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exercise testing and

prescription in older adults


P R E S E N T E D B Y- D R . P U S H P L ATA A RYA , P T
A S S T. P R O F.
L FA M S
Introduction
Physical activity prescription is an under-utilised tool for improving community health.In the
right dose, physical activity can help to prevent, treat, and manage a range of chronic health
conditions that increasingly impact the quality of life and physical function of individuals on a
global scale.
Safe and effective exercise prescription requires careful consideration for the target individual's
health status, baseline fitness, goals and preferences.

Several national and international organisations provide clinicians and allied health professionals
with guidelines for how to screen, assess, and, when appropriate, prescribe exercise for the
benefit of their patients/clients.
Pre-exercise Screening
Before starting a physical activity program, the American College of Sports Medicine (ACSM) and the
American Heart Association (AHA) recommend screening to identify cardiovascular risk
factors.Screenings help mitigate the risk for adverse responses to exercise, as even moderate
physical activity can trigger cardiac events in individuals who are largely sedentary.

With this in mind, two instruments are recommended to facilitate the risk screening process for
fitness professionals. The most commonly used questionnaire is the PAR-Q, followed by the Fitness
Facility Pre-participation Screening Questionnaire.
The PAR-Q is a brief 7 item questionnaire that uses a yes/no answer format to identify personal risk
factors.
In comparison, the Fitness Facility Pre-participation Screening Questionnaire is slightly longer and
captures more detailed information about cardiovascular symptoms.
Screening results in stratifying prospective participants into 3 levels of risk: low, moderate, and high.
Low risk individuals: are men younger than 45 and women younger than 55 with no more than one
cardiovascular risk factor.
Moderate risk: stratification pertains to men over 45 and women over 55 with 2 or more risk factors.
The highest risk category includes any individual with known cardiovascular, pulmonary or metabolic
disease or who demonstrates signs or symptoms of cardiovascular disease.
Signs and symptoms that automatically lead to high
risk stratification include:
Pain, discomfort in the chest, neck, jaw, arms, or other areas that may be due to ischaemia.
Shortness of breath at rest or with mild exertion.
Dizziness.
Orthopnaea or paroxysmal nocturnal dyspnea.
Ankle oedema.
Palpitations or tachycardia.
Intermittent claudication.
Unusual fatigue or shortness of breath with usual activities.
Known heart murmur.
From this information, a decision about the need for medical clearance/consultation can be made prior
to further testing. Next page is a summary of medical clearance and testing recommendations based
on the risk level of the individual and the intensity of exercise in which he or she wishes to participate
Risk Profile Medical Clearance/Consultation Exercise Testing Conditions

Low-risk individuals & vigorous exercise Not necessary Submaximal or maximal testing; no physician
present, emergency procedures in place

Moderate-risk individuals & moderate exercise Not necessary Submaximal or maximal testing; no physician
present, emergency procedures in place

Moderate-risk individuals & vigorous exercise Recommended Physician supervision recommended for maximal
exercise testing

High-risk individuals & moderate to vigorous Recommended Physician supervision recommended for submaximal
exercise or maximal exercise testing
Assessment of Exercise Capacity
Multiple protocols for measuring baseline exercise capacity exist. For aerobic capacity, exercise
testing falls into 2 categories:
maximal and sub-maximal testing.
Maximal testing is reserved for assessing the capacity of individuals who participate in vigorous
exercise.
Sub-maximal testing is adequate for individuals who will only participate in moderate or low-
intensity exercise.
Exercise Prescription
Exercise prescription is based on 5 principles: type, duration, frequency, intensity, and volume.
Type refers to mode of exercise training, with the main forms being aerobic (i.e. endurance
training), resistance (i.e. strength training), flexibility, and balance. The length and number of
exercise sessions performed within a given time frame, are described by duration and frequency,
respectively. Intensity is defined as the level of effort being exerted by the participant and can be
measured in a variety of ways. Common measures of aerobic intensity include the following:
Borg Rating of Perceived Exertion Scale (RPE)
Target heart rate: Percent of maximum heart rate (HR max) or Karvonen Formula/Heart Rate Reserve
(HRR)
Metabolic Equivalents (METS)
Maximum oxygen consumption (VO2 max)
Each measure has guidelines for what parameters denote vigorous, moderate, and low intensity
exercise.
Measurement Low Intensity Moderate Intensity Vigorous Intensity

Borg RPE scale (0-10) <5 5-6 ≥7

HR max 50- 63% 64- 76% 77-93%

METS <3 3-6 >6

VO2 max 20-39% 40-59% 60-84%


With moderate intensity the patient will have a faster heart beat, feel warmer, and breath harder. An
example is brisk walking.
With vigorous intensity the patient will get warm quickly, perspire, breath much harder, and will
struggle to maintain a conversation.
The final principle of exercise prescription is volume. Volume is a sum of the intensity, frequency,
duration, and longevity of a physical activity program.
Recommendations regarding frequency, time, and intensity have been established for each type of
exercise training.
Type Frequency Intensity Time/Duration Examples

Aerobic (Endurance) 5 days/week Moderate 30 minutes (for 150 Vigorous walking,


minutes per week) jogging, swimming,
hiking, cycling

Resistance (Strength) 2-3 days/week 60-70% of 1 rep max 8-12 repetitions, 2-4 sets Free weights, bodyweight
(novice), 40-50% of 1 rep with 2-3 minutes rest in exercise, calisthenics
max (sedentary person, between
older adult)

Flexibility 2-3 days/week Until feeling of tightness. Hold 10-30 seconds, 2-4 Ballistic, static, dynamic,
times to accumulate 60 proprioceptive
seconds per stretch neuromuscular
facilitation

Balance 2-3 days/week Has not been determined. 20-30 minutes Tai Chi, Yoga
The way in which these recommendations are applied depends on multiple factors. In developing a
program prescription, health professionals must consider fitness level, fitness goals, exercise
preferences, equipment availability, and other personal factors that may impact participation.

For example, if a patient or client is starting at a low level of fitness, an initial program may include
low to moderate intensity, aerobic exercise that the individual enjoys and fits his or her time
schedule to encourage adherence. In addition, the patient or client may have to work up to meeting
the recommended 150 minutes per week.
Apply the FITT principle when prescribing exercise:

Frequency
◦ How many times a week for an activity?
◦ For sedentary individuals, start with 2-3 days/week of aerobic exercise and build up to 5 days/week.
Help pt to establish an exercise routine.

Intensity
◦ How hard to exert?
◦ Someone new to exercise should start at a low intensity, but health changes occur at a moderate
exercise intensity
Type
◦ Which type of activity agreed with the patient?
◦ Should be enjoyable, affordable, and achievable

Time
◦ How long in minutes
◦ This does not include the warm up or cool down.
◦ 10 min bouts of exercise can be accumulated throughout the day
◦ If walking is the exercise - first increase the time before increasing the intensity (walking uphill/at a quicker
pace)
Exercise Progression
Progression is way in which frequency, intensity, and duration of an exercise program are increased.
Advancement of an exercise program should be incremental to encourage participant adherence and
avoid injury.
Recommendations for progressing aerobic exercise include increasing the duration of sessions 5 to
10 minutes every 1-2 weeks for the first 4-6 weeks.Frequency and intensity can be progressed as
tolerated. Overall volume should be monitored for adverse effects decreased if necessary.
In the case of resistance exercise, increasing repetitions is favoured before increasing load.
Once the maximum repetitions for a target range have been achieved, load can be increased by
approximately 5% so that no more than the lower limit of repetitions can be performed.
Implications for Physical Therapist Practice

As experts in exercise across the life span, physical therapists stand to play an important role in
promoting, prescribing and managing exercise programs.
A randomized control trial suggests home-based exercise and nutrition strategies have a positive
outcome on the frailty score and physical performance in the pre-frail or frail older adults.
In addition to being a tool to remediate impairments, activity limitations, and participation
restrictions, exercise prescription should also be used to improve the fitness and well being of
patients and clients.
https://youtu.be/yAFb0vxopmc
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