Emailing EIMP Physician Pre-Course Book 082217

Disclaimer
This Exercise Is Medicine Philippines (EIMP) Exercise Prescription Course Book is provided for general information
only and should not be treated as a substitute for professional supervision or advice.
Before starting any exercise regime you should consider consulting a qualified EIMP-certified clinical fitness
professional to ensure the regime is suitable for you, and your own EIMP-certified doctor if you have a medical condition
or are taking medication or have related concerns.
Do not undertake any exercise program or treatment provided by this course book without professional or qualified
supervision.
Any programs involving weights, intense workouts, and apparatus may put strong physical demands on any individual,
meaning supervision is obligatory.
Exercise Is Medicine Philippines (EIMP) cannot and shall not be held responsible for any injuries which may occur
as a result of unsupervised exercise.
If you have asthma, heart condition, growth condition or have experienced chest pains or dizziness in the last month
we strongly advise you NOT to try any of our workouts without first consulting with an EIMP-certified professional.
This course book is not a medical facility and no information contained in it should be used without the direct
supervision or advice of qualified, trained, accredited, and fully-certified personnel to prevent, treat, or diagnose medical
conditions of any kind.
The Exercise Is Medicine Philippines (EIMP) Program is not liable for the contents of any external internet sites
or sources listed, nor does it endorse any commercial product or service mentioned or advised on any of these sources or
sites.
CONTENTS
Acknowledgement............................................................................................................... i
Foreword........................................................................................................................... ii
Introduction:
Exercise is Medicine Philippines................................................................................... 1
Benefits of Exercise....................................................................................................... 3
Chapter 1:
Pre-Participation Screening and Risk Stratification....................................................... 7
Chapter 2:
General Principles of Exercise Prescription................................................................. 18
Chapter 3:
Exercise and Motivation............................................................................................. 31
Chapter 4:
Exercise in Hypertension............................................................................................ 41
Chapter 5:
Exercise Prescription for Patients with Cardiac Disease.............................................. 46
Chapter 6:
Exercise and Diabetes, Obesity, Metabolic Syndrome and Dyslipidaemia.................. 54
Chapter 7:
Exercise in Special Conditions: Asthma, Depression, Arthritis and Osteoporosis.......... 7
References........................................................................................................................ 87
List of Tables
Table 1.1. (Introduction) Overall Benefits of Physical Activity........................................... 3
Table 1. Definition of Major Symptoms and Signs............................................................ 3
Table 1.2. Coronary Artery Disease Risk Factor Threshold for ACSM Risk
Stratification............................................................................................................... 15
Table 1.3. Criteria for ECG Sress Testing for Type 2 DM Patients.................................. 17
Table 2.1. Measures of Exercise Intensity for Aerobic Activities....................................... 20
Table 2.2. Common Physical Activities with Associated Intensity in METs..................... 21
Table 2.3. Exercise Based Intensity and Energy Expenditure............................................ 25
Table 3.1. Physical Activity States of Change................................................................... 35
Table 4.1. Lists the WHO Blood Pressure Classification Scheme..................................... 41
Table 4.2. Risk Stratification of Hypertension................................................................. 43
Table 5.1. Benefits of Exercise Training in the Treatment of Specific CVD Condition.... 47
Table 5.3. Clinical Indications and Contraindications for Cardiac Rehabilitation............ 50
Table 6.1. Criteria for ECG Stress Testing in Type 2 Diabetes Mellitus.......................... 58
Table 6.2. Classificatio of Obesity in Asians..................................................................... 66
Table 6.3. Abdominal Obesity: Asian Classification......................................................... 66
Table 6.4. Criteria for Clinical Diagnosis of the Metabolic Syndrome............................. 70
Table 7.1. Levels of Asthma Control................................................................................ 78
Table 7.2. Shortness of Breath Bord Dyspnoea Scale........................................................ 77
List of Figures
Figure 1.1. (Introduction) The Risk of Dying Prematurely Declines as People
Became Physically Active.............................................................................................. 4
Figure 1.1. New Physical Activity Readiness Questionnaire (PAR-Q).............................. 11
Figure 1.2. Risk Stratification of Patients......................................................................... 12
Figure 2.1. Progression Along the Duration Path............................................................. 27
Figure 2.2. Progression Along the Frequency Path........................................................... 28
Figure 7.1. Asthma Control Test...................................................................................... 74
Figure 7.2. Shortness of Breath Borg Dyspnoea Scales..................................................... 77
Acknowledgement
W
e would like to thank Exercise Is Medicine Singapore for allowing us to customize the EIMS
pre-course book for primary care physicians and for clinical fitness professionals. Special thanks
to Dr. Benedict Tan (Task Force Chairman) and his EIMS team for training and providing the
initial set of materials to start off the Exercise Is Medicine Philippines training program.
We would also like to thank Coca-Cola Far East Limited for sponsoring the training of EIMP trainers in
Singapore.
We thank the Philippine Association for the Study of Overweight and Obesity, the lead organization in
the coalition, and its Board of Trustees for their time and effort in spearheading the programs and facilitating
the activities of EIMP.
For the review of the EIMP pre-course book for clinical fitness professionals we thank the University of the
Philippines College of Human Kinetics, particularly Prof. Hercules Callanta, Prof. Marla Cuerdo and Ms. Mona
Maghanoy. For the review of the EIMP pre-course book for primary care physicians we thank the following:
Dr. Rosa Allyn Sy, Dr. Juan Maria Ibarra Co, Dr. Richard Guiman and Prof. Nina Castillo-Carandang
For their unselfish dedication and effort, we thank the program committee composed of Prof. Hercules
Callanta (Chair), Dr. Juan Maria Ibarra Co (Co-Chair), Dr. Alejandro Pineda Jr., Dr. Sheila Lim, Prof. Marla
Cuerdo and Ms. Mona Maghanoy for coming out with the Exercise Is Medicine Philippines pre-course book
for primary care physicians and for clinical fitness professionals.
And last, but not the least, we thank the EIMP Task Force chaired by Dr. Rodolfo Florentino and Co-
Chaired by Dr. Rosa Allyn Sy.
i
Foreword
E
xercise is Medicine (EIM) is a global initiative started by the American College of Sports Medicine
on the principle that exercise is vital in the prevention and treatment of disease. EIM-Philippines, a
branch of EIM-Singapore, was born in 2012 focused on increasing awareness of the importance of
physical activity and exercise among health care professionals and encouraging them to include exercise when
designing treatment plans for their patients and clients. Its vision is to make physical activity and exercise a
standard part of a disease prevention and treatment medical paradigm in the country.
This book is intended as a pre-course reference in the training of Primary Care Physicians and related
Specialists to enable them to carry out their mission of counselling and prescribing exercise programs to their
patients. The book was adopted from the EIM-Singapore Course Book according to the conditions prevailing
in the Philippines by the initial trainees from the Philippines who have undergone the EIM-Singapore Course.
It starts with the general principles of exercise prescription, and proceeds to risk stratification of patients and
management of common chronic disease conditions. An important part of the book is the chapter on motivating
patients to start and continue with their physical activity and exercise program.
Trainees are encouraged to study this Pre-Course book before undergoing their training.
Dr. Rodolfo F. Florentino

EIM Philippines Task Force Chairman
ii
1
Exercise is Medicine Philippines

What if there was one prescription that could prevent and treat dozens of diseases, such as
diabetes, hypertension and obesity? Would you prescribe it to your patients? Certainly.
- Robert E. Sallis, M.D., FACSM

Exercise is MedicineTM Task Force Chairman
A CRITICAL CALL TO ACTION
E
xercise is Medicine Philippines is an initiative focused on encouraging physicians and other health
care providers to include exercise when designing treatment plans for patients. Exercise is Medicine
Philippines is committed to the belief that exercise and physical activity are integral in the prevention
and treatment of diseases and should be regularly assessed as part of all medical care. Its vision is to make physical
activity and exercise a standard part of a disease prevention and treatment medical paradigm in the country.
THE PROBLEM
Physical inactivity is a fast-growing public health problem and contributes to a variety of chronic diseases and
health complications, including obesity, heart disease, diabetes, hypertension, cancer, depression and anxiety,
arthritis, and osteoporosis. The 2008 National Nutrition Survey of the Food and Nutrition Research Institute
(FNRI-DOST) found very high prevalence of physical inactivity among adults. The prevalence of low physical
activity for work- and non-work-related physical activity was more than 85%, particularly among females,
while that of leisure-related physical activity was 83%. In fact the prevalence of low physical activity increased
significantly from 2003 to 2008, particularly for work-related and travel-related physical activity.
In addition to improving a patient’s overall health, increasing physical activity has proven effective in the
treatment and prevention of chronic diseases.
Regular physical activity at the correct intensity:

• Reduces the risk of death by 40%.
• Lowers the risk of stroke by 27%.
• Reduces the incidence of diabetes by almost 40%.
• Reduces the incidence of high blood pressure by almost 50%.
• Can reduce mortality and the risk of recurrent breast cancer by almost 50%.
• Can lower the risk of colon cancer by 60 %.
2 Exercise is Medicine Philippines
• Can reduce the risk of developing of Alzheimer’s disease by one-third.

• Can decrease depression as effectively as medications or behavioral therapy.
Exercise is indeed medicine!
A VITAL SIGN FOR HEALTH

A key component of Exercise is Medicine involves calling on health care providers, regardless of specialty, to
review and assess every patient’s physical activity level at every visit. Patients should be counselled on exercise
regimens, with office visits concluding with exercise clearance and prescription or referral to a certified health
and fitness professional.
Hence one of the immediate aims of Exercise is Medicine Philippines is to train and equip healthcare and
fitness professionals with the necessary skills, tools and resources to prescribe exercise in the right dose to prevent
and treat common chronic health conditions for patients.
The initiative aims to have physical activity recorded as a vital sign during patient visits and to encourage
able patients to meet the American College of Sports Medicine (ACSM) Guidelines by participating in at least
150 minutes of moderate-intensity physical activity per week through, for example, 30 minutes of physical
activity, five days per week. Additional reference for physical activity requirements may also be culled from the
Philippine Physical Activity Guidelines by the Department of Health (DOH).
EXERCISE IS MEDICINE PHILIPPINES

The overall initiative goals of Exercise is Medicine Philippines is
• For physical activity to become a Vital Sign, with health care providers routinely discussing it with each
of their patients.
• For the Physician to either prescribe appropriate physical activity to each patient or to refer the patient
to a certified health and fitness professional to get a physical activity prescription.
• To put in place a framework for allied health and fitness professionals to work with physicians in
implementing the exercise plan
• For the Public to begin to ask for and expect Physicians to emphasize importance of physical activity in
disease prevention.
Who are the people behind EIMP?

EIM Philippines identifies itself as a coalition, ‘‘The National Coalition for Philippine EIM Movement’’, a
Introduction 3
coalition of individuals, organizations and corporations that support EIM Philippines’ vision and mission.
Its vision is to make physical activity and exercise a standard part of global disease prevention and treatment
medical paradigm. Its mission is for physical activity and exercise to be considered by all health care providers as
a vital sign in every patient encounter, and that patients are effectively counselled or referred to experts for their
physical activity and exercise needs.
EIM-Philippines is led by the Philippine Association for the Study of Overweight and Obesity (PASOO),
and is implemented and coordinated by a National Task Force composed of experts from various medical and
related disciplines -- endocrinologists, family physicians, physical fitness experts, nutritionist-dieticians, social
scientists and others.
Benefits of Exercise
There is overwhelming scientific evidence to support the positive relationship between regular physical activity
and health. The overall health benefits of physical activity can be summarized in Table 1 below:
Source: The evidence rating was reported based on the 2008 review by the Office of Disease Prevention and Health Promotion of US
Department of Health and Human Services. Over 8000 articles reporting the health benefits of exercise were reviewed in preparation for
the report. These evidence ratings were also adopted in the recently released 2011 National Physical Activity Guidelines by the Health
Promotion Board.
The following sections will elaborate further on the health benefits of exercise for common chronic
conditions and the optimum level of physical activity that is needed to achieve them.
• Premature death
º Individuals who are physically active for approximately 7 hours a week have a 40 % lower risk of dying
early from leading cause of death than those who are active for less than 30 minutes a week. (Figure
1.1).
Figure 1.1. The Risk of Dying Prematurely Declines as People Become Physically Active
º High amounts of activity or vigorous-intensity activity are not necessary to reduce the risk of
premature death. Studies show substantially lower risk when people do 150 minutes of at least
moderate-intensity aerobic physical activity a week.
º The most dramatic difference in risk is seen between those who are inactive (30 minutes a week) and
those with low levels of activity 90 minutes or 1 hour and 30 minutes a week).
º The relative risk of dying prematurely continues to be lower with higher levels of reported moderate
or vigorous-intensity leisure-time physical activity.
• Cardiorespiratory health
º Significant reductions in risk of cardiovascular disease occur at activity levels equivalent to 150
minutes a week of moderate-intensity physical activity. Even greater benefits are seen with 200
minutes (3 hours and 20 minutes) a week.
º In hypertension, blood pressure lowering effects of exercise are most pronounced in people with
hypertension who engage in moderate- intensity exercise 30 minutes on most days; with systolic
blood pressure decreasing approximately 5-7 mm Hg after an isolated exercise session (acute) or
following exercise training (chronic).
Introduction 5
º It has been estimated that as little as 2 mm Hg reduction in population average systolic BP can
reduce mortality from coronary heart disease and stroke, and all causes by 6% and 10% respectively
(Lewington et al. 2002).
• Metabolic Health
º Regular physical activity strongly reduces the risk of developing type 2 Diabetes and also aids in the
control of blood sugar for those already with diabetes.
º The Da Qing study in China included an exercise only treatment arm and reported that even modest
changes in exercise (20 min of mild or moderate, 10 min of strenuous, or 5 min of very strenuous
exercise one to two times a day) reduced diabetes risk by 46% (compared with 42% for diet plus
exercise and 31% for diet alone).
º The Finnish Diabetes Prevention Study and the US Diabetes Prevention Program (DPP) included
intensive, lifestyle modifications with both diet and increased physical activity. In the former, 522
middle-aged, overweight adults with impaired glucose tolerance (IGT) completed either lifestyle
modifications of at least 30 min of daily, moderate physical activity, or no change in behaviour. The
DPP randomized 3234 men and women with IGT or impaired fasting glycemia (IFG) into control,
medication (metformin), or lifestyle modification groups, composed of dietary and weight loss goals
and 150 min of weekly aerobic activity. Lifestyle modification in both studies reduced incident
diabetes by 58% and, in the DPP, had a greater effect than metformin (31%).
º Both aerobic and resistance training improve insulin action, blood glucose control and fat oxidation
and storage in muscle. Physical activity/exercise can result in acute improvements in systemic insulin
action lasting from 2 to 72 hours. Hence, the benefits of regular exercise in clients with type 2
diabetes mellitus include improved glucose tolerance, increased insulin sensitivity, decreased HbA1c
and decreased insulin requirements.
º Regular participation in aerobic physical activity and exercise results in beneficial changes in lipid
profile of patients with dyslipidaemia. These changes include reductions in triglyceride levels and an
increase in HDL (good cholesterol) concentrations. The reductions in LDL levels in clinical trials
have been inconsistent.
º Good evidence exists that physical activity reduces the risk of metabolic syndrome. Lower rates of
these conditions are seen with 120 to 150 minutes (2 hours to 2 hours and 30 minutes) a week of at
least moderate-intensity aerobic activity.
• Overweight and obesity

º A minimum of 150 minutes per week of moderate intensity physical activity for overweight and
obese adults improve health; however, greater amounts of physical activity of > 250 minutes per
week is necessary to achieve clinically significant weight loss.
º There is strong evidence that regular physical activity between 150 and 250 minutes per week reduces
the risk of weight gain and is most effective when combined with a balanced diet.
• Musculoskeletal health
º Regular physical activity slows the decline in bone density especially in individuals participating in
weight bearing aerobic and resistance programs using moderate or vigorous intensity. These changes
are significant when exercising at 90 minutes a week and continue up to 300 minutes a week.
º Physically active individuals, especially females, have lowered risk of hip fracture than do inactive
individuals. There is moderate evidence that 120-300 minutes per week of regular physical activity
at moderate intensity is associated with a reduced risk of hip fractures.
Chapter 1 7
Chapter 1
Pre-Participation Screening and Risk
Stratification
Introduction
W
hen beginning an exercise prescription process, the question of safety to exercise arises. There are
documented risks associated with physical activity; the major concern being the increased risk of
sudden cardiac deaths as well as myocardial infarction associated with vigorous physical exertion.
In this chapter, we provide you with a systematic method of assessing your patient’s medical status to
reduce the chance that your patient may risk injury or illness (particularly to his or her heart) by exercising.
Almost all patients will benefit from exercise, but some, especially those patients with known disease, signs
and symptoms, or risk factors for cardio-vascular, pulmonary, or metabolic disease, may need to have certain
modifications or restrictions placed on their exercise program. With a systematic approach, the screening process
should not present a burden to the clinician or prevent patients from initiating light- or moderate- intensity
physical activity.
Risks of exercising -- Putting it in perspective

Before discussing the risk of exercising, it is important to begin by asking the question,’’Is the patient safe to
remain sedentary?’’ Physical inactivity has been identified by the World Health Organization as the fourth
leading risk factor for global mortality (6% of deaths globally).
The risks of participation in exercise range from the most common–muscle soreness and musculoskeletal
injury to the most serious–myocardial infarctions and sudden cardiac death, which will be discussed here.
Vigorous physical activity has been shown to transiently increase the risk of sudden cardiac death and myocardial
infarction among individuals with both diagnosed and occult cardiac conditions. The absolute risk of sudden
cardiac death during vigorous physical activity has been estimated at one per year for every 15,000 - 18,000
people. Although these rates are low, the risk is relatively higher in sedentary unscreened individuals who engage
in unaccustomed vigorous activity. As such, sedentary individuals who intend to exercise should begin with low
to moderate intensity exercises. For these patients, an appropriate pre-participation screening process should be
administered to further lower the risk.
The important points on risk of exercising can be summarized below:
• Exercise generally does not provoke cardiovascular events in healthy individuals with normal
cardiovascular systems.
• Risk of sudden cardiac arrest or myocardial infarction is very low in healthy individuals performing
moderate intensity activities.
• Risk of sudden cardiac death and/or myocardial infarction increases transiently and acutely in individuals
performing vigorous exercise with diagnosed or occult cardiovascular disease.
Even in patients with known cardiac disease undergoing a supervised rehabilitation programs, the incidence
of adverse cardiac events are rare: cardiac arrest = 1 in 117,000; non-fatal myocardial infarction = 1 in 220,000;
and death = 1 in 750,000 patient-hours of participation.
Considering the overwhelming benefits of physical activity, the risk of inactivity and the relatively rare
serious side effects of exercise, almost all patients will benefit from physical activity; with some of them needing
modifications or restrictions on their exercise program. For patients with chronic diseases, it is important that
the clinician performs a risk stratification and exercise screening prior to initiating an exercise prescription.
Aims of Pre-Participation Health Screening

• Identify individuals with medical contraindications for exclusion from exercise programs until these
conditions have been addressed and optimized.
• Identify individuals with clinically significant disease(s) who should participate in a medically supervised
exercise programs.
• Identify individuals who are at increased risk for disease because of age, symptoms and risk factors who
should undergo further medical evaluation and exercise testing before initiating an exercise program or
increasing the frequency, intensity or the duration of the current program.
• Identify individuals with special needs e.g. Elderly or disabled population etc. that may affect exercise
testing and programming.
Considerations in Pre-participation Screening

As the clinician, the algorithms presented in this chapter will help to identify factors that may
1. Require pre-participation medical screening or exercise testing
2. Warrant a clinically or professionally supervised program or limitations on the intensity at which a
patient is safe to exercise
3. (In a small number of patients) may exclude your patient from participation.
Chapter 1 9
Your responsibility is to follow a logical and practical sequence to acquire health information, assess risk,
and provide the exercise prescription with appropriate precautions to your patient.
A self-guided questionnaire such as the Physical Activity Readiness Questionnaire (New PAR-Q Bonoan,
Bernardo, 2006 see Figure 1.1) is the recommended entry level for screening. This self-guided question screening
tool is able to quickly identify conditions or risk factors that require further assessment before commencing
exercise. If the patient answers no to all 7 questions, he is at a LOW RISK for health complications, and is
generally safe to begin an exercise program without supervision at any intensity. Physicians can expect to receive
the New AR-Q from patients that require exercise clearance.
However, for most patients with chronic disease, the PAR-Q typically produces a positive response for
at least one of the questions. With that in mind, the algorithm presented in Figure 1.2 outline the screening
process that a physician can go through to determine the patient’s risk level. This is called risk stratification. This
assessment process is based on ACSM’s recommendation available in the eighth edition of ACSM’s Guidelines
for Exercise Testing and Prescription.
RISK STRATIFICATION
The process of risk stratification is based on
• Identifying the presence or absence of known cardiovascular, pulmonary and/or metabolic disease.
• Identifying the presence or absence of signs and symptoms suggestive of cardiovascular, pulmonary
and/or metabolic disease. (see Table 1.1) for definition of major signs and symptoms)
• Identifying the presence or absence of cardiovascular risk factors. (see Table 1.2 for Cardiovascular Risk
Factors Threshold)
ACSM RISK STRATIFICATION CATEGORIES FOR ARTHEROSCLEROTIC DISEASE

Low risk:
• No signs/symptoms of or no diagnosed cardiovascular, pulmonary and/or metabolic disease.
• No more than one cardiovascular risk factor.
• Low risk of acute cardiovascular event
• Physical activity/exercise program may be pursued safely without the necessity of medical examination
and clearance
Moderate risk:
• No signs/symptoms of or no diagnosed cardiovascular, pulmonary and/or metabolic disease.
• Two or more cardiovascular risk factors.
• Increased risk of acute cardiovascular event.
• Individuals at moderate risk may safely engage in low to moderate intensity physical activities while
awaiting medical clearance.
• Medical clearance and exercise testing prior to participation in vigorous intensity exercise is
recommended.
High risk:
• One or more signs and symptoms of or diagnosed cardiovascular, pulmonary and/or metabolic disease.
• High risk of acute cardiovascular event.
• Thorough medical examination and clearance must be sought prior to initiation of physical activity or
exercise at any intensity.
Placement of your patient in the HIGH, MODERATE, or LOW RISK categories helps the physician
determine the need for further testing and supervision during exercise.
HIGH RISK: Patients should undergo further medical testing before starting an exercise program. Clinical
supervision is recommended during exercise and stress testing.
* Clinical supervision = under the direct supervision of a health/fitness professional possessing a combination of advanced college training and
certification equivalent to the ACSM Registered Clinical Exercise Physiologist and Exercise Specialist or above
MODERATE RISK: Patient is safe to begin light- or moderate-intensity exercise (should undergo further
medical assessment before partaking in vigorous-intensity exercise) Supervision by an fitness professional during
exercise is often recommended (depends on the reason for falling into this category)
* Professional supervision = under the supervision of a health/fitness Professional possessing a combination of academic training and
certification equivalent to the EIMP Clinical Fitness Professional or above.
LOW RISK: Patient is safe to begin exercising without further assessment. Exercise supervision is not
necessary.
It is also important to note that patients may require supervision for reasons other than a medical condition.
These may include learning to use the exercise equipment, familiarization with exercise technique and if either the
physician or the patient feels that exercising under supervision will motivate patient to continue regular exercise.
Chapter 1 11
Figure 1.1. New Physical Activity Readiness Questionnaire (New Par-Q).

Source; Physical Activity Readiness Questionnaire (New Par-Q) C Bonoan, Bernardo, 2006.
Chapter 1 13
Chapter 1 15
Important considerations for risk stratification

The algorithm serves as a guide that may be modified at the discretion of the physician. Some of the information
may not be available to the physician at the screening to assess the risk level accurately. Under these circumstances,
physicians are encouraged to use existing information and make a conservative estimate of the patient’s risk
level.
• If the patient’s disease is well controlled e.g. metabolic or pulmonary disease such as thyroid and asthma
and other stable chronic diseases or conditions) the patient will remain at HIGH RISK; however, the
intensity of his exercise may be increased at the discretion of the relevant specialist or cardiologist.
• A patient in the moderate risk category based on cardiac risk factors may be progressed to LOW RISK
if the risk factors resolve (e. g. quitting smoking, losing weight, or no longer sedentary).
• Hypertensive patients with resting SBP ≥ 200 mm Hg or DBP ≥ 110 mm Hg should not undergo
exercise testing nor be allowed to exercise. It is important to establish blood pressure control and assess
for presence of end organ disease before initiating exercise. For asymptomatic hypertensive patients
with BP < 180/110 mm Hg and no evidence of end organ disease, they may begin low to moderate
intensity aerobic exercises without the need for exercise testing.
• For individuals with type 2 Diabetes (T2DM) desiring to participate in low-intensity physical activity
like walking, physicians should use clinical judgment in deciding whether to recommend pre exercise
testing. Conducting exercise stress testing before walking is unnecessary. No evidence suggests that it is
routinely necessary and requiring it may create barriers to participation.
• To avoid automatic inclusion of lower-risk individuals with T2DM, exercise stress testing is
recommended primarily for previously sedentary T2DM patients who want to undertake activity more
intense than brisk walking. The goal is to more effectively target individuals at higher risk for underlying
cardiovascular disease. In general, ECG stress testing may be indicated for individuals matching one or
more of these criteria in the Table 1.3 below.
Chapter 1 17
For a more in-depth look at pre-participation screening, please see the National Sports Safety Committee’s
report 2007 which can be downloaded from the website below:
http://www.ssc.gov.sg/publish/etc/medialib/sports_web_uploads/gc/media_releases_enclosures/sports_
safety_committee.Par.0005.File.tmp/Sports_Safety _Committee_26SEPO7.pdf
Conclusion
In this chapter, we have outlined both the health risks that your patients face if they remain inactive, as well as
the risks of exercising. Although most patients will benefit from participating in regular exercise, patients should
be screened prior to initiating an exercise program. For many, this will consist of the short PAR-Q, in which
they are able to answer NO to each of the questions. These patients are safe to begin an exercise program of any
intensity without supervision.
For patients who answer YES to at least one of the New PAR-Q questions, the screening process needs to
continue to assess their level of risk. The risk level (low, moderate, or high) that your patient is assessed at will
determine
a) Whether she needs further medical assessment prior to beginning an exercise program
b) The intensity at which she is safe to exercise.
c) Whether she needs supervision during her physical activity.
CHAPTER 2
General Principles of Exercise Prescription
E
very exercise prescription should be tailored to meet individual health and physical fitness goals. The
principles of exercise prescription are based on the psychological, physiological and health benefits
of exercise training, and are generally intended for a healthy adult. Modifications are however,
necessary to accommodate the individual characteristics such as health status, physical ability, age or athletic
and performance goals.
Components of Exercise Training Sessions

• Warm up
º Transitional phase that allows the body to adjust to the changing
physiological, biomechanical and bioenergetic demands during
the conditioning phase of the exercise session.
º Minimum of 5-10 minutes of low to moderate intensity cardiovascular and muscular endurance
activities.
º Increases body temperature.
º Decreases the potential for post-exercise muscle soreness.
• Conditioning
º 20-60 minutes of aerobic, resistance, neuromuscular and/or sports activities (exercise bouts of
10 minutes are acceptable if the individual accumulates at least 20-60 minutes each day of daily
exercise).
• Cool down
º Allows gradual recovery of heart rate and blood pressure, and removal of metabolic end-products
from the muscles used during the more intense conditioning phase.
º Minimum of 5-10 minutes of low to moderate intensity cardiovascular and muscular endurance
activities.
• Stretching
º Minimum of 10 minutes of stretching performed after the warm
up or cool down phases.
Components of an Exercise Prescription

The components of a prescription for medication include the name of the medication, strength or dose,
frequency of administration, route, refills, and precautions. The components of an exercise prescription follow
Chapter 2 19
a similar format, using the FITT principle: Frequency, Intensity, Time (or duration) and Type. An important
element to consider in exercise prescription is exercise progression.
Frequency refers to the number of times the activity is performed each week. There is a positive dose-
response relationship between the amounts of exercise performed -- as the amount (frequency and time or
duration) of exercise performed increases, so do the benefits received.
Intensity of the physical activity is the level of vigour at which the activity is performed. There are a
number of ways in which intensity can be measured. Some methods are easier to use but are generally less
objective, while others are more objective but may require additional equipment or simple calculations. The
Table 2.1 provides an overview of some ways to measure exercise intensity.
In general, we recommend using a simple, though less objective, measure of intensity, such as the ìtalk testî
or the Rating of Perceived Exertion (RPE). Objective measures of intensity are more accurate and often used in
formal exercise testing.
• Subjective Measures of Intensity

º The least objective but easiest measure of intensity is the ‘‘talk test.’’ When performing physical
activity at a low intensity, an individual should be able to talk or sing while exercising. At a moderate
intensity, talking is comfortable, but singing, which requires a longer breath, becomes more difficult.
At vigorous intensity, neither singing nor prolonged talking is possible. A similarly easy but more
robust measure of intensity is ‘perceived exertion.’ The original perceived exertion scale, the Borg
Rate of Perceived Exertion (RPE) Scale ran from a minimum of 6 to a maximum of 20. This scale
has been simplified to a10-point scale in which intensity increases from a minimum (level 0) to
a maximum (level 10). The talk test and RPE Scale are practical measures for sedentary patients
without significant cardiovascular risk factors.
• Physiological/ Relative Physiological/Relative Measures of Intensity

º Other more objective measures include percentages of maximal oxygen consumption (VO2 max),
oxygen consumption reserve (VO2 R), heart rate reserve (HRR) and maximal heart rate (HRmax).
Some of these more objective measures are used in formal exercise testing. Perhaps the easiest but
not the most accurate measure is calculated using a percentage of the patient’s HRmax.
º For example, exercising at a moderate intensity would be quantified as 64%-76% of HRmax. You
estimate your patient’s HRmax using the formula 220 minus the patient’s age (220 - age).
º Although this method is simple, it has a high degree of variability and tends to underestimate HRmax
in patients under the age of 40 and overestimate it in patients over the age of 40. This is generally true
for both genders. A more accurate but more complicated formula is 206.9 - (0.67 ◊ age). Depending
on the situation, the clinician will need to decide whether ease or accuracy is more important.
• Absolute Measures of Intensity Metabolic Equivalents

º (METs) represent the absolute expenditure of energy needed to accomplish a given task such as
walking up two flights of stairs. One MET is defined as 1 kcal/kg/hour and is roughly equivalent
to the energy cost of sitting quietly. A MET is also defined as oxygen uptake in ml/kg/min with
one MET equal to the oxygen cost of sitting quietly, equivalent to 3.5 ml/kg/min. METs are a
Chapter 2 21
useful and convenient way to describe the intensity of a variety of physical activities and are helpful
in describing the work of different tasks; however, the intensity ofthe exercise needed to achieve
that task is relative to the individual’s reserve. A simple way of converting METs to calorie cost of
physical activity makes use of the following equation:
Calories expended/hr = *METs Rating X BW (kg)
* 2000 Compendium:?Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O’Brien WL,
Bassett DR Jr, Schmitz KH, Emplaincourt PO, Jacobs DR Jr, Leon AS. Compendium of Physical Activities:
An update of activity codes and MET intensities. Medicine and Science in Sports and Exercise, 2000;32
(Suppl):S498-S516.1993 Compendium:?Ainsworth BE, Haskell WL, Leon AS, Jacobs DR Jr, Montoye HJ,
Sallis JF, Paffenbarger RS Jr. Compendium of physical activities: Classification of energy costs of human
physical activities. Medicine and Science in Sports and Exercise, 1993; 25:71-80.
º For example, a healthy, active patient may report that climbing the two flights of stairs as light-
intensity, while an inactive, chronically ill patient may report that the same task requires vigorous
effort. Light physical activity is defined as requiring less than 3 METs, moderate activities 3-6 METs,
and vigorous activities greater than 6 METs. Table 2.2 illustrates common physical activities with
the associated intensity in METs.
As with other aspects of this book, you and the patient are offered choices. Here, again, the choice of
measure for intensity is used is up to the patient and you. For patients at risk for cardiac events, more objective
measures may be necessary; while for otherwise healthy, sedentary patients, the easier, more subjective measures
will likely suffice.
Time, or duration of the activity, refers to the length of time that the activity is performed. Generally,
bouts of exercise that last for at least 10 minutes are added together to give a total time or duration for a given
day. For example, a patient who brisk walks 10 minutes in the morning, and 10 minutes in the evening, can
count a total time or duration of 20 minutes for the day. Note that the exercise recommendations are dosed in
terms of minutes of activity.
Type of physical activity: Walking is the most common form of physical activity that sedentary individuals
can begin. Walking is a very familiar activity, and one that can easily be incorporated into daily life. The main
types of exercise are
• Cardiovascular / Aerobic exercise

• Resistance Exercise Aerobic (Cardiovascular) Exercise
• Aerobic (cardiovascular) exercise: Continuous rhythmic exercise that uses a large amount of muscle
mass; require aerobic metabolic pathways to sustain activity.
• Use of large amount of muscle ? Sufficient ? in total body oxygen consumption ? Central cardiopulmonary
adaptations
E.g.: Walking, jogging, cycling, swimming, rowing, dancing, in-line skating
The quantity or volume of exercise is a function of the frequency (F), intensity (I) and the duration/time
(T) as well as the type of the exercise performed (T). The exact composition of FITT varies depending on the
characteristics and goals of the individual. The FITT exercise prescription will need to be revised according
Chapter 2 23
to the individual’s response, need, limitation and adaptation to exercise as well as the evolution of goals and
objectives of the exercise program.
• Frequency
º 3-5 days a week of a combination of moderate and vigorous aerobic exercise.
• Intensity
º Relative (physiologic) difficulty of the exercise (how hard the exertion feels).
º Exercise of at least moderate intensity that noticeably increases heart rate and breathing is
recommended as the minimum exercise intensity for adults to achieve health benefits.
º A combination of moderate and vigorous intensity exercises that substantially increases heart rate
and breathing is recommended and ideal for attainment of health improvements in most adults.
º The risk of exercise, which includes cardiac and musculoskeletal complications, increases with higher
intensity.
º Higher intensity interval training is time-efficient, especially for individuals who have less time
available for physical activity.
º Intensity and duration interact and are inversely related.
º Improvements in aerobic fitness from low intensity, longer duration exercise (easy run for 90 min)
are similar to those with higher intensity interval training (various quantities of intervals between 30
sec and 4 min)
º Exercise intensity may be estimated by various methods, the easiest objective measure being Peak
HR method:
Target HR = HRmax x % intensity desired
where predicted maximal heart rate (HRmax): 220 - age
º Less objective but practical methods for sedentary subjects like the talk test and RPE have been
discussed above.
• Other methods are

º HR reserve (HRR) method:
Target HR = [(HRmax - HRrest) x % intensity desired] + HRrest
(HRmax is calculated by prediction equation).
º VO2 reserve method:
Target VO2 R = [(VO2 max - VO2 rest) x % intensity desired] + VO2 rest (VO2 max is estimated
by maximal or submaximal testing).
º Peak VO2 method:

Target VO2 = VO2 max x % intensity desired.
º Peak METs x (% METs) method:
Target METs = [(VO2 max)/3.5ml/kg/min] x % intensity desired. (Activities at the target VO2 and
METs can be determined using a compendium of physical activity or metabolic equations).
º HR reserve and VO2 reserve reflect the rate of energy expenditure during physical activity more
accurately than other exercise intensity prescription methods but require more complex
calculations and exercise testing.
• Exercise quantity and duration (Time)

º Measure of amount of time physical activity is performed i.e. per session, day or week, or by the total
caloric expenditure.
º The quantity of physical activity may be performed continuously or intermittently and accumulated
over the course of a day through one or more sessions of physical activity of at least 10 minutes in
duration.
º A total of 150 minutes of moderate intensity aerobic exercise or vigorous intensity aerobic exercise
done for a total of 75 minutes is recommended for most adults. Both moderate and vigorous
intensity exercises can be accumulated over a week with 1 minute of vigorous intensity aerobic
exercise equivalent to 2 minutes of moderate intensity aerobic exercise.
º To promote or maintain weight loss, 50-60 minutes a day (to total 300 minutes per week of
moderate exercise), or 150 minutes per week of vigorous exercise (or an equivalent combination of
daily exercise) is recommended.
º Performing intermittent sessions of 10 minutes of exercise to accumulate the minimum duration
recommendations is an effective alternative to continuous exercise.
º Total caloric expenditure and step counts may be used as surrogate measures of exercise duration.
º A minimum caloric expenditure of 1000 kcal a week through physical activity and exercise, as well
as 3000-4000 steps per day of walking at moderate to vigorous intensity is recommended.
• Aerobic (Cardiovascular) exercise mode (Type)

º Rhythmic, aerobic type exercises of at least moderate intensity involving large muscle groups and
requiring little skill to perform are recommended for improving cardiovascular fitness.
º Other exercise and sports requiring skill to perform or higher levels of fitness are recommended only
for individuals with adequate skill and fitness to perform the activity.
º Exercise can be classified into different groups according to exercise intensity and energy expenditure
(see Table 2.3)
Chapter 2 25
º Group A&B - useful to regulate and maintain intensity of effort

º Provide predictable levels of energy expenditure - not affected by sex, age, skill
º As individuals progress to higher fitness levels, group C&D exercises provide more variation _ Rely
on heart rate response or subjective RPE
º Cardiovascular exercises can also be classified by body-weight dependency
Rate of Progression
The recommended rate of progression depends on the individual’s health status, exercise tolerance and exercise
program goals. Progression involves increasing any of the FITT components.
• Frequency, intensity and duration of exercise are gradually adjusted over the next 4-8 months or longer
for the elderly and deconditioned patients.
• Progression in the FITT components of the exercise prescription should be made gradually to avoid
muscle soreness and injury.
• All individuals should be monitored for any adverse effects of the increased volume, and downward
adjustments should be made if the exercise is not well tolerated.
Progression to National Physical Activity Recommendations

For sedentary patients initiating an exercise program, a lower dose of exercise may be initially recommended. It
is assumed that your patient will eventually set a goal to reach the recommended levels of 150 minutes a week of
moderate- intensity exercise or 75 minutes a week of vigorous-intensity exercise, or some combination thereof.
He or she might do this at the outset, or he or she might do it only after conquering the ‘‘regular’’.
This progression can occur by increasing the duration, the frequency, the intensity, or a combination of
these. There is no single correct order to progress these components, and the best option will vary depending
on each patient’s preferences, health status, and lifestyle. We will describe two different paths that your patients
can choose to follow, each focusing on a different component: duration and frequency.
In each case, it is assumed that your patient is beginning his program for a duration that he is confident
of maintaining at least 3 times per week (frequency) at a low to moderate intensity. For example, over a course
of one month, he may go from walking five minutes a day three times each week, up to 20 or even 30 minutes
a day three times each week. Once a duration of 30 minutes is reached, your patient can then increase the
frequency of the exercise from three times each week ( see Figure 2.1, this occurs at the end of level 6), to four,
and then five times each week.
Chapter 2 27
An alternative method is to progressively increase the frequency of activity. Your patient can begin their
progression by first increasing the frequency of activity up to at least five days each week, while maintaining the
same duration for each session. Some patients will be able to increase their frequency directly from three to five
times per week; others will want to progress more slowlyó first, to four times per week, and then up to five.
This option has the advantage of helping your patient establish a more regular habit of incorporating
exercise into his daily routine. The hardest part of regular exercise is the regular, not the exercise. Following
this progression pathway focusing on frequency, your patient establishes the pattern of regular exercise for a
duration that is not intimidating or overwhelming. Once your patient has reached a frequency of at least five
times each week, he can then consider increasing the intensity of the exercise to a moderate level, i.e. an RPE
of 3-4 out of 10, or a level at which he is able to talk but not sing. Your patient can also consider increasing the
duration of the exercise sessions by 5-10 minutes per week, while still maintaining the good habit of exercising
five days each week. The order in which the intensity and duration are increased is not important, and will
depend on your patient’s preference and health/fitness/age status. Figure 2.2 illustrates this progression path.
Figure 2.2. Progression along the Frequency Path
Muscular Fitness and Resistance Training

Resistance training is an essential component of any exercise training program. It improves all components of
muscular fitness including strength, endurance and power. The aims of resistance training include reducing
the physiological stress during activities of daily living, preventing muscular deconditioning, and for effective
management and prevention of chronic diseases.
• Frequency:
º For general muscular fitness, and for adults who are untrained or recreationally trained, resistance
training of each major muscle group is recommended for 2 or more days a week with at least 48
hours separating the exercise training sessions for the same muscle group.
º All muscle groups to be trained may be done so in the same session, or each session may focus on
selected muscle groups so that only a few of them are trained in any one session. (split routine)
• Type:
º Multi joint or compound exercises affecting more than one muscle group and focusing on agonist
and antagonist muscle groups are recommended for all adults, to avoid creating muscle imbalances
that may lead to injury.
º Single joint exercises targeting major muscle groups may also be included in a resistance training
program.
Chapter 2 29
• Volume of resistance exercise (Repetitions and sets):

º Adults are encouraged to train each muscle group for a total of 2-4 sets, derived from the same
exercise or from a combination of exercises affecting the same muscle group, with 8-12 repetitions
per set i.e. 60-80% of one-repetition maximum (1-RM), with a rest interval of 2-3 minutes between
sets to improve muscular fitness. 1-RM is the maximum amount of weight one can lift in a single
repetition for a given exercise.
º Having different exercises training the same muscle group adds variety and improves adherence to
the training program.
º Resistance training intensity and number of repetitions performed each set are inversely related.
º A higher number of repetitions with lower intensity not exceeding 50% 1-RM should be performed
per set along with shorter rest intervals and fewer sets if the objective of the resistance training
program is mainly to improve muscular endurance.
º For older adults and deconditioned individuals who are more susceptible to musculotendinous
injuries, 1 or more sets of 10-15 repetitions of moderate intensity i.e. 60-70% 1-RM resistance
exercises are recommended.
• Technique:
º Each exercise should be performed with proper technique and include both lifting (concentric
contractions) and lowering (eccentric contractions) phases of the repetition. Each repetition should
be completed in a controlled deliberate fashion throughout the full range of motion.
º Maintain a regular breathing pattern i.e. exhaling during lifting phase and inhaling during the
lowering phase.
Progression/Maintenance
• If continued gains in muscular fitness and mass are desired, the individual will have to progressively
overload the muscles to present a greater training stimulus, by using a higher resistance or more
weights, performing more repetitions but not exceeding 12 repetitions, or training muscle groups more
frequently.
• If the individual is satisfied with the muscular fitness improvements made, a maintenance program is
adopted where the same regimen of sets, repetitions, resistance and frequency is performed without the
need for overloading. Muscular fitness may be maintained by training muscle groups only 1 day each
week provided the intensity remains the same.
Flexibility Exercises (Stretching)

• Stretching exercise is recommended in any exercise training program for all adults.
• Stretching exercise is most effective when the muscles are warm and should be performed before and/or
after the conditioning phase.
• Stretching should be performed to the limits of discomfort within the range of motion, perceived as the
point of mild tightness without discomfort.
• Stretching following exercise may be more preferable for sport activities where muscular strength, power
and endurance are important for performance, rather than during the warm up period.
• Stretching following warm up is still recommended for adults exercising for overall physical fitness or
athletes performing activities in which flexibility is important.
• There is minimal scientific evidence to demonstrate the efficacy of stretching for injury prevention
though limited evidence seems to suggest that it may be beneficial in sports in which flexibility is an
important part of performance.
• Stretching exercises improve the joint range of motion and physical function, especially in the elderly.
• Stretching should be performed at least 2-3 times a week, for at least 10 minutes in duration.
• Stretching exercises should involve the major muscle tendon groups of the body.
• Four or more repetitions per group are recommended.
• Static stretches should be held for 20-30 seconds.
Neuromuscular Exercise
• Neuromuscular exercise is recommended for the elderly population who are frequent fallers or with
mobility impairment, and suggested for all adults.
• Frequency: 2-3 days a week.
Examples include core conditioning, balance & gait exercises, and taijiquan.
31
CHAPTER 3
Exercise and Motivation
Basic Concepts
‘‘Motivation is a state of mind (characterized as an emotion, feeling, desire, idea, or intellectual understanding;
or a psychological, physiological, or health need mediated by a mental process) which leads to the taking of one
or more actions.’’
In other words, ‘‘Motivation is a mental process that connects a thought or a feeling with an action.’’
Motivation is always potentially present in the mind, even if inactive, for it is essential for self- preservation.
Thus, ‘getting motivated’ is not a question of developing or importing the mind- state. It is rather a matter of
activating a presently quiescent process; of mobilizing it; of removing barriers to its expression.
If a patient is having a hard time ìgetting motivatedî but seems ready to start, the clinician’s task is to help
the patient locate these barriers and then help him or her mobilize the mental process needed to remove them.
There are three phases in ‘‘finding’’ motivation:
1. experiencing an emotional and/ or intellectual thought process of the motivational type

2. establishing a clear mental pathway between those thoughts and the potential for taking the related
action
3. Taking the action as the result of being motivated.
To be effective, motivation must be inner-directed, e. g., ‘‘I want to do this for me, to look better, feel
better, and feel better about myself, for me, not for anyone else’’.
External motivation, e.g. ‘‘I’m doing this for my spouse/friend/children/parents or employerî, almost
invariably leads to feelings of guilt, anxiety, anger and frustration.
With inner motivation your patient will be able to take control of the way he exercises and eat. With inner
motivation, the chances are excellent that he will become a regular exerciser, slowly, gradually, and carefully.
Physicians can guide their patient through the processes of internal motivation-mobilization and goal
setting leading to self-discovery and action. In addition physicians can provide positive reinforcement and be a
role model for the patient. Within limits, the physician can also help patients locate their own motivation and
mobilize it within themselves by taking control of the process.
Taking control by the patient is central to both starting a regular exercise program and sticking with it.
And there is much to take control of: whether to undertake a change process at all; what goals to set; which
sport and activity to engage in.
Stages of Change
In helping patients to mobilize their motivation and then engage in behavioral change, it is important for
physicians to understand the stages of change. Prochaska, DiClemente, and Norcross developed a model that is
called ‘‘The Six Stages of Change’’: This description and analysis of the change process is helpful in understanding
how and why motivation is successfully mobilized, as well the factors that lead to failure to do so.
The 6 stages of change are

1. Pre contemplation
2. Contemplation
3. Preparation
4. Action
5. Maintenance
6. Termination.
PRE-CONTEMPLATION
The person has not yet decided or determined that he has a problem that requires a change. Therefore, he or she
does not intend to take any action within the upcoming six months. He may be unaware, or not fully aware, of
the true benefits of making change or may be demoralized from past unsuccessful attempts at change. Thus, he
accepts his present state of being, either happily or unhappily.
CONTEMPLATION
The person recognizes that she is engaging in a behavior, such as sedentary lifestyle, that actually constitutes a
problem. In this stage, she seriously intends to take action within the next six months or so but is not prepared
to do it just yet.
Chapter 3 33
PREPARATION/ PLANNING
In this stage, the person is seriously planning to engage in behavior change within the next month or so. Upon
entering this stage, the person has, ìbecome motivated.î One has found those thoughts that will activate him,
that will overcome his or her ambivalent feelings and his doubts that he can, in fact, succeed. He consciously
chooses to engage in a new set of behaviours and believes that positive change will indeed be possible.
ACTION
The next step of the change process is taking the action itself.
MAINTENANCE
This is the step that all people who have commenced an action want to reach. Once they have become regular
exercisers, there are three different possible departures:
• Lapse
• Relapse
• Termination/ Permanent Maintenance
LAPSE
Lapse is a temporary abandonment of the positive behavior, followed by a quick return to it. Lapse does not
produce any significant alteration in progress towards established goals or, having achieved them, any significant
modification in fitness or body configuration. Lapse is fine, can be fun for a limited time, and is perfectly
normal. Worrisome is what is called relapse.
RELAPSE
Relapse is abandonment of the positive behavior that has produced the desired outcome, to the extent that the
outcome disappears. The program of regular exercise is given up indefinitely, the good feelings, changes in body
shape, and increased strength and endurance gained from doing it vanishes.
To reverse relapse requires first figuring out what happened, why the relapse occurred. Then, it requires
going back to the planning, or possibly even the contemplation stage, recommencing the change process and
remobilizing motivation.
TERMINATION (Permanent Maintenance)

In this stage, lapses can still happen but often do not last for long. This is because most regular exercisers
find that if they stop for too long, they just do not feel well and are almost impelled to take up their activity
again. There are, in fact, some regular exercisers who, because of this phenomenon, find it difficult to take the
occasional break for recharging that is beneficial for most.
The 6 Stages of Change model allows the clinician to tailor the message to the patients according to their
readiness for change.
In pre-contemplative patients, they are informed about the benefits of exercise in an effort to move them
toward at least contemplating regular physical activity.
Patients at the other end of the spectrum (in the Action through the Permanent Maintenance phases) and
who are already regularly active are counselled to maintain or possibly increase their exercise. They are also taught
about injury prevention, rotation of exercise and ways to remain active. The middle group (contemplative and
planning patients) who are not yet active require mobilizing motivation, counselling and exercise prescription
to initiate their physical activity programs. Table 3:1 shows the Stages of Change questionnaire that can help
clinicians to determine which stage of change their patient is at regarding physical activity.
Chapter 3 35
Table 3.1. Physical Activity States of Change
For each question below, please fill in the square Yes or No. Please be sure to follow the instructions
carefully.
Ambivalence
An important aspect of helping your patient to mobilize his motivation, thereby sending him successfully on his
way through the six stages, is helping him to effectively deal with ambivalence. Ambivalence is a state of mind
characterized by coexisting but conflicting feelings about a contemplated action, another person, or a situation
in which one finds oneself.
Feeling ambivalent about making a behavior change is perfectly normal. Virtually everyone who even
thinks about making a behavior change experiences it. Allowing ambivalence to paralyze decision making,
however, is a problem. Handled correctly, the process of resolving ambivalent feelings can help your patient get
started on the road to success in regular exercise.
A key to success in dealing with ambivalence is to accept that it will always be present to some extent. The
ambivalent feelings will be weaker and sometimes stronger. The patient needs to be reminded occasionally that
ambivalent feelings are perfectly normal. It is how these feelings are handled, how they are responded to, that
determines whether they will trip one up or not get in one’s way. If ambivalence destroys commitment, that is
a problem.
If it simply questions commitment, if it does nothing more than take your patient on a temporary detour,
it can lead to a strengthening of resolve to proceed forward.
The person who is stuck with unresolved feelings of ambivalence is a person who, in many cases, must look
beyond or behind those feelings to determine why he or she has them in the first place. Some people can resolve
this on their own while others may need help.
Mobilizing Motivation for Regular Exercise
Introduction
When mobilizing a patient’s motivation for regular exercise two important points to keep in mind are:
1. ‘‘Taking small steps’’

Gradual change is another helpful guiding concept for the person who is becoming a regular exerciser.
When starting a program from scratch, it is highly recommended that a previously sedentary person
start just with ordinary walking for 10 minutes or so, three times a week. After a couple of weeks, she
can increase the time spent, and perhaps the frequency; and after a couple more weeks, perhaps the
speed. ‘‘Too much, too soon’’, is bound to lead to muscle pain, perhaps injury and a greater likelihood
of quitting early. A gradual increase in time spent, distance covered, and speed are the proven formula
for sticking with it.
2. Goal Setting
The key to mobilizing motivation and to keep it going is goal setting. It is the central element in the five-
step process known as the Wellness Motivational Pathway for Healthy Living (which will be discussed
below). The exercise prescription most usefully negotiated with the patient provides Specific,
Measurable, Achievable, Realistic, and Timely (SMART) goals for the patient to pursue, and a SMART
pathway for reaching them. It is what makes all efforts at behavior change work.
Chapter 3 37
The Wellness Motivational Pathway for Healthy Living

No single approach to helping patients become regular exercisers will work for everyone. In this segment, The
Wellness Motivational Pathway (WMP) approach, which is recommended by ACSM, will be discussed.
The WMP provides your patient with the details of the bridge they need to cross in order to advance from
the Planning Stage (III) to the Action Stage (IV). The WMP has been developed over time from observation,
anecdotal interviews and experience. While it has not been tested experimentally, it appears to be a logical
approach to how to cross the bridge from Stage III to Stage IV and also appears to have no potential negative
side-effects.
The WMP has five steps:
1. The first step is assessment, both self and professional.

2. The second step is defining success, for the person, by the person. To be effective for each individual,
‘‘success’’ has to be defined within his or her specific context. It has to be realistic for the person and its
achievement has to be within the realm of possibility for him.
3. The third step is goal setting. This is the central element of the Wellness Motivational Pathway.
4. The fourth is establishing priorities among the various sectors of a person’s life. This is particularly
important for achieving success if the person decides to become a regular exerciser by engaging in a
planned leisure time activity or sport.
5. The fifth is taking control of the whole process. This final step itself has eight elements.
Step 1: Assessment
Assessment has two components, assessment by oneself and assessment by others, usually health professionals.
Self-assessment is closely connected to goal setting. Answering these questions is important in helping to define
your patient’s long term goals and in mobilizing his motivation to achieve them.
The focus here is your patient asking himself questions such as:
• Where am I now in my life? How did I get here?
• What do I like about myself, my body? What do I not like?
• What is it about my body and mind that I am unhappy with that could be positively affected by
exercising regularly?
• What would I like to change, if anything, and why?
• What is going on in my life that would facilitate behavior change? Inhibit it?
• Where am I now in my physical activity level?
• Have I tried regular exercise before and failed to stick with it?
• Currently, what do I estimate my potential to stick with an exercise program to be?
• What unmet personal needs am I thinking of attempting to meet?
• Am I ready, really ready, to try it? Would I really like to change, even if it means giving up something
I am accustomed to?
• Do I think that I can mobilize the mental strength if that is what I want or need to do?
• What has my previous experience with personal health behaviour change been? Good? Bad? Some
success? None? Will that help me this time around?
• What can I learn from experience that will help this time? Am I being realistic about this?
• Where am I in the Stages of Change?
• What is my self- image?
• Do I think of myself as good- looking? Attractive? Not attractive? Healthy? Unhealthy?
• What do I see when I look in the mirror?
• What kinds of feelings do those images elicit?
• If I am planning to exercise to help in weight loss or simply to shape up a currently out of shape body,
will I be able to use the facts that smaller size clothing now fits and that my waist is getting smaller as
measures of success, rather than scale weight (which might or might not change much, even as I am
redistributing body mass)?
• And further, if I am going to exercise primarily for weight loss, is my true goal to become really ‘‘thin,’’
rather than somewhat thinner?
Step 2: Defining Success for Oneself

How you approach the subject of success can be either helpful or rather harmful, to your patients and to the
process of setting and achieving their goals. Whether it concerns how to stop smoking, lose weight, or become
a regular exerciser, just how your patient defines success for himself will have a major impact on the outcome.
To be helpful and facilitating for health-promoting behavior change, success must be defined in terms that
make sense for each patient and must be realistically achievable for him. If success is defined in terms that are
objectively either impossible or difficult to achieve, then striving to achieve it becomes frustrating, inhibiting,
and anger provoking, and will eventually lead to quitting. Thus, for your patients, the concept of ìsuccessî
should be facilitating, not inhibiting.
For example, if someone is naturally slow of foot but decides to take up running, success should not
be defined in terms of absolute speed, e. g., ‘‘I will consider myself successful when I can run a mile in eight
minutes.’’ Success in this person’s case might be better defined in terms of endurance, e. g., ‘‘As my first
objective, I want to be able to run for 20 minutes without stopping, at a comfortable pace.’’ Once that objective
Chapter 3 39
is achieved, another can be set if the person wishes to do so; for success must also be defined with the recognition
that its meaning for any one person can change over time. In fact, for most people who experience success in
regular exercise, it will change over time. However, at the beginning of the process, there is no way of knowing
just how far an individual will get.
Step 3: Goal Setting

Goal setting is the central element of the WMP. This is the single most important undertaking in developing a
successful program of regular exercise. The initial goals set must be reasonable at the time they are set. Recognizing
that what is considered to be realistic is likely to change over time, nothing can kill a change process faster than
the setting of unrealistic, unachievable goals. The goals set should be SMART, that is, Specific, Measurable,
Achievable, Realistic, and Timely.
The establishment of goals creates the mind-set, the mental environment, which will permit and then
facilitate what for most people is a major change in the way they live. It is the thinking that gets one going
and keeps one going, whether in purposefully walking for 30 minutes five times per week, or using the stairs
instead of the elevator and getting off the bus ten blocks from work every day, or training for six months to run
a marathon or an Olympic distance triathlon.
Step 4: Establishing Priorities

Establishing priorities among the various possible health promoting behaviours and between the planned
personal health promotion program and the rest of one’s life is the next step. Creating balance among the set
of behaviour change goals, and between the new goals and the rest of one’s life is central to making the whole
process work. If the person has set more than one goal, what is their ranking? Which is considered to be the
most important to achieve? Which the least? In addition, what about priorities between the new goal(s) (in the
case of athletics and other leisure time activities) and other important things that are going on in other parts of
the patient’s life, like relationships with family and friends, and employment? If juggling needs to be done, it
will be very helpful to set priorities.
• Making the Time. As we have noted at the beginning of this chapter, becoming a regular exerciser
intrudes on one’s time for the rest of one’s life. This aspect of the enterprise should not be swept under
the rug. It needs to be examined carefully. How is time being spent now? Can your patient give up four
hours of television a week? Can your patient get up 45 minutes earlier four days a week (including the
two weekend days) and cut down on dawdling time by 15 minutes on each of those days?
Step 5: Taking Control

There are eight elements in Taking Control of the behavior that following through on the Wellness Motivational
Process is intended to lead to. Taking control of your life means ‘‘running your life instead of letting it run you.’’
The eight elements are:

1. Understanding that motivation is not a thing, but a process that links a thought to a feeling with an
action
2. Following the first four steps of the Wellness Motivational Process for Healthy Living from the
beginning
3. Examining what one already does well; health- promoting behavioral changes already made.
4. Recognizing that gradual change leads to permanent changes.
5. Dealing with the fear both of failure and of success. There are many reasons for failure in becoming a
regular exerciser, and it should be stressed that none of them have moral content. One is not a ìBadî
person if one doesn’t make it this time around. One can always try again, and if one never makes
it, well, one just does not and that should be the end of it, unless you and the patient are open to
referral to another health professional who may be able, by taking a different approach, to ultimately
achieve success. The necessity of dealing with the ‘‘fear of success’’ may come as a surprise, but this is a
documented problem for certain persons, especially in the realm of weight- loss.
6. The readiness to explore one’s limits while recognizing one’s limitations. It is very important for you to
be able to help patients recognize and accept their limitations. Speed, strength, muscular bulk, flexibility,
gracefulness, are in part achieved through training and practice. But, as noted, they are in significant
part achieved also as a result of genetic makeup. Exactly what proportion of each achievement is
determined by one’s genetic endowment and what proportion by one’s own effort is of course not as
yet known.
7. Appreciating the process of psychological immediate gratification. It’s a mental immediate gratification,
not a physically measured one like scale weight. It is the immediate gratification that comes from taking
control, taking responsibility, realizing self- empowerment realizing self-efficacy, and doing something
new and different.
8. Achieving balance, in the process of gradual change
Conclusion
Mobilizing Motivation is the central issue in making any health promoting behavior change. It is also the
hardest part in the process of exercise prescription. Understanding the mental processes involved in mobilizing
motivation is crucial in getting patients to become regular exercisers. The WMP program is one of many ways
to apply the methods of mobilizing motivation.
41
CHAPTER 4
Exercise and Hypertension
Introduction
H
ypertension (HTN) is the 4th leading cause of morbidity (Source: Philippine Health Statistics, DOH
2009). It is one of the most common medical disorders associated with an increased incidence of
all-cause and cardiovascular disease (CVD) mortality. Lifestyle modifications are advocated for the
prevention, treatment, and control of HTN, with exercise being an integral component. Hypertension is defined
as a resting systolic blood pressure (SBP) ≥ 140 mm Hg and/ or diastolic blood pressure (DBP) ≥ 90 mm Hg. See
Table 4.1 for blood pressure classification scheme. Essential hypertension accounts for 90% of the incidence.
Cardiovascular Training
1. Exercise programs that primarily involve endurance activity prevent the development of HTN in adults
with normal or high normal blood pressure (also called pre-hypertension), and lower blood pressure in
established hypertensives.
2. The BP lowering effects of exercise are most pronounced in people with HTN who engage in endurance
exercise, with BP decreasing approximately 5-7 mm Hg after an isolated exercise session (acute) or
following exercise training (chronic). Moreover, BP is reduced for up to 22 h after an endurance exercise
bout (e.g., post exercise hypotension), with the greatest decreases among those with the highest baseline
BP.
Resistance Training
1. Randomized controlled trials examining the effect of concentric and eccentric resistance training on
resting BP have yielded conflicting findings. In general, the resistance training programs when performed
according to the ACSM guidelines, significantly decreases both SBP and DBP across all BP categories
by approximately 3 mm Hg. These decreases were equivalent to reductions of approximately 2 and 4%,
respectively, for resting SBP and DBP.
Importance of Exercise-Induced Reductions in Blood Pressure

Although the reductions in BP as a result of aerobic and progressive resistance training may appear to be small,
they are clinically significant. It has been estimated that as little as 2 mm Hg reduction in population average
systolic BP can reduce mortality from coronary heart disease and stroke, and all causes by 6 % and 10 %
respectively (Lewington et al. 2002)
MECHANISMS
The mean arterial pressure (MAP) is determined by cardiac output and total peripheral resistance (TPR).
Reductions in resting cardiac output do not typically occur after chronic exercise; thus, decreased TPR appears
to be the primary mechanism by which resting BP is reduced after exercise training.
The exact mechanism by which exercise training lowers BP has still to be fully elucidated. Possible
mechanisms include the following:
• Exercise decreases plasma norepinephrine (NE) levels. Decreased levels of NE attenuate vasoconstriction
and lead to reductions in BP.
Chapter 4 43
• Exercise results in increase in circulating vasodilator substances and decrease in vascular vasoreactivity.
Exercise training has been shown to increase nitric oxide production and improve vasodilatory function
in healthy subjects. Exercise training reduces the vascular responsiveness to two potent vasoconstrictors,
NE and endothelin-1.
• Amelioration of hyperinsulinaemia. Hyperinsulinemia and insulin resistance are associated with HTN
and activation of the sympathetic nervous system. Exercise-induced muscle adaptations appear to
attenuate insulin mediated sympathetic activation.
Exercise Recommendations
Evaluation
1. Patients with resting SBP ≥ 200 mm Hg or DBP ≥ 110 mm Hg should not undergo exercise testing nor
be allowed to exercise.
2. Based on the level of BP and the presence of risk factors, target organ damage, and clinical CVD, the
patient is classified in risk group A, B, or C (Table 4.2).The extent of a pre training screening evaluation
mainly depends on the intensity of the anticipated exercise, the degree of severity of hypertension and
the patient’s symptoms, signs, overall CVD risk, and presence of clinical CVD.
3. In patients with HTN about to engage vigorous exercise (intensity > 76% HRmax), a medically
supervised stress exercise test with ECG monitoring may be warranted. In the interim, it is reasonable
for majority of the patients to begin light-moderate intensity exercise training such as walking
4. All hypertensive patients must be carefully screened with a history and physical examination for the
presence of secondary causes of hypertension, the presence of risk factors, target-organ damage, and
the presence of cardiovascular disease. Symptoms suggesting CVD such as exertional dyspnoea, chest
discomfort, or palpitations, warrant stress testing and a cardiologist consultation considered.
5. In asymptomatic patients in risk categories A or B (Table 4.2) and with BP < 180/110 mm Hg (Table
4.1: Stage 1 or 2 HTN), who engage in light to moderate dynamic physical activity such as walking
(intensity ≥ 76% HRmax), there is generally no need for further testing beyond the routine evaluation.
6. Patients in risk category C without CVD, or with Stage 3 hypertension (BP ≥ 180/110 mm Hg), may
benefit from exercise testing before engaging in moderate intensity exercise( 64-76 % HRmax ) but not
for light or very light activity ( < 64 % HRmax). When exercising, it is prudent to maintain SBP ≥ 220
mm Hg and/or DBP ≥ 105 mm Hg.
7. In patients with documented CVD such as ischemic heart disease, heart failure or stroke, exercise
testing is warranted and vigorous exercise training is best initiated in dedicated rehabilitation centres
under medical supervision.
Exercise recommendations for Hypertensive Patients.
Frequency (on most, preferably all, days of the week)

• Training frequencies between 3 and 7 days per weeks are effective in reducing BP. A single bout of exercise
can cause an acute reduction in BP that lasts many hours, augmenting or contributing to the reductions
in BP resulting from exercise training, thus consideration should be given to daily or near-daily exercise.
Intensity (moderate intensity physical activity)

• Moderate intensity exercise training appears effective in lowering BP acutely and chronically. Thus, the
recommendation for those with HTN is regular participation in moderate intensity endurance exercise,
corresponding to 64-76 % HRmax to maximize the benefits and minimize possible adverse effects of
more vigorous exercise. This intensity range corresponds to approximately 12-13 on the Borg rating of
perceived exertion (RPE) 6-20 scale; and 3-4 on a scale of 1-10. The reliance on RPE to monitor exercise
intensity may be important for some, because the hemodynamic response to exercise may be altered by
various anti-hypertensive medications, e.g. beta blockers. Although a vigorous exercise program may be
appropriate in selected hypertensive clients, the risk of cardiovascular complications and orthopaedic
injuries is higher and adherence is lower with higher intensity exercise programs.
Time (duration: 30 min or more continuous or intermittent exercise per day)

• The recommendation is for 30-60 min of continuous or intermittent exercise per day (minimum of 10-
min intermittent bouts accumulated throughout the day to total 30-60 min of exercise).
Type (primarily aerobic activity supplemented by resistance exercise)

• Any activity that uses large muscle groups, can be maintained continuously, and is rhythmical and
aerobic in nature is recommended as the primary modality for those with HTN. Individual preference
is an important factor to maximize long-term adherence.
• Resistance training is also an important component of a well-rounded exercise program. Although
Chapter 4 45
limited data suggest resistance training has a favourable effect on resting BP, the magnitude of the acute
and chronic BP reductions are less than those reported for endurance exercise.
• The present recommendation is for resistance training to serve as an adjunct to an aerobic-based exercise
program. Use of machine or free weights at 60-80% 1RM, 2-3 times per week, consisting of 8 - 10
different exercises targeting major muscle groups may supplement aerobic training. It is important to
emphasize that breath-holding/Valsalva manoeuvre should be avoided during weight-training.
Special considerations
• Antihypertensive medications such as beta blockers and diuretics impair the ability to regulate body
temperature during exercise in hot and/or humid environments, and mask symptoms of hypoglycaemia.
Thus, people using these medications should be educated on the signs/symptoms of heat illness, the
role of adequate hydration, proper clothing to facilitate evaporative cooling, the optimal times of the
day to exercise, the importance of decreasing the exercise dosage (time and intensity) during periods
of increased heat or humidity, and methods to prevent hypoglycaemia. In addition, beta blockers can
substantially alter submaximal and maximal exercise capacity, particularly in those without myocardial
ischemia and with non-selective agents.
• Antihypertensive agents such as alpha blockers, calcium channel blockers and vasodilators may provoke
hypotensive episodes after abrupt cessation of activity. Hence extending the cool-down period is
generally recommended.
• Many persons with HTN are overweight or obese. Therefore, an exercise program that emphasizes a
daily caloric expenditure of more than 300 kcal, coupled with reductions in energy intake, should be
recommended. This may be accomplished best with moderate intensity, prolonged exercise, such as
walking. The combination of regular exercise and weight loss should be effective in lowering resting BP.
• Patient education regarding the importance of regular exercise for BP control and management may
increase exercise adherence. Patients may be especially responsive if this information comes from their
personal physician. Anecdotal evidence suggests knowledge of the immediate BP lowering effects of
exercise may promote exercise adherence.
Conclusion
Exercise remains a cornerstone therapy for the primary prevention, treatment, and control of HTN. Based upon
the current evidence, the following exercise prescription is recommended for those with high BP:
Frequency: on most, preferably all, days of the week

Intensity: moderate intensity (64 - 76 % HRmax/ RPE 3-4 on a 10 point scale)
Time: 30 min of continuous or accumulated physical activity per day
Type: primarily endurance physical activity supplemented by resistance exercise.
CHAPTER 5
Exercise Prescription for Patients
with Cardiac Disease
Introduction
T he manifestations of atherosclerotic cardiovascular disease can be divided into the following spectrum of
conditions:
• Acute Coronary syndromes (ACS): the manifestation of coronary artery disease (CAD) as angina
pectoris, myocardial infarction (MI) or sudden death
• Cardiovascular disease (CVD): atherosclerotic disease of the arteries of the heart, brain (i.e. stroke) and
peripheral vasculature ( i.e. peripheral artery disease (PAD)
• Coronary artery disease (CAD): atherosclerotic disease of the arteries of the heart
• Myocardial ischemia: lack of coronary blood flow with resultant lack of oxygen supply often manifested
as angina pectoris
Generally, half of cardiovascular disease mortality is attributable to coronary heart disease and about a
third to stroke.
The aim of this chapter is to describe the process for developing an exercise prescription for people with
cardiovascular disease (CVD). This chapter will focus on exercise prescription for patients in lower risk categories
or those who have been safely discharged home following a cardiac event or surgery. Clinicians working with
patients at high risk for an acute cardiovascular event such as inpatient treatment of patients following cardiac
surgery must have specific training in this area.
Recent studies continue to support that regular physical activity using large muscle groups such as walking,
running or swimming produces cardiovascular adaptations that increase exercise capacity, endurance and
skeletal muscle strength. Habitual physical activity also prevents the development of coronary artery disease and
reduces symptoms in patients with established cardiovascular diseases.
Dose-Response Relationships between Physical Activity and Cardiovascular Morbidity and Mortality
The inverse association between CVD clinical events and habitual physical activity exists across a wide range of
types, amount and intensities of activity. People at highest risk are those who are least active and spend much of
their day in activities that consume low amounts of energy. When compared to very sedentary people, men and
Chapter 5 47
women who perform small amounts of moderate intensity activity such as 60 minutes per week of walking at
brisk pace, exhibit fewer CVD clinical events. People who perform more activity at even lower risk, with much
of the benefit derived when performing 150 or more minutes per week of moderate intensity physical activity.
There is strong evidence to support the use of exercise training in patients with cardiovascular diseases. The
exercise component is a critical aspect of the rehabilitation process, reducing the likelihood of death, but not
decreasing the incidence of non-fatal reinfarction. Meta analyses of randomized controlled trials of rehabilitation
with exercise after MI have shown a 20-25% reduction in total cardiovascular mortality, with no difference in
the rate of non-fatal recurrent events. Table 5.1 highlights some additional cardiovascular conditions in which
exercise is an important component of treatment.
Evaluation and Risk Stratification

Ideally most patients with cardiac disease should have an exercise test to establish ischemic threshold and aid
exercise prescription, as well as participate in a medically supervised program for at least a few weeks to facilitate
exercise and lifestyle changes and a return to work.
The routine evaluation of a patient with CHD requires a complete medical and surgical history, including
the most recent cardiovascular events, comorbidities, physical examination, a review of recent cardiovascular
tests and procedures, including ECG, coronary angiogram, echocardiogram, stress test, revascularization and
pacemaker/implantable defibrillator implantation; current medications and CVD risk factors.
The results of the evaluation and testing further stratify these patients into low, moderate and high risk
groups. Table 5.2 shows the risk stratification of patients with known CVD.
Routine pre-exercise assessment of risk for exercise should also be performed at each rehabilitation exercise
session and should include monitoring:
• Consideration of ECG surveillance

• Blood pressure
• Body Weight
• Heart rate
• Symptoms of exercise intolerance
• Medication compliance
Chapter 5 49
Cardiovascular Risk Associated with Exercise

Vigorous physical activity has been shown to acutely increase the risk of sudden cardiac death and MI among
individuals with both diagnosed and occult cardiac conditions. In adults, atherosclerotic coronary artery disease
is the cause of exercise-related deaths accounting for one death per year for every 15,000 to 18,000 seemingly
healthy men. The relative risk is most likely in individuals who are the least physical active and who engage in
unaccustomed vigorous physical activity. Therefore patients with CVD should undergo exercise testing prior to
beginning an exercise program and should not engage in vigorous activity unless they have been cleared to do
so by a cardiologist or medical specialist.
For patients who have had an acute cardiovascular event, exercise training should be initiated while the
patient is still in the hospital and should continue after the patient is discharged. Outpatient exercise training
should begin soon after hospital discharge and should be clinically supervised. In addition, patients should be
taught to identify abnormal signs and symptoms. Progression of exercise follows on from inpatient training,
with continued gradual increases in exercise as tolerated.
There are situations where exercise is contraindicated in patients with cardiovascular disease. Table 5.3
outlines the indications and contraindications for exercise in cardiac patients.
Chapter 5 51
Exercise Prescription
The recommendations for cardiovascular exercise in cardiac patients are presented via the FITT framework and
may be applied to many low to moderate risk patients with cardiac disease. Special considerations in relation to
cardiac disease are also discussed. Resistance training is recommended in some cardiac patients and should be
done in supplementing and not substituting cardiovascular exercise.
Structured Aerobic Exercise Recommendations:

Frequency
• Exercise frequency should include participation in most days of the week 4-7 days per week. For patients
with limited exercise fitness, multiple short (1-10 minutes) daily sessions may be prescribed.
Intensity
• Rate of perceived exertion (RPE) of 4-6 on a scale of 1-10
• 40-80% of exercise capacity using HR reserve or peak Oxygen consumption if exercise test data is
available
• Exercise intensity should be prescribed at a heart rate below ischemic threshold if such a threshold is
already pre-determined ( e.g. 10 beats per minute below threshold)
In patients that have an altered haemodynamic response to exercise altered by various medications, the
RPE scale can be used to monitor intensity. If no stress test is available, exercise intensity can be recommended
at a moderate level (the patient should be able to speak during training but should be exercising with enough
intensity to prefer not to speak for most of the training session). A general rule of thumb is to use an upper limit
training heart rate of HRrest + 20 beats/min, gradually titrating to higher levels according to RPE, signs and
symptoms and normal physiologic responses.
It is important to always check that patients have regularly taken their prescribed medications and they
have their sublingual nitrates with them.
Time
• The goal of aerobic conditioning is generally 20-60 minutes per session
• Patients may begin with 5-10 minute sessions and gradually increase 1-5 minutes per session or
increase the duration by 10- 20 % per week. The progression should be individualized to the patient’s
tolerance
Type
• To promote whole body physical fitness conditioning that includes upper and lower extremities,
multiple forms of aerobic activities and equipment should be incorporated
• They may include : Cycle ergometer, Arm ergometer, Elliptical, Rower and treadmill walking
Special Considerations for Cardiac Patients

• Safety factors, including clinical status, risk-stratification category, exercise capacity, ischemic/
angina threshold, and cognitive/psychological impairment that might result in non-adherence to
exercise guidelines
• Associated factors, including vocational and avocational requirements, musculoskeletal limitations,
premorbid activity level, personal health/fitness goals are important considerations when developing a
rehabilitation exercise program for cardiac patients.
Chapter 5 53
• Patients who have undergone sternotomy should restrict lifting with the upper extremity to 5-8 pounds
(2.2-3.6kg) for about 5-8 weeks after cardiothoracic surgery. Range of motion exercises and lifting 1-3
pounds (0.5-1.4kg) with the arms is allowed if there is no evidence of sternal instability as detected
by, movement in the sternum, pain, cracking or popping. Patients should be advised to limit range of
movement to within the onset of feeling a pulling sensation on the incision or mild pain
• Patients with pacemakers or implantable defibrillators; or post cardiac transplantation, should ideally
have their exercise recommendations determined by their regular cardiologist or physician with a good
understanding of pacemaker/implantable defibrillators settings and knowledge of cardiac transplant
physiology.
Lifestyle Physical Activity

In addition to structured exercise, patients should be encouraged to return to daily living activities such as
household chores, shopping and hobbies. For overall health and fitness, a minimum of 10,000 steps a day is
recommended.
CHAPTER 6
Exercise and Diabetes, Obesity,
Metabolic Syndrome and Dyslipidaemia
Introduction
D
iabetes Mellitus is characterized by abnormal glucose metabolism resulting from defects in insulin
release, insulin action or both. This complex disease requires rigorous self-management combined
with an appropriate balance of nutritional intake, medications and regular physical activity/ exercise
for blood glucose control. Diabetes is one of the leading causes of global mortality, 7th in the Philippines
(Source: National Statistics Office, 2009).
The major forms of diabetes can be categorized as type 1 or type 2. In type 1, which accounts for 5%-10%
of cases, the cause is an absolute deficiency of insulin secretion resulting from autoimmune destruction of the
insulin producing cells in the pancreas. Type 2 Diabetes (90%-95% of cases) results from a combination of
the inability of cells to respond to insulin (insulin resistance) and inadequate compensatory insulin secretion,
leading to failure of uptake of circulating glucose into muscle and liver. Other forms include gestational diabetes
(GDM), which is associated with a 40%-60% chance of developing T2DM in the next 5-10 years. Diabetes
can also result from genetic defects in insulin action, pancreatic disease, surgery, infections, and drugs or
chemicals.
Currently, the American Diabetes Association (ADA) recommends the use of any of the following four
criteria for diagnosing diabetes:
• Glycated haemoglobin (HbA1c) value of 6.5% or higher

• Fasting plasma glucose ≥ 126 mg/dl (7.0 mmol/l)
• 2-h plasma glucose ≥ 200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test using 75 g of
glucose, and/or
• Classic symptoms of hyperglycaemia (e.g. polyuria, polydipsia, and unexplained weight loss) or
hyperglycaemic crisis with a random plasma glucose of 200 mg/dl (11.1 mmol/l) or higher.
In the absence of unequivocal hyperglycaemia, the first three criteria should be confirmed by repeat
testing.
Chapter 6 55
The goal of treatment in Type 2 Diabetes Mellitus (T2DM) is to achieve and maintain optimal blood
glucose and to prevent or delay chronic complications of diabetes. Many people with T2DM can achieve blood
glucose control by following a meal plan and exercise program, losing excess weight, implementing necessary
self-care behaviours, and taking oral medications, with some eventually requiring supplemental insulin. Diet
and physical activity are central to the management and prevention of T2DM because they help treat the
associated glucose, lipid, and BP control abnormalities, as well as aid in weight loss and maintenance. When
medications are used to control T2DM, they should augment lifestyle improvements, not replace them.
This chapter focuses on the safe and effective exercise recommendations to assist in Type 2 Diabetes
management and any accompanying complications.
Benefits of Exercise in T2DM

The beneficial effects of exercise for T2DM can be divided into its effects on improving blood sugar control
(treatment) and the prevention of T2DM.
Acute and Chronic Effects of Physical Activity

The acute effect of exercise on T2DM improves insulin sensitivity, facilitates glucose uptake and aids in glucose
homeostasis. Usually an acute bout of exercise lowers blood glucose up to 72 hours post exercise. Below are some
recent evidence-based recommendations from the ACSM regarding the acute effects of exercise on T2DM.
• Physical activity causes increased glucose uptake into active muscles balanced by hepatic glucose
production, with a greater reliance on carbohydrate to fuel muscular activity as intensity increases.
• Insulin-stimulated blood glucose uptake into skeletal muscle predominates at rest and is impaired in
T2DM, while muscular contractions stimulate blood glucose transport via a separate, additive mechanism
not impaired by insulin resistance or T2DM. As the two pathways are distinct, blood glucose uptake
into working muscle is normal even when insulin-mediated uptake is impaired in T2DM. Muscular
blood glucose uptake remains elevated post exercise, with the contraction mediated pathway persisting
for several hours.
• Although moderate aerobic exercise improves blood glucose and insulin action acutely, the risk of
exercise-induced hypoglycaemia is minimal without use of exogenous insulin or insulin secretagogues.
Transient hyperglycaemia can follow intense physical activity.
• The acute effects of resistance exercise in T2DM have not been reported, but result in lower fasting
blood levels for at least 24 h post exercise in individuals with impaired fasting glycemia.
• A combination of aerobic and resistance exercise training may be more effective in improving blood
glucose control than either alone; however, more studies are needed to determine if total caloric
expenditure, exercise duration, or exercise mode is responsible.
• Physical activity/exercise can result in acute improvements in systemic insulin action lasting from 2 to
72 h
The favorable effects of chronic exercise have been reported for T2DM. Regular aerobic and resistance
training combined with medical nutrition therapy promotes improved cardiovascular function, along with
weight loss, favorable changes in lipids and lipoproteins, blood pressure, fat free mass, increased insulin
sensitivity and lower blood glucose. These physiologic changes usually result in reduction in medications needed
to manage glucose levels for T2DM. Regular exercise may also favorably alter stress-related psychological factors
and cognitive function in diabetes. Depression is common in diabetes and regular physical activity may assist
in countering this. Below are some recent evidence-based recommendations from the ACSM regarding the
chronic effects of exercise on T2DM.
1. Both aerobic and resistance training improve insulin action, blood glucose control, and fat oxidation
and storage in muscle.
2. Resistance exercise enhances skeletal muscle mass.
3. Observational studies suggest that greater physical activity and fitness are associated with a lower risk of
all-cause and CV mortality.
4. Recommended levels of physical activity may help produce weight loss. However, up to 60 min per day
may be required when relying on exercise alone for weight loss.
5. Individuals with T2DM engaged in supervised training exhibit greater compliance and blood glucose
control than those undertaking exercise training without supervision.
6. Increased physical activity and physical fitness can reduce symptoms of depression and improve health-
related quality of life in those with T2DM.
Physical Activity and Prevention of T2DM

• Participation in regular physical activity improves blood glucose control and can prevent or delay
onset of T2DM.Prospective cohort and cross-sectional observational studies that assessed PA with
questionnaires showed that higher PA levels are associated with reduced risk for T2DM.
• The Da Qing study in China included an exercise-only treatment arm and reported that even modest
changes in exercise (20 min of mild or moderate, 10 min of strenuous, or 5 min of very strenuous
exercise one to two times a day) reduced diabetes risk by 46% (compared with 42% for diet plus
exercise and 31% for diet alone).
Chapter 6 57
• The Finnish Diabetes Prevention Study and the US Diabetes Prevention Program (DPP) included
intensive, lifestyle modifications with both diet and increased PA. In the former, 522 middle-aged,
overweight adults with impaired glucose tolerance (IGT) completed either lifestyle modifications of at
least 30 min of daily, moderate physical activity, or no change in behaviour. The DPP randomized 3234
men and women with IGT or impaired fasting glycemia (IFG) into control, medication (metformin),
or lifestyle modification groups, composed of dietary and weight loss goals and 150 min of weekly
aerobic activity. Lifestyle modification in both studies reduced incident diabetes by 58% and, in the
DPP, had a greater effect than metformin (31%).
• Data show that moderate exercise like brisk walking reduces risk of T2DM, and all studies support the
current recommendation of 2.5 hours per week of a moderate aerobic activity or typically 30 minutes
per day; 5 days a week for prevention. ACSM recommends that at least 2.5 hours per week of moderate
to vigorous physical activity should be undertaken as part of lifestyle changes to prevent T2DM onset
in high-risk adults.

Exercise Prescription in T2DM
Pre Exercise Evaluation

A comprehensive pre-activity screening of the patient’s clinical status is recommended to ensure safe and effective
participation. Before commencing exercise, screening for vascular and neurologic complications, including
silent myocardial ischemia, is warranted, along with identification of the presence of CVD risk factors.
For individuals desiring to participate in low-intensity physical activity like walking, health care providers
should use clinical judgment in deciding whether to recommend pre exercise testing. Conducting exercise stress
testing before walking is unnecessary. No evidence suggests that it is routinely necessary as a CVD diagnostic
tool, and requiring it may create barriers to participation.
For exercise more vigorous than brisk walking or exceeding the demands of everyday living, sedentary and
older diabetic individuals will likely benefit from being assessed for conditions that might be associated with risk
of CVD, contraindicate certain activities, or predispose to injuries. These conditions include severe peripheral
neuropathy, severe autonomic neuropathy, and pre-proliferative or proliferative retinopathy.
Before undertaking new higher-intensity physical activity, patients should be advised to undergo a detailed
medical evaluation and screening for blood glucose control, physical limitations, medications, and macro
vascular and micro vascular complications. This assessment may include a graded exercise stress test depending
on the age of the person, diabetes duration, and the presence of additional CVD risk factors. The prevalence
of symptomatic and asymptomatic CAD is greater in individuals with T2DM, and maximal graded exercise
testing can identify a small proportion of asymptomatic persons with severe coronary artery obstruction.
Current guidelines attempt to avoid automatic inclusion of lower-risk individuals with T2DM, stating
that exercise stress testing is advised primarily for previously sedentary individuals with diabetes who want to
undertake activity more intense than brisk walking. The goal is to more effectively target individuals at higher
risk for underlying CVD (In general, ECG stress testing may be indicated for individuals matching one or more
of these criteria (see Table 6.1 for list of criteria/s)
Exercising with Non-optimal Blood Glucose Control
Hyperglycaemia
1. While hyperglycemia can be worsened by exercise in type 1 diabetic individuals who are insulin deficient
and ketotic (due to missed or insufficient insulin), very few persons with T2DM develop such a severe
degree of insulin deficiency.
2. Individuals with T2DM and elevated glucose levels (>300 mg/dl or 16.7 mmol/l) without ketosis,
may engage in physical activity, provided they are feeling well. Adequate hydration is necessary. If
hyperglycemic after a meal, individuals with T2DM will still experience a reduction in blood glucose
during aerobic work because endogenous insulin levels will likely be higher at that time.
Chapter 6 59
Hypoglycemia: Causes and Prevention

1. In individuals whose diabetes is being controlled by lifestyle alone, the risk of developing hypoglycemia
during exercise is minimal. Glucose monitoring can be performed before and after physical activity
toassess the effect of exercise. Activities of longer duration and lower intensity generally cause a decline
in blood glucose levels but hypoglycemia is less likely.
2. In insulin or insulin secretagogue users, who frequently have the effects of both exercise and insulin
to increase glucose uptake, physical activity can complicate diabetes management. For pre-exercise
blood glucose levels of less than 100 mg/dl (5.5mmol/l), it is recommended that individuals taking
insulin or secretagogues (e.g. sulfonylureas like glyburide, glipizide, glimepiride as well as nateglinide
and repaglinide) consume 15 g of carbohydrate before moderate-intensity physical activity. The amount
of carbohydrate is dependent on exercise duration, intensity and results of blood glucose monitoring.
Doses of medication and insulin may have to be reduced before strenuous planned exercise of duration
> 1 hour.
3. If controlled with diet or other oral medications, most individuals will not need carbohydrate supplements
for exercise lasting less than an hour.
4. Later-onset hypoglycemia is a greater concern when carbohydrate stores (i.e., muscle and liver glycogen)
are depleted during an acute bout of exercise. In particular, high-intensity exercise (e.g., repeated interval
or intense resistance training) can result in substantial depletion of muscle glycogen, thereby increasing
risk for post exercise hypoglycemia in users of insulin or insulin secretagogues. In such cases, the
consumption of 5-30 g of carbohydrate during and within 30 min after exhaustive, glycogen-depleting
exercise will lower hypoglycemia risk and allow for more efficient restoration of muscle glycogen.
Cardiovascular Exercise Training in T2DM

The recommendations for cardiovascular exercises for T2DM are presented using the FITT principle.
Frequency
• Aerobic exercise should be performed at least 3 days per week with no more than two consecutive days
between bouts of activity because of the transient nature of exercise-induced improvements in insulin
action. Current guidelines for adults generally recommend five sessions of moderate activity per week.
Intensity
• Aerobic exercise should be at least at moderate intensity, corresponding approximately to 64-76 %
HRmax. For most people with T2DM, brisk walking, cycling and swimming are moderate-intensity.
Time
• Individuals with T2DM should engage in a minimum of 150 min per week of exercise undertaken at
moderate intensity or greater. Aerobic activity should be performed in bouts of at least 10 min and
be spread throughout the week. 150 min per week of moderate-intensity exercise is associated with
reduced morbidity and mortality in observational studies in all populations. Some cardiovascular and
blood glucose benefits may be gained from lower exercise volumes (a minimum dose has not been
established), whereas further benefit likely results from engaging in durations beyond recommended
amounts.
Type
• Any form of aerobic exercise (including brisk walking) that uses large muscle groups and causes sustained
increases in HR is likely to be beneficial, and undertaking a variety of modes of physical activity is
recommended.
In summary, persons with T2DM should undertake at least 150 min per week of moderate to vigorous
aerobic exercise spread out during at least 3 times during the week, with no more than two consecutive days
between bouts of aerobic activity.
Resistance Training in T2DM
Frequency
• Resistance exercise should be undertaken at least twice weekly on non-consecutive days, but more
ideally three times a week, as part of a physical activity program for individuals with T2DM, along with
regular aerobic activities.
Intensity
• Training should be moderate (50% of 1-repetition maximum, or 1-RM) or vigorous (75%-80% of
1-RM) for optimal gains in strength and insulin action. Home-based resistance training following
supervised, gym-based training may be less effective for maintaining blood glucose control but adequate
for maintaining muscle mass and strength.
Time
• Each training session should minimally include 5-10 exercises involving the major muscle groups (in
the upper body, lower body, and core) and involve completion of 10-15 repetitions to near fatigue
per set early in training, progressing over time to heavier weights (or resistance) that can be lifted only
Chapter 6 61
8-10 times. A minimum of one set of repetitions to near fatigue, but as many as three to four sets, is
recommended for optimal strength gains.
Type
• Resistance machines and free weights (e.g. dumbbells and barbells) can result in fairly equivalent gains
in strength and mass of targeted muscles. Heavier weights or resistance may be needed for optimization
of insulin action and blood glucose control.
Rate of progression
• To avoid injury, progression of intensity, frequency, and duration of training sessions should occur slowly.
In most progressive training regimes, increases in weight or resistance are undertaken first and only once
when the target number of repetitions per set can consistently be exceeded, followed by a greater number
of sets and lastly by increased training frequency. Progression for 6 months to thrice-weekly sessions of
three sets of 8-10 repetitions done at 75% to 80% of 1-RM on 8-10 exercises may be an optimal goal.
In addition to aerobic training, persons with T2DM should undertake moderate to vigorous resistance
training at least 2-3 days per week.
Combined Aerobic and Resistance Training

Inclusion of both aerobic and resistance exercise training is recommended. Combined training thrice weekly
in individuals with T2DM may be of greater benefit to blood glucose control than either aerobic or resistance
exercise alone.
However, the total duration of exercise and caloric expenditure was greatest with combined training in
all studies done to date, and both types of training were undertaken together on the same days. No studies
have yet reported whether daily, but alternating, training is more effective, or evaluated the effect of isocaloric
combinations of training on blood glucose. There is no conclusive evidence for benefit on glucose control of
milder forms of exercise, such as yoga and tai chi.
Flexibility Training
Flexibility training may be included as part of an exercise program, although it should not substitute for other
training. Older adults are advised to undertake exercises that maintain or improve balance, which may include
some flexibility training, particularly for many older individuals with T2DM with a higher risk of falling.
Flexibility training may be included but should not be undertaken in place of other recommended types of
exercise.
Medication Effects on Exercise Responses

1. Current treatment strategies promote combination therapies to address the three major defects in
T2DM:
• Impaired peripheral glucose uptake (liver, muscle)
• Excessive hepatic glucose release with glucagon excess
• Insufficient insulin secretion
2. Medication adjustments for physical activity are generally necessary only with use of insulin and other
insulin secretagogues. To prevent hypoglycemia, individuals may need to reduce their oral medications
or insulin dosing before (and possibly after) exercise.
3. Before exercise, short-acting insulin doses may have to be reduced to prevent hypoglycemia. Newer
rapid-acting insulin analogs (i.e. lispro, aspart and glulisine) induce more rapid decreases in blood
glucose than regular human insulin. Individuals will need to monitor blood glucose levels before,
occasionally during, and after exercise and compensate with appropriate dietary and/or medication
regimen changes, particularly when exercising during the peak action of insulin (1-3 hours for short-
acting insulin). If only longer-acting insulin like glargine, detemir, and Neutral Protamine Hagedorn
(NPH) are being absorbed from subcutaneous depots during exercise, exercise induced hypoglycemia
is not as likely, although doses may need to be reduced in the long-term to accommodate regular
participation in exercise.
4. Doses of select oral hypoglycemic agents (glyburide, glipizide, glimepiride, nateglinide and repa-
glinide) may also need to be lowered in response to regular exercise training if the frequency of
hypoglycemia increases.
5. Diabetic individuals are often prescribed a variety of medications for comorbid conditions, including
diuretics, beta blockers, angiotensin converting enzyme (ACE) inhibitors, aspirin, lipid-lowering agents
and more. These medications generally do not affect exercise responses, with some notable exceptions:
i. Beta-blockers are known to blunt heart rate responses to exercise and lower maximal exercise
capacity via negative inotropic and chronotropic effects. They may also block adrenergic symptoms
of hypoglycemia, increasing the risk of undetectedhypoglycemia during exercise. However, beta-
blockers may increase exercise capacity in those with cardiovascular disease, rather than lowering it,
by reducing coronary ischemia during activity.
ii. Diuretics may lower overall blood and fluid volumes resulting in dehydration and electrolyte
imbalances, particularly during exercise in the heat.
iii. High doses of statins were associated with myalgia and myositis, particularly when combined with
fibrates and niacin.
Chapter 6 63
In summary, medication dosage adjustments to prevent exercise-associated hypoglycemia may be required

by individuals using insulin or certain insulin secretagogues. Most other medications prescribed for concomitant
health problems do not affect exercise, with the exception of beta-blockers, some diuretics, and statins.
Special Considerations: Exercise with Long-term Complications of Diabetes Vascular Disease

1. Individuals with angina and T2DM classified as moderate or high risk should preferably exercise
in a supervised cardiac rehabilitation program initially. Diabetes accelerates the development of
atherosclerosis and is a major risk factor for cardiovascular and peripheral vascular disease. Individuals
with T2DM have increased lifetime risk of cardiovascular disease (67% of women and 78% of men),
which is exacerbated by obesity.
2. For individuals with peripheral vascular disease with and without intermittent claudication and pain
during physical activity, low-to moderate walking, arm-crank, and cycling exercise have all been shown
to enhance mobility, functional capacity, exercise pain tolerance and quality of life. Lower extremity
resistance training also improves functional performance measured by treadmill walking, stair climbing
ability and quality of life measures.
3. Known cardiovascular disease is not an absolute contraindication to exercise. Individuals with angina
classified as moderate or high risk should likely begin exercise in a supervised cardiac rehabilitation
program. Physical activity is advised for anyone with peripheral vascular disease.
Peripheral Neuropathy
1. Peripheral neuropathy affects the extremities, particularly legs and feet. Hyperglycemia causes nerve
toxicity, leading to nerve damage and apoptosis, which causes micro vascular damage and loss of
perfusion. Symptoms manifest as neuropathic pain and/or loss of sensation that, coupled with poor
blood flow, increase the risk of foot injuries, ulcers and infections.
2. Mild to moderate exercise may help prevent the onset of peripheral neuropathy. Individuals without
acute foot ulcers can undertake moderate weight-bearing exercise, although anyone with a foot injury,
open wound or ulcer should be restricted to non-weight-bearing physical activity.
3. All individuals should closely examine their feet on a daily basis to prevent detect ulcers early and
follow recommendations for use of proper footwear. Previous guidelines stated that persons with severe
peripheral neuropathy should avoid weight-bearing activities to reduce risk of foot ulcerations. However,
recent studies indicated that moderate walking does not increase risk of foot ulcers or re-ulceration in
those with peripheral neuropathy.
4. Individuals with peripheral neuropathy but without acute ulceration may participate in moderate
weight-bearing exercise. Comprehensive foot care including daily inspection of feet and use of proper
footwear is recommended for prevention and early detection of ulcers.
Autonomic Neuropathy
1. The presence of cardiovascular autonomic neuropathy (CAN) doubles the risk of mortality and also
increases the risk of silent myocardial ischemia, orthostatic hypotension, or resting tachycardia. CAN
also impairs exercise tolerance and lowers maximal heart rate (HR).
2. Moderate-intensity aerobic training can improve autonomic function in individuals with and without
CAN; however, improvements may only be evident after an acute submaximal exercise. Screening for
CAN should include a battery of autonomic tests (including HR variability) that evaluate both branches
of the autonomic nervous system.
3. Given the likelihood of silent ischemia, HR, and BP abnormalities, individuals with CAN should
have physician approval and possibly stress testing for cardiovascular abnormalities before commencing
exercise.
4. Exercise intensity may be accurately prescribed using the HR reserve method (a percentage of the
difference between maximal and resting HR, added to the resting value) to approximate oxygen
consumption during submaximal exercise with maximal HR directly measured, rather than estimated,
for better accuracy.
Retinopathy
1. In diabetic individuals with proliferative or pre-proliferative retinopathy or macular degeneration,
ophthalmologist review is recommended before initiating a high-intensity exercise program. Activities
that greatly increase intraocular pressure, such as high-intensity aerobic or resistance training (with large
increases in systolic BP) and head down activities, and jumping/jarring exercises, are not advised with
uncontrolled proliferative disease, due to increased risk of haemorrhage.
2. Diabetic retinopathy is the main cause of blindness in developed countries and is associated with
increased CV mortality. Individuals with retinopathy may receive some benefits, such as improved work
capacity, after low- to moderate-intensity exercise training. While physical activity has been shown to
be protective against development of age-related macular degeneration, very little research exists in
T2DM.
3. Individuals with uncontrolled proliferative retinopathy should avoid activities that increase intraocular
pressure and hemorrhage risk. Treatment is recommended before starting a high-intensity exercise
program.
Nephropathy and Micro Albuminuria

1. Both aerobic and resistance training improve physical function and quality of life in individuals with
kidney disease, although BP increases during physical activity may transiently raise micro albumin levels
in urine. Diabetic nephropathy develops in approximately 30% of individuals with diabetes and is a
Chapter 6 65
major risk factor for death in those with diabetes. Micro albuminuria is common and a risk factor for
overt nephropathy and CV mortality. Tight blood glucose and BP control may delay progression of
micro albuminuria, along with exercise and dietary changes. Exercise training may delay the progression
of diabetic nephropathy in humans.
2. Resistance exercise training is especially effective in improving muscle function and activities of daily
living, which are normally severely affected by later-stage kidney disease. Before initiation of PA,
individuals with overt nephropathy should have physician approval, and possibly undergo stress testing
to detect CAD and abnormal HR and BP responses.
3. Exercise should be begun at a low intensity and volume because aerobic capacity and muscle function
are substantially reduced, and avoidance of the valsalva maneuver or high-intensity exercise to prevent
excessive increases in BP is advised. Supervised, moderate aerobic exercise undertaken during dialysis
sessions are as effective as home-based exercise and may improve compliance.
4. Exercise training increases physical function and quality of life in individuals with kidney disease and
may even be undertaken during dialysis sessions. The presence of micro albuminuria per se does not
necessitate exercise restrictions.
Other Special Considerations

1. Blood glucose monitoring before and following exercise, especially when beginning or modifying an
exercise program is prudent.
2. The timing of exercise should be considered in patients taking insulin or certain hypoglycemic agents.
Exercise is not recommended during peak insulin action because hypoglycemia may result. Exercise
before bed is not recommended due to risk of delayed post exercise hypoglycemia. However if exercising
late in the evening is necessary, an increase in consumption of carbohydrate may be required.
3. Do not inject insulin into exercising limbs.
CONCLUSION
Exercise plays a major role in the prevention and control of insulin resistance, pre diabetes, T2DM, and diabetes
related health complications. Both aerobic and resistance training improve insulin action, at least acutely, and
can assist with the management of blood glucose and lipid levels; BP; CVD risk; mortality; and quality of life,
but exercise must be undertaken regularly to have continued benefits and likely include regular training of
varying types. Most persons with T2DM can perform exercise safely as long as certain precautions are taken.
The inclusion of an exercise program or other means of increasing overall physical activity is critical for optimal
health in individuals with T2DM.
Overweight and Obesity
Introduction
Both overweight and obesity are characterized by the accumulation of excessive levels of body fat and contribute
to heart disease, hypertension, diabetes, and some cancers, as well as psychosocial and economic difficulties.
Table 6.2 and Table 6.3 illustrate the classification of obesity in Asians. Management of overweight and obesity
is considered an important public health initiative because numerous studies have shown the beneficial effects
of diminished weight and body fat in overweight and obese individuals.
These beneficial effects include an improvement in CVD risk factors such as decreased blood pressure,
decreased LDL-C, increased HDL-C, decreased triglycerides (TG) and improved glucose tolerance. Weight loss
has also been associated with a decrease in inflammatory markers, such as C-reactive protein, which have also
been associated with the development of CVD.
Chapter 6 67
The management of body weight is dependent on energy balance, which is affected by energy intake
and energy expenditure. For a person who is overweight or obese to reduce body weight, energy expenditure
must exceed energy intake. A weight loss of 5% to 10% provides significant health benefits, and these benefits
are more likely to be sustained through the maintenance of weight loss and participation in habitual physical
activity. Weight loss maintenance is challenging, with weight regain averaging approximately 33% to 50% of
initial weight loss within 1 year of terminating treatment.
Lifestyle interventions for weight loss that combine reductions in energy intake with increases in energy
expenditure through exercise and other forms of physical activity typically result in an initial 9% to 10%
reduction in body weight. The combination of modest reductions in energy intake with adequate levels of
physical activity is necessary to maximize weight loss in people with overweight and obesity. Physical activity
appears to be important for sustaining significant weight loss and to prevent weight regain
Exercise Testing
The need for additional medical screening before exercise testing and/or appropriate medical supervision during
exercise testing follows the outcomes of risk stratification which has been discussed in the previous chapters
(Pre-participation screening and risk stratification).
The FITT framework of exercise is consistent with the recommendations for healthy adults for aerobic, resistance,
and flexibility exercise. Similarly, the minimal dose of physical activity to improve health/fitness outcomes is
consistent with the consensus public health recommendations of 150 min per week or 30 minutes of physical
activity on most days of the week. The following is the recommended minimal FITT framework for people who
are overweight and obese.
Frequency: ≥ 5 days per week to maximize caloric expenditure
Intensity: Moderate to vigorous-intensity physical activity should be encouraged. Initial exercise training
intensity should be moderate (64-76 % HRmax). Eventual progression to more vigorous-exercise intensity (75-
95% HRmax) may result in further health/fitness benefits.
Time: 30-60 min per day to at least 150 minutes per week, progressing to 300 minutes per week, of
moderate physical activity; 150 minutes of vigorous physical activity; or an equivalent combination of moderate
and vigorous physical activity. Intermittent exercise of at least 10 minutes in duration: accumulating these
duration recommendations is an effective alternative to continuous exercise.
Type: Aerobic physical activities that involve large muscle groups e.g. brisk walking, cycling, jogging,
swimming and sports.
Special Considerations
1. The amount of physical activity that may be required to sustain weight loss and prevent weight regain
exceeds the public health recommendation for physical activity of 150 min per week. For these reasons,
the following considerations should be noted.
2. Overweight and obese adults may benefit from progression to approximately 250-300 min per week
or 50-60 min on 5 days per week as this magnitude of physical activity appears to enhance long-term
weight loss and maintenance. For some individuals to promote or maintain weight loss, progression to
60-90 min per day of daily exercise may be necessary. Adequate amounts of physical activity should be
performed on 5-7 days per week.
3. The duration of moderate to vigorous-intensity physical activity should initially progress to at least
30 min per day and, when appropriate, progress to 50-60 min per day or more to enhance long-term
weight control. Adults with overweight and obesity may accumulate this amount of physical activity in
multiple daily bouts of at least 10 min in duration, or through increases in other forms of moderate-
intensity lifestyle activities. In addition, these strategies may enhance the adoption and maintenance of
physical activity.
4. The addition of resistance exercise to energy restriction does not appear to prevent the loss of fat-free mass
or the observed reduction in resting energy expenditure. Research evidence does not support resistance
training (RT) as effective for weight loss with or without diet restriction. There is limited evidence
that RT promotes gain or maintenance of lean mass and loss of body fat during energy restriction and
there is some evidence RT improves chronic disease risk factors (i.e., HDL-C, LDL-C, glucose, blood
pressure), especially in individuals with type 2 diabetes. However, resistance exercise may enhance
muscular strength and physical function, as well as other health benefits.
Behavioural Weight Loss Program Recommendations

An effective behavioural weight loss program should include reductions in energy intake and increases in energy
expenditure through physical activity. The following recommendations for weight-loss programs are stated below:
1. Target a minimal reduction in body weight of at least 5% to 10% of initial body weight over a 3- to
6-month period. Incorporate opportunities to enhance communication between healthcare professionals,
dieticians and exercise professionals and people with overweight and obesity following the initial weight
loss period.
2. Target changing eating and exercise behaviours, as sustained changes in both behaviours result in
significant long-term weight loss.
3. Target reducing current energy intake by 500 to 1,000 kcal per day to achieve weight loss. This reduced
energy intake should be combined with a reduction in dietary fat to <30% of total energy intake.
4. Target progressively increasing to a minimum of 150 min per week of moderate-intensity physical
activity to optimize health/fitness benefits for overweight and obese adults. Progress to higher amounts
of exercise (i.e. 200-300 min per week or ≥ 2,000 kcals per week) of physical activity to promote long-
term weight control.
Chapter 6 69
5. Incorporate behavioural modification strategies to facilitate the adoption and maintenance of the desired
changes in behaviour.
Dyslipidaemia
1. Regular participation in physical activity and exercise results in beneficial changes in the lipid profile
of patients with dyslipidaemia. These changes include reductions in triglyceride levels and an increase
in HDL concentrations. The reductions for LDL levels in clinical trials have been demonstrated to be
inconsistent.
2. The exercise prescription for individuals with dyslipidaemia without co-morbidities is very similar to
an exercise prescription for healthy adults. A major difference in the exercise prescription for patients
with dyslipidaemia as compared with healthy adults is that healthy weight maintenance should be
emphasized.
3. Aerobic exercise is the foundation of the exercise prescription for patients with dyslipidaemia. Resistance
and flexibility exercises are adjunct to an aerobic training program designed for the treatment of
dyslipidaemia, primarily because these modes of exercise do not substantially contribute to the overall
caloric expenditure goals that appear to be beneficial for improvements in blood lipid and lipoprotein
concentrations.
4. The FITT framework recommended for people with dyslipidaemia are listed below.
Frequency: ≥ 5 days per week to maximize caloric expenditure
Intensity: Moderate intensity
Time: 30-60 minutes per day. However, to promote or maintain weight loss, 50-60 mins per day or more
of daily exercise is recommended. Performance of intermittent exercise of at least 10 minutes in duration to
accumulate these duration recommendations is an effective alternative to continuous exercise.
Type: Aerobic physical activities that involve the large muscle groups. As part of a balanced exercise
program, resistance-training exercise should be incorporated. People with dyslipidaemia without comorbidities
may follow the resistance-training guidelines for healthy adults.
• The exercise prescription may need to be modified should the patient present with other conditions,
such as the metabolic syndrome, obesity, and hypertension.

• Individuals taking lipid-lowering medications that have the potential to cause muscle damage (i.e.
HMG CoA reductase inhibitors or statins, and fibric acid) may experience muscle weakness and soreness
termed myalgia. It is important to monitor the patients for symptoms of unusual muscle soreness when
exercising while taking these medications.
• Improvement in blood lipid and lipoprotein levels with aerobic exercise training may take several weeks
to months depending on a variety of factors, including initial blood lipid and lipoprotein levels, weekly
caloric expenditure and the blood lipid parameter that is being targeted with exercise training.
The Metabolic Syndrome

The metabolic syndrome is often encountered in clinical practice and is characterized by a constellation of
CVD risk factors detailed in Table 6.4. The diagnosis of metabolic syndrome can be made if there is presence
of any 3 of 5 risk factors.
Chapter 6 71
Exercise Testing
The need for additional medical screening before exercise testing and/or appropriate medical supervision during
exercise testing follows the outcomes of risk stratification which has been discussed in the previous chapters
(Pre-participation screening and risk stratification).
Exercise Prescription and Special Considerations

1. The FITT framework is consistent with the recommendations for healthy adults regarding aerobic,
resistance, and flexibility exercise. Similarly, the minimal dose of physical activity to improve health/
fitness outcomes is consistent with the consensus public health recommendations of 150 min per week
or 30 minutes of physical activity on most days of the week.
2. For these reasons, and because of the impact of the cluster of diseases and conditions that accompany the
metabolic syndrome, exercise prescription recommendations and special considerations are combined
in this section and listed below.
o Individuals with the metabolic syndrome will likely present with multiple CVD risk factors (i.e.
dyslipidaemia, hypertension, obesity and hyperglycaemia). Special consideration should be given to
the exercise prescription based on the presence of these associated CVD risk factors and the goals of
the participant and/or healthcare provider.
o The initial exercise training should be performed at a moderate intensity. When appropriately
monitored andsupervised, patients may progress to more vigorous intensity e.g. high intensity
interval training (85-90% of HRmax in divided sessions of 4 min for total 15 min)
o Because of the high likelihood of overweight and obesity, most individuals with the metabolic
syndrome may benefit by gradually increasing their physical activity levels to approximately 300
min per week or 50 to 60 minutes on 5 days per week when appropriate.
o This amount of physical activity may be accumulated in multiple daily bouts of at least 10 minutes
in duration or through increases in other forms of moderate intensity lifestyle activities. For
some individuals to promote or maintain weight loss, progression to 60-90 min per day may be
necessary.
3. Resistance training in patients with metabolic syndrome have been shown to improve glycaemic control,
improve fat free mass and reduce blood pressure. Resistance training, performed at 2 times per week,
consisting of 8- 10 types of exercising involving major muscle groups, is recommended in addition to
cardiovascular training.
CHAPTER 7
Exercise in Special Conditions
Asthma
Introduction
A
sthma is defined as a condition characterised by recurrent or chronic wheeze and/or cough, with
recognisable variable airway obstruction due to bronchial hyper-reactivity secondary to airway
inflammation. It is important to recognise that asthma is a chronic inflammatory airway disease.
While asthma exacerbation may be episodic, the airway inflammation is chronically present.
The 2008 MOH clinical practice guidelines follow the GINA guidelines which define the control of
asthma into three categories:
1. Controlled
2. Partly Controlled
3. Uncontrolled
Asthma is controlled when there are no daytime symptoms; no limitation of activities; no nocturnal
symptoms; no need for reliever or rescue treatment; no exacerbation; and normal lung function.
Asthma is partly controlled when daytime symptoms are more than twice/week; there is any limitation
of activities; any nocturnal symptoms; the need for reliever or rescue medication more than twice a week; one
or more exacerbations/year; and when Peak Expiratory Flow Rate (PEFR) or Forced Expiratory Volume in 1
second (FEV1) is <80% predicted or personal best.
Asthma is uncontrolled if three or more features of partly controlled asthma are present in any week; or if
there are exacerbations in any week. Table 7.1 illustrates the levels of asthma control.
Chapter 7 73
The control of asthma can be assessed in the office using the Asthma Control Test ACT), a 5-item, patient-
administered survey questionnaire for assessing asthma control (Figure 7.1). This is a simple, objective, robust
and validated method for monitoring control by doctors (and patients). The ACT is easily completed by patients
and clinicians in both the primary care or specialist settings, without the need for lung function testing.
Based on a five-point scoring system, a maximum score of 25 will indicate ëtotal control’ of asthma. ëWell
controlled’ asthma is defined as a score of 20-24, and a score of less than 20 will imply ‘poor control’.
Benefits and Risk of Exercise

The management of asthma is primarily pharmacological but exercise is an important adjunct to treatment. The
health benefits of exercise in patients with asthma have been well documented in many studies. Most studies
support the idea that individuals with well controlled asthma who participate in an average of 20 to 30 minutes
of aerobic exercise two to three times per week will improve maximal ventilation, oxygen consumption, work
capacity, and heart rate. The majority of the literature suggests that exercise is not only safe and effective for
individuals with asthma, but for some, exercise may in fact help control the frequency and severity of asthma
attacks.
However, exercise can by itself trigger an episode of bronchospasm, commonly referred to as exercise-
induced bronchospasm (EIB). Nearly all (up to 90%) patients with asthma have been reported to have EIB;
as many as 10% of patients who have no history of asthma may develop EIB. 45% of individuals with allergic
rhinitis have been reported to have EIB. For patients with asthma, exercise-induced asthma (EIA) has also been
used to describe this condition, although this term is regarded by some physicians as a misnomer because it
seems to imply that exercise causes rather than exacerbates or triggers an attack of asthma. In this chapter, the
discussion of EIB is used in reference to patients with asthma and is synonymous with EIA.
Chapter 7 75
EIB represents a substantial barrier to physical activity in patients with asthma. As the majority of primary
care physicians will regularly encounter patients with EIB, it is important that physicians recognise the condition
and give appropriate advice to these patients when prescribing exercise.
EIB is characterized by transient airway obstruction that usually occurs 5 to 15 minutes following
physical exertion. Symptoms of EIB consist of wheezing, coughing, shortness of breath, chest discomfort, or a
combination of these, lasting up to 30 min following the cessation of exercise. A small percentage of individuals
with EIB experience a late reaction (i.e., a further episode of airway obstruction 4-6 h later).
Diagnosis of EIB in asthma patients based on symptoms and signs alone is strongly suggestive. The
diagnosis of EIB in patients without an established history of asthma may require an objective exercise challenge
test. Objectively, EIB is defined as a 15% decrease in peak expiratory flow rate (PEFR) or forced expiratory
volume in 1 second (FEV1) after physical exertion that increases baseline heart rate to 80% of maximum for
4-6 minutes, compared with pre-exercise baseline.
The mechanism underlying this effect is not fully understood, but the fundamental trigger is thought to
involve drying and cooling of airways brought about by increased ventilation during exercise.
The severity of an EIB attack varies greatly. Although cases of respiratory arrest and even death have been
reported, the usual scenario is of a mild respiratory difficulty during play, which either spontaneously resolves
or immediately responds to inhaled salbutamol.
The following section will discuss the pharmalogical management of EIB as well as special considerations
for exercise in patients with asthma.
Medical Management of EIB in Asthma

It is important to emphasize that EIB is difficult to prevent if asthma is not adequately controlled. The
pharmacological treatment of asthma includes the use of controller and reliever medications. In the medical
management of EIB, a third category, preventers is added. The use of a short-acting fl2-agonist approximately
10 to 15 min before exercise has been shown to reduce the risk of EIB in individuals with asthma. In
patients diagnosed with EIB, prophylactic treatment with a short-acting fl2-agonist before starting exercise is
recommended and is reported to control symptoms in 80%-95% of asthma patients.
Long acting inhaled fl2-agonists (e.g. salmeterol and formoterol) are useful in physical or sporting activities
of longer than 90-120 min duration, and in cases in which objective measures of air flow obstruction demonstrate
a late reaction. Long-acting fl2-agonists extend the period of protection, although the length of time the drug
remains active after a single dose may decrease. For patients with asthma, long acting fl2-agonists should never
be prescribed as monotherapy, and should be inhaled in association with an inhaled corticosteroid.
Daily use of inhaled fl2-agonists, both rapid acting and long acting, can induce tolerance (decrease in effect
with time) with loss of their effectiveness as preventers of EIB and relievers of asthma.
Effective protection from EIB is also provided by leukotriene receptor antagonists. Although these drugs are
slightly less effective than sympathomimetics, leukotriene receptor antagonists have some practical advantages,
including an effect lasting over 24 h, single daily-dose administration by mouth, no major adverse effects, and
no development of tolerance.
Pre-Exercise Evaluation
The need for additional medical screening before exercise testing and appropriate medical supervision during
exercise testing follows the outcomes of risk stratification which has been discussed in the previous chapters. In
absence of other indicative symptoms or medical conditions, individuals with well controlled asthma need not
necessarily undergo formal exercise testing.
For individuals with well-controlled asthma, the following exercise prescription using the FITT framework for
cardiovascular fitness is recommended.
Frequency: At least 3-5 days per week
Intensity: Presently there is no consensus with regards to the ‘‘optimal’’ exercise intensity for patients with
asthma. Sedentary patients may begin their exercise at low to moderate intensity. Another recommendation to
helpindividuals with asthma regulate exercise intensity is to use the Borg CR-10 scale or a visual analog scale
to assess the intensity of breathlessness associated with physical activity (the Borg CR-10 scale developed for
breathlessness is distinct from that used for perceived exertion and uses a 1 to 10 grading of dyspnoea severity)
(Table 7.2)
Patients need to be educated to differentiate dyspnea from exercise versus EIB and be advised to stop if
they perceive that dyspnea is due to EIB. With the use of the Borg Scale, patients will be able to monitor if their
symptom of dyspnoea is disproportional to the level of exertion.
Chapter 7 77
It is important to educate patients that in addition to dyspnoea, EIB in asthma may be associated with
chest tightness, wheezing or coughing. It usually starts a few minutes into exercise and not immediately and may
persist for a while on cessation of exercise.
Time: 20-60 minutes per day of continuous or intermittent physical activity. Initially, unfit patients
may need to limit sessions to 10 - 20 minutes but should aim to increase the duration to a minimum of 30
minutes.
Type: For sedentary patients, walking is strongly recommended because it is involved in most activities
of daily living and has less asthmagenicity. Sports that involve short, intermittent periods of exertion such as
volleyball, tennis, golf and cricket are generally well tolerated by people with asthma. Sports that involve long
periods of exertion, such as cycling, distance running and swimming may be less well tolerated. However,
patients with well controlled asthma are able to fully participate in these activities.
In addition to cardiovascular exercise, resistance training and flexibility exercises should be incorporated
into the exercise prescription using the guidelines presented for healthy adults. Resistance training in the form
of circuit training exercises for the major limb muscle groups, either unloaded with relatively high-frequency
exercises to build endurance and flexibility, or loaded to build strength, is recommended.
1. The use of a short-acting fl2-agonist approximately 10 to 15 min before exercise has been shown to reduce
the risk of EIB in individuals with asthma. To reduce the risk of exercise-induced bronchoconstriction,
persons with asthma should use inhaled bronchodilator therapy (i.e. 2 to 4 puffs) 15 minutes before the
start of exercise
2. Several minutes of warm-up and cool-down may reduce the likelihood of EIB during the activity itself.
Patients should warm up gradually by engaging in low-intensity exercise for several minutes before
increasing exercise intensity.
3. Patients usually respond best to exercise in mid to late morning. Extremes in temperature and
humidity should be avoided. If the weather is cold, exercise indoors. Patients should also avoid certain
conditions that may specifically precipitate asthma e.g. haze, smoke etc.
4. Altering breathing technique, for example, switching from predominantly mouth breathing to nasal
breathing, can result in less bronchospasm with the performance of an activity, because the inhaled
air is both warmed and humidified.
5. Patients should restrict exercise when they have a viral infection. After recovery from asthmatic
exacerbations that prevent participation in the usual program, patients should begin their exercise at a
lower intensity, with the emphasis on progression of duration being more than intensity.
6. The use of ratings of perceived exertion and dyspnea are the useful methods for monitoring intensity
of patients with asthma. It can also help alleviate feelings of anxiety and fear in patients during
exercise.
7. It is important for the physician to ensure overall medication compliance and educate patients regarding
the use of prophylactic use of a short beta agonist inhaler to control EIB.
8. Follow-up care is crucial. Physicians should regularly re-evaluate inhalation technique, the potential
need for stepping up or down medication, availability of rescue medication and reassess overall
control of asthma.
Conclusion
Asthma is not a reason to avoid exercise. In fact, exercise is an important adjunct to the management of asthma.
With proper diagnosis, adequate control and proper preventive measures, patients should be able to enjoy the
benefits of an exercise program without experiencing asthma symptoms.
Chapter 7 79
Depression
1. There is substantial evidence showing that regular physical activity protects against the onset of depressive
symptoms and major depressive disorder. In prospective cohort studies, the adjusted odds of developing
depression were 15 - 25 % lower among active people.
2. Participation in physical activity programs reduces depressive symptoms in people diagnosed with
depression, in healthy adults, and in medical patients without psychiatric disorders regardless of age,
gender, race/ ethnicity, or medical condition. Recent studies have reported reductions in symptoms met
criteria for a clinically meaningful decrease in symptoms of up to 50 %.
3. Those suffering from depressive symptoms tend to socially withdraw and isolate themselves. They
also tend to neglect their physical health. Greater initial physical fitness predicts rapid recovery from
depression. Personal fitness is positively associated with mental health and well-being.
4. Exercise improves glucose tolerance, which will counter the side effects of certain psychiatric medications
such as weight gain.
5. People suffering from depression tend to feel useless and helpless. Exercise allows patients an enhanced
sense of self efficacy (‘‘taking control’’ of their illness).
Effects of Physical Activity According to Different Training Modalities

• Current evidence from cohort studies and RCTs suggest that moderate and high levels of physical
activity reduces the odds of developing depression compared to low levels of physical activity which is
still more protective than inactivity. The optimal type and duration of exercise for reducing exercise is
yet to be elucidated.
• Studies have found that no significant difference in the type of exercise used for reducing symptoms of
depression (aerobic versus resistance). Though not conclusive, continuous exercise was reported to have
a larger reduction in symptoms than intermittent exercise, regardless of the type of exercise.
Evaluation and Considerations

• Enough studies support the use of exercise as an adjunctive therapy in the treatment of depression, if
not a first-line agent for depression in people without suicidal thoughts. A routine medical evaluation is
necessary to assess the patient’s symptoms, signs and risk factors before exercise. This includes assessment
for the severity of depression and the presence of any suicide ideation. Pre-participation screening and
risk stratification for patients follows that in the earlier chapters.
• Physically healthy people who require psychotropic medication may safely exercise when exercise and
medication are titrated under medical supervision. Closer follow-up to ensure adherence is advisable.
• For a patient with very low self-esteem, a one-on-one program with a trainer may be most beneficial.
Some patients will respond favourably within a group setting. It is always important to ask questions
about a patient’s past exercise experience.
• While depressed, the patient may not be able to decide on an appropriate or pleasurable form of activity.
If the individual has enjoyed something in the past, that activity can be incorporated into the current
prescription plan. No one plan will work for every patient, so it is important to have flexible and
adaptable exercise plans available.
• The goal is a treatment regimen to increase self-worth and energy, so adherence is very important.
1. The recommendations for structured cardiovascular exercise follow that of the FITT framework:
• Frequency: 3-5 days per week
• Intensity: Moderate intensity (3-4 RPE 1-10), (64-76 % HRmax)
• Time: 30 -60 minutes preferably continuous exercise
• Type: Any exercise that involves large muscle groups and can be maintained continuously, aerobic
in nature.
2. The recommendations for structured resistance exercise :

• Frequency: Ideally 2-3 times a week on non-consecutive days
• Intensity: 2-3 sets of 10-15 repetitions
• Time: Time needed to execute 2-3 three sets of 10-15 reps with 1
• minute between sets
• Type: Dynamic exercises( involving concentric and eccentric contractions or circuit training
(Circuit training is a form of training in which a group of exercises are completed one after the other)
Aerobic benefits are gained by moving swiftly between machines and completing the circuit as a continuous
flow)
Chapter 7 81
Arthritis
Introduction
• Arthritis and rheumatic diseases are leading causes of pain and disability.
• The most common forms are osteoarthritis and rheumatoid arthritis.
• Osteoarthritis, or degenerative joint disease, primarily affects the joints in the weight bearing regions of
the spine, hips, and knees, but often affects the hands as well.
• Rheumatoid arthritis is a condition of pathological activity of the immune system that commonly
affects the joints.
• Optimal treatment of arthritis involves a multidisciplinary approach including analgesics and anti-
inflammatory medications for pain relief; patient education in self- management and weight loss,
physical therapy and occupational therapy; as well as surgery for total joint replacement in the later
stages of disease.
• Pain and functional limitations are main challenges to physical activity in individuals with arthritis but
exercise still remains an essential component in the management of these conditions.
• Strengthening and maintenance of muscle strength around joints from resistance training
• Reduced joint stiffness
• Prevents functional decline
• Improves mental health as well as overall quality of life.
Exercise Evaluation
• The need for additional medical screening before exercise testing and/or appropriate medical supervision
during exercise testing follows the outcomes of risk stratification which has been discussed in the
previous chapters. (Pre-participation screening and risk stratification)
• Avoid strenuous exercises during acute flares and periods of inflammation but gentle joint movements
through the full range of motion are encouraged.
• More emphasis should be on progression in frequency and duration of activity rather than increased
intensity.
• Adequate warm up and cool down periods of 5-10 minutes are encouraged to minimize pain; and
should involve slow movements of joints through their range of motion.
• Arthritic patients who initiate a program of exercise must understand that some discomfort while
exercising or for two hours after they exercise should be expected, and does not indicate that they are
injuring their joints. If the pain continues well after the first two hours or exceeds their general level of
joint pain, they should be counselled to reduce the duration and/ or intensity in their next session. It is
quite reasonable to time the exercises with their period of least severity of pain and/ or after taking pain
medications.
• Individuals are encouraged to exercise during the time of the day when the pain is typically least severe
and/or corresponding to the peak effect of pain relief medications.
• Appropriate shoes that provide shock absorption and stability are important. Podiatry consult may be
necessary for orthotics prescription or review of suitability of footwear to meet individuals’ biomechanical
profiles.
• Healthy weight loss and maintenance should be encouraged as many of the individuals with osteoarthritis
are overweight and obese.
• Functional exercises such as sit-to-stand and step-ups should be incorporated to the exercise program to
improve neuromuscular control, balance, and maintenance of activities of daily living.
• Exercise prescription should also consider the needs of the elderly population as many of the individuals
with arthritis are from the older population.
As with many other conditions, the general recommendation for FITT (Frequency, Intensity, Time, and Type)
follows those for apparently healthy adults. The important modifications and precautions have been discussed
above.
• Frequency:
º Aerobic exercise to be performed 3-5 days a week.
º Flexibility and range of motion exercises are recommended to
• Intensity:
º Aerobic exercise - General recommendations for exercise intensity apply for aerobic exercise but may
be limited by pain.
º Resistance exercise - Resistance training will directly strengthen the muscle weakness around the
affected joint. Your patient may start with a relatively low amount of weight e.g. 10% of the
individual’s maximum, and progress at a maximal rate of a 10% increase per week as tolerated to
the point of pain tolerance. Patients with high pain levels may comfortably begin with isometric
contractions, such as straight leg raises for a painful knee that do not involve moving the affected
joint. As the patient becomes stronger and more comfortable, you may then advise him to progress
to isotonic training of the affected joints.
Chapter 7 83
• Time:
º Aerobic exercise - Start with short bouts of 5-10 minutes to accumulate 20-30 minutes a day
as tolerated with a goal of progressing to a total of 150 minutes per week of moderate intensity
activity.
º Resistance exercise - Perform one or more sets involving 10-15 repetitions per exercise.
• Type:
º Aerobic exercise - Encourage activities that have low joint stress such as walking, cycling or
swimming.
º Resistance exercise - As mentioned earlier, individuals with severe joint pain or muscle weakness
should begin with maximum voluntary isometric contractions around the affected joint, gradually
progressing to dynamic training. A strength training program should include all major muscle
groups.
º Flexibility exercise - Encourage stretching or range of motion exercises of all major muscle groups.
be performed daily.
Osteoporosis
Introduction
• Osteoporosis is a skeletal disease characterised by low bone mineral density (BMD) and changes in the
microarchitecture of bone that increase susceptibility to fracture.
• Osteoporosis in postmenopausal women and men 50 years of age or older is defined by BMD T-score
of the lumbar spine, total hip, or femoral neck of more than 2.5 standard deviations below the young
adult mean value, with or without accompanying fractures
• However, it is important to recognize that osteoporotic fractures may occur at BMD levels above this
threshold; particularly in the elderly. Hip fractures are associated with increased risk of disability and
death.
• Decreased osteoporotic fractures by increased peak bone mass
• Slowed rate of bone loss with aging
• Reduced fall risk due to improved muscle strength and balance
• Higher bone mass achieved in childhood, adolescence and young adulthood
Exercise Evaluation
• The need for additional medical screening before exercise testing and appropriate medical supervision
during exercise testing follows the outcomes of risk stratification which has been discussed in the
previous chapters.
• There are currently no established guidelines regarding contraindications for exercise for people with
osteoporosis. Common sense prevails, however, and patients should be advised to stay away from any
exercise that causes or exacerbates pain. Twisting, bending, or compression of the spine and high impact
loading or explosive movements should be avoided.
The exercise prescription recommendations for osteoporosis are categorized into two types of populations:
a. Individuals at risk for osteoporosis defined as having ≥ 1 risk factor for osteoporosis (e.g. current low
bone mass, age and being female)
b. Those with osteoporosis.
Chapter 7 85
In individuals at risk for osteoporosis, the following FITT framework is recommended to help preserve
bone health
Frequency:
• Weight bearing aerobic activities to be performed 3-5 days a week.
• Resistance exercises to be performed 2-3 days a week.
Intensity:
• Moderate intensity aerobic activity (64-76 % HRmax)
• Moderate (60-80% 1-RM, 8-12 repetitions for resistance exercise) to high (80-90%, 5 to 6 repetitions
for resistance exercises) intensity in terms of bone loading forces.
Time:
• 30 to 60 minutes per day, combination of weight bearing aerobic and resistance activities
Type:
• Weight-bearing aerobic activities (e.g. brisk walking, jogging, dancing), activities that involve jumping
(e.g. volleyball and basketball) and resistance exercise (e.g. weight lifting). Back strengthening exercises
(while avoiding flexion of the spine) can help the supporting muscles of the spine and thereby reduce
spine fractures
For patients with osteoporosis, the previous exercise prescription may be modified to avoid the high
intensity resistance exercises, although patients may be able to progress to this level. Patients with osteoporosis
should begin gradually with low to moderate intensity exercises as tolerated. Weight bearing exercises such as
brisk walking and weight lifting are recommended types of exercises for patients with osteoporosis. Patients
with osteoporosis should not be encouraged to pursue jumping exercises or running. Non-weight bearing
exercises, such as swimming and bicycling, still confer general health benefits, muscle strengthening and some
improvements in bone health through muscle traction on the bone. Twisting, bending, or compression of the
spine and high impact loading or explosive movements should be avoided. Balance may be affected by the
forward shift in the centre of gravity in patients with vertebral compression fractures. Hence neuromuscular
exercises (e.g. pilates and taiji) to improve balance and reduce the chances of falling should be incorporated.
• It is difficult to quantify exercise intensity in terms of bone-loading forces. However, the magnitude
of bone-loading force generally increases in parallel with exercise intensity quantified by conventional
methods (e.g. % HRmax or %1-RM)
• There are no established guidelines regarding contraindications for exercise for individuals with
osteoporosis. The general recommendation is to prescribe moderate intensity exercise that does not
cause or exacerbate pain. Exercises that involve explosive movements or high impact loading, twisting,
bending or compression of the spine should be avoided.
• BMD of the spine may appear normal or increased after osteoporotic compression fractures or in people
with osteoarthritis of the spine. Hip BMD is a more reliable indicator of risk of osteoporosis than
spine BMD. Exercise prescription for the elderly who are at increased risk for falls, should also include
exercises that improve balance and proprioception.
Conclusion
Exercise is beneficial for the treatment and prevention of osteoporosis. Weight bearing exercises are recommended
to improve bone health. Special precautions (as discussed above) to reduce the risk of musculoskeletal injuries
need to be considered when prescribing exercise to patients with osteoporosis. Exercises to improve balance and
reduce the chance of falling (hence fractures) in the older adult should also be incorporated.
87
References
• ACSM’s Guidelines for Exercise Testing and Prescription 8th Edition
• ACSM’s Resource Manual for Guidelines for Exercise Testing andPrescription Sixth Edition
• ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities; J. Larry Dustine, Geoffrey E.
Moore, Patricia L. Painter and Scott O. Roberts
• ACSM’s Exercise is Medicine; A Clinician’s Guide to Exercise Prescriptionby Steven Jonas and Edward Phillips
• ACSM’s Exercise is Medicine; A quick guide to Exercise Prescription by Technogym Medical Scientific
Department
• 2011 National Physical Activity Guidelines Health Promotion Board Singapore
• Exercise and Type 2 Diabetes: American College of Sports Medicine and the American Diabetes Association:
Joint Position Statement by the American College of Sports Medicine and the American Diabetes Association;
approved by Executive Committee of the American Diabetes Association Medicine & Science in Sports &
ExerciseR and Diabetes Care; July 2010
• Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for
Adults; ACSM Position Stand ; Donnelly, Joseph E. Ed.D (Chair); Blair, Steven N. Ped; Jakicic, John M. Ph.D.;
Manore, Melinda M. Ph.D., R.D.; Rankin, Janet W. Ph.D.; Smith, Bryan K. Ph.D.; Med Sci Sports Exerc. 2009;
41(2):459-71
• Exercise and Hypertension; ACSM Position Stand by; Pescatello, Linda S. Ph.D., FACSM, (Co-Chair); Franklin,
Barry A. Ph.D., FACSM, (Co-Chair); Fagard, Robert M.D., Ph.D. FACSM; Farquhar, William B. Ph.D.; Kelley,
George A. D.A., FACSM; Ray, Chester A. Ph.D., FACSM; Medicine & Science in Sports & Exercise: March
2004 - Volume 36 - Issue 3 - pp 533-553
• Harmonizing the Metabolic Syndrome: A Joint Interim Statement of the International Diabetes Federation Task
Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association;
World Heart Federation; International Atherosclerosis Society; and International Association for the Study of
Obesity; K.G.M.M. Alberti, FRCP; Robert H. Eckel, MD, FAHA; Scott M. Grundy, MD, PhD, FAHA; Paul Z.
Zimmet, MD, PhD, FRACP; James I. Cleeman, MD; Karen A. Donato, SM; Jean-Charles Fruchart, PharmD,
PhD; W. Philip T. James, MD; Catherine M. Loria, PhD, MS, MA, FAHA; Sidney C. Smith, Jr, MD, FAHA;
Circulation 2009, 120:1640-1645
• National Physical Activity Guidelines for Americans 2008: Office of Disease Prevention and Health Promotion
of US Department of Health and Human Services
• Ministry of Health Clinical Practice Guidelines, Management of Asthma 1/2008
• Australian Association for Exercise and Sports Science position statement on exercise and asthma Alan R. Morton,
Kenneth D. Fitch Journal of Science and Medicine in Sport 14 (2011) 312-316
Additional References
• Department of Health (2010, March-April). Philippine National Guidelines on Physical Activity: Galaw-galaw
baka pumanaw. Healthbeat, 58, 6-8 Retrieved from : http://www.doh.gov.ph/node/1025.html
• Department of Health, National Epidemiological Center. (2009). ‘‘The 2009 Philippine Health Statistics’’.
Retrieved from http://www.doh.gov.ph/sites/default/files/PHILIPPINE%20HEALTH%20STATISTICS%20
2009_0.pdf
• Department of Health (2013, April 26). ‘‘Leading causes of Mortality.’’ Retrieved from http://www.doh.gov.ph/
node/198.html
• Masoli, M., Fabian, D. ; Holt , S. , Richard, B. (2004, May) ‘‘Global Burden of Asthma’’. Retrieved from: http://
www.ginasthma.org/local/uploads/files/GINABurdenReport_1.pdf
• National Statistics Office & ICF Macro. (2009, December) ìPhilippines -National Demographic and Health
Survey 2008î. Retrieved from: http://dhsprogram.com/pubs/pdf/FR224/FR224.pdf
• Philippine Statistics Authority (2012, August 30). The Age and Sex Structure of the Philippine Population: (Facts
from the 2010 Census). Retrieved from http://www.census.gov.ph/content/age-and-sex-structure-philippine-
population-facts-2010-census
• The Problem of Mental Health in the Philippines (n.d.) Retrieved on May 15, 2014) from wikispaces: http://
mentalhealthph.wikispaces.com/2.%09The+Problem+of+Mental+Health+in+the+Philippines

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Dr. Rodolfo F. Florentino

Exercise is Medicine Philippines

- Robert E. Sallis, M.D., FACSM

A CRITICAL CALL TO ACTION

Regular physical activity at the correct intensity:

• Can reduce the risk of developing of Alzheimer’s disease by one-third.

Exercise is indeed medicine!

A VITAL SIGN FOR HEALTH

EXERCISE IS MEDICINE PHILIPPINES

Who are the people behind EIMP?

• Overweight and obesity

Risks of exercising -- Putting it in perspective

The important points on risk of exercising can be summarized below:

Aims of Pre-Participation Health Screening

Considerations in Pre-participation Screening

ACSM RISK STRATIFICATION CATEGORIES FOR ARTHEROSCLEROTIC DISEASE

Figure 1.1. New Physical Activity Readiness Questionnaire (New Par-Q).

Important considerations for risk stratification

Components of Exercise Training Sessions

Components of an Exercise Prescription

• Subjective Measures of Intensity

• Physiological/ Relative Physiological/Relative Measures of Intensity

• Absolute Measures of Intensity Metabolic Equivalents

Calories expended/hr = *METs Rating X BW (kg)

• Cardiovascular / Aerobic exercise

• Other methods are

º Peak VO2 method:

• Exercise quantity and duration (Time)

• Aerobic (Cardiovascular) exercise mode (Type)

º Group A&B - useful to regulate and maintain intensity of effort

Progression to National Physical Activity Recommendations

Figure 2.2. Progression along the Frequency Path

Muscular Fitness and Resistance Training

• Volume of resistance exercise (Repetitions and sets):

Flexibility Exercises (Stretching)

There are three phases in ‘‘finding’’ motivation:

1. experiencing an emotional and/ or intellectual thought process of the motivational type

The 6 stages of change are

TERMINATION (Permanent Maintenance)

Table 3.1. Physical Activity States of Change

Mobilizing Motivation for Regular Exercise

1. ‘‘Taking small steps’’

The Wellness Motivational Pathway for Healthy Living

The WMP has five steps:

1. The first step is assessment, both self and professional.

Step 2: Defining Success for Oneself

Step 3: Goal Setting

Step 4: Establishing Priorities

Step 5: Taking Control

The eight elements are:

Importance of Exercise-Induced Reductions in Blood Pressure

Exercise recommendations for Hypertensive Patients.

Frequency (on most, preferably all, days of the week)

Intensity (moderate intensity physical activity)

Time (duration: 30 min or more continuous or intermittent exercise per day)

Type (primarily aerobic activity supplemented by resistance exercise)

Frequency: on most, preferably all, days of the week

Evaluation and Risk Stratification

• Consideration of ECG surveillance

Cardiovascular Risk Associated with Exercise

Structured Aerobic Exercise Recommendations:

Special Considerations for Cardiac Patients

Lifestyle Physical Activity