronmental pollution.e.7.7 Knowledge of selecting appropriate testing and training modalities according to the age and functional capaCity of the individual.23 1.7.7.7 1. and tarsals Ability to identify the joints of the body. femur.

g. mode.7. patello-femoral pain syndrome.g. Visual. contusions. the purported mechanism of action. INJURY PREVENTION. Knowledge of the following terms: shin splints.6 1. and exercise intolerance (dizziness.8. Knowledge of the importance of maintaining normal hydratIOn before.32 1. minerals. Kinesthetic) and how to apply teaching and training techniques to optimize a client's training session Knowledge of the types of feedback and ability to use communication skills to optimize a client's training session. Knowledge of and skill in obtaining basic life support and cardiopulmonary resuscitation certification. written emergency procedures. Knowledge of the physical and physiological signs and symptoms of overtraining.10. vitamins.3 1.9. Body Mass Index. bradycardia. intensity.10.11 1. cardiovascular/pulmonary complications.7. Knowledge of the components of an equipment maintenance/repair program and how it may be used to evaluate the condition of exercise equipment to reduce the potential risk of injury.8. Ability to describe the advantages and disadvantages of various commerCial exercise equipment in developing cardiorespiratory fitness. SAFETY. syncope.5 1. prescribe. . Knowledge to define the following terms: obesity. fainting/syncope. . posters. Skill in demonstrating appropriate emergency procedures during exercise testing and/or training.9. . anorexia nervosa. fad diets). fats..10 1. .10.12 1. Associative. hypoglycemia/hyperglycemia. strain. Autonomous Knowledge of specific techniques to enhance motivation (e.8. recognition.e.10.3 1. and metabolic disorders. and monitoring techniques in exercise programs for apparently healthy clients or those who have medical clearance to exerCise . strains. bursitis. NUTRITION AND WEIGHT MANAGEMENT 1. hypotension/hypertension. electriC simulators. exercise testing. Knowledge of the legal implications of documented safety procedures. and standing bent-over toe touch.. Knowledge of the different types of learners (Auditory. and muscular endurance. bulletin boards.9. Knowledge of appropriate emergency procedures (i. HUMAN BEHAVIOR AND COUNSELING 1. tennis elbow.31 1. hypothermia/hyperthermia). tachypnea) and metabolic abnormalities (e. . full squats. and demonstrate appropriate fleXibility exercises for all major muscle groups. creatine.. Knowledge of safety plans..8.9.7. sprain. sweat suits.10. double leg raises. Knowledge of basic precautions taken in an exercise setting to ensure participant safety. the use of incident documents. percent fat.94 1. Knowledge of common nutritional ergogenic aids.14 1.g. continuous.14 1. bulimia nervosa. personnel responsibilities) in a health and fitness setting.g. .1 0. fractures). cardiovascular/pulmonary complications (e. plantar fasciitis.6 1. overweight.8 1. social support). diet alone. and after exercise. etc. stress fracture. Knowledge of potential musculoskeletal injuries (e.5 1. tendonitis. during. tachycardia.10. progression.13 1. . Ability to explain and implement exercise prescription guidelines for apparently healthy clients or those who have medical clearance to exercise Ability to adapt frequency. level of supervision..2 Knowledge of the role of carbohydrates.8.10. Knowledge of the importance of an adequate daily energy intake for healthy weight management. and circuit training programs. Knowledge of the stages of motivational readiness. duration. . protein. and ongoing safety training.12 1.8.10.10. low back pain. telephone procedures.1 1.8. Ability to periodize a resistance training program for continued muscular strength development . muscular strength.10.7 1.2 1.. Ability to design training programs using interval. and proteins as fuels for aerobic and anaerobic metabolism. Knowledge of the female athlete triad . fat. strains/sprains. and any risk and/or benefits (e. Knowledge of basic first aid procedures for exercise-related injuries. Define extrinsic and intrinsic reinforcement and give examples of each. and the legal implications of carrying out emergency procedures.730 1.g.APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 321 320 SECTION IV / APPENDICES 1. yoga plough.8.8. sodium bicarbonate. saunas. AND EMERGENCY PROCEDURES 1.9 1. lean body mass. emergency procedures.10.7.7. Knowledge of the USDA Food Pyramid. such as bleeding. games.1 0.35 1.1 1. musculoskeletal injuries. body wraps. and exercise training. Knowledge of the guidelines for caloric intake for an individual deSIring to lose or gain weight. Ability to idenify the components that contribute to the maintenance of a safe environment.7 1.1 1.13 1. sprains.8.) Ability to describe the health implications of variation in body fat distribution patterns and the significance of the waist to hip ratio.1 0.8 1..15 1. and rotator cuff tendonitis.10 1. and alcohol. Knowledge of the cPT's responsibilities.2 Knowledge of at least five behavioral strategies to enhance exercise and health behavior change (e.6 1.33 1. and pollution on the physiological response to exercise. Knowledge of the initial management and first aid techniques associated with open wounds. Knowledge of the number of kilocalories equivalent to losing 1 pound of body fat.g. altitude.36 Ability to modify exercises based on age and physical condition.9.7.9 1. and first aid techniques needed during fitness evaluations. Knowledge of the effects of diet plus exercise. Knowledge of the number of kilocalories in one gram of carbohydrate.3 Knowledge of the 3 stages of learning: Cognitive.8. humidity. goal setting.16 1. competitions). limitations. hurdlers stretch.29 1. carbohydrates. protein/amino acids.5 1.84 1. Knowledge of the myths and consequences associated with inappropriate weight loss methods (e.4 1. bee pollen. forceful back hyperextension. Knowledge of hypothetical concerns and potential risks that may be associated with the use of exercises such as straight leg sit-ups. Knowledge of the effects of temperature..10. and exerCise alone as methods for modifying body composition..g.10. reinforcement. and body fat distribution Knowledge of the relationship between body composition and health. heat injury).8. fractures. vibrating belts.11 1. Ability to evaluate. Ability to design resistive exercise programs to increase or maintain muscular strength and/or endurance.8.7.34 1. .

Knowledge of metabolic risk factors or conditions that may require consultation with medical personnel before testing or training.1. arrhythmia.12.11. and claudication. shoulder.10 Knowledge of common drugs from each of the following classes of medications and describe their effects on exercise: antianginals.10 1.1. 1. bradycardia.2 1. angina pectoris. cardiac output. superior. Knowledge of the interrelationships among center of gravity. and hypoglycemia.2 1 1. and connective tissues.APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 323 322 SECTION IV / APPENDICES 1. Knowledge of the common theories of muscle fatigue and delayed onset muscle soreness (DOMS). and ethics in relationships dealing with clients.11.1. base of support. Knowledge of the definition of the following terms: inferior.1 1 12. Knowledge of the following curvatures of the spine: lordosis.3 Knowledge of the basic structures of bone.1. Knowledge of the basic principles of electrical conduction of the heart. hyperventilation. fainting or dizzy spells.19 . scoliosis. lateral. agonist. stroke volume. supination. respiratory. and carrying or moving objects Ability to define aerobic and anaerobic metabolism.1 1.12. tachycardia. antagonist.8 1. independent contractor classifications as they relate to personal trainers Knowledge of appropriate professional conduct.7 1. jogging. cholesterol: high-density lipoprotein and low-density lipoprotein) profiles. practice standards.1 1. Knowledge of the plane in which each muscle action occurs. thyroid disease. including body weight more than 20% above optimal.5 1. abduction. psychotropics. skeletal muscle. extreme breathlessness at rest or during exercise. balance. Knowledge of how lifestyle factors. new onset discomfort in chest.7 Knowledge of the cPT's role in administration and program management within a health/fitness facility. osteoarthritis.17 Ability to assist or "spot" a client in a safe and effective manner during resistance exercise PROGRAM ADMINISTRATION. circumduction. Knowledge of the physiological adaptations that occur at rest and during submaximal and maximal exercise following chronic aerobic and anaerobic exercise training. and emphysema. and low back pain. Knowledge of the physiological adaptations associated with strength training. Knowledge of the physiological principles related to warm-up and cool-down.12.18 1. Knowledge of cardiovascular risk factors or conditions that may require consultation with medical personnel before testing or training. antihypertensives. systolic blood pressure. and it's implications. pronation.1. cold tablets. Knowledge of musculoskeletal risk factors or conditions that may require consultation with medical personnel before testing or training. influence blood lipid and lipoprotein (i. tendonitis.9 Knowledge of cardiovascular.12. metabolic. myocardial infarction. osteoporosis. and other allied health/medical/fitness professionals. Knowledge of respiratory risk factors or conditions that may require consultation with medical personnel before testing or training. Knowledge of how heart rate.1.11 1.7 1. Knowledge of the following terms: ischemia. QUALITY ASSURANCE. or arm.1.1. and musculoskeletal risk factors that may require further evaluation by medical or allied health professionals before participation in physical activity.12. and vasodilators. 1.1 14 11. stability. Knowledge of fundamental biomechanical principles that underlie performance of the following activities: walking.11 Knowledge of the effects of the following substances on exercise: antihistamines.1. and oxygen consu mption. and Abilities (KSAs): GENERAL POPULATION/CORE: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE 1. including inappropriate changes of resting or exercise heart rate and blood pressure. alcohol. diet pills.. changes in the pattern of discomfort during rest or exercise. lactic acid.e. BMI> 30. extension. professional business practices and ethical promotion of personal training services CLINICAL AND MEDICAL CONSIDERATIONS ACSM Health/Fitness Instructor® Knowledge. adduction.12.1.11. diastolic blood pressure. 1.9 1. bronchodilators. exercise-induced bronchospasm.11'6 1.11.6 1.12. hypoglycemics.5 1.15 1. hyperextension. including asthma. employers.1 13 1.8 1.6 1. blood pressure. Knowledge of the types of exercise programs available in the community and how these programs are appropriate for various populations. Knowledge to describe normal cardiorespiratory responses to static and dynamic exercise in terms of heart rate. Knowledge of and the ability to use the documentation required when a client shows abnormal signs or symptoms during an exercise session and should be referred to a physician.6 1.12.3 1. Knowledge of the role of aerobic and anaerobic energy systems in the performance of various activities. caffeine. knowledge of and ability to implement effective. medial. diabetes or glucose intolerance. rotation. oxygen consumption. it's phases of contraction. Knowledge of the risk factor concept of Coronary Artery Disease (CAD) and the influence of heredity and lifestyle on the development of CAD. neck.12.11. Knowledge of the differences in cardiorespiratory response to acute graded exercise between conditioned and unconditioned individuals.4 1. running. weight lifting. 1.1. and stabilizer. Knowledge of professional liability and most common types of negligence seen in training environments Understand the practical and legal ramifications of the employee vs. flexion.2 1. and anaerobic threshold. and kyphosis Knowledge to describe the myotatic stretch reflex. cycling. physical activity.17 11. Knowledge of the structure of the skeletal muscle fiber and the basic mechanism of contraction. rheumatoid arthritis. including nutrition. and nicotine. including acute or chronic back pain. blood pressure. swimming.112 1. Skills. Knowledge of risk factors that may be favorably modified by physical activity habits.11.12.3 1.4 1.4 1. antiarrhythmics.5 1. AND OUTCOME ASSESSMENT 1. bronchitis. ' Knowledge of the basic anatomy of the cardiovascular system and respiratory system. tranquilizers.11. and proper spinal alignment. and heredity.1. and oxygen consumption responses change with adaptation to chronic exercise training.10.

. eccentric.6 1.. Knowledge of plasma cholesterol levels for adults as recommended by the National Cholesterol Education Program. coordination. Knowledge of the basic properties of cardiac muscle and the normal pathways of conduction in the heart.1. .42 1. humerus. and tetanus with respect to muscle contraction. the factors involved in its genesis and progression.28 11. quadriceps. Knowledge of the importance of a health/medical history. Knowledge of muscle fatigue as it relates to mode.38 1. 1. abductors. and obtaining rating of perceived exertion (RPE) at rest and during exercise according to established guidelines. and resting and maximal blood pressure.2. triglycerides.1. hypertension. .2 13.3 1. Skill in accurately measuring heart rate. skinfolds and bioelectrical impedence.23 1. Skill in measuring skinfold sites.4 1.1.1. cardiac output.9 1. and the accumulative effects of exercise.1.1. muscular endurance. body compOSition. . radiUS..3. ..36 1. Knowledge of the limitations of informed consent and medical clearance prior to exercise testing. hydrostatic weighing. Knowledge of the risk factor concept of CAD and the influence of heredity and lifestyle on the development of CAD. sets. physical activity.2.1. Isotonlvlsometrlc. Intensity.1. Knowledge of blood pressure responses associated with acute exerCise. Knowledge of twitch. Ability to identify the majOr bones and muscles.~r .310 1. stroke volume.1.35 1. hypertension. Knowledge of the atherosclerotic process. and arteriovenous oxygen difference. hamstrings. tidal volume. including nutrition. Knowledge of the physiological principles involved In promoting gains In muscular strength and endurance. but are not limited to. Knowledge of how each of the following differs from the normal condition. repetitions. muscular strength. adductors.1.2 1. dUring exerCise. f d··· d Knowledge of the concept of detraining or reversibility 0 con ItIonlng an its implications in fitness programs. Knowledge of how the principle of speCifiCity relates to the components of fitness. . ulna. heat and cold tolerance. carpals.. .25 1. and tarsals. duration. and pulmonary disease).32 1. high-density lipoprotein cholesterol (HDL-C).6 1.24 1. Knowledge of the categories of participants who should receive medical clearance prior to administration of an exercise test or participation in an exercise program.34 1. gluteus maximus.37 1. .1. metabolic. Knowledge of the effect of the aging process on the musculoskeletal and cardiovascular structure and function at rest. strernum.324 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDJUNI: LI:K r IrlLA r IUI~~ 1. and the potential role of exercise in treatment. . Knowledge of how lifestyle factors.3. Knowledge of the value of a medical clearance prior to exercise participation. including changes in body position. and atherosclerosis. pectoraliS major. and musculoskeletal risk factors that may require further evaluation by medical or allied health professionals before participation in physical activity. maximal oxygen consumption. Knowledge of the sliding filament theory of muscle contraction.20 1. latiSSimus dorSI. tibia. but are not limited to the clavicle. erector spinae.1 Knowledge of the physiological and metabolic responses to exercise associated with chronic disease (heart disease. . resting and maximal heart rate. .1. blood pressure.1. Knowledge of cardiovascular.1 .1.1 . Knowledge of the following terms: progressive reSistance.40 .7 1.. femur.39 1.1 1. the following: trapezius. Knowledge of and ability to describe the Implications of ventilatory threshold (anaerobic threshold) as it relates to exercise training and cardiorespiratory assessment. . and heredity. Major bones Include.. TClHDL-C ratio.33 1. and gastrocnemius. plyometrlcs. . . internal and external obliques. biceps.3..3. 1.11 1.3. hypertrophy. respiratory rate. . pulmonary ventilation.30 1. concentric. . . fibia. and dUring recovery. influence lipid and lipoprotein profiles.1. Ability to locate the anatomic landmarks for palpation of peripheral pulses PATHOPHYSIOLOGY AND RISK FACTORS 1. FITNESS AND CLINICAL EXERCISE TESTING 12.41 1. scapula. summation. . Knowledge of and ability to describe the physiological adaptations of the respiratory system that occur at rest and during submaxlmal and maximal exercise following chronic aerobic and anaerobic training.2. . Major muscles Include.3.27 1.31 1. and body composition.3. and hypoventilation. strength. dyspnea. Knowledge of risk factors that may be favorably modified by physical activity habits Knowledge to define the following terms: total cholesterol (Te). Knowledge of and skill to demonstrate exercises for enhanCing musculoskeletal flexibility.. skeletal diameters. low-density lipoprotein cholesterol (LDL -C). Knowledge of and ability to describe the changes that occur In maturation from childhood to adulthood for the follOWing: skeletal muscle: bone structure. HEALTH APPRAISAL. Knowledge of and skill to demonstrate exercises designed to enhance muscular strength and/or endurance of specific major muscle groups.25 1.1.43 Ability to identify the joints of the body Knowledge of the primary action and joint range of motion for each major muscle group. Valsalva maneuver. . . Knowledge of the advantages/disadvantages and limitations of the various body composition techniques including air displacement.21 1.1.2.5 1.26 Knowledge of the characteristics of fast and slow twitch fibers. cardiovascular fitness. triceps. plethysmography. reaction time. rectus abdominis.3. diabetes mellitus. . respiratory.22 1.1. . flexibility. Ability to identify the major bones.8 1. and girth measurements used for estimating body composition Skill in techniques for calibration of a cycle ergometer and a motor-driven treadmill.7 1.3. atrophy.1.1.. . Knowledge of the response of the following variables to acute static and dynamic exercise: heart rate.3 1. Ability to locate the brachial artery and correctly place the cuff and stethoScope in position for blood pressure measurement.4 Knowledge of and ability to discuss the physiological basis of the major components of physical fitness: flexibility.28 1. .1 . . Knowledge of the physical and psychological signs of overtraining and to provide recommendations for these problems.29 1. hypoxia. Knowledge of relative and absolute contra indications to exercise testing or participation.2.

Ability to explain the purpose and procedures for monitoring clients prior to.14 1.. and type of physical activity necessary for development of cardiorespiratory fitness in an apparently healthy population 1. stress and anxiety levels. and persons with low back pain.3.7 Knowledge of and ability to describe the unique adaptations to exercise training in children. and body composition assessments for apparently healthy individuals and those with stable disease. and progression and how they relate to exercise programming. cool-down. antihypertensives.20 1. Ability to obtain informed consent.7.. during. family history of cardiac disease. and circuit training programs. muscular endurance.8 Knowledge of common orthopedic and cardiovascular considerations for older participants and the ability to describe modifications in exercise prescription that are indicated.24 Skill in the use of various methods for establishing and monitoring levels of exercise intensity.7.25 Ability to identify and apply methods used to monitor exercise intensity. determine appropriate protocols. warm-up. 1.720 Knowledge of the concept of "Activities of Daily Living" (ADLs) and its importance in the overall health of the individual.e. determine an appropriate submaximal or maximal protocol.17 1. and after cardiorespiratory fitness testing. pregnant and postnatal women. different ambient temperatures. Knowledge of the benefits and risks associated with exercise training in prepubescent and postpubescent youth.1 1.7. obese persons. and perform assessments of muscular strength. orthopedic limitations. Ability to describe the purpose of testing. 1. continuous. and rest with regard to strength training. Ability to analyze and interpret information obtained from the cardiorespiratory fitness test and the muscular strength and endurance.16 1. CM-5).7. aerobic stimulus phase. psychotropics. antiarrhythmics.1 1.4 . Knowledge of specific leadership techniques appropriate for working with participants of all ages. prescribed medications. adolescents. PATIENT MANAGEMENT AND MEDICATIONS 1.1 142 Knowledge of how each of the following differs from the normal condition: premature atrial contractions and premature ventricular contractions. flexibility.7.3.g. Knowledge of the effects of the following substances on exercise response: antihistamines. alcohol. 1. and older participants.7.7.721 Skill to teach and demonstrate the components of an exercise session (i.3. number of sets. Ability to identify appropriate criteria for terminating a fitness evaluation and demonstrate proper procedures to be followed after discontinuing such a test.16 Knowledge of special precautions and modifications of exercise programming for participation at altitude. and perform an assessment of cardiovascular fitness on the cycle ergometer or the treadmill. Ability to instruct participants in the use of equipment and test procedures.3.including the use of skinfold calipers.17 Knowledge of the importance of recording exercise sessions and performing periodic evaluations to assess changes in fitness status. humidity.21 1.5. EXERCISE PRESCRIPTION AND PROGRAMMING 1. Ability to obtain a health history and risk appraisal that includes past and current medical history. 1.15 1. aerobic stimulus phase.12 1. 1. cool-down. ElECTROCARDIOGRAPHY AND DIAGNOSTIC TECHNIQUES 14.7.326 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 327 1.3.6 Knowledge of the differences in the development of an exercise prescription for children. caffeine. frequency. recreational. 1. continuous.5. 1. hypoglycemics. 1. bronchodilators.22 Skill to teach and demonstrate appropriate modifications in specific exercises for the following groups: older adults.7.18 1. 1. 1. adolescents.3.3.3. muscular strength and/or endurance. Ability to describe the purpose of testing. cold tablets. specificity.7. including heart rate and rating of perceived exertion. warm-up.7. muscular strength/endurance. Ability to perform various techniques of assessing body composition. and older participants with regard to strength. nutritional habits. 1.5 Knowledge of how to modify cardiovascular and resistance exercises based on age and physical condition.3 Knowledge of the relationship between the number of repetitions.15 Knowledge of the components incorporated into an exercise session and the proper sequence (i.2 1. 1. and nicotine. and flexibility). diet pills. and vasodilators.11 Knowledge of and the ability to describe exercises designed to enhance muscular strength and/or endurance of specific major muscle groups.13 Knowledge of the various types of interval. and METs. and work tasks. 1. activity patterns. 17.3. Ability to identify individuals for whom physician supervision is recommended during maximal and submaximal exercise testing. 1.26 Ability to describe modifications in exercise prescriptions for individuals with functional disabilities and musculoskeletal injuries 1. preexercise evaluation. and environmental pollution. standard.e. RPE. Ability to modify protocols and procedures for cardiorespiratory fitness tests in children.22 1.2 Knowledge of common drugs from each of the following classes of medications and describe the principal action and the effects on exercise testing and prescription: antianginals.19 Knowledge of the types of exercise programs available in the community and how these programs are appropriate for various populations 1. adolescents.3.19 1. intensity. and exercise (Mason Likar) electrocardiograms (ECGs)..714 Knowledge of approximate METs for various sport. as well as commonly used bipolar systems (e.7.7. 1. 1. duration. 1718 Knowledge of the advantages and disadvantages of implementation of interval.7.3.3. tranquilizers. and motor skills.9 Knowledge of selecting appropriate testing and training modalities according to the age and functional capacity of the individual.7. 1.7.7. including heart rate. and flexibility.12 Knowledge of the principles of overload.13 1.23 Ability to locate common sites for measurement of skinfold thicknesses and circumferences (for determination of body composition and waist-hip ratio). and smoking and alcohol use. functional capacity.7.10 Knowledge of the recommended intensity.23 Skill to teach and demonstrate appropriate exercises for improving range of motion of all major joints.7. Knowledge of the benefits and precautions associated with resistance and endurance training in older adults. flexibility).7. 1. Ability to locate the appropriate sites for the limb and chest leads for resting. and older adults. and circuit training programs.7.

8.8.29 1.7.31 1. and alcohol.1 .5 1. and monitoring techniques in exercise programs for patients with controlled chronic disease (e.8 1..8.2 Knowledge of the role of carbohydrates. and exercise alone as methods for modifying body composition. Knowledge of the USDA Food Pyramid.7.7. social support). Ability to adapt frequency.12 1. Ability to teach a progression of exercises for all major muscle groups to improve muscular strength and endurance. Define extrinsic and intrinsic reinforcement and give examples of each. intensity. and stepping exercise Ability to explain and implement exercise prescription guidelines for apparently healthy clients. bee pollen) Knowledge of nutritional factors related to the female athlete triad syndrome (I. and target heart rates and apply the information to an exercise prescription. and evaluate individualized and group exercise programs based on health history and physical fitness assessments.2 19. progression. fat.8. Knowledge of the guidelines for caloric intake for an individual desiring to lose or gain weight. bands. cycle ergometry.16 1.4 1. Ability to convert weights from pounds (Ib) to kilograms (kg) and speed from miles per hour (mph) to meters per minute (m/min. Ability to describe the health implications of variation in body fat distribution patterns and the significance of the waist to hip ratio HUMAN BEHAVIOR AND COUNSELING 1. percent fat. during. Ability to modify exercise programs based on age. continuous.15 1. Knowledge of the importance of an adequate daily energy intake for healthy weight management.7 1. L/min.10 1.8. level of supervision.g. Ability to describe the advantages and disadvantages of various commercial exercise equipment in developing cardiorespiratory fitness.8.42 1743 1.1 . the purported mechanism of action. diet alone. lean body mass.7. and any risk and/or benefits (e. each. sodium bicarbonate. creatine.8 18. Ability to identify proper and improper technique in the use of resistive equipment such as stability balls.g.g..1 1.7. Nutrition for Physical Fitness Position Paper of the American Dietetic Association. Knowledge of the number of kilocalories in one gram of carbohydrate.1 1. competitions). cycling.95 1.328 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 329 1. hypertension). METs. recognition.9.7. musculoskeletal problems. protein/amino acids. resistance bars. and body fat distribution. Ability to modify exercises based on age and physical condition. posters. and after exercise. and exercise-induced asthma.9. . appraisal threat during exercise testing) and how it may affect physiological responses to testing.44 1. carbohydrates.9. NUTRITION AND WEIGHT MANAGEMENT 1.8.7. Knowledge of the importance of maintaining normal hydration before.45 1.1/min.27 1.7. increased risk clients.30 1.1).28 1.e.9. V0 2 . Ability to communicate effectively with exercise participants.e.8. goal setting. Ability to identify proper and improper technique in the use of cardiovascular conditioning equipment (e.1/min. saunas.. and clients with controlled disease. reinforcement. overweight.. body wraps. and water exercise equipment.g. stationary cycles.3 1.8.1 .46 Ability to differentiate between the amount of physical activity required for health benefits and the amount of exercise required for fitness development. and/or mL/kg FFW.17 Knowledge of the relationship between body composition and health. Ability to prescribe exercise intensity based on V0 2 data for different modes of exercise.4 1. treadmills.14 1. vibrating belts. Knowledge of the stages of motivational readiness.9. implement.. elliptical trainers). Knowledge of the effects of diet plus exercise. Ability to determine training heart rates using two methods: percent of agepredicted maximum heart rate and heart rate reserve (Karvonen).9 1. and osteoporosis) Knowledge of the NIH Consensus statement regarding health risks of obesity.7. performance.41 1. Ability to determine the energy cost in METs and kilocalories for given exercise intensities in stepping exercise.40 1.6 187 18. physical condition. menstrual cycle abnormalities. diabetes mellitus. weights.8. mode. Knowledge of specific techniques to enhance motivation (e. heart disease.. bulletin boards. and muscular endurance. games. Ability to convert METs to V0 2 expressed as mLlkg.6 1. duration. protein.7.7. Ability to design.35 1. Knowledge of the difference between fat-soluble and water-soluble vitamins. Knowledge of the importance of calcium and iron in women's health Knowledge of the myths and consequences associated with inappropriate weight loss methods (e. Ability to evaluate flexibility and prescribe appropriate flexibility exercises for all major muscle groups Ability to design training programs using interval.3 1. sweat suits. minerals.37 1738 1739 1.9.7. anorexia nervosa.11 1.13 1.8..7. Knowledge and ability to determine energy cost. bulimia. and during horizontal and graded walking and running. Knowledge of three counseling approaches that may assist less motivated clients to increase their physical activity.36 1. and proteins as fuels for aerobic and anaerobic metabolism. including graded and horizontal running and walking. Knowledge of extrinsic and intrinsic reinforcement and give examples of . and the ACSM Position Stand on proper and improper weight loss programs. fats.8. KnOWledge of symptoms of anxiety and depression that may necessitate referral to a medical or mental health professional. Knowledge to define the following terms: obesity. Knowledge of the number of kilocalories equivalent to losing 1 pound of body fat. vitamins. and current health status.8. electric simulators. muscular strength. Knowledge of at least five behavioral strategies to enhance exercise and health behavior change (e.32 1733 1734 1.8.7. Knowledge of the five important elements that should be included in each counseling session.g. and circuit training programs. eating disorders.g. stairclimbers.. Knowledge of common nutritional ergogenic aids. obesity. pregnancy and/or postpartum. Ability to design resistive exercise programs to increase or maintain muscular strength and/or endurance. KnOWledge of the potential symptoms and causal factors of test anxiety (i. fad diets).7.

1. the use of incident documents. training exercise leaders.2.1 0.1012 hyperthermia) Knowledge of the initial management and first aid techniques associated with open wounds. Skill in demonstrating appropriate emergency procedures during exercise 2. hypotension/hypertension..2.10.2.1 testing and/or training. tendonitis. Knowledge of the following terms: shin splints. and goal setting. and claudication. and rotator cuff tendonitis.11. these programs are typically Exercise Science. NOTE: The KSAs listed above for the ACSM HealthlFitness Instructor'" are the same KSAs for educational prog~ams seeking undergraduate (bachelor's degree) academic accreditation through the CoAES.14 1. Knowledge of and the ability to use the documentation required when a client shows signs or symptoms during an exercise session and should be referred to a physician.4 Knowledge of cardiovascular risk factors or conditions that may require consultation with medical personnel before testing or training.coaes.3 1.g . obesity. and hypoglycemia. AND EMERGENCY PROCEDURES 1. arthritis.11.16 5.10. including acute or chronic back pain.3 1. fainting or dizzy spells. sprain. such as bleeding. hypothermia/ 1. hurdlers stretch.10. tennis elbow. Knowledge of hypothetical concerns and potential risks that may be associated with the use of exercises such as straight leg sit-ups.4 1. limitations. retention.9 standing bent-over toe touch Knowledge of safety plans.108 2. and pollution on the physiological response to exercise. thyroid disease.10. and immunosuppressive disease.8 1.4 1.11.7 1. and ongoing safety training. and Knowledge of how to manage of a fitness department (e. Knowledge of the causes of myocardial ischemia and infarction.2 Knowledge of the health/fitness instructor's role in administration and program management within a health/fitness facility. and metabolic disorders Knowledge of the components of an equipment maintenance/repair program and how it may be used to evaluate the condition of exercise equipment to reduce the potential risk of injury. including Inappropnate changes of resting or exercise heart rate and blood pressure. low back pain. Knowledge the pathophysiology of hypertension..1 1. 8MI> 30. INJURY PREVENTION. osteoporosis.2.102 Knowledge of and skill in obtaining basic life support and cardiopulmonary resuscitation certification. lectures. sprains. patellar femoral pain syndrome.11.g.11. syncope.g. strains. heat injury). bursitis. rheumatoid arthritis. Knowledge the effects of the above diseases and conditions on cardiorespiratory and metabolic function at rest and during exercise PULMONARY: PATHOPHYSIOLOGY AND RISK FAGORS 3. tachycardia. bradycardia.11. new onset discomfort in chest. double leg raises. AND OUTCOME ASSESSMENT Knowledge of musculoskeletal risk factors or conditions that may require consultation with medical personnel before testing or training. please visit www.1 1.6 1. osteoarthritis.11.. diabetes or glucose Intolerance.2. and exercise training.330 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 331 SAFETY. emergency procedures. altitude. including body weight more than 20% above optimal. including asthma.org. hyperlipidemia. 1. full squats.10. QUALITY ASSURANCE.2 2.10. Knowledge of basic first aid procedures for exercise-related injuries.5 1. and low back pain. Ability to administer fitness-related programs within established budgetary guidelines. and the legal implications of carrying out emergency procedures 1. fractures). hypoglycemia/hyperglycemia.10. chronic diseases. tachypnea) and metabolic abnormalities (e. ORTHOPEDIc/MUSCULOSKELETAL: PATHOPHYSIOLOGY AND RISK FAGORS 1.103 1. neck.7 2. bronchitis. plantar fasciitis. shoulder. strains/sprains.g .9 1. humidity. osteoporosis. Ability to develop marketing materials for the purpose of promoting fitnessrelated programs. CARDIOVASCULAR: PATHOPHYSIOLOGY AND RISK FAGORS 1. Kinesiology. tendonitis.10.5 1. SpeCifICally. or arm.e.11. METABOLIC: PATHOPHYSIOLOGY AND RISK FACTORS 4. Ability to create and maintain records pertaining to participant exercise adherence.. and first aid techniques needed during fitness evaluations.11 Knowledge of potential musculoskeletal injuries (e.2. contusions. andlor Physical Education departments With profeSSional development tracks for those students interested in careers in the fitness industry_ For more information. forceful back hyperextension.1 1. Knowledge of the Importance of tracking and evaluating member retention. working within a budget.1 Knowledge of respiratory risk factors or conditions that may require consultation with medical personnel before testing or training.10. 1. workshops) and educational materials. Skill to demonstrate exercises used for people with low back pain. Knowledge of basic precautions taken in an exercise setting to ensure participant safety. changes in the pattern of discomfort during rest or exercise. Knowledge of the physical and physiological signs and symptoms of overtraining.10. personnel responsibilities) in a health and fitness setting.13 Knowledge of metabolic risk factors or conditions that may require consultation with medical personnel before testing or training. musculoskeletal injuries. fainting/syncope. and emphysema. Knowledge of the legal implications of documented safety procedures. extreme breathlessness at rest or during exercise. written emergency procedures. fractures.6 1.g . cardiovascular/pulmonary complications (e. yoga plough. scheduling.1015 1. exercise testing. cardiovascular/pulmonary complications. exerCISe-induced bronchospasm. chronic obstructive pulmonary diseases. Knowledge of appropriate emergency procedures (i. stress fracture. running staff meetings). diabetes. and exercise intolerance (dizziness. . strain.10 Knowledge of the health/fitness instructor's responsibilities.1 1.2.17 Ability to identify the components that contribute to the maintenance of a safe environment.10. PROGRAM ADMINISTRATION.. Knowledge of the effects of temperature. Ability to develop and administer educational programs (e. telephone procedures.11.

treadmill. starting levels. brachial.3. double product.g.1.16 1.1. and vasospastic angina.3. Identify the cardiorespiratory responses associated with postural changes. and metabolic diseases.4 Describe coronary anatomy. organize.3. Select and perform appropriate procedures and protocols for the exercise test..18 1. sestamibi.4 Summarize the atherosclerotic process. temperature.3. pulmonary. Describe anatomical landmarks as they relate to exercise testing and programming. perform.1. metabolic. and metabolic diseases. protocol. ramping versus incremental protocols. atypical. technetium. tidal volume. Describe the importance of accurate and calibrated testing equipment (e. Knowledge of acute and chronic adaptations to exercise for apparently healthy individuals (low risk) and for those with cardiovascular.332 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 333 ACSM Exercise Specialist® Knowledge. 1. pulmonary. treadmill.11 EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE in response to exercise testing and training in healthy and disease states.1 1. ergometers. Describe and conduct immediate postexercise procedures and various approaches to cool-down. Describe the cardiorespiratory and metabolic responses that accompany or result from pulmonary diseases at rest and during exercise.19 1. Describe the effects of variation in environmental factors (e. oxygen saturation. pulmonary.1. Conduct pre-exercise test procedures.1. popliteal.11 1. and/or metabolic diseases or with low functional capacity.9 1.1. Describe the differences in the physiological responses to various modes of ergometry (e. pulmonary. Describe activities that are primarily aerobic and anaerobic.7 1. altitude) for normal individuals and those with cardiovascular.2 1.8 1.3. O2 consumption.5 1. Instruct the test participant in the use of the RPE scale and other appropriate subjective rating scales.3. Determine maximal oxygen (0 2) consumption and describe the methodology for measuring it. Skills.5 1. Describe the normal and abnormal cardiorespiratory responses at rest and exercise. blood pressure. Obtain informed consent and describe its purpose. Describe the effects of age.8 1 1.10 Examine the role of diet on cardiovascular risk factors such as hypertension.22 .17 1.9 1.2 Describe common procedures and apply knowledge of results from radionuclide imaging (e.3.2.3. and health status on the selection of an exercise test protocol.7 1.6 1.6 1. Record.3. carotid. and VE/VC0 2 1. Knowledge of exercise testing procedures for various clinical populations including those individuals with cardiovascular. thallium.. cardiac output.10 1.3.2. weight.3.3. humidity.g. and oxygen consumption) at appropriate intervals during the test. minute ventilation.2.3. sporVexercise. femoral. HEALTH APPRAISAL.1.34 1.5 1. Plot the normal resting and exercise values associated with increasing exercise intensity (and how they may differ for diseased populations) for the following: heart rate. Identify individuals for whom physician supervision is recommended during maximal and submaximal exercise testing. Ability to measure oxygen consumption during an exercise test. 1. blood lipids and body weight. ECG. length of stages. household.7 1. expansion.3 1.15 1. including modes of exercise. stroke volume. and Abilities (KSAs): 1.3.14 1. Ability to provide testing procedures and protocol for children and the elderly with or without various clinical conditions. Locate and palpate anatomic landmarks of radial. FITNESS AND CLINICAL EXERCISE TESTING 1. and expected outcomes.1 11.12 Discuss the effects of isometric exercise in individuals with cardiovascular. Describe basic equipment and facility requirements for exercise testing.1 1. including current hypotheses regarding onset and rate of progression and/or regression.3.3 11.3.3 1.3. symptoms. PATHOPHYSIOLOGY AND RISK FACTORS 1. heart rate.1.3. Identify the mechanisms by which functional capacity and cardiovas. and interpret necessary calculations of test data.12 1. RPE and other scales.2. Knowledge of the unique hemodynamic responses of arm versus leg exercise and of static versus dynamic exercise. VdNt. single photon emission computed tomography (SPEeT».3. and tibialis arteries. 'MV0 2 ..10 1.20 1. such as the dyspnea and angina scales. Describe and analyze the importance of the absolute and relative contraindications of an exercise test.2. Describe the influence of exercise on cardiovascular risk factors./ cular.2. Select an appropriate test protocol according to the age and functional capacity of the individual.g.9 1.21 1.g.6 1. Describe the lipoprotein classifications and define their relationship to atherosclerosis or other diseases. level of fitness. Describe the pathophysiology of the healing myocardium and the potential complications after acute myocardial infarction (MI) (extension. and leisure time activities. Define the determinants of myocardial oxygen consumption and the effects of exercise training on those determinants. electrocardiograph. breathing frequency.13 1.1.2.2. cycle and arm ergometers) as they relate to exercise testing and training. pulmonary.11 1.2 1. and frequency of data collection. increments of work. and metabolic diseases in terms of exercise modality. Accurately record and interpret right and left arm pre-exercise blood pressures in the supine and upright positions. Identify the metabolic equivalent (MET) requirements of various occupational.3.2.8 1. .. Compare and contrast the differences between typical.2. physiological measurements. arteriovenous O2 difference. Describe the physiological effects of bed rest and discuss the appropriate physical activities that might be used to counteract these changes. and sphygmomanometers). systolic and diastolic blood pressure. Describe the cardiorespiratory and metabolic responses in myocardial dysfunction and ischemia at rest and during exercise.3.g. Obtain and interpret medical history and physical examination findings as they relate to health appraisal and exercise testing. Measure physiological and subjective responses (e. rupture) Describe silent ischemia and its implications for exercise testing and training. and neuromuscular adaptations occur 1.2.

sinus bradycardia and tachycardia..g. MEDICAL AND SURGICAL MANAGEMENT 1. pulmonary disease.4. Define the ECG criteria for initiating and/or terminating exercise testing or training.4.15 1. 1.3 1.6 Compare and contrast benefits and risks of exercise for individuals with CAD risk factors and for individuals with cardiovascular.. ventricular fibrillation.24 1. 1.2 143 1. antihypertensives. Parkinson's disease.25 1. supraventricular premature contractions and tachycardia.7. . atrioventricular blocks.3 Describe mechanisms and actions of medications that may affect exercise testing and prescription.4. 1. couplets.6. Knowledge of the concept of "Activities of Daily Living" (ADLs) and its importance in the overall rehabilitation of the individual.8 1.4.1 1.g. and other thrombolytic agents. stent) as an alternative to medical management or bypass surgery.4.. heart rate. blood pressure. pulmonary.1 1. gout.7 1.4 Summarize the purpose of coronary angiography. Describe and apply Baye's theorem as it relates to pretest likelihood of CAD and the predictive value of positive or negative diagnostic exercise ECG results. tachycardia).4.6. Identify ECG changes that correspond to ischemia in various myocardial regions. Design appropriate exercise prescription in environmental extremes for normal individuals and those with cardiovascular.4. Describe the differences between Q-wave and non-Q-wave infarction.26 1. congestive heart failure. Design.7.4.3.28 1. and metabolic disease. diabetes.4.3. 1. Identify the ECG patterns at rest and responses to exercise in patients with pacemakers and ICDs. hypoglycemics. EXERCISE PRESCRIPTION AND PROGRAMMING 1. during exercise.16 1.5 1.4.19 1.g. and recovery.g.3.g. Identify potentially hazardous arrhythmias or conduction defects observed on the ECG at rest.. Describe indications and limitations for medical management and interventional techniques in different subsets of individuals with CAD and PAD. pulmonary circulation) and their potential relationship to cardiovascular. and drug therapy.18 Obtain and interpret a pre-exercise standard and modified (MasonLikar) 12-lead ECG on a participant in the supine and upright position. atrial flutter and fibrillation. sinus arrest.7.10 1. and infarction.14 1.11 1. form.5. and their effects at rest and during exercise (e.. antianglnals. Design a supervised exercise program beginning at hospital discharge and continuing for up to six months for the following conditions: MI. and points of insertions as it relates to exercise programming. 1. Administer and interpret basic resting spirometric tests and measures including FEV1.4. PCI. pulmonary. antiarrythmics. and/or metabolic diseases. oxygen consumption.4. Identify ECG changes that typically occur due to hyperventilation. tissue plasminogen activase.23 1. as well as commonly used bipolar systems (e. medical management of CAD. Explain indications and procedures for combining exercise testing with radionuclide or echocardiographic imaging. and cardiac transplants. rate of perceived exertion. salvos. Describe potential causes of various cardiac arrhythmias.7. PATIENT MANAGEMENT AND MEDICATIONS 1. bronchodilators. pulmonary.4 1. or recovery. Identify neuromuscular disorders (e. Identify the variables measured during cardiopulmonary exercise testing (e. pericarditis. ventilation. and MVV.20 Identify and describe the significance of ECG abnormalities in designing the exercise prescription 'and in making activity recommendations. and lipid-lowering agents). and metabolic diseases. and metabolic disease.0.29 1. pulmonary.4. psychotropics.1 Describe percutaneous coronary and peripheral interventions (e. implement and supervise individualized exercise prescriptions for people with chronic disease and disabling conditions.3.. muscle actions. foot drop.3. 1. PTCA. injury. and metabolic disorders. cardiac chamber enlargement. multiple sclerosis) as they relate to modifications of exercise testing and programming. during exercise.7. weight management. ELECTROCARDIOGRAPHY AND DIAGNOSTIC TECHNIQUES 1. their indications for care.6 1.2 Describe basic joint movements.4.4. Describe the aerobic and anaerobic metabolic demands of exercise testing and training in individuals with cardiovascular.30 Describe normal and abnormal chronotropic and inotropic responses to exercise testing and training.2 1. Discuss the appropriate use of static and dynamic exercise for individuals with cardiovascular.12 Identify resting and exercise ECG changes associated with the following abnormalities:bundle branch blocks and bifascicular blocks.334 SECTION IV / APPENDICES APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 335 1.7. vasodilators.4.3. Describe myocardial ischemia and identify ischemic indicators of various cardiovascular diagnostic tests.5 1. angina: LVAD.1 List indications for use of streptokinase.4. myocardial ischemia. specific joint problems) as they relate to modifications of exercise testing and programming.4. pulmonary.4.3. Identify orthopedic limitations (e.3. Recognize medications associated in the clinical setting.27 1. and/or metabolic diseases undergoing exercise testing or training. Identify the causes of false positive and false negative exercise ECG responses and methods for optimizing sensitivity and specificity. Ability to minimize ECG artifact Describe the diagnostic and prognostic implications of the exercise test ECG and hemodynamic responses. CM-5).17 1. Compare and contrast obstructive and restrictive lung diseases and their effect on exercise testing and training. chronic pulmonary disease. electrolyte abnormalities. FVC. and exercise (Mason Likar) electrocardiograms (ECGs). ventricular premature contractions (including frequency. ventilatory threshold. Identify resting and exercise ECG changes associated with cardiovascular disease. CABG. hypertensive heart disease.5. Describe the diagnostic and prognostic significance of ischemic ECG responses and arrhythmias at rest.g.13 Locate the appropriate sites for the limb and chest leads for resting. standard.5.2 1. anticoagulant and anti platelet drugs.9 1.

7.. and metabolic dise~ses on ~er~or~~nce and safety during exercise testing and training.3 1.1 1.9.2 1.9. respiratory.18 1. diet.7.8.2 1. DeScribe the psychological issues to be confronted by the patient and by family members of patients who have cardiovascular disease and/or who have had an acute Ml or cardiac surgery. and flexibility exercise training on the structure and function of the cardiovascular.8. job loss) that might prompt a psychological consult or referral to other professional services. Discuss equipment adaptations necessary for different age groups. resistance. pulmonary. respiratory. and metabolic diseases. elastic bands. implantable cardiac defibnll~tor (I~D) dl~charge. Identify the psychological issues associated with an acute cardiac event versus those associated with chronic cardiac conditions. Identify and discuss specific outcome collection instruments that could be used to collect outcome data in a cardiac or pulmonary rehabilitation program.3 / Describe the acute responses to aerobic and resistance exercise training on the function of the cardiovascular. Skills. Describe the principle of specificity of training as it relates to the mode of exercise testing and training.19 1. and diabetes that are recommended to minimize disease progression and optimize disease management.7. pulmonary. such as exercise. and immune systems. pulmonary. pulmonary and/or metabolic diseases.9.8. and children. Identify and discuss various outcome measurements that could be used in a cardiac or pulmonary rehabilitation program.APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 337 336 SECTION IV / APPENDICES 1. neuromuscular. QUALITY ASSURANCE. and for overal patient safety.3 ACSM Registered Clinical Exercise Physiologist Knowledge. cardiac arrest. HUMAN BEHAVIOR AND COUNSELING 1. AND OUTCOME ASSESSMENT 1. water aerobics) for individuals with cardiovascular. Design a strength and flexibility programs for individuals with cardiovascular.1 Discuss the role of outcome measures in chronic disease management programs such as cardiovascular and pulmonary rehabilitation programs. Describe the general principles of crisis management and factors influencing coping and learning in illness states 1. elderly.10. Identify characteristics that correlate or predict poor compliance to exercise programs. PROGRAM ADMINISTRATION.g. Compare and contrast dietary practices used for weight reduction and address the benefits. and after administration of an exercise test and/or exercise session.11 1. return to work and physical activity. during.1.7. .7 Identify the psychological stages involved with the acceptance of death and dying and ability to recognize when it is necessary for a psychological consult or referral to a professional resource.2 1.7.15 1. hypoglecemla and hypergly~emia.1 Describe and discuss dietary considerations for cardiovascular and pulmonary diseases.4 1.10. Determine appropriate testing and training modalities according to the age and functional capacity of the individual. pulmonary.712 1. bench stepping. ~IS~ stratify mdlvlduals with cardiovascular.7.16 1.6 Respond ap~ropriately to emergency situations (e. transient ischemic attack (TIA) or stroke.7. isodynamic exercise.9.1 List and apply five behavioral strategies as they apply to lifestyle modifications.4 1. endocrine. musculoskeletal.710 1. and scientific support for each practice. musculoskeletal.9. Organize GXT and clinical data and counsel patients regarding issues such as ADL. bronchospasm.20 1.10.8 1. Describe the chronic effects of aerobic. Ability to modify exercise testing and training to the limitations of peripheral arterial disease (PAD).10. Describe the effects of cardiovascular. SAFETY. and low fat diets such as the American Heart Association recommended diet. risks. neuromuscular. Identify individuals who require exercise testing prior to exercise training. Des~ribe the appropriate procedures for maintaining emergency eqUipment and supplies. metabolic.2 1113 1.7. and Abilities (KSAs): KSA# GENERAL POPULATION/CORE: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE 1.13 Describe the importance of warm-up and cool-down sessions with specific reference to angina and ischemic ECG changes. Describe the indications and methods for ECG monitoring during exercise testing and training. Calculate the effect of caloric intake and energy expenditure on weight management. and immune systems.2 1.10. sudden onset ~ypotension.1.14 1. ~erious cardiac arrhythmias.5 1. MI) whlc~ might anse before. metabolic.5 1. Identify and explain the mechanisms by which exercise may contribute to preventing or rehabilitating individuals with cardiovascular. List ~edicati~ns that should be available for emergency situations in exercise testmg and training sessions Describe the emergency equipment and personnel that should be pr~s~nt in a~ exercise testing laboratory and rehabilitative exercise trammg settmg.11. endocrine. chronic heart failure.7. or metabolic diseases. Describe the importance of and appropriate methods for resistance training in older individuals. using appropriate materials and understanding the prognostic mdlcators for high-risk individuals.11. Describe signs and symptoms of maladjustment and/or failure to cope during an illness crisis and/or personal adjustment crisis (e. and medication management. Describe relative and absolute contraindications to exercise training.7. Examples of dietary practices are high protein/low carbohydrate diets.1 1.6 1.g.9 1. Describe common gait abnormalities as they relate to exercise testing and programming. and metabolIC dl~e~se~.17 1. stress. AND EMERGENCY PROCEDURES 1.9.g.7.10.7. 1.9.21 1.7 Prescribe exercise using nontraditional modalities (e. Recognize observable signs and symptoms of anxiety or depressive symptoms and the need for a psychiatric referral.. INJURY PREVENTION. Mediterranean diet.7. and strategies to increase exercise adherence. 1. NUTRITION AND WEIGHT MANAGEMENT 1.

7. spirometer. colds. AHA) Explain the physiological adaptations to exercise training that may result in improvement in or maintenance of health.3.e. breathing reserve.3. respiratory exchange ratio. Get Up and Go. peripheral pulses.20 1.3.3.3. during and after exercise interventions. heart rate.g. air quality (e. Explain how environmental factors may affect the physiological responses to exercise. blood pressure.3. mean arterial pressure. ventilatory (anaerobic) threshold. tachycardia. cardiovascular (ie. heart rate. dyspnea. strength and flexibility training) for individuals with co-morbid disease.3.3. and methods that may counteract these effects. Identify SA.3 1.7. respiratory rate. and apply appropriate precautions to reduce risks to the patient. substrate utilization). and mean arterial pressure and explain how these determinants may be altered with aerobic and resistance exercise training. myocardial injury. and radionuclide tests Select and administer appropriate exercise tests to evaluate functional capacity. mechanical cycle ergometer and arm ergometer.g. apply. Determine atrial and ventricular rate from rhythm strip and 12-lead ECG and explain the clinical significance of abnormal atrial or ventricular rate (e. bone density). Berg Balance Scale. and other relevant factors. neuromuscular. oxygen saturation.7 1. and muscular endurance and other common measures employed for diagnosis and prognosis of disease. US Surgeon General. Explain the physiological effects of physical inactivity. Institute of Medicine. stroke volume.1 1.g. Identify contra indications to an exercise session Appropriately select and administer functional tests to measure patient outcomes and functional status including the 6 minute walk.338 SECTION IV / APPENDICES APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 339 1.10 1. subendocardial and transmural ischemia. symptoms (e. lactate and ventilatory (anaerobic) threshold.13 1.15 1. lung function). ACSM. musculoskeletal. measuring blood pressure. respiratory gas analyzer (Metabolic cart)).5 17. presenting concise information to other health care providers and third party payers. etc). electrocardiograph. Describe the physiological determinants of V02. Instruct individuals with chronic disease in techniques for performing physical activities safely and effectively in an unsupervised exercise setting. acute illness) health.3. muscle structure.19 1. CO. ozone. and infarction and explain the clinical significance of each.4 1. motorized/computerized treadmill. blood pressure.. and ausculating heart and lung sounds.1.5 1. Physical Performance Test.10 List typical values in sedentary and trained persons for oxygen uptake. AHA). heart rate. claudication).6 11. rate pressure product. and bundle branch blocks from a rhythm strip & 12-lead ECG..3.18 1.. ratings of perceived exertion and discomfort (chest pain..8 1. Administer exercise tests consistent with US nationally accepted standards for testing (Ie. FITNESS AND CLINICAL EXERCISE TESTING 1. MV02. humidity.e.9 1.e. atrial. musculoskeletal (i.e. Pulmonary diseases). Explain the health benefits of a physically active lifestyle.3.. and ventricular dysrhythmias from a rhythm strip & 12-lead ECG. and immune system (i. Recognize and respond to abnormal signs and symptoms during exercise. and following exercise in patients with chronic disease according to health status. . AV. Appropriately select. medical treatment. Select and employ appropriate techniques for preparation and measurement of ECG.9 11.14 1. ventilatory volumes and capacities.. expired gases. GENERAL POPULATION/CORE: EXERCISE PRESCRIPTION AND PROGRAMMING 1.17 1. pharmacologic. muscular strength. Identify ECG changes associated with drug therapy. Conduct a brief physical examination including evaluation of peripheral edema. Design and supervise comprehensive exercise programs for outpatients with chronic disease Determine the appropriate level of supervision and monitoring recommended for individuals with known disease based on chronic disease risk stratification (e.3. blood pressure. obtaining a focused medical history and results of prior tests and physical exam.g .3. Extract and interpret clinical information needed for safe exercise management of individuals with chronic disease Identify probable disease-specific endpoints for testing in a patient with chronic disease or disability. and tidal volume at rest and during submaximal and maximal exercise. the hazards of sedentary behavior and summarize key recommendations of US national reports of physical activity (e.1.g.1 17.6 1. and describe appropriate alterations in exercise recommendations due to environmental conditions and patient health status.. Evaluate patient outcomes from serial outcome data collected before.4 11.11 1.7. angina.2 1.3 1. glucose and lipid metabolism).3.g. including ambient temperature.3. heart rate.. respiratory rate. ventilation (including ventilatory (anaerobic) threshold). oxygen saturation. functional.3.7. Determine an individual's pre-test and post-test probability of CHD. myocardial oxygen consumption.1. bioenergetics (e. and explain the clinical significance of each. Develop and supervise an appropriate Exercise Prescription (e. Metabolic. Identify sinus. minute ventilation.16 1. claudication). and other measures as needed before.2 1.4 1. cardiovascular. bradycardia). environmental conditions. resting Metabolic rate. RPE.1.8 1.3 1. electrolyte abnormalities. disease-specific risk factor assessment (i. air pollution) and altitude.5 1 1. during and following exercise. Discuss strengths and limitations of various methods of measures and indices of body composition. Calibrate lab equipment used frequently in the practice of clinical exercise physiology (e. Interpret the variables that may be assessed during clinical exercise testing including maximal oxygen consumption. systolic and diastolic blood pressure.g. dyspnea. Implement appropriate precautions prior to.6 Adapt Exercise Prescriptions for patients with comorbid conditions and disease complications.3. and current health status.12 1.7 Conduct pre-test procedures including explaining test procedures to the patient and obtaining informed consent. Metabolic syndrome. including bed rest.e.. and interpret body composition tests and indices. atherosclerosis).3. pulmonary (i. and explain the clinical significance of each. ACSM. aerobic. including metabolic (i. Explain the mechanisms underlying the physiological adaptations to aerobic and resistance exercise training including those resulting in changes in or maintenance of maximal and submaximal oxygen consumption. cardiac output.3.g. during. strength. and flexibility in patients with chronic disease. and immune function. metabolic..3. CVD. ECG. identify factors associated with test complications. Identify contra indications to exercise testing. echocardiography. GENERAL POPULATION/CORE: HEALTH APPRAISAL.

indications. laryn. stress management. goscope.5 2.. and transplant. Select and apply behavioral techniques such as goal setting. first responder) Including basic cardiac life support.3. treatments... . . diagnostic techniques.5 Summarize contemporary theories of health behavior change including social cognitive theory.2 1. clinical practice guidelines for the prevention. which enhance adoption of and adherence to healthy behaviors including exercise. current health status.10. fatigue.. including echocardiography. 2.2 2. and other laboratory tests) and surveys (e. and key clinical findings of cardiovascular diseases Explain the ischemic cascade and its effect on myocardial function. and social support. drugs. and program goals. and flexibility exercise in individuals with cardiovascular diseases. treatment and management of cardiovascular diseases (e. malpractice.7 2. GENERAL POPULATION/CORE: PROGRAM ADMINISTRATION. Describe the epidemiology..5 1. grams Describe the psychological issues associated with acute and chronic illness such as depression. major side effects.9. AED. CARDIOVASCULAR: PATHOPHYSIOLOGY AND RISK FACTORS 2. CARDIOVASCULAR: MEDICAL AND SURGICAL MANAGEMENT 2. physiologic responses to.9. AND EMERGENCY PROCEDURES 2.2 2. physical work simulations.1 Describe appropriate staffing for exercise programs and exercise testing laboratories based on factors such as patient health status. health belief model and apply techniques to promote healthy behaviors including physical activity.6. document and report treatment outcomes uSing patient-relevant results of tests (e. weight management. including the etiology and rate of progression of disease. Explain how cardiovascular disease may affect physical examination findings. liability.3 Develop an appropriate Exercise Prescription (e.6 1. and illness GENERAL POPULATIONICORE: SAFETY. on the exercising individual.4 1. etc.S. and supplies present in an exercise . dyspnea.. joint immobilization. informed consent.3. negligence. and lifestyle management. contracts.2.11.4 1. social isolation. ACe. physical functioning and health-related quality of life) Explain legal issues pertinent to health care delivery by licensed and non.6.94 1.10.g.2 1.10. revascularization procedures. AHA. biomarkers.11. standards of care) and legal risk management techniques Identify patients requiring referral to a physician or allied health services such as physical therapy.1. Explain how cardiovascular diseases may affect the physiological responses to exercise training on the ischemic cascade and the components of the Fick equation.3 1.113 Explain the common medical and surgical treatments of cardiovascular diseases including pharmacologic therapy. and explain the purposes. Design & adapt Exercise Prescriptions for individuals with cardiovascular disease to accomodate physical disabilities and complications due to cardiovascular diseases Design and supervise comprehensive outpatient exercise programs for individuals with cardiovascular disorders.4 2. . resistance.11. pacemakers. and potential complications of pharmacological and pacing stress testing in individuals with cardiovascular diseases. aerobic.13 Describe the indications for. . theory of planned behaVior. dietary counseling. and biomarkers (e. CARDIOVASCULAR: HEALTH APPRAISAL.7. QUALITY ASSURANCE AND OUTCOME ASSESSMENT Describe common techniques used to diagnose cardiovascular disease. etc) and explain the indications. Recognize and respond to abnormal signs and symptoms in individuals with cardiovascular diseases such as pain.6.10. radionuclide imaging. lCD.g.. INJURY PREVENTION.9. testing laboratory and therapeutic exercise session area. peripheral edema. Describe characteristics associated with poor adherence to exercise pro. theory of reasoned action. including preventive care. Counsel patients with chronic diseases and conditions on tOPiCS such as disease processes. oxygen.6.1 2.g. name common generic and brand names drugs within each class.g.1 27.3. and enVIronmental considerations GENERAL POPULATION/CORE: HUMAN BEHAVIOR AND COUNSELING CARDIOVASCULAR: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE 2.2.1 2.3 111.3 1.2 2.1 2. Explain how treatments for cardiovascular disease.2. Describe the potential benefits and hazards of aerobic. activation of EMS.g. and suicidal ideation. Develop and implement a plan for responding to emergencies.e. risks and normal and abnormal results for each.3 2. behavioral) to identify and manage cardiovascular risk. FITNESS AND CLINICAL EXERCISE TESTING 1. obesity.3. musculoskeletal limitations.340 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 341 1. List necessary equipment and supplies for exercise programs and exercise testing laboratories.9.10. relapse prevention. bereavement. if any. risk factors.2 2.4 1. .3 Explain current hypotheses regarding the pathophysiology of atherosclerosis. torts..6 27. facilities.. NHLBI) List the drug classifications commonly used in the treatment of individuals with cardiovascular diseases. may affect the rate of progression of disease. strength and flexibility training) for individuals with cardiovascular disease.. Recognize signs and symptoms of failure to cope during personal crises such as Job loss. List the key clinical findings during a physical exam of a patient with cardiovascular diseases. lipoproteins. Transtheoretical model. and the effects. Apply current US national guidelines for primary and secondary prevention of heart disease (e. CARDIOVASCULAR: EXERCISE PRESCRIPTION AND PROGRAMMING 1. Explain factors that may increase anxiety prior to or during exerCISe testing and describe methods to reduce anxiety.5 List routine emergency equipment.2 1 11. limitations. Troponin. Summarize key recommendations current U. pathophysiology.77 Modify the Exercise Prescription or discontinue exercise based upon patient symptoms. hostility. Select.12 1.1 1.1 1.g.6 1.9. Explain Universal Precautions procedures and apply as appropriate.9. aggression.g. including community referrals. Verify operating status of emergency equipment including defibrillator. pharmacologic.. angiography. exercise tests. psychosocial and social services Develop a plan for patient discharge from therapeutic exercise program.6. Provide immediate responses to emergencies (I. CK. licensed health care professionals providing rehabilitative services and exercise testing (e. pharmacologic testing.

name common generic and brand names drugs within each class..3.7.. indications.2. major side effects. bility exercise in individuals with Pulmonary diseases. Renal Failure.3 3.1. Diabetes.7. pharmacologic.3. pathophysiology. aerobic.1 312 Describe the potential benefits and hazards of aerobic. Explain how scheduling of exercise relative to meals can affect dyspnea. Hyperlipidemia.1 4.74 4. low hematocrit. PULMONARY: PATHOPHYSIOLOGY AND RISK FACTORS 313 3.2. . on the exercising individual.6.2 Describe the epidemiology.S. limitations. flexibility training) for individuals with chronic Pulmonary diseases . capacity.S. fluid overload..3. List the risk factors for Pulmonary disease and explain methods of reducing risk. expiratory volume. surgery.6.4 4. Renal Failure. vital . if any. aerobic. and orthopedic problems METABOLIC: MEDICAL AND SURGICAL MANAGEMENT 4. FITNESS AND CLINICAL EXERCISE TESTING Describe the epidemiology. inspiratory volume. GFR.APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 343 342 SECTION IV / APPENDICES METABOLIC: PATHOPHYSIOLOGY AND RISK FACTORS 2. functional capacity. edema. Recognize and respond to abnormal signs and symptoms in individuals with Metabolic diseases such as hypo/ hyperglycemia.2. pathophysiology.g. including the etiology and rate of progression of disease.3 3.2.1 3. clinical practice guidelines (e.. peripheral neuropathies.2. Diabetes. List the drug classifications commonly used in the treatment of IndiViduals with Pulmonary diseases and disabilities.7. may affect the rate of progression of disease. risk factors. Explain how Pulmonary diseases may affect the phySiOlogic responses to aerobic. obesity.5 4.3.3 Explain how Pulmonary disease may affect physical examination findings List the key clinical findings during a physical exam of a patient With Pulmonary disease . Frailty) Explain current hypotheses regarding the pathophysiology of Metabolic diseases. if any.4 Describe common techniques used to diagnose Metabolic diseases including biomarkers. functional capacity.6. residual volume. List the key clinical findings during a physical exam of a patient with Metabolic disease(s).6.1.4 4.4 Instruct an individual with cardiovascular diseases and disabilities in techniques for performing physical activities safely and effectively in an unsupervised exercise setting.3.6.. and flexibility exercise in individuals with Metabolic diseases.6. risk factors.6 3. and after an exercise session. Describe the potential benefits and hazards of aerobic. and flexibility exercise. including preventive care. and key clinical findings of Pulmonary diseases . strength. cough.2 4. glucose tolerance testing. List the drug classifications commonly used in the treatment of patients with Metabolic disease. and transplant.g.3 4.g. PULMONARY: EXERCISE PRESCRIPTION AND PROGRAMMING 4.g. risk factors. and explain the purposes. and key clinical findings of Pulmonary diseases .6 3. lipoproteins.4 3. NIH. resistance.3 4. Explain appropriate techniques for monitoring blood glucose before. strength. METABOLIC: EXERCISE PRESCRIPTION AND PROGRAMMING 3.4 3. resistance. and explain the purposes. name common generic and brand names drugs within each class.1 3. Recognize and respond to abnormal signs and symptoms in individuals with Pulmonary diseases such as wheezing. Have knowledge of lung volumes and capacities (e. Design and supervise comprehensive outpatient exercise programs for Individuals with chronic Pulmonary disease. Explain how Pulmonary diseases may affect range of motion. pathophysiology. behavioral) to identify and manage cardiovascular risk. fatigue.g. and explain methods for preventing adverse effect METABOLIC: HEALTH APPRAISAL.1 3. Explain how treatments for Metabolic diseases.7. Instruct an individual with Pulmonary diseases in proper breathing techniques and exercises and methods for performing physical activities safely and effectively in an unsupervised exercise setting. on the exercising individual. dyspnea.4 4.5 3.6.3. muscular strength and endurance. ADA. national guidelines for prevention of Metabolic diseases to identify and manage disease complications and reduce cardiovascular risk (ie ADA) Apply current U. PULMONARY: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE 4. and safety.1 Develop an appropriate Exercise Prescription (e. and safety. NHLBI) for the prevention. and key clinical findings of Metabolic diseases (e. Describe the probable effects of dialysis treatment on exercise performance. major side effects.2 3. loss of appetite. Explain how Metabolic diseases may affect the physiologic responses to aerobic. may affect the rate of progression of disease. Apply current U. and explain methods for preventing adverse effects Describe the probable effects of hypo/hyperglycemia on exercise performance. treatment and management of Metabolic diseases (e. .2. resistance. FITNESS AND CLINICAL EXERCISE TESTING 431 3.2. PULMONARY: HEALTH APPRAISAL. indications.3. including preventive care. and flexi.g. risks and normal and abnormal results for each. Hyperlipidemia. functional residual capacity.6.6.S. Obesity. and hypotension. national guidelines for primary prevention of heart disease (e. . Explain how treatments for Pulmonary disease. peak flow rate) and how they may differ between normals and patients with Pulmonary disease.2 3.1 3. during. 4.3 4. resistance.7 Summarize key recommendations of current U. and flexibility exercise. and transplant. PULMONARY: MEDICAL AND SURGICAL MANAGEMENT 4. and the effects. tidal volume. Frailty) Explain the common medical and surgical treatments of Metabolic diseases including pharmacologic therapy.7.2 Develop an appropriate Exercise Prescription (e.2 Describe the epidemiology.2 4. . total lung capaCity.g. and the effects. and explain the indications. Obesity. flexibility training) for individuals with Metabolic disease.6. Design & adapt Exercise Prescriptions for individuals with chroniC Pulmonary diseases to accommodate physical disabilities and complications due to Pulmonary diseases . surgery.2. Explain the common medical and surgical treatments of Pulmonary diseases including pharmacologic therapy. sputum.

and the physiological responses to exercise. and flexibility exercise. tendonitis/impingement syndrome.g. Multiple Sclerosis.. ORTHOPEDIc/MUSCULOSKELETAL: EXERCISE PRESCRIPTION AND PROGRAMMING 6. Multiple Sclerosis. agility. and supervise an Exercise Prescription for patients with complications due to Metabolic diseases (e.1 7. adapt. including preventive care.g. fatigue.7..2 7. ACS. and key clinical findings of orthopedic/musculoskeletal diseases & disabilities (e.g.4 Recognize and respond to abnormal signs and symptoms in individuals with Neuromuscular diseases and disabilities such as muscle weakness.. resistance. resistance.2 7. muscle weakness ORTHOPEDIC/MUSCULOSKELETAL: MEDICAL AND SURGICAL MANAGEMENT 5.2 6. Peripheral Neuropathy. NIH) . Explain how cancer therapy (e.7. Parkinson's Disease. which includes work hardening. low back pain. NEUROMUSCULAR: HEALTH APPRAISAL. Epilepsy) Instruct an individual with Neuromuscular diseases and disabilities in techniques for performing physical activities safely and effectively in an unsupervised exercise setting.5 Describe the immediate and long-term influence of medical therapies for NIH on Cardiopulmonary and musculoskeletal responses to exercise training. and the effects. cognitive deficit. osteoporosis/fibromyalgia. osteoporosis.3 Instruct an individual with musculoskeletal diseases and disabilities in techniques for performing physical activities safely and effectively in an unsupervised exercise setti ng.1. on the exerciSing individual Explain how treatments for musculoskeletal disease. and flexi.7.g.344 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 345 4. strength training and flexibility exercise routines to accommodate patients with complications due to Neuromuscular diseases and disabilities (e. work fitness.4 Adapt the Exercise Prescription based on the functional limits and benefits of assistive devices (e. range of motion. and flexibility exercise in individuals with Neuromuscular diseases & disabilities (e. Muscular Dystrophy. resistance. Muscular Dystrophy. anemia. retinopathy. Polio and Post Polio Syndrome.1 5..3. osteoporosis. and flexibility training) to accommodate patients with complications due to musculoskeletal diseases & disabilities (e. Design. AIDS.3 Describe the potential benefits and hazards of aerobic.1.g. Apply current US.1.7.7. work conditioning. vision impairment. organ transplant.7.3 4. NEUROMUSCULAR: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE 4. strength. Parkinson's Disease. resistance. such as fatigue.7.1 6..1. arthritis. Polio and Post Polio Syndrome. and the appropriate dose of avoidance of physical activity in patients with back pain.g. Cerebral Palsy. Spinal cord injury. muscular strength and endurance. IMMUNOLOGIC: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE 5.g. national guidelines for primary and secondary prevention of NIH disease (e. Peripheral Neuropathy. on exercise performance in patients with Neuromuscular diseases and disabilities Explain how Neuromuscular diseases and disabilities may affect range of motion.6. Describe the appropriate use of rest. low back pain. strength.2 5. Describe the effects of non motor complications. Stroke and Head Injury.1. arthritis.4 5. name common generic and brand names drugs within each class. Amyotrophic Lateral Sclerosis.1. hypertension and during hemodialysis treatments) Design and supervise comprehensive outpatient exercise programs for individuals with Metabolic diseases. flexibility training) for individuals with Neuromuscular diseases and disabilities including those treated with surgery.1 Recognize and respond to abnormal signs and symptoms in individuals With musculoskeletal diseases and disabilities such as pain.. major side effects. range of motion. low back pain.3 5.. FITNESS AND CLINICAL EXERCISE TESTING 6. adapt. Spinal cord injury. Describe the potential benefits and hazards of aerobic.1 6.7. surgery. Design. and job coaching. agility. and explain the purposes. Adapt. Epilepsy) Explain how Neuromuscular diseases may affect the physiologic responses to aerobic. pathophysiology. amputations. and flexibility exercise in individuals with musculoskeletal diseases and disabilities (e.6. FITNESS AND CLINICAL EXERCISE TESTING 6. hypotension. wheelchairs. and canes) Develop an appropriate Exercise Prescription (e. Chronic Fatigue Syndrome) Explain how NIH diseases may affect the physiologic responses to aerobic. and Supervise aerobic. cancer. may affect the rate of progression of disease. Stroke and Head Injury. crutches. balance.1 Explain exercise training concepts specific to industrial or occupational rehabilitation. Cerebral Palsy. Instruct individuals with Metabolic diseases in techniques for performing physical activities safely and effectively in an unsupervised exercise setting.1.1 Describe the epidemiology. Explain how musculoskeletal diseases and disabilities may affect functional capacity.2 5.g. indications. and tendinitis/impingement syndrome.1.g. NEUROMUSCULAR: EXERCISE PRESCRIPTION AND PROGRAMMING 5. and flexibility exercise. lumbar stabilization. radiation.1.' bility exercise in individuals with NIH disease (e.3 7. and amputation) ORTHOPEDIc/MUSCULOSKELETAL: HEALTH APPRAISAL.2. bleeding disorders.1. balance. risk factors.g.1 5. resistance. Explain how musculoskeletal diseases may affect the physiologic responses to aerobic.7. and flexibility exercise.3. spinal extension-flexion exercises vs.3 6. amputation). arthritis.1 List the drug classifications commonly used in the treatment of patients with musculoskeletal diseases and disabilities. reSistance.7. and chemotherapy) may affect functional capacity. Amyotrophic Lateral Sclerosis. muscular strength and endurance.1. if any. ORTHOPEDIc/MUSCULOSKELETAL: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE 5.4 6. aerobic.2 Design. and supervise an Exercise Prescription (aerobic.4 5.1.g. tendonitis/impingement syndrome and amputation) 7. ORTHOPEDIc/MUSCULOSKELETAL: PATHOPHYSIOLOGY AND RISK FACTORS Describe the potential benefits and hazards of aerobic. autonomic neuropathies.12 6.

bleeding disorders. please visit wwvl.3. name common generic and brand names drugs within each class. and surgery. FITNESS AND CLINICAL EXERCISE TESTING 1.12 1. major side effects. Bronchodilators.10A Ability to identify the process to train the exercise staff in cardiopulmonary resuscitation. Ability to describe the causes of myocardial ischemia and infarction. . chronic diseases. cueing.21 Describe the epidemiology. train.1 Recognize and respond to abnormal signs and symptoms in individuals with NIH diseases such as fatigue. and immunosuppressive disease. anemia. pathophysiology. GENERAL POPULATION/CORE: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE 1. Chronic Fatigue Syndrome) Instruct an individual with immunologic/hematological diseases and disabilities in techniques for performing physical activities safely and effectively in an unsupervised exercise setting.51 Ability to identify and describe the principal action. and health appraisals.1 Additional KSAs required (in addition to the ACSM Health/Fitness Instructor® KSAs) for programs seeking academic accreditation in Applied Exercise Physiology The KSAs that follow.2. IMMUNOLOGIC: EXERCISE PRESCRIPTION AND PROGRAMMING 1. osteoporosis. Chronic Fatigue Syndrome) Design. reinforcement strategies.72 7. and evaluate appropriate staff personnel for performing exercise tests.10.g.coaes. represent the KSAs for educational programs in Applied Exercise Physiology seeking graduate (master's degree) academic accreditation through the CoAES. obesity. and explain the purposes.3 7. cardiorespiratory. physician interaction. diabetes. Knowledge of the muscular. mechanisms of action. cancer.3 List the drug classifications commonly used in the treatment of patients with NIH disease. GENERAL POPULATION/CORE: HEALTH APPRAISAL. oxygen cost of activity (economy). hyperlipidemia.3 KSA # 1. anemia. GENERAL POPULATION/CORE: PATHOPHYSIOLOGY AND RISK FACTORS 7.6. tachycardia.3. Ability to design and evaluate emergency procedures for a preventive exercise program and an exercise testing facility. Antihypertensives. NIH) for the prevention. and injury care techniques. Summarize key recommendations of current u. treatment and management of NIH diseases (e. FITNESS AND CLINICAL EXERCISE TESTING Ability to describe the relationship between biomechanical efficiency. flexibility training) for individuals with NIH disorders (e. and self-monitoring.7.3 7.7A Develop an appropriate Exercise Prescription (e.1. Knowledge of the legal implications of documented safety procedures.10. adapt. fitness evaluations. bleeding disorders. cancer. and performance of physical activity.org.coaes. Knowledge of the use and value of the results of the fitness evaluation and exerCise test for various populations.1 1. and the effects. cancer. Psychotropics. anemia. equipment. risk reduction strategies.1 1. AIDS. and Vasodilators. IN ADDITION TO the ACSM Health/Fitness Instrudor® KSAs above. Ability to describe the effects of the above diseases and conditions on cardiorespiratory and metabolic function at rest and during exercise. ACS. Ability to recruit.2 7. staffing needs. and metabolic responses to decreased exercise intensity.g.g.10.3. Chronic Fatigue Syndrome) Explain the common medical and surgical treatments of NIH diseases including pharmacologic therapy. chronic obstructive pulmonary diseases. For more information. indications. and the interventions that may potentially delay or reverse the atherosclerotic process. AIDS.g. INJURY PREVENTION. the factors causing it. AND EMERGENCY PROCEDURES 1. risk factors. Hypoglycemics.6.S.3.6. Ability to train staff in safety procedures. arthritis. GENERAL POPULATIONICORE: SAFETY. documentation. AIDS.9. 1.org.4 Ability to define atherosclerosis. marketing.1 7. Ability to design and implement a fitness testing/health appraisal program that includes. and ongoing safety training. strength. 1.2.2 1. and supervise the Exercise Prescription to accommodate patients with physical disabilities and complications due to NIH diseases Design and supervise comprehensive outpatient exercise programs for individuals with immunologic/hematological disorders (e.2 1. anemia. aerobic. organ transplant. IMMUNOLOGIC: MEDICAL AND SURGICAL MANAGEMENT 121 1. organ transplant.2.4 Knowledge of the selection of an appropriate behavioral goal and the suggested method to evaluate goal achievement for each stage of change.2 1. problem solving. AIDS. motivation. on the exercising individual.g. if any. the use of incident documents. 1.3 7. cancer. and major side effects from each of the following classes of medications: Antianginals. please visit www. goal setting. GENERAL POPULATIONICORE: MEDICAL AND SURGICAL MANAGEMENT 1.g. Knowledge of the selection of an appropriate behavioral goal and the suggested method to evaluate goal achievement for each stage of change. For more information. bleeding disorders. bleeding disorders. Antiarrhythmics. but is not limited to.9. Chronic Fatigue Syndrome) IMMUNOLOGIC: HEALTH APPRAISAL. GENERAL POPULATION/CORE: HUMAN BEHAVIOR AND COUNSELING NOTE: The KSAs listed above for the ACSM Registered Clinical Exercise Specialist'" are the same KSAs for educational programs in Clinical Exercise Physiology seeking graduate (master's degree) academic accreditation through the CoAES.71 7.346 SECTION IV / APPENDICES APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 347 IMMUNOLOGIC: PATHOPHYSIOLOGY AND RISK FACTORS 1. organ transplant. organ transplant.1 Ability to describe modifications in exercise prescription for individuals with functional disabilities and musculoskeletal injuries.3. Ability to describe the pathophysiology of hypertension. and program evaluation.2 Knowledge of and ability to apply basic cognitive-behavioral intervention such as shaping.13 7. and key clinical findings of NIH diseases (e. clinical practice guidelines (e. dyspnea.

6 111. 111..11.37 Knowledge of facility layout and design.5 111.. and improve profitability in the workplace.18 1. and evaluation of a marketing plan Knowledge of the components of a needs assessment/market analysis. Ability to describe the development. including income statements. 111. evaluation. Ability to describe a management plan for the development of staff. Ability to identify the steps in the development.35 Knowledge of the principles of day-to-day operation of a fitness center. smoking cessation. reduce health care costs. and updating capital and operating budgets. revising. confidentiality of records. Ability to define and describe the total quality management (TQM) and continuous quality improvement (CQI) approaches to management. Ability to describe the principles of developing and evaluating product and services.7 1 11. staff allocation. 111.9 111. 1. contract. medical advisor. continuing education. liability. Ability to describe and diagram an organizational chart and show the relationships between a health/fitness director. back care. 1. bonuses. standards of care.348 SECTION IV / APPENDICES APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 349 GENERAL POPULATION/CORE: PROGRAM ADMINISTRATION. and benefits.27 111. partnership. and daily tracking of customer utilization..44 Knowledge of management and principles of member service and communication. 1. and vendors. and continuing education of participants. reduce employee loss time.43 Ability to coordinate the operations of various departments.26 Ability to manage personnel effectively. Knowledge of and ability to describe performance reviews and their roll in evaluating staff. and management.29 1. feedback. Ability to understand and analyze financial statements. owner.54 Ability to describe the means and amounts by which health promotion programs might increase productivity. 111.21 111. indemnification.39 Ability to describe a plan for implementing a housekeeping program. incentive programs. market analysis. Ability to describe effective interviewing.11.34 Knowledge of program-related break-even and cost/benefit analysis. including wages. day care. 111.16 1. including data analysis and reporting. 111.31 1. 1. 111.11. including. housekeeping. the front desk. Knowledge of administration.11.38 Ability to establish and evaluate an equipment preventive maintenance and repair program.45 Skills in effective techniques for communicating with staff. and return on investment.11. Knowledge of the principles of marketing and sales. 111. malpractice.11.1146 Knowledge of and ability to provide strong customer service.19 111. documentation. and revision of policies and procedures for programming and facility management. management.20 111. Knowledge of compensation. Ability to manage expenses with the objective of maintaining a positive cash flow. relationships with health care providers. maintenance and repair. and financial planning.11.11 1.17 111. marketing. facility management. confidentiality. and educational programs to maintain a comprehensive and current state-of-the-art program. exercise programming. management and supervision of personnel.11. potential customers. and establishing pricing.1113 1.11. consent. and development of a budget and of the financial aspects of a fitness center. including procedures. staff training. assets.4 1. Ability to describe the decision-making process related to budgets.25 111. 111.49 Knowledge of the principles of health promotion and ability to administer health promotion programs.36 Knowledge of the principles of pricing and purchasing equipment and supplies.1114 111. members. budgets. Ability to describe the significance of a benefits program for staff and demonstrate an understanding in researching and selecting benefits. 111. promotion. hiring. management.11. balance sheets. cash flows.52 Knowledge of and ability to access resources for various programs and delivery systems. Ability to interpret applied research in the areas of exercise testing.11. spreadsheet report development.1112 1.40 Ability to identify and explain the operating policies for preventive exercise programs. Knowledge of the legal obligations and problems involved in personnel management. Knowledge of the importance of short-term and long-term planning. Knowledge of administration.53 Knowledge of the concepts of cost-effectiveness and cost-benefit as they relate to the evaluation of health promotion programming.11.g. Ability to identify the various forms of a business enterprise such as sole proprietorship. Ability to develop a risk factor screening program.22 1. evaluating. Knowledge of techniques for advertising. 111. 111. body mechanics. fitness.30 111. 1. and S-corporation.47 Ability to develop and implement customer surveys.1133 111. Knowledge of basic accounting principles such as accounts payable.48 Knowledge of the strategies for management conflict. implementation. but not limited to. nutrition and weight management. Knowledge of methods for implementing a sales commission system. accrual.42 Ability to implement capital improvements with minimal disruption of client or business needs.10 111. Knowledge of and ability to describe various staff training techniques. accident and injury reporting. accounts receivable. Knowledge of various sales techniques for prospective members. cash flow.8 1. liabilities. program evaluation. pool. marketing and promotion. and staff.28 1. Ability to write and implement thorough and legal Job descriptions Knowledge of personnel time management techniques. . Knowledge of the procedures involved with developing.11. negligence. and the legal concerns regarding emergency procedures and informed consent.11. 1.15 111.11.23 1. corporation.1 Knowledge of the specific and appropriate content and methods for creating a health promotion program.2 111. 111. and pro forma projections.24 111.11. 111. rehabilitation.3 1. and follow-up.11. Ability to describe how the computer can assist in data analysis. 1. facility management. health regulations. health care providers. stress management. QUALITY ASSURANCE AND OUTCOME ASSESSMENT 1111 1. and public relations. and substance abuse). and community development.50 Knowledge of health promotion programs (e. billing. Knowledge of the principles of financial management.32 1. and employee termination procedures.41 Knowledge of the legal concepts of tort.

prepal1icipation risk stratill· cation for cardiac patients. skills. ahilities) recjuisites for. 13-1. 259t. 31b-32b Absolute intensitv. 258t Amiodarone. (see Zafirlukast) Accupril. 312 KSA (knowledge. contact information.26 Albuterol. Boards. 263t Amlodipine. risk stratification criteria for cardiac patients.56t Angiotensin II receptor antagonists cardiorespirato. (see Niledipine. 26lt Angina scales of assessment. 262t 351 . generic and brand names of. 256t. those followed by t denote tables. (see ~Iaximal oxygen uptake) AeroBid. abilities) requisites for. Program. and salmeterol) Ach-icor. 160 AJupent. defined. effects of. those followed by b denote boxes.Index Page numbers in italics denote figures. (see Pioglitazone) Acute mountain sickness. 311. (see Ramipril) Alternath'e stretch. 311. 26lt Aceon. 19-36. 154 Activit)" Pyramid. A AACVPR (American Association of Cardiovascular and PulmonaI)' Rehabilitation).313--31-1 KSA (knowledge.). clinical signi/lcance of. skills. 337-346 ACSM Certi/lcation Resource Center. 28-29. (see Methyldopa) Akloril. USh Angiotensin converting enzyme (ACE) inhibitors "ith calcium channel blockers. 332-337 as Health/Fitncss Instructor. (see Quinapril. 5-7 prepal1icipation health screening guidelines of. (see Angiotensin converting enzyme (ACE) inhibitors) Acebutolol. 264t. 1I8b Aerobic po\\'er. and hydrochlorothiazide) Alpha adrenergic hlockers cardiorespiratOly efTects of. 311. for health related physical /Itness. 314--316 as Personal Trainer. (see Methyldopa. (see Lo"astatin. 4 Acwlate. 313 KSA (knowledge. (see Flunisolide) Aging. (see Metaproterenol) Am"'yl. long-acting) Aldomet. 133. 255t Altace. 317-323 as Registered Clinical Exercise Physiologist. 165-167 recommendations for. l67 257t generic and brand namcs of. 33b-35b AIlNACS~1 HealthlFitness FaCility Prepartidpation Scrf>ening Questionnaire. ahilities) requi. (see Fluticasone. generic and brand nameS of. 262t generic and hrand names of. 323-33l. 265t Alcohol. 19-31 risk strati/lcation categories of. 2. 311 ACSM University Connection Endorsement 22. and niacin) AED (automated external defibrillator). 265t Aklactone. 255t. 307t Adherence to exercise program. 19-22. 309-310 as Exercise Specialist. 312 KSA (knowledge. 310 goals of. 310~311. (see Glimepiride) Amiloride. 3J.31. preparticipation screening and risk strati/lcation. 45-46 Advair. 26lt Amyl nitrite. skills. (see Perindopril) ACSM (American College of Sports Medicine) Certification Resource Center. (see Elderly people) AHA (American Ileal1 Association). 311 KSA (knowledge. 346-349 information antI application materials for. 257t cardiorespiratOlY effects of. abilities) requisites f"r. 167b Adult Treatment Panel III (ATP III). sites for. 262t with diuretics. cardiorespiratory effects of. 258t.ur Diskus. and f1uticasone) Ad".l certifications of. 33b-35b AHNACSM. 256t. 28t ACSM cel1i/lcation. and hydrochlorothiazide) ACE inhibitors. (see Salmeterol. 133-l34 mission of. 270 Aerobic /Itness. (see Spironolactone) Aldalat. 107 symptoms and clinical significance of.. 310 ' Activities of daily living (ADLs). cholesterol dassi/lcation of. 257t. skills. ahilities) requisites for. 262t and hydrochlorothiazide. skills. 309-349 (see also ACS~1 certification) Committee on Certification and Registry Actos. (see QUinapril) Accuretic. contact information.

3 Atacand. cardiorcspirator\' effeds 01. (see Clonidine) Central alpha agonists. 2. generic and hrand names of.58t-2u9t Antiplatelt-'l ag~nts ". classification and m~HlagP1l1ent of. 64-6. 47t Body composition. Cal an SB. J31>-J39 Arthritis. (see lrhesartan. . 102 energy rt:'qllirelllent~ for.>9 Body mass index (13"-'1. 99.5t.l. (see Tcrbutaline) Bretvlium. 264t antiarrhythmic agents. . 108 Blood mmlillers cardiorespiratory effects of. 26lt blood modillers. . 240t f()r tt-'sting chil(lren. 26. (see Clonidine) Catapres TfS patch. extended release) Cardizem LA. generic and hrand names of.58t Bretylol.57-6:3 Antiarrhytlll11ic <.idc. 1>7t Bcnicar.• 264t IT or-. and hydrochlorothiazide) Atenolol. 2.t '.5 exercise testing of. 248-249 energy expenditure goals in. 1. 76-78.51-153 stimulus phase of. Z56t. (see Verapamil. 310 Caffeine. 2.57t. 118h potential f'rror sources.~~3 df'llsitolnetric Inpasurement 01.XIlnal Astrand~1hynlingnOlllogram. 2. 70. exercise associated. 258t cardiorespiratory effects of. J 17b. 12 in carcliac rehabilitation. 262t hypoglycemic agents. 264t Beclovent. cardiorespIratory eHeds oC . extended release) Cardura.-ls.3h Bloud profilf' analyses. (see Verapamil. 2. 26.v. 264t nicotine. 240-241 fitness testing of.lJ names of.S7. 4. 261 t ami chlorthialidOlw. :) .5 in young individuals. tion. 259t Antico<. conversion to hody composition.5. and centrally acting drugs and diuretics. (see ACSM certification) Children. 139-141 progression of training in. (see Diltiazem.56t Calculations.:) ». 13 in exercise testing.5-46 Atromid. 264t Cholybar. 266t " ' ()l. 67t other nwasllrewellts 01". (see Captopril. 1.5t ATP [] I (AdnIt Treatment Panel [] I). norms of. 244-245 clinical exercise testing 01'. of sition . 264t anticoagulants.58t.lgu1alltS.55t Certification. Q . (see Bret\'linm) Ilrc\'ihloc.0 A\'alide.. 266t Cailliet's protective hamstring stretch. c<lrdioreSplratory effects of. 66. 2. (see Camlcsartan) Alacand !lCT. modific(l. nb Cardiovascular disease. 65 or WOrHPIl. and management. 146--148 for elderly people. 99 Beclomethasonc. 255t.lgf'lIts . 7.)9t Bluobd pressure. 261t 2. generic and brand names of.{. 266t antigout medications. 266t bronchoclilators. 2()2t and amlodipine. 2. 2.:5t .165.5t. . 2. cardiorespiratory effects of. 26. (see Metabolic calculations) Candesartan. 2611 Catapres.5 " '__ 3Jb-35b Cardioquin.lmtilipemic agents. norms or.5. (see Nicardipine. 11._66t generic and brand nalll~>s of. (see Ipratropium) _ Automated cxternal defibrillator (A£D). 262t anorexiants. (see Cholestyramine) . cardiorespiratory cf{~>clS of. (see Clofibrate) Atrm'cnt.53-154 CardiorespiratOlY fitness.. 1>5. 24t-25t. 2. 266t psychotropiC agents. and hydrochlorothiazidc) A\'andia. 259t Allied Health Education Programs). '-"with diuretics. 241-245 and adult prescription models. 25Ht .264t _ generic and brand names of. 266t peripheral dilators. (see TriamcinolOlw) Bod\' ht distribution.5. 111 Cardiac glycosides.59t Cholesterol testing. 8b-9b maximal oxygen uptake in.59t BOlle integrity. exercise related. (see Timolol) Blood gases. 262t-263t anticholinergic agents.5. and activity encouragement. 67t Bod\' density.. Astrand-l\hYllling cycle ergometer. (see Ilydralazine) Arlll cycling. and assesslllent.5t thyroid medications. 251>t cardiorespiratory effects or. 2Ci6t beta blockers. 51> discase risk classificatiol\ based on. (see Beclolllethasone) Bndesllnide. 257t and hydrochlorothiazide. and hydrochlorothiazide) Captopril. generic and brand . 264t CardiorespiratOlY exercise prescription.1). 2. 243 exercise prescription for. 259t Appt-'tite suppressants. 266t insulins. 243-244 unique physiologic responses of. 2:39 dnring exercise testing.5t . and diuretics. 266t 139-154 for children. 257t c CAAJ-J EP (COInrnission on Accreditation of hody compo- . 264t. 14t. 2:3B B Balke-Warp protocol. 241-24. nat.57t Carbon dioxide output (VC02).. 266t antihistamines.55t-260t Brethine. 119 clinical significance uf.5 preparticipation risk screening in. (see Bosiglitazone) Avapro. Antidepressants. (see also CoronalY artery disease) major signs or symptoms of.57t Capoten. 31. (see Quinidine) CardiorespiratolY effects. 259t ~'illl SVlllpatllo1nitnetics. 88 Calan. sustained release) Cardiac e\'ents. (see Olniesadan) Beta-2 receptor agonists. Anligout llledications. Ci5.2. 148-149 grouping activities in. immediate release) Anticholinergic agents.2. 262t Chlorpropamide. 3 Brand ll~llnes.2. 264t steroidal antiinflammatOly agents. 11-1.1l1lCS of. 44t names of. SRt predicted hody fat percentage based on.~allles of" .77 adult. 4. 2. 238t Chlorothiazide. 2.lorotbi. 264t caffeine. (see Doxazosin) Carvedilol. 72-74 64-6. 6.wior ch'\1Igc . 4. 200t Bjk-' add seqllestrants. and ergometry. generic and hrand namcs or. . 60t norms of.1l1acort. in dinical respiratOl)' testing.55t generic and hrand nallles of.237-240 electrocardiographic changes in._G6t generic and hrand nal1le~ 01. cardiurespiratol)' e pets Al1tillistalnines.5t Antilipemic agents " '. generic and hrand names uf. in pre-exerclse evalua- in.5. 262t angiotensin Il receptor antagonists. 2. 260t Aprcsoline. 205-207 . long acting) Calcium channel blockers.")' cardiorespiratury effects of.5--46 Cholestyramine. 286 Carboxyhemoglobin. . Bi<1uanidps.lCS of. generic iliid hral1d and Imlrod.5t Atorvastatill.59t. in pre-exprcise evaluatIon. 2. 265t vasodilators.) or men. 260t. cardiorcspiralun" el1cets of. 2611 pentoxifylline. 264t . 70. 4:3-44. 262t xanthine derivatives. 141-146 modes of exercise in. 239-240 resistance training for. _6~t-_63t generic and bra.57t Bench 1)f~SS test. cholesterol classification of. 266t digit<llis. 66t. Betapacc. 255t.51 specillcity of training in. 245 sedentary. (see Diltiazem. 163-16. 266t Cholesterol absorption inhibitor.26Jt BJA (bio~ledric impedance analysis).26~t OelH:'ric and hrand names of. 149-1.3-~4.59t testinO' un. patterns 01. J9-36 Cardizem CD.5.5t in adults. 57 '__ . 2611 diuretics. 251>t Bisllprolol. 122.57t 166b practical reco1l11llf'ndations for. 266t population specific. of lnedications.)1>-. (see £"nlllol) Bf()11Chodilators cardiorespiratory efrpcts of. 264t sympathomimetic agents.l(} namE'S of.59t-260t Bruce treadmill protocol. 21>9t. 2.56t.5Cit Cardiac rehabilitation cardiac events in. 4.olol 2.INDEX 353 352 INDEX Bumetanide. 262t angiotensin converting enzyme (ACE) inhibitors. 26lt 'md lwdrochlorothiazide. 13-1. 262t Bumex. (see Captopril) Capozide. 2. (see Sotalol) Bct<~. in. 237 lifestyle activity encouragement in. 259t. 2. (see Irbcsaltan) A'l. genenc and hrand Blo:adre. cardiorespirato r!' efleets . ' Anorexianls. 46--47 normal adult variahles in. Sllhl11i:l. 255t generic and brand names of. 12 preventing. 26lt diet pills. 2. exercise prescdption in. 290-291 Arrlwthmi. 2. 257t. 1. \67h Bpnazepril. 265t nitrates. 2661 Anthropometric lllc<!Sllrelllcnl. 244-24. Beh. cardiorespiratory elleds of. by physical activity. 13. YMCA. 66--67 submaximal exercise testing of.5~~ . 255t Z6. 2Mt antiplatelet agents. AnU"iotellsin II (COI/tilll/cd) g(-'>lleric . 243 physiologic responses of. 108 Cardene SB. 1~5h . 140b intensity of exercise in.'. 242-243 cardiorespiratory training in. summary of. 266t calcium channel blockers. Beta blllckers. generic and hrand llawes of. 2.5 duration of exercise in. 76-. 2~3t '-' metabolic f'qnatiun for gross oxygen lIptakt in children. anthropometric mcasurement ~I: u .' moti\'ation amI readiness for. generic and brand names of. 1. 99 endurance til1iC by gendpr ~\Ilcl age un. 10:3-105. 28 screening for. . 2Cilt generic and brand names of. (see Bumetanide) mast cell stabilizers.5t alpha adrenergic blockers. 240 endurance of. (sec Candesartan. 66 improvement in. and brand 1l. 2Ci1l-2Ci6t alcohol. 12-13 in individuals with sickle cell trait. 262t and hydrochlorothiazide. of medications. generic and brand names of. 239 exercise menu for. 264t tTcllcric and Im.

11l-29. 247 exercise tl'sting 01'. 11. n. col(niti\'e skills. 248-249 c\ercist" prescription for. 2. and llleaSIJ rement. 117b. 264t Clonidine. 14S-149 Energy requirements.5 CoIexe\'e1am. 304~10-5 heat e.)' ewrcise. individuals.109t special considerations in. lS3t tranSlnllraJ infarct localiz. 20t-2lt. 111 sllpnwcntricular versus ventricular ectopic heats. :307-30S .4 D Data interpretation. physical activity and hl'alth.ut rate and blood pressure'.57t-258t loop.ercise testing. 124-l28 of e1derh people.poso re as. 1:3t risk stratif'ication in.·L'Omlllt'ndcd. 10.304--30. lS0t-28lt waveform inte'l1retation in. 158t. 9:3-94.1. 2.146-147 flexibilih' excrcise and range of motion in.. 70. 279 Electrocardiograpll)" in clinical e\ereise tl'sting. llO-11l precllOr. 2. 310 (1)1(1 m('. (s('(' Colestipol) Colestipol. 10(. 159t CirClIlllfert'J)ce siles procedures. 105. scales for assessing. J. 12-1:3 in indidduals with sicklf' cell trait.5 reduction of.5.J) DE>V\ (dual en('rg" x-ral' ahs0'l. 2057t and beta hlockers. 34fi-.50t Cool dm. :300 cold exposure . (sr(' \\'arf~lrin) COl'era liS. 1611 Diovan. 310 acadeJllic accreuitatjoll hv. 69. 124--12H. 1-16 ' cardiorespiratory e:xercise for. ilnd Il\'drochlorothiazide) .ercis" related. (S('I' Isradipine) D~Tenillm. 144 Disopyramidl'. (.-124 heart rate response ill. 11 Dehydration. 276t-278t automated external del'ibrillators in. 98-99 mechanicallv braked. . 99-102 and associated metabolic costs. 25. 1. 149-250 Electrocardiogram (ECC) inte'1. 11-15 in adults. L2 prel'enting. 11 ill cardia<: rellahiJitation. (s('(' Cliclazidl') Diastolic hlood prl'ssure.16-11. 1601 Crunch't.55t cardiorespiratolY erreds or. and chlorothiazide) Diuretics and ACE inhihitors.10-112.\ercise. 2:38.5-129 supervision of. 1:1-15 ill youne.8 Ijnliting signs or symptoms ill. Y.: \'ahw of. extended release) Dilantin. 22 ACS~I risk stratification categories ill. 102-103 as screening tool f()r coronary ~lIier)' disease. (s('(' Cll'buridc) Diahetl's mellit. ". of cardiorespiratory exercise. Nadolol. Pre-exercise e\'aluation) ACSM . lOS-I 09 prognostic applications of. 110 Edecrin. JOS upper body. 111 tennination of. 170 e<. 16-1t C:olestid. 1.~al (chest lead) placement. 49. (s('e Hesel1'ine. E\ercis(' testing. :31~1. 1--1-6-148 Dyazide. 104t ['ostexereis" period in. (see Cardjorespiratorv ("xercise prescription) lOnerI(" halance. 1. 98 risk f. (Sl'(> Amiodarorle) Corcl(. I I J Dofl'lilide. (see Valsartan) Diol'an HC1'.354 INDEX INDEX 355 CiiazapriJ. 119-122.. J06h. for Ilealth/Fitness Instruc'tor in Applied Exercise Physiolo!(j'. 30(h10-l high altitude in.ereise testing.sSt. Ethaclynic acid) Eiderii' people.itional asseSSlllt-'nts in.\leA. 107 Dysrhythmias. t:3S. 1l7h.'clor thresholds in. D\'naCirc CH.". SCit Curl-up test.. (see RoslI\'astatin) Crolllollll inhaled. cardiorespiratory cf'f'eets of.55t combined. by physical actil'it). 64-6. 126 cOlllpptenc) in. 94t proglj()stic signifkanc(' of l)('ak exercise capacity in. 257t Dinril. (s('(' 1sos~rhidc dinitrale) Diltiazl'm.7-10 el'idence of. (se(' II/SO ~lctaholic calcnlations) Environmental considerat-ions. I (part rate n:~pollse) Death.t normal QT interval as function of heart ra!l'.ation. (see Ipratrupilllll. as en\'ironnlcnt. (s('(' 1'orsl'lllide) Densitollll'trl'.t. (Sl'(. lS. 69 sllhlll<lxilllaJ" testillg with. and Il\'drochlorothiazidl') Dij. in clinical e. indications for. fl9 Emergency medical plan. lS6-199.tiollletn'l. cardiorespiratOlY effects 01'. 1. generic and hrand names of. 315-:316 COIltraindications. 9:3 applications nf. (s('e I'\adolol) Coronary artel. in clinical exercise testing. IlSb Diet pills. 107 Clinical exercise testing. 107-10& he. 305 Cold illnesses.LS. 16-11 Comhivt'llt.149 Conditioning pllas~. 119 clinical sil(nifkance of. 161t and ldodipine. XH.1. 20"5-210 f'\ercise testing in. to pre-exercisc {-'valuatioJ].. :304-30. 12:3 measurements during.J~orithlll IlJr. generic and brand names of. lOS electrocardiographic 1l1onitoring. 156t. 1. ewrcises. hyperglycemia and hypoglycC'lllia in. 261t and central alpha a~onists.5.59. Elt'ctro<:ardiograpll:.s. IJ 9 elct:trocardiograph wavefortlls in. 262l Drugs. (s('(' Chlorothiazide) Dohlltamille. and hendroflulllPthiazide) Coumadin. 115-116. 22-29 for cardiac patipnts. extendcd releaxe. 121. 19. 179t resting 12-lead.279.'dms 1<>1'. transderlll.. 257t potassium sparing. specific genf'ric naillf') Dukf' nomogram. 1:37-145 compared with imaging ~tress tesb. 1791 atrioventricillar hlock. 285t normal limits and wave/orllls.56t Dilacor. of KSAs. 15(. or cardiol"espirator:' e. 72-74 testing children Oil. nomograms of. scales for assessing. 1661 Digitalis. (s('1' Can'edilol) Corl(ard. 116h S1' sl'gment ele\'ation. 102 Clol'ibrate.retation. 103-108 hlood g'L"". 96-97 preparticipation health screeninl( in. 22-29 recomlllendations in. (se(' Phenl'toin) Dilatrate. normal limits and waveform inlel1"'etation in. 2.50 Content malter. 111-114 for retnrn to work. in heat. :306-:307 ref('rences on. J09h (s('(' a/so ACSM certilkation) diagnost ic.50 r('sistance trainin~ for. I J9-112 gas exchange and \"(-'Iltilatory responses in. 109h. 12J. (. 211-212 Dyspnea. (8('(' Tri<lmterene. 282t Ellpstad protocol. 65 DiaBeta. (s('(' Chlo'l. of physical acti\"ity. 270 potential. 31-:35 supervision rec. .5t Clopidogrd. .10-112 indications for. 2. 100-101 references on. 257t Endurance exercise. 60h-6lb starltlardized descriptioll of. lOt Doxazosin. and alhuterol) Commission all Accn:ditation 01' Alljed Ilealih Edncation Programs (CAA II EP). :34&-349 Cold.30:3 Dellladex. exercise prescription in.2SI add. exercise associated.yridallloll'. 25S1 generic and hrand names of. 19-:36. 161t Cilostazol. (Sl'(.. 60h-61h Claudication. effeds of inhalation of.~'('e Clinical excrcise testing. 11 I ST segment normalization (absence of change).ropamilk') Diagnostic exercise testing.5 Dl'poniL (s('~ 1\itrogil'cerin. 107-10S exercise prescription in. cardiac. 257t and angiotensin II recf'ptor antagonists. 2. 162t Diupres.l\llrelllent Committee on Accreditation for tilt' E:\er<:ise Sciences (CoAES).ll f~lctor.5 gas exchange and \'cntilahJI)' responses. 9(1-99 monitoring intclyals during. in clinical exercise testing. 138-139 E EBC1' (dectron beam computed tomography). 10:3-105 sul)jectivt' ratings and symptoms. 1:3 / in exercise testing.·st.161 t Digoxin. 117h-llSh blood pressure response in. 110-11 I Diabinese. (se(' \'alsartan. (spl' ~Iedications. 280t-281. 93-96 of children.561. 121-112 S1' sel(llIent displacement.':we Triamtcrene) Dyslipidemia. N6-250 imaging llIodalities ill. (s('(' Dilliazem. 9:3-9.5t. (se(' (dso Arill cyclinl(. :30-31 pretest likelihnod of. 8m Cycle erl(ollleter. of' ohtaining target heart range. 267.-107 mndes of. 20'.juipment and drugs required in. 29-30 medical clearance in. signs of. generic and brand names of. 173t-175t Enalapril. 16S1-2691 key componcnts of'.5 Cold air. (see "erapamil) Cozaar.5--119 (see also Clinical e. 11. 15St.5St Dose response relationship. 127-128 Duration. generic and hrand nanl('S of. f()r Health/Fitness Instructor in Applied Exercise PIl\'siolol('. 5R-. 117b. (s('e II/SO Clinical exercise testing) Diamicron.59t Direct method.:ornmendations in. Sb-9h Corzide. 270.59t CoAES (Colll1llittee on Accreditation for tilt-' Exercise Sciences).J:39 Conlarone. in carchorespirato. 9:3-96 interpretinl( results of. 1:38 ' C011ditiolling stage.\en::ise capacit) in lIlen with. (s('(' Electrocardiography) Echocardiograph:. (see Losartan) Crestor. LeI( cvclinl() 'arlll: 102 clinical testing with. a\'oiding..lS2t S1' segment depression. 6 Energ)' expenditure goals. 310 academic accreditation 1)\". dise<L"~t' per~l'llt nu"nnal e. &41> fitness categories in. 2. 157t and hydrochlorothiazide. 239t Cycle ergometry protocol. 2S4t at rim'cntricular dissociation. 30--31 risk l.5St. Ill-I 12 ECe. ~-lb fitness C<-ltegories in. 1. 126-12.'-> prolocols of.

96--97 Exercise intensity. I 16-1 I H limiting signs or symptoms in. classification of 45t fitness) ph.imal v('rsus submaxjmal.f--128 lidse n('gatiw results in. 216-219 osteoporosis. 264t ~~'I)(->'ric name's. 266t Clllconorl1l. 257t and hydrochlorothiazide. 94-95 blood pressure assessment in.'326 PJ()gldl1l <ldllllJ)lstration {judlltv 53-54. 168-173 resistance training in. 138 supervision of. 133-134 benefits of regular. . hlood pressurp response in. 41.31 electrocardiography and diagnostic techniCjU('S.259t Foreed expiratory I'olume (FEV).9-90 ' H('altfl/Fitness Inslructor. 135-136 adherence to. abilities) requisites for.Jtb screening) pllTlclples and gUIdelines in. 213-215 immune response. 136-137 general guidelines for. 262t Eprosartan. 260t. S5~S6 <. (see F1uticasone) . 49. 221-223 specificity of.3. (sec ~Iigiitol) Craded e'". and glvburide) " C. (see also Physical activity) ACSM public health recommendations for. 55-92 informed consent in. 5-7. and range of motioll of self'cted joints. of. 67~(ih modes of. 227-229 references for. 266t Clipizide. 93-95 (see also Clinical exercise testing) diagnostic value of.l1lfl"rozil. 2. 259t.5t-260t Clrth lllf'aSUrelllellts. 93-114 (see also Clinical exercise testing) references on. 335-336 health appraisal. 139-154 for children. 39.50 Flovent. (see Exercise prescription) Exercise session format.t Pitiless cardiorespiratory (sec Cardiorespirator\' H 11 f) L cholest('rol.58-59. 138-139 design of. 262t Frequency. 136-137 Exercise Specialist.5t Field test(s). 154-158 interprding resnlls of'. 2. 32. 264t and salmeterol. 163t summar\.31 . 64 Fal mass (F~I). 2. 3 (see also Physical fitness) physiologic.356 INDEX INDEX 357 Eplerenone. 9. 163-165 cardiorespiratOlY. 1IIb-IISb J 19-122 ga~ ('\change and ventilatory r0sponses Ill. in normal healthy men.5 Cuanf~lcille. 60h~ Ib L2:3-124 heart rate r0sponse in. (see \letabolic calculations) Equipment. Exercise. '261t Fenoflbrate. 85~9 functional. 6'>-76 1Il1lscllL~r strength and pndllranc(' in. 6&. 3 and immune response. and emergency procedures. 346-. 12. 90-92 risk of'careLac elenl in.5 (see also Prep.d \'ital capacit\· (F\'C). 148-149 for lIexibility.59t Flu\'astatin. 134-135 progression of exercise in. 336 medical and surgical management. skills. (see Hepaglinidej Gillcophage. /01' Applied Exercise Physiology accreeLtation.56t. F Fat free lIl'l>S (FFM). 335 prograrn administration. 240-241 clinical.5h lIlterpr('ting r<.56 pre-exer<. and clinical exercise testing.Jth related. 89-90 contraindications to. :12. 262t 147-141. 22. ". generic and brand :39-. Pr('-e.55 ref('rpnccs 011. and outcome 221-222 components of.<udlogl<lph w<l\efOlIll S III Cas partial pressures. 43b.'). 257t . 41-42 after myocardial infarction.5St. 76-78 of children. emergency medical. 46-47 body composition in. 3-4 Flccainide.sults 01: 116-124.3 referenees for.54 (sef' also lisk associated with. 161-162. 337 safety. and measurement pro('edures. and clinical e'x('rcise testing. 149-151 and recreational activities. 123 ref('renc<'s for. 137-138 Exercise program. 207-211 dyslipidemia. 5-1. 10-15 Exercise capacity.5S-160 in elderly people. 12-13. 79-. 69-70 Field lest e'iualions. 98-99 submaximal testing on. 264t Fluticasone. . 332-333 patient management and prepalticipation health screening in. 69 arm.lssulance. J24-12.l'sical. 313 Exercise testing. (see Cldlllrid. 56-57 lIexibility in. cycle. 126 diagnostic \-aluf' of. 51. 143-146 by oAygen uptake. quality upper bod\'. 337 requirements and competencies of. 102-103 C:~lllpar(~d with imaging stress tests.:ise l1letabohe pathophysiology and risk lactors. Equations. 165-167 behavioral changes in. 102 clinical testing with. 47-t~) PUl1)oses of. 311 KSA (knowledge. 11. abilities) requi~ites for. 101. 1I1ltrition and wcight management-. 7-10 and cardiorespiratOlY fitness. 26lt Ethacl)""ic acid. 163-165 objecth'es of.. fitness. J 1fl-122 gas exchange and ventilatory responses assurance.5. ]2. (see ~Ictformin) Glilcosidas(' inhibitors. H7t 1.prehenSive 93-94. 266t Climepiride. 329 exercise prescription and programming. Functional capacit\' testing. ACSM certified 311 KSA (knowl('dge. causes of.5-96 F'llwsemide. 333-334 human behavior and counseling. 135 cool dOM' exercises in. 246-247 ell\~ronment for. 336 pathophysiology and risk factors. 72-74 testing children on. 326 ('\ercise physiology and related exercise J !c'alth and fltlless (''"<tillation. 64 Felodipine. science. 229-232 pulmonary elisease. 239t Esmolol. . 141-142 by heart rate. (see Metformin. 219-220 obesity. 291.sting. he'alt" appraisal. 247 energy expenditure goals in. 5&-. 66-67 defined. Flunisolide. 102-J03 (see also Graded exercise testing) he. 2. 32~329 G Gas exchange ~n clinical rcspiratOJ)' t('sting. 268t Ergometer. 12S-129 sensitivity of. 135 for elderly people.. 257t. 135.Iv"unde. 142-143 rating of perceived exertion in.50t in coronary artery disease evaluation.2. 162t health relat~d. 1 15-129 (see also Clinical exercise testing. 158-160 format of exercise session in. of medications. 57-66 (see also Body composition) cardiorespiratOlY.nticipation be.5-227 pregnancy. 79~0 test sequence and measures in. 43-44. 2057t. 149-151 rate of progression in. (see Moricizine) references for.) Clvs('t. 260t.:ise f'\'aluation in. 2.rcise tcsting (GXT). 2fll.211-212 hypertension. 232-236 upper respiratOly tract infection. 136 maintenance of training elTect in.5&t Fbibility. 266t Clvnase. generic and brand name's of. :3:J 1 pathophysiology and risk faclors..('alt rate respnnse in. <lI1d OIltcome <lssessment . cardiorespiratOlY. J24-128 of elderly people. 205-207 diabetes mellitus. 117h-lJ8b blood pressure r('sponsc in.5 patient management and medications. 12:3-124 orthopedic/muscilloskeletal pathopll)'siologv and nsk lactors. 331 .2. Fosinopril:2. 335 nutrition and weight management. 221-223 metabolic s)Oldrome. motivating. 259t 1""11('S oC 260t C:'ucotrol. skills.56t. ex~rcis(' session. 49.349 cardio\'ascular pathophysiology and risk faclors..5 order of tests in. J2:3-124 I. J63t warm up exercises in. 238.\ercise e\"aluation) Cliclaziek. 1. I :36-l:37 . 332 exercise prescription and programming. 12S-12fl m<'lx. 262t Ethmozine. 102 Ezetimibe.xercise prescription for. 119 electrocardiograph waveforms in. 51.5. 2. 151-153 stimulus or conditioning phase of. 52-53 instructions for participants in. 2. 260t. '260t. 66-80 (see also Cardiorespiratory fitness) inte'1JCeting results of. . injuty prevention. 264t Pihric acid derivati\'(~s. 257t. 3. 160-161 motivation in. C(. fitness.30<3.3--:1:11 adeLtional.44t blood profile analyses in. 332--337 electrocardiography and diagnostic techniques.55t. 325-326 human ':chavior and counseling. 7hh medications. 1. 146 Exercise prescription.. 14t termination-of-testing criteria in. 76-78. con. 112-114 comprehensive.59t. j 19 0Iectlo(. Force.. Prepalticipation health screening) diagnostic. of cardiorespiratory ('xel"(. 95-96 graded.56 . I fl~3. 223-225 peripheral altelial disease. 205 mthritis. 136 principles of. ACSM certified. . 138 assessment.5-1 16. l07-IUI-{ JI1 graded ex('rcise I<. 25Ht in. 334-335 exercise physiology and related exercise science. 133-134 individualized. 241-245 in clinical conditions. 25&1. 2. (sec Glipizide) ~Iuco\'ance. 32:1--325 :326-321. 116-lJ8 Jin~itillg signs or symptoms in.57 plllmomlJy function ill. 78. 4S Fonnat. 70.

and hydrochlorothiazide) Latrel. 5l. 141-142 by heart rate. (see Digoxin) Lanoxin. 260t Imaging modalities. in resistance training. and hydrochlorothiazide) Informed consent. 26lt Isradipine. Lazol. of cardiorespiratOlY exercise.)' training in. 260t Humalog 50/50. 256t. 57--ti6 (see also Body composition) cardiorespirato. 256t. 259t. 52--53 Inhibace. 79-85 order of tests in. 260t Iletin 11 NPH. 266t gene. (see Isosorbide mononitrate) I rnrnune response L Labetalol. ellects of.28t additional assessments in. 26lt cardiorespiratory effects of. 45-46. (see Isosorbide mononitrate) Isokinetic muscular strength testing. for cardiac patients. 49. (see Verapamil. 66--67. of training effect. 260t Hetin [IB. 260t Lasix. 163t warm up exercises in. 20t-2lt ACSM . (see Betaxolol) KSA (knowledge. 257t. (see Digoxin) Lantus Injection. 306--307. 165-167 cardiorespirato. 262t Hydrodensitometry. 89-90 environn1ent for. 55-92 body composition in. in pre-exercise evaluation.ption. of cardiorespiratol)' 142-143 estimating. 257t Ismo. 222-223 in upper respiratory tract infection. 259t Humalog. (see Propranolol LA. 151 cell stabilizers cardiorespiratory effects of. 56 p. 256t. in graded exercise testing. 30--31 medical clearance in. 138 references for. and emergency procedures. 144-146 Kerlone. (see Hydrochlorothiazide) Hydropres. immediate release) Isoptm SH. 56--57 purposes of. 67-68 302t Heat illnesses. goals of. (see Inclapamide) Lungs. signs of. (see Eplerenone) Instructions for participants. Limiting signs or symptoms. gene. Pulmonary function) Hypoglycemic agents carcliorespiratOlY eflects of. (see Benazepril. abilities) requisites ACS~[. (see Terazosin) Hyzaar. 257t. 312 [ndapamide. horizontal and grade.l.nciples and guidelines in. 123 Lipase inhibitors. 302 dehydration in. 289t. 262t Hydrochlorothiazide. 110-112 lmdur. 257t and hydrochlorothiazide. and hydrochlorothiazide) 315-316 for Exercise Specialist certification.INDEX 359 358 INDEX Hemt rate (HH) in cardiorespiratOl)' exercise. 31-35 supervision recommendations in. 76--78 comprehensive. and amlodipine) Lovastatin. 150 . 72-74 energy requirements for. 79-80 carruorespiratOl)' test sequence and measures in. 160 H~lG-CoA reductase inhibitors.. 143-146 by oxygen uptake. 305 H)trin. (see Lasmtan. and niacin. 303-304 safe exercise duration in. of cardiorespiratOlY exer- Iletin lJ Lente. 298. 56-57 flexibility in. 257t Lotensin.. 214t special considerations in. 331 safety. 160-161 motivation in. 262t Indcral. 163-165 objectives of. gene. 259t lrbesartan. 19. 317-323 for Registered Clinical Exercise Specialist 337-346 ' M ~laintenance. 82-83 Jsoptm. (see Benazepril. 42b Lanoxicaps. 260t Hypothermia. of obtaining target heart cIse evaluation. 213 exercise prescription in.val.5 energy expenditure goals in. (see Enalapril. 68-76 muscular strength and endurance in. and hydrochlorothiazide) Lapressor SH. 303 and humidity.sk stratification categories in. (see Mctoprolol. 5 ~[aximal ox)'gen uptake (V02max). generic and brand names of 260t ' Levatol. (see Pulmonary disease. 255t. 144-146 Heart rate response.151-153 stimulus or conclitioning phase of. J39-154 components of. (see Pirbuterol) ~[aximal aerobic capacity. 332-337 for HealthlFitness Instructor certification 323-331. 260t Humulin R.. 221-222 Improvement stage. 298t percentile values for. 103-105 clinical significance of. 155 Health promotion. 260t Humalog 70/30. 13. 79t Maximal "oluntal)' ventilation (MVV). 22.'ention. 22-29 range. (see also Ox)'gen uptake) ~Iast in cardiorespiratOlY exercise prescription and exercise. 56 and normal QT inte. 292t K Karvonen method. b. 301-302 increased risk of. 149-151 rate of progression in. l33-134 Health screening.y. 138 supervision of. in pre-exercise evaluation Lean bo?)' mass. 142-143 rating of perceived exertion in. l68-173 resistance training in. 22-29 risk stratification in. 53-54 ' Leg cyclmg. (see Fluvastatin) Leukotriene antagonists maximal versus submaximal. (see Minoxidil) Lopid. 214-215 lifestyle modillcations in managing. (see Atorvastatin) Lisinopril. 260t [ntal. 134-135 progression of exercise in. (see Fenofibrate) Laniten. 116--118 Heat acclimatiZ<ltion to. 148-149 flexibility exercises in. 290-291 Lescol. preparticipation. and ergomctry. 256t. (see Heserpine. 45t cise. 300-302 risk of illness due to. 209t Hypertension.c and brand names of. 70. 260t Humulin L. (see o/so Dyslipidemia) Lipitor. 266t generic and brand names or. (see letoprolol) Lasa. and hydrochlorothiazide) Hyperglycemia and hypoglycemia. 310 ' claSSification/numbering systern for. 90-92 test termination criteria in. J36--137 inclividualized. 303-3001 High altitude illnesses. 260t Humulin U. (see Isosorbide dinitrate) lsosorbide dinitrate. 260t Humalog Mix. 22 ACSM guidelines for. 28-29. guidelines for. 117b determination or. 49 ' 30-31 exercise. (see CrOmOI)11 inhaled) Intensity.c and brand names of. 66--80 (see olso CardiorespiratOlY fitness) interpreting results of. 1. energy reqlllrements for. classification of. 20t-2lt. 19. (see Propranolol) Inderide. 26lt Laboratory tests. long acting) Isord. 259t modes of. (see Penbutolol) Lexxel. (see Cilazapril) Inspra. 260t Humulin N.58-160 format of exercise session in. 261t Isosorbide mononitrate. 78. 29-30 exercise testing recommendation in. 257t and hydrochlorothiazide. 259t Lovastatin. 215 exercise testing in. 282t Ilemt nlte (HH) rese. (see Benazepril) Latensin HCT. and felodipine) Lidocaine. 264t generic anc! brand names of. skills. 257t Lithium. 160-161 Mamtenance stage.)' effects of. 137-138 Health related exercise testing. 55 references for.ve method. 143-146 during clinical exercise testing.c and brand names of 260t ' Lip~d and lipoprotein assessment. (see Verapamil. in clinical exercise testing. 154-158 specificity 01'. (see Trandolapril) Maxair. (see Gemfibrozil) Lapressor HCT. 165-167 for children. 243 ' exercise prescription and motivatinO' 163-165 "'. 262t ancl hydrochlorothiazide. on physical activity. 68 interpreting. 30-31 testing supervision recommendations in. 85-89 instructions in. 330 requirements and competencies of. 146 lpratropium. 256t.. carcliorespiratory effects of. in pre-exer- Jogging. 264t and albuterol. 138-139 design of. 4 Health related exercise presc'. 136 principles of.. (see also Pre-exercise evaluation) ACSM algorithm for. 51.tan. 307t High risk stretch.64 HydroDilll. 260t Hydralazine.' risk level. 258t Lifestyle physical activit\". 215 Insulins cardiorespirato. (see Furosemide) LDL cholesterol. of obtaining target heart range. 76 Ilealth/Fitness Instructor (col1til1ued) pulmonm} pathophysiology and risk factors. in exercise testing.l.346-349 ' for Personal Trainer certification. 292t metabolic equation for gross oxygen uptake m. 135 cool down exercises in. 149-151 and recreational activities. 136 maintenance of training effect in. 133-134 adherence to. injut)' preYention. 297-298 field testing equations for. and disease pre. 78b Health related physical IItness. 260t ~[avik. 161-162. 2601t Lafibra. in pre-exercise evaluation. 265t and inhibitors.

sodilators. (see Prazosin) ~linitran. :23)t-25~t appetite suppressants. 255t ~Ie\'acor. HI \I'lszide. 28 screcning 1'01'. 260t ~Iethy!dopa. 27:3t-27.Jpha agonists and diuretics.INDEX 361 360 INDEX antiarrhytll111ic a~ents.ic!ia. (sec Labetalo!) N0111ace. 26. (see Disopyramide) NOlvasc. 289t in leg cycling. 8J ~lVV (maximal "oluntal)' ventilation).59t steroidal antiinflammatory agents.. 260t beta bloekers.5t diureties. 298-299 and target work rates. serum enzymes indicating. 256t :--iitroglyn. 26-lt caneine. 260t periplieral dilators. 291-296 practice. and hydrochlorothiazide) ~loe. 256t. 266t and glyhlll'ide. (see :\itroglycerin.'olin L. 266t beta blockers. 2611 and bendroHumethiazide. (see ~Ietolazone) Myocardial inf~lI'ction. (sec :-litroglycelin. (see . and ergometl)'. 260t. (sec Sibutramine) ~letabolie ealculations. 49. 286-287 Oretic. 260t nitrates and nit roglyccrin. 288-291.59t Niaspan. 262t Modurctic. 85 test procedures for. 260t lipase inhibitors. (see Fosinopril) Montelukast. sublingual) :\i"alin ~. 257t mast cell stabilizers. 26-H sympathomimetie agents. 287-288 percentile values for. 26lt NicoQid. 256t translingual.. sustained release) :--litrodisc. 260t antilipemic agents. 25ft respir. 83. 257t alpha adrcnergie blockers. 256t sustained release. 256t. 26! t-266t alcoho!. 259t bronchodilators. (see I'\itroglycerin. 260t I-repetition maximum (I-RM). b. 260t. 80.5t gencric and brand names of. 26. 2. 216-217 exercise prescription in. (see Jsosorbide mononitrate) Monopril. transdermal) . 262t ~ Ietoprolo!.e.' phvsicirJ ac!i. 5. and hydrochlorothiazide) ~licronase. 260t I'\et oxygen uptake. (see :\itrogkcerin. 289t. 26. sublingual) :\itrostat. 26 It and h\'drocldornlhiazidc. (see :--Jial'in) Nieardipine.'it.51t Nitro-Derm.5t. 80 in healtb related physical Iltness testing. translingual) Nitrong. in preparticipatioll llcalth SlT('Clling.gOllists with dillretics.y ge ll uptake measurements in. 261t Nimodipine (:\imotop).'el ical use of. and hnlrochlorothiazidc') ~Iechallic:all~' hraked <':~'cle er~olllet('rs. 271t-272t potential elll('rgenc~ . 257t Omalizumab. 225 Overload. b-9b ' . 26:31 \Iesiti!.. (sec Tolbutamide) Odistat. 256t potassium sparing dillre-tics. 26J t generic and brand names of. 134-135. (see I\itroglycerin. 2571-25~t inslllins.'\itroglycerin. 256t sublingual. 258t. 4. 2G6t antiarrlwthmic agents. (sec \Iexiletine) ~Iicardis. (see . 2.. 257t angiotensin conn~lting enzyme (ACE) inhibitors with diuretics. generic and brand names or. 291 walkin" and rnnnin". (see Amiloride. '(.cll'. 24t-2. and ergomet. transderma!) ~linizide. (ACE) inhibitors. 259t-260t ealcillm ehannel bloekers. 26-lt ~Ietronnin. 264t emergene\'. 2.2.56t. (see :-Jitroglycerin.H anti platelet agellts. 26. (see Amiloride) Miglitol. 291. 256t transdermal. 266t antihistamines. 260t ~O\'Olin R. 261t generic and brand names of. 287 Niacin.2. 2621 xanthine derh'ati\es.55t hlood nlodi!\inl( agents. 266t ealcium channel bloekers. 263t M0I1Jhoiogic Iltness.:drochlorothiazide) ~lidamor. 297-298 m. 262t <lllorl''\iants.ft steroidal antiinflalilinator:' agents. 266t Minipress.5. 6H ~ledical clearance. 25. 22-29 ~ledical history <. 217-218 exercise preventing onset of. 260t lellkotriene antagonists and inhibitors. 266t m'l~t cell stabilizers. 286 in ease studies. 260t \Ie. 67. 255t alpha and heta bloekers. sustained releasc. 2~3-29-t \'02 measurements in.:al situation plans cl1wrgc!1cy. 26-lt nicotine. (see Amlodipine) :--Io\'olin 70/30. 257t ~Ionoket. 26Jl diuretics.ilelille. (see Nitroglycerin. 266t Naughton protocol. 296-297 rcfc:renc:es on. 8~1 ~luscular endurance. 260t Morbidity and mOltalit)' decrease. 256t. 2. 290-291 stepping. 255t angiotensin conn>lting ellz:'mc (ACl::) inhibitors. transdermal) I'\itrogard. 262t angiotensin II receptor antagonists.29:3 gross oX:'gell consumption and expression in. 2~6-2b8 pr. 1l0-1l1 ~la. (sec . 2S6-28R ~Ietabolic disease major signs or symptoms of. 286-287 in energy eX1Jencliture. 266t insulins. :3 ~Ietaholic syndrome. transmucosal) I'\itroglyeerin. 260t I'\o.55t.. drugs.'. 79t in stepping. (see Telmisartan. 266t Osteoporosis.)' contraction).276t-278t 1l01H. 257t (lIl~iot(-'nsin II receptor anta. 259t I'\ifedipine. 256t. exercise testing after. 2. 2fi9t.. 2(). 289t.2.51-260t aldosterone receptor bloekers.\itrocine. (sec Tria. 289t.5t ~Ietohv. 258t. long-acting. 25.56t angiotensin con\'crting enzyme (ACE) inhibitors with calciulIl channel blockers. 264t. -lOh ~ledi<. 2.. 83t upper body. 45 :-Jedocromil.ipril. 266t broncbocUiators. 28 -290 N :\adolol. with answers.·. 259t thiazide diuretics. 142-14:3 and espression in METs. 256t celltral alpha agollists and centrally actine. 255t :-Jateglinide. 257t ~Ieglitinides. 66-67 in ann cycling. 262t-26:3t anticholinergic agents. 265t tll\Toid medications. progressive. 265t . 2561 cardiac gl:Tosides. sustained release) NitroQuick. 257t.:0l11p01lents. 217 recommended weight loss programs in. 68-69 Multiple set resistance training. 262t angiotensin conn-rting cnz~ll1(. 261t cardiorespiratOl)' cffects of. 26Jt blood modifiers.. (sec Tellnisartan) Micardis HCT. 4. 7 exercise testing in. 157-158 ~Iuscle function tests. sustained release) :\itrolingual.5t.291.57t o Obesity. (see :--Jitroglycerin. 260t.5l ~I<. 289t in Illcl"\imal oxygcJl uptake estimation. (see Hydrocblorothiazide) Orinase. metabolic equations [or.6It pentosiklline. 29:3 in energy expenditurc cstimation.'\itrogh:cerin.e. 123-124 ~lykron. 260t :\ormodyne.'dications eardiorespiratUlY e!Teds of. 2651 alpha adrener~ie blockers.266t peripheral dilators. 260t 1\ uclear imaging. 256t Nitro-Bid.:we Lovastatin) ~Ie.. 262t and hydrochlorothiazide.5t nitrates. 262t h~popJ:Temic agents. 266t antigollt medicatiuns.56t ohesit\' managing agents.ltory age'nts.terene.55t beta bloekers and dilll'l'lics.. 218 Olmesartan. 224-225 special considerations in. 256t transmucosal. 287-2R8 leg and ann er~ometry. 25. 291 in walking and running. sustained release) . 266t psychot ropic agents.'lllergcl1cy. 259t.58t antidiahetic agel1ts. 257t angiotensin II receptor <llitagonists.5t and Il\'drochlurothiazide. 256t. in c:linical exercise testing. 81-82 Open circuit spirometl)'. :3 Motor driven treadmills. 2. 218-219 special considerations in. exercise prescription ill. 82t MVC (maximum volunta.. 288-290. (see Prazosin) ~Iinosidil. 266t digitalis. 2. 2. 2611 diet pills. 81-83 of legs. (see Gkburide) ~licrozide. (see Nitroglycerin. 19-36 \letaholie eCl'li"a!ents (~I ETs).. 2. 223-224 exercise testing and prescription in. transdermal) :-Jitro-Dur. (see Nitroglycerin. 290-291 in eardiorespiratol)' exercise prescription. 260t. 2611 Nisoldipine. 5.)'. 289t. 219-220 ~Ietaproterenol. 25. 294-296 and eon\'t'rsion to Nt l':'1's. 84b Muscular strength. 268t-269t generic and hrandnames or. 157 Ox'ygen uplake (\'02). in pre-exercise <. 255t central i. ~Ioricizi. 264t anticoaguhults. 291-296 Metaholie Iltness. 26Jl Nitrates cardiorespiratOl)' effects of.lee H. 290-291 measuring.5t antilipemic agents. 94-95 ~lyocarcLal tissue damage. 99 :-JCEP (:--Iational Cholesterol Education Program).56t. (.'Yaluation.\iacin) Nicotinic acid cardiorespiratOl)' cffects of. 291-296 gross. 260t loop diorelies.'\iI1lUlll "OIUlllaIY contraclion (~IVC).

5--7 Pulmic'ort. 1. .sical Acti\ity I\~adin~ss Qucstionnaire). and category-mtio scales. and clinical exercise testing. 7it il~ resistance training. 2. 345 ncuromuscular. 266t genel. 39. 40h physical ('\:a~llin<ltioJl components in. PIl\'siologic IItness.5t. in clinical c\:crcisc testin~. quality assurance...'astatin) Pra\'astatin. 3 enerh')' requirements of.. t6:3-1 (i.57 Ilesibilil\' io. 24t-25L 2h screening for.5 cool down e\:erc. . conclusions or. 2. 67-6R 1110dcs 68-76 muscular strength and endllrance in.' Hating of perC'C'i\'ed 0xertion (HPE). 7Hh !(oals of. 322-:323 R Rain. 4t PI{"sical Acti. 4th PIl\'sical fitness.I"'C Albnterol) Public health. 48t in pre-€'\:ercise evaluation.571.16 metabolic.5 special considerations in. f''\eITises f(Jr.'rcise prescription. ~5-<~9 instrllcti'ons in. in obtainin~ target heart Q Questran. 76-78 comprehensh'e. IO~-I09 22: . 49.5. 22. 229 Pulmonary function in obstructi\'e lung disease..5-126 ' Pre)-e\:~rci.5-! components of.less Questionnaire (PAR-Q). ih. (se(' Quinidine) QuinidinC'.~f motion. 2. (SN' I\ifedipine. 15~ 160 format (~f exercise session in.5 Hamipril.'sical acti\"jh'. 2~11 speoal consid('rations in. 1:3. 149-151 and recreational aethities. I".3~12 health apprai. 2.ss.INDEX 362 INDEX PI\)'siC<l\ exanlinalion components. . 1:38 supelYision of. 133--134 Physical fitncss program. 6 Ph"sical acthih' intensity.56l.5. 26. 250 Hate of progression. 47--t9 references for. 56 lll. (see B"udesonide) Pulmon<lI)' disease.5 sllpcn:ision r('commendations in. abilities) r"'1"isites for.. . (see Pr". 2. :31-:3. Quinaglute.344 pulmollal. .5 recommendations for. 163-lfi. 22-29 fnr cardiac patil'nts.'ises in. +-. 27 Pellhlltnlol.'39 carcum·ascular. 321-322 requircments and competencies of. R9. :141 immunologic. 228-22~ ('.-11llatio1l of.:ise in. 66-80 (s('(' also Cardiorespiratory fitness) cardiorespiratory test seqllence and measures in. 26 I t Pioglitazone. (. 3--4 Pi Ildolol. of cardiorespiratory exercise. Propafi. '50t informed cons('nt in. 26. 5fr. 1. 262t Po~te'\ercis(' period. 160-\6\ moti\'<ltion in. 227 ('\:eITis(' prescription in. 9()-~)2 test termination critelia in. ..14 aelherenee to. 341 imml1Jlologic.5t 363 p P. lOt intensih" of c1assiilcalion of. 166b Recreational adidty. (see Hatine. physical l'itIlCSS. 146 categories of. 10-15 Physical Activity and lIelllth (U. 84b IItness categories in. 232h Preparticipation health screcning. (sec Lisinoprii) Prinzide.5\-\.5. risk Ie"el. long-actin") Pro~ralll. of gradcd exercise testing 124b. 4. 20t-21t 2ry ACS~I risk stratification cat('gori~s i~l 28-29.. ilnd hydrochlnrothiazide) ProcainamidC'.56t.36 principles of. 264t.54 laboratory tests in.5 progression of e). :144-:345 pulmonary..C'n.26 Peripheral dilators carclior0spiratory effccts of. 259t Prazosin.5 exercise testing and prescription in. 266t Pirll1lterol. 42h lipid and lipoprotein' ass(-'ssment in. (s('(' Felodipine) Pletal. 2.5. 317~323 dinieal and lIledieal considerations. or.. 4t terms describing.=ercises in. (.5 ener~y expenditure goals in. inj\ll)' prevention. 2. 263t Propranolol..58t. . 262t Predictive value.58t.5\ . 227-22H major sihrrls or symptoms of... cOillprchensi\e.44t " hlood profile analvs0s in 46-47 contraindications ~to. 2. 76--78 106--1~1~ .5~) Provl'ntil..3:38-:3:39 cardim'<lsclllar. 136-1:3/ indi\'idllalized.31. (se(' PIl\'sical fitness. 13') references for. 2.)-160.5--316 Prandin. Sfi Pre\·alitc. 19. SlIrgeon Ceneral). (s. 54 Pregnanc\'. (ser Proeainamide) Proeardia XL.'. 322safety.c and hrand 11. 144 Perindopril.16.5 object i\'C's of.92 body composition in.s~ eV~llation. 300-. 320 program aclministmtion. . 22.1-30. 1.57 purposes of..5 1. 22. (sre also Physical adi\ih') .51 ' Progrf'SSi\l~ O\'erload.-~I assessments in.5t Phl\ix.. 262t Ramp tC'sts. dellnec\. III Phenytoin. 136 lllaintf'nance of training effect in. 161-162. and c1iniC'al cxercise {I'sting. . of pen..56t. S. 148.. ACSM certified.. 90 f"11\ironnll'l1t fur. L6.5 OIthop0dic/musC'ulosk0letal . exercise testing for) ..--l:3. 34:3 exercise physiolog)' and related exercise exercise prescription and pro~ralilllling. 256t Persantine. 12. 2:30h e\:er~is(' testing and prescription in. 2.lCerone. and ACS~ I recommendations for ph.:3 . 163t warm lip e.312 Pharmacologic stress testing. (Sl'(' Lisinopril.i'h' Headi. 2. 286-299 (set also Metabolic calculations) el1\"ironlnental considerations in.. 138 Regist~red Clinical Exercise Physiologist. 2. 01' KSAs. 2.5-4Ji medical history compOllcnts in. 262t QlIinora. J3. (see also Pre-e:\prcisc e\'aJllation) .-L3. 318 science.'3----. 2:31-:232 termination of exercise in. 156 Readmess to change modC'\.. 79-&5 order of tests in. 229-2:31 COlltr:\illClications fur ('\:ercise (hiring. 260t.3.28t ' addition.J. and emergency procedures. (see c:Jopidogrel) Plcndil. h9-90 exercise prescription for. 22-29 risk stratification in.57t Quinidex. 56-. 55. 262t Pe. 33h346 c\:ercise ph~'siology and related exercise scicnC'e. 2Ci \ t Propr'41Olol LA. 320-32\ Iluldtion and weight management. abilities) requisites for. 64 Pnkthiazide.):3-1.f. L.3\1 KSA (knl~vledgc'.lON' Procainamide) .5t. t39-1.5.30.5. of cardiorespiraton ('\:ercisc.('scriptiOlI) Progression. 149-1. 7-LO e\'idellce of.(>t' Quinidine) Qvar. 5.. 149-151 rate ol'progression in.-L\:imal \'C'1'SllS suhm<l. 138.:eiw'u exertion) Percent or I i HlllilX. 22. (sec A miodarone) PAH-Q (Ph. (we' Cholest\Tamioe) Prinivi\.308 (s(!(' also Emirollmcntal considerations) health and. :345 () rt hoped ic/mllSculoske letal... 99 Range. (scc Repaglinide) Pravachol. 3:37~338 cardiovascular :340 immunologic.5. fitness. in llf'alth related E"'=t.\('Tcise testill~ in.3-18 defined. (scc Dipyridamole) Personal Trainer. (.59t.. (.52-. 3--l. 19. 47-49 in restrictive lung disease. eY.\:"('C Physical fitness.5-167 cardiorespiratory training in..5t Proprioccpli\'e n('tlroll~lISCIIJar facilitation (PNF). 3\ 8--320 health appraisal.58 . :30-=31 llIcdical clearance in.. and h"lrochlorothiazide.1111l'S of. 6-7 regular. J49-1.5'. in pree\:ercise ('\'alnation. 2. (st'e Quinidine) Quinap"il. J9--36 special considerations ill.a\. 7-10 risk associat0d with. fitn. 139 design or. (see Bec1oll1e1hasolle) range. :346 metaholic. :317--3\8 human behavior and counseling. 1:3.1b pulmonary function in. J5. (s('(' Exercise' P'. (SI'(' Cilostazol) plethysmography. 262t and hyelrochlorothiazidC'. :310~311 KSA (knowledge. 48t Push-up test. 1. conditions for.57-66 (se(' also Bod:' cOlnpositiOl\) cardiorespiratOly.~ Quinidioe) Quinalan.5-\67 moti~lation ill.3t Physteal activity. and outcome assessll''l('nt. stages in. dose response relationship and. l:3/-1:3R ('\:ercise testing for. . .=imal.5. :341-:342 ' (-'\:ercise prescription and programming.5 lifestvle.5 refc'renc. (see also I repartlclpahon health screening) blood pressure assessment in 43-44 4. 16'3--173 resistance training in. . ACSM certified.{". in cardiorespiratory e'\f"rcise.3 instructions for participants in. 261t Pentoxi!\·lIine. 49.3b. skills. 2.-15B specilkityof.. exercise prescription ("or) PIl\'sieal fitlless testing.. (SCI' also Physical fitness) ACS~l pllblic health recommendations for.5-7 benefits ami risks of.5-2.. 56 principles and guidelines in. dassillcation of.. 2. 266t Percei\"ed E''\cltion.J. .t. S1. 4. 26:3t Procan SR. :34:3-:344 nellromuscular. skills. 2.s lor. :3.57 PrOllcstyl. 41-42. 149 Ilesibilil\' exercises ill. .ipheral artery diseas~.59t.'none.51. 8. 51. 29-:30 c\:elTisc testing recommendation in.58l. 30-3l Pretest instructions. ACS~I algorithm for. as e!wirollrnental [actor.55t. benefits of. Practice ar~a. (sec CholestlTamine) Quetelet index.53 stimullls or conditioning phase of. 1:3+.

119 clinical significance of. 69-70 Rosiglitazone. is(' testing. 262t and verapamil. 117b ' ~iazae. 108 Return-to-work exercise testing. and eblorthialidone) fenormlll.5. 22J-222 v \'alsartan. (see Alhuterol) VentJicular cksrlnthmias. 26. 257t.enoretic. 158 multiple set.56t V"relan PM. generalized.34-13. 2. 259t RPE. generic and brand names of. 61. 144-146 rnetabolic calculations in. 260t. 345 Surgeon Genera!"s Report (SGR).w'e Moexipril. 289t. 341 immunologic. Vasodilators cardior"spiratOlv "ffeets of. interpreting.51-15:3 Training effect.5 specificity of. (see Dofl'tilide) Tilade. 255t Resistance training.INDEX 364 INDEX Self-administered questionnaires. (''Xereise promoting. 257t and hydrochlorothiazidl'. 262t and hydrochlorothiazide. (sec i\itrogl~'('erin. 121 clinical signiHcance of. 2571. maintenance of. cardiorespirato. (see Colesevelam) Wet bulb globe temperature (\VBCT). 22 Selr motivation assessment scale.J signiHcance of. 218-219 Welchol. 151-153 of graded exercise testing. 6J t Illeasurement procedures for. 341 immunologic. motor drivl'n. (see Pol)~hiazide) Repaglinide. 266t Rosuvastatin. 259t. (see Acebutolol) of clinical exercise testing. 88 procedures for. energy requirements for. 245 for elderly people. 342 program administration. 260t Supervision 5 Salmeterol. 154-158 for children.2. (.') . 2.59 Walking horizontal and grade. of graded exercise testing. 90t Skin fold equations. exercise prescription in. quality assurance. 342 pathophysiology and lisk factors cardiovascular.561. IOJ submaximal. 159-160 Subjective ratings. 259t. 155 Renese. (see Eprosartan) Teveten IICT. (sec Nl'docromil) Timolide.133-134 Sympathomimetic agents orthopedic/musculoskeletal. 289t. 286-287 Spironolactone. 25. 2611 immediate release. 2601. 121-122 clinical significance of. 3. 156 Stretching exercises. 90t procedures for. 292t metabolic equation for gross ox')'gen uptake in. (see Trandolapril. Sensitivity. 260t. 255t and hydrochlorothiazide. 255t. 257t. (see Atl'nolol. l07-JO~ graded exercise testing. 4 Relative metabolic rate. 124b Serevent. (see Reserpine) Sibutramine. 293t metabolic equation for gross oxygen uptake in. (see Nateglinide) Step testing. 266t Tolbutamide. 263t Tolazalllide.591. 2611 and hydrochlorotbiazide.74 of. (see Timolol. 118b Triamterene. 1LI Vasotec. 257t Tenex. (see Propafenone) exercise. (sl'e EnalapriL and Iwdrochlorothiazid. 260t. 2. 12 Sinwastatin. 7. 125 principle of. 259t Respiratory exchange ratio (RER). 259t Singulair. 122 c1inic. 67. (sec Tocainide) Toprol XL. 163t of preparticipation he. 56 ' Te\'etan. 2. (see Ticlopidine) Ticlopidine.59t. 58-59 diseas" risk c1assiHcation and.24 \'entolin. 88 percentiles for. 156 RespiratOly agents. 120-122 in absence of coronary altery disease. 291 submaximal. (see Eprosartan. deHned. 264t. 292t in.. (see ~I