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General Guidelines (medscape)

Resistance and repetitions


See the list below:

Resistance: The appropriate resistance may be provided by hand weights, elastic


resistance, calisthenics, or machines and should be no more than what one can lift for
approximately 15-20 repetitions. Perceived effort should only be moderate or
somewhat hard.

Repetition: A set is a group of repetitions, such as 2 or 3 sets of 15 repetitions. The


number of sets depends on several factors, including time constraints, motivation, and
personal goals. One to 3 sets are adequate for strength development. Add 1 set per
week, increasing up to 3 sets.

Progress: Progression can be made as one finds that the weight being used can be
lifted more than 20-25 times. One should then increase the resistance slightly (eg, add
1-5 lb) and resume the training. As one reaches muscle fatigue, more stimulation of
the muscle tissue results in protein being added to the muscle groups. Significant
strength changes generally occur within 6 weeks.

Other: Stretching should also be part of the exercise plan.

Type of exercise (mode)


See the list below:

Intensity: This should range from low to moderate for healthy individuals.

Duration: Continuous aerobic activity for 20-60 minutes is recommended.

Frequency
o Individuals with a less than a 3-MET capacity should engage in multiple short
sessions each day.
o Individuals with a 3- to 5-MET capacity should engage in 1-2 sessions per
day.
o Individuals with a greater than 5-MET capacity should engage in 3-5 sessions
per week.

Energy (caloric) expenditure


See the list below:

Per-minute calculation: To calculate kilocalories per minute (kcal/min), multiply the


METs times 3.5 times body weight in kilograms (kg) and divide by 200 (ie, kcal/min
= [METs 3.5 kg body weight]/200). For example, the energy (caloric) expenditure
of a 70-kg individual at a prescribed 6-MET capacity with a weekly goal of 1000 per
week is calculated as (6 3.5 70 kg)/200, which equals 7.35 kcal/min (30.87
kJ/min). To convert kilocalories to kilojoules, note that 1 kcal = 4.2 kJ.

Per-week calculation: This determines the exercise duration per week. Using the
numbers from the example above, divide 1000 kcal (4200 kJ) by 7.35 kcal/min (30.87
kJ/min), which equals 136 min/wk or approximately 20-30 minutes, 6 d/wk.

Lifetime activities
See the list below:

Vary the type of activity. Pick an activity that is enjoyable. The activity can be any
type that uses most muscles, elevates the heart rate, and may be sustained for 20
minutes or longer. For example, one may find stationary cycling boring but enjoy
playing tennis or racquetball.

Vary the duration and intensity within the guidelines. Some days, decrease the
intensity of the activity but increase the duration. On other days, warm up and then
increase the intensity to the upper range of the guidelines but decrease the duration.

Contract with a friend (buddy system) or participate in group classes.

Use music for rhythm. If an activity is boring, either change it or find another one that
is enjoyable. For example, if one is stationary cycling, videos that show outdoor
scenery are available. Also, new saddles are available that make cycling much more
comfortable.

Make exercising enjoyable by selecting at least 2 activities that are enjoyable.

Conditioning may be realized from many activities if applied correctly.

Walk daily, whether one has a dog or not.

Selecting the right physical activities


See the list below:

Select physical activities that are enjoyable, use most of the muscles, are rhythmic,
and may be sustained for several minutes to an hour.

Plan to exercise every other day until more adequately adapted to the activity.

Think of the frequency, intensity, time, and type (ie, FITT) plan.

o Frequency: This is how often per week one will perform the exercise. Plan on
most days of the week.
o Intensity: This is how hard one exercises. Moderate effort is appropriate.
o Time: This is the duration of each session. Start off with as little as needed (10
min if necessary).
o Type: This is the choice of physical activity, which can include recreational
activities and domestic or occupational activities. A short list of each follows:

Recreational activities

- Participating in aerobic activity classes; performing calisthenics,


gymnastics, low-impact aerobics, martial arts

- Backpacking, climbing hills, stair climbing, walking, hiking,


orienteering, running

- Playing badminton, baseball, basketball, catch (eg, flying discs),


cricket, handball, racquetball, lacrosse, rugby, shuffleboard, table
tennis, tennis, volleyball, water polo

- Body building, bowling, boxing, cycling, dancing, fencing,


gardening, golfing, horseback riding, hunting, in-line skating, skating,
rope skipping, skiing, snow shoeing, weight lifting, windsurfing

- Canoeing, sailing, scuba diving, swimming, fishing, participating in


water activities

Domestic or occupational activities Cleaning windows, doing


housework, mowing, packing and unpacking, plowing, sanding,
sawing, sweeping, stocking shelves, pushing a wheelbarrow,
performing yard work, etc

Set goals, which may include those regarding health, improving physical capacity or
performance.

Motivation may be helpful for compliance. See the following tips:


o Join a class or facility, or contract with a friend (buddy system).
o Listen to one's body (eg, slowing down or skipping if tired or ill). Start at the
present level to prevent soreness.
o Exercise at the same time each day.
o Make sure to have good-quality nutrition.

o Make exercising a priority; scheduling a time benefits the individual.


o Get advice if help is needed.

General Principles of Exercise Prescription


In order to engage in safe and effective exercise program, one should follow the following
steps:
1. To assist in the development of safe and efficient exercise prescription and
optimize safety during exercise testing, it is important to screen potential
participants for risk factors and/or symptoms of various cardiovascular,
pulmonary and metabolic diseases, as well as conditions that may
aggravated by exercise.
o

Complete ACSM Pre-Participation Screening


or
one of two self guided forms (PAR-Q or AHA/ACSM Health/Fitness
Facility Pre-participation Screening Questionnaire)

2. Follow recommendations set by the ACSM Pre-Participation Screening.


o

If medical clearance in not warranted, proceed to step three and/or


four and/or five.

If medical clearance is warranted, complete the recommended


guidance (receive medical clearance) and then proceed to step
three and/or four and/or five.

3. General cardiorespiratory exercise programming:


o

Frequency: 3 to 5 sessions per week

Intensity: 40/50-85% of Heart Rate Reserve (HRR)

Duration: 20 to 60 minutes

Activity:Large muscle groups dynamic activity

Each exercise session should include warm-up and cool-down


period.

Energy expenditure

4. General resistance exercise programming:


o

Frequency: 2 to 3 sessions per week

Repetitions and Sets: 2 to 4 sets with 8 to 12 repetitions per set.


For older adults and deconditioned individuals, use 1 set of 10 to 15
repetition

Activity: 8 to 10 exercises including all major muscle groups

Rest Intervals: 2 to 3 minutes between sets

5. General flexibility exercise programming:


o

Frequency: 2 to 3 session per week

Intensity: Stretch to tightness at the end of the range of motion


but not pain

Duration: 15 to 60 seconds, repeat at least 4 times per stretch

Activity: Static stretch all major muscle groups.

* It is always a wise idea to consult an exercise professional before engaging in any type
of exercise.
The information from the above pages was cited from:
American College of Sports Medicine., Thompson W. R., Gordon N. F., Pescatello L. S.
(2010) ACSM's guidelines for exercise testing and prescription. 8th ed. Philadelphia:
Lippincott Williams & Wilkins

Principles Of Exercise Prescription

I. General Principles
Exercise prescription should always include :
a) the mode of exercise
b) the intensity of exercise
c) the duration of exercise
d) the frequency of exercise
e) the rate of progression of the patient's physical activity
These parameters should be taken into account whether you are
prescribing exercise for the healthy individual or the patient with
disease. In all cases, the exercise prescription should be developed with
careful consideration for the individual's health history, risk factor
profile, the patient's strength and flexibility, any orthopedic conditions
that may exist, behavioral characteristics, personal goals and
availability of exercise facilities.

II. The Prescription


Mode of Exercise
Mode of Activity : Any activity that uses large muscle groups,
performing rhythmic exercise which can be sustained for 15-60 minutes
of continuous exercise, and which is aerobic in nature becomes an
appropriate mode of exercise activity for most patients. Activities such
as walking, wogging (walking in water), jogging, jarming (moving the
arms rapidly forward and backward), running, skating, bicycling, rowing
and cross country skiing (Nordic Tracking) are considered to be highly
aerobic activities. Some of these activities are inappropriate for cardiac
patients but walking, bicyling, walk-jogging, and light rowing are
usually considered appropriate for the uncomplicated cardiac patient
and the non-cardiac patient.
No matter what is wrong with the patient, each session of exercise
should be started with a 10-15 minute warm-up period of low intensity
exercise - an exercise intensity that is lower that the steady state
exercise at which the patient will be training. Cool-down should be as
long as warm-up and should include a gradually declining exercise
intensity than that at which the patient exercised during steady state.
It is advantageous to add stretching and flexibility exercises prior to
the warm-up period and following the cool-down period.

Intensity of Exercise
Intensity of Exercise : The intensity of exercise for an apparently
healthy individual is usually between 40 % - 85 % of their VO2max or its
equivalent in heart rate which is 55 % - 90 % of maximal heart rate. For
the cardiac patient, the ideal heart rate training zone will be between
40% - 75% of the maximum symptom limited heart rate as determined
from a graded exercise treadmill test.
Determining the exercise intensity for any patient is always adjusted in
light of the patient's physical work capacity. For females above the age
of 50 and for males above the age of 40, it is highly recommended that
they undergo a graded exercise stress test (GXT). This test is most
often performed on a treadmill although GXT's can be done on an
ergometer. When a GXT is performed, a thorough physician will provide
the following pieces of information :

resting heart rate

maximum symptom limited heart rate

resting systolic and diastolic blood pressures

maximum symptom limited systolic and diastolic blood pressures

maximum MET's attained - preferrably at the onset of symptoms

This data can be used very nicely in a modified Karvonen's formula. The
formula looks like this :
Target Heart Rate=[(Max HR Achieved - HR @ rest) x (Activity Fraction)]
+ HR @ rest
The Activity Fraction is defined as : [(.6 - .8) + (Max METs
Achieved/100)]
An example of how to calculate an activity fraction is :
Activity Fraction = (.6 + (12 METs/100)) = .72
The value of .72 would be the multiplier that you would insert into the
Karvonen formula.
Now let's give an example of how to use the entire Karvonen formula.
Mr. Stevenson just had a maximum symptom limited graded exercise
stress test with the following data :
Resting Heart Rate Before The GXT = 70 bpm
Maximum Symptom Limited Heart Rate Achieved = 160 bpm
Maximum METs Obtained During The GXT = 10 METs
Resting Blood Pressure = 120/80
Maximum Symptom Limited Blood Pressure = 180/78
So, taking this information and inserting it into the formula to obtain
the training heart rate (THR) looks like this :
THR = [(160 BPM - 70 BPM) x (.6 +(10 METs/100)) + 70 BPM]
THR = 133 BPM will be the starting heart rate for Mr. Stevenson as he
begins his new exercise program.
When Mr. Stevenson begins his treadmill walking or his bicycle
ergometer training program in your clinic, you will start him out
performing exercise that will generate a steady state exercise heart
rate of 133 beats per minute give or take 1-2 beats. This would be
considered to be a safe exercise intensity because it falls nearly 30
beats below the heart rate that he had during the GXT at which he
began to develop symptoms. Those symptoms during the GXT that told
his physician that he was having trouble coping with the intensity may
have been S-T segment depression, significant dyspnea or a grade II
angina. So, if you exercise Mr. Stevenson 30 beats below the heart rate
at which he developed symptoms, then in all likelihood the patient is
exercising in a work intensity zone that is safe.
Frequently, physicians do not send all of the GXT data that they have
compiled on your patient. There is no reason why it should not be on

the referral but many times it is not. What would happen if the
physician only writes on the referral the maximum METs obtained, or
just the blood pressure or heart rate information. Can you write a safe
exercise prescription with only partial inormation from the GXT ? Yes,
fortunately you can write a meaningful exercise program even when
only part of the GXT data is given to you. Lets determine how we can do
this.
Case #1 :Only the heart rate data from the GXT is sent over on the
referral form from the physician's office
You can use Mr. Stevenson's data in the Karvonen formula like this :
THR = [((160 BPM - 70 BPM) x .6) + 70 BPM
THR = 124 BPM
Mr. Stevenson will begin his exercise program in your clinic performing
exercise at a steady state heart rate of 124 bpm.
Case #2 :Only the blood pressure data from the GXT is sent over on the
referral form from the physician's office
You can use Mr. Stevenson's GXT data in the Karvonen formula like
this :
Target Systolic BP (TSBP)=[((SBPmax - SBPrest) x .6) + SBPrest]
TSBP=[((180 - 120) x .6) + 120]
TSBP=156
Mr. Stevenson would reproduce an exercise intensity on the bike or
treadmill that would produce a systolic blood pressure of 156 mm Hg
pressure.
Case #3 :Only the maximum METs performed from the GXT is sent over
on the referral form from the physician's office
You can use Mr. Stevenson's GXT data in the Karvonen formula like
this :
Training MET Level=(.6 + (10 METs/100) x 10 METs
Training MET Level=7.0 METs
Mr. Stevenson will begin his exercise program in your clinic performing
an exercise intensity equivalent to 7.0 METs. Published MET tables can
give you the type of exercise and its intensity that is equivalent to 7.0
METs.

Duration of Exercise
The duration of exercise should always be from 15-60 minutes
depending on the patient's physical work capacity. The more debilitated

and untrained the patient is, the shorter the exercise session. In some
cases, the patient may not even be able to exercise continuously for 15
minutes. In this case, the exercise bouts can be broken up into shorter
sessions throughout the day such as 3 five minute sessions or five 3
minute sessions. This allows the patient to accumulate 15 minutes of
physical training with the training sessions interspersed throughout the
day. As an example of this strategy, patients with peripheral vascular
disease, such as intermittent claudication, will have to exercise for
short durations multiple times each day until they build a tolerance to
the work requirement.
As the patient continues to exercise regularly, each session will become
a little longer until the minimum of 15 minutes can be performed in a
single session. Progress the patient from this point gradually until they
can exercise from 30-60 minutes continuously.

Frequency of Exercise
Exercise frequency is usually 3 times per week and advanced over time
until it is 5-7 times per week. Frequency is highly dependent on a
patient's condition. For example, a type I diabetic should exercise 7
days per week in order to more effectively regulate their blood glucose
as well as regulate the amount of insulin they must take throughout the
day. Exercise training has similar effects as insulin because it, too,
stimulates the transport of glucose from the blood into the working
muscle cells.
However, a type II diabetic should only exercise 4-5 times per week.
These patients are not totally insulin deficient. In fact, type II diabetics
may actually produce normal or supernormal amounts of insulin. They
suffer from a problem called peripheral resistance - i.e. - the cells of the
body are not as sensitive to the effects of insulin binding to its receptor.
Hence, insulin fails to stimulate the muscle cells of the body to take up
glucose from the blood as effectively as in normal subjects. Therefore,
the larger issue for type II diabetics is weight reduction since most of
these patients struggle with obesity. The idea to exercise type II
diabetics only 4-5 times per week instead of daily is : 1) to reduce the
likelihood of overuse injuries in an obese and physically unfit
individual ; 2) to assist the patient in reducing body mass - i.e. - the
reduction of percent body fat ; and 3) to help regulate blood glucose
levels. These two examples help us to understand that frequency of
exercise is greatly dependent on the patient's medical condition.

Rate of Progression

Rate of progression - how fast you advance an individual in their


exercise program - is one of the more artful aspects of exercise
prescription. Intensity of exercise is the only other more important
aspect of exercise prescription.
Again, the rate of progression is heavily dependent on the physical
condition of the patient. It may take many days to several weeks to
advance the exercise intensity of a patient who is very ill. Indeed, rate
of progression may be almost a non-consideration if the patient is very
fragile. Certainly, patients with cancer, AIDS, or end-stage renal failure
can be so gravely ill that regular advances of exercise intensity are not
realistic goals. In these patients, it may only be reasonable to have
daily exercise at whatever intensity they can handle - a variable day-today change in exercise intensity because they are so ill.
In patients with whom rate of progression is a realistic goal, there are a
couple of ideas to consider when progressing the exercise prescription.
1. Increase duration of exercise before frequency and intensity. It is
an acceptible exercise strategy to have the patient workup to 4560 minutes of continuous steady state exercise per exercise bout.
Once the patient begins to say the 45-60 minute exercise sessions
are getting too easy to perform, then it is time to increase the
frequency of exercise per week from 3 times to 4-5 times per
week. However, it is highly advisable to reduce the duration of
each exercise session down to 25-30 minutes per session so that
the patient can tolerate the addition of 1-2 days of additional
exercise. Then as the patient accomodates to the extra days of
exercise, begin to gradually increase duration back to 45-60
minutes.
2. Once the patient is exercising 45-60 minutes per day for 5 days
per week, then it is time to increase the intensity of exercise.
Small increases in the exercise intensity will have to be
accompanied by an initial reduction in duration. Patients who are
working harder should be allowed to shorten their duration to 30
minutes if they were exercising between 45-60 minutes. It may
also be necessary to reduce by one day the weekly frequency of
exercise. Within a few days, the patient's duration can again be
made longer followed by the addition of one day in the weekly
frequency back up to 5 days a week.
As you can quickly see, the exercise prescription for most patients is
continuously evolving. The physical therapist should first advance the
duration of individual workout sessions, followed by the increase in
weekly exercise frequency. Exercise intensity should be the last of the
variable to be advanced.

It goes without saying that whenever the patient's exercise prescription


is advanced, it is a smart practice to re-assess the patient's response to
the new exercise intensity. The clinically acceptible ways to monitor the
patient's response to the new prescription are such things as :
1. Monitor the patient's heart rate to the new exercise prescription.
2. Monitor the patient's blood pressure response to the new changes
in the prescription.
3. Teach the patient to effectively use the Borg Scale of the Ratings
of Perceived Exertion (RPE). The Borg Scale is a rating scale of
relative physical exertion. The numbers in the scale have
descriptors telling the patient what each number means. For
example, the number 13 has a descriptor of "somewhat difficult".
Other numbers on the scale have descriptors like : "light", "very
light", "very hard", etc. All patients should exercise at an RPE of
10-13 which is interpreted as light to somewhat difficult. Since
the scale is a relative scale rather than an absolute scale, the
meaning of "somewhat difficult" will be different for all patients
dependent on their physical conditioning and their disease state.
Because the scale is subjective, the absolute work output
between two different patients will be very different. The
perceived work, though, will still be 13 or somewhat hard for both
patients.
4. Teach the patient to use the dyspnea scale
5. Teach the patient to use the anginal scale especially if the patient
has a known history of cardiovascular disease.
These tools will help you to monitor the patient's response to a new
change in the exercise prescription. This will keep you from having any
anxiety over how the patient is tolerating the changed prescription.
These tools will reassure the patient that they are being carefully
monitored and will help the patient to accept the new changes to their
exercise prescription. It will also keep the patient exercising in a safe
manner.