Clinical Aspect of

Exercise Physiology
Definition, Description, Focus
• Services are also offered in community,
• Clinical Exercise Physiology-Involves the corporate, commercial, university fitness and
application of exercise science to prevent and wellness centers, nursing homes, and senior
delay the onset of chronic disease in healthy citizen centers.
participants or provide therapeutic or functional
benefits to patients with underlying pathologies.

• Clinical Exercise physiologists are healthcare

professionals who use fundamental principles of
exercise physiology in clinical settings to
minimize the risk of chronic diseases associated
with physical inactivity and to treat those
already afflicted.

• Services may be provided in several medical

settings such as hospitals, rehabilitation
centers, and outpatient clinics.
Scope
• The scope of practice ranges from apparently
healthy individuals with no known medical
problems to patients with documented
cardiovascular, pulmonary, metabolic, rheumatoid,
orthopedic, and/or neuromuscular diseases and
conditions.
• Exercise Therapy may be altered by specific
treatments such as drugs and medications,
surgical procedures, radiation therapy,
orthopedic bracing, casting, or splinting
dialysis, and diet therapy.

• Clinical exercise physiologists are responsible

for Exercise testing and evaluation and
supervision of safe and effective exercise
programs in a healthcare setting .

• A knowledge of normal physiological responses to

acute and chronic exercise is essential before
attempting to prevent, manage, or rehabilitate
disease.
Scope continued
• For example heart rate and blood pressure
responses to exercise can be reduced
significantly by a drug called Beta Adrenergic
Blocking Agent which is commonly used to
manage
angina or hypertension.
• Exercise itself can produce effects requiring
alterations in other therapies the patient is
receiving.
• Clinical exercise Physiologists should have a
solid background in basic exercise physiology
combined with more advanced training, including
pathophysiology of chronic diseases, pharmacology
of drugs and medicines, medical terminology,
medical record keeping and charting, ECG
interpretation, exercise testing, business
management and marketing, and nutrition and diet
therapy.

• For example It is often necessary for insulin

dosages to be reduced in patients with Type I
Diabetes because exercise changes the
pharmacokinetics of subcutaneously injected
drugs.
Clinical Testing and Evaluation Principles
• An important tool in clinical settings to
clear individuals for safe participation in
physical activity and also as a basis for
exercise prescription.

• Two broad classifications of exercise testing

• 1. Diagnostic Testing- performed to see how

sick someone is

• 2. Functional Capacity Testing- performed to

see how well someone is

• In other words the diagnostic test is performed

to uncover underlying disease while the
functional test is performed to determine the
capacity for exercise.
Exercise Tests
• Exercise tests, weather for diagnostic or
functional purposes, are usually incremental in
nature and as such are referred to as a graded
exercise test (GXT).

• Graded-means that the exercise is progressed in a

stepwise fashion from light to maximum levels.

• A number of Exercise Protocols are usually

performed on the treadmill or cycle ergometer are
available to the examiner, depending on the
purpose of the test and the population being
tested.

• For example The same GXT test would not be

performed on a young adult as would be performed
on a 70 year old person.
Screening
• Is extremely important in determining an
individuals suitability for an exercise program.

• Exercise may not be safe for everyone

especially
people with pre-existing medical conditions,
such
as coronary artery disease.

• For a limited number of individual, exercise

TESTING alone could be harmful to them and
should
not be done for medical reasons.
Physical Examination
• Many patients require a physicians referral
before they can undergo exercise testing or enter
into an exercise program.
• The ACSM has developed guidelines to aid the
healthcare professional in determining the safety
of exercise for individuals.
• These guidelines suggest that it is unnecessary
for men under the age of 40 and women under the
age of 50 who have no symptoms of heart disease
and are apparently healthy, and have fewer than
two risk factors for Coronary Artery Disease to
have a medical evaluation by a physician before
starting an exercise program.
• Exercise programs conducted in non-medical
settings require a physicians referral for
anyone over the age of 35.
Health History
• The purpose is to a) Identify and exclude
individuals with medical contraindications to
exercise, b) identify individuals with clinically
significant disease conditions who should be
referred to a medically supervised exercise
program, c) identify individuals with symptoms
and risk factors for a disease who should receive
further medical evaluation before starting an
exercise program, d) identify individuals with
special needs for safe exercise participation.
Physiologic Measurements Heart Rate

• Blood Pressure
• Blood Glucose
• Serum cholesterol
• Resting ECG (before diagnostic test)
• Abnormalities in any of these measurements
may
indicate underlying health problems such as
heart
disease, hypertension, or diabetes, which may
warrant further medical evaluation before
proceeding with the actual test. (Often
expected
in diagnostic testing)
Heart Rate

• Resting HR usually measured for at least 60 secs.

after the individual has been sitting for 5 mins.

• Methods chest auscultation w/ sensitive

stethoscope or radial pulse or carotid artery
palpitation.

• Exercise and Clinical settings HR is determined

through readings obtained from the ECG recordings
and directly off the digital display of the
oscilloscope.
Blood Pressure

• Arterial blood pressure is a function of the • During relaxation phase of the heart-diastole-pres
arterial blood flow each minute (cardiac output) sure decreases.
and the resistance offered by the vasculature to • This decrease in pressure is called Diastolic
that flow. blood pressure which gives and indirect
• When the heart contracts and pushes blood, the indication of total peripheral resistance or the
vessels do not allow all the blood to instantly ease with which blood flows through the arteries
flow to all areas of the body as fast as it is to the capillaries.
being ejected from the heart? This creates • BP-is the product of cardiac output and
pressure which can be recorded. peripheral resistance.
• The highest pressure recorded during a heart beat
occurs during the contraction aka the systole of
the left ventricle and is called the systolic
blood pressure. provides estimate of work by
heart and the pressure exerted on the walls.
Blood Pressure Continue

• Hypertension-resting BP that is chronically

elevated.
• Normal BP is approx. 120/180 mm Hg for males and
110/170 mm Hg for females.
• Exercise will result in an increase in cardiac
output causing and increase in BP.
• Systolic BP can increase approx. 200 mm Hg in
health, fit men and women.
• Systolic BP multiplied by the heart rate is
called Double Product (also referred to as the
rate pressure product) which provides an estimate
of the myocardial (heart tissue) oxygen demand.
Rating of Perceived Exertion(RPE)

• It is important during GXT to determine the

participants psychological perception of the
intensity of the exercise.

• Psychologist Borg developed the original scale.

• The numerical scale 6-20 closely related to HR

from resting to maximum when multiplied by 10
(60-200 bpm)

• A new scale has been developed that measures from

1-10.
Electrocardiogram (ECG)
• ECG is important for diagnosing problems
associated with abnormal cardiac electrical
conductivity and rhythm, insufficient supply of
oxygen to the myocardium, and presence of damage
to the myocardium.

• The outer surface of the heart cells is positive

and the inner surface is negative. This
electrical condition of the cell is referred to
as being polarized. Immediately before
contraction the cell receives a jolt of
electrical activity, which causes a complete
reversal of the cells polarity, meaning the
positive charge is now on the inside of the cell.
This process is called depolarization, which
produces action potential.
Submaximum GXT
• Gives an estimate of ones maximum fitness level.
• Done by evaluating ones cardio respiratory
response to a sub maximal exercise.
• Gives an estimate of ones VO2 Max.
• Less expensive to perform and safer for the
participant.
• VO2max Can be estimated from equations that
either calculate V02max from the last work
achieved on the GXT, from the oxygen
requirement
for horizontal and graded walking on a treadmill,
or from a subjects HR response to a series of
sub maximum work rates.
• Test is usually taken to a workload that elicits
70-85 of the age predicted maximum HR.
Maximum GXT
• Is used for many reasons, ranging from
measurement of VO2max in the world-class athletes
to the diagnosis of abnormal cardiorespiratory
function in cardiac patients.
• This test is taken until complete exhaustion or
until the point at which abnormal physiologic
responses occur.
• Abnormal signs and symptoms may include blood
pressure and ECG changes as well as chest
pain-angina pectoris, shortness of
breath-dyspnea, or lightheadedness.
• Maximum GXT are important because many
abnormalities don’t occur until the workload is
at a high intensity.
Special Populations and Clinical Exercise Physiology Practice
•Major disease states served by clinical exercise
physiologists
•Cardiovascular Disease
•Pulmonary Disorders
•Metabolic Disorders
•Inflammatory Disorders
•Orthopedic Disorders
•Neurovascular Diseases and Conditions
Cardiovascular Disease

• Leading cause of death in the U.S.

• For individuals that survive, a program that
emphasizes both physical and psychosocial
rehabilitation is important.
• People who have the atherosclerosis
susceptibility gene are 50 more likely to have
CHD.
• Atherosclerosis-normally involves injury to the
endothelial wall on the artery.
• Lipids accumulate between the junction of the
inner and middle linings of the artery, resulting
in obstruction of blood flow.
Pulmonary Disorders
• Commonly separated into 3 Groups
• Obstructive (asthma, chronic bronchitis, and
emphysema)
• Restrictive (Pulmonary fibrosis, chest wall
deformity, and neuromuscular weakness)
• Disordered Control of Breathing (sleep apnea
and
obesity hypoventilation)
• Hypoxemia-Deficiency of oxygen in arterial
blood
Metabolic Disorders

• Any defect in the metabolic processes that allows

for fuels to be properly stored in the body,
delivered to active muscles, and oxidized for
energy.
• Can interfere with exercise performance.
Type I Diabetes (Insulin dependant mellitus)

• Occurs primarily as the result of a defect in

which the immune system mistakenly turns on its
own body and destroys the insulin producing
B-Cells .
• After the autoimmune destruction of the B-cells,
little or no endogenous insulin is produced, and
the body is unable to move glucose through the
blood stream into body cells to be used for
energy or to be stored as glycogen.
• Symptoms include frequent urination, unusual
thirst, weight loss, blurred vision, extreme
fatigue, and increased susceptibility to
infection.
Type II Diabetes (noninsulin-dependent diabetes
mellitus

• Occurs as a result of insulin resistance and

account for 90-95 of all diabetes cases.

• Insulin resistance is strongly associated with

physical inactivity.

• Strong genetic predisposition for developing type

II diabetes.
Obesity

• Obesity is the excess accumulation of body fat,

and is an important health problem in the U.S.
• Obesity is associated with and increased
frequency of atherogenic risk factors including
Hypertension, Hyperinsulinemia, type II diabetes,
and reduced HDL, it also is associated with
osteoarthritis and various types of cancer.
• You are obese is your body mass index is
30.0-39.9 and morbidly obese if your BMI exceeds
40.0.
• Develops from a combination of genetic and
environmental factors.
Rheumatologic Diseases
• Encompass disorders of the musculoskeletal
system.
• Often chronic and often leads to disability
• Clinical exercise physiologists can play a role
in minimizing disability through appropriate
evaluation and exercise prescription.
Osteoarthritis
• Most common type of arthritis
• Characterized by local deterioration of
cartilage, leading to joint space loss and new
bone formation.
• Typically affects weight-bearing joints,
specially the knees and hips.
• Risk factors include advanced age, obesity,
genetic factors, trauma, and repetitive use.
Rheumatoid Arthritis

• Present in only 1 of the population.

• A systematic autoimmune disease of unknown cause
whose major features are redness, swelling,
warmth, and significant stiffness of the joints.
• Pre-disposing factors include age, female sex,
lower socioeconomic status, and genetics.
• Has been reported to have increased mortality
rates, and patients with severe forms of this
disease may die 10 to 15 years earlier than
expected.
Orthopedic and Neuromuscular Diseases and
Conditions

•These range from relatively rare diseases

affecting the central nervous system and the
muscle cells, to the widespread occurrence of
pain affecting to neck and back.
Lower Back Pain

• Is the most frequent musculoskeletal complaint

for all people at all ages.
• Acute lower back pain is typically, first treated
with a mild analgesic, such as acetaminophen,
along with a warm shower.
• Other treatments include better posture and
exercise to strengthen and relieve the stress
from the back.
Muscular Dystrophy
• Most common muscular disease in children.
• It is a collection of hereditary conditions that
lead to biochemical and structural changes within
the muscle cell.
• Results in the muscle wasting with and
incremental disease in muscle strength, leading
to disability, deformity, and often death.
Duchene MD

• Most common and destructive MD.

• Caused by a sex-linked recessive genetic defect
and affects young boys at a rate of 1 out of
every 3,500 live births.
• Usually appears between the ages of 2-6 yrs.
Old
• No cure for MD, although exercise therapy
maybe
useful in maintaining mobility.
Multiple Sclerosis
• Most common neurological disease in early to
middle adulthood.
• Twice as common in women.
• Disease of the central nervous system
characterized by loss of myelin sheath.
• Suffer from reduced lifespan, bust most will
survive at least 25 years from diagnosis.
• Important to work closely with members of a
healthcare team,, as the disease progresses, to
plan appropriate levels of activity and to adapt
exercise performance and exercise equipment to
allow patients with MS to maintain their highest
level of functional ability.
Advances in Clinical Exercise Physiology

• Important breakthrough in basic research have led

to meaningful applications in the treatment of
chronic disease.
• Physical activity is now considered to be a
critical role therapies that at one time wouldn’t
have been imagined.
Heart Transplantation
• Approx. 2,800 heart transplants are performed
each year.
• Established treatment for advanced heart disease
• 1 year survival rates are now over 80
• Exercise appears to have a critical role in
post-transplant therapy.
• Although advances are being made there is
currently no way to establish nervous system
connections between the patient and the new
heart.
• The heart beats faster at rest, typically from
100-110 bpm and responds more slowly to exercise.
Thankyou 