Institute of Sports Science

Exercise Physiology, Training & Training Therapy Research Group

Annual conference of Doctoral School of Behavioural, Social

and Health Sciences in ESTONIA; 01-03/11/2018

“Exercise Prescription and Training in Health

and disease”

Univ. Prof. Dr. Peter Hofmann, FACSM

Key Problems – CVD

Each year cardiovascular disease

(CVD) causes 3.9 million deaths in
Europe and over 1.8 million deaths in
the European Union (EU).

CVD accounts for 45% of all deaths in

Europe and 37% of all deaths in the
EU.

In 2015, more than 85 million people in

Europe were living with CVD and
almost 49 million people were living with
CVD in the EU.

European Cardiovascular Disease Statistics 2017

 Key Problems – Risk Factors

 Dietary factors make the largest contribution to the risk of CVD mortality and CVD DALYs at
the population level across Europe of all behavioral risk factors. High systolic blood pressure
makes the largest contribution of all the medical risk factors.

 The prevalence of smoking in the EU is lower than in Europe as a whole among men but
higher than in Europe among women.

 Few adults in European countries participate in recommended levels of physical

activity, with inactivity more common among women than men.

 Levels of obesity are high across Europe and in the EU in both adults and children, although
rates vary substantially between countries.

 The prevalence of diabetes in Europe is high and has increased rapidly over the last
ten years, increasing by more than 50% in many countries.

 Overall CVD is estimated to cost the EU economy €210 billion a year.

European Cardiovascular Disease Statistics 2017

Key Problems – Life Style Related Diseases

Warburton et al.: Health benefits

of physical activity: the evidence.
CMAJ 2006; 174 (6): 801-809.

European Cardiovascular
Disease Statistics 2017
Key problems - Physical InActivity

 Lack of Physical Activity increases the

risk of heart disease and other chronic
diseases.
 The WHO showed an urgent need to
increase physical activity worldwide in single
individuals and on population wide basis.
 Approx. 3% of health costs in developed
countries are due to physical inactivity (=
less than 2.5 hours of moderate or less than
1 hour of vigorous physical activity per
week). 40% of all EU adults are
physically inactive!

European Cardio-Vascular Disease Statistics 2008

 Key problems – Physical (In-)Activity

Participation in regular physical activity and/or aerobic exercise

training is associated with a reduction in cardiovascular disease
prevalence and mortality, while a sedentary lifestyle increases the risk of
CVD by increasing the risk of hypertension, high triglycerides, low HDL
(‘good’) cholesterol, diabetes and obesity .

The World Health Organization recommends that adults undertake at least

150 minutes of moderate intensity aerobic physical activity per week, at least
75 minutes of vigorous intensity aerobic activity, or a combination of
moderate and vigorous activities.

In older adults aged 65 years and above, the WHO additionally recommends
participation in muscle strengthening activities on at least two days a week,
while for children and adolescents, they recommend at least 60 minutes of
moderate to vigorous intensity physical activity per day .

European Cardiovascular Disease Statistics 2017

Physical Activity and Risik

 A low fitness level increases the mortality risk

substantially.
 The increase in fitness reduces mortality risk by 44%

in men.
 A normal body weight (BMI below 25) and regular
moderate to vigorous physical activity reduce
mortality risk in middle aged and older men and
women

Scientific studies showed, that regular moderate

physical activity significantly reduces the mortality risk
and improves health and fitness.
Type 2 diabetes may be prevented by a healthy life
style in combination with early medical treatment!

Ryan, A.S.: Exercise in aging: its important role in mortality, obesity and insulin resistance. Aging health. 2010 October ; 6(5): 551–563.
Key problems – Physical (In-)Activity

European Cardiovascular Disease Statistics 2017

Key problems – Physical (In-)Activity

European Cardiovascular Disease Statistics 2017

Key problems - Obesity

 Overweight and Obesity have increased dramatically in the last

decades and are still increasing.

 The main causes are overfeeding and lack of Physical Activity!

 Obesity and physical Inactivity increase the risk for

cardiovascular diseases, type 2 – diabetes mellitus, hypertension,
hyperlipidaemia and cancer.

 Obesity and a low fitness level are significantly related to an

increased all cause and cardiovascular mortality risk.

 Obesity , insulin resistance and Inactivity increases with age.

Ryan, A.S.: Exercise in aging: its important role in mortality, obesity and insulin resistance. Aging
health. 2010 October ; 6(5): 551–563.
Key Problems – Overweight / Obesity

European Cardiovascular Disease Statistics 2017

US Obesity Trends 1990 – 2017

Prevalence of Self- 1990 2000

Reported Obesity
Among U.S. Adults by
State and Territory
https://www.cdc.gov/
obesity/data/
prevalence-maps.html

2017
2010

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% 2017 ≥ 35%

Key problems – Obesity

US

European Cardiovascular Disease Statistics 2017

Key problems – Diabetes

European Cardiovascular Disease Statistics 2017

 Physical Inactivity in Adults ≥ 20 Jahre -2008 – (left)
Diagnosed Diabetes rate in Adults ≥ 20 Jahre ≥ 20 years – (right)

INACTIVITY DIABETES
ca. 600.000 in AUT

Obesity
Percent
0 - 6.5
6.6 - 8.0
8.1 - 9.4
Percent
0 - 20.0 9.5 - 11.1
20.1 - 24.4 > 11.2
24.5 - 28.2
28.3 - 32.7
> 32.8
Definitions

Physical Activity, Exercise Training, Physical Fitness and Sport are

terms prescribing different concepts.

Physical Activity
Physical Activity is defined as any bodily movement produced by skeletal muscles that
requires energy expenditure (WHO).

Exercise / Exercise Training

Exercise Training is a sub-group of Physical Activity, which is planned, structured and
regularly repeated exercises aiming to improve or stabilize exercise performance /
fitness and its components.

(Physical) Fitness
Physical Fitness is a set of features related to health and/or performance. The degree of
fitness is measured by specific fitness-/performance. Each kind of physical activity
influences physical and mental fitness.

Sport / Sports
An activity involving physical exertion and skill in which an individual or team competes
against another or others for entertainment.
Physical Activity & Mortality

Associations between sedentary behaviors (daily sitting/TV-viewing time)

and mortality from cardiovascular disease (CVD) and cancer dependent on levels of
physical activity (PA).

A dose-response association between sitting time (9%-32% higher risk; p for trend

<0.001) and TV time (3%-59% higher risk; p for trend <0.001) with CVD mortality was
observed in the 'inactive', lowest quartile of PA.
Associations were less consistent in the second and third quartiles of PA, and there
was no increased risk for CVD mortality with increasing sedentary behaviors in the most
active quartile.
Associations between sedentary behaviors and cancer mortality were generally weaker;
6%-21% higher risk with longer sitting time observed only in the lowest quartile of PA.

PA modifies the associations between sedentary behaviors and CVD and

cancer mortality. These findings emphasize the importance of higher volumes
of moderate and vigorous activity to reduce, or even eliminate these risks,
especially for those who sit a lot in their daily lives.

Ekelund U, et al: Do the associations of sedentary behaviour with cardiovascular disease mortality and cancer mortality differ by physical
activity level? A systematic review and harmonised meta-analysis of data from 850 060 participants. Br J Sports Med. 2018 Jul 10. pii: bjsports-
2017-098963. doi: 10.1136/bjsports-2017-098963.
Physical Activity & CVD / Diabetes

The relationships between physical activity (PA) and both cardiovascular disease (CVD) and
type 2 diabetes mellitus (T2DM) have predominantly been estimated using categorical
measures of PA, masking the shape of the dose-response relationship. In this systematic
review and meta-analysis, for the very first time we are able to derive a single continuous PA
metric to compare the association between PA and CVD/T2DM, both before and after
adjustment for a measure of body weight.

An increase from being inactive to achieving recommended PA levels (150

minutes of moderate-intensity aerobic activity per week) was associated with lower
risk of CVD mortality by 23%, CVD incidence by 17%, and T2DM incidence by
26% (relative risk [RR], 0.77 [0.71-0.84]), (RR, 0.83 [0.77-0.89]), and (RR, 0.74 [0.72-0.77]), respectively, after
adjustment for body weight.

The greatest gain in health is associated with moving from

inactivity to small amounts of PA.

Wahid A, et al.: Quantifying the Association Between Physical Activity and Cardiovascular Disease and Diabetes: A Systematic
Review and Meta-Analysis. J Am Heart Assoc. 2016 Sep 14;5(9). pii: e002495. doi: 10.1161/JAHA.115.002495.
Physical Activity and Cancer

Leisure-time physical activity has been associated with lower risk of heart-disease and
all-cause mortality, but its association with risk of cancer is not well understood.

A total of 1.44 million participants (median [range] age, 59 [19-98] years; 57%
female) and 186 932 cancers were included.
High vs low levels of leisure-time physical activity were associated with lower
risks of 13 cancers. Body mass index adjustment modestly attenuated associations for several
cancers, but 10 of 13 inverse associations remained statistically significant after this adjustment.

Leisure-time physical activity was associated with higher risks of malignant

melanoma and prostate cancer. Associations were generally similar between
overweight/obese and normal-weight individuals. Smoking status modified the
association for lung cancer but not other smoking-related cancers.

Leisure-time physical activity was associated with lower risks (7%) of many
cancer types. Health care professionals counseling inactive adults should
emphasize that most of these associations were evident regardless of body
size or smoking history, supporting broad generalizability of findings.
Moore SC, et al.: Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016
Jun 1;176(6):816-25. doi: 10.1001/jamainternmed.2016.1548.
Physical Activity & Fitness

Physical Inactivity – the biggest public health problem of the 21st

century?
The risk to die from cardio-vascular
disease is significantly related to the
level of fitness but independent from
Body Mass Index (BMI).

Physical inaktivity and a low fitness-

level increase the risik.

2316 men with typ 2 diabetes at the start. 179 deaths during study.

See also Poster by E. Mäestu et al.: Low

fitness is associated with metabolic risk
independently of central adiposity in a
cohort of 18-year olds.

Blair: Physical inactivity: the biggest public health problem of the 21st century. Brit. J. Sports Med. 2009; 43: 1-2.
Limitations and Needs

Limitation is the measurement of Physical Activity

 Heterogeneity of PA assessment across studies

 Self-report methods mostly questionnaires
 Validity of the method, especially for assessing PA in the past and
low intensity PA

Courneya, K.S., Friedenreich, Ch.M. (eds.): Physical Activity and Cancer. In: Schlag, P.M., Senn, J.-
J. (Series eds.). Recent Results in Cancer Research. Springer Heidelberg 2011.

Need for reproducible exercise prescription (intensity, duration,

frequency, progression, volume and duration of the intervention) in
RCT´s!
Kristin L Campbell, K-L., Neil, S.E., Winters-Stone, K.M.: Review of exercise studies in breast cancer survivors:
attention to principles of exercise training. BJSM Online First

Hofmann P, Tschakert, G.:Special Needs to Prescribe Exercise Intensity for Scientific Studies. Cardiology
Research and Practice. 2011, Article ID 209302, 10 pages, doi:10.4061/2011/209302.
, published on June 10, 2011 as 10.1136/bjsm.2010.082719.
 Evidence for Exercise as a Therapy

Today there is clear evidence, that exercise

training has positive effects on pathogenesis,
aerobic exercise performance (fitness),
Quality of Life (QoL) and symptoms in at least
26 different chronic diseases. Exercise
training is therefore a powerful therapy option
for most if not all chronic diseases.
Kujala U.M.: Evidence on the effects of exercise therapy in the treatment of
chronic disease. Br J Sports Med 2009, 43(8): 550-555.
Pedersen B.K., Saltin B.: Evidence for prescribing exercise as therapy in
chronic disease. Scandinavian Journal of Medicine and Science in Sports
2006, 16(1): 3-63).
Pedersen BK, Saltin B.: Exercise as medicine - evidence for prescribing
exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports.
2015 Dec;25 Suppl 3:1-72.

Low exercise performance is a strong

predictor of mortality.
Warburton D.E.R., Nicol C.W., Bredin S.S.D.: Health benefits of physical
activity: the evidence. CMAJ 2006, 174(6): 801-809.
Evidence
 Evidence

Pedersen B.K., Saltin B.: Evidence for prescribing exercise as therapy in chronic disease. Scandinavian Journal of Medicine and Science in
Sports 2006, 16(1): 3-63).
Pedersen BK, Saltin B.: Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci
Sports. 2015 Dec;25 Suppl 3:1-72.
Exercise Training Therapy

 Short time ago patients suffering from

chronic diseases were told not do any
exercise, although some beneficial effects
have been described in the literature.

 Nowadays exercise training is an

integral part of the treatment of patients
with chronic diseases.

 Training intensity is increasing and

today, highly intense interval training is
applied.

 However, we lack sufficient information

regarding the mode and the intensity of safe
exercise training in chronic disease.
Exercise and CV Mortality

Although recommended in guidelines for the management of coronary heart

disease (CHD), concerns have been raised about the applicability of evidence from
existing meta-analyses of exercise-based cardiac rehabilitation (CR).

Overall, CR led to a reduction in cardiovascular mortality (relative risk: 0.74; 95%

confidence interval: 0.64 to 0.86) and the risk of hospital admissions (relative risk:
0.82; 95% confidence interval: 0.70 to 0.96). There was no significant effect on
total mortality, myocardial infarction, or revascularization. The majority of studies (14
of 20) showed higher levels of health-related quality of life in 1 or more domains
following exercise-based CR compared with control subjects.

Exercise-based CR reduces cardiovascular mortality, hospital

admissions and improvements in quality of life. These benefits appear
to be consistent across patients and intervention types and were
independent of study quality, setting, and publication date.

These results support the Class I recommendation of current international clinical

guidelines that CR should be offered to CHD patients
Anderson L. et al.: Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease: Cochrane Systematic Review and Meta-Analysis. J Am
Coll Cardiol. 2016 Jan 5;67(1):1-12. doi: 10.1016/j.jacc.2015.10.044.
Exercise Training Therapy & Guidelines
Exercise Training Therapy &
Pharmacotherapy
Exercise and / or Drug Therapy?

To determine the comparative effectiveness of exercise versus drug

interventions on mortality outcomes.
No statistically detectable differences were evident between exercise and drug
interventions in the secondary prevention of coronary heart disease and
prediabetes. Physical activity interventions were more effective than drug treatment
among patients with stroke. Diuretics were more effective than exercise in heart
failure. Inconsistency between direct and indirect comparisons was not significant.

Although limited in quantity, existing randomized trial evidence

on exercise interventions suggests that exercise and many drug
interventions are often potentially similar in terms of
their mortality benefits in the secondary prevention of coronary heart
disease, rehabilitation after stroke, treatment of heart failure, and
prevention of diabetes.

Naci H, Ioannidis JP.: Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. Br J
Sports Med. 2015 Nov;49(21):1414-22. doi: 10.1136/bjsports-2015-f5577rep.
Physical Activity & Fitness

Changes of Fitness by Exercise Training.

The higher the volume and intensity - the higher the effects!
Effects of volume and / or intensity of exercise

Moderate vs. Strenous Intensity (O’Donavan et al. 2005)

25
20
15
10
VO2max
5
T-C
0
LDL-C
-5 Trig
-10
VO2max - maximal oxygen

-15 uptake
TC – total cholesterol
LDL-C – low density („bad“
-20 cholesterol
Trig - triglicerids
control moderate vigorous
Mechanisms

Mechanims to explain health effects of Physical

Activity and Exercise Training
Mechanisms

Positive influence on Modulation of the immune

hormone systems system
(Estrogens und Steroids)

Physical Activity

reduced Risk !

Positive changes of insulin, Positive modulation of

blood glucose and inflammatory processes
adipocytokines

McTiernan, A.: Mechanisms linking physical activity with cancer. Nature Reviews, Cancer, Volume 8,
March 2008, 205-211.
Intensity of exercise

Although there is still some lack about the specific physiological

adaptations and the biological mechanisms induced by variable
exercise training work loads, an increasing number of
publications show that high-intensity training (constant or
interval-type exercise) gained greater positive effects, than
training at low or moderate intensity.
Kemi O.J., Wisloff U.: High-intensity aerobic exercise training improves the heart in health and disease. J
Cardiopulmon Rehab Prevent 2010, 30(1): 2-11

Tjonna A.E., Lee S.J., Rognomo O., Stolen T.O., Bye A., Haram P. M., Loennechen J.P., Al-Share Q.Y., Skogvoll E.,
Slordahl S.A., Kemi O.J., Najjar S.M., Wisloff U.: Aerobic interval training versus continuous moderate exercise as a
treatment for the metabolic syndrome: A pilot study. Circulation 2008, 118: 346-354

or similar adaptations with a markedly lower training volume.

Gibala M.J., McGee S.L.: Metabolic adaptations to short-term high-intensity interval training: A little pain for a lot of
gain? Exerc Sport Sci Rev 2008, 36(2): 58-63
Standards

Incremental Exercise
 Lactate-Performance-Diagnostics

(A) Three-zone model:

Zone 1 below ventilatory (VT)/lactate
(LT) threshold 1;
Zone 2 above VT1/LT1 and below
VT2/LT2;
Zone 3 above VT2 and below VO2peak.

(B) Five-zone model:

Zone 1: below VT1/LT1;
Zone 2 equal to VT1/LT1;
Zone 3 below VT2/LT2;
Zone 4 equal to VT2/LT2;
Zone 5 above VT2 and below VO2peak.

LT, lactate threshold; VT, ventilatory

threshold.

The past 2 decades have witnessed a growing body of work investigating the feasibility and efficacy of exercise therapy on a
broad array of outcomes in many different oncology scenarios.
Despite this heterogeneity, the exercise therapy prescription approach and the dose tested has been largely similar. Thus,
current exercise therapy prescriptions in the oncology setting adopt a one-size-fits-all approach. In this article, then authors
provide an overview of personalization of exercise therapy in cancer using the principles of training as an overarching
framework.

Specifically, we first review the fundamentals of exercise prescription in chronic disease before focusing attention on application
of these principles to optimize the safety and efficacy of exercise therapy on (1) cancer treatment–induced cardiovascular toxicity
and (2) tumor progression and
metastasis.
Jones LW, Eves ND, Scott JM.: Bench-to-Bedside Approaches for Personalized Exercise Therapy in Cancer. Am Soc Clin Oncol Educ Book. 2017;37:684-694.
 Cell-to-Cell Lactate Shuttle

Once thought to be the consequence of oxygen lack in

contracting skeletal muscle, the glycolytic product lactate is
formed and utilised continuously under fully aerobic
conditions. ‘Cell-cell’ and ‘intracellular lactate shuttle’
concepts describe the roles of lactate in delivery of oxidative
and gluconeogenic substrates as well as in cell signalling.
Examples of cell-cell shuttles include lactate exchanges

(i) between white-glycolytic and red-

oxidative fibres within a working muscle
bed
(ii) between working skeletal muscle and
heart;
(iii) between tissues of net lactate release
and gluconeogenesis.

Lactate shuttles exist in diverse tissues including in the brain,

where a shuttle between astrocytes and neurons is linked to
glutamatergic signalling. Because lactate, the product of
glycogenolysis and glycolysis, is disposed of by oxidative
metabolism, lactate shuttling unites the two major processes
of cellular energy transduction. Lactate disposal is mainly
through oxidation, especially during exercise when oxidation
accounts for 70–75% of removal and gluconeogenesis the
remainder. Lactate flux occurs down proton and concentration
gradients that are established by the mitochondrial lactate
oxidation complex.
Brooks, G.A., Fehey, Th.D., Baldwin, K.M.: Exercise Physiology.
Brooks, G.A.: Lactate. Link Between Glycolytic and Oxidative Human Bioenergetics and Ist Applications. (4th ed). McGraw Hill
Metabolism. Sports Med 2007; 37 (4-5): 341-343 Boston, 2005: 84.
 PHASE I PHASE II PHASE III

LTP2
1st workload

LTP1
rest

0 10 20 30 40 50 60 70 80 90 100 %Pmax
PHASE I PHASE II PHASE III
M La=0 S M La>0 S M La>>0 S
E P P E E P P E P E

EM > PM La rest ES = PM equilibrium ES < PM exp. increase

 Lactate-concentration, lactate rate of appearance
(Ra) und lactate rate of disappearance (Rd)

16 Phase I Phase II Phase III

14

12

La (mmol.l-1)
10

4 LTP2
LTP1
2

0
0 20 40 60 80 100
P (%)

Hofmann, P., Tschakert, G., Pokan, R., von Duvillard, S.P.: Three-
Brooks, G.A., Fehey, Th.D., Baldwin, K.M.: Exercise Physiology. Phase Time Course of Physiological Variables During Incremental
Human Bioenergetics and Ist Applications. (4th ed). McGraw Hill Cycling in Young Male and Female Subjects. Med. Sci. Sports
Boston, 2005: 200. Exerc. 42, 2010, 5: S238.
Catecholamine Response

6 14
Plasma-catecholamines Adr
present a similar pattern
5 Nor 12
than the lactate

Noradrenalin (nmol/l)
La

Adrenalin (nmol/l)
performance curve. Above 10
LTP2 / VT2 adrenalin, 4

La (mmol/l)
noradrenalin but also 8
dopamin (not shown)
3
increase substantially.
6
Below LTP1 /VT1 there is no
2 LTP2
substantial increase in 4
catecholamines but
LTP1
between LTP1 / VT1 and 1 2
LTP2 / VT2
catecholmanines increase 0 0
slightly. 0 100 200 300
P (W)
WONISCH, M., HOFMANN, P., SCHMID, P., POKAN, R.: Zusammenhang zwischen „anaerober Schwelle“, Katecholaminen und Arrhythmien bei
Patienten mit Herzerkrankungen. Österr. J. Sportmed. 37, 2007, 2/3: 50-56.
 VETP1
LTP1

Three –Phases
Two Turn Points

Hofmann, P. Tschakert, G.: Special Needs to Prescribe

Exercise Intensity for Scientific Studies. Cardiology
Research and Practice. Volume 2011, Article ID 209302,
10 pages doi:10.4061/2011/209302.

Binder et al.; Methodological approach to the first and

second lactate threshold in incremental
cardiopulmonary exercise testing. European Journal of
Cardiovascular Prevention and Rehabilitation 2008,
15:726–734.

Hofmann, P., Pokan, R.: Value of the Application of the

Heart Rate Performance Curve in Sports. Int. J. Sports
Physiology and Performance 5, 2010, 4 (Dec): 437-447.
Lactate Performance Curve and
Exercise Performance

Time course of blood lactate

concentration and first (LTP1) and
second (LTP2) lactate turn points in
an incremental cycle ergometer
exercise test in differently trained
male and female healthy sports
students and two top level athletes.
The determination of LTP´s was
independent of the exercise
performance.
The main difference in performance
can be seen by a later increase in
blood lactate concentration at LTP 1 in
the trained subjects. This may
indicate a lower lactate production or
a higher intramuscular lactate
clearance in these subjects.
Hofmann, P., Dohr, K., Seibert, F.-J., Wonisch, M., Pokan, R., Smekal, G., Schwaberger, G.: Relationship between Lactate Turn Point and
Maximal Performance in Young Healthy Male and Female Subjects of Different Exercise Performance Level. In: Cabri, J., Alves, F., Araujo, D.,
Barreiros, J., Diniz, J., Veloso, A. (eds.). Book of Abstracts of the 13th Congress of the European College of Sport Science, 9-12 July 2008
Estoril, Portugal, 2008: 470.
Exercise Training Therapy

Pmax (168±4, 198±4,

213±5, 223±5 W) and P
during phase I (64±2;
87±3; 101±3; 106± 3 W)
increased significantly (p ≤
0.001). %Pmax (38±1%,
44±1%, 47±1%, 48±1%)
significantly increased
from start to the end of the
intervention.

Pokan et al.: In CAD Patients, Performance Improvements are Achieved only During Phase I of Energy
Supply While in Exercise Therapy. Med Sci Sports Exerc 2015.
Standards

Constant Load Exercise

 Critical Lactate Clearance &
Maximal Lactate Steady State

(MLSS)

Beneke, R.: Methodological aspects of maximal lactate

steady state–implications for performance testing. Eur J
Appl Physiol (2003) 89: 95–99.

Concept of a critical lactate clearance point. The relationship between lactate concentration and time is depicted
(left) during four continuous exercises of graded intensities: A the easiest and D the hardest. Exercise intensity C is
the maximum that can be tolerated without evoking a continuous rise in blood lactate. The capacity to clear lactate
is sufficient to allow a maximal lactate concentration steady state. Though lactate clearance capacity may not be
maximal at this point and clearance can increase if lactate rises (as in D) a critical clearance point has been
achieved in C beyond which the dynamic steady state cannot be maintained.
Brooks, G.A., Fehey, Th.D., Baldwin, K.M.: Exercise Physiology. Human Bioenergetics and Ist Applications. (4th ed). McGraw Hill Boston,
2005: 504.
 PHASE I PHASE II PHASE III

1st workload
LTP2

rest
LTP1

0 10 20 30 40 50 60 70 80 90 100 %Pmax
PHASE I PHASE II PHASE III
M La=0 S M La>0 S M La>>0 S
E P P E E P P E P E

EM > PM La rest ES = PM equilibrium ES < PM exp. increase

 Maximal Lactate Steady State

14 La < LTP1 La < LTP2 N=24

La > LTP1 La > LTP2
12
La (mmol.l-1)

10
Phase III
8

4 Phase II
2
Phase I
0
0 10 20 30
time (min)

Blood lactate concentration at four constant load exercise tests 5% below, at and 5% above LTP 1 and LTP2 in trained
and untrained male and female subjects of different age and fitness level.
Tschakert, G., Müller, A., Gröschl, W., Burgsteiner, H., Wallner, D., Hofmann, P.: 2012, unpublished results)
 Lactate & catecholamine response

Moser, O.: Exercise in Type 1 Diabetes Mellitus: Effects of different standardized cycle ergometer exercise modalities
on blood glucose concentration, metabolic, cardio-respiratory and hormonal response . Diss. Univ. Graz 2015-.
Standards

Interval Exercise
Tschakert und Hofmann 2014

H
I
G
H

I
N
T
E
N
S
I
T
Y
Exercise Prescription – Interval Exercise

Components of intermittent Power Output (W)

exercise: tpeak

Ppeak
 Intensity of work out (Ppeak)
 Duration high intensity (tpeak)
Pmean
 Intensity of recovery (Prec)
trec
 Duration of recovery (trec) Prec

 Mean work load (Pmean)

Time (s)
 Number of intervals and ttotal
Pmean = (Ppeak · tpeak + Prec · trec) / (tpeak + trec)
Tschakert, G., Gröschl, W., Schwaberger, G., von Duvillard, S.P., Hofmann, P.: Prescription for aerobic high-intensity interval
training by means of incremental exercise tests markers. Med. Sci. Sports Exerc. 41, 2009, 5 (Suppl.): S430.
Exercise Prescription
 Interval vs. Continuous – Meta-studies

Elliott AD et al.: Interval Training Versus Continuous Exercise in Patients with Coronary Artery Disease: A Meta-Analysis.
Heart Lung Circ. 2014 Sep 16. pii: S1443-9506(14)00687-8.

In patients with CAD, INTERVAL appears more effective than CONTINUOUS for the
improvement of aerobic capacity in patients with CAD. However, long-term studies
assessing morbidity and mortality following INTERVAL are required before this
approach can be more widely adopted.

Pattyn N. et al.: Aerobic interval training vs. moderate continuous training in coronary artery disease patients: a
systematic review and meta-analysis. Sports Med. 2014 May;44(5):687-700.

In CAD patients with preserved and/or reduced LVEF, AIT is superior to MCT for
improving peakVO2, while MCT seems to be more effective in reducing body
weight. However, large, well-designed, randomized controlled trials are warranted to
confirm these findings.
Haykowsky MJ. et al.: Meta-analysis of aerobic interval training on exercise capacity and systolic function in patients with
heart failure and reduced ejection fractions. Am J Cardiol. 2013 May 15;111(10):1466-9.

In clinically stable patients with heart failure with reduced ejection fraction, INT is more
effective than MCT for improving peak VO2 but not the LVEF at rest.
Interval & constant load exercise

How about the risks?

Risks

Rognmo et al. (2012) investigated the risks for cardio-vascular events for high-intensity Interval
exercise training versus moderate constant load exercise in 4846 coronary heart disease
patients (175 820 training hours)

The rate of complications was 1 in 129 456 hours for

moderate exercise and 1 in 23 182 for high-intensity
exercise = 1 : 5.6
„The results of the current study indicate that the risk of a cardiovascular event is low
after both high-intensity exercise and moderate-intensity exercise in a cardiovascular
rehabilitation setting“

However, moderate exercise seems to be safer but data for short high-
intensity interval exercise are missing.
Rognmo Ø, Moholdt T, Bakken H, Hole T, Mølstad P, Myhr NE, Grimsmo J, Wisløff U.: Cardiovascular risk of high- versus
moderate-intensity aerobic exercise in coronary heart disease patients. Circulation. 2012 Sep 18;126(12):1436-40.
Keteyian SJ.:Swing and a miss or inside-the-park home run: which fate awaits high-intensity exercise training? Circulation. 2012
Sep 18;126(12):1431-3.
Halle M.: Letter by Halle regarding article, "Cardiovascular risk of high- versus moderate-intensity aerobic exercise in coronary
heart disease patients". Circulation. 2013 May 28;127(21):e637.
 Exercise Prescription Standards

100 PHASE I PHASE II PHASE III Phase I: up to 70% der HRmax

 Constant load exercise for recovery (short
90 duration)

80  Long duration ultra distance exercise

 Recovery part of interval exercise
70
LTP2  Occupational work
60 1. Bel. Stufe  Metabolically balanced at the local muscular level
not limited in time.
50 LTP1
Ruhe Phase II: up to 90% der HRmax
0 10 20 30 40 50 60 70 80 90 100 %Pmax  Moderate to intense constant load exercise
PHASE I PHASE II PHASE III
 Mean workload for interval exercise
M La=0 S M La>0 S M La>>0 S
 Main aerobic exercise training zone
E P P E E P P E P E
 Metabolically balanced at the systemic level but
limited in time

EM > PM Ruhe La ES = PM Equilibrium ES < PM exp. Anstieg Phase

© Hofmann III: uo to 100% der HRmax
 Heavy to very heavy intensity constant load
exercise inducing clear fatigue and early termination
 Workloads of high intensity intervals

Hofmann P, Tschakert G.: Special needs to prescribe exercise intensity for scientific studies.
 No metabolic balance at the local muscular and the
Cardiol Res Pract. 2010 Dec 15;2011:209302. systemic level and clearly limited in time.
 Exercise Prescription
Standards
 Exercise below TP1 gives no increase in blood lactate concentration (La) as well as catecholamine levels
(Nor, Adr) above baseline and can be sustained for a long duration of several hours.

 An increase in workload above TP1 but staying below TP2 increases blood lactate concentration (La) as
well as catecholamine levels (Nor, Adr) above baseline, but a steady state is built up (at least for the time
investigated).

 Increasing workload above TP2 increases blood lactate concentration (La) as well as catecholamine levels
(Nor, Adr) without reaching a steady state and exercise has to be terminated early.
12 800
<TP1 >TP1 <TP2 >TP2 <TP1 >TP1 <TP2 >TP2 <TP1 >TP1 <TP2 >TP2
2500
10
600
2000
8
La (mmol.l -1 )

Adr (pg.ml -1 )

Nor (pg.ml -1 )
1500
6 400

4 1000

200
2 500

0 0 0
0 10 20 30 40 0 10 20 30 40 0 10 20 30 40
time (min) time (min) time (min)

Time course of blood lactate (La) adrenalin (Adr) and noradrenalin (Nor) concentration during constant load exercise just below
and above the first (LTP 1) and the second (LTP2) lactate turn points.

Adapted from: Moser, O.; Tschakert, G.; Mueller, A.; Groeschl, W.; Hofmann, P.; Pieber Th.; Lawrence, J.; Koehler, G. Short-acting insulin
reduction strategies for continuous cycle ergometer exercises in patients with type 1 diabetes mellitus. Asian Journal of Sports Medicine. 8,1.
2017. e42160. doi:10.5812/asjsm.42160.
Exercise Prescription

Duration and number of repetitions

Duration -Threshold

At a given intensity the duration of exercise there is a hormonal response due

to the development of some kind of fatigue

Viru, A. A. : Adaptation in sports training. Boca Raton: CRC Press 1995:32

 Definition of Duration

Relationship between intensity and duration of exercise of fatigue, recovery and

supercompensation (modified: Platonov 1999: 48-51).
Workload
Recovery
1 2 3 4
(WH) 24-48h
time
Exercise Performance

100% W H
85-90% W h

55-65% W H
At a given intensity the duration of exercise
defines the load:
1 – low; 2 – moderate; 3 – sub-maximal; 4 –
maximal – The marker is the duration until
1/3 2/3 3/3 distict fatigue.
t WH t WH t WH Only in sub-maximal and maximal load
Stop of exercise compensated or distinct fatigue can be seen
leading to delayed recovery and subsequent
adaptation.

Hofmann, P., Tschakert, G., Müller, A.: Grundlagen der Trainingslehre. Teil I: Allgemein Grundlagen. Kompendium
der Sportmedizin. 2015. 
Velocity-Distance Relationship in
Running and Swimming

Hofmann P, Tschakert G.: Intensity- and Duration-Based Options to Regulate Endurance Training. Front Physiol. 24,
2017, 8: 337. doi: 10.3389/fphys.2017.00337.
Prescription of Optimal Duration

Hofmann P, Tschakert G.: Intensity- and Duration-Based Options to Regulate Endurance Training. Front Physiol. 24,
2017, 8: 337. doi: 10.3389/fphys.2017.00337.
Power – Duration Relationship

CP Patient/ Gesund/Trainiert
400

Patient
Gesund
300 Trainiert

30 min Dauer
lt. Empfehlung

Pmax (W)
200 199 W

70 % T

70% G
129 W

40% T
100

70% P
40% G
80 W

40% P

0
100 1000 10000
time [s]

Mezzani A, Corra` U, Giordano A, Colombo S., Psaroudaki M, Giannuzzi P.: Upper intensity limit for prolonged
aerobic exercise in chronic heart failure. Med Sci Sports Exerc 2010; 42: 633–639.
 Power – Duration Relationship

Duration calculated from figure

from Mezzani et al. 2010. Trained
have almost 5 times the duration at
Duration at TP1 and TP2 the same relative intensity at TP1
and about double the duration at
600
Patient
100 TP2 compared to healthy untrained
Untrainiert
and patients; patients and healthy
500
80
untrained are similar in duration at
Trainiert
the same relative intensity of TP1
and TP2. The maximal duration at
time at TP1 (min)

time at TP2 (min)

400
60 TP2 is approx. 20 min - the usual
300 recommendations of 30 min at this
40
intensity should be discussed
200 critically. Lower intensities such as
TP1 intensity can be maintained for
100
20 2-3 hours in patients and healthy
untrained and up to 10 hours in the
trained. As at least 70% of the
0 0
maximal duration are necessary to
TP1 TP2 induce training effects in untrained
and patients approx. 15 min of
exercise at TP2 are sufficient to
induce effects.
Hofmann et al.: unpublished re-evaluation of data from Mezzani et al. 2010
Physical Load Distribution - Polarisation

HIIIE
Flight / Fight

Hypothetical
distribution of
Physical Activity in
stone age „Homo
sapiens“.

Boullosa DA, Abreu L, Varela-Sanz A, Mujika I.: Do olympic athletes train as in the Paleolithic era?
Sports Med. 2013 Oct;43(10):909-17.
High intensity training needs a
polarized model of periodization

HIT

Distribution of training intensities related to the whole year training volume. Left side
“classical“ threshold-model with a high training volume between VT 1 / LTP1 and VT2 /
LTP2 and right side the “polarized-model” with a high training volume below VT 1 / LTP1
accompanyied by training above VT2 / LTP2 but low volumes between both thresholds
(modified: Seiler & Kjerland 2006).
Hofmann, P., Tschakert, G., Müller, A.: Grundlagen der Trainingslehre. Teil I: Allgemein Grundlagen. Kompendium
der Sportmedizin. 2017. 
Take home Message

 Inactivity is a major health problem and Physical

Activity may help to reduce the risk!

 More activity at moderate to high intensity is more

beneficial!

 Standardized exercise training is needed in patients

to prescribe exercise as a medicine!

 Higher intensities do have a higher risk in patients

but yield higher benefits!

PA, Exercise and Fitness are important “confounders” for

Health Studies without exercise interventions! Measures of
PA and Fitness need to be tracked!
 Institute of Sports Science
Exercise Physiology, Training & Training Therapy Research Group

Annual conference of Doctoral School of Behavioural, Social

and Health Sciences in ESTONIA; 01-03/11/2018

Thank You for Your endurance!

Peter Hofmann