SENIOR EDITORMitchell H. Whaley, PhD, FACSMProfessor and ChairSchool of Physical Education, Sport and Exercise SCience

Ball State University

MunCie, Indiana

ASSOCIATE EDITOR-CLINICALPeter H. Brubaker, PhD, FACSMAssociate Professor and Executive DirectorHealthy Exercise and lifestyle Programs

Department of Health and Exercise Science

Wake Forest University

Winston-Salem, North Carolina AMERICAN COLLEGEOF SPORTS MEDICINE

SEVENTH EDITION

4~ L1pPINCOn WILLIAMS & WILKINS.. A Wolters Kluwer Company

Philadelphia' Bahimorc • New York· londonBuenos Aires . Hoog Kong. Sydney . Tokyo

ACSM'sGUIDELINES FOR

EXERCISE TESTING

AND PRESCRIPTION

••:l=;;b •••••••

I-Min Lee, MD, FACSMTimothy McConnell, PhD, FACSM

Jonathan N. Myers, PhD, FACsM

Frank X Pizza, PhD, CSMThomas W. Rowland, MD, FA

Kerry Stewart, EdD, FAC;~CSMPaul D. Thompson, MD, CSMJanet P. Wallace, PhD, FA

AUTHORSLawrence Armstrong, PhD, FACSM

Gary J. Balady, MDMichael J. Berry, PhD, FACSM

Shala E. Davis, PhD, FACSM

Brenda M. Davy, PhD, RD, LC

Kevin P. Davy, PhD, FACSM

Barry A. Franklin, PhD, FACSMNeil F. Gordon, MD, PhD, MPH, FACSM

ASSOCIATE EDITOR-FITNESSRobert M. Otto, PhD, FACSMProfessor and DirectorHuman Performance LaboratoryDepartment of Health, Physical Education, and

Human Performance SciencesAdelphi University

Garden City, New York

3 Pre-Exercise Evaluations 39MedICal History, Physical Examination, and Laboratory Tests 39

Blood Pressure 43lipids and lipoproteins 45Blood Profile Analyses 46Pulmonary Function 47

Section II Exercise Testing

viixxi

XiX

2930

335677

10111212121313

19

192128

Health Appraisal. Risk Assessment. and Safety of Exercise

PrefaceNota BeneContributorsAbbreviations

Benefits and Risks Associated With Physical ActivityPhysical Activity and Fitness Terminology

Public Health Perspective for Current RecommendationsDivergent Physical Activity Recommendations

Benefits of Regular Physical Activity and/or ExerCiseDose-Response Relationship

Risks Associated With ExerCIseSudden Death Among Young IndividualsExerCise Events in Those With Sickle Celf TraitExercise-Related Cardiac Events in AdultsRisks of Cardiac Events During Exercise TestingRisks of Cardiac Events During Cardiac RehabilitationPrevention of Exercise-Related Cardiac Events

Preparticipation Health Screening and Risk StratificationPreparticipation Screening Algorithm

Risk Stratification and Medical ClearanceAdditional Preparticipation AssessmentsExercise Testing and Testing Supervision

RecommendationsRisk Stratification for Cardiac Patients

Contents

2

Section I

Kerry Stewart, EdD, fACSMAssociate Professor of MedicineDi\ision of Cardiology

Dire<.:tor. Johns I (opkins ((cartHealthJohns Hopkins Bayview ]\·ledkalCenter

Baltimore, !\Iaryland

Paul D. Thompson, MD, fACSMDirector, Pre\'enh\'e Cardiology("\lifoI'd I JospitalHmiford, Connecticut

Janet P. Wallace, PhD, fACSMProft'ssor and Director of AdultFitnes~

Dep;uiment of KinesiologyI ndianil U ni\'crsity

Bloomington. (ndiana

Jonathan N. Myers, PhD, fACSMClinical Assistant Professor oft\ledicine

Dep;:uilllent of CardiologyStanl'orJ Unin~rsity

Palo Alto \'A Ilcalth Care SystemPalo Alto. CaJifornia

xii CONTRIBUTORS

Francis X. Pizza, PhDProfessor

Department of Kinesiology

The Uni\'ersity ol'1'oledoToledo, Ohio

Thomas W. Rowland, MD, fACSMProfessor, Departmcnt of Pediatrics

Tufts Uni\'ersih' School of MedicineBoston. Massachusptts

Director, PeJiatric CardiologyBm State t\ledieal Center

Sp~illgfield, Massa<;htlsetts

xiii

xiv CONTENTS

Contraindications to Exercise Testing 49

Informed Consent 49Participant Instructions 51

4 Health-Related Physical Fitness Testing and Interpretation 55

Purposes of Health-Related Fitness Testing 55

Basic Principles and Guidelines 56Pretest Instructions 56Test Order 56Test Environment 56

Body Composition 57Anthropometric Methods 57Densitometry 64Other Techniques 65Body Composition Norms 66 rCardiorespiratory Fitness 66The Concept of Maximal Oxygen Uptake 66Maximal versus Submaximal Exercise Testing 67Modes of Testing 6BCardiorespiratory Test Sequence and Measures 76Test Termination Criteria 78Interpretation of Results 79 I

Muscular Strength and Muscular Endurance 80Muscular Strength 81Muscular Endurance 83 ~

Flexibility 85

A Comprehensive Health Fitness Evaluation 89

5 Clinical Exercise Testing 93 ~Indications and Applications 93

Diagnostic Exercise Testing 93

~Exercise Testing for Disease Severityand Prognosis 94

Exercise Testing After Myocardia/Infarction 94Functional Exercise Testing 95

Exercise Test Modalities 96Exercise Protocols 99

Upper Body Exercise Testing 102

Testing for Return to Work 102Measurements During Exercise Testing 103

Heart Rate and Blood Pressure 103Electrocardiographic Monitoring 105Subjective Ratings and Symptoms 106Gas Exchange and Ventilatory Responses 107Blood Gases 108Indications for Exercise Test Termination 108

Postexercise Period 108

CONTENTS xv

Exercise TestlOg With Imaging Modalities 110Exercise Echocardiography 110Exercise Nuclear Imaging 110Pharmacologic Stress Testing 111Electron Beam Computed Tomography 111

SuperviSion of Exercise Testing 112

Section III Exercise Prescription

115

115

116116119119123123124124125125126126

133134135

136136137138138138139139141146

148149150150151151

153

Interpretation of Clinical Exercise Test DataExercise Testing As a Screening Tool for Coronary

Artery Disease

Interpretation of Responses to Graded ExefCIse TestingHeart Rate ResponseBlood Pressure ResponseElectrocardiographic WaveformsLimiting Signs and SymptomsGas Exchange and Ventilatory Responses

DiagnostIC Value of ExerCise TestingSensitivitySpecificityPredictive ValueComparison With Imaging Stress TestsPrognostic Applications of the Exercise Test

General Principles of Exercise PrescriptionPrinciples of TrainingOvervIew of the Exercise PrescriptIonThe Art of ExerCise Prescnption

Components of the Training SessionWarm-upStimulus or Conditioning PhaseRecreadonalAcd0desCool-Down

Cardiorespiratory ExerCise PrescriptionMode of ExerciseExercise IntensityExercise Duration

Energy Expenditure Goals

Rate of ProgressionInitial Conditioning StageImprovement StageMaintenance Stage

Training SpecifiCitySummary of Guidelines for Cardiovascular

Stimulus Phase

6

7

xvi CONTENTS

Resistance Exercise Prescription 154Flexibility Exercise Prescription 158Maintenance of the Training Effect 160Program Supervision 161Methods for Changing Exercise Behaviors 163

Strategies for Increasing Exercise Adherence 165Encourage Lifestyle Physical Activity 165

8 Exercise Prescription Modifications for Cardiac Patients 174Inpatient Rehabilitation Programs 174Outpatient Exercise Programs 177

Exercise Intensity for the Cardiac Patient 178Modes of ExerCise for Cardiac Patients 181Progression of Exercise for the Cardiac Patient 182Recommended Total Dose or Volume of Exercise

for Cardiac Patients 183Exercise Prescription Without a Preliminary Exercise Test 184Types of Outpatient Programs 186Benefits of Endurance Training in Cardiac Patients 188Resistance Training for Cardiac Patients 189

Eligibility and Exclusion Criteria forResistance Training 189

Time Course for Resistance Training 190Resistance Training Prescription for Cardiac Patients 190

Exercise Training for Return to Work 191Special Cardiac Patient Populations 191

Myocardial Ischemia 191Congestive Heart Failure 193Pacemakers and Implantable

Cardioverter Defibrillators 194Cardiac Transplant Recipient 197Cardiac Surgery and Percutaneous Transluminal

Coronary Intervention 199

9 Other Clinical Conditions Influencing Exercise Prescription 205Arthritis 205

Exercise Testing 206Exercise Prescription 206Special Considerations 207

Diabetes Mellitus 207Exercise Testing 208Exercise Prescription 208Special Considerations 210

Dyslipidemia 211Exercise Testing 212

CONTENTS xvii

Exercise Prescription 212Special Considerations 212

Hypertension 213Exercise Testing 214Exercise Prescription 21 5Special Considerations 21 5

Obesity 216Exercise Testing 217Exercise Prescription 217Special Considerations 218Recommended Weight Loss Programs 218

Metabolic Syndrome 219Exercise Testing and Prescription 220

Immunology 221Exercise and Upper Respiratory Tract Infections 221Immune Responses to Exercise 222Exercise Testing 222Exercise Prescription 223Special Considerations 223

OsteoporosIs 223Exercise Testing 224Exercise Prescription 224Special Considerations 225

Peripheral Arterial Disease 225Exercise Testing 226Exercise Prescription 226Special Considerations 226

Pulmonary Diseases 227Exercise Testing 227Exercise Prescription 228Special Considerations 229

Pregnancy 229Exercise Testing 231Exercise Prescription 231Special ConsideratIOns 231

10 Exercise Testing and Prescription for Children andElderly People

ChildrenClinical laboratory TestingFitness TestingExercise Prescription

Elderly PeopleExercise TestingExercise Prescription

237237237240241

246246247

xviii CONTENTS

Section IV Appendices

ABCoEF

Common MedicationsEmergency ManagementElectrocardiogram IECG) InterpretationMetabolic CalculationsEnvironmental ConsiderationsAmerican College of Sports Medicine Certifications

Index

255267279286300309

351

Abbreviations

AACVPR American Association of CAD coronary artery dIseaseCardiovascular and CDC Centers for DiseasePulmonary Rehabilitation Control and Prevention

ABI ankle/brachial systolic CHF congestive heart failure

pressure index CHO carbohydrate

ACE anglotensin·converting CI cardiac Indexenzyme COPD chronic obstructive

ACGIH American Conference of pulmonary disease

Governmental Industrial CPAP continuous positive

Hygienists airway pressure

ACOG American College of CPR cardiopulmonary

Obstetricians and resuscitation

GynecologIsts CPK creatine phosphokinase

ACP American College of CRQ Chronic RespiratoryPhysicians Questionnaire

ACSM American College of DBP diastolic blood pressure

Sports Medicine DOMS delayed onset muscle

ADl adivities of daily livIng soreness

AHA American Heart ECG electrocardiogram

Association (electrocardiographic)

AICD automatic implantable EF ejection fraction

cardioverter defibnllator EIB exercise-Induced

AIHA American Industrial bronchoconstrictlon

Hygiene Association EIH exerCIse-induced

AMA American Medical hypotension

Association ERV expiratory reserve

AMS acute mountain sickness volume

AST aspartate aminotrans- ES Exercise Speciallst<!l

ferase FC functional capaCIty

AV atrioventricular FEV,o forced expiratory volumeBIA bioelectrical impedance in one second

analysis FFM fat-free massBlS basic life support F102 fraction of inspiredBMI body mass mdex oxygenBP blood pressure FICO" fraction of inspiredBR breathing reserve carbon dioxideBUN blood urea nitrogen FN false negativeC ceiling (heat stress) FP false positive

limit fRV functional residualCABG(S) coronary artery bypass volume

graft (surgery) FVC forced Vital capaCIty

xix

ABBREVIATIONS xxi

SVT supraventricular VMT ventilatory muscletachycardia trainingTHR target heart rate 1iO, volume of oxygenTLC total lung capacity consumed per minuteTN true negative \{)2max maximal oxygen uptakeTP true Positive V02peilk peak oxygen uptakeTPR total peripheral IiO,R oxygen uptake reserveresistance %IiO,R percentage of oxygenTV tIdal volume

uptake reserveVC vital capaCIty VT ventilatory threshold\cO, volume of carbon WBGT wet-bulb globedioxIde per minute

temperature\iE expired ventilatron per WHR waist·to·hip ratiominute W-P-W Wolff·Parkinson·WhiteVEmax maxImal exercise YMCA Young Men's Christianventilation

AssociationYo inspired ventilatIon per YWCA Young Women's

minuteChristian Association

xx ABBREVIATIONS

GXT graded exercise test P,P2 partial pressure ofHAPE high-altitude pulmonary artenal oxygen

edema PAC premature atrialHOL high-density lipoprotein contractionHFD HealthIFltness Director· PAR-Q PhySical ActivityHfl HealthIFltness Readiness Questionnaire

InstruetorSM PO Program DlreetorsMHR heart rate PEmax maximal expIratoryHRmax maximal heart rate pressureHRR heart rate reserve Plmax maximal InspiratoryHR rest resting heart rate pressureIC Inspiratory capacity PNf proprioceptive neuro-ICD implantable cardioverter muscular facilitation

defibrillator Po, partial pressure of100M insulin-dependent oxygen

diabetes mellitus PTCA percutaneous translumi·KSAs knowledge, skills, and nal coronary angiopJasty

abilities PVC premature ventricularLAO left aXIs deviation contractionLBBB left bundle-branch block PVO peripheral vascularLDH lactate dehydrogenase diseaseLDL low-denSity lIpoprotein RER respiratory exchangeL-G-L Lown-Ganong-Levlne ratioLLN lower limit of normal RAO nght aXIs deviationLV left ventricle (left RAL recommended alert limit

ventricular) RBBB right bundle-branchMCHC mean corpuscular hemo- block

globin concentration rep repetitionMET metabolic equivalent RIMT resistive inspiratoryMI myocardial infarction muscle trainingMUGA multigated acquisition l-RM one repetition maximum

(scan) RPE rating of perceivedMVC maximal voluntary exertion

contractIon RQ respiratory quotientMW maXImal voluntary RV reSidual volume

ventilation RVG radlonuclide ventriculog-NCEP National Cholesterol raphy

Education Program RVH rrght ventricularNIOOM non-InSUlin-dependent hypertrophy

dIabetes mellitus S,)02 percent satur.atlon ofNIH NatIonal InstItutes of arterial oxygen

Health SBP systolic blood pressureNIOSH National Institute for SEE standard error of

Occupational Safety and estimateHealth SPECT Single photon

NYHA New York Heart emission computedAssociation tomography

Health AppraisaLRisk Assessment, andSafety of Exercise

Chapter 1 Benefits and Risks Associated WithPhysical Activity

Chapter 2 Preparticipation Health Screening andRisk Stratification

SECTION

I

Benefits and RisksAssociated WithPhysical Activity

•••CHAPTER

1

•

II

II

IIII

TIJi~ chapter pro\'ides operational definitions for terminology used throughoutIhf' hook related to physical adi\'it)' allli fitness, and thell provides a review of:1) the current public:: health reWl'llll1enrlatiolls for physical activity, 2) tlw hC'althand fitness benefits asso<:ia{l'd with regular physical activity aneVor l'xcn.:isl', and:3) the risks associated with exercise. The chaplf'l" ctllH.:ludcs with a brief descrip­tion of recommendations for redlll:illg tl1(--' incidence ami severil) of ('\('rdse­related eomplicalions ill prilll<tf) and secondary pn:>\('ntioll programs.

Physical Activity and Fitness TerminologyIt is important to SlItlllllari/(' s('\,eral key terms dell ned e!<;('WiJerc l

.:! that are usedthroll!!;llout the text. Physical aclidry is dpfllwd a.s Ixxlily TllO\'ement that is pro­duced by tIle eontmetion of ~keletal muscle and tllilt stlbstantiall~ inereaSt's cner­~. P'\pf'nditnre. Exercisl'. a t)lW of physieal aeti\ it), is dl'fllleJ as planned, strm:­tured, and rf'petitiw' hodily 1ll00f'Tllf'nt dOlle to illlprO\(' or Tllaintain onf' or mort'coltlponenls of pllysieal Iltness. Physical fiflless is a Illllltidilllellsional eonceptlilat lIas beell defined as a set of allribllips ,llat people possess or achie\'<.' lhatrelates to llle ability to ]1erf"orlrl pll)'sieal adivity', and is eomprised or skill·n'lat·ed, Iw<tltll-relatcd, ami phYSiologic eomponent.,,2. Skill-related components ofpll)'sical Illnpss inclllde agility, halancf', coordination, speed, power, alld reactiontillie, and are associall'd ttlostly with sport and motor skills perfonnance. Ilcalth­relal<'d physieal fitness is ilssociated with tlw ahility to perform daily adivitieswith Vigor. ami the POss('ssion of" traits and eapaeities that an' assoeiatpd \\ith alow risk of prelllature lkH.'lopmenl of h)lx)kinclic disf'a..'ips «(',g., those associal­ed with plJysical inacti\it~lllpalth-rpIaIPd COllllKlllellts of fllness Include cardio­\"ilsclliar endurance. lllu,elliar strength and endufiUlce. nexibilit). and Ixxl)composition. Physiologi<.· lit ness difTers from he~llth-rf'lalcd fitness ill that ilincludes nonperformall<;i> (."Omlx>nenls that relale to hiological systems iltnu·(,lIced by habilual activity. Physiologic fitness incilldf's:

• ~Ietabolic fitness: Th(' "Ialll:' of melaoolie systems and variables predidi\I'the risk for diabetes and cardiovascular disease

• ~lorphologic fitness: The status of body wmp0l'oitioual fadoy<:irclIlllferencc, IXldy fal l."Onlent. and regional hody fat di"BOlle integrity: The st<1tus of bOllc mineral dellsity

• The linking of adjectives to physiologic ranges (e,g" light -20%--::3H9t \021{)

is based on participation in acthities ranging from 20 to 60 mintltes, which rep­resents the recommended session duration within most exercise prescriptions.

Adapted from United States Dep<lrtment of Hea;\h and Human Serv,ces Phys.cal actll/lty and health: A report of theSurgeon General. 1996; AmenCdn College of Sports Med,clne PosItion Stand The recommended quantity andquality of exerCise fex developing and maintaining card,or{";piralory and muscular fitness, and fleXibility m heal1hy

. adults Me<! SCI Sports Ellerc 1998;30975-991, Howley ET Type of actiVIty r('Stst,Jr!ce, aerob,c and le,sure versusOCcupa\lonal physical actll/lty Med SCi Sports Exerc 2001;335364-5369

Abbreviations METs, metabolIC eqUIValent UnitS (I MET ... 35 mL·kg I· mm I); VOlR, oxygen uptake reserve; HRR,heart ral@ reserve

Table 1-1. Classification of Physical Activity Intensity

Relative Intensity Absolute Intensity Ranges (METs) AcrossFitness levels

Intensity V02R ('Yo) Maximal 12 MET 10 MET 8 MET 6 METHRR (%) HR (%) V02...ax V02...ax V02...ax VOl.....

Very light <20 <SO <3.2 <2.8 <2.4 <2.0light 20-39 SO-63 3.2-S.3 2.8-4.5 2.4-3.7 2.0-3.0Moderate 40-S9 64-76 S.4-7.5 4.6-6.3 3.8-S.1 3.1-4.0Hard (vigorous) 60-84 77-93 7.6-10.2 6.4-8.6 S.2-6.9 4.1-S.2Very hard 2:85 2:94 2:10.3 2:8.7 2:7.0 ~5.3

Maximal 100 100 12 10 8 6

5CHAPTER 1/ 8ENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY

Au illlportant mission of the Allierican College of Sports ~lf'didne (ACSM) is topronlole incrt'ased physical adi\ it~ and fitness to the puhlit,. hI order to advancethis mission, ewrds(' program professionals nlll~t be fall1iliar \\ ith existing publichealth statetllellls that t"elalt' to ph)sical activity alld tllllst stay abreast of'tlLee\ohing scientific literalurc relatl'd to current ami future ph)sical acli\;ty rec­Otnllll'lldatiolls. Curn'llt l't.:'C(lltIIHCndatiolls·1 ':'i h<l\f' expanded thl' traditlollalemphaSiS on forlllall'xerciw' prescriptions to include a broader pllblic health per­spectiw on physical aCtitily. The intellt of these reporh is twofold: 1) to int'reaseboth professional alld publit' aWar('lleS$ of the health bellefits as~ociated withdaily ph~~ieal acth;ty, and 2) to dn\\\ atlention 10 the altlotltlts and inh'llsities ofphysical aeti\ ity IH:'cl?ssary to achic\"(-' these helle-fits, which are 10\\\'1' thall Illosethought 11l'CeSSar~ to ;\chit'H' the traditional physiol(l~ic training effect associatedwith exen:ise', A major thellle within tlK'se public health reports3-·j is that moretraditiol1al excrc:ise recolnnlendatiollS' Ilavl' overlooked tile lllllllL'roUS Ilealtltbt'nerlts associated \\;th regular participation in intermittent. 1l1()(leratc~.il1tensity

physical activity (e.g., <20 lIdllutes per session and <.50lff, of maxilllal aerobicpower), In fact, it was r('cogtliz(~d that health IWllcfits call be obtained from arallge of activities, with longer total duration required for less intense acthities,.md shorter total duration rl'qllircc! fur 1l10tT intcns(' activities.

Two key factors~feasibility and emcat.:y-w(>re important in the developmentof the recommendations that eillpilasizpl! IlllXlcmlt'-intcnsih phv~ical acti\ilv,which can be acclllllulated to achieve health bCl\I'l"its. The ell~1 rL's~dt reprL'st'tlt­ed all attempt to halance feasibility and ('mCaL: in de\t'loping public health n"c­ommendations fllr physical acli\ ity. Became Americans are lrigldy scdC'lItar)' (111eI9'-J8 estill1alt'~ indicating tll:.lt almost 40% of adults do not ell~ag:c in any leisure­time physical aclivit)')IO, persllading sedelltal~' iudi\ iduals to become physicall)active is I1l000e likely to be successful whell the largt't lewl of pll)'sical activit\ is

Public Health Perspective for Current Recommendations

• The theoretic basis for lhl' table is the lillk betwet'll the {/(ljrdir.;e and the rd­a!ivl' physiologic rallg£'. with tlte rl:'lliainder of the (:ohlmm containing data toillustrate the concept that a giH'1l ~I ET \·"Ine {t>,g.. -! ~I ETs} n.:pn.>sellts vary·ing rc/atirt' illtellsiti('s across tIl{: range of fillll'SS h-,vcls t) pically round wit hinhealthy adults (e.g.. 6-12.\1 ET').

• ~1.Lx:imal aerohic capacity t~l)icall~ declines ;wross the life ,...pan7; tll<:,r<'foH.', a

givcl1 ~1l:T vahl(.' (e.g., '-1 .\1 ETs) tYJlicalt~ represents a higher reLative illtetlsi~

I) for older eompared \\ ith ~Ollllgf'r in<lh·iduals. HO\\l.'\er, it should be re<:og­llized that pllysicall) adi\(' older individ'lals m<l) haH' f1ttW,~s Ie-vels at orabow that of sed(.'l1tary ~Oltllger adults.

• f\lthough till' nll~;ng ~I ET ran~e a,~ociatl'd with modaate physical acti\-il)'f()IIml within Tahle 1·1 diff('rs from tilt' absolute range found in earlier \'er­sions of this tnt (i,(~" :3-6 .\1 ET<; independent of fitnt'ss le\'(.'1 or age)"~·tI, itshould lw noted that the ranges ilre quite consistent for indi\iduals willi fllnc·tional capaciti('s less than or l'qual to JO .\1 ETs, Ther<'forl', brisk walkin~ at:3 to -l mpll still represellts lJIor/emti'-intensil) ph~'sical adi\it) for mosthealthyadlllts.

SECTION II HEALTH APPRAISAL, RISK ASSESSMENT, AND SAFETY OF EXERCISE4

Both health-related and physiologic fitness IlleUSlires are c1osel) allied withhealth promotion antI disease prevention and can be modified through regularphysical activity aml exercise.

Professionals should recognize that both the qnality and quantity of physicalactivity recommendations described in later chapters of this text relate to exerciserecommendations and should not be viewed as incon::;istent or contra!) to exist­ing physical activity recommendations for the general puhlic3

6.

In addition to definitions for physical activity, exercise, and physical fitness,there is a recognized need to standardize the lise of terms related to physkal activ­it)' intensitr·'. This issue has been problematic in that adjedh'es s\lch as tight, tOlC,moderate, vigorous, and hard hav€' been associated with a \\ide range of physio­logiC equi\'alents, such as metabolic equivalents (~I ETs) or percentagl's of Jll<'l.ximaloxygen uptake, Likewise, several of the aforementioned t('rms have been useo todescribe quantities of physical acthit)' expressed in kilocalories expended per ses­sion or per week. To aid in the standard \lse of lenninology describing physicalactivity intensity, the authors of the Surgeon Ceneral's report3 pro\ided a c1a"sili­cation scheme, which has been modirled several times"'" and is sllllllllarized inTable 1-1. The table contains an ordinal set of adjectivcs that are arl>itraril~

anchored to a set of physiologic intensity ranges. In addition, the physiologic intcn­sity ranges have been expressed ill both relath'e and absolute tl:'rlllS, Relati(;(' il/tell­

sity is derlned using a percentage of an indhidllal's maximal oxygen uptake reser\{:,or heart rate reserve, whereas absoLllte illtellsity has heen defin('d using ~I ETs withvalues for each intensity categol)' pro\ided across a range of functional capacities,

The following points should be considered when interpreting the informationwithin Table I-J:

DIVERGENT PHYSICAL ACTIVITY RECOMMENDATIONS

An impOltant component of the current recommendations·3-5 that has notbeen emphasized suffiCiently is the dose-response relationship between physicalactivity and health. In other words, some activity is better than none, and moreactivity (up to a point) is better than less. Although the optimal dose of phys­ical activity has yet to be defined, the well-established relationship betweenphysical activity and various health benefits clearly supports the need for profes­sionals to encourage the public to engage in at least moderate amounts and inten­sities of daily physical activity. The health benefits of increasing physical activity\\~thin the general population are potentially enormous because of both the highprevalence of sedentary lifestyle lo and the impact of increased physical activity onlowering disease riskll

.

moderate, rather than the traditional higher-intensity level. Thus, there was anattempt to define the lowest, most effective level of physical activity that couldprovide health benefits.

Two conclusions from the Surgeon General's RepOlt, Physical Activity andHealth3

, remain prudent general guidelines for physical activity and public health:

• "Significant health benefits can be obtained by including a moderate amountof physical activity (e.g., 30 minutes of brisk walking or raking leaves, 15 min­utes of running, or 45 minutes of playing volleyball) on most, if not all, days ofthe week. Through a modest increase in daily acti\~ty, most Americans canimprove their health and quality of life."

• "Additional health benefits can be gained through greater amounts of physi­cal activity. People who can maintain a regular regimen of activity that is oflonger duration or of more vigorous intensity are likely to derive greaterbenefit."

7CHAPTER 1 / BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY

A large body of laboratory- and population-based studies has documented themany health and fitness benefits associated with physical actl\'lty and enduranceexercise training, such as improved physiologic, metabolic, and psychologiCparameters, as well as decreased risk of many chronic diseases and prematuremortality (Box 1_1)3.w Physical activity and exercise clearly prevent occurrencesof cardiac events; reduce the incidence of stroke, hypertensIon, type 2 diabetesmellitus, colon and breast cancers, osteoporotic fractures, gallbladder disease,obesity, depression, and anxiety, and delay mortaliti·19-2., .. ~dditionally, severalstudies have examined the impact of change in physical actIVity or fItness m rela­tion to developing coronary heart disease or dying prematurell6-32: These dataindicate that individuals who change from a sedentary lifestyle to bemg phYSical­ly active, or who change from being physically unfit to physically fit, experiencelower rates of disease and premature mortality compared \\'lth those who contm­ue to remain sedentary or unfit. This holds true from middle age to older age (for­ties to eighties), indicating that it is never too late to become physically active to

achieve health benefits27

DOSE-RESPONSE RELATIONSHIP

In recent years, there has been much interest in the nature and shape of the dose­response CUlve between physical activity and health W Although physical activityclearly has been documented to reduce the risk of the diseases listed pre\'lously(see Box 1-1), the data are far less clear regarding the minimal dose of phYSICalactivity that is required, as well as what fUlther lisk reductions occur with additionalamouqts (duration andlor intensity) of physical activity. Besides the SCIentific valueof these data, such information is also pertinent for public health recommendatIOnsin order to balance the feasibility of the recommendations proposed \\~th their effi­cacy in preventing vmious diseases or health conditions. Therefore, fUltherresearch is needed to more clearly define the minimal dose of physical activity .asso­ciated ~th prevention of various diseases and health conditions and to clmity theshape of the dose-response cUlve. It is also likely that the minimum dose and shapeof the dose-response cUlve differs for various health conditions. For example, 111 thediscussion of public health recommendations, it seems that greater amounts of

Benefits of Regular Physical Activity and/or Exercise

activity per day. Taken collectively, these reports emphasize the additional vol,­ume of physical activity, above the 30 minutes cited ~thin the Surgeon General sreport, that is likely necessary to: 1) prevent the onset of obesity, 2) effect weightloss in overweight adults, and 3) prevent weight regam m formerly obese adults.However, these reports also acknowledge the myriad health benefIts assocJatedwith 30 minutes a day of moderate-intensity physical activity. This consensus ISclearly supported by recent studies in men and women of different races, show­ing risk reductions of some 20% to 50% in corona? heart dIsease and cardIOvas­cular disease incidence rates ~~th moderate-intenSity physical actl\'lty, which canbe accumulated in short bouts, compared with sedentary behavior

I4-

ls. The rec­

ommendations also agree that there is a dose-response relationship, with greaterbenefits occurring at higher duration andlor intensity of physical activity.

SECTION II HEALTH APPRAISAL, RISK ASSESSMENT, AND SAFETY OF EXERCISE6

Although the Surgeon General's recommendation of30 minutes of light to mod­erate activity on most days of the week is a well-established public health rec­ommendation, more recent reports have made recommendations for greatervolumes of physical activity6.12.n Are the recommendations found \vithin thesereports in conflict with those found \vithin the Surgeon General's report? Forthe most part, the answer is no. The clear focus of these recent reports was ener­gy balance, and their recommendations identified the higher volume of physicalactivity necessary to prevent weight gain and reduce weight regain follo~~ng

weight reduction. In 2001, ACSM updated its Position Stand on weight loss andprevention of weight gain for adults 12, and concluded that overweight adultsshould increase their activity to approximately 45 minutes of exercise per day(i.e., 200-300 minutes/week) to facilitate weight loss and prevent weight regain.The following year, in a report on guidelines for healthy eating, the Institute ofMedicine (10M) recommended 60 minutes a day of moderate-intensity physicalactivity to prevent weight gain and accrue additional weight-independent healthbenefits. And finally, in 2003, the International Association for the Study ofObesity (IASO) concluded that 45 to 60 minutes of moderate physical activityper day is required to prevent the transition to overweight and obesity in adults,and that prevention of weight regain may require 60 to 90 minutes of moderate

Improvement in Cardiovascular and Respiratory Function• Increased maximal oxygen uptake resulting from both central and

peripheral adaptations

• Decreased minute ventilation at a given absolute submaximal intensity• Decreased myocardial oxygen cost for a given absolute submaximal

intensity

• Decreased heart rate and blood pressure at a given submaximalintensity

• Increased capillary density in skeletal muscle

• Increased exercise threshold for the accumulation of lactate in theblood

• Increased exercise threshold for the onset of disease signs or symptoms(e.g., angina pectoris, ischemic ST-segment depression, claudication)

Reduction in coronary artery disease risk factors• Reduced resting systolic/diastolic pressures

• Increased serum high-density lipoprotein cholesterol and decreasedserum triglycerides

• Reduced total body fat, reduced intraabdominal fat

• Reduced insulin needs, improved glucose tolerance• Reduced blood platelet adhesiveness and aggregation

Decreased morbidity and mortality

• Primary prevention (i.e., interventions to prevent the initial occurrence)

• Higher activity and/or fitness levels are associated with lower deathrates from coronary artery disease

• Higher activity and/or fitness levels are associated with lowerincidence rates for combined cardiovascular diseases, coronaryartery disease, stroke, type 2 diabetes, osteoporotic fractures,cancer of the colon and breast, and gallbladder disease

• Secondary prevention (i.e., interventions after a cardiac event [toprevent another])

• Based on meta-analyses (pooled data across studies), cardiovascularand all-cause mortality are reduced in postmyocardial infarctionpatients who participate in cardiac rehabilitation exercise training,espeCially as a component of multifactorial risk factor reduction

• Randomized controlled trials of cardiac rehabilitation exercisetraining .involving postmyocardial infarction patients do not supporta reduction In the rate of nonfatal reinfarction ~

physical activity are required to prevent unhealthy weight gain compared with theamount needed to reduce the risk of cardiovascular disease.

Whereas Box 1-1 contains a list of health related benefits attributed to a moreactive lifestyle, Table 1-2 summarizes the available data on the inverse dose­response relationship between physical activity and selected health outcomesW

The categOlies use an evidence-based approach developed by the NationalInstitutes of Health3.1, which places greater emphasis on data from large, random­ized clinical trials. Although randomized trails are considered the gold standard forclinical research, it is often impractical to conduct such studies. For example, stud­ies of physical activity and the primary prevention of coronary heart disease wouldrequire many subjects (thousands to tens of thousands) followed for several years.It would be impossible to maintain good compliance with physical activity overthis time, and in addition would be prohibitively expensive. To emphasize thispoint, it is to be noted that cigarette smoking is clearly believed to cause lung can­cer, even though no randomized clinical trials on this topic have ever been con­ducted. Table 1-2 summarizes results from a large body of observational studies,which indicate an inverse dose-response relationship between physical activity anda variety of health conditions. The clearest of these relationships is for all-causemortality, cardiovascular disease, and coronmy heart disease. A smaller body ofevidence also indicates likely inverse dose-response relations for weight and fatdistribution, type 2 diabetes mellitus, colon cancer, quality of life, and independ­ent living in older persons. Finally, a small body of data, including data from ran­domized clinical tJials, suggests the lack of an inverse dose-response for bloodpressure and depression and anxiety. More research is needed on certain healthconditions to define the dose-response relationship for physical activity.

When the knowledge of the additional health and fitness benefits associatedwith greater quantities and intensities of physical activity and/or exercise iscombined with the fact that the list of chronic diseases favorably affected byexer­cise continues to grow, there remains a clear need for medically and scientifical­ly sound primary and secondmy prevention programs. These exercise programsshould be designed and supervised by qualified profeSSionals who possesstraining in exercise testing and prescription (see Appendix F for academic andexperience prerequisites for ACSM certification).

9

~ Box 1-1, continued

CHAPTER 1 I BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY

Other postulated benefits

• Decreased anxiety and depression• Enhanced physical function and independent living in older persons• Enhanced feelings of well being

• Enhanced performance of work, recreational, and sport activities

*Adapted from references 3, 19: United States Department of Health and Human Services.

Physical activity and health: a report of the Surgeon General, 1996; Kesaniemi YK,

Danforth E Jr, Jensen MD, et al. Dose-response issues concerning physical activity andhealth: an evidence-based symposium. Med Sci Sports Exerc 2001 ;33:5351-358.

, , I

SECTION II HEALTH APPRAISAL, RISK ASSESSMENT, AND SAFETY OF EXERCISE8

Risks Associated With Exercise

Table 1-2. Evidence for Dose-Response Relationship Between PhysicalActivity and Health Outcome*

*From Kesaniemi YK, Danforth E Jr, Jensen MD, et al. Dose-response issues concerning physical activity and health:

an evidence-based symposium. Med Sci Sports Exerc 2001;33:5351-358.

tNo mdlcates a lack of eVidence for a "dose-response" for the relationship between the health outcome and

physical activity; it does not indicate the absence of a favorable relationship.

i:lnverse dose-response for primary prevention, but not for improvement in blood glucose control in patients Withdiabetes.

11

Men Women

50 15 0

11 2766222

CHAPTER 1 / BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY

SUDDEN DEATH AMONG YOUNG INDIVIDUALS

'Adapted from Van Camp Sp' Bloor CM, Mueller FO, et al. Nontraumatlc sports death in high school and college

athletes. Med Sci Sports Exerc 1995;27:641-647.

Disorder

Among individuals younger than 35, the risk of sudden cardiac death during exer­cise is low because the prevalence of occult disease is low. The absolute incidenceof death during or within an hour of sports participation among United Stateshigh school and college athletes has been estimated as one death per year forevelY 133,000 men and 769,000 women, respectivell~.These numbers overesti­mate the incidence of cardiac events because only 100 of the 136 deaths withidentifiable causes of death in this report were caused by cardiac disease. Thereason for lower rates of exercise-related cardiac death among women is unclear,but is characteristic of most studies on this topic.

Congenital cardiac abnormalities and nonatherosclerotic, acquired myocar­dial disease are the primmy cause of exercise-related cardiac deaths in youngerindividuals. Atherosclerotic coronmy artery disease is rare (Table 1_3)'J~--40 In theUnited States, the most common cause of exercise-related sudden cardiac deathis hypeltrophic cardiomyopathy3s,4o,41. This is not true for other populations. Forexample, arrhythmogenic right ventricular cardiomyopathy is the most frequentcause of exercise-related sudden cardiac death in ItalyH Such observations sug­gest that the causes of exercise-related sudden death differ by both the age of thesubjects and the population examined.

tThree also had coronary anomalies; one had Wolff·Parkinson-White syndrome.

tlncludes anomalous lett coronary artery (LCA) from nght sinus of Valsalva (N = 4); Intramural left antenor

descending (LAD) (N = 4); anomalous LCA from pulmonary artery (N = 2); anomalous nght coronary artery (RCA)

from left sinus (N ~ 2); hypoplastic RCA (N = 2); and ostial ridge of the LCA (N = 2). Three subjects With coronary

anomalies also had hypertrophic cardiomyopathy and are tabulated with that group.

Hypertrophic cardiomyopathytProbable hypertrophic cardiomyopathyCoronary artery anomalies:j:MyocarditisAortic stenosisCardiomyopathyAtherosclerotic coronary diseaseAortic ruptureSubaortic stenosisCoronary aneurysmMitral prolapseRight ventricular cardiomyopathyCerebral arteriovenous malformationSubarachnoid hemorrhage

Table 1-3. Cardiac Causes of Death in High School and College Athletes*(N = 100)

Category ofEvidence

CCC

CCB

B

C

Evidence for InverseDose-ResponseRelationship

YesYesNotInsufficient dataInsufficient dataYesYes:j:YesInsufficient dataYes

Not

SECTION 1/ HEALTH APPRAISAL, RISK ASSESSMENT, AND SAFETY OF EXERCISE10

Variable

All-cause mortalityCardiovascular and coronary heart diseaseBlood pressure and hypertensionBlood lipids and lipoproteinsCoagulation and hemostatic factorsOverweight, obesity, and fat distributionType 2 diabetes mellitusColon cancerLow back pain, osteoarthritis, and osteoporosisQuality of life and independent living in

older personsDepression and anxiety

Category definitions:

Category A: Evidence IS from endpoints of well-designed randomized clinical trials (RCTs) (or trials that depart

only minimally from randomization) that provide a consistent pattern of findings in the population for which

the recommendation 15 made. It requires substantial numbers of studies Involving substantial number ofparticipants.

Category B: EVidence IS from endpoints of intervention studies that Include only a limited number of RCTs,

post hoc or subgroup analySIS of RCT, or meta-analysIs of RCTs. In general, Category B pertains when few

randomized tnals exist, they are small in size, and the tnal results are somewhat Inconsistent, or the tnals were

undertaken In a population that differs from the target populatIOn of the recommendation.

Category C: Evidence IS from outcomes of uncontrolled or nonrandomized tnals or observational studies.

Category D: Expert Judgment is based on the panel's syntheSiS of eVidence from expenmental research deScribed

in the literature and/or denved from the consensus of panel members based on clinical experience or knowledge

that does not meet the listed criteria. This category is used only in cases where the provision of some guidance

was deemed valuable but an adequately compelling clinical literature addreSSing the subject of the recommen­

dation was deemed InsuffiCient to Justify placement In one of the other categories (A through C).

Habitual physical activity reduces the incidence of atherosclerotic cardiovasculardisease, Neveltheless, vigorous physical exertion also acutely and transientlyincreases the risk of sudden cardiac death:J4 ,:J5 and acute myocardial infarction:J6.:J7

It is impOltant to remember that exercise only provokes cardiovascular events inindividuals with preexisting hemt disease, whether diagnosed or occult. Exercisedoes not provoke cardiac events in individuals with normal cardiovascular systems.Consequently, the lisk of exercise for any population depends on its prevalence ofcardiac disease.

EXERCISE-RELATED CARDIAC EVENTS IN ADULTS

RISKS OF CARDIAC EVENTS DURING EXERCISE TESTING

EXERCISE EVENTS IN THOSE WITH SICKLE CELL TRAIT

13CHAPTER 11 BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY

PREVENTION OF EXERCISE-RElATED CARDIAC EVENTS

exercise testing in high-risk patients has a higher risk. The o\'erall risk of exercisetesting in a mixed subject population is approximately six cardiac events (e.g.,myocardial inf~lrction, ventricular fibrillation, other important dysrhythmia ordeath) per 10,000 tests (Table 1-4). These results include exercise testing that issupcrvised by nonphysicians""'.

RISKS OF CARDIAC EVENTS DURING CARDIAC REHABILITATION

Individuals with diagnosed coronary artery disease are at the highest risk of expe­riencing a cardiac event during exercise, and it has been estimated that vigorousexercise increases the risk of a cardiac event 100 times in this population'19.Nevertheless, studies of cardiac events during cardiac rehabilitation documentthat the risk of vigorons exercise ill such supervised populations is extremely low(Table 1-,5). ObViously, these data cannot be extrapolated to vigorous exercise incardiac patients who are not supervised because such patients are not monitored,nor are facilities for cardiac resuscitation readily available. Howe\'er, a review ofseven randomized and four nonrandomized tr1als of home-based cardiac rehabil­itation indicated that there was no increase in cardiovascular complications of thisapproach versus formal center-based exercise programs2

.''.

As discussed, acute plaque disl'llption is the likely cause of most cardiac eventsin prcviously asymptomatic individuals. In contrast, both acute plaque rupturcand ventricular dysrhythmias arising from previously infarcted myocardium con­tribute to cardiac events in patients with diagnosed coronal)' heart disease.

The development and evaluation of strategies to reduce the risk of vigorous exer­cise have been negatively impacted by a low incidence of events. Interventions can­not be proposed and tested because an enormous number of subjects would haveto participate to document effectiveness. Consequently, recommendations forstrategies to reduce cardiac events are based primmily on common sense andexpert opinion. FLllthermore, the paucity of exercise-related cardiac events makesit difficult to quantiJY the benefit of any routine screening procedures, Someexperts recommend extensive preparticipation screening ofyoung subjects prior tosports participation using electrocardiographlO or echocanliographl'. However,this approach is controversial and not presently recommended by all organizations.An expelt panel from The Amelican Hemt Association recommends a prepmtici­pation physical examination of young athletes, but does not recommend routineelectrocardiography or echocardiograph/2

. Some expelts and organizations rec­ommend routine exercise stress testing prior to initiating vigorous exercise pro­grams in adults with risk hlctors. This approach also is controversial and notendorsed by all expeJi panels. The ACSM recommends exercise stress testing priorto vigorous exercise for "moderate" or "high-lisk individuals" including men over45 and women over ,55 years of age, indi\'iduals \\'ith more than one coronaty dis­ease risk factor, and those \vith ]..'10wn coronaI)' disease (see Chapter 2), Mostauthorities agree \vith these recommendations for those \\'ith established coronal}altelY disease (CAD). In contrast, the American College of Cardiology and theAmeTican Hemt Association Guidelines for Exercise Testing considered the use-

SECTION II HEALTH APPRAISAL, RISK ASSESSMENT, AND SAFETY OF EXERCISE12

In contrast to the overall low incidence ofexercise-related deaths in young subjects,individuals with sickle cell trait have a remarkably higher incidence of exertion­related death. Sickle cell trait is much more common in the African-American thanthe White population. Kark et a1.4

:3 examined deaths during basic training in 2

million U.S. militalY recruits behveen 1977 and 1981. All of the sudden, "unex­plained" deaths were related to physical exertion and attTibuted to cardiac events,heat illness, or exertional rhabdomyolysis. It is not possible to deCipher exactly howmany of the exercise-related deaths were related to cardiac causes. Nevertheless,the relative risk of sudden unexplained death among AfJican-Americans with sicklecell trait was 27 times higher than in those without it. The absolute death rate inAfrican-Americans with sickle cell trait duTing 8 to 11 weeks of basic training canbe estimated as one death for evelY 3,105 recruits, with an annual rate of one deathfor evelY 478 to 660 recruits. This is remarkably higher than the annual rate ofexer­cise deaths among other populations of militmy age. Athletic trainers and otherswho supelvise young athletes during vigorous exertion should be aware of thispotential problem in AfTican-American athletes.

The risks of exercise in adults are considerably higher than in younger subjectsbecause of the increased prevalence of atherosclerotic cardiovascular disease.The most widely cited studies, performed in Rhode Island44 and Seattle35

, esti­mated an incidence of sudden cardiac death dUling vigorous exertion in healthyadults as only one death per year for every 15,000 to 18,000 individuals. This is alow incidence of cardiovascular events, but both studies demonstrated that therate of sudden cardiac death during or immediately after vigorous exertion washigher than that duTing more leisurely activities. Exercise also acutely increasesthe risk of acute, nonfatal myocardial infarction36

.37 Interestingly, both the inci­

dences of exertion-related sudden cardiac death35 and acute myocardial infarc­tion36

.37 are higher in individuals who exercise infrequently.

The mechanism of sudden cardiac death and acute myocardial infarction inpreviously asymptomatic adults is probably acute coronary plaque rupture lead­ing to coronmy thrombosis. Atherosclerosis decreases the flexibility of the coro­nary arteries. The increased frequency of cardiac contraction and the increasedexcursion of the coronary arteries during exercise produce increased bending andflexing of these arteries. This increased fleXing can produce cracking in the ath­erosclerotic plaque, which leads to platelet aggregation and subsequent acutecoronary thrombosis. Such atherosclerotic plaque disruption with acute throm­botic occlusion has been documented by angiography in individuals withexercise-induced cardiac events45-47

As noted, the Tisk of exercise varies with the prevalence of underlying coronaryartely disease in the population. Consequently, the risk of exercise stress testingalso valies with the populations studied. Exercise stress testing performed inpreviously healthy individuals has a low rate of cardiovascular events, whereas

15

REfERENCES

1. Caspersen C), Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: defini­

tions and distinctions for health-related research. Public rlealth Rep 1985: I00: 126-131.2. President's Councll on Pbysical Fitness. Definitions: health. fitness. and physical acti\;ty. Research

Digest, 2000.3. United States Department of Health and Human Sen·ices. Ph)"sical activity and health: a report of

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fulness of routine exercise testing prior to vigorous exercise in asymptomatic per­sons as less well established by evidence or opinion (Class IIB)'53.54 Such diver­gence of opinion leaves the decision about the necessity of a prepmticipation exer­cise test in healthy subjects largely to the clinician.

Procedures for redUCing the risks of vigorous exercise during exercise train­ing, exercise stress testing, and cardiac rehabilitation have not been evaluatedrigorously. Nevertheless, several Simple measures seem prudent. Individuals withknown cardiovascular disease should receive medical clearance prior to vigorousexercise training. Individuals who seek to start an exercise program should bequeried as to their reasons for initiating exercise, because some patients with newsymptoms of cardiovascular disease initiate exercise programs in an attempt toreassure themselves that they are well. It is also important that practitionerssupervising vigorous exercise programs or testing have training in cardiac life sup­port and established procedures for dealing with emergencies. These proceduresshould be reviewed and practiced at least several times yearly (see Appendix B).Also, because the incidences of exercise-related sudden cardiac death amI acutemyocardial inftuction are more frequent in physically unfit subjects, individualsinitiating exercise programs should be encouraged to stalt slowly and progressgradually. It is also impOltant that exercising adults know the prodromal symp­toms of CAD. Some victims of exercise-related cardiac events underestimatedthe importance of their symptoms prior to deathH Finally, if young or older indi­viduals develop exercise-induced symptoms such as chest discomfort, unel..'pect­ed dyspnea, or syncope, they should be fully evaluated by a physician prior toretuming to vigorous activity.

CHAPTER 1 / BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY

Abbreviation: MI, myocardial infarction.

Reference Cardiac Arrest MI Fatalities MI and Arrest

Van Camp61 111,996 293,990 783,972 81,101

Digenio62 120,000 160,000 120,000

Vongvanich 63 89,501 268,503 268,503 67,126

Franklin64 146,127 97,418 292,254 58,451

Average 116,906 219,970 752,364 81,669

•Adapted from Franklin SA, Sonzhelm K, Gordon S, et al. Safety of medically supervised outpatient cardiac rehablll'tation exerCise therapy: a 16'year follow·up. Chest 1998;114:902-906.

Table 1-5. Number of Participants for One Cardiac Event in Cardiac

Rehabilitation Programs*

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SECTION 1/ HEALTH APPRAISAL, RISK ASSESSMENT, AND SAFETY OF EXERCISE

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14

5. ~ationaJ Institutes of Ilealth. Physical acti,·it., and cardiO' as<:lIlar health. ~ lJ I COnSf>I1SlIS

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Infarction Onset Study Investigators. N Engl J Med 199:3;:329:1617-168:3.:37. Giri S, Thompson PD, Kiernan FJ, et al. Clinical and angiographic characteristics of exertion·related

acute myocardial infarction. JAYIA 1999;282: 17:31-17:36.:38. Van Camp SP, Bloor CM, Mueller Fa, et a1. Nontraumatic sports death in high school and college

athletes. Med Sci Sports Exerc 1995;27:641-647.:39. Maron BJ, Hobelts WC, McAllister HA, et al. Sudden death in young athletes. Circulation 1980;

62:21&--229.40. Burke AP, Farh A, Virmani H, et al. SpOlts·related and non·spurts·related sudden cardiac death in

young adults. Am Heart J 199J;111:.5G8-575.41. Maron 13J, Shirani J, Poliac LC, et al. Sudden death in young competitive athletes. Clinical, demo·

graphic, and pathological profiles. JAMA 1996;276:199-204 .42. Thiene G, Nava A, Corrado D, et a1. Right ventricular cardiomyopathy and sudden death JIl young

people. N Engl J Med 1988;3J8:119-1:3:3. .4:3. Kark JA, Posey DM, Schumacher HR, et al. Sickle-cell trait as a risk factor for sudden death JIl

physical training. N Engl J Med 1987;:317:781-787.44. Thompson PD, Stern YIP, Williams P, et a1. Death during jogging or running. A study of 18 cases.

JAMA 1979;242:1165-1267.45. Black A, Black MM, Gensini G. Exertion and acute coronary artelY injury. Angiology 197.5;26:

759-78:346, Ciampricotti H, Deckers J'oV, Taverne H, et al. Charaeteristics of conditioned and sedentary men

with acute coromuy syndromes. Am J CardioI1994;7:3:219-222.47. Hammoudeh AJ, Halt J1. Coronary·plaque rupture in acute coronary syndromes triggered by snow

shoveling. N Engl J ~Ied 1996;3:3.5:2001.48. Knight JA, Laubach CA Jr, Butcher HI, et al. Supen~sion of clinical exercise testing by exercise phys·

iologists. Am J Cardiol 1995;75:390-391. .49. Cobb LA, Weaver WD. Exercise: a risk for sudden death in patients with coronalY heart disease.

J Am Coli Cardio! 1986;7:215-219.50. Kragel AH, Hoberts WC. Sudden death and cardiomegaly unassociated with coronary, valvular, con·

genital or specific myocardial disease. Am J Cardio] 1988;61:659-660..51. Corrado D, Basso C, Schiavon M, et al. Sereening for hypertrophic cardiomyopathy in young

athletes. N Engl J Med 1998;:3:39::364-:369.52. Maron BI. Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive

athletes. A statement for health profeSSionals from the Sudden Death Committee (clinicalcardiology) and Congenital Carcliac Defects Committee (cardiovascular disease in the young),

American Heart Association. Circulation 1996;94:850-856.5:3. (>ibbons HI. Balady GJ, Beasley J'V, et a1. ACC/AHA guidelines for exercise testing: executive sum·

mary. A report of the American College of Cardiology/American Heart Association Task Force on

Practice Guidelines (Committee on Exercise Testing). Circulation 1997;96::34.5-:3.54.54. Gibbons RI. Balady GI. Bricker J, et al. ACC/AHA 1002 guideline update lor exercise testing: a

report of the American College of Cardiology/American Heart Association Task Force on PracticeGuidelines (Committee on Exercise Testing). 1002. American College of Cardiology weh site

www.acc.orglclinicaVguidelines/exercise/dirindex.htm55. McHenry PL. Hisks of graded exercise testing. Am J Cardiol 1977;:39:93.5-9:37.56. Hochmis P, Blackburn H. Esercise tests. A survey of procedures, safety, and litigation experience in

approximately 170,000 tests. JAM A 1971;217:106J-I066.

16 SECTION 1/ HEALTH APPRAISAL, RISK ASSESSMENT, AND SAFETY OF EXERCISE CHAPTER 1 I BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY 17

19

Preparticipation Screening AlgorithmPrepmticipation screening procedures should be valid, cost effective, and timeefficient. Procedures range from self-administered questionnaires to sophisticateddiagnostic tests, Exercise program profeSSionals should establish prepalticipatscreening procedures appropdate for their clients or a facility's target population.To provide guidance on the appropliate depth and breadth of prepmticipationhealth screening, ACSM offers the algOJithm presented in Table 2-1. ThealgOlithm defines three leuels of screening \vith the intent of presenting a logicalsequence of assessment and decision making. It is generally accepted thatmany sedentm)' individuals can safely begin a )ight- to moderate-intensity (see

CHAPTER

2••••••Preparticipation HealthScreening and RiskStratification

This chapter presents guidelines related to preparticipation health screening andlisk stratification for individuals initiating a self-guided physical activity regimen orthose enteling plimary or secondary prevention exercise programs. To this end, theAmelican College of Sports Medicine (ACSM) recognizes other published guide­lines by the Ametican Hemt Association (AHA) and the Amelican Association ofCardiovascular and Pulmomu), Rehabilitation (AACVPR)I~5. Exercise programprofeSSionals should review these other documents, as well as revisions to them,when establishing program-specific policies for prepmticipation health screeningand medical clearance. .

To aid in the development of a safe and effective exercise prescription andoptimize safety during exercise testing, it is important to screen potential par­ticipants for risk f~1ctors ancIJor symptoms of various cardiovascular, pulmonalY,and metabolic diseases, as well as conditions (e.g., pregnancy, orthopedicinjury) that may be aggravated by exercise. The pUl1Joses of the preparticipa­tion health screening include the following:

• Identification and exclusion of individuals vvith medical contraindications toexercise

• Identification of indi\~duals at increased risk for disease because of age,symptoms, and/or dsk hlctorS who should undergo a medical evaluation andexercise testing before stmting an exercise program

• Identification of persons with clinically significant disease who should partic­ipate in a medically supel'\~sed exercise program

• Identification of indi\~dualswith other special needs

18 SECTION 1/ HEALTH APPRAISAL, RISK ASSESSMENT, AND SAFETY OF EXERCISE

57. irving )13, Bruce HA, OeHotien TA. Variations in and significance of systolic pressure during ma.xi­mal exercise (treadmill) teslin~. Am J Cardiol 1977;39:841-888.

58. Atterhog JII. Jonsson B, Samuelsson B.. Exercise tt'sting: a prospective study of complieation rates.Am Hearl J J979;98:512-579.

59. Stuart HJ Jr, Ellestad MIl. Nalional survey of pxercise strpss testin" f',cilities. Chest 1.980;17:94-97.60. Cibbons L, Blair SN, Kohl I IW. et al. The salety of m'Lxirnal exercise lestin~. Circulation 1989;80:

846-852.

61. Van Camp SP, Peterson HA. Cardiovascular CUlllrlications of outpatient cardiac rehabilitationprograms. JA:-IA 1986;2.56: I I60-J 163.

62. Di"enio AG. Sim JC, Do\\'des\\'ell HJ, et al. Exercise-related cardiac arrest in cardiac rehabilitation.The Johannesbur" experience. S Afr ~Ied J 1991;79: 188-191.

63. \'ong-'anich P, Paul-Labrador :-IJ, ~Iprz C:\. Safety of nwdicalh supe'Yised exercise in a cardiacrehabilitation center. Am J Cardio! 1996;17:]:383-]:38.5.

64. Franklin BA, Bonzheim K, Cordon S, el "I. Safety of l1ledicaJly supervised outpatient cardiac reha­bililation exercise therapy: a 16-year follow-up. Chest 1998;114:902-906

RISK STRATIFICATION AND MEDICAL CLEARANCE

Table 1-1) physical adi\~ty regimen ,\~thout the need for extensive medicalscreening 2.1>-8; therefore, Levcl 1 screening ma)' be all that is necessary for mostindi,~duals seeking to adopt a more active lifestyle. However, it should bc notedthat many exercise programs incorporate all three levels descJibed in Table 2-1into their procedures regardless of the outcome from each level. This should notbe ~ewed as inappropliate, because information gained in subsequent screeningsteps can enhance the safcty and effecti"eness of the exercise prescliption.FUlthermore, the prepalticipation screening recommcndations in Table 2-1 relateto both self~ and profeSSionally guided exercise regimens; therefore, physiciansand other allied health professionals counseling clients or patients to adopt a moreactive lifestyle should provide appropliate screening as palt of the physical activi­ty counseling process. Finally, regardless of the scope of prepalticipation screen­ing employed, information should 'he intell)reted by qualified profeSSionals andresults should be documented2

.

The initial screening step in Table 2-1 is deSigned to yield information regarding liskstratification and the need for medical dearance plior to heginning or Significantlyincreasing physical actil~ty. This process requires identification of the presence of:

• Coronary attery disease (CAD) lisk factors (Table 2-2)Signs or S)~llptoms of cardiovascular, pulmon,uy andlor metabolic disease(Table 2-3)

• Known cardiovascular, pulmona,y, andlor metabolic disease

As an initial, minimal step, it is recommended that prospective exerciserscomplete a self-admillistered questionnaire that serves to alert those with ele­vated risk to consult their physician (or other appropriate health care provider)prior to participation2

.9

.10 As self-administered surveys, such forms can be

incorporated into: 1) physical aeti,~ty promotional materials deSigned for thegeneral public, 2) routine paperwork completed within the scope of a physicianoffice visit, or 3) ently procedures at health/fitness or clinical exercise programfacilities. The modified AHA/ACSM Health/Fitness Facility PreparticipationScreening Questionnaire (Fig. 2-1) and the Physical Activity ReadinessQuestionnaire (PAR-Q; Fig. 2-2) II represent examples of self-administeredsurveys recommended for use at Level 1 screening for individuals seekingeither self- or profeSSionally guided regimens. \Vhen medica] clearance is rec­ommended from the questionnaire results, palticipants should be advised toobtain such clearance prior to participation. Individuals recommended formedical clearance may further benefit from initial participation in a profes­sionally guided program. Although both surveys are effective in identifyingindividuals who would benefit from medical consultation prior to participation,the AHA/ACSM questionnaire provides greater detail regarding cardiovasculardisease risk factors and symptoms, and it identifies a broader scope of chronicdiseases that might be aggravated hy exercise. Thus, the AHA/ACSM question­naire is more useful for identifying ACSM risk strata (Table 2-4). Although theuse of either questionnaire is acceptable at Level I screening, many health/

(texl COnlill11f'S on page 27)

21CHAPTER 2 / PRE PARTICIPATION HEALTH SCREENING AND RISK STRATIFICATIONSECTION 1/ HEALTH APPRAISAL, RISK ASSSESSMENT, AND SAFETY OF EXERCISE20

.-I

NQ)

-=ell~

Hypertension threshold based on National High Blood Pressure Education Program. The Seventh Report of the Joint

National Committee on Prevention. Detection. Evaluation. and Treatment of High Blood Pressure (JNCl). 2003. 03­5233.

" ''"'0' /R'~A~k's'" KAS'''S'M'''. A'O "'m 0' mRC'"

Table 2-2. coronh Artery Disease Risk Factor Thresholds for Use WithACSM Risk Stratification

Lipid thresholds based on National Cholesterol Education Program. Third Report of the National Cholesterol

Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol inAdults (Adult Treatment Panel III). NIH Publication No. 02-5215, 2002.

Impaired FG threshold based on Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Follow­up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160-3167.

Obesity thresholds based on Expert Panel on Detection Evaluation and Treatment of Overweight and Obesity in

Adults. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of over­weight and obesity in adults-the evidence report. Arch Int Med 199B;158:1855-1867.

Sedentary lifestyle thresholds based on United States Department of Health and Human Services. Physical activityand health: a report of the Surgeon General. 1996.

tProfessional opinions vary regarding the most appropriate markers and thresholds for obesity and therefore, alliedhealth profesSionals should use clinical judgment when evaluating this risk factor.

*Accumulating 30 minutes or more of moderate physical activity on most days of the week

INotes: It is common to sum risk factors in making clinical judgments. If HDL is high, subtract one risk factor from

the sum of positive risk factors, because high HDL decreases CAD risk.

23

Clarification/Significance

continued

One of the cardinal manifestations of cardiac disease, in partic­ular coronary artery disease

Key features favoring an ischemic origin include:• Character: Constricting, squeezing, burning, "heaviness"

or "heavy feeling"• Location: Substernal, across midthorax, anteriorly; in both

arms, shoulders; in neck, cheeks, teeth; in forearms, fingersin interscapular region

• Provoking factors: Exercise or exertion, excitement, otherforms of stress, cold weather, occurrence after meals

Key features against an ischemic origin include:• Character: Dull ache; "knifelike," sharp, stabbing; "jabs"

aggravated by respiration• Location: In left submammary area; in left hemithorax• Provoking factors.' After completion of exercise, provoked

by a specific body motionDyspnea (defined as an abnormally uncomfortable awareness of

breathing) is one of the principal symptoms of cardiac andpulmonary disease. It commonly occurs during strenuousexertion in healthy, well-trained persons and during moderateexertion in healthy, untrained persons. However, it should beregarded as abnormal; when it occurs at a level of exertionthat is not expected to evoke this symptom in a given individ­ual. Abnormal exertional dyspnea suggests the presence ofcardiopulmonary disorders, in particular left ventricular dys­function or chronic obstructive pulmonary disease.

Syncope (defined as a loss of consciousness) is most commonlycaused by a reduced perfusion of the brain. Dizziness and, inparticular, syncope during exercise may result from cardiac dis­orders that prevent the normal rise (or an actual fall) in cardiacoutput. Such cardiac disorders are potentially life-threateningand include severe coronary artery disease, hypertrophic car­diomyopathy, aortic stenosis, and malignant ventricular dys­rhythmias. Although dizziness or syncope shortly after cessa­tion of exercise should not be ignored, these symptoms mayoccur even in healthy persons as a result of a reduction invenous return to the heart.

Orthopnea refers to dyspnea occurring at rest in the recumbentposition that is relieved promptly by sitting upright or standing.Paroxysmal nocturnal dyspnea refers to dyspnea, beginningusually 2 to 5 hours after the onset of sleep, which may berelieved by sitting on the side of the bed or getting out of bed.Both are symptoms of left ventricular dysfunction. Althoughnocturnal dyspnea may occur in persons with chronic obstruc­tive pulmonary disease, it differs in that it is usually relievedafter the person relieves himself or herself of secretions ratherthan specifically by sitting up.

Sign or Symptom

Pain, discomfort (orother anginalequivalent) in thechest, neck, jaw,arms, or otherareas that mayresult fromischemia

CHAPTER 2 / PREP7~iTI~;EA/H;;~NG Af;:T~TTAT'ON

Table 2-3. Ma~ Sign~ or Symptoms SU9t:tive of Cardiovascular,Pulmonary, or Metabolic Disease*t

Shortness of breathat rest or withmild exertion

Dizziness or syncope

Orthopnea orparoxysmalnocturnaldyspnea

Myocardial infarction, coronary revascularization, or suddendeath before 55 years of age in father or other male first­degree relative, or before 65 years of age in mother orother female first-degree relative

Current cigarette smoker or those who quit within the previ­ous 6 months

Systolic blood pressure ;;-,140 mm Hg or diastolic ;;-,90 mmHg, confirmed by measurements on at least two separateoccasions, or on antihypertensive medication

Low-density lipoprotein (LDL) cholesterol> 130 mg·dL- 1 (34mmol·L-') or high-density lipoprotein (HDL) cholesterol<40 mg·dL- 1 (1.03 mmol·L- 1

), or on lipid-lowering med­ication. If total serum cholesterol is all that is available use>200 mg·dL-1 (5.2 mmol-L-1

) rather than low-densitylipoprotein (LDL) >130 mg·dL-1

Fasting blood glucose ;;-,100 mg·dL-1 (5.6 mmol·L-1) con­firmed by measurements on at least two separate occasion

Body mass index >30 kg'm-2

or

Waist girth> 102 cm for men and >88 cm for womenor

Waist/hip ratio: ;;-'0.95 for men and ;;-'0.86 for womenPersons not participating in a regular exercise program or not

meeting the minimal physical activity recommendations:tfrom the U.S. Surgeon General's Report

Defining Criteria

Defining Criteria

>60 mg·dL-1 (1.6 mmol-L-1)

Positive Risk Factors

2. Cigarette smoking

4. Dyslipidemia

3. Hypertension

1. Family history

5. Impaired fastingglucose

6. Obesityt

7. Sedentary lifestyle

1. High-serum HDLcholesterol l

Negative Risk Factor

tThese signs or symptoms must be interpreted within the clinical context in which they appear because they arenot all specific for cardiovascular, pulmonary, or metabolic dIsease.

*Modified from Gordon S, Mitchell as. Health appraisal in the non-medical setting. In: Durstine JL, King AC, PainterPL, eds. ACSM's resource manual for guidelines for exercise testing and prescription. Philadelphia: Lea & Febiger,1993:219-228.

Table 2-3. Major Signs or Symptoms Suggestive of Cardiovascular.Pulmonary. or Metabolic Disease*t (continued)

25

If you marked any of these statementsin this section, consult your physicianor other appropriate health careprovider before engaging in exercise.You may need to use a facility with amedically qualified staff,

If you marked two or more of thestatements in thiS section you shouldconsult your physician or other appro­priate health care provider beforeengaging in exercise. You might bene­fit from using a facility with a profes­sionally qualified exercise staff t toguide your exercise program.

You should be able to exercise safelywithout consulting your physiCian orother appropriate health care providerin a self-guided program or almostany facility that meets your exerciseprogram needs.

CHAPTER 2/ PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION

FIGURE 2-1, AHA/ACSM Health/Fitness Facility Preparticipation Screening

Questionnaire*

Assess your health status by marking all true statements

__ None of the above

Cardiovascular risk factorsYou are a man older than 45 years.

-- You are a woman older than 55 years, have had a-- hysterectomy, or are postmenopausal.

__ You smoke, or quit smoking within the previous 6 months.__ Your blood pressure is > 140/90 mm Hg.

You do not know your blood pressure.-- You take blood pressure medication.

-- Your blood cholesterol level is >200 mg/dL.-- You do not know your cholesterol level.-- You have a close blood relative who had a heart attack or-- heart surgery before age 55 (father or brother) or age 65

(mother or sister). .__ You are physically inactive (i.e., you get <30 minutes of

physical activity on at least 3 days per week).You are >20 pounds overweight.

HistoryYou have had:

a heart attack__ heart surgery

cardiac catheterization=coronary angioplasty (PTCA)__ pacemaker/implantable cardiac__ defibrillator/rhythm disturbance

heart valve diseaseheart failure

__ heart transplantation

__ congenital heart disease

Symptoms . .__ You experience chest discomfort With exertion.__ You experience unreasonable breathlessness.__ You experience dizziness, fainting, or blackouts.__ You take heart medications.

Other health issuesYou have diabetes.

-- You have asthma or other lung disease.=You have burning or cramping sensation in your lowerlegs when walking short distances.You have musculoskeletal problems that limit yourphysical activity. .You have concerns about the safety of exerCISe.=You take prescription medication(s).You are pregnant.

. . . H rt Association. ACSMlAHA Joint Position*Modified from American College of Sports MediCine and Amellcan ~ n olicies at healthlfitness facili-Statement: Recommendations for cardIovascular screening. staffing, an emerge cy pties. Med Sci Sports Exerc 1998:1018.

'Professionally qualified exercise staff refers to appropriately trai~ed i~~i~~deU:;::~~i~~~:~~:~~~e:~~;~~~~nFg,practical and clinical knowledge, skills, and abllttles commensura e WI

Bilateral ankle edema that is most evident at night is a char­acteristic sign of heart failure or bilateral chronic venousinsufficiency. Unilateral edema of a limb often resultsfrom venous thrombosis or lymphatic blockage in thelimb. Generalized edema (known as anasarca) OCcurs inpersons with the nephrotic syndrome, severe heart fail­ure, or hepatic cirrhosis.

Palpitations (defined as an unpleasant awareness of theforceful or rapid beating of the heart) may be inducedby various disorders of cardiac rhythm. These includetachycardia, bradycardia of sudden onset, ectopicbeats, compensatory pauses, and accentuated strokevolume resulting from valvular regurgitation.Palpitations also often result from anxiety states andhigh cardiac output (or hyperkinetic) states, such asanemia, fever, thyrotoxicosis, arteriovenous fistula, andthe so-called idiopathic hyperkinetic heart syndrome.

Intermittent claudication refers to the pain that occurs in amuscle with an inadequate blood supply (usually as aresult of atherosclerosis) that is stressed by exercise. Thepain does not occur with standing or sitting, is repro­ducible from day to day, is more severe when walkingupstairs or up a hill, and is often described as a cramp,which disappears within 1 or 2 minutes after stoppingexercise. Coronary artery disease is more prevalent in per­sons with intermittent claudication. Diabetics are atincreased risk for this condition.

Although some may be innocent, heart murmurs may indi­cate valvular or other cardiovascular disease From anexercise safety standpoint, it is especially important toexclude hypertrophic cardiomyopathy and aortic stenosisas underlying causes because these are among the morecommon causes of exertion-related sudden cardiacdeath.

Although there may be benign origins for these symp­toms, they also may signal the onset of, or change inthe status of cardiovascular, pulmonary, or metabolicdisease.

Clarification/Significance

SECTION 1/ HEALTH APPRAISAL, RISK ASSSESSMENT, AND SAFETY OF EXERCISE24

Sign or Symptom

Ankle edema

Palpitations or tachycardia

Intermittent claudication

Known heart murmur

Unusual fatigue orshortness of breathwith usual activities

No changes permitted. You are encouraged to photocopy the PAR.Q but only if you use the entire form.

FIGURE 2-2. PAR-Q form.

Men <45 years of age and women <55 years of age who areasymptomatic and meet no more than one risk factor threshold

from Table 2-2Men ~45 years and women ~55 years or those who meet the

threshold to wo or more risk factors from Table 2-2Individuals with one or~;gns and symptoms listed in Table

2-3 or known cardiovascular, * pulmonary, t or metabolic oF

disease

fltness and clinical exercise program facilities incorporate a more elaboratehealth/medical history questionnai re deSigned to provide additional detail

regarding selected health habits and medical histOlY.

Table 2-3 presents a listing of major signs or symptoms suggestive of cardiovas­cular, pulmonalY <mellor metabolic disease, along ~vith additional information toaid the clinician in the chuification and significance of each sign or symptom

20

The presence of most of these factors can be identified using the AHNACSMQuestionnaire; however, a few (i.e., Olthopnea, ankle edema, healt murmur)require a more thorough medical histOlY anellor examination.

Once symptom and risk factor information is known, candidates for exercisetesting or training can be stratified based on the likelihood of untoward events

ACSM Risk Categories

Coronary Artery Disease Risk Factors

ACSM lisk stratification is based, in part, on the presence or absence of the CADrisk factors listed in Table 2_26 . 12- 15. The lisk factors in Table 2-2 should notbe viewed as an all-inclusive list, but rather as a group with clinically relevantthresholds that should be considered collectively when making decisions aboutthe level of medical clearance, the need for exercise testing plior to initiatingpatticipation, and the level of supelvision for both exercise testing and exerciseprogram patticipation. The scope of the list, and the threshold for each fisk factor,should not be viewed as inconsistent ~vith other fisk factor lists that are intendedfor use in predicting coronalY events prospectively dUling long-term follow-upI6,

because the intended use for the list in Table 2-2 is to aid in the identification ofoccult coronary attery disease. Furthermore, other variables, such as majordepression, also have been suggested as positive lisk factors in the plimary

and secondalY prevention of CAD 17-19

Major Signs or Symptoms Suggestive of Cardiovascular. Pulmonary.

and Metabolic Disease

*Cardiac, peripheral vascular, or cerebrovascular disease.

tChronic obstructive pulmonary dIsease. asthma, interstitial lung disease, or cystic fibrosis (see Reference 24:American Association of Cardiovascular and Pulmonary Rehabilitation Guidelines for pulmonary rehabilitation pro­

grams. 2nd ed. Champaign, IL: Human KinetICS, 1998:97-112.

tDiabetes mellitus (IDDM, NIDDM), thyroid disorders, renal. or liver disease.

2. Moderate risk

3 High risk

1. Low risk

Table 2-4. ACSM Risk Stratification Categories

CHAPTER 21 PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION~ 27

DELAY BECOMING MUCH MORE ACTIVE:• If you are not feeling wetl because of a temporary alness such as

a cold or a fever wait until you feel better; or• if you are or may be pregnant talk to your doctor before you

start becoming more active.

0"', _

VI'ITNESS

PLEASE NOTE: II your health changes SO thai you then answer YES toany of the above questions, tell your fitness or health professional.

Ask whether you should change your physical activity plan.

PAR-Q & YOU

Talk with your doctor by phone or in person BEFORE you start be<oming much more physically active or BEFORE you have a fitness appraisal Tellyour doctor about the PAR·Q and which questions you answered YES. .

• You may be able to do any activity you want as long as you start slowIy,and build up graduall'1 Or, 'PJ may need to restrict 'PJr activities tot~ whICh are safe f~ 'PJ. Talk with your doctor about the kinds of activIties you wish to participate in and foDow his/her advice.

• Find out whICh communrty programs are safe and helpful for you.

YES to one or more questions

SECTION II HEALTH APPRAISAL, RISK ASSSESSMENT, AND SAFETY OF EXERCISE

0 Z.

0 3.

0 4.

0 5.

0 6.

NO

o 1, Has your doctor ever said that you have a heart condition and that you should only do phys' I t"recommended by a doctor? tea ac IVIIy

Do you feel pain in your chest when you do physical activity?

In the past month, have you had chest pain when you were not doing physical activity?

Do you lose your balance because of dizziness or do you ever lose consciousness?

Do you ~ave a bone .or joint ~roblem (for example, back, knee or hip) that could be made worse bchange In your phySical actiVity? y a

~~:~; doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart con-

o 7. Do you know of any other reason why you should not do physical activity?

26

YES

o

oooo

o

o

If you answered NO honestly to.at! PAR-Q questions, you can be reasonably sure that you can:• start becomlng much more physically active - begin slO\l/ly aoo build up gradually This is the

safest and easiest way to go.

• take part in a fitness appraisal this is an excellent way to determine your basic fitness SOthat you can plan the best way lor you to live actively. It is also highly recommended that youhave your blood pressure evaluated. If your reading is over 144/94, talk with your doctorbefore you start becoming much more physically active.

If

you

answered

(A Questionnaire 'or People Aged 15 to 69)

Regular physical activity is fun and healthy. and increasingly more people are starting 10 become more active every day. Being more active is very safe for mostpeople. However. some people should check with their doctor before they start be<:oming much more physically active.

If you are planning to become much more physically active than you are now start by answerin the seve ..ages of ,15 and 69, the PAR-Q will teU you if you should check with your docto~ before you start. 91f you areno~~;~;n: In Ih~ box beldOw. If you are between ~hevery actIVe, check with your doctor. y ars 0 age, an you are not used to being

Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.

Sou.rce: Physical A.ctiv,ty Readiness Questionnaire (PAR-Q) © 2002.S f Reprinted wtth permission from the CanadianoCiety or Exerose Physiology. http://www.csep.ca/forms.asp.

Note: This ~hysi~at. activity dearance is valid for a maximum of 1Z months from the date it is completed andcsJII~ be,ome.....Iod ,f you, 'ond'tion ,h.nge. '0 th.t you would .n.we, YES to .ny of the .e.en quest;on•.

~IJPE ©CanadianSooetyforExercistPhyslology ..... Health SanteSupported by: .,... Canada Canada continued on other side...

NOTE: If ttl! PAR-Q bMgis •. give'! to a person bdore h! or she participates ll\ a jXlyslcal aetlVlty program (If a fitn!ss apprarsaJ, llis SKtIOfl may b! used for I!gaI or adminislrative pur~

I have read, understood and completed this questionnaire. Any questions I had were answered 10 my full satisfaction:

SlGHATl.flf:OFPARENTorGt.Wil:lW'l (lor parl"""ntsl,lrdet" ltll!ag!oI mapily)--

NAME ~

Inlormedlkro!th(PAR·Q· TI'ltCar.acianSooetyIorExerClSe~HealthCanada andthis quesbomalf!. consuh. yoor doctor prior 10 physical activity. • thelr agmts asSUI'll! no iahiIrty lor persons who und!flak! physical~ and rll"llbJbt alter completmg

PhysicaiActivJty~adiness

~ionnairt·PAR-Q

(reo.'ised2002)

ADDITIONAL PREPARTICIPATION ASSESSMENTS

Following risk stratification, additional fitness and/or clinical assessments andprocedures may be incorporated into the preparticipatiotl screening (Level 2screening). The depth and breadth of these additional assessments vaty as a func­tion of:

• Type of program (i.e., self- or professionally guided)• Intended training intensity (i.e., moderate versus vigorous) (see Table 1-1)• Individual risk strata (see Table 2-4) .

For self-guided physical activity regimens of light to moderate intensity, littleadditional assessment is needed beyond the ACSM-AHA Questionnaire provid­ed that one adheres to all medical clearance recommendations contained vvithin

29CHAPTER 2/ PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION

the form. Such regimens should incorporate the physical activity rccommenda­tions from the U.S. Surgeon Gencral6 A specific self-guided regimen suitable forpreviously sedentalY individuals can be found in the ACSM Fitness Book lo Itshould be noted that individuals in need of medical clearance as defined by theAHAlACSM Questionnaire wouldlikcly benefit from patiicipation in fUliher fit­ness assessment and a profeSSionally guided training regimen.

For individuals seeking a profeSSionally guided excrcise regimen, approvedconsent forms for exercise testing and training should be completed (see Chapter3 for examples of forms), and any additional fitness and/or clinical assessments(including exercise testing) should follow procedures described in Chapters 3through 5 for either clinical or nonclinical exercise settings.

EXERCISE TESTING AND TESTING SUPERVISIONRECOMMENDATIONS

No sct of guidelines for exercise testing and participation can cover all situa­tions. Local circumstances and policies vary, and specific program proceduresalso are properly diverse. To providc somc general guidance on the need for amedical examination and exercise testing prior to participation in a moderate tovigorous exercise program, ACSM suggests the recommendations prescntcd inLevel 3 of Table 2-1 for determining when a medical examination and diagnos­tic exercise test are appropriate and whcn physician supervision is recom­mended. Although the testing guidelincs are less rigorous for those individualsconsidered to be low risk, the information gathered from an exercise test maybe useful in establishing a safe and effective exercise prescription for theseindividuals. The exercise testing recommendations found in Table 2-1 reflectthe notion that the tisk of cardiovascular events increases as a function of phys­ical activity intensity (i.e., moderate versus hard). Although Table 1-1 providesboth absolute and relative thresholds for moderate and hard intensity physicalactivity, exercise profeSSionals should choose the most applicable definition(i.e., relative or absolute) for their setting when making decisions about thelevel of screening prior to exercise training and physician supervision duringexercise testing. It should be noted that the recommendations for medicalexamination and exercise testing for moderate risk individuals desiring vigorousexercise (Table 2-4) are consistent \vith those found within recent AHAGuidelines ( See Box 2-2; categories A-2 and A-3).

The degree of medical supelvision of exercise tests varies appropJiatelyfrom physician-supe'vised tests to situations in which there may be no physicianpresent l The degree of physician supelvision may differ with local policies andcircumstances, the health status of the patient, and the expelience of the labora­tOlY staff. The appropriate protocol should be based on the age, health status,and physical activity level of thc person to be tested. Physicians responsible forsupervising exercise testing should meet or exceed the minimal competenciesfor supelvision and interpretation of results as established by the AHA (see Box5-3) 22. In all situations where exercise testing is performed, sitc personnel shouldat least be cetiified at a level of basic Ii fc suppOli; preferably, one or more staffshould be cetiified in advanced cardiac life support (ACLS). \Vhenever possible,testing should be performed by ACSM-credentialed personnel, because these

SECTION 1/ HEALTH APPRAISAL, RISK ASSSESSMENT, AND SAFETY OF EXERCISE28

during participation. This stratification becomes progressively more important asdisease prevalence increases in the population under consideration. Using age,health status, symptom, and tisk factor information, prospective participants canbe classified into one of three tisk strata (see Table 2-4) for triage to fUtiherscreening ptior to participation. Once risk strata are established, further screen­ing recommendations are provided in Table 2-l.

Inherent within the concept of tisk stratification is the impression that signsand symptoms (see Table 2-3) represent a higher-level concern for decision mak­ing as compared with risk factors (see Table 2-2). However, hypertension repre­sents a unique risk factor in that it may be aggravated by acute exercise. Therefore,although it appears vvithin Table 2-2, special consideration should be given tohypertensive patients when screening for exercise testing or training. The SeventhReport of the Joint National Committee on Prevention, Detection, Evaluation,and Treatment of High Blood Pressure (JNC7)t3 recommends a thorough med­ical history, physical examination, routine laboratory tests, and other diagnosticprocedures in the evaluation of patients with documented hypetiension. Becausehypertension is commonly clustered with other tisk factors associated with cardio­vascular disease (i.e., dyslipidemia, obesity, diabetes), most hypetiensive patientspresenting for exercise testing or training fall into the moderate- or high-riskcategory as defined in Table 2-4. For such individuals, the requisite medicalexamination in Table 2-3 is consistent with the screening recommendations forhypertensive patients outlined in JNC7. However, in cases of isolated hyperten­sion (i.e., hypertension is the only presenting tisk factor from those in listed inTable 2-2), prudent recommendations for prepatiicipation screening should bebased on the severity of the hypertension (see Table 3-1 for JNC7 classifications)and the desired intensity of exercise. For low-lisk patients (see Table 2-4) with iso­lated stage 1 hypertension «160/100 mm Hg), exercise testing generally is notnece.ssary for clearance to engage in up to moderate intensity exercise «60% ofthe V02R). However, it is advisable for such patients to have physician clearanceprior to participation. On the other hand, if the patient has documented stage 2hypertension, or a patient with stage 1 hypertension desires to engage in moreintense exercise training (>60% of the V02R), an exercise assessment is recom­mended to quantify hemodynamic responses dUting exercise to aid in the estab­lishment of prudent guidelines for exercise training 21

Risk Stratification for Cardiac Patients

credentials document the individual's knowledge, skills, and abilities directlyrelated to exercise testing.

31

~ Box 2-1, continued

MODERATE RISK

Characteristics of patients at moderate risk for exercise partici­pation (anyone or combination of these findings places apatient at moderate risk)• Presence of angina or other significant symptoms (e.g., unusual short­

ness of breath, light-headedness, or dizziness occurring only at highlevels of exertion [?-7 METsJ)

• Mild to moderate level of silent ischemia during exercise testing orrecovery (ST-segment depression <2 mm from baseline)

• Functional capacity <5 METs

Nonexercise Testing Findings

• Rest ejection fraction = 40%-49%

Characteristics of patients at high risk for exercise participation(anyone or combination of these findings places a patient athigh risk)• Presence of complex ventricular dysrhythmias during exercise testing or

recovery• Presence of angina or other significant symptoms (e.g., unusual short­

ness of breath, light-headedness, or dizziness at low levels of exertion[<5 METs] or during recovery)

• High level of silent ischemia (ST-segment depression ?-2 mm frombaseline) during exercise testing or recovery

• Presence of abnormal hemodynamics with exercise testing (i.e.,chronotropic incompetence or flat or decreasing systolic BP withincreasing workloads) or recovery (i.e., severe postexercise hypotension)

Nonexercise Testing Findings

• Rest ejection fraction <40%• History of cardiac arrest or sudden death

• Complex dysrhythmias at rest• Complicated myocardial infarction or revascularization procedure

• Presence of congestive heart failure• Presence of signs or symptoms of posteventlpostprocedure ischemia

• Presence of clinical depression

*Reprinted from Williams MA. Exercise testing in cardiac rehabilitation: exercise prescrip­tion and beyond. Cardiol Clin 2001;19:415-431, with permission from Elsevier.

HIGH RISK

CHAPTER 2/ PREPARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION

•• f •• I I •

SECTION II HEALTH APPRAISAL, RISK ASSSESSMENT, AND SAFETY OF EXERCISE

Risk Stratification Criteria for Cardiac Patients'

LOWEST RISK

30

Characteristics of patients at lowest risk for exercise participa­tion (all characteristics listed must be present for patients toremain at lowest risk)• Absence of complex ventricular dysrhythmias during exercise testing

and recovery

• Absence of angina or other significant symptoms (e.g., unusual short­ness of breath, light-headedness, or dizziness, during exercise testingand recovery)

• Presence of normal hemodynamics during exercise testing and recovery(i.e., appropriate increases and decreases in heart rate and systolicblood pressure with increasing workloads and recovery)

• Functional capacity ?- 7 METs

Nonexercise Testing Findings

• Resting ejection fraction ?-50%

• Uncomplicated myocardial infarction or revascularization procedure• Absence of complicated ventricular dysrhythmias at rest• Absence of congestive heart failure

• Absence of signs or symptoms of posteventlpostprocedure ischemia• Absence of clinical depression ~

Cardiac patients may be fUither stratified regarding safety during exercise usingpublished guidelines. Risk stratification criteria from the AACVPR are presentedin Box 2_13. Recommendations for. the dura~ion of monitored exercise trainingand/or educatIOn based on the nsk factor profile have now been suggested23. TheAHA has developed a more extensive risk classification system for medical clear­ance of cardiac patients (Box 2-2)1. The AHA guidelines provide recommenda­tions for participant and/or patient monitOling and supelvision and for activityrestliction. Exercise program professionals should recognize that the AHA guide­lines do not consider comorbidities (e.g., type 1 diabetes mellitus, morbid obesi­ty, severe pulmonal)' disease, debilitating neurologic or orthopedic conditions)that could result in modification of the recommendations for monitOling andsupelvision dUling exercise training.

32 SECTION 1/ HEALTH APPRAISAL, RISK ASSSESSMENT, AND SAFETY OF EXERCISE

Class A: Apparently Healthy Individuals• Includes the following individuals

1. Children, adolescents, men <age 45, and women <55 years whohave no symptoms of or known presence of heart disease or majorcoronary risk factors

2. Men ~45 years and women ~55 years who have no symptoms or

known presence of heart disease and with <2 major cardiovascularrisk factors.

3. Men ~45 years and women ~55 years who have no symptoms orknown presence of heart disease and with ~2 major cardiovascularrisk factors.

• Activity guidelines: No restrictions other than basic guidelines

• ECG and blood pressure monitoring: Not required• Supervision required: None. Although it is suggested that persons

classified as Class A-2 and particularly Class A-3 undergo a medicalexamination and possibly a medically supervised exercise test beforeengaging in vigorous exercise.

Class B: Presence of known, stable cardiovascular disease withlow risk for complications with vigorous exercise, but slightlygreater than for apparently healthy individuals• Includes individuals with any of the following diagnoses:

1. CAD (MI, CABGS, PTCA, angina pectoris, abnormal exercise test.

and abnormal coronary angiograms) whose condition is stable andwho have the clinical characteristics outlined below;

2. Valvular heart disease, excluding severe valvular stenosis or regurgi­tation with the clinical characteristics outlined below;

3. Congenital heart disease; risk stratification should be guided by the27th Bethesda Conference recommendations 25

4. Cardiomyopathy; ejection fraction ~30%; includes stable patientswith heart failure with any of the clinical characteristics as outlinedbelow but not hypertrophic cardiomyopathy or recent myocarditis

5. Exercise test abnormalities that do not meet the criteria outlined inClass C.

• Clinical characteristics:1. New York Heart Association class 1 or 22. Exercise capacity ~6 METs3. No evidence of congestive heart failure

4. No evidence of myocardial ischemia or angina at rest or on the exer­cise test at or below 6 METs

5. Appropriate rise in systolic blood pressure during exercise ~

CHAPTER 2/ PRE PARTICIPATION HEALTH SCREENING AND RISK STRATIFICATION

~ Box 2-2. continued6. Absence of sustained or nonsustained ventricular tachycardia at rest

or with exercise7. Ability to satisfactorily self-monitor intensity of activity

• Activity guidelines: Activity should be individualized, with exercise pre­scription by qualified individuals and approved by primary health care

provider• Supervision required: Medical supervision during initial prescription ses­

sion is beneficial. Supervision by appropriate trained nonmedical per­

sonnel for other exercise sessions should occur until the individualunderstands how to monitor his or her activity. Medical personnelshould be trained and certified in advanced cardiac life support.Nonmedical personnel should be trained and certified in basic life sup­

port (which includes CPR).• ECG and blood pressure monitoring: Useful during the early prescrip-

tion phase of training, usually 6 to 12 sessions.

Class C: Those at moderate to high risk for cardiac complicationsduring exercise and/or unable to self-regulate activity or under­stand recommended activity level• Includes individuals with any of the following diagnoses:

1. CAD with the clinical characteristics outlined below2. Valvular heart disease, excluding 'severe valvular stenosis or regurgi­

tation with the clinical characteristics outlined below3. Congenital heart disease; risk stratification should be guided by the

27th Bethesda Conference recommendations. (Fuster V, Gotto AM,Libby P. 27th Bethesda Conference: Matching the intensity of risk

factor management with the hazard for coronary disease events. JAm Coli Cardiol 1996;27:964-976.)

4. Cardiomyopathy; ejection fraction ~30%; includes stable patientswith heart failure with any of the clinical characteristics as outlinedbelow but not hypertrophic cardiomyopathy or recent myocarditis

5. Complex ventricular arrhythmias not well controlled

• Clinical characteristics:1. NYHA class 3 or 4

2. Exercise test results:

• Exercise capacity <6 METs• Angina or ischemia ST depression at workload <6 METs• Fall in systolic blood pressure below resting levels with

exercise• Nonsustained ventricular tachycardia with exercise

3. Previous episode of primary cardiac arrest (i.e., cardiac arrest thatdid not occur in the presence of an acute myocardial infarction or

during a cardiac procedure)

33

REFERENCES

1. Fletcher CF, Balady Cj, An"terdam EA, et al. Exercise standards (ur testing and training. A state­

ment for health care professionals from the American Healt Association. Circulation 2001;104:1694-1740.

2. American College of Sports Medicine and American lIe'lIt Association. ACS~IIAHA joint Position

Statement: Hecommendations for cardiovascular screening, staffing, and cmergency policies athealth/fitness facilities .•\Ied Sci SPOltS Exerc 1998;1018.

3. American Association of Cardiov",cldar and Pulmonal)' Hehabilitation. Guidelines f"r CardiacHehabilitation and Sccondar)' Prel'ention Programs. 4th cd. Champaign, lL: /luman Kinctics, 200:3.

4. Maron Bj, Araujo CC, Thompson PD, et al. Hecommendations for prcpalticipalion screcuing andthe assessment of cardiovascular disease in m,,,ters athletes. Circulation 200/;IQ.3:327-.334.

.5. Maron Bj, Thompson PD, Puffer jC, et al. Cardio\'ascular preparticipation screening ofcompetitil'cathletes. A statement f"r health professionals from the Sudden Death Committee (cliuical cardi%­

b')') and Congenital Cardiac Defects Committce (eardiO\',,,cular dis,""se in the )'oung). AmericanHealt Association. Circulation J996;94:8.50-8.56.

6. United States Department of Health and Human Senices. Physical actilih' and health: a report ofthe Surgeon Ceneral. J996.

35AND RISK STRATIFICATIONCHAPTER 21 PREPARTICIPATION HEALTH SCREENING

. . I I I' . I . Ith A recommendation [rom theI . SN l' I Physic'll 'u:lIvltv am PlI) 1(; W.l .I. Pate HR. Pratt M, B atr 1. e ". . ~' 1'I A .' "11 College of Sports Meuicine. JA~IACenters for Disease Control and PreventulIl clill t Ie mellc. I

1995;273:402-407. I '0 . I ""><ic,,.1 'Icti\'it)' in the [,revention and Ireat-I 'D P' ·,ILeta.Gxeluseaml ,""8. Thompson PO, Buc mel , m,. 'I' C' '. 1'1'012003.107:3109-:31 Hi.

/' I .). r· ·'udio\'a5<.:ular (ISease. 1I<':11 ell I, 1 . I '" ,,_ 2ndment 0 at lerose elo IC (;( . . CSl\I' I 'uth/f'tness Eldlitv standards ;Ul( gUll e lOtS.9, American College of Sports MecllclJ1e. A _ l' S lee I •

. [i 11 '11 Kinetics 199/. J [ed. Champ,up;n, ,: um, I " fi I k "rd ed Champaign, IL: uman

LO. American College of Sporls Medicine. ACSM Itness '00 . ,). ,

Kinetics,2003.. .... I .. ' I ". pAH-Q and ,·ou. Gloucester, Ontario: Canadian SocietyI I. Canadian Society fur Exel else P 1) SIO ag. . _

fur Exercise ph\'siolog)', 1.994. "I' I I' t I' Ihe N'Itiol1'lJ Cholesterol EducationI Ed r Prognm I llf( ,epol 0 1 < < I

12. National Cholcstcro "uca JOn , .' I'. IT"'ltmcntoI'High BlonuCholesteroProgram (NCEp) £xpelt Panel on Deteellon, E\'a upatl,oln, "t'." :'"0' ()9-5915 90<>9

' P I III) 9009 NIH U, IC'"0IL, . __ , __in Adnlts (Adult lreatment ane . -. _. '['I S ' '" th Helmrt of the Joint National

. 1 31 I 1" ., Education Program. Ie. lltll C-)13. National Hlg I 1 OO( HSSUIC . . 1T' 'Itment of High Blood Pressure ON I.

COlllmittee on Pre\"entioll, Detection, E,'aluatJon, <lilt Ie.

200:3.03-5233. 'fi . I'D'. betes Mellitus. Follow-up repOlt onExpert Committee on the Diagnosis anu ClaSSIlcatl~n ~ 31,la

O31~-

14. fu' b 1ft· Dhhetes Glre 9003·2,,:. ,,- I. Ithe diagnosis 0 1<1 ('tes me I us. '. I' T' -. 't I' Ovenveight and Ohesity in Auu ts.

P I D t dion E\"uuallOll ,lIll le.ltmen 0 I 1 f'15. Experi cll1l' un e e . < I '.1 I' the identific'ltion evaluation, arl( treatmen 0I t f II Ith Clinic'l gUlue II1[>S on " c-

Nationalnstitueso ea. '. A ..II tMedI998·158:1855-18ul.. I I '.' . I It ·-the el'ldence report. IC 1 n I , " ..

overwl'lgllt al1<. U )l'Slt) III cl(us", f' _ , I he'lit disease usillO' nsk factor Cclt-Hi. \\'ilson P\V, D'Agostillo B.S, Le\')' 0, et al. Pn'( H.:tlon 0 eOIOl1cll) c, r-:,

egories. Circulatioll .1998;97: 1837-1847. . 1 I ' term mortality risk in patients withB'Ireroot JC (-[elms ~I I, ~Iark DB, et al. DepreSSion ~ml ong-

17.. '1" A jCa'diol1996.78:613-6]1. .corOllary artery (lse,Llle, m I _ '. . .. 'k r -to _for coromuy artery disease III mell:

·1 DE Mead LA, Chang pP. pt a!. DepreSSion IS a liS ac I "

18 1'01 ( , . ,d 1998.158: 1422-1426. .the [Jrecllrsors stud), A/ch Intern ~I(; , 1 .', 'In antecedent to healt chsease

j A F·' I DJ et a DepreSSion "s ,19. Ferketich AK. Schwal1zhaum ,Ill, " . M' 19000'160:1261-1268.

. I, IIANES I stlldv. Arch Inteln I el ~, . .among WOlllf'1I and rllf'n III t 1<. . . ~ I' .. J tting In: Durstme JL, KlIlg AC.II BS H ItI ·1 )pl"lis·\1 In the non-meu(;,t se . .

20. Cordon S, ~Iitehe . ea 1 'I ,., I f. '1 I' 's for exercise testing and prescription.Painter PL. eds. ACS~rs resource manlla 01 gU1(. e 111(;.

I 1 I I · L & Fehiuer [993·9[9-228. NI d S . SotsPhi a( e I' lla: (~a "'.'~ ,.... I. >. 'cise Hnd hypertension. I e CI I' I .21. Amt'rican ColJf'ge of SPOlts ~led1(':lIle. POSition stcll1t. ext' I .

Exerc 2004:36:53.3-553. .1.'. C lI~ue of CanJiology/American Heart. JZ B'lhd)' C et '". Amellc"n 0 eo> > II f

22. Hodgers GP, Ayaman -, ", , t' .. .(' ,ort of the American Co ege 0. . I t c' shtelilent on stress ttS mg.•1 I I . r

Association c.:Iulica cOllljJe en l' c. 'C II r Phvsicians-American SocIety ()• 1-:1 -t Assochtlon/AmerJcan 0 ege 0 -,'

Cardiolol,,,iAmertean eal . , C' .. I. tion 9OO0'L02: 1726-1738.' I" l~,·k F -' .. on Clinical Competf>ll(.:e. lI(;lI cl -, . I' " .

IlIte,."al Me( Icme "s OIC(. . 1,1 for risk stratification and dehvelY 0 cal-. - F t·' .. T Dnrnlller AM. A new 1ll0(C "1' ,

2:3. HOltman JL, 1....<\ OJl clln<: , I I ,. · .. d ll1'1rngcment of patients Wit 1 (.'oronat;dio\'asclilar rehahilitation sClyices in t 1e ung-terlll c II1l(;c ••

. . .' I·' 998·18: LJ3-123. '. ,arterv dlseasc. J Ccu<.ho He ld) I , I' ,I . I 'I't'ltioll Cliidelllles for pulmonu), .. f' C I· {' . l . and PlIlnlOIl<lIV \t 1d)1 I < .

24. American Assocmtion 0 ar<'lO\<lsCU'lI. II II .' K'I,etics 1998:97-.112.9 I 1 CI·, "p'ugn ~: um"" I , .

rehabilitation programs, :.nc t'<.. 1< I • , I'. ., ~I' tehing the intensity of risk factor Illan-'I I '11 I' 97th Bl'lhesda Con elence.. ,l '_

25. Fuster\', Gotto A,,·, ~I "y . - .. ' ". J Am Coil Caruiol.l996;27:964-9i6.agcment with the hazard for coron<Uy disease e\ <: nts.

SECTION II HEALTH APPRAISAL, RISK ASSSESSMENT, AND SAFETY OF EXERCISE

~ Box 2-2. continued

34

4. A medical problem that the physician believes may be life threateningActivity guidelines: Activity should be individualized, with exercise pre­scription provided by qualified individuals and approved by primaryhealth care provider.

• Supervision: Medical supervision during all exercise sessions until safetyis established.

• ECG and blood pressure monitoring: Continuous during exercise ses­sions until safety is established, usually ~ 12 sessions.

Class 0: Unstable disease with activity restrictiont• Includes individuals with

1. Unstable ischemia

2. Severe and symptomatic valvular stenosis or regurgitation;

3. Congenital heart disease; criteria for risk that would prohibit exerciseconditioning should be guided by the 27th Bethesda Conferencerecommendations. 25

4. Heart failure that is not compensated5. Uncontrolled arrhythmias

6. Other medical conditions that could be aggravated by exercise

• Activity gUidelines: No activity is recommended for conditioning purpos­es. Attention should be directed to treating the patient and restoring thepatient to class C or better. Daily activities must be prescribed on thebasis of individual assessment by the patient's personal physician

*Modified from Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testingand training. A statement for health care professionals from the American HeartAssociation. Circulation 2001; 104:1694-1740.

tExercise for conditioning purposes is not recommended.

Exercise Testing

SECTION

II

Medical History, Physical Examination. and Laboratory TestsThe pre-exercise test medical hist01Y should be thorough and include both pastand current information. Appropriate components of the medica! hist01)' are pre­sented in Box 3-1. A preliminmy physical examination should be performed by aphysician or other qualified personnel before exercise testing moderate- andhigh-risk subjects (see Table 2-4). Appropriate components of the physical exam­ination specific to subsequent exercise testing are presented in Box 3-2.

This chapter contains information related to pre-exercise testing procedures andserves as a blidge between the risk, stratification concepts presented in Chapter2, the fitness assessment (see Chapter 4), andJor clinical exercise testing concepts(see Chapters 5 and 6). Although each of the chapter elements (e.g., medical his­tory, physical examination, identification of exercise contraindications, informedconsent procedures) relate to both health and fitness and clinical exercise set­tings, the lower-risk population typically encountered in the health and fitnesssetting generally justifies a less sophisticated approach to the pre-exercise testprocedures. Therefore, abbreviated versions of the medical history and physicalexamination procedures described within this chapter are reasonable within thehealth and fitness setting.

The extent of medical evaluation necessary before exercise testing depends onthe assessment of risk as determined from the procedures outlined in Chapters 1and 2. For many persons, especially those with coronary artery disease (CAD)and other cardiovascular disorders, the exercise test and accomp<\l1)ing physicalexamination are critical to the development of a safe and effective exercise pro­gram. In today's health care environment, not all persons warrant extensive test­ing; however, it is important to work with health care providers in understandingthe importance of the baseline exercise evaluation. This evaluation providesgreater assurance of exercise safety by identifying residual myocardial ischemia,significant dysrhythmias, and the effect of certain medical therapies.

A comprehensive pre-exercise test evaluation in the clinical setting generallyincludes a medical history, physical examination, and laboratory tests. The goal ofthis chapter is not to be totally inclusive or to supplant more specific referenceson each subject, but rather to provide a concise set of guidelines (or the pre-exer­cise test participant assessment.

CHAPTER

3•••••Pre-Exercise Evaluations

39

41

'For more detailed information see Bickley LS Bate's pocket guide to physical examinationand history taking. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2003.

Appropriate components of the physical examination may include the

following:

• Body weight; in many instances, 'determination of body mass index(BMI), waist girth, and/or body composition (percent body fat) is

desirable• Apical pulse rate and rhythm• Resting blood pressure, seated, supine, and standing• Auscultation of the lungs with specific attention to uniformity of breath

sounds in all areas (absence of rales, wheezes, and other breathing

sounds)• Palpation of the cardiac apical impulse, point of maximal impulse (PMI)• Auscultation of the heart with specific attention to murmurs, gallops,

clicks, and rubs• Palpation and auscultation of carotid, abdominal, and femoral arteries• Evaluation of the abdomen for bowel sounds, masses, visceromegaly,

and tenderness• Palpation and inspection of lower extremities for edema and presence

of arterial pulses• Absence or presence of tendon xanthon:a and skin xanthelasma• Follow-up examination related to orthopedic or other medical condi­

tions that would limit exercise testing• Tests of neurologic function, including reflexes and cognition (as

indicated)• Inspection of the skin, especially of the lower extremities in known

diabetics

CHAPTER 3/ PRE-EXERCISE EVALUATIONS

Identification and risk stratification of persons with CAD and those at highrisk of developing CAD are facilitated by review of previous test results, such ascoronary angiography or exercise nuclear or echocardiography studies1

Additional testing may include ambulatory ECG (Holter) monitoring and phar­macologiC stress testing to further clarify the need for and extent of intervention,assess response to treatment such as medical therapies and revascularizationprocedures, or determine the need for additional assessment. As outlined in Box3-3, other laboratory tests may be warranted based on the level of risk and clini­cal status of the patient. These laboratOlY tests may include, but are not limitedto, serum chemistries, complete blood count, comprehensive lipoprotein profile,and pulmonary function.

~JI

'-'-=--11

1t:t~11

. I

SECTION II/EXERCISE TESTING

Appropriate components of the medical history may include the following:

• Medical diagnosis. Cardiovascular disease including myocardial infarction;percutaneous coronary artery procedures including angioplasty, coronarystent(s), and atherectomy; coronary artery bypass surgery; valvular sur­gery(s) and valvular dysfunction (e.g., aortic stenosis/mitral valve disease);other cardiac surgeries such as left ventricular aneurysmectomy and car­

diac transplantation; pacemaker and/or implantable cardioverter defibril­lator; presence of aortic aneurysm; ablation procedures for dysrhythmias;symptoms of ischemic coronary syndrome (angina pectoris); peripheral

vascular disease; hypertension; diabetes; obesity; pulmonary diseaseincluding asthma, emphysema, and bronchitis; cerebrovascular disease,including stroke and transient ischemic attacks; anemia and other blooddyscrasias (e.g., lupus erythematosus); phlebitis, deep vein thrombosis or

emboli; cancer; pregnancy; osteoporosis; musculoskeletal disorders; emo­tional disorders; eating disorders.

• Previous physical examination findings. Murmurs, clicks, gallop rhythms,other abnormal heart sounds, and other unusual cardiac and vascularfindings; abnormal pulmonary findings (e.g., wheezes, rales, crackles);abnormal blood sugar, blood lipids and lipoproteins, or other significantlaboratory abnormalities; high blood pressure; edema

• History of symptoms. Discomfort (e.g., pressure, tingling, pain, heavi­ness, burning, tightness, squeezing, numbness) in the chest, Jaw, neck,back, or arms; light-headedness, dizziness, or fainting; temporary lossof visual acuity or speech, transient unilateral numbness or weakness;

shortness of breath; rapid heart beats or palpitations, especially if asso­ciated with physical activity, eating a large meal, emotional upset, orexposure to cold (or any combination of these activities)

• Recent illness, hospitalization, new medical diagnoses, or surgicalprocedures.

• Orthopedic problems, including arthritis, joint swelling, and any conditionthat would make ambulation or use of certain test modalities difficult.

• Medication use, drug allergies.

• Other habits, including caffeine, alcohol, tobacco, or recreational (illicit)drug use.

• Exercise history. Information on readiness for change and habitual levelof activity: type of exercise, frequency, duration, and intensity.

• Work history with emphasis on current or expected physical demands,noting upper and lower extremity requirements.

• Family history of cardiac, pulmonary, or metabolic disease, stroke, orsudden death.

• For more detailed information see Bickley LS Bate's pocket guide to physical examinationand history taking. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2003.

40

43

I : '"

CHAPTER 3/ PRE-EXERCISE EVALUAT.IONS

BLOOD PRESSURE

1. Patients should be seated quietly for at least 5 minutes in a chair withback support (rather than on an examination table) with their feet onthe floor and their arm supported at heart level. Patients should refrainfrom smoking cigarettes or ingesting caffeine during the 30 minutespreceding the measurement.

2. Measuring supine and standing values may be indicated under specialcircumstances.

3. Wrap cuff firmly around upper arm at heart level; align cuff withbrachial artery.

4. The appropriate cuff size must be used to ensure accurate measurement. The bladder within the cuff should encircle at least 80% of theupper arm. Many adults require a large adult cuff.

5. Place stethoscope bell below the antecubital space over the brachialartery.

6 Quickly inflate cuff pressure to 20 mm Hg above first Korotkoff sound.7. Slowly release pressure at rate equal to 2 to 5 mm Hg per second;8. Systolic BP is the point at which the first of two or more Korotkoff

sounds is heard (phase 1) and diastolic BP is the point before the dis­appearance of Korotkoff sounds (phase 5).

9. At least two measurements should be made (minimum of 1 minuteapart).

10. Provide to patients, verbally and in writing, their specific BP numbersand BP goals.

'Modified from National High Blood Pressure Education Program. The Seventh Report ofthe Joint National Committee on Prevention, Detection, Evaluation, and Treatment of HighBlood Pressure (JNC7) 2003 03-5233.

Measurement of resting blood pressure (BP) is an integral component of the pre­exercise test evaluation. Suhsequent decisions should be based on the avcragc oftwo or more properly measured, seated BP readings recorded during each of twoor more office visits:] SpeCific techniques for measuring BP are critical to accuracyand detection of high BP and are presented in Box 3-4. In addition to high BP read­ings, unusually low readings also should be evaluated for clinical significance. TheSeventh RepOlt of the Joint National Committee on Prevention, Detection,Evaluation, and Treatment of lligh Blood Pressure (INCi) provides guidelines forhypertension detection and management3

. Table 3-1 summarizes the J1\Ci rec­ommendations for the classification and management of BP for adults.

The relationship between 'BP and risk for cardiovascular events is continuous,consistent, and independent of other risk factors. For individuals 40 to 70 yearsof age, each increment of 20 min Hg in systolic BP or 10 IlJIIl Hg in diastolic BP

SECTION II/ EXERCISE TESTING

Apparently healthy (low risk) or individuals at increased risk,but without known disease (moderate risk)• Fasting serum total cholesterol, LDL cholesterol, HDL cholesterol, and

triglycerides.• Fasting blood glucose, especially in individuals ~45 years old and

younger individuals who are overweight (BMI ~25 kg'm-2) and have

one or more of the following risk factors for type 2 diabetes: a first­degree relative with diabetes, member of a high-risk ethnic population(e.g., Black, Hispanic American, Native American, Asian American,and Pacific Islander), delivered a baby weighing >9 Ibs or history ofgestational diabetes, hypertension (BP ~ 140/90 mm Hg in adults), HDLcholesterol of :540 mg·dL-1 and/or triglyceride level ~ 150 mg'dL-1, pre­viously identified impaired glucose tolerance or impaired fasting glucose(fasting glucose ~ 100 mg'dL-1

), habitual physical inactivity, polycysticovary disease, and history of vascular disease

• Thyroid function, as a screening evaluation especially if dyslipidemia ispresent

Patients with known or suspected cardiovascular disease(high risk)• Preceding tests plus pertinent previous cardiovascular laboratory tests

(e.g., resting 12-lead ECG, Holter monitoring, coronary angiography,radionuclide or echocardiography studies, previous exercise tests)

• Carotid ultrasound and other peripheral vascular studies• Consider measures of homocysteine, Lp(a), high sensitivity C-reactive

protein, fibrinogen, LDL particle size, HDL subspecies, and number(especially in young persons with a strong family history of CAD and inthose persons without traditional coronary risk factors)

• Chest radiograph, if congestive heart failure is present or suspected• Comprehensive blood chemistry panel and complete blood count as

indicated by history and physical examination (see Table 3-3)

Patients with pulmonary disease• Chest radiograph• Pulmonary function tests (see Tables 3-4 and 3-5)• Other specialized pulmonary studies (e.g., oximetry or blood gas analysis)

42

Although a detailed descliption of all the physical examination procedures listedin Box 3-2 and the recommended laboratOlY tests listed in Box 3-3 are beyond thescope of this text, additional information related to assessment of blood pressure,cholesterol and lipoproteins, other blood chemistries, and pulmoll<lIY fimction areprovided in the follOwing section. For more detailed descriptions of these assess­ments, the reader is referred to the work of Bickle/.

Initial Drug Therapy

§Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.

Abbreviations: DBP, diastolic blood pressure; SBP, systolic blood pressure.

TABLE 3-1. Classification and Management of BloodPressure for Adults*t

45

NormalBorderline highHighVery high

LowHigh

OptimalNear optimal/above optimalBorderline highHighVery high

CHAPTER 3 / PRE-EXERCISE EVALUATIONS

DesirableBorderline high

, High /)(C,coJ etv lrs -reid

<402:60Triglycerides

<150150-199200-499>500

<200200-2392:240HDL Cholesterol

<100100-129130-159160-189;",190Total Cholesterol

LDL Cholesterol

*From National Cholesterol Education Program. Third Report of the National CholesterolEducation Program (NCEP) Expert Panel on Detecllon, EvaluallOn, and Treatment of HighBlood Cholesterol In Adults (Adult Treatment Panel III). 2002. NIH PublicallOn No. 02-5215.

TABLE 3-2. ATP III Classification of LOL, Total, and HOLCholesterol (mg'dL-1)*

LIPIDS AND LIPOPROTEINS

The Third Report of the Expcrt Panel on Dctcction, Enllualion, and Trcatmentof Hieth Blood Cholestcrol in Adults (Adult Treatment Panel Ill, or ATP lJ I)outlin~s the ational Cholesterol Education Program's (1\CEP's) recommenda­tions for cholesterol testing and management (Table 3-2)~. ATP III identifieslow-density lipoprotcin (LDL) cholesterol as the primary target ~or cholesterol­lowering therapy. This designation is bascd on a widc v,ariety oj eVidence IIlcb­cating that elevated LDL cholesterol is a powerful risk factor [or CAD and that,lowerin et of LDL cholesterol results in a striking reductIOn In the lllCldence ofCAD. T~lblc :3-2 summarizes the ATP III classifications of LDL, total, and IlDL-

cholesterol and triglycerides.According to ATP Ill, a low IIDL cholesterol leycl is strongly and imerseh

associated with the risk for CAD. Clinical trials prm'ide snggesti\'e e\idence thatraising HDL cholesterol levels reduces the risk for CAD. Howe\'er, it remainsuncertain whcther raisinet IlDL cholesterol le\'els per se, independent of other

b I'changes in lipid ancl!or nonlipid risk factors, reduces the risk for CAD. In \'icwothis, ATP III does not identif)1 a specific HDL cholesterol goallcvel to reach \\~ththerapy. Bather, nondrug and drug therapics that raisc HDL c~lOlestcrol that alsoare part of the management of other lipid and nonlipid risk factors are encour-

aeted by ATP Ill.b There is growing evidencc for a strong association betwecn ele\'ated triglyc-

eride leyels and CAD Jisk. Recent studies sug.,2;est that 'some species of triglyceridc-

Drug(s) forcompellingindications.*

Drug(s) forcompellingindications.*

Otherantihypertensivedrugs, asneeded.

Antihypertensivedrug(s)indicated

Without WithCompelling CompellingIndication Indications

Noantihypertensivedrug indicated

Antihypertensivedrug(s)indicated.

Two-drugcombination formost.§

Or ;",100 Yes;",160

SECTION II/ EXERCISE TESTING44

doubles the risk of cardiovascular disease across the entire BP range from llsnsto lSS/11S mm Hg. According to J C7, persons with a systolic BP of 120 to 139mm Hg or a diastolic BP of SO to S9 mm Hg should be considered as prehlJper­tensive and require health-promoting lifestyle modifications to prevent cardio­vascular disease.

Lifestyle modification, including phYSical activity, weight reduction (if need­ed), a DASH eating plan (i.e., a diet rich in fruits, vegetables, and low-fat dailyproducts with a reduced content of saturated and total fat) (see Box 9-3), dietarysodium reduction (no more than 100 mmol or 2.4 g sodium/day), and moderationof alcohol consumption, remains the cornerstone of antihypertensive therapy.However, J C7 emphasizes the fact that most patients \vith hypertension whorequire drug therapy in addition to lifestyle modification require two or moreantihypertensive medications to achieve the goal BP (i.e., <140/90 mm Hg, or<130/S0 mm Hg for patients with diabetes or chronic kidney disease).

BP SBP DPB Lifestyle

Classification mm Hg mm H~ Modification

Normal <120 And <80 Encourage

Prehypertension 120-139 Or 80-89 Yes

Stage 1 140-159 Or 90-99 YesHypertension

Stage 2Hypertension

-From National High Blood Pressure Education Program. The Seventh Report of the JOint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNO). 2003. 03-5233.

tTreatment determined by highest BP category.

*Compelling IndICations Include heart failure, post myocardial infarction, high coronary heart dISease fisk, diabetes,chronic kIdney disease, and recurrent stroke prevention. Treat patients With chronIC kidney disease or diabetes to BP goalof < 130/80 mm Hg.

BLOOD PROFILE ANALYSES

Multiple analyses blood profiles are evaluated commonly in clinical exerciseprograms. Such profiles may proVide useful information about an individual's over­all health status and ability to exercise and may help to explain certain ECG abnor­malities. Because of varied methods of assaying blood samples, some caution isadvised when comparing blood chemistries from different laboratories. Table 3-3gives normal ranges for selected blood chemistries, derived from a variety ofsources. For many patients "vith CAD, medications for dyslipidemia and hyperten­sion are common. Many of these medications act in the liver to lower blood cho­lesterol and in the kidneys to lower blood pressure. One should pay particularattention to liver function tests such as alanine transaminase (ALT), aspmtatetransaminase (AST), and bilirubin as well as to renal (k'idney) fimction tests such ascreatinine, blood urea nitrogen (BUN), and BUN/creatinine ratio in patients onsuch medications. Indication of volume depletion and potassium abnormalities can

47

Women

35-180

11.5 15.536-48

3.9-5.6

7-34 wl-14-35 wl-1

Neutral

<1.5 mg-dl"

150--450 (xl 09/L)60-99 mg·dL- 1

4-24 mg-dL- 1

0.3-14 mg-dL- 1

7-272.3-7.8135-150 mEq-dL- 1

3.5-5.5 mEq-dl- 1

98-110 mEq-dl- 1

278-302 mOsm/kg8.5-10.5 mg·dL- 1

4.0-5.2 mg -dL- 1

2.5-4.5 mg·dL- 1

6.0-8.5 9 -dl- 1

3.0-5.5 g-dl- 1

2.0-4.0 g-dl- 1

1.0-22

4-11 (x109/L)

Men

40-190

4.0-8.9

13.5-17.540-52

4.5-6.5

*Certain variables must be interpreted in relation to the normal range of the ISSUing laboratory.

tFasting blood glucose ;;,,100 is considered Impaired fasting glucose. Reference 13: Expert ComiTlittee on theDiagnosis and Classification of Diabetes Mellitus. Follow-up report on the diagnoSiS of diabetes mellitus. DiabetesCare 2003;26:3160-3167.

Abbreviations: SGOT. serum glutamic-oxaloacetic transaminase; AST. aspartate transaminase (formerly SGOT);SGPT, serum glutamic-pyruvic transaminase; ALT, alanine transaminase (formerly SGPT).

b; seen in the sodium and potassium measurements. These tests should be appliedjudiciously and not used as finite ranges of normal_

PULMONARY FUNCTION

Pulmonary function testing with routine spirometJy is recommended for all slllok-tl1e age of 45 and in any person presentmg WIth dyspnea (shortness of

~~ ··8·_ .breath), chronic cough, wheezing, or excesstve mucus production. SpnometlY IS a

I t· I, Sl'mple and noninvasive test that can be performed easIly. Whenre a lVe)

Hemoglobin (g.dL-1)

Hematocrit (%)Red cell count

(Xl0 12/L)Mean cell hemoglobin

concentration(MCHC)

White blood cellcount

Platelet countFasting glucosetBlood urea nitrogen

(BUN)CreatinineBUN/creatinine ratioUric acid (mg'dL- 1)SodiumPotassiumChlorideOsmolalityCalciumCalcium, ionPhosphorusProtein, totalAlbuminGlobulinA1G ratioIron, total (jJ.g-dL-1)Liver Function TestsBilirubin(SGOT) (AST) 8--46 wL-1(SGPT) (ALT) 7--46 wL-1

CHAPTER 3/ PRE-EXERCISE EVALUATIONS

Variable

TABLE 3-3. Typical Ranges of Normal Values for Selected BloodVariables in Adults*

SECTION II/EXERCISE TESTING46

rich lipoproteins, notably, cholesterol-enriched remnant lipoproteins, promoteatherosclerosis and predispose to CAD. Because these remnant lipoproteinsappear to have atherogenic potential similar to that of LDL cholesterol, ATP IIIrecommends that they be added to LDL cholesterol to become a secondary tar­get of therapy for persons with elevated triglycerides. To accomplish this, non­HDL cholesterol is calculated by subtracting HDL cholesterol from the totalcholesterol level.

The metabolic syndrome is charactelized by a constellation of metabolic riskfactors in one individual. Abdominal obesity, atherogenic dyslipidemia (i.e.,elevated tliglycerides, small LDL cholesterol particles, and reduced HDL choles­terol), elevated blood pressure, insulin resistance, prothrombotic state, and proin­flammatOly state generally are accepted as being charactelistic of the metabolicsyndrome. The root causes of the metabolic syndrome are overweight and obesity,physical inactivity, and genetic factors. Because the metabolic syndrome hasemerged as an important contributor to CAD, ATP III places emphasis on themetabolic syndrome as a risk enhancer.

ATP III designates hypertension, cigarette smoking, diabetes, overweight andobesity, physical inactivity, and an atherogenic diet as modifiable nonlipid risk fac­tors, whereas age, male gender, and family histOlY of premature CAD are non­modifiable non lipid risk bctors for CAD. Triglycerides, lipoprotein remnants,lipoprotein (a), small LDL particles, HDL subspecies, apolipoproteins B and A-I,and total cholesterol-to-HDL cholesterol ratio are designated by ATP III as emerg­ing lipid risk factors. Homocysteine, thrombogenic and hemostatic factors, inflam­matory markers (e.g., high sensitivity C-reactive protein), and impaired fastingglucose are designated by ATP III as emerging nonlipid risk factors.

The guiding plinciple of ATP III is that the intensity of LDL-lowering therapyshould be adjusted to the individual's absolute risk for CAD. Since publication ofATP III, major clinical trials have been published that question the treatmentthresholds for LDL. In pmticular, an LDL goal of <70 mgidL appears to be appro­priate for those in a categOlY of "velY high" lisk.5 The ATP III treatment guidelinesare summmized in the ACSM Resource Manual. Additional guidelines for the pli­mary and secondmy prevention of cardiovascular diseases recently have beenupdated by the Americm1 Hemt Association6.7

Severity of Obstructive Disease: This interpretation is based on the assessment of boththe FEV" expressed as a percent of predicted, and the FEV,/FVC ratio,

49CHAPTER 31 PRE-EXERCISE EVALUATIONS

Contraindications to Exercise Testing

lung cancer, heali attack and stroke and can be used to identifY patients in whichinterventions, such as smoking cessation, would be most beneficial. In addition tothe preceding tests, the determination of the m,Lximal voluntal)' ventilation (MVV)also should be obtained during routine spirometric testing, Results from this testoften can be used to help evaluate ventilatory responses obtained dUling gradedexercise testing lO

For certain individuals the risks of exercise testing outweigh the potential bene­fits, For these patients it is important to carefully assess risk versus benefit whendeciding whether the exercise test should be performed, Box 3-5 outlines bothabsolute and relative contraindications to exercise testing", Performing the pre­exercise test evaluation and the carefi.d review of prior medical histOty, asdescribed earlier in this chapter, helps identify potential contraindications andincrease the safety of the exercise test. Patients with absolute contraindicationsshould not perform exercise tests until such conditions are stabilized or ade­quately treated. Patients with relative contraindications may be tested only aftercareful evaluation of the risklbenefit ratio, However, it should be emphasizedthat contraindications might not apply in certain specific clinical situations, suchas soon after acute myocardial infarction, revascularization proceJure, or bypasssurgelY or to determine the need for, or benefit of, di'ug therapy. Finally, condi­tions exist that preclude reliable diagnostic ECG information from exercise test­ing (e,g., left bundle-branch block, digitalis therapy), The exercise test may stillprovide useful information on exercise capacity, dysrhythmias, and hemodynam­ic responses to exercise. In these conditions, additional evaluative techniquessuch as echocardiography or nuclear imaging can be added to the exercise test toimprove sensitivity, specificity, and diagnostic capabilities,

Emergency departments are increasingly performing an exercise test on low­lisk patients who present with chest pain (i.e" within 4 to 8 hours) to rule outmyocardial infarctionll

,12. Generally, these patients include those who are nolonger symptomatic and who have unremarkable ECGs and no change in serial car­diac enzymes, However, exercise testing in this setting should be performed onlyas part of a carefully constructed patient management protocol and only afterpatients have been screened for high-risk features or other indicators for hospitaladmission, Table 3-5 is a quick reference source for serum concentrations ofenzymes commonly used as indices of myocardial damage or necrosis.

Informed ConsentObtaining adequate informed consent hom paliicipants before exercise testing andparticipation in an exercise program is an important ethical and legal consideration.Although the content and extent of consent forms may vary, enough informationmust be present in the informed consent process to ensure that the participantknows and understands the pUllJoses and risks associated with the test or exerciseprogram, The consent form should be verbally explained and include a statementindicating that the patient has been given an oppoliunity to ask questions about the

.......~II!

Characteristics

Characteristics

FVC less than the lower limit of normal but 2: 70% of predictedFVC 60% to 69% of predictedFVC 50% to 59% of predictedFVC 34% to 49% of predictedFVC <34% of predicted

SECTION III EXERCISE TESTING

Stage

48

0: At risk FEV, 2:80% of predictedFEV,/FVC 2:70%With chronic symptoms: cough, sputum production, dyspnea

I: Mild FEV, 2:80% of predictedFEV,/FVC <70%With or without chronic symptoms

II: Moderate FEV, 30% to 79% of predictedIIA: FEV, 50% to 79% of predictedliB: FEV, 30% to 49% of predicted

FEV,/FVC <70%With or without chronic symptoms

III: Severe FEV, <30% of predictedFEV,/FVC <70%

Stage

performing pulmonary function testing, standards for the performance of thesetests should be followed9 Although many spirometric tests are <1\'ailable, the mostcommon\\- used include the forced \ital capacity (FVC), the forced e:-.piratory vol­ume in 1 'seconJ (FEV,), and the FEV,/F\'C ratio, Results from these tests can beused in the ear\\- identification of patients at risk for the de\'elopment of bothrestricti\'e and 'obstrudi\'e pulmonary disease before s~'mptoms developing,IIm\'e\'er, it should be emphasized that pulmonary function test results prm'ideinformation that is close\\- related to s\'mptoms anJ should not be intell1reted inisolation, AJJitional\\-, Table 3-.,1 illustrates how these tests can be useJ to deter­mine the se\'erity of'both obstructi\'e and restrictive lung diseases, This spiromet­ric classification ~f lung disease has pro\'ed useful in preJicting health status, use ofhealth care resources, Je\'c1opment of exacerbations, and mortality. Additionally,abnormal pnlmonarv hllldion test results can be indicatin' of an increascJ fisk for

TABLE 3-4. Schema for Determining the Severity of Both Obstructive andRestrictive Lung Diseases from Pulmonary Function Tests*

'References 14, 15, 16: From Pauwels RA, BUist AS, Calverley PM, et al. Global strategy for the diagnOSIs, manage­ment, and prevention of chroniC obstructive pulmonary disease NHLBIIVVHO Global InitIative for ChroniCObstructive Lung Disease (GOLD) Workshop summary. Am J Resplr Cnt Care Med 2001;1631256-1276; Amencan

ThoracIC SOCIety. lung function testing: selection of reference values and interpretative strategies. Am Rev Respl(DIS 1991; 144'1202-1218; Aaron SD, Dales RE, Cardinal P How accurate IS spirometry at predicting restrictive pul­monary Impairment> Chest 1999,115:869-873

MildModerateModerately severeSevereVery severe

Severity of Restrictive Disease: This interpretation is based on the assessment of theFVC, expressed as a percent of predicted. In patients where spirometry indicates arestrictive pattern, the measurement of total lung capacity is needed to confirm arestrictive defect.

51

Time Course of Change(When AbnormallyElevated)

Appears at 4-6 hours; peaks at12-24 hours; returns to normalwithin 72 hoursAppears within hours andpeaks at about 24 hourswithout reperfusion; returns tonormal within 2-4 daysAppears about 4-6 hours;peaks at 24 hours, remainselevated 5-10 days

CHAPTER 3/ PRE-EXERCISE EVALUATIONS

<5% of total CK

<0.5 ng.mL 1

Normal Value'

Females 10-70 U.L 1

Males 25-90 U·L- 1

Enzyme

TABLE 3-5. Serum Enzymes (Myocardial Tissue Damage or Necrosis)

Troponin I

Creatine phosphokinase(CPK or CK)

CK myocardial band(CK-MB)

'Normal values vary depending on the laboratory and the method used. The SGOT and LDH enzymes are no longer

used as "cardiac enzymes" and have been replaced by the others.

procedure and has sufficient information to give informed consent. Note specificquestions from the p<Uticipant on the form along with thc responses provided. Theconsent form must indicate that the patticipant is free to \\~thdraw from the pro­cedure at any hme. If the palticipant is a minor, a legal guardian or parent mustsign the consent form. It is advisable to check \vith autliOlitative bodies (e.g., hos­pital tisk management, institutional review boards, facility legal counsel) to deter­mine what is appropJiate for an acceptable informcd consent process. Also, all rea­sonable effOlts must be made to protect the plivacy of the patient's health infor­mation (e.g., medical histOty, test results) as described in the Health InsurancePOttahilit)' and Accountability Act (HIPPA) of 1996. A sample consent form forexercise testing is provided in Figure 3-1. No sample form should be adopted for aspecific program unless approved by local legal counsel.

vVhen the exercise test is for purposes other than diagnosis or prescription(i.e., for expetimental purposes), this should be indicated duting the consentprocess and reflected on the Informed Comelli Form; and applicable policies forthe testing of human subjects must be implemcnted. A copy of the Policy onHuman Subjects for Research is periodically published in ACSM's journal,Medicine and Science in Sports alld Exercise.

Because most consent forms include a statement that emergency proceduresand equipment are available, the program must ensure that available personnelare appropriately trained and authorized to carry out emergency procedures thatuse such equipment. \Vlitten emergency policies and procedures should be inplace, and emergency dlills should be practiced at least once every 3 months ormore often when there is a change in staff. See Appendix B for more informationon emergency management.

Contraindications to Exercise Testing*,{;:s

SECTION II/ EXERCISE TESTING

Absolute• A recent significant change in the resting ECG suggesting significant

ischemia, recent myocardial infarction (within 2 days), or other acute

cardiac event

• Unstable angina• Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic

compromise• Symptomatic severe aortic stenosis• Uncontrolled symptomatic heart failure• Acute pulmonary embolus or pulmonary infarction

• Acute myocarditis or pericarditis• Suspected or known dissecting aneurysm• Acute systemic infection, accompanied by fever, body aches, or swollen

lymph glands

Relativet• Left main coronary stenosis• Moderate stenotic valvular heart disease• Electrolyte abnormalities (e.g., hypokalemia, hypomagnesemia)• Severe arterial hypertension (i.e., systolic BP of >200 mm Hg and/or a

diastolic BP of > 11 0 mm Hg) at rest

• Tachydysrhythmia or bradydysrhythmia• Hypertrophic cardiomyopathy and other forms of outflow tract

obstruction• Neuromuscular, musculoskeletal, or rheumatoid disorders that are exac-

erbated by exercise• High-degree atrioventricular block

• Ventricular aneurysm• Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or

myxedema)• Chronic infectious disease (e.g., mononucleosis, hepatitis, AIDS)• Mental or physical impairment leading to inability to exercise adequately

'Modified from Gibbons RJ, Balady GJ, Bricker J, et al. ACC/AHA 2002 gUidelme updatefor exercise testing: a report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines (Committee on Exercise Testing). 2002.American College of Cardiology web site.www.acc.org/clinical/guidelineslexercise/dirlndex.htm

tRelative contraindications can be superseded if benefits outweigh risks of exercise. Insome instances, these individuals can be exercised with caution and/or using low-level endpoints, especially if they are asymptomatic at rest.

: ,

50

PARTICIPANT INSTRUCTIONS

Explicit instructions for patticipants bcfore exercise testing increase test \'alidityand data accuracy. \Vhenever possible, written instruction~ along \vith a descril;­tlon of the evaluation should be provided well in advance of the appointment so

FIGURE 3-1. Sample of informed consent form for a symptom-limitedexercise test.

Informed Consent for an Exercise Test1. Purpose and Explanation of the Test

You will perform an exercise test on a cycle ergometer or a motor-dliven tread­mill. The exercise intensity will begin at a low level and will be advanced instages depending on your fitness level. \Ve may stop the test at any timebecause of signs of fatigue or changes in your heali rate, ECG, or bloodpressure, or symptoms you may expeJience. It is impOliant for you to realizethat you may stop when you wish because of feelings of fatigue or any otherdiscomfOli.

2. Attendant Risks and DiscomfortsThere exists the possibility of celiain changes occurring during the test. Theseinclude abnormal blood pressure, fainting, irregular, fast or slow heali rhythm,and in rare instances, heart attack, stroke, or death. Every effOli will be madeto minimize these risks by evaluation of preliminalY information relating toyour health and fitness and by careful observations during testing. Emergencyequipment and trained personnel are available to deal with unusual situationsthat may arise.

3. Responsibilities of the ParticipantInformation you possess about your health status or previous experiences ofheart-related symptoms (e.g., shortness of breath with low-level activity,pain, pressure, tightness, heaviness in the chest, neck, jaw, back, and/orarms) with physical effort may affect the safety of your exercise test. Yourprompt reporting of these and any other unusual feelings with effort duringthe exercise test itself is velY important. You are responsible for fullydisclosing your medical histOlY, as well as symptoms that may occur duringthe test. You are also expected to report all medications (including nonpre­scription) taken recently and, in particular, those taken today, to the testingstaff.

4. Benefits to Be ExpectedThe results obtained from the exercise test may assist in the diagnosis of yourillness, in evaluating the effect of your medications or in evaluating what typeof physical activities you might do \vith low risk.

5. InquiriesAny questions about the procedures used in the exercise test or the results ofyour test are encouraged. Ifyou have any concerns or questions, please ask usfor further explanations.

6. Use of Medical RecordsThe information that is obtained duJing exercise testing will be treated as priv­ileged and confidential as described in the Health Insurance Portability andAccountability Act of 1996. It is not to be released or revealed to any personexcept your referring physician without your written consent. However, theinformation obtained may be used for statistical analysis or scientific purposeswith your right to pJivacy retained.

7. Freedom of ConsentI hereby consent to voluntarily engage in an exercise test to detcrminc 1111'

exercise capacity and state of cardiovascular health. ~ly permission to perfon;lthis exercise test is gil'en ,·oluntarily. I understand that I am free to stop thetest at any point if I so desire.

I have read this form, and I understand the test procedures that I will performand the attendant Jisks and discomfolis. Knowing these Jisks and discomforts,and having had an 0ppOJiunit)' to ask questions that have been answered to mI'satisfaction, I consent to paJiicipate in this test. .

the clien~ or patient can prepare adequately. Thc followi'lg points should be con­Sidered for inclusion in such pre!iminaJ)' instructions; however, specific instruc­tlOns vaJ)' IV1th test type and PU'l)Osc.

• Participants should refrain from ingesting food, alcohol, or caffeine or usingtobacco products within 3 hours of testing.

• PaJiicipants should be rested for the assessment, avoiding significant exertionor exercise on the day of the assessment.

• Clothing should permit freedom of movement and include walking or runningshoes. Women should bling a loose-fitting, shOJi-sleeved blouse that buttonsdown the front and should avoid restrictive undergarments.

• If the evaluation is on an outpatient basis, p<uiicipants should be made awarethat the evaluation may be fatigUing and that they may wish to have someoneaccompany them to the assessment to drive home afterward.

• If the test is for diagnostic purposes, it may be helpful for patients to discon­tinue prescribed cardiovascular medications, hut only \\~th physician approval.Currcntly prescribed antianginal agents alter the hemodynamic response toexercise and Significantly reduce the sensitivity of ECG changes for ischemia.

, Patients taking intermediate- or high-dose l3-b1ocking agents may be asked totaper their medication over a 2- to 4-day period to minimize hypcradrenergicwithdrawal responses.

• If the test is for functional purposes, patients sT/lJIIld continue their medicationregimen on their usual scheduIe so that the exercise responses lvill be consis­tent \vith responses expected during exercise training.

53

Signature of Patient

Signature of \Vitncss

Signature of Physician or Authorized Delegate

CHAPTER 3/ PRE-EXERCISE EVALUATIONS

FIGURE 3-1. continued

Date

Date

Datc

SECTION II/EXERCISE TESTING52

55

Purposes of Health-Related Fitness Testing

CHAPTER

4-••.-Health-Related PhysicalFitness Testingand Interpretation

As evidence continues to evolve regarding the health benefits of phYSical activityand exercise, the focus on health-related phYSical fitness, and physiologic fitnessappear to supersede that of skill-related phYSical fitness. I ,2 See Chapter 1 for adetailed descliption of the aforementioned terms. The health-related compo­nents of phYSical fitness have a strong relationship "vith good health, are charac­terized by an ability to perform daily activities with vigor, and demonstrate thetraits and capacities associated with low risk of premature development of thehypokinetic diseases (e.g., those associated with phYSical inactivity)l Both health­related and phYSiologiC fitness measures are closely allied with disease preventionand health promotion and can be modified through reguJar phYSical activity andexercise.

A fundamental goal of primaly and secondalY interv~ntion programs is pro­motion of health; therefore, such programs should focus on enhancement ofhealth-related and phYSiologiC components of phYSical fitness. As palt of theACSM Pre-Participation Screening (Table 2-1), Level 2 recommends an addi­tional Pre-Palticipation Assessment that precedes the development of an exerciseprescription. This chapter provides gUidelines for the Level 2 Pre-ParticipationAssessment through the measurement and evaluation of health-related phYSicalfitness in presumably healthy adults.

Measurement of phYSical fitness is a common and appropJiate practice in pre­ventive and rehabilitative exercise programs. The purposes of health-related fit­ness testing in such programs include the follOwing:

• Educating participants about their present health-related fitness status rela­tive to health-related standards and age- and sex-matched norms

• Providing data that are helpful in development of exercise prescriptions toaddress all fitness components

• Collecting baseline and follow-up data that allow evaluation of progress byexercise program participants

• Motivating palticipants by establishing reasonable and attainable fitness goals• StratifYing cardiovascular lisk

54 SECTION III EXERCISE TESTING

REFERENCES

• Participants should bring a list of their medications, including dosage and fre­quency of administration, to the assessment and should report the last actualdose taken. As an alternative, participants may wish to bring their medicationswith them for the exercise testing staff to record.

• Drink ample fluids over the 24-hour peliod preceding the test to ensure nor­mal hydration before testing.

1. Fuster v, Pearson TA. 27th Bethesda Conference: Matching the intensity of risk factor managementwith the hazard for coronmy disease events. September 14-15, 1995. J Am Coli Cardiol 1996;27:957-1047.

2. BiclJey LS. Bate's pocket guide to phYSical examination and histOly taking. 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2003.

3. National High Blood Pressure Education Program. The Seventh Report of the JOint NationalCommittee on Prevention. Detection, Evaluation, and Treatment of High Blood Pressure ONC7).2003. 03-5233.

4. National Cholesterol Education Program. Third Report of the National Cholesterol EducationProgram (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterolin Adults (Adult Treatment PanellII). 2002. NIH Publication No. 02-5215.

5. Grundy SM, Cleeman JI, Noel Bairey Merz C et al. Implications of recent clinical trials for theNational Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coli Cardiol2004;44:720-732.

6. Pearson TA, Blair SN, Daniels SR, et al. American Heart Association Science Advisory andCoordinating Committee. AHA Guidelines for Primary Prevention of Cardiovascular Disease andStroke: 2002 Update: Consensus panel guide to comprehensive risk reduction for adult patients\vithout coronary or other atherosclerotic vascular diseases. Circulation 2002;106:388--391.

7. Smith SC Jr, Blair SN, Bonow BO, et al. AHA/ACC Scientillc Statement: AHA/ACC guidelines forpreventing heart attack and death in patients \vith atherosclerotic cardiovascular disease: 2001update. A statement for healthcare professionals from the American Heart Association and theAmerican College of Cardiology. Circulation 2001;104:1577-1579.

8. Ferguson GT, Enright PL, Buist AS, et al. Office spirometry for lung health assessment in adults:a consensus statement from the National Lung Health Education Program. Chest 2000;l!7:l!46-1161.

9. American Thoracic Society. Standardization of spirometry, 1994 Update. Am J Bespir Crit CareMed 1995;152:!l07-!l36.

10. American Thoracic Society and American College of Chest Physicians. ATS/ACCP Statement oncardiopulmonary exercise testing. Am J Hespir Crit Care Med 2003;167(2):2!l-277.

11. Gibbons HJ, Balady GJ, Bricker J, et ,J. ACC/AHA 2002 guideline update for exercise testing: areport of the American College of Cardiology/American Heart Association Task Force on PracticeGuidelines (Committee on Exercise Testing). 2002. American College of Cardiology web site.\\~,~v.acc.orgiclinicaVguidelines/exercise/dirIndex. htm

12. Braunwald E, Antman EM, Beasley J"V, et al. ACC/AHA 2002 guideline update for the manage­ment of patients with unstable angina and non-ST-segrnent elevation myocardial infarction: a reportof the American College of Carlliology/American Heart Association task force on practice guide­lines. 2002. http://www.acc.orgiclinicaVguidelines/unstable/unstable.pdf.

13. Expert Committee on the Diagnosis and Classillcation of Diabetes Mellitus. Follow-up report onthe diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160-3167.

14. Pauwels HA, Buist AS, Calverley PM, et al. Global strategy for the diagnosis, management, and pre­vention of chronic obstructive pulmonary disease. NHLBI/\VHO Global Initiative (or ChronicObstructive Lung Disease (GOLD) Workshop summary. Am J Hespir Crit Care Med 2001;163:1256-]276.

15. American Thoracic Society. Lung function testing: selection of reference values and inteqJretativestrategies. Am Hev Hespir Dis 1991;144:1202-1218.

16. Aaron SD, Dales HE, Cardinal P. How accurate is spirometry at predicting restrictive pulmonaryimpairment? Chest 1999;115:869-873.

TEST ORDER

PRETEST INSTRUCTIONS

Basic Principles and Guidelines

Body Composition

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 57

ture and ventilation should be controlled as much as pOSSible. To minimizeanxi~ty, the test procedures should be explained adequately, and the. testenvironment should be quiet and private. The room should be eqUlpped WIth acomfortable seat and/or examination table to be used for resting blood pressureand heart rate and/or electrocardiographic (ECG) recordings. The demeanorof personnel should be one of relaxed confidence to put the subject atease. Testing procedures should not be rushed, and all procedures must beexplained clearly prior to initiating the process. These seemingly minor tasksare accomplished easily and are important in achieving valid and reliabletest results.

It is well established that excess body fat is associated with hypertension, type 2diabetes, stroke, coronalY healt disease, and hyperlipidemia.3 Approximately65% of Americans are classified ovelweight (body mass index [BMI] >25) andalmost 31 % classified as obese (BMI >30)4 In 1960 to 1962, 1971 to 1974, 1976to 1980, 1988 to 1994, and 1999 to 2000 the incidence of obeSity in the UnitedStates was 13.4%, 14.5%, 15%, 23.3%, and 30.9%, respectively. The twofoldincrease in adult obesity since 1980 coincides with an alarming trend in theincidence of ovelweight children in the United States, who displayed an increasefrom approXimately 4% in 1970 to 15% in 20005

.6 This almost fourfold increase

in 20 years shows no signs of abatement. Although there is almost no differencein obesity levels of males based on race and ethnicity, the incidence of obesity ofBlack women is 50%, Mexican-Amelican women 40%, and ''''hite womenapproXimately 30%4 Consequently, assessment of body composition should beemphaSized throughout the life span.

Basic body composition can be expressed as the relative percentage of bodymass that is fat and fat-free tissue using a two-compaltment model. Body com­position can be estimated with both laboratory and field techniques that vmy interms of complexity, cost, and accuracy. Different assessment techniques arebriefly reviewed in this section; however, the detail associated with obtainingmeasurements and calculating estimates of body fat for all of these techniques isbeyond the scope of this text. More detailed descliptions of each technique areavailable in Chapter 12 of the ACSM Resource Manllal~ for Guidelines forExercise Testing and Prescription, 5th ed. and elsewhere.'-9 Before collectingdata for body composition assessment, the technician must be trained, routinelypracticed in the techniques, and already have demonstrated reliability in his orher measurements, independent of the technique being used. Experience can beaccrued under the direct supelvision of a highly qualifled mentor in a controlledtesti ng environment.

ANTHROPOMETRIC METHODS

SECTION II/EXERCISE TESTING56

'Vhen multiple tests are to be administered, the organization of the testing ses­sion can be velY important, depending on what physical fitness components are tobe evaluated. nesting measurements such as heart rate, blood pressure, height,weight, and body composition should be obtained first. When all fitness compo­nents are assessed in a Single session, resting measurements should be followed(in order) by tests of cardiorespiratOly (Cn) endurance, muscular fitness, and flex­ibility. Testing cn endurance after assessing muscular fltncss (which elevates healtrate) can produce inaccurate results about an individual's cn endurance status,palticularly when tests using HR to predict aerobic fitness are used. Likewisc,dehydration rcsulting [rom CR endurance tests might influence body compositionvalues if measured by bioelectJical impedance analysis (BIA).

All pretest instructions should be provided and adhered to plior to anival at thetesting facility. Celtain steps should be takcn to ensure client safety and comfOltbefore administeling a health-related fitness test. A minimal recommendationis that individuals complete a questionnairc such as the ACSM-AHA form (see Fig.2-1). A listing of prelimimuy instl1Jctions for all clients can be found in Chapter 3under Patient Instructions. These instructions may be modified to meet your needs.

The information obtained from health-related physical fltncss testing, in combi­nation with the individual's health and medical information, is used by the healthand fitness professional to help an indi\idual achieve specific fitness goals. Anideal hcalth-related physical fitness test is reliable, \'alid, relati\'ely inexpensive,and easv to administer. The test should \ield results that are indicative of thecurrent 'state of fitness, reflect changc frol;l physical activih" or exercise interven­tion, and be directly comparable to normativc data.

The follOWing should bc accomplished before thc p<uticipant anives at the test site:

• Assure all forms, score sheets, tables, graphs, and other testing documents areorganized and available for the test's administration.

• Calibrate all equipment a minimum of once each month to ensure accuracy(e.g., metronome, cycle ergometcr, treadmill, sphygmomanometer, skinfoldcalipers)

• Organize equipment so that tests can follow in sequence without taxing thesame muscle group repeatedly.

• Pro\ide informed consent form (see Fig. 3-1).• Maintain room temperature of 68°F to 72°F (20°C-22°C) and humiditv of

less than 60%. '

TEST ENVIRONMENT

The test environment is important for test validity and reliability. Test anxiety,emotional problems, food in the stomach, bladder distention, room tempera-

Measurements of height, weight, circumferences, and skinfolds are used toestimate body compOSition. Although skinfold measurements are more difficultthan other anthropometJic procedures, they provide a better estimate of bodyfatness than those based only on height, weight, and circumferences. 10

Circumferences

Disease Riskt Relative to NormalWeight and Waist Circumference

59

BMI Health Risk 20-39 yr 40-59 yr 60-79 yr(kg'm ')

Males

<18.5 Elevated <8% <11% <13%18.6-24.9 Average 8%-19% 11%-21% 13%-24%25.0-299 Elevated 20%-24% 22%-27% 25%-29%>30 High ~25% ~28% ~30%

Females

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION

TABLE 4-2. Predicted Body Fat Percentage based on Body Mass Index(BMI) for African-American and White Adults*t

<18.5 Elevated <21% <23% <24%18.6-24.9 Average 2'1 %-32% 23%-33% 24%-35%25.0-29.9 Elevated 33%-38% 34%-39% 36%-41 %>30 High ~39% ~40% ~42%

'See reference 13: From Gallagher D, Heymsfleld 58. Heo M. et al Healthy percentage body fat ranges: an .approach for developing gUidelines based on body mass index Am J Clin Nutr 2000;72.694-701. Adapted With

permission by the American Journal of Chnlcal Nutrition. © Am J Clin Nutr Amencan SOCiety for (lln1(al Nutrition.

tNote: Standard error of est,mate IS :!:S% for predICting percent body fat from 8MI (based on a four-compartmentestimate of body fat percentage)

precise. A cloth tape measure \\~th a spring-loaded handle (Gulick) reduces skincompression and improves consistency of measurement. Duplicate measUl ementsare recommended at each site and should be obtained in a rotatlOnal IIlstead of aconsecutin' order. The average of the two measures is used pro\~ded each meas­ure is \\~thin .5 nUll. Box 4-1 contains a description of the common sites.

The waist-to-hip ratio (\\'HR) is the circumference of the waist divided bythe circumference of the hips (see Box 4-1, buttocks and hip measure)and hasbeen used as a simple method for determining body fat distribution18 I-Ie<~th

risk increases with WHH, and standards for risk vmy with age and sex. Forexample, health risk is veri; higll for young men when \'VHH is more than 0.9.5and for young women when WHR is more th~\Jl 0.86. For people 60 to 69 yearsold, the \VI-! H values are greater than 1.~3 for men and greater than 0.90 fOlwomen for the same risk classi fication,s·lo

The waist circumference can be used alone as an indicator of health riskbecause abdominal obesit\' is the issue. The Expert Panel on the Identification,Evaluation and Treatment of Overweight and Obesity in Adults prOVided a clas­sification of disease risk based on both EMI and waist circumference as shownin Table 4-1." Furthermore, a new risk stratification scheme [or adults basedon waist circumference has been proposed (Table 4-3).'9 This can be usedI · . . . . I 13Ml t . I . to cll 'Olll'C dl'sease risk (see Table 4-a one or In conjunctIon WIt 1 0 cv,\ U,\ e I ..

1). All assessm~nts should include a minimllll1 of either waist circumference orEMI, but preferably both, for risk stratification.

Skinfold Measurements

Eody composition determined from skin[old measuremcnts correlates well(r = .70-.90) \\~th body composition determined by hydrodenSiometly.9 The

Men, >102 emWomen, >88 em

High

Very highVery highExtremely high

Men, :5102 emWomen, :588 em

Increased

HighVery highExtremely high

<18.5185-249250-299

300-349350-39.9~40

SECTION II/EXERCISE TESTING58

The pattem of body f~\t distribution is recognized as an impoliant predictor of thehealth risks of obeSity. I 1Android obeSity which is charactelized by more f~\t on thetrunk (abdominal f~lt), prO\~des an increased lisk of h)pe'iension, t)1)e 2 diabetes,dyslipidemia, coronary <\liery disease, and premature death compared \\~th indi­\'iduals who demonstrate g)110id obeSity (fat distlibuted in the hip and thigh).15

Gilih measurements may be used to predict body composition and equationsare available for both genders and a range of age groups. 16.17 The accuracv may he\\'ithin 2..5% to 4% of the actual body COmposition if the subject possesses similareharactelistics of the origimJ validation population and the gilih measurements are

UnderweightNormalOverweightObesity, classIIIIII

TABLE 4-1. Classification of Disease Risk Based on Body Mass Index(BMI) and Waist Circumference*

Body Mass Index

The EMl, or Quetelet index, is used to assess weight relath'e to height and is cal­culated by w\iding body weight in kilograms b\· hCight in meters squared (kg'm-2).For most people, obesity-related health problems increase beyond a EMI of 2.5,and the Expert Panel on the Identification, Ewluation, and Treatment ofOven.veight and Obesity in Adults II lists a 13M! of 2.5.0 to 29.9 kg'm-2 for over­weight and a BMI of greater than or equal to 30.0 kg'm-2 for obesity Although,BMI hlils to distinguish between body Elt, muscle mass, or bone; an increasedliskof hypeliension, total cholesterolJlIDL cholesterol ratio, coronalY disease, andmOliality rate are associated with a 13MI greater thall :30 kg'm- 2 Cfable4_]).12 A 13MI of less than 18..5 kg'm-2 also increases the lisk ofcardiovascular dis­ease and is responsible for the lower portion of the .I-shaped curve of EM] \'ersuscardiovascular risk. The use of specific 13M] \'alues to predict percentage body fatand health lisk is in the initial stages of cle\'e]opment (Table 4_2).1:3 Because of tberelatively large standard error of estimating percent bt from BMI (::!::.5% bt),10other methods ofbocl)' composition assessment should he IIsed to predict hod\' fat­ness during a fitness assessment.

*See Reference 11: Modified from Expert Panel. ExecutIVe summary of the clinical guidelines on the IdentIfication,evalualion. and treatment of overweight and obeSity In adults Arch Intern Med 1998; 158: 1855-1867

tDisease risk for Type 2 diabetes. hypertension, and cardiovascular disease. Dashes (_) Indicate that no addItionalrisk at these levels of 8MI was assigned. Increased waist CIrcumference can also be a marker for Increased riskeven in persons of normal weight.

Forearm:

Abdomen:

Males

<80 em (31.5 in)80-99 (315-390)100-120 (395-470)>120 (470)

Waist Circumference cm (in)

Females

<70 cm «285 in)70-89 (28.5-350)90-109 (355-43.0)> 11 0 (>43.5)

Very lowLowHighVery High

Risk Category

Procedures• All measurements should be made with a flexible yet inelastic tape

measure.

• The tape should be placed on the skin surface without compressing thesubcutaneous adipose tissue

• If a Gulick spring loaded handle is used, the handle should be extendedto the same marking with each trial.

• Take duplicate measures at each site and retest if duplicate measure­ments are not within 5 mm.

• Rotate through measuremenfsites or allow time for skin to regainnormal texture.

Modified from Callaway CW, et al. Circumferences: 39-80 In Lohman TG, Roche AF,Martorell R. eds. Anthropometric Standardization Reference Manual. Champaign, IL:Human Kinetics, 1988.

'See reference 19: From Bray GA. Don't throw the baby out with the bath water. Am J Clin Nutr

2004;70(3):347-349. Adapted with permission by the American Journal of Clinical Nutrition. © Am J Clin NutrAmerican Society for Clinical Nutrition.

TABLE 4-3. New Criteria for Waist Circumference in Adults*

CHAPTER 4 / HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 61

~ Box 4.1, continued

plinciple behind this technique is that the amount of subcutaneous fat is propor­tional to the total amount of body fat. It is assumed that close to one-third of thetotal fat is located subcutaneously. The exact proportion of subcutaneous-to-totaJfat varies with sex, age, and ethnicity.2o Therefore, regression equations used toconvert sum of skinfolds to percent body fat must consider these variables forgreatest accuracy. Box 4-2 presents a standardized descliption of skinfold sitesand procedures. Refer to the ACSM Resource Manual, .5th ed. for photographsof the skinfold sites. To improve the accuracy of the measurement, it is recom­mended that one train with a skiJJed technician, use video media that demon­strate proper technique, participate in workshops, and accrue experience in asupervised practical environment. The accuracy of predicting percent fat fromskinfoJds is approximately pJus or minus 3..5% assuming that appropriate tech­niques and equations have been used s

Factors that may contlibute to measurement error vvithin skinf6Jd assessmentinclude poor technique andlor an inexperienced evaluator, an extremely obese or

I I

With the subject standing upright and relaxed, a hori­

zontal measure taken at the greatest anterior extensionof the abdomen, usually at the level of the umbilicus

With the subject standing erect and arms hangingfreely at the sides with hands facing the thigh, a hori­zontal measure midway between the acromion andolecranon processes.

With the subject standing erect and feet together, ahorizontal measure is taken at the maximal circumfer­ence of buttocks. This measure is used for the hipmeasure in a waisVhip measure.

With the subject standing erect (feet apart ~20 cm), ahorizontal measure taken at the level of the maximumcircumference between the knee and the ankle, per­pendicular to the long axis.

With the subject standing, arms hanging downwardbut slightly away from the trunk and palms facing

anteriorly, a measure perpendicular to the long axis atthe maximal circumference.

With the subject standing, legs slightly apart (~1 0 cm),a horizontal measure is taken at the maximal circum­ference of the hip/proximal thigh, just~thegluteal fold. C\bo lieWith the subject standing and one foot on a bench sothe knee is flexed at 90 degrees, a measure is takenmidway between the inguinal crease and the proximalborder of the patella, perpendicular to the long axis

With the subject standing, arms at the sides, feettogether, and abdomen relaxed, a horizontal measureis taken at the narrowest part of the torso (above the

umbilicus and below the xiphoid process) The NationalObesity Task Force (NOTF) suggests obtaining a hori­zontal measure directly above the iliac crest as a

method to enhance standardization. Unfortunately,current formulae are not predicated on the NOTFsuggested site. ~

SECTION II / EXERCISE TESTING

Arm:

Buttocks/Hips:

Calf:

HipSlThigh

Mid-Thigh

Waist:

60

I • I

extremely lean subject, and an improperly calibrated caliper (tension should be setat -12 g'mm -2).21 Vmious regression equations have been developed to predictbody density or percent body fat from skinfold measurements. For example, Box 4­3 lists generalized equations that allow calculation of body density without a loss inprediCtion accuracy for a wide range of individuals.2

1.22 However, if a population­specific equation is needed, Heyward and Stolarczyk provide a qUick referenceguide to match the client to the correct equation based on sex, age, ethnicity, fat­ness, and spOJi8

MEN• Seven-Site Formula (chest, midaxillary, triceps, subscapular, abdomen,

supra iliac, thigh)Body density = 1.112 - 0.00043499 (sum of seven skinfolds)

+ 0.00000055 (sum of seven skinfolds)2- 0.00028826 (age) [SEE 0.008 or -3.5% fat)

• Three-Site Formula (chest, abdomen, thigh)Body density = 1.10938 - 0.0008267 (sum of three skinfolds)

. + 0.0000016 (sum of three skinfolds)2 - 0.0002574 (age)[SEE 0.008 or -3.4% fat)

_. Three-Site Formula (chest, triceps, subscapular)Body density = 1.1125025 - 0.0013125 (sum of three skinfolds)

+ 0.0000055 (sum of three skinfolds)2 - 0.000244 (age)[SEE 0.008 or -3.6% fat)

WOMEN• Seven-Site Formula (chest, midaxillary, triceps, subscapular, abdomen,

suprailiac, thigh)Body density = 1.097 - 0.00046971 (sum of seven skinfolds)

+ 0.00000056 (sum of seven skinfolds)2- 0.00012828 (age) [SEE 0.008 or -3.8% fat)

_. Three-Site Formula (triceps, suprailiac, thigh)Body density = 1.099421 - 0.0009929 (sum of three skinfolds)

+ 0.0000023 (sum of three skinfolds)2 - 0.0001392 (age)

~~ , [SEE 0.009 or -3.9% fat)

~• Three-Site Formula (triceps, suprailiac, abdominal)

Body density = 1.089733 - 0.0009245 (sum of three skinfolds)+ 0.0000025 (sum of three skinfolds)2 - 0.0000979 (age)

[SEE 0.009 or -3.9% fat)

'See reference 22: Adapted from Jackson AS, Pollock ML. Practical assessment of bodycomposition. Phys Sport Med 1985;13:76-90; Pollock ML, Schmidt DH, Jackson AS.Measurement of cardiorespiratory fitness and body composition in the clinical setting.Comp Ther 1980;6:12-17.

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 63

I II I

Vertical fold; 2 cm to the right side of the umbilicus

Vertical fold; on the posterior midline of the upper arm,~way between the acmrnioLLar.:u;Lole.aanon process­~~with the arm held freely to the side of the body

Vertical fold; on the anterior aspect of the arm over thebelly of the biceps muscle, 1 cm above the level used tomark the triceps site

Diagonal fold; one-half the distance between the ante­rior axillary line and the nipple (men), or one-third of thedistance between the anterior axillary line and the nipple(women)

Vertical fold; at the maximum circumference of the calfon the midline of its medial border

Vertical fold; on the midaxillary line at the level of thexiphoid process of the sternum. An alternate method isa horizontal fold taken at the level of the xiphoid/sternalborder in the midaxillary line.

Diagonal fold (at a 45-degree angle); 1 to 2 cm belowthe inferior angle of the scapula

Diagonal fold; in line with the natural angle of the iliaccrest taken in the anterior axillary line immediately supe­nor to the iliac crest

Vertical fold; on the anterior midline of the thigh, mid­way between the proximal border of the patella and theinguinal crease (hip)

SKINFOlD SITEAbdominal

Triceps

Biceps

Chest/Pectoral

Medial Calf

Midaxillary

Subscapular

Procedures

• All measurements should be made on the right side of the body with thesubject standing upright

• Caliper should be placed directly on the skin surface, 1 cm away from thethumb and finger, perpendicular to the skinfold, and halfway betweenthe crest and the base of the fold

• Pinch should be maintained while reading the caliper• Walt 1 to 2 seconds (not longer) before reading caliper

• Take duplicate measures at each site and retest if duplicate measure­ments are not within 1 to 2 mm

• Rotate through measurement sites or allow time for skin to regain nor­mal texture and thickness

r Thigh

'* Suprailiac

62 SECTION II / EXERCISE TESTING

-rt rCMA 1e (Ylc( \e~~...;;..;...:...-.._-----_.-

DENSITOMETRY

Plethysmography

Hydrodensiometry (Underwater) Weighing

Population Age Gender % Body Fatt

Race(481/Db)-4.34American Indian 18-60 Female

Black 18-32 Male (437/Db)-39324-79 Female (485/Db)-439

Hispanic 20-40 Female (4.87/Db)-441

Japanese Native 18-48 Male (497/Db)-452

Female (4 76/Db)-4.2861-78 Male (487/Db)-441

Female (495/Db)-450

White 7-12 Male (530/Db)-489

Female (535/Db)-49513-16 Male (507/Db)-464

Female (510/Db)-46617-19 Male (499/Db)-455

Female (505/Db)-46220-80 Male (495/Db)-450

Female (5,01/Db)-4.57

Levels of Body Fatness(5,26/Db)-4.83Anorexia 15-30 Female

Obese 17-62 Male (5.00/Db)-4.56

'See reference 8: Adapted, with permission, from Heyward VH, Stolarczyk LM, Applied Body Composition

Assessment. Champaign, IL: Human Kinetics, 1996; 12.

tPercent body fat is obtained by multiplying the value calculated from the equation by 10O,

TABLE 4-4. Population-Specific Formulas for Conversion of Body Density(Db) to Percent Body Fat*

OTHER TECHNIQUES

Additional assessment techniques of dual energy x-ray absorptiometry (DEXA)and total body electrical conductivity (TOBEC) are reliable and accurate meas­ures of body composition, but these techniques are not popular for general healthfitness testing because of cost and the need for highly trained personnel.9

Techniques of bioelectrical impedance analysis (BrA) and near-infrared interca­dence are used for general health fitness testing, Generally, the accuracy of BIAis similar to skinfolds, as long as a stringent protocol is followed and the equatIonsprogrammed into the analyzer are valid and accurate for the populations beingtested,27 Near-infrared intercadence requires additional research to substantIatethe validity and accuracy for body composition assessment.28 Detailed explana­tions of these techniques are found in Chapter 12 of ACSM's Resource Manualfor Guidelines for Exercise Testing and Prescription, 5th ed,

CHAPTER 4 / HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 65

'sition provide a variety of new equations that should increase the accuracy of theestimate of percent fat when applied to different populations, These equatIOns(Table 4-4) are likely to improve over time as additional studies are done onlarger samples within each population groups

SECTION II/EXERCISE TESTING64

This technique of measuring body composition is based on Archimedes' princi­ple, which states that when a body is immersed in water, it is buoyed by a coun­terforce equal to the weight of the water displaced. This loss of weight in waterallows calculation of body volume. Bone and muscle tissue are denser than water,whereas fat tissue is less dense. Therefore, a person ,vith more FFM for the sametotal body mass weighs more in water and has a higher body density and lowerpercentage of body fat. Although hydrostatic weighing is a standard methodfor measuring body volume and hence, body compOSition, it requires specialequipment, the accurate measurement of residual volume, and significant coop­eration by the subject.23 For a more detailed explanation of the technique (seeChapter 12 of ACSM's Resource Manual for Guidelines for Exercise Testing andPrescription, 5th ed.),

Body volume also can be measured by air rather than water displacement. Onecommercial system uses a dual-chamber plethysmograph that measures bodyvolume by changes in pressure in a closed chamber. This technology showspromise and generally reduces the anxiety associated with the technique ofhydrodensiometiy.lo,23,24 For a more detailed explanation of the technique, seeChapter 12 of ACSM's Resource Manual for Guidelines for Exercise Testing and

prescr1(~~h eeJr \+-Conv~rsion ~ho~/D~nsity to Body Composition

Percent body fat can be estimated once body density has been determined. Two ofthe most common prediction equations llsed to estimate percent body fat frombody density are derived [rom the two-component model of body composition:2.5.26

% fat = Body~:nsity - 4142

% fat = 495 , - 450Body Density

Body composition can be estimated [rom a measurcment of whole-body density,using the ratio of body mass to body volume. In this technique, which has beenused as a reference or criterion standard for assessing body composition, the bodyis divided into two components: the hit mass (FM) and the fat-free mass (FFM).The limiting factor in the measurement of body density is the accuracy of thebody volume measurement because body mass is measured simply as bodyweight. Body volume can be measured by hydrodensiometry (underwater)weighing and by plethysmography.

Each method assumes a slightly different density of both fat and fat free mass.Ongoing research, using the three- and [our-component models of body compo-

BODY COMPOSITION NORMS

THE CONCEPT OF MAXIMAL OXYGEN UPTAKE

Cardiorespiratory Fitness

TABLE 4-6. Body Composition (% Body Fat) for Women*

Age

Percentile 20-29 30-39 40-49 50-59 60+

90 14.5 15.5 18.5 216 21.180 17.1 18.0 21.3 25.0 25.170 19.0 20.0 23.5 26.6 27.560 20.6 21.6 24.9 28.5 29.350 22.1 23.1 26.4 30.1 30.940 237 24.9 28.1 31.6 32.530 25.4 27.0 30.1 33.5 34.320 27.7 29.3 32.1 35.6 36.610 32.1 32.8 35.0 37.9 39.3

'Data proVided by the Institute for AerobiCS Research, Dallas, TX (1994). Study population for the data set was pre­dominantly White and college educated. The follOWing may be used as desCflptors for the percentile rankings:well above average (90), above average (70), average (50), below average (30), and well below average (10).

MAXIMAL VERSUS SUBMAXIMAL EXERCISE TESTING

Open-circuit spirometty is used to measure V02011",. In this procedure, thesubject breathes through a low-resistance valve (,vith nose occluded) while pul­momu)' ventilation and expired fractions of O2 and CO2 are measured. Modernautomated systems pro,ide ease of use and a detailed p,intout of test results thatsave time and effort.3-3 However, attention to detail relative to calibration is stillessential to obtain accurate results. Administration of the test and interpretationof results should be reserved for profeSSional personnel with a thorough under­standing of exercise science, Because of the costs associated with the equipment,space, and personnel needed to carry out these tests, direct measurement of\102,mL\ generally is reserved for research or clinical settings.

\\Then direct measurement of V0201,,,, is not feasible or desirable, a valiety ofsubmaximal and maximal exercise tests can be used to estimate \'0201m" These testshave been validated by examining: 1.) the correlation between directly measuredV0201m' and the V02",,,, estimated from physiologic responses to submaximal exer­cise (e.g., heart rate at a speCified power output); or 2) the correlation betweendirectly measured V02011,,, and test performance (e.g_, time to run 101' 1.5 miles, ortime to volitional fatigue using a standard graded exercise test protocol).

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 67

The decision to use a maximal or subm,vdmal exercise test depends largely on thereasons for the test and the availability of appropriate equipment and personnel.V02011,., can be estimated using conventional exercise te~t protocols, by consider­ing test duration at a given workload on an ergometer and using the predictionequations found in Appendix D. The user would need to consider the populationbeing tested and the standard error of the associated equation, Maximal testshave the disadvantage of requiring participants to exercise to the point of voli­tional fatigue and might require medical supervision (see Chapter 2) and emer­gency equipment. However, maximal exercise testing offers increased sensitivityin the diagnosis of eoronmy artely disease in asymptomatic individuals and

SECTION II/EXERCISE TESTING66

There are no unh-ersaJly accepted norms for body composition; however, Tables4-5 and 4-6, which arc based on selected populations, provide percentile valuesfor percent body fat in men and women, respectively. A consensus opinion for anexact percentage body fat value associated ,vith optimal health lisk has vet to bedefined; however, a range 10% to 22% and 20% to .32% for men and' women,respecti,-ely, is considered satisfactory for health.29

Cardiorespiratory fitness is related to the ability to perform large muscle, dynam­ic, moderate-to-high intensity exercise for prolonged periods. Performance ofsuch exercise depends on the functional state of the respiratory, cardiovascular,and skeletal muscle systems. CardiorespiratOl)' fitness is considered health-relat­ed because: 1) low levels of CR fitness have been associated \\ith a marked'"increased lisk of premature death from all causes and specifically from cardi~­

vascular disease, 2) increases in cn fitness arc associated ,vith a reduction indeath from all causes, and3) high levels of cn fltness arc associated ,vith higherlevels of habitual physical activity, which in turn are associated \\ith many healthbenefits.3(h32 The assessment of cn fitness is an important pali of a plimary orseconda!y intervention program.

Maximal oxygen uptake (V02m"J is accepted as the critelion measure of CRfitness. Maximal oxygen uptake is the product of thc maximal cardiac output(L blood'min- 1

) and alierial-venous oxygen difference (mL O2 per L blood).Significant variation in V02""., (L'min- l) across populations and fitness levelsresults plimarily from differences in maximal cardiac output; therefore, \'0201"" isclosely related to the functional capacity of the heari_

TABLE 4-5. Body Composition (% Body Fat) for Men*

Age

Percentile 20-29 30-39 40-49 50-59 60+

90 7.1 11.3 13.6 15.3 15.380 9.4 13.9 16.3 179 18.470 118 15.9 18.1 19.8 20.360 14.1 17.5 19.6 21.3 22050 159 19.0 21.1 227 23.540 17.4 20.5 22.5 24.1 25.030 19.5 223 24.1 25.7 26.720 22.4 24.2 26.1 27.5 28.510 25.9 27.3 28.9 30.3 312'Dala provided by the lnslitute of Aerobics Research, Dallas, TX (1994). Sludy population for the data set was

predominantly White and college educated. The followin9 may be used as descriptors for the percentile rankings'well above average (90), above average (70), average (50), below average (30), and well below average (10).

MODES OF TESTING

Commonly used modes for exercise testing include field tests, treadmill tests,cycle ergometry tests, and step tests. Medical supervision may be reqmred formoderate or high-risk individuals for each of these modes. Refer to Table 2-1 forexercise testing and supervision guidelines. There are advantages and disadvan-

tages of each mode:

• Field tests consist of walking or running a certain distance in a given time(i.e., 12-minute and 1.5-mile run tests, and the 1- and 6-minute walk test).The advantages of field tests are that they are easy to administer to large num­bers of individuals at one time and little equipment (e.g., a stopwatch) is need­ed. The disadvantages are that they all potentially could be maximal tests,. an~by their nature, are unmonitored for blood pressure and heart rate. An mdl­vidual's level of motivation and pacing ability also can have a profound Impacton test results. These all-out run tests may be inappropriate for sedentmy indi­viduals or individuals at increased risk for cardiovascular and musculoskeletalcomplications. However, \102,,,,", can be estimated from test resul.ts. .

• Motor driven treadmills can be used for submaximal and maximal testmgand often are used for diagnOStic testing. They provide a common form of

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION. 69

exercise (i.e., walking) and can accommodate the least fit to the fittest indi­viduals across the continuum of walking to running speeds. Tevertheless, apractice session might be necessarv in some cases to permit habituationand reduce anxiety. On the other hand, treadmills usually are expensive, noteasily transpOliable, and make some measurements (e.g., blood pressure)more difficult. Treadmills must be calibrated to ensure the accuracy of thetest. In addition, holding on to the support rail should not be permitted toensure accuracy of the metabolic work.

• Mechanically braked cycle ergometers are excellcnt test modalities forsub maximal and maximal testing. They are relatively inexpensive, easily trans­portable, and allow blood pressure and the electrocardiogram (if appropriate)to be mcasured easily. The main disadvantage is that cycling is a less f~lIniliar

mode of exercise for many Americans, often resulting in limiting localizedmuscle fatigue. Cycle ergometers provide a non-weight-bearing test modalityin which work rates are easily adjusted in smaJl work-rate increments, andsubjects tend to be least anxious using this device. The cycle ergometer mustbe calibrated and the subject must maintain the proper pedal rate becausemost tests require that hemi rate be measurcd at specific work rates.Electronic cycle ergometers can deLiver the same work rate across a range ofpedal rates, but calibration might require speCial equipment not available inmost laboratories. Some electronic fitness cycles cannot be calibrated andshould not be used for testing.

• Step testing is an inexpensi,"e modality for predicting CR fitness by measur­ing the hemi rate response to stepping at a fixed rate andlor a fixed step heightor by measuring postexercise recovery heart rates. Step tests require little orno equipment; steps are easily transportable; stepping skill requires little prac­tice; the test usually is of short duration; and stepping is advantageous for masstesting.:31 Postexercise (recovery) heart rates decrease with improved CR fit­ness and test results arc easy to explain to partieipants.:35 SpeCial precautionsmight be needed for those who have balance problems or are extremelydeconditioned. Some Single stage step tests require an energy cost of 7 to 9metabolic equivalents (METs), which may exceed the maximal capacity of theparticipant.:36 The workload must be appropriate to the fitness level of theclient. In addition, inadequate compliance to the step cadence and excessivefatigue in the lead limb may diminish the value of a step test. Most tests areunmonitored because of the difficulty of measuring heart rate and bloodpressure during a step test.

Field Tests

Two of tbe most widely used running tests for assessing CR fitness are tbeCooper 12-minute test and the l.5-mile test for time. Thc objcctive in the 12­minute test is to cover the greatest distance in the allotted time period, and forthe 1.5-mile test it is to run thc distance in the shortest period of time. V02m 'L'can be estimated from the equations in Appendix D.

The Rockport One-Mile Fitness Walking Test has gained \\~de popularity as aneffective means for estimating CR fitness. In this test, an indi\~dual walks 1 mile asfast as possible, preferably on a track or a level surface, and hemi rate is obtained

SECTION II/EXERCISE TESTING

provides a better estimate of \'02,,,,", (see Ch.apter 5). Additionally, the use ofopen circuit spirometry during maximal exercise testmg allo.ws for the accurateassessment of anaerobic threshold and the measurement of V02 ,,,,"v

Practitioners commonly rely on submaximal exercise tests to assess CR fitnessbecause maximal exercise testing is not always feasible in the health and fitnesssetting. The basic aim of submaximal exercise testing is to determine the heartrate (HR) response to one or more submaximal work rates and usethe results topredict \102max' Although the primmy purpose of the te.st has traditionally beento predict \102max from the HR-workload relatIOnship, It IS ll~portant to obtamadditional indices of the client's response to exercise. The practItIOner should usethe various submaximal measures of heart rate, blood pressure, workload, RPE,and other subjective indices as valuable information regarding one's ~unctionalresponse to exercise. This information can be used to evalua:e submaxlmal exer­cise responses over time in a controlled environment and to fine-tune an exercise

prescription. . .Estimates of \102max from the HR response to submaxllnal exercise tests are

based on several assumptions:

• A steady-state heart rate is obtained for each exercise work rate and is consis-

tent each day.• A linear relationship exists between heart rate and work rate.• The maximal work load is indicative of the maximal V02·

• The maximal heart rate for a given age is uniform.• Mechanical efficiency (i.e., \102at a given work rate) is the same for evelyone.• The subject is not on medications that alter heart rate.

Note: The most accurate estimate of \102'mLX is achieved if all of the preceding

assumptions are met.

68

Submaximal Exercise Tests

Cycle Ergometer Tests

Patients completing less than 300 meters during the 6-minute walk, demon­strate a limited short-term survival.39

• I

• I

1. Obtain resting HR and BP immediately prior to exercise in the exerciseposture.

2. The client should be familiarized with the ergometer. If using a cycleergometer properly position the client on the ergometer (i.e., uprightposture, 5-degree bend in the knee at maximal leg extension, hands inproper position on handlebars).

3. The exercise test should begin with a 2- to 3-min warm-up to acquaintthe client with the cycle ergometer and prepare him or her for the exer­cise intensity in the first stage'of the test

4. A specific protocol should consist of 2- or 3-minute stages with appro­priate increments in work rate.

5. Heart rate should be monitored at least two times during each stage,near the end of the second and third minutes of each stage. If heart rate> 11 0 beats'min-\ steady-state heart rate (i.e., two heart rates within5 beats'min-') should be reached before the workload is increased.

6. Blood pressure should be monitored in the last minute of each stage andrepeated (verified) in the event of a hypotensive or hypertensiveresponse.

7. Perceived exertion and additional rating scales should be monitored nearthe end of the last minute of each stage using either the 6-20 or 0-10scale (see Table 4-8).

8. Client appearance and symptoms should be monitored and recordedregularly.

9 The test should be terminated when the subject reaches 70% heart ratereserve (85% of age-predicted maximal heart rate), fails to conform tothe exercise test protocol, experiences adverse signs or symptoms,requests to stop, or experiences an emergency situation.

10. An appropriate cool-down/recovery period should be initiated consistingof either:a. continued exercise at a work rate equivalent to that of the first stage

of the exercise test protocol or lower; or,b. a passive cool-down if the subject experiences signs of discomfort or

an emergency situation occurs11. All physiologic observations (e.g., heart rate, blood pressure, signs and

symptoms) should be continued for at least 5 minutes of recoveryunless abnormal responses occur, which would warrant a longerposttest surveillance period. Continue low-level exercise until HR andblood pressure stabilize, but not necessarily until they reach preexerciselevels.

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 71SECTION II/EXERCISE TESTING70

in the final minute. An alternative is to measure a lO-second heart rate immediate­lyon completion of the I-mile walk, but this may overestimate the \102m", com­pared to when hemt rate is measured dUling the walk. \102m,,, is estimated from aregression equation (found in Appendix D) based on weight, age, sex, walk time,and heart rate.37 In addition to independently predicting morbidity and mortality3.~

the 6-minute walk test has been used to evaluate cn Fitness ""rithin some clinicalpatient populations (e.g., persons \\rith congestive hemt failure or pulmonary dis­ease). Even though the test is considered submaximal, it may result in near maxi­mal performance for those with low fitness levels or disease. Several multivmiateequations are available to predict peak oxygen consumption from the 6-minutewalk; however, the follo\\ring equation requires minimal clinical information ::39

• Peak \102 = V02 mL·kg-1·min- l = [0.02 X distance (m)] - [0.191 X age(yr)] - [0.07 X weight (kg)] + [0.09 X height (cm)] + [0.26 X npp (x 10-')]+ 2.45o m = distance in meters; yr = year; kg = kilogram; cm = centimeter;

RPP = rate pressure product (HR X systolic blood pressure in mm Hg)• n2 = 0.65 SEE = 2.68

Both Single-stage and multistage submaximal exercise tests are available to esti­mate \102m", from simple heart rate measurements. Accurate measurement ofhemt rate is critical for valid testing. Although hemt rate obtained by palpation isused commonly, the accuracy of this method depends on the experience and tech­nique of the evaluator. It is recommended that an electrocardiograph, heart ratemonitor, or a stethoscope be used to determine heart rate. The use of a relativelyinexpensive hemt rate monitor can reduce a significant source of error in the test.The sublmLximal heart rate response is easily altered by a number of environmen­tal (e.g., heat ancllor humidity, see Appendix E), dietary (e.g., caffeine, time sincelast meal), and beha\rioral (e.g., anxiety, smoking, pre\rious acti\rity) factors. Thesevmiables must be controlled to have a valid estimate that can be used as a refer­ence point in a person's Fitness program. In addition, the test mode (e.g., cycle,treadmill, or step) should be consistent \\rith the primary acti\rity used by thepmticipant to address specificity of training issues. Standardized procedures forsubmaximal testing are presented in Box 4-4. Although there are no specificsubmaximal protocols for treadmill testing, several stages from any of the tread­mill protocols found in Chapter 5 can be used to assess subm,L'Cimal exerciseresponses. Preexercise test instructions were presented in Chapter 3.

The Astrand-Rhyming cycle ergometer test is a Single-stage test lasting 6 min­utes 40 For the population studied, these researchers observed that at 50% of\102 ,m" the average heart rate was 128 and 138 beats' min -I for men and women,respectively. If a woman was working at a \102 of 1.5 L'min -[ and her HR was

138 beats'min-I, then her V02 "1<" was estimated to be 3.0 L·min- I . The sug­gested work rate is based on sex and an individual's fitness status as follows:

1.500

1.200

1.050

300

750

450

600

900

Work load(kg/min)

Women Men

.....0.8 ....Step test 0.9 30033 em 40 em

Women Men 1.0(weight, kg)

40 1.1

LI 1.2 450

1.6 40 1.350

1.4

0 '1:5 600

60 501.6

1.7

70 1:8 750

601.9

2.080

"'-- 9002.1

702.2

902.3

2.480

2.5

2.6

90 2.7

2.8

2.9

100 3.0

3.1

3.2

3.3

3.4

3.5

IV02max,170

166

162 172

158 168

154 164

150 160

146 156

142 152

138 148

134 144

130 140

126 136

122 132

128

124

120

CHAPTER 4 / HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 73

FIGURE 4-1. Modified Astrand-Ryhming nomogram. (Reprinted with permission fromAstrand P-O, Ryhming I. A nomogram for calculation of aerobic capacity [physical fit­ness] from pulse rate during submaximal work. J Appl Physiol 1954;7:218-221.)

1.101000.870.830.780.750.710.680.65

Correction Factor

300 or 600 kg'm'min- I (50 or 100 watts)600 or 900 kg'm'min -I (loa or 1.50 watts)300 or 450 kg'm'min- I (50 or 75 watts)450 or 600 kg'm'min- I (75 or 100 watts)

SECTION II/EXERCISE TESTING

men, unconditioned:men, conditioned:

women, unconditioned:women, conditioned:

72

The pedal rate is set at 50 rpm. The goal is to obtain HR values between 125and 170 beats'min- I, and HR is measured during the fifth and sixth minute ofwork. The average of the two beart rates is then used to estimate V02",,", from anomogram (Fig. 4-1). This value must then be adjusted for age (because maximalHR decreases \\~th age) by multipl)~ng the V02""" value by the following correc­tion factors: 36

Age1525354045505560

\/ 65

/ In contrast to the single-stage test, Mantz et al 41 measured HR .It a series ofsubmaximal work rates and extrapolated the response to the subject's age-predict­ed maximal heart rate. This has become one of the most popular assessment tech­niques to estimate V02",,,,, and the YMCA test is a good example.42 The YMCAprotocol uses two to four, 3-minute stages of continuous exercise (Fig. 4-2). Thetest is deSigned to raise the steady-state HR of the subject to between 110beats' min -1 and 70% HRR (85% of the age-predicted maximal I-l~) for at least twoconsecutive stages. It is im oliant to remember that two consecutive HR meas­urements must be obtained within this HR ranae to Jredict V02"",,, In t 1e YMCA

rotoco , each wor' i'ate IS per onne or at least 3 mimi es an 1eart rates arel'ecorded durin t 1e 111" to 30 seconds of th,e second and third minutes. If thesetwo heart rates ValY by more t 1an 5 eats'min , t 1e work rate should be main­tained for an additional minute. The test administrator should recognize the errorassociated with age-predicted maximal HR and monitor the subject throughout thetest to ensure the test remains submaximal. The heali rate measured during the lastminute of each steady-state stage is plotted against work rate. The line generatedfrom the plotted points is then extrapolated to the age-predicted maximal heart rate(e.g., 220-age), and a perpendicular line is dropped to the x-axis to estimate thework rate that would have been achieved if the person had worked to maximum(Fig. 4-3). V02",,,., can be estimated from the work rate using the formula inAppendix D. These eqllations are valid to estimate oxygen consumption at sub­maximal steady state workloads from 300 to 1,200 kg'm'min -I, therefore cantionmust be used if extrapolating to workloads outside of this range. The two linesnoted as ::': 1 SD in Figure 4-3 show what the estimated V02""" would be if the

Treadmill Tests

Step Tests

120C1050900750600

Work rate (kg.m.min-1)

450300

200

190

-,.... 180i:'E

170III-lUQ) 160.0-Q)- 150lU...-...lU 140

Q)

::I:130

120

110

150

22.5 steps'min- I . These tests require oxygen uptakes of about 25.8 and 29.5mL.kg-I'min- L, respectively. Heart rate is measured as described for the cycletest, and V0

2m'L' is estimated frolll the nomogram (see Fig. 4-1). In contrast, Maritz

et al.41 used a single-step height (30.5 cm) and four-step rates to systematicallyincrease the work rate. A steady-state HR was measured for each step rate and aline formed from these HI\ values was extrapolated to age-predicted maximal HR;the maximal work rate was determined as described for the YMCA cycle test.V0

2rm" can be estimated from the formula [or stepping in AppendL'X D. Such step

tests should be modified to suit the population being tested. The Canadian HomeFitness Test has demonstrated that such testing can be performed on a large scale

and at low cost.:35-'J7,4~:3Instead o[ estimating V02max from I-H\ responses to several submaximal

work rates, a wide variety of step tests have been developed to categorizecardiovascular fitness on the basis of a person's recovery HR [ollowing a

FIGURE 4-3. Heart rate responses to three submaximal work rates for a 40-year old,sedentary woman weighing 64 kg VOzmax was estimated by extrapolating the heartrate (HR) response to the age-predicted maximal HR of 180 beats·min-

1

(based on220-age). The work rate that would have been achieved at that HR was determinedby dropping a line from that HR value to the x-axis. VOzmax, estimated using theformula in Appendix D and expressed in L'min~l, was 2.2 L·min-

I. The other two

lines estimate what the VOzmax would have been if the subject's true maximal HR

was:,:1 SD from the 180 beats' min-1

value.

CHAPTER 4/ HEALTH-RELATED PHYSICAL FITNESS TESTING AND INTERPRETATION 75

Q;J 150 kgm/minstage (0.5 kg)

HR<80 HR: 80-90 HR: 90-100 HR>100

750 kgm/min 600 kgm/min 450 kgm/min 300 kgm/min(2.5 kg)' (2.0 kg) (1.5 kg) (1.0 kg)

900 kgm/min 750 kgm/min 600 kgm/min 450 kgm/min(3.0 kg) (2.5 kg) (2.0 kg) (1.5 kg)

1050 kgm/min 900 kgm/min 700 kgm/min 600 kgm/min(3.5 kg) (3.0 kg) (2.5 kg) (2.0 kg)

SECTION III EXERCISE TESTING74

subject's true maximal HR were 168 or 192 b . ~ Ibeats'min-J.Partoftheerrorl'llvo] d' .. e~ts'mm , rather than 180ve l1l esllmatmg VO f· b .responses occurs because the ~o . I. (''''0 2m,,, 10m su ma;{]mal I-IRlInu el;:';:, - aae) can p"d Imaximal HR In '1dditioll" b . b 10Vl eon yan estimate of

., , ell ors can e attnbuted t . ... '.(workload) and imprecise stead .t. t I 0 maCCl1late pedalmg cadence

, y-s a e lemt rates.

Directions:1 Set the 1st work rate at 150 kgm/min (0.5 kg at 50 rpm)2 If the HR In the third minute of the stage is'

<80, set the 2nd stage at 750 kgm/min (2 5 k

~!~~~:;m:i:~~i:;;:~o~{g:r~~(~i{ig~J&~)3 S~~~h~oT~~~~~:~~S:~:~u~~e~a~~COrding to the work rates in

FIGURE 4-2. YMCA cycle ergometry protocol R . .appropriate for an ergometer with a flywheel ~:I~t:~:~e;tIngs shown here are

The primary exercise modality [or submaximal ex .... . . . .been the cycle eraometer altll It .. d '11 1 el Clse testmg tradltlOnal1y has

b ,oug 1 lea ml s nve bee d .The same endpOint (709\ HRR . 85(J1 [ , n use m many settings.

o 01 10 0 age-predict I . I Hand the stages of the test I ld b 3 . ec maxIma R) is used,

Is lOU e mmutes or lOll"er t . .' d

-IR response at each staae TI HR I b 0 enSUle a stea y-state'b' le va ues are e t.. ltdmaximal HR and YO . . x lapo a e to age-predicted

, , 2m,,, IS estllnated usina the f· I'highest speed andlor grade tl . t Id I b OImu a III Appendix D from the

, lcl WOU lave bee I . d'[ Iworked to maximum Mo t . . - n ac lleve L t le person had

. s common treadmtll p' t . l ( CIused, but the duration of each stag I Id b . 10

1oco s see lapter 5) can be

e s lOU e elt east 3 mmutes.

I4thl~

r-;;dl~

~~

Step tests have also been used to estunate YOoused a smgle-step heIght of 33. f. .nMV Astrand and Ryhming

J6

cm OJ women and 40 cm for men at a rate of

CARDIORESPIRATORY TEST SEQUENCE AND MEASURES

standardized step test. The 3-Minute YivlCA Step Test is a good example ofsuch a test. This test uses a 12-inch (30.S-cm) bench, with a stepping rate of24 steps'min 1 (estimated oxygen cost of2S.8mL'kg I'min- I

). After exerciseis completed, the subject immediately sits down and heart rate is counted [or 1minute. Counting must start within ,5 seconds of the end of exercise. Heart ratevalues are used to obtain a qualitative rating of fitness from published norma­tive tables. 42

A minimum of heart rate, blood pressure, and rating of perceived exertion (RPE)should be measured during exercise tests. After the initial screening process,selected baseline measurements should be obtained prior to the start of the exer­cise test. Taking a resting ECG prior to exercise testing assumes that trained per­sonnel are available to interpret the ECG and provide medical guidance. AnECG is not necessary when diagnostic testing is not being done, and when appar­ently healthy individuals are being tested \vith submaximal tests. The sequence ofmeasures is listed in Box 4-4.

Heart rate can be determined using several techniques, including radial orcarotid pulse palpation, auscultation with a stethoscope, or the use of heart ratemonitors. The pulse palpation technique involves "feeling" the pulse by plaCingthe first and second fingers over an mtery (usually the radial artery located nearthe thumb side of the wrist or the carotid mtery located in the neck near the lar­ynx). The pulse is typically counted for 15 seconds, and then multiplied by 4, todetermine the per-minute HR. Although the carotid pulse might be easier toobtain, one should not press too hard with the palpating fingers because thiscould produce a marked bradycardia in the presence of a hypersensitive carotidsinus reflex. For the auscultation method, the bell of the stethoscope should beplaced to the left of the sternum just above the level of the nipple. This methodis most accurate when the heart sounds are clearly audible and the subject's torsois relatively stable. Hemt rate telemetry monitors ("heart rate watches") ,vithchest electrodes have proved to be accurate and reliable, prOvided there is nooutside electrical interference (e.g., emissions from the display consoles of com­puterized exercise equipment).44 Many electronic cycles and treadmills haveembedded this HR technology into the equipment.

Blood pressure should be measured at heart level with the subject's armrelaxed and not grasping a handrail (treadmill) or handlebar (cycle ergometer).To help ensure accurate readings, the use of an appropriate-sized blood pressurecuff is important. The rubber bladder of the blood pressure cuff should encircleat least 80% of the subject's upper arm. If the subject's ann is large, a normal-sizeadult cuff ,,,,,ill be too small, thus resulting in an erroneous elevated reading (theconverse is also true). Blood pressure measurements should be taken with a mer­cury sphygmomanometer adjusted to eye level or a recently calibrated aneroidmanometer. SystoliC and diastolic blood pressure measurements can be used asindicators for stopping an exercise test (see next section), To obtain accurateblood pressure measures during exercise, follow the guidelines in Chapter 3 (Box3-4) for resting blood pressure; however, obtain blood pressure in the exerciseposition. In addition, if the fourth Korotkoff sound can not be discerned, the fifth

77

"Strongest I"

Heavy

Highest possible

Light

Just noticeable

"No I"

Absolute maximum

o Nothing at all0.30.5 Extremely weak0.71 Very weak1.52 Weak2.53 Moderate45 Strong67 Very strong89

10 Extremely strong11

Category-Ratio Sealet

67 Very, very light89 Very light

1011 Fairly light1213 Somewhat hard1415 Hard1617 Very Hard1819 Very, very hard20

Category Scale

TABLE 4-7. Category and Category-Ratio Scales for Ratings of

Perceived Exertion*

k f'f d 1 Id be obt-:tined Durin Cf e,ercise, it is alh-isable to obtain theKorot 0 soun s lOU ,. b

f 'st fourth and fifth Korotkoff sounds. ,," III R'PE 'be '1 v'lluable indicator for monitoring an indl\'ldual s exerCise to -

can " ] . I ..., 1 ,·t "Ites" 1 'e Although, perceived exertion ratings corre ate Wit 1 exel clse leal I, '

elall c ..k I".tes ]'Irge interindividual variability in RPE with both healthy asanc WOl " " . I I' .. t" f tl ewell as cardiac patients mandates caution in the ulllversa ap~ Ica Ion ~, . 1 .

I45 B ·Cf'S RPE sC'lle was de\'eloIJed to allow the exelTlsel to subJectl\ elv

SC'l es 01 ' 1ft .. ' I" I~r [eelinCfs durin Cf exercise, taking into account persona 1 nessIate lIS or b b I r' 1, I 16 R1tillCfS C'1Jl belevel environmental conditions, and genera atlgue eve s, '."".' ,

, d b I 1 ...·1 factors mood states environmental conlhtlOns,inOuence Y psyc 10 OgIC" .,: .. I ., 'se Illolles and aCfe which reduce its utility. I, Cnrrently, two RPE sC,les

exelCI ., b' .. t 't 01'd I . d· tIle origill"ll or category scale, which rates cxerclse In ensl y I

are WI eyuse. 'c . [10 Btl RPE.1 f 6 to '70 "Ild the reviseu or category-ratlO scale 0 0 to . 0 1

a sca e 0 ~ ," . b" t II 1 . '[able '_7 Either scale is a[J[Jropnate as a su Je.ctlve 00.SC'l es are s lown III "±. [ , di Cf

, , , '. t ·t· Cf tIle RPE c'm be used as an indication 0 Illlpen n""Dunn Cf exel clse es I11b,' , [r'fatigue. ivlost apparentl)' healthy subjects reach their subjective lin~lt 0 atl~~l:l~t

RPE of 18 to 19 (very very hard) 011 the category Borg scale 01 9 to ]0 .' ,a:

lystron Cf) on the catc;01y-ratio scale; therefore, RPE can be used to Illomtor

;rogress t~ward maxim:' exertion during exercise testing. It is important to

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION

of the Borg scales It 15 necessary to*Copynght Gunnar Borg. Reproduced With permISSion. For correct usage • S Ifollow the administration and instructions gIven In Borg G. Borg's Perceived Exertion and Pain ca es.

Champaign. IL: Human Kinellcs, 1998.

tNole: ON the Category-Ratio Scale, "I" represenls IntenSily

SECTION II/EXERCISE TESTING76

TEST TERMINATION CRITERIA

Graded exercise testing, whether maximal or submaximal, is a safe procedure whensubject screening and testing guidelines (see Chapter 2) are adhered to.Occasionally, for safety reasons, the test may have to be terminated prior to the sub­ject reaching a measured \70201",,, volitional hltiglle, or a predetermined endpoint(i.e., 50% to 70% HRR or 70% to 85% age-predicted maximal HR). Because of theindividual variation in maximal heart rate, the upper limit of 85% of an estimatedmaximal heart rate may result in a maximal effort [or some individuals. Generalindications-those that do not rely on physician involvement or ECG monitOling­for stopping an exercise test are outlined in Box 4-5. More speciflc terminationcritelia for clinical or diagnostic testing are prOvided in Chapter 5.

79

44.241.037.836.234.633.031.428.326.7

60+(N = 1,244)

50-59(N = 5,641)

49.044.241.039.437.836.234.631.429.9

Age (yr)

50.649.045.844.241.039.436.234.631.4

40-49(N = 13,109)

52.150.647.444.242.641.039.436.233.0

30-39(N = 11,158)

55.152.149.047.444.242.641.037.834.6

20-29(N = 2,234)

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION

INTERPRETATION OF RESULTS

Table 4-8 prOvides normative values for \102m,,, (mL·kg-l·min -I), with speciflcreference to age and sex. Research suggests that a \702m", below the 20th percentilefor age and sex, which is often indicative of a sedentmy lifestyle, is associated withan increased Iisk of death from all causes.30 In a compmison of the fitness status of

Percentile

TABLE 4-8. Percentile Values for Maximal Aerobic Power(mL. kg-1·min-1)*

*Data were obtaIned from the Initial examination of apparently healthy men enrolled In the AerobICS Centerlongitudinal Study (AClS), 1970 to 2002. The study population for the data set was predominantly White andcollege educated. Maximal treadmill exerCIse tests were administered usrng a modifIed Balke protocol. MaXimaloxygen uptake was estimated from the final treadmill speed and grade using the current ACSM equations foundin this edition of the Guidelines. The data are provided courtesy of the AClS investigators. The Cooper Institute,Dallas, TX. The AClS IS supported 10 part by a grant from the National Institute on Aging (AG06945). SN Blair,Principal Investigator. The follOWing may be used as descriptors for the percentile rankings: well above average(gO). above average (70), average (50), below average (30), and well below average (10).

Percentile values for maximal oxygen uptake (mL'kg "min-') in men.

908070605040302010

*Data were obtained from the initial examination of apparently healthy women enrolled in the Aerobics Centerlongitudinal Study (ACLS), 1970 to 2002. The study population for the data set was predominantly White andcollege educated. Maximal treadmill exerCIse tests were administered using a modified Balke protocol. Maximaloxygen uptake was estimated from the hnal treadmill speed and grade uSing the current ACSM equations foundin thiS edition of the Guidelines. The data are proVided courtesy of the ACLS Investigators, The Cooper Institute,Dallas, TX. The AClS is supported In part by a grant from the National Institute on Aging (AG06945), SN Blair,PrinCipal Investigator. The following may be used as descriptors for the percentile rankings: well above average(90), above average (70), average (50), below average (30), and well below average (10).

Percentile values for maximal oxygen uptake (mL·kg- 1 ·min-') in women.

Age (yr)

Percentile 20-29 30-39 40-49 50-59 60+(N = 1,223) (N = 3,895) (N = 4,001) (N = 2,032) (N = 465)

90 49.0 45.8 42.6 37.8 34.680 44.2 410 39.4 34.6 33.070 41.0 394 36.2 33.0 31.460 39.4 36.2 34.6 31.4 28.350 37.8 34.6 33.0 29.9 26.740 36.2 33.0 31.4 28.3 25.130 33.0 314 29.9 26.7 23.520 31.4 29.9 28.3 25.1 21.910 283 26.7 25.1 219 20.3

'" I.

SECTION II / EXERCISE TESTING78

• Onset of angina or angina-like symptoms

• Drop in systolic blood pressure of > 10 mm Hg from baseline blood pres­sure despite an increase in workload

• Excessive rise in blood pressure: systolic pressure >250 mm Hg or dias­tolic pressure> 115 mm Hg

• Shortness of breath, wheezing, leg cramps, or claudication• Signs of poor perfusion: light-headedness, confusion, ataxia, pallor,

cyanosis, nausea, or cold and clammy skin

• Failure of heart rate to increase with increased exercise intensity• Noticeable change in heart rhythm• Subject requests to stop

• Physical or verbal manifestations of severe fatigue• Failure of the testing equipment

*Assumes that testing is nondiagnostic and is being performed without direct physician

involvement or ECG monitoring. For clinical testing, Box 5-2 provides more definitive andspecific termination criteria.

use standardized instructions to reduce problems of misinteqJretation of RPE.The following are recommended instructions for using the RPE scale duringexercise testingAS

During the exercise test tee want you to pay close attention to how hard youfeel the exercise tcork rate is. This feeling should reflect your total amount ofexertion and fatigue, combining all sensations and feelings of physical stress,effort, andfatigue. Don't concern youn-elf Leith anyonefactor such as leg pain,shortness of breath or exercise intensity, but try to concentrate on you r total,inner feeling of exertion. Try not to underestimate or or.;erestimate your feel­ings of exertion; be as accurate as you can.

Muscular Strength and Muscular Endurance

81CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION

difficult to interpret. Individnals should participate in huniliarizationJpracticesessions with the equipment, and adhere to a specific protocol (including apredetermined repetition duration and range of 1lI0tion) ill order to obtain a reli­able score that can be used to track true physiologic adaptations over time. Thestandardized conditions or protocol should include:

• Strict postu re• Consistent repetition duration (movement speed)• Full range of motion• Use of spotters (when necess'lIy)• Equipment familiarization• Proper warm-up

A change in one's muscular fitness over time can be based on the absolutevalue of the external load or resistance (e.g., newtons, kilograms [kg], or pounds[lb]), but when comparisons are made between individuals, the values should beexpressed as relative values (per kilogram of body weight [kg/kg]). In both cases,caution must be used in the interpretation of the scores because the norms maynot include a representative sample of the individual being measured, a stan­dardized protocol may be absent, or the exact test being used (free weight versusmachine weight) may differ.

MUSCULAR STRENGTH

Although muscular strength refers to the external force (properly expressed in new­tons, although kilograms and pounds are commonly used as well) that can be gen­erated by a specific muscle or muscle group, it is commonly expressed in terms ofresistance lifted. Strength can be assessed either statically (no overt muscularmovement or limb movement) or dynamically (movement of an external load orbody pmt, in which the muscle changes length). Static or isometric strength can bemeasured conveniently using a variety of devices, including cable tensiometers andhandgrip dynamometers. UnfOltunately, measures of static strength are specific toboth the muscle group and joint angle involved in testing; therefore, their utility indescribing overall muscular strength is limited. Peak force development in suchtests is commonly referred to as the maximum voluntalY contraction (MVC).

Traditionally, the I-repetition maximum (l-RM), the greatest resistance thatcan be moved through the full range of motion in a controlled manner with goodposture, has been the standard for dynamic strength assessment. However, amultiple RM can be used, such as 4- or 8-RM, as a measure of muscular strength,which may allow the participant to integrate evaluation into their training pro­gram. For example, if one were training with 6 to 8 RM, the performance of a6 RM to momentary muscular fatigue would provide an index of strength changesover time, independent of the true l-RM. Estimatillg a l-RM from such tests isproblematic, and generally not necessaly. The number of lifts one can perform ata fixed percent of a l-RM for different muscle groups (e.g., leg press versusbench press) varies tremendously, thus rendering an estimate of l-RM impracti­ea1.50

•51 However, the true l-RM is still a popular measure.·51 Valid measures of

general upper body strength include the l-RM values for bench press or militmypress. Corresponding indices of lower body strength include l-RM values for leg

SECTION II/EXERCISE TESTING80

Muscular strength and endurance arc health-related fitness components that mavimprove or maintain the follO\\ing:

• Bone mass, which is related to osteoporosis• Glucose tolerance, which is related to type 2 diabetes• Musculotendinous integrity, which is related to a lower risk of injUly, includ­

ing low-back pain• The ability to cany out the activities of daily living, which is related to

sel f-esteem• The fat-free mass and resting metabolic rate, which are related to weight

management

The ACSM has melded the terms muscular strength and muscularendurance into a category termed "muscular fitness" and included it as an inte­gral portion of total health-related fitness in a position stand on the quantityand quality of exercise to achieve and maintain fitness.~9 Muscular strengthrefers to the abilily of the muscle to exert force.' Muscular endurance is themuscle's ability to continue to perform for successive exertions or many repel i­

tions. J Traditionally, tests allowing few «3) repetitions of a task prior to reach­ing momentary muscular fatigue have been considered strength measures,whereas those in which numerous repetitions (> 12) are performed prior tomomentary muscular fatigue were considered measures of muscularendmance. However, the performance of a maximal repetition range (i.e., 4, 6,8) also can be used to assess strength. ,

Muscle function tests are velY specific to the muscle group tested, the type ofcontraction, the velocity of muscle mO\'ement, the type of equipment, and thejoint range of motion. Results of anyone test are specific to the procedures Ilscd,and no single test exists for evaluating total body muscular endurance or muscu­lar strength. Unfortunately, few muscle endurance or strength tests control forrepetition duration (speed of movement) or range of motion, thus results are

anyone individllal to published norms, the accuracy of the classification is depend­ent on the similarities between the populations and methodology (estimated vsmeasmed \'Olm"" ma;ximal \'ersus subm'Lximal, etc.). Although submaximal exer­cise testing is not as precise as ma,ximal exercise testing, it pro\ides a reasonablyaccurate reflcction of an individual's fitness at a lower cost and reduced lisk, andrequires less time and effort on the part of the subject.

Some of the assumptions inherent in a subm'L~imal test are more easil\' met(e.g., steady-state healt rate can be verified), whereas others (e.g., estimated max­imal hl'alt rate) introduce unknown errors into the prediction of \'01""". "'henan individual is given repeated submaximaJ exercise tests over a period of weeksor months and the heart rate response to a fixed work rate decreases over time,it is likely that the indiddual's CR fitness has improved, independent of theaccuracy of the \'Olm,,, prediction. Despite differences in test accuracy andmethodology, virtually all evaluations can establish a baseline and be used to trackrelative progress.

82 SECTION II / EXERCISE TESTING

press or leg extension. Norms, based on resistance lifted divided by body mass forthe bench press and leg press are provided in Tables 4-9 and 4-10, respectively.The following represents the basic steps in l-RM (or any multiple RM) testingfollo\\~ng familiarizationJpracti<:e sessions:·52

1. The subject should warm-up by completing a number of submaximalrepeti tion s.

2. Determine the 1 HM (or any multiple HM) within four trials with rest periodsof 3 to 5 minutes between trials.

3. Select an initial weight that is \\~thin the subject's perceived capacity(-50%-70% of capacity).

4. Hesistance is progressively increased by 2.5 to 20 kg until the subject cannotcomplete the selected repetition(s). All repetitions should be performed at thesame speed of movement and range of motion to instill consistency betweentrials.

5. The final weight lifted successfully is recorded as the absolute loR ormultiple RM.

Isokinetic testing involves the assessment of maximal muscle tension through­out a range of joint motion set at a constant angular velocity (e.g., 60 angles per

TABLE 4-9. Upper Body Strength*t

Age

Percentile 20-29 30-39 40-49 50-59 60+

Men90 148 1.24 1.10 0.97 08980 1.32 1.12 1.00 0.90 08270 1.22 1.04 0.93 0.84 07760 1.14 0.98 0.88 079 07250 1.06 0.93 0.84 0.75 0.6840 0.99 0.88 0.80 0.71 0.6630 0.93 0.83 076 0.68 0.6320 088 0.78 0.72 0.63 0.5710 0.80 071 0.65 0.57 0.53Women90 0.90 0.76 0.71 0.61 0.6480 0.80 0.70 0.62 0.55 0.5470 0.74 0.63 0.57 0.52 0.5160 070 0.60 0.54 0.48 04750 0.65 0.57 0.52 0.46 0.4540 0.59 0.53 0.50 044 04330 0.56 0.51 047 042 0.4020 0.51 0.47 043 0.39 0.3810 0.48 0.42 038 0.37 0.33

"'One repetition maximum bench press, with bench press weight ratio = weight pushed/body weight

tAdapted from Institute for AerobiCS Research. Dallas, 1994. Study population for the data set was predominantlyWhite and college educated A Universal DVR machine was used to measure the l-RM. The follOWing may b.

used as desCflptors for the percentile rankings. well above average (90). above average (70). average (50), belowaverage (30), and well below average (10).

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 83

TABLE 4-10. Leg Strength*t

Age

Percentile 20-29 30-39 40-49 50-59 60+

Men90 2.27 207 1.92 1.80 1.73

80 213 1.93 1.82 1.71 1.62

70 205 1.85 1.74 1.64 1.56

60 197 1.77 1.68 1.58 149

50 191 1.71 1.62 1.52 143

40 1.83 1.65 1.57 1.46 13830 1.74 1.59 1.51 1.39 13020 1.63 1.52 1.44 1.32 12510 1.51 143 135 1.22 1.16Women90 1.82 1.61 148 137 13280 1.68 1.47 1.37 125 1.1870 1.58 1.39 1.29 1.17 1.1360 1.50 1.33 1.23 1.10 1.0450 1.44 1.27 1.18 1.05 0.9940 137 1.21 1.13 0.99 0.9330 1.27 115 1.08 0.95 0.8820 1.22 1.09 1.02 0.88 0.8510 1.14 1.00 0.94 0.78 0.72

'One repetition maximum leg press With leg press weight ratio = weight pushedlbody weight.

tAdapted from Institute for AerobICS Research, Dallas, 1994. Study population for the data set was predominantlyWhite and college educated. A Universal DVR machine was used to measure the l-RM The follOWing may be

used as desCflptors for the percentile ranklngs: well above average (90). above average (70), average (50), below

average (30), and well below average (10).

second). Equipment that allows control of the speed of joint rotation (degrees/sec)as well as the ability to test movement around various joints (e.g., knee, hip, shoul­der, elbow) is available from commercial sources. Such de\~ces measure peakrotational force or torque, but an impOttant drawback is that this equipment isextremely expensive compared to other strength-testing modalities.''»

MUSCULAR ENDURANCE

Muscular endurance is the ability of a muscle group to execute repeated con­tractions over a period of time sufficient to cause muscular fatigue, or to maintaina specific percentage of the maximum voluntary contraction for a prolongedperiod of time. If the total number of repetitions at a given amount of resistanceis measured, the result is termed absolute muscular endlll'ance. If the numberof repetitions performed at a percentage of the l-RM (e.g., 70%) is used bothpre- and posttesting, the result is termed relative muscular endurance. Simplefield tests such as a curl-up (crunch) test5.1.5~ or the maximum number of push­ups that can be performed without rest5~ may be used to evaluate the enduranceof the abdominal muscle groups ancl upper body muscles, respectively. Although

'See reference 54: Canadian Society for Exercise Physiology. The Canadian Physical

Activity, Fitness & Lifestyle Approach: CSEP-Health & Fitness Program's Health-Related

Appraisal & Counseling Strategy. 3rd ed. Canadian Society for Exercise Physiology, 2003.

t Alternatives include: 1) having the hands held across the chest, with the head activating a

counter when the trunk reaches a 3D-degree position 55 and placing the hands on the

thighs and curling up until the hands reach the knee capsS6 Elevation of the trunk to 30degrees is the important aspect of the movement.

*An alternative includes doing as many curl-ups as possible in 1 minute

CURL-UP (CRUNCH)1. Individual assumes a supine position on a mat with the knees at 90

degrees. The arms are at the side, palms facing down with the middlefingers touching a piece of masking tape. A second piece of maskingtape is placed 10 cm apart. t Shoes remain on during the test.

2. A metronome is set to 50 beats·min- 1 and the individual does slow,controlled curl-ups to lift the shoulder blades off the mat (trunk makesa 30-degree angle with the mat) in time with the metronome at a rateof 25 per minute. The test is done for 1 minute. The low back shouldbe flattened before curling up.

3. Individual performs as many curl-ups as possible without pausing, to amaximum of 25.:1:

FlexibilityFlexibility is the ability to move a joint through its complete range of motion. Itis important in athletic performance (e.g., ballet, gymnastics) and in the ability tocarry out the activities of daily living. Consequently, maintaining flexibility of alljoints bcilitates movement; in contrast, when an activity moves thc structures ofa joint beyond a joint's shOitened range of motion, tissue damagc can occur.

Flexibility depends on a number of specific vmiables, including distensibility ofthe joint capsule, adequate warm-up, and muscle viscosity. Additionally, compli­ance ("tightness") of vmious other tissues such as ligaments and tendons affects therange of motion. Just as muscular strength is specific to the muscles involved, flex­ibility is joint specific; therefore, no single flexibility test can be used to evaluatetotal body flexibility. LaboratOlY tests usually quantify flexibility in terms of range

scientiHc data to support a cause-effect relationship betwecn abdominal strengthand low back pain are lacking, poor abdominal strength or endurance is com­monly thought to contlibute to muscular low back pains .5..56 Procedures forconducting the push-up and curl-up (crunch) muscular endurance tests are givenin Box 4-6, and fltness categories are provided in Tables 4-11 and 4-12, respec­tively.

Resistance training equipment also can be adaptcd to measure muscularendurance by selecting an appropriate submaximal Icvel of resistance and meas­uring the number of repetitions or thc duration of static contraction beforefatigue. For example, the YMCA bench press test involves performing standard­ized repetitions at a rate of 30 lifts or reps min -1 Men arc tested using anSO-pound barbell and women using a 3.5-pound barbell. Subjects are scored bythe number of successful repetitions conlpleted.42 The YMCA test is an excellentexample of a test that attempts to control for repetition duration and posturcalignment, thus possessing high reliability. Normative data for the YMCA benchpress test are presented in Table 4-13.

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 85

TABLE 4-11. Fitness Categories by Age Groups and Gender for Push-ups*

Age

Category 20-29 30-39 40-49 50-59 60-69

Gender M M F M F M M

Excellent 36 30 30 27 25 24 21 21 18 17Very good 35 29 29 26 24 23 20 20 17 16

29 21 22 20 17 15 13 11 11 12Good 28 20 21 19 16 14 12 10 10 11

22 15 17 13 13 11 10 7 8 5Fair 21 14 16 12 12 10 9 6 7 4

17 10 12 8 10 5 7 2 5 2Needs Improvement 16 9 11 7 9 4 6 1 4 1

'See reference 54: The Canadian Physical Activity, Fitness & lifestyle Approach: CSEP-Health & Fitness Program'sHealth-Related Appraisal and Counseling Strategy. 3rd ed. Reprinted With permission from the Canadian Societyfor Exercise Physiology, 2003.

. ,

SECTION II / EXERCISE TESTING

PUSH-UP1. The push-up test is administered with male subjects starting in the stan­

dard "down" position (hands pointing forward and under the shoulder,back straight, head up, using the toes as the pivotal point) and femalesubjects in the modified "knee push-up" position (legs together, lowerleg in contact with mat with ankles plantar-flexed, back straight, handsshoulder width apart, head up, using the knees as the pivotal point)

2. The subject must raise the body by straightening the elbows and returnto the "down" position, until the chin touches the mat. The stomachshould not touch the mat.

3 For both men and women, the subject's back must be straight at alltimes and the subject must push up to a straight arm position.

4. The maximal number of push-ups performed consecutively without restis counted as the score.

5. The test is stopped when the client strains forcibly or unable to main­tain the appropriate technique within two repetitions.

84

.'

Shoulder GirdleFlexion 90-120 Extension 20-60

Abduction 80-100Horizontal Abduction 30-45 Horizontal Adduction 90-135

Medial Rotation 70-90 Lateral Rotation 70-90

ElbowFlexion 135-160Supination 75-90 Pronation 75-90

TrunkFlexion 120-150 Extension 20-45

Lateral Flexion 10-35 Rotation 20-40

Hip10-30Flexion 90-135 Extension

Abduction 30-50 Adduction 10-30

Medial Rotation 30--45 Lateral Rotation 45-60Knee

Flexion 130-140 Extension 5-10Ankle

Dorsiflexion 15-20 Plantarflexion 30-50Inversion 10-30 Eversion 10-20

*Reprinted with Permission from Norkin C. Levangie P. Joint Structure and Function: A Comprehensive Approach,2nd Ed. Philadelphia: FA Davis, 1992.

TABLE 4-14. Range of Motion of Select Single Joint Movements (degrees)*

CHAPTER 4 / HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 8786 SECTION II / EXERCISE TESTING

TABLE 4-12. Fitness Categories by Age Groups and Gender for Partial TABLE 4-13. YMCA Bench Press Test: Total Lifts*

Curl-up* Age

Category 18 25 26-35 36-45 46-55 56-65 >65Age

Gender M M M M M MCategory 20-29 30-39 40-49 50-59 60-69

Excellent 64 66 61 62 55 57 47 50 41 42 36 30Gender M M F M F M M F

44 42 41 40 36 33 28 29 24 24 20 18Excellent 25 25 25 25 25 25 25 25 25 25 Good 41 38 37 34 32 30 25 24 21 21 16 16Very good 24 24 24 24 24 24 24 24 24 24 34 30 30 29 26 26 21 20 17 17 12 12

21 18 18 19 18 19 17 19 16 17 Above average 33 28 29 28 25 24 20 18 14 14 10 10Good 20 17 17 18 17 18 16 18 15 16 29 25 26 24 22 21 16 14 12 12 9 8

16 14 15 10 13 11 11 10 11 8 Average 28 22 24 22 21 20 14 13 11 10 8 7Fair 15 13 14 9 12 10 10 9 10 7 24 20 21 18 '18 16 12 10 9 8 7 5

11 5 11 6 6 4 8 6 6 3 Below average 22 18 20 17 17 14 11 9 8 6 6 4Needs Improvement 10 4 10 5 5 3 7 5 5 2 20 16 17 14 14 12 9 7 5 5 4 3*See reference S4: The Canadian Physical Activity, Fitness & lifestyle Approach: CSEP-Health & Fitness Program's Poor 17 13 16 13 12 10 8 6 4 4 3 2Health-Related Appraisal and Counseling Strategy. 3rd ed. Reprinted with permission from the Canadian Society 13 9 12 9 9 6 5 2 2 2 2 0for Exercise Physiology, 2003.

Very poor <10 6 9 6 6 4 2 1 1 1 1 0

*Reprinted from YMCA Fitness Testing and Assessment Manual with permission of the YMCA of the USA, 101 N.

Wacker Drive, Chicago, IL 60606.of motion, e),:pressed in degrees. Common devices for this purpose include vatiousgoniometers, electrogoniometers, the Leighton flexometer, inclinometers, and tapemeasures. Comprehensive instmctions are available for the evaluation of flexibilityof most anatomic joints.57

.58 Visual estimates of range of motion can be useful in fit­

ness screening, but are inaccurate relative to directly measured range of motion.These estimates can include neck and tmnk flexibility, hip flexibility, lower extrem­ity flexibility, shoulder flexibility, and postural assessment. A more precise meas­urement of joint range of motion can be assessed at most anatomic joints follov,ringshict procedures57

.58 and the proper use of a goniometer. Accurate measurements

require in-depth knowledge of bone, muscle, and joint anatomy, as well as expeti­ence in administeting t11e evaluation. Table 4-14 provides normative range ofmotion values for select anatomic joints. Additional information can be found in theACSM Resource Manual.

The sit-and-reach test has been used commonly to assess low back and hip­joint fleXibility; however, its relationship to predict the incidence oflow back painis limitedS9 The sit-and-reach test is suggested to be a better measure of ham­shing flexibility than low-back flexibility60 However, the relative impOttance ofhamstring flexibility to activities of daily living and sports performance requiresthe inclusion of the sit-and-reach test for health-related fitness testing until a cri­terion measure evaluation of low back flexibility is available. Although limb andtorso length disparity may impact on the sit-and-reach scoring, modified testingthat establishes an individual zero point for each participant has not enhanced thepredictive index for low back flexibility or low back pain 61

.62

The back saver unilateral sit and reach test measures each limb independentlyas opposed to the standard simultaneous measurement of both limbs. One limb isheld straight while the knee of the other limb is flexed and the plantar surface ofthe foot on the flexed limb is placed on the floor adjacent to the medial surface ofthe knee of t11e straight limb. The back saver test is purpOtted to reduce excessivedisk compression, posterior ligament tension, and erector spinae muscle strain,

while permitting the assessment of limb asymmctlyfi.1 A comp<lIison of the two ver­sions of the sit and reach test found no difference in mO\'ement in the sit and reachand in Cailliefs protective-hamstJing stretch.6.J Although asymmetJic stretching isappropriate for flexibility training, a lack of nonnative data for adults precludes theinclusion of the back saver unilateral sit and reach test at this time.

TABLE 4-15. Fitness Categories by Age Groups for Trunk Forward FlexionUsing a Sit-and-Reach Box (cm)*t

Age

Category 20-29 30-39 40-49 50-59 60-69

Gender M M F M F M M

Excellent 40 41 38 41 35 38 35 39 33 35Very Good 39 40 37 40 34 37 34 38 32 34

34 37 33 36 29 34 28 33 25 31Good 33 36 32 35 28 33 27 32 24 30

30 33 28 32 24 30 24 30 20 27Fair 29 32 27 31 23 29 23 29 19 26

25 28 23 27 18 25 16 25 15 23Needs Improvement 24 27 22 26 17 24 15 24 14 22

-The Canadian Physical ActIVity, fitness & lifestyle Approach: CSEP-Health & fitness Program's Health-RelatedAppraisal & Counseling Strategy. 3rd ed. Repnnted with permiSSion from the Canadian Society for ExercisePhysiology, 2003.

tNote: These norms are based on a sit-and-reach box In which the "zero" point is set at 26 em. When using a boxin which the zero point is set at 23 em, subtract 3 em from each value in this table.

A typical fitness assessment includes the follOWing:

AComprehensive Health Fitness Evaluation

Poor lower back and hip flexibility may, in conjunction with poor abdominalstrength/endurance or other causative factors, contJibute to development of mus­cular low back pain; however, this hypothesis remains to be substantiated,55Methods for administeling the sit-and-reach test are presented in Box 4-7­Normative data for two sit-and-reach tests are presented in Tables 4-15 and 4-16,

CHAPTER 4/ HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION 89

• Prescreeninglrisk stratification• Resting HR. BP, height, body mass, ECG (if appropJiate)• Body composition

o Waist circumferenceSkin fold assessment

• CardiorespiratOlY FitnessSubmaximal YMCA cycle ergometer test

• Muscular Strength1-,4-,6-, or 8-RM upper body (bench press) and lower body (leg press)

• Muscular Enduranceo Curl-up testo Push-up test

• FlexibilitySit-and-reach test or goniometlic measures of isolated anatomic joints

Additional evaluations may be administered; however, the aforementionedcomponents of a fitness evaluation represent a comprehensive assessment thatcan be performed within 1 hour. The data accrued from the evaluation should be

• I

SECTION" / EXERCISE TESTING

Pretest: Participant should perform a short warm-up prior to this testand include some stretches (e.g., modified hurdler's stretch) Itis also recommended that the participant refrain from fast, Jerkymovements, which may increase the possibility of an injury. Theparticipant's shoes should be removed.

1. For the Canadian Trunk Forward Flexion test, the client sits without shoesand the soles of the feet flat against the flexometer (sit-and-reach box) atthe 26-cm mark. Inner edges of the soles are placed within 2 cm of themeasuring scale. For the YMCA sit-and-reach test, a yardstick is placed onthe floor and tape is placed across it at a right angle to the 15-inch markThe participant sits with the yardstick between the legs, with legs extend­ed at right angles to the taped line on the floor. Heels of the feet shouldtouch the edge of the taped line and be about 10 to 12 inches apart. (Notethe zero point at the fooVbox interface and use the appropriate norms.)

2. The participant should slowly reach forward with both hands as far aspossible, holding this position approximately 2 seconds. Be sure that theparticipant keeps the hands parallel and does not lead with one hand.Fingertips can be overlapped and should be in contact with the measur­ing portion or yardstick of the sit-and-reach box.

3. The score is the most distant point (in centimeters or inches) reachedwith the fingertips. The best of two trials should be recorded. To assistwith the best attempt, the participant should exhale and drop the headbetween the arms when reaching. Testers should ensure that the kneesof the participant stay extended; however, the participant's knees shouldnot be pressed down. The participant should breathe normally during thetest and should not hold his or her breath at any time. Norms for theCanadian test are presented in Table 4-15. Note that these norms use asit-and-reach box in which the "zero" point is set at the 26-cm mark Ifyou are using a box in which the zero point is set at 23 cm (e.g.,Fitnessgram), subtract 3 cm from each value in this table. The norms forthe YMCA test are presented in Table 4-16.

*Diagrams of these procedures are available from Golding LA, Myers CR, Sinning WE.YMCA Fitness Testing and Assessment Manual, 4th ed. YMCA of the USA, 101 N. WackerDrive, Chicago, IL 60606. Canadian Society for Exercise Physiology. The Canadian PhysicalActivity, Fitness & Lifestyle Approach: CSEP-Health & Fitness Program's Health-RelatedAppraisal & Counseling Strategy. 3rd ed. Canadian Society for Exercise Physiology, 2003

88

REFERENCES

TABLE 4-16. Percentiles by Age Groups and Gender for YMCA Sit-and­Reach Test (Inches)*

Age

Percentile 18-25 26-35 36-45 46-55 56 65 >65

Gender M F M M M M M

90 22 24 21 23 21 22 19 21 17 20 17 2080 20 22 19 21 19 21 17 20 15 19 15 1870 19 21 17 20 17 19 15 18 13 17 13 1760 18 20 17 20 16 18 14 17 13 16 12 1750 17 19 15 19 15 17 13 16 11 15 10 1540 15 18 14 17 13 16 11 14 9 14 9 1430 14 17 13 16 13 15 10 14 9 13 8 1320 13 16 11 15 11 14 9 12 7 11 7 1110 11 14 9 13 7 12 6 10 5 9 4 9'Reprinted from YMCA Fitness Testing and Assessment Manual with permission of the YMCA of the USA, 101 N.

Wacker Drive, Chicago, IL 60606. The following may be used as deSCriptors for the percentile ran kings: well aboveaverage (90), above average (70), average (50), below average (30), and well below average (10)

interpreted by a competent professional and conveyed to the client. This infor-mation is central to the development of a client's short- and long-term goals, aswell as forming the basis for the initial exercise prescription and subsequent eval-uations to monitor progress.

91CHAPTER 41 HEALTH-RELATED PHYSICAL TESTING AND INTERPRETATION

1.5. Folsom AB, Kaye SA, Sellers TA, et al. Body fat distrihution and5-year risk of death in older women.

JAMA 1993;26H:483-48716. Tran ZV, \Veltman A. Ceneralized equation for predicting body density of worllf'11 from girth meas-

nrements. Med Sci Sports Exerc 1989;21:101-104.17. Tran ZV, \Veltman A. Predkting body curnpositiun of lllcn from girth me'-lSnrell1ents. HUIll Biol

1988;60:167-1/.5.18. Bray GA, Gray DS. Ohesity. Part I. Pathogenesis. West J Med 1988;149:429-441

19. Bray GA. Don't throw the haby out with the bath water. Am J Clin Nutr 2004;79:.347-349.

20. Hoehe AF. Anthropomet,y' and ultrasound. In: Hoehe AF, Ileymsfieid SB, Lohman TG, eds.

H nman Body Composition. Champaign, IL: Iinman Kinetics, 19f)6: 167-18H.

21: Heyward VH. Practical hody composition assessment lor children, adults, and older adults. Int J

Sport Nutr 1998;8:28.5-.307.22. Jackson AS, Pollock ML Practical assessment of body composition. Phys Sport Med

198.5;1:3(.3) :76-90.23. Going BS. Densitometry. Til: Boehe AF, I-Ieymsl'ield SB, Lohman TG, eds. Human Body

Composition. Champaign, 1L: 1,luman Kinetics, 1996::3-23.24. Dernpstcr P, Aitkens S. A new air displacement lllethod for the detf'rmination orhuman body com­

position. Med Sci Sports Exerc 199.5;27:J692-1697.25. Brozek J, Grade F, Anderson J. Densitornetric analysis 01" body composition: revision of some I1 llan ­

titative assumptions. Ann NY Acad Sci 1%.3;110: 11.3-140.26. Siri ,\IE. Body composition from nuid spaces and denSity. Univ Calif Donner Lab Med Phys Rep,

19.5627. Hendel 11\1', Cotfredsen A, I-Iojgaard L, et al. Change in hlt-free mass sed by hioelectrical imped­

ance, total body potassiurn and dual energy X-ray absOllltiometJy dnring prolonged weight loss.

Scand J Clin Lab Invest 1996;56:671-67').28. Mclean KP, Skinner JS. Validity of Futrex-.5000 for body composition determination. Med Sci Sports

ExelT 1992;24:2.5.3-2.58.29. Lohman TG. Body composition methodolob'v in sports medicine. Phys SportsmedI982;10:47-,58.

.30. Blair SN, Kohl IIW .3rd, Barlow CE, d al. Changes in physical fitness and all-cause mortaht)'.

A prospective study of healthy and unhealthy men. JAMA 1fJ95;27.3: 1093-1098..31. Blair SN, Kohl 11\1' 3rd, Palfenbarger HS Jr, ct al. Physical fitness and all-cause mortality.

A prospective study ol'healthy men and women. JAMA 1989;262:2395-2401.32. Sesso HD, Paffenharger RS Jr, Lee 1M. Physical activity and coronary heart disease in men: The

Halvard Alumni Health Study. Circulation 2000;102:975-980..33. Davis JA, ed. Direct determination of aerohie power. In: Maud PJ, Foster C, eds. Physiological

Assessment of Human Fitness. Chclll1pajgn, IL: Human Kinetics, 189.5:9-17.

.34. McConnell TR CardiorespiratOlv assessment of apparently healthy populations. Tn: Roitman JL, ed.

ACSM Hesource Manual lor Guidelines for Exercise Testing and Prescription. 4th eel. Baltimore:

Williams & Wilkins: Baltimore. 2001:361-.37.5..3.5. Jette M, Campbell J, Mongeon J, et al. The Canadian Home Fitness Test as a predictor lor aerohic

capacity. Can Med Assoc J 1976;114:680-682.36. Astrand P-O. Aerobic work capacit.'-I in men and women with special reference to agc. Acta Physiol

Seand 1960;49(suppl):4,5-6037. Kline eM, Porcari Jr, I-lintenneister H, ct a1. Estimation of \10 2111 <1X frorn a one-mile track walk,

gendcr, age, and body weight. Med Sci Sports Exerc IfJ87;19:2.5:3-2.59.38. Bittner V, vVeincr DH, Yusuf S, et al. Prediction of mortality and morbidity with a (i-minute walk

test in patients with left ventricular dvsl'unction. lAMA 1993;270: 1702-1707.39. Cahalin LP, Mathier MA, Semigran MI, et al. T';e six minnte walk tcst predicts peak oxygen uptake

arrd survival in patients with advancecl heart Elilure. Chest ]996;110:325-.332.40. Astrand P-O, Hyhming 1. A nomogram for calcnlation of aerohic capacity (physical fitness) I'rom

pulse rate during suhm;Lximal work. J Appl Physiol 19.54;7:218-22].41. Maritz JS, Morrison JF, Peter J. A practical method of estimating an individllal's maximal oxygen

uptake, Ergonomics 1961;4:97-122.42. Golding LA. YMCA Fitness Testing and Assessment Manual. Cha,npaign, fLo Human Kinetics,

1989.4.3. Shephard HJ, Thomas S, Weller 1. The Canadian 110me Fitness Test. \fJ91 update. Sports Mecl

1991;11:.3.58-366.44. Leger L, Thivierge M. Hcart rate monitors: validity, stahilitv and functionality. Phys Sport Med

1988; 16:14.3-1.51.

SECTION III EXERCISE TESTING90

1. President's Coul1ciJ on Physie<J Fitness. Dcnnitiolls: health, fitness, and physical activity. Hescarch

Digest, 2000.

2. Caspersen C.I, PowelJ KE, Christenson GM. Physical activity, exercise, and physical fitness: defini­

tions and distinctions lor health-relatcd research. Public Health Hcp 198.5;100:126-1.31.

.3. National Institutes of Ilealth. ITcalth implications of obcsity. Annals of Internal Medicine

198.5;16.3: 107,3-1077.

4. Flegal KM, Carroll MD, Ogden CL, et al. Prevalenee and trends in obesity among US adnlts,

1999-2000 JAMA 2002;288: 1723-1727.

.5. Ogden CL, Flegal KM, Carroll MD, et al. Prevalence and trcnds in ovenvcight among US children

and adolescents, 1999-2000. JAMA 2002;288: 1728-17.32.

6. Troiano HI', Flegal KM. Ovelweight children and adolescents: description, epidemiolo1(", alld

demographics. Pediatrics 1998;101:497~504.

7. Kaminsky LA, ('cl. ACSM's Hesourc:e Manual for Guidelines [or Exercise Testing and Prescription.

Baltimore: Lippincott Williams & Wilkins, 200.5.

8. He),,'ard VH, Stolarczyk LM, eds. Applied Body Composition Assessment. Champaign, IL: Human

Kinetics, 1996; 12.

9. Hoche AF, Ileymsfield SB, Lohman TG, eds. Hnman Body Composition. Champaign, IL: Human

Kinetics, 1996.

JO. Lohman TG, Houtkooper L, Going SB. Body I"t measuremcnt goes high-tech. ACSNl's Health

Fitness J 1997; 1(I ):.30-.3.5

11 Panel E. Executive SllllllllaJY of the clinical guidelines 011 the identification, evaluation, and treat­

ment of overweight and obesity in adults. Arch rntern Med 1998; 1.58:18.55-1867.

12. Hilllm EB, Stampfer MJ, Giovanllllcci E, et '-11. Budy size and rat dislribution as predictors of coro­

nalY heart discase among middle-aged and older US men. Am J Epidemiol 199.5;141:1117-] 127.

1.3. Gallagher D, Ileymsfieid SB, lleo M, et al. Healthy percentage hody fat ranges: an approach (or

developing guidelines based on hody mass index. Am J Clin NutI' 2000;72:694-701.

14. Van Hallie TB, ed. Topography of body fat: relationship to risk of cardiovascular and other diseases.

In: Lohman TG, .Hoche AF', Martorell H, cds. Anlhropometric Standardization Hden::'nce Manual.

Champaign, IL: Iluman Kinetics, 19R8.

93

DIAGNOSTIC EXERCISE TESTING

Indications and Applications

CHAPTER

5•••••

Diagnostic exercise testing is best used in patients with an intermediate proba­bility of angiographically significant coronmy altery disease (CAD) as determinedby age, gender, and symptoms (Table .5-1). Asymptomatic individuals generallyrepresent those with a low likelihood (i.e., <10%) of Significant CAD. Diagnosticexercise testing in asymptomatic individuals gcnerally is not indicated. However,exercise testing may be useful in asymptomatic persons whcn multiple riskfactors are present, I indicating at least a moderate risk of experiencing a seriouscardiovascular event within .5 years." It also may be indicated in those who areabout to start a vigorous exercise program (see Chapter 2), or those involved inoccupations in which cardiovascular events may affect public safety. In general,patients with a high probability of disease (e.g., typical angina, prior coronaryrevascularization or myocardial infarction [MI]) are tested to assess residualmyocardial ischemia and prognosis rather than for diagnostic purposes. Exerciseelectrocardiography for diagnostic purposes is less accurate in women largelybecause of a greater number of false-positive responses. Although differences intest accuracy between men and women may be in the order of 10% on average,the standard exercise test is considered the initial diagnostic evaluation of choiceregardless of gender. 1

The exercise test may he used for diagnostic, prognostic, and therapeutic appli­cations, espeCially in regard to exercise prescription (see Chapters 7 and 8).

Standard graded exercise tests are used in clinical applications to assess apatient's ability to tolerate increasing intcnsities of exercise while clectrocardio­graphiC (ECG), hemodynamic, and symptomatic responses are monitored formanifestations of myocardial ischemia, electrical instability, or other exertion­related abnormalities. Gas exchange and ventilatory responses also are common­ly assessed during the exercise test, pmticularly in patients with chronic heartfailure, in those whom preoperative risk is indeterminate, among postmyocardialinfarction (post-MI) patients who wish to return to moderate heavy occupations,or in patients with known or suspected pulmonary limitations.

Clinical Exercise Testing

92 SECTION II/EXERCISE TESTING

45. WhaJeyMH, Brubaker PH, Kaminsky LA, et a!' V,Jidity of rating of perceived exertion during grad­ed exercise testlllg III apparently healthy adults and cardiac paticnts. J Cardi I R h· b'l1997;17:261-267. opu e a I

46. Noble BJ, Borg GA, Jacohs T, et a!' A categOly-ratio perceived exertion scale: relationship to hloodand muscle lactates and heart rate. Med Sci Sports Exerc 19R3;1.5:.523-.52R.

47. Hobertson HJ, Noble BI· Perception of physicaJ exertion: methods, mediators, and applicationsExerc Sport Sci Hev 1997;2.5:407--452. .

48. Morgan W, Borg GA, eds. Perception of effort in the prescription of phvsical activity. Nelson T, ed.Mental Health and Emotional Aspects of Sports. Chicago: American Medical Associ'ltion1976:126--129. ' ,

49. American College of SPOlts Medicine. Position Stand: The recommended quantitv and qualitv ofexerCIse for developmg and maintaining cardiorespiratOlY and nlUSClllar fltness, and f1exibilit~t inhealthy adults. Med Sci Sports Exerc 1998;30:97.5-991. .

50. Hoeger WW, Barette SL, Hale DR. Helationship hetweeo repetition and selected percentages ofone repetltlon m'LXImum. J Appl SPOlt Sci Hes W87;1(1):lJ-13.

51. Hoeger WW,Hopkms DH, Bareete SL. Helationship hetween repetitions and selected percentagesof one repetitIon IncLXllllUTn: a comparison between untrained and trained males and females. JAIJ ISport Sci Hes 1990;4(2):47-54 p

.52. Logan P, Fomasiero D,. Abernathy P, et aI, eds. Protocols for the assessment of isoinertial strength.In. Fore CJ, ed. PhYSlOloglcaJ tests for elite athletes. Champaign, lL: Human Kinetics, 2000:200-221.

53. Graves JE, Pollock ML, Blyant CX, eds. Assessmcnt of mllScnlar strength and endurance, 4th ed.In: HOitman JL, ed. ACSM's Hesource Manual I,ll' Cuidelines for Exercise Testing and Prescription.Baltimore: Llpplllcott Williams & Wilkins, 2001 :376-:380.

54. Canadian Society for Exercise Physiology. The Canadian Physical Activity. Fitness & LilestvleApproach:. CSEP-HeaJth ~ Fitness Program's Health-Belated Appraisal & Counseling Stratei\". :3rded. CanadIan SOCIety lor ExerCIse PhYSiology, 2003.

55. Diener MH, Golding LA, Diener D. Validity and rcliahilitv of a onc-minute half sit-up test ofabdomlllal muscle strength and endurance. Sports Med Training Hehah 199.5;(;:.5-119.

.56. Faulkner RA, Sprigings EJ, McQuarrie A. et a!' A partial curl-up protocol f,n' adults hased on ananalYSIS 01 two procedures. Can J Sport Sci 1989;]4: 13.5-141.

.57. Clarkson H.. Musculoskeletal Assessment, Joint Bange of Motion and ManuaJ Muscle Strength.Baltlmore: Lippincott Williams & Wilkins, 1999.

.58. Palmer ML, Epler ME, eds. Fundamentals of Musculoskeletal Assessment Techniques. 2nd ed.PhiladelphIa: Llpplllcott-Baven, 1998.

.59. Jackson AW, Morrow JH Jr, Brill PA, et aJ. Belations of sit-up and sit-and-reach tests to low backpalll III adults. J Orthop Sports Phys Ther 1998;27:22-26.

60. Jackson AW, Baker AA. The relationship of the sit and reach test to criterion measures of hamstringanel back fleXIiJihty JJ1 young females. Res Q Exerc Sport 1986;.57(3): 18.3-11\6.

61. Hoeger WVV, Hopkins DR. A comparison of the sit and reach and the modi lied sit and reach in themeasurement of flexibility in women. Res Q Exerc Sport 1992;6.3: 191-19.5.

62. Minkler S, Patterson P. The validity of' the modified sit-and-reach test in college-age students. liesQ Exerc SPOlt 1994:6.5: 189-192.

63. Cailliet H. Low Back Pain Syndrome. Philadelphia: FA Davis. 1988:17.5-179.

64. ~i~J~o~n \V.P, Sharpe GL, \IVasserman JF. Lumhosacral movement in the sit-and-reach and inCulhet s protective-bamstring stretch. Spine l(J94, 19:2127-2 1:30.

65. Protas EJ, ed. Flexibility and range of' motion. In: Hoitman IL, ed. ACSM's I",somcc Manual forGuidelines for Exercise Testing and Prcscription. Baltimore' Li!J!'incott Williallls & Wilkins 9001.381-390.' ~ .

94 SECTION II/EXERCISE TESTING

TABLE 5-1. Pretest Likelihood of Coronary Artery Disease*t

Typical Definite Atypical/Probable NonanginalAge Gender Angina Pectoris Angina Pectoris Chest Pain Asymptomatic30-39 Men Intermediate Intermediate Low Very low

Women Intermediate Very low Very low Very low40-49 Men High Intermediate Intermediate Low

Women Intermediate Low Very low Very low50-59 Men High Intermediate Intermediate Low

Women Intermediate Intermediate Low Very low60-69 Men High Intermediate Intermediate Low

Women High Intermediate Intermediate Low*See reference 1: Reprinted with permission from Gibbons RJ, Balady GJ, Bricker JT, et al. ACCIAHA 2002

GUideline Update for Exercise Testing; a report of the American College of Cardlologyl American Heart AssociationTask Force on Practice GUidelines; Committee on ExerCise Testing, 2002. American College of Cardiology web site:www.acc.orglcllnlcaVguldellneslexerciseldirlndex.htm

tNo data eXISt for patients who are <30 or >69 years, but it can be assumed that prevalence of CAD increases

with age. In a few cases, patients with ages at the extremes of the decades listed may have probabilities slightlyoutSide the high or low range. High Indicates >90%; intermediate, 10%-90%; low, <10%; and very low, <5%.

The use of maximal or sign/symptom-limited exercise testing has expandedgreatly to help guide decisions regarding medical management and surgical ther­apy 111 a broad spectrum of patients. For example, immediate exercise testing ofselected low-nsk patients presenting to the emergency department with chestpain is now. increasingly employed to "rule out myocardial infarction,"3 and helpmake deCISions regarding which patients require hospital admission.4 Generally,patients who may be safely discharged include those who are no longer sympto­matiC, and those with unremarkable ECGs and normal selial cardiac enzymeassays (e.g., no appreCiable rise in the level of troponin).

EXERCISE TESTING FOR DISEASE SEVERITY AND PROGNOSIS

Exercise testing is useful for the evaluation of disease severity among persons withknown or suspected CAD. Data derived from the exercise test are most usefulwhen considered in context with other clinical data. Information related to liskfactors, symptoms, functional capaCity, and myocardial ischemia dming the exer­cise test must be considered together. The magnitude of ischemia caused bya coronal)' leSIOn generally is proportional to the degree of ST-segment depres­SIOn, the number of electrocardiographic (ECG) leads involved, and the durationof ST-segment depreSSion in recovely. It is inversely propOltional to the ST slope,the double product at which the ST-segment depreSSion occurs, and the maximalhealt rate, systolic blood pressure, and metabolic equivalent (MET) levelachteved. Several numeric indices of prognosis have been published and are dis­cussed in Chapter 6.5,6

EXERCISE TESTING AFTER MYOCARDIAL INFARCTION

Exercise testing after MI can be performed before or soon after hospital dis­c.harge (as early as 4 days after MI) for prognostiC assessment, activity presclip­tion, and evaluatIOn of medical therapy. Submaximal tests may be used before

CHAPTER 5/ CLINICAL EXERCISE TESTING 95

hospital discharge at 4 to 6 days after acute MI. Low-level exercise testingprovides sufficient data to make recommendations about the patient's ability tosafely perform activities of daily living and serves as a guide for early ambulatOl)'exercise therapy. Symptom-limited tests are usually performed at more than14 days after MI.] As contemporal)' therapies have led to dramatic reductions inmOltality after MI, the use of exercise testing in the evaluation of prognosis haschanged. Patients who have not undergone coronary revasculmization and areunable to undergo exercise testing appear to have the worst prognosis. Otherindicators of adverse prognosis in the post-MI patient include ischemic ST­segment depreSSion at a low level of exercise (particularly if accompanied byreduced left ventricular systolic function); functional capacity of less than 5METs; and a hypotensive blood pressure response to exercise.

FUNCTIONAL EXERCISE TESTING

Exercise testing is useful to determine functional capacity. This information canbe valuable for activity counseling, exercise prescliption, return to work evalua­tions, disability assessment, and to help estimate prognOsiS. Functional capacitycan be evaluated based on percentile ranking (based on apparently healthy menand women) as presented in Table 4-8. Exercise capacity also may be reported astlle percentage of e},:pected METs for age using a nomogram (Fig. 5-1), \\~th

100% being normal (separate nomograms are provided for referred men \vithsuspected CAD and in healthy men).' Normal standards for exercise capacitybased on directly measured \102,mLx are also available for women and by ageSWhen using a pmticular regression equation for estimating percentage of normalexercise capacity achieved, factors such as population speCifiCity, exercise mode,and whether exercise capacity was measured directly or estimated should be con­sidered.

Previous studies in persons \vithout known coronal)' altel)' disease have iden­tified a low level of aerobic fitness as an independent risk factor for all-cause andcardiovascular mortali tyB,lO Recently, investigators extended these analyses to527 men with cardiovascular disease who were referred to an outpatient cardiacrehabilitation program. I! Oxygen uptake at peak exercise on a cycle ergometerwas directly measured 13 weeks after acute myocardial infarction (N = 312) orcoronary mtel)' bypass surgel), (N = 215). All tests were terminated at a com­parable endpoint, that is, volitional fatigue. Duling an average follow-up of6.1 years, 33 and 20 patients died of cardiovascular and noncardiovascular cases,respectively. Figure 5-2 shows the inverse relationship between peak oxygenuptake and subsequent mOltality. Those with the highest cardiovascular and all­cause mOltality averaged :::;4.4 METs. In contrast, there were no deaths amongpatients who averaged 2::9.2 METs.

Another studl2 repOlted on 3,679 men with coronal)' disease who werereferred for treadmill exercise testing for clinical reasons. Those \vith an exercisecapacity of :::;4.9 METs had a relative risk of death of 4.1 compared to those \vitha fitness level 2::10.7 METs over the average follow-up of 6.2 years. For eveI)' 1­MET increase in exercise capacity there was a 12% improvement in survival.Similarly, findings from the National Exercise and Heatt Disease Project amongpost-MI patients demonstrated that evel)' I-MET increase after the training

30

97CHAPTER 5/ CLINICAL EXERCISE TESTING

Exercise Capacity(% of Normal in Healthy Men)

20 0

25

30 2

35 3

40 Active 450

45 50 60 5

CIl 50 60 70 6Cl 70 80« 55 80 90 7

90 0060 10 110 8110 lJ)

65 120 120 Sedentary 9 ~w

130 130 ::70 140 140

10150 150

75 11

80 12

85 13

90 14

15

16

17

18

o

2

3

4

5

Active 6

7 ~w::

8

9

10

11

12

13

14

15

8090

100110

120130

140150

Sedentary

6070

8090

100110

120130

140150

50

45

40

35

Exercise Capacity(% of Normal in Referred Men)

SECTION II/EXERCISE TESTING

20

25

60

65

70

75

80

85

90

CIl 55Cl«

96

(FIGURE 5-1. Nomograms of percent normal exercise capacity in men with suspectedcoronary artery disease who were referred for clinical exercise testing (this page) and inhealthy men (page 97)

period conferred an approximate 10% reduction in mortality [i·om any cause,regardless of the study group assignment, over a 19-year follow-up. 11

Exercise Test ModalitiesThe treadmill and cycle ergometer are the most commonly used devices for clin­ical exercise testing. Treadmill testing provides a more common form of physio­logic stress (e.g., walking) in which subjects are more likely to attain a slightly

FIGURE 5-1. (continued) See reference 7: Reprinted from Morris CK, Myers J, FroelicherVF, et al. Nomogram based on metabolic equivalents and age for assessing aerobicexerci'se capacity in men. J Am Coli CardioI1993;22:175-182, with permission fromthe American College of Cardiology Foundation.

higher oxygen consumption (\102) and peak heart rate than during cycle ergome­ter testing14

,15 The treadmill should have handrails for patients to steady them­selves, but holding the handrails can reduce the accuracy of estimatedexercise capacity and the quality of the ECG recording, and should be discour­aged, However, it may be necessary for some individuals to hold the handrails

99CHAPTER 5 I CLINICAL EXERCISE TESTING

less movement of the patient's arms and thorax during cycling, it is easier toobtain better quality ECG recordings and blood pressure measurements .However, stationalY cycling is an unfamiliar method of exercise for many and ishighly dependent on patient motivation. Thus, the test may end prematurely (i.e.,because of localized leg fatigue) before a cardiopulmonary endpOint has beenachieved. Lower \'alues for \'02m'" during cycle ergometer testing (versus tread­mill testing) can range from 5% to 25%, depending on the participant's condi­tioning and leg strength. 1-1-16

Arm ergometry is an alternative method of exercise testing for patients whocannot perform leg exercise. Because a smaller muscle mass is used during armergometry, V02max during ann exercise is generally 20% to 30% lower than thatobtained during treadmill testingJ7 Although this test has diagnostic utility,lb ithas been largely replaced by the nonexercise pharmacologic stress techniquesthat are described later in this chapter. Arm ergometer tests can be used for activ­ity counseling and exercise prescription for certain disabled populations (e.g.,spinal cord injUly), and individuals who perform primarily dynamiC upper bodywork during occupational or leisme-time activities.

Exercise ProtocolsThe protocol employed for an exercise test should consider the purpose of thetest, the specific outcomes desired, and the characteristics of the individual beina

tested. Some of the most common exercise protocols and the predicted \102 fo~each stage are illustrated in Figure .5-3. The Bl'1lce treadmill test remains themost commonly used protocol; however, it employs relatively large increments(i.e., METs per stage) evelY 3 minutes. Consequently, changes in phYSiologicresponses tend to be less uniform and exercise capacity may be markedly overes­timated when it is predicted from exercise time or workload. Protocols with larg­er increments (e.g., Bruce, Ellestad) are better suited for screening youngerand/or phYSically active individuals, whereas protocols with smaller increments,such as Naughton or Balke-Ware (i.e., 1 MET per stage or lower), are preferablefor older or deconditioned individuals and patients with chronic diseases.

The ramp protocol is an alternative approach to incremental exercise testingthat has gained popularity in recent years, in which the work rate increases in aconstant and continuous manner.15.19.20 Although ramp testing using a cycleergometer has been available for many years, many of the major treadmill man­ufacturers recently developed controllers that ramp speed and grade. Both indi­vidualized 19 and standardized ramp tests, such as the BSU/Bruce ramp,20 havebeen used. The former test individualizes the rate of increase in intensity basedon the 'suhject, and the latter matches work rates to equivalent time periods onthe commonly used Bmce protocol, but increases in ramp r~lshion. Advantages ofthe ramp approach include the follOWing: 15

• Avoidance of large anclunequal increments in workload• Uniform increase in hemodynamic and phYSiologic responses• More accurate estimates of exercise capacity and ventilatOly threshold• Indi\~dualizing the test protocol (individualized ramp rate)• Targeted test duration (applies only to individualized ramp protocols)

20 30 40

Peak 02 uptake (mL·kg-1·min-1)

10

0 ..... """"" ..,.. """"'......

0.....,. ..,.... -.,. ...,..........

SECTION II I EXERCISE TESTING

40 __----------------......

40 __----------------

......~>-

:'::: 30m­...oE... 20~juen~o 10

~I1lU

......~>- 30

:':::I1l­...oE 20QlenjI1l

-~ 10:;;:

lightly for balance. An emergency stop button should be readily available tosupervising staff.

Cycle ergometers are less expensive, require less space, and make less noisethan treadmills. Incremental work rates on an electronically hraked cycleergometer are more sensitive than mechanically braked ergometers hecause thework rate can be maintained over a wide range of pedal rates. Because there is

10 20 30 40

Peak 02 uptake (mL·kg-1.min-1)

FIGURE 5-2. Relation between peak oxygen uptake with all cause mortality (top) andcardiovascular mortality (bottom) in patients with coronary artery disease. Shaded arearepresents 95% confidence limits. See reference 11: Modified from Journal of theAmerican College of Cardiology, 23(2) 358-363, Vanhees L, Fagard R, ThiJs L, et alPrognostic significance of peak exercise capacity in patients with coronary arterydisease. © 1994 American College of Cardiology Foundation.

98

100 SECTION II / EXERCISE TESTING

FUNCTIONAL CLINICAL O2 COSTMETS

BICYCLECLASS STATUS ml/kg/min ERGOMETER

BRUCE RAMP

3MINSTAGES

73.5 21MPH/%AGR

5.5 I 2070 20

FOR 70 KG

66.5 19 BODY WEIGHT

>-Kpm/min

I- 63 18 (WATTS):>i=

5.0 -1() 18c( 59.5 17uf

"c( 56.0 16z

NORMAL 0

ANDI- 52.5 15zw

I cz 49.0 14 1500w PER 30 SECll. (246)

4.2 Iw 16 MPH/%GRc>="

45.5 13 3.0 25.0J: 3.0 24.0!:i 1350

42.0 12 (221) 3.0 23.0c(w 3.0 22.0J: 3.0 21.0

38.5 11 12003.0 20.0

>--(197)

3.0 19.0

35.0 10 1050 3.4 I 3.0 18.014 3.0 17.0

(172) 3.0 16.031.5 9 3.0 15.0>- 900J: 3.0 14.0

!:i 28.0 8(148) 3.0 13.0

c(750 3.0 12.0

~"- (123)2.5 I 3.0 11.0

>- 24.5 7 12ex: 3.0 10.0

i5 600 3.0 9.0z 21.0 6 (98) 3.0 8.0w

II c 3.0 7.0w 450en c 17.5 5

3.0 6.0w ()

(74)

1.7 I 3.0 5.0I-:E ~

10 3.0 4.0

:::i :; 14.0 4 300 3.0 3.0

'-- 12 (49) 3.0 2.0

III ll. 10.5 3 3.0 1.0:; 150 3.0 0>-en (24) 2.5 0

7.0 2 2.0 0L- 1.5 0

IV 3.5 1 1.0 00.5 0

FIGURE 5-3. Common exercise protocols and associated metabolic costs of each stage.

--"1

CHAPTER 5/ CLINICAL EXERCISE TESTING 101

I

I~ITREADMILL PROTOCOLS METS

.Rue, BALKE- USAFSAM "SLOW" MODIFIED ACIP MOD.

RAMP WARE USAFSAM BALKE NAUGHTON-

1ERMIN(CHF)

?H/%GR f-----

r 5.8 I 20 21

=lt6 If-----

2019 %GRADE.,1 AT 3.3

f-----

MPH19

f-----1 MIN

18 18

ISTAGES f-----

~Ol18 17

f-----

-4.8 I 17 16

I 26 MPH/%GR MPH/%GR f-----

253.3 25 3.4

1524.0

4.5124 f-----

I 16 23 MPH/%GR MPH/%GR 14

*2 I16

22 3.0 25 3.1 24.0 3.0 I 25 f-----

21 13

.1 I 15 20 3.3 20 3.0 22.5 3.0 I 22.5 f-----

+1 19 3.0 21.0 12

&=18 3.0 20 3.0 I 20 f-----

14 17 11

16 3.0 17.5 3.0 17.5 3.0 I 17.5 f-----3.3 15.4 I 14

15 MPH/%GR 1014

I3.0 I 15• 2 25 3.0 15 f----

~13 3.0 14.0 9

I 3.1 I 13 12 3.0 112.5 f-----3.0 12.511

I83.3 10 2 20

8 I 12 10 3.0 10.53.0 I f-----

j,l."iI '" 93.0 10 10

I 2.5 I7

12 82 I 3.0 I15 3.0 7.5 7.5 f-----

~3 I7 3.0 7.0 611

I. 6

I2.0 I 10.5- .1 I 10 3.3 5 2 10 3.0 5 f-----

I5 5

~? I

4 3.0 3.0 2.0 I 7.0 f-----

t::n10

32 I

3.0 2.5

UT5 4

2 2.5 2.0 2.0 I 3.53.3 0 3.0 0 f-----

~311 35

2 I..n 2.0 0 0 2.0 0 2.0 0.01.5 I

IDI0 2- I 1.0 I 0 1.0 I 0 f-----

• 1

"""'"IIIl.J..

UPPER BODY EXERCISE TESTING

103CHAPTER 5/ CLINICAL EXERCISE TESTING

k " 'tl type of cardiac event or interventional procedure, associatedto wor valles WI 1I' t' and IJrocrnosis d '

comp Ica Ions, " b .., d "d '11 or c Icle ergometer grade exerciseThe value of a symptom-limIte t,lea m~, ts ~n return-to-work status is well

test (eXT) in evaluating and co~nse mg pa le~lln IlelIJ '1ssess IJrocrnosis, Second,d >~ F' tl ' tient s responses c, , b d

establishe ,- Irst, le pa _ 'h' be comIJared to the estimate' d 'lk MEl capacI,/ can

measured or estImate pe, ", b t assess eXIJected relative energy, , t of the patIent s JO 0, , 'f

aerobIC reqUlremen s I ' I de llallds are considered appropnate Id >5 F' t IYltients p lyslca I, omdeman S,- Ol mos ',' , , t' e "1ges less than or equal to 5 '/0' , . eneltture requlJ emen av I, ,

the 8-hour enelg) exp 'd ( ,5--45 minutes) are \\~thin guidelmes pre-peak METs and peak Job ,deman ~ e,g(" 809f IJeak METs or lower), Most jobscribed for a home exercIse proglam e,g" 0

2-t

tasks require less than 5 METfs.. 't t leeeled to IJro\~de realistic advice onI eXT ' tI I)' hlJe 0 exercIse es I ,T le IS le on,} "f 'd'" tl'ellts However some pattentsk C ,tl e m'lJonty 0 cm lac pa, ,

return-to-wor status tOIl, r ' b d d ell'frel

, subst-lntialJ)1' Ii' J t f lcr i JO eman s II ,

may benefit from fUliber unctlOna es Balbi ' t'ents \\'1'tb borderline IJbysicald 'I tI eXT especr y p,1 1

from that evaluate \\'1t 1 le '" d' b deillands those \\~th concomi-" l' I' to tbe 'lIltlclpate JO ,

work capacity III re atJOns IIp 'I' those concerned about resuming a pbySi-tant left ventriclJ lar dysfunctiOn

l, ane~od 'd' 'oIJortionate m)locardial demands

d ' 'b Job tasks t lat pi 0 uce ISPI kcally deman Illg.l

0' 1 ' " tatl'c muscular contraction, wor'd eXT ' ,I de t lOse requlJ Illcr S , ,

compare to a IIlC u d ' ,b 'tt t I e'1VY work 24 T)mical physl-' 't' t'ess an IIltelml en 1, 'rcombined \\'lth tempera me s I, , , to work involving a static mus-ologic responses include a greaterpressoj, leisp~ltlseand decrease in stroke volume

' " , 'ocrreSSlve nse m leal Ia e ,cular contJactJOn, ,I pI b, , I,d len increase in myocardIal OAy-over time for work in a hot ell\'1ronment, ane a su e

d 'I' t 'n'ttent hem')' work.gen deman s \\'1t 1 III ell I 'b ,dlninistered when insufficient' l' tl t' k(s) in questIOn can e a

Tests Slmu atmg .le as , 't' 'b'l'ty to resume work \vithin a' , , l bl t detenmne a patlen s a I I ,informatlOn IS aval a eo, t "sk for serious arrhythnm1s orbl d ' of s'1fety. For pattents a I I , , dreasona e eglee, e 't" crlll'1Y be considered, SIJecw!Jze'b b I, t Y EC mOll! ollnb 'ischemia on the.l

0, am u a 01 I t', Id \T'11IJar work simulators) also' (B' If 0 'e T lerapeu IC al ,

work sllllUlators e,g" a 1m I 't 't '11 be set UIJ to evaluate t)'Pes>6 I I I' Ie ineA-pensl"e es s c, I ,

are available,- a t 10Ug 1 sImp, _>4 A 'I t c'11'l'Vin cr test can be used tod 'I' eXl - welg 1 -, /' b

of work not evaluate \\'1t 1 a ' , 'k' b'lleel \\~th light dynamiCC j' Itt 1 '1VY St'ltlC WOl com I

evaluate tolerance lor Igl Ole, , ,,', teness for returning to occu-work and is t)lJically performed to assess appl OP! 1'1pational activities,

Measurements During Exercise Testing" linical exercise testing include beart rate and

Common variables assessed dUllllg c" 11 as signs 'md symIJtoms,e 1 bl'edlve ratmgs, as we, ,blood pressure, EC c langes, su , 1 'llmted during the

. 'I, nses 'llso are common yev, ,Expired gases and venti atOly lespo " uch 'lS heart failure and pulmonatyexercise test, particularly III certalll glOupS, s ,disease patients,

HEART RATE AND BLOOD PRESSURE

, d b ~ re durin cr, and after theHeart rate and blood pressure should be measlUle eo, ded fl'equency andbI 5 'J 'd' tes t le recommengraded exercise test. Ta e -:., III Ica

SECTION" / EXERCISE TESTING102

Whichever exercise protocol is chosen, .it should be individualized so that thetreadmill speed and increments in grade are based on the subject's capability,Ideally, increments in work rate should be chosen so that the total test time rangesbetween 8 and 12 minutes,I,~,2J For example, increments of 10 to 15 watts (1 \V ==6,12 kg'm' min -I) per minute can be used on the cycle ergometer for elderlypersons, deconditioned individuals, and patients \·\~th cardiovascular or pulmonmydisease, Increases in grade of 1% to 3% per minute, \\~th constant belt speeds of1,5 to 2,5 mph, can be used for treadmill tests for these same populations,

Although no longer \videly used, submaximal testing can be an appropriatechoice for predischarge, post-iVfI evaluations, and for patients who may be at highrisk for serious rhythm disturbances, abnormal blood pressure responses, orother adverse signs or symptoms, Submaximal tests can be useful for makingactivit} recommendations, adjusting the medical regimen, and identifying theneed for further interventions, These tests are stopped frequently at a predeter­mined level, such as a heart rate of 120 beats'min -lor a MET level of5, but thismay vary based on the patient and clinical judgment. When performed in thismanner, submaximal tests have been useful in risk stratifying post-MI patients,

An arm cycle ergometer can be purchased as such, or modified from an eXistingstationaIy cycle ergometer by replaCing the pedals \vith handles and mountingthe unit on a table at shoulder height. Similar to leg cycle ergometers, these canbe braked either mechanically or electrically, Work rates are adjusted by alteringthe cranking rates and/or resistance against the flywheel. \Vork rate incrementsof 10 \V evelY 2 to 3 minutes, at a cranking rate of 50 to 60 IFm, have beenapplied to a broad spectrum of patients,22 Arm ergometiy is best performed inthe seated position with the fulcrum of the handle adjusted to shoulder height.Electrocardiographic leads should be placed to minimize muscle artifact fromupper body movement, Blood pressure can be measured with the individualdropping one arm and continuing to arm crank witb the other, or during brief restperiods between stages, However, systolic blood pressures taken by the standardcuff metbod immediately after arm crank ergomet!y are likely to underestimate"true" physiologic responses,2:3 Blood pressures can also be measmed at the thigbdming arm ergometlY testing,

Testing for Return to Work

The decision to return to work after a cardiac event is a complex one, \vith about15% to 20% of patients failing to resume work.2~ Both medical and nonmedicalfactors contribute to tbis loss of employment,

\~Tork assessment and counseling are useful in optimiZing return-to-work deci­sions, Early discussion of work-related issues \vitb patients, preferably beforehospital discharge, may help establish reasonable return-to-work expectations,Discussion \\~th the patient could include a job histOJY analysis to: 1) ascertain jobdemands and concerns, 2) establish tentative time lines for work evaluation andreturn, 3) individualize rehabilitation according to job demands, and 4) deter­mine speCial work-related needs orjob contacts,2~The appropriate time to return

Abbreviations: HR, heart rate; SP, blood pressure; RPE, ratings of perceived exertion; sec, seconds

TABl~ 5-2. Re.commended Monitoring Intervals Associated withExercise Testmg*

105CHAPTER 5/ CLINICAL EXERCISE TESTING

Potential Sources of Error in Blood~. 'Jf1;

: I

for blood pressure assessment at rest and potential sources of error during exer­cise, respectively. If systolic blood pressure appears to be decreasing withincreasing exercise intensity, it should be retaken immediately.27 If a drop insystolic blood pressure of 10 mm Hg or more occurs with an increase in workrate, or if it drops below the value obtained in the same position before testing,the test should be stopped, particularly if accompanied by adverse signs or symp­toms. (See Box 5-2 for test termination criteria.) Anxious patients who demon­strate a drop in systolic blood pressure during the onset of exercise, withoutcorresponding signs and symptoms, do not warrant test termination.

ELECTROCARDIOGRAPHIC MONITORING

• Inaccurate sphygmomanometer

Improper cuff size

Al,Iditory acuity of technician

Rate of inflation or deflation of cuff pressure

Experience of technician

Reaction time of technician

• Faulty equipment*. Improper stethoscope placement or pressure

• Background noise~. Allowing patient to hold trea'dmill handrails or flex elbow

• Certain physiologic abnormalities (e.g., damaged brachial artery, subcla­

vian steal syndrome, arteriovenous fistula)

A high-quality ECC is of paramount importance in an exercise test. Proper skinpreparation is essential for recording the electrocardiogram. It is importantto lower the resistance at the skin-electrode interface and thereby improve thesignal-to-noise ratio, The general areas for electrode placement should beshaved, if hair is present, and cleansed with an alcohol-saturated gauze pad, ThesuperfiCial layer of skin then should be removed using light abrasion '""ith fine­grain emery paper or gauze, The electrodes then are placed according to stan­dardized anatomic landmarks (see Appendix C). Twelve leads are available; how­ever, three leads, representing the inferior, anterior, and lateral distribution areroutinely monitored throughout the test. Because electrodes placed on wrists andankles obstruct exercise and cause artibet, the limb electrodes commonly areaffixed to the torso at the base of the limbs for exercise testing. 28 Because torsoleads may give a slightly different ECG configuration when compared with thestandard 12-lead resting ECG, use of torso leads should be noted on the ECG.23

Substantial breast tissue or abdominal adiposity may warrant modification ofstandard electrode placement to minimize movement artifact.

Signal processing techniques have made it possible to average ECG waveformsand remove noise, but caution is urged because signal averaging can actually distort

Monitored continuously;recorded during the last5 sec of each minute

A fter Exercise Test

Measured and recordedimmediately postexerciseand then every 2 minthereafter

Monitored continuously;recorded immediatelypost-exercise, during thelast 15 sec of first minuteof recovery, and thenevery 2 min thereafter

Monitored continuously;recorded as observed

Obtain peak exercisevalue then not measuredin recoveryGenerally not needed inrecovery

During the Test

Monitoredcontinuously;recorded duringthe last 15 sec ofeach stage (intervalprotocol) or the last15 sec of each2 min time period(ramp protocols)Monitoredcontinuously;recorded during thelast 5 sec of eachminute

Measured andrecorded during thelast 45 sec of eachstage (intervalprotocol) or the last45 sec of each 2 mintime period (rampprotocols)Monitoredcontinuously;recorded asobservedRecorded duringthe last 5 sec ofeach minuteMeasuredcontinuously

Before Exercise Test

Monitoredcontinuously;recorded supineposition andposture ofexercise

Monitoredcontinuously;recorded supineposition andposture ofexerciseMeasured andrecorded insupine positionand posture ofexercise

Monitored ­continuously;recorded asobservedExplain scale

SECTION" / EXERCISE TESTING104

Variable

ECG

HR:I:

BPH

Signs andsymptoms

RPE

Gas exchange Baseline readingto assure properoperational status

'See Reference 44: Adapted, by permISSion from Brubaker PH K . kDisease: Champaign, IL: Human Kinetics 20(J2:182. ' amlns y LA, Whaley MH. Coronary Artery

tNotes An unchanged or decreaSing s t I bl dverified Immediately) ys 0 JC 00 pressure with increasing workloads should be retaken (I e

tin addition BP and HR should be addOCcur ssesse an recorded whenever adverse symptoms or abnormal ECG changes

sequence of these measures. A standardized procedure should be 'ldo Jt If.each JaboratOlY so that baseline measures can be assessed more acc <., t II et I 01

repeat testing is performed. < lila e y w len

Although numerous devices have been devc10IJed to 'lUtOlll'lte bloodme'lS' t d " < < pressu re< 1II emen s unng exerCise, they arc genenlJ . t, . 'f' h. .. ' y plone 0 <utI act, t us manualmedSUl ements remalll the preferred method Bo 3 4 d 5 1. xes - an ,- suggest methods

the signal.2H Moreover, most manufacturers do not specify how such proceduresmodify the ECC. Therefore, it is important to consider the "real timc" ECG datafirst, using filtered data to aid in the interpretation if no distOltion is obvious.

ABSOLUTE INDICATIONS• Drop in systolic blood pressure of > 10 mm Hg from baselinet blood

pressure despite an increase in workload, when accompanied by otherevidence of ischemia

• Moderately severe angina (defined as 3 on standard scale)• Increasing nervous system symptoms (e.g., ataxia, dizziness, or near

syncope)• Signs of poor perfusion (cyanosis or pallor)• Technical difficulties monitoring the ECG or systolic blood pressure• Subject's desire to stop• Sustained ventricular tachycardia• ST elevation (+ 1.0 mm) in leads without diagnostic Q-waves (other

than V, or aVR)

107CHAPTER 5/ CLINICAL EXERCISE TESTING

GAS EXCHANGE AND VENTILATORY RESPONSES

1. Definite discomfort or pain, but on'" of initial or modest levels (established,but minimal)

2. Moderate discomfort or pain from which the patients attention can be divert­ed (e.g., by conversation)

3. Intense pain (short of grade 4) from which the patients attention cannot bediverted

4. Excruciating and unbearable pain

Claudication

]. Mild, barely noticeable2. Moderate, bothersome3. Moderately severe, very uncomfortable4. Most severe or intense pain ever experienced

Angina

specific symptomatic complaints (e.g., degree of chest pain, burning, discomfort,dyspnea, leg discomfort/pain) should be assessed routinely dming clinical exer­cise tests. Patients are asked to provide subjective estimates during the last 15seconds of each exercise stage (or every 2 minutes during Hamp protocols) eithcrverbaJly or manually. For example, the individual can provide a number verballyor point to a number if a mouthpiece or face mask is being used. The exercisetechnician should state the number out lond to confirm the correct rating. Eitherthe 6-20 categOl), scale or the 0-10 categOl)'-ratio scale (see Chapter 4) mav beused to assess RPE during exercise testing.2

.5 Before the start of the exercise test,the patient should be given clear and concise instructions for use of the selectedscale. Generic instructions for explaining either scale are provided in Chapter 4.

Use of alternative rating scales that are specific to subjective symptoms arerecommended when subjects become symptomatic during exercise testing.Frequently used scales for assessing the patients' level of angina, claudication,andlor dyspnea are as follows:

Dyspnea

1. Light, barely noticeable2. Moderate, bothersome3. Moderately severe, very uncomfortable4. Most severe or intense dyspnea ever experienced

In general, reaching a rating of 3 on the angina scale or a degree of chest dis­comfort that would cause the patient to stop normal daily activities, are reasonsto terminate thc exercise test. However, higher levels of dyspnea or claudicationmay be acceptable during the exercise test.:JO

SECTION II/EXERCISE TESTING

RELATIVE INDICATIONS• Drop in systolic blood pressure of > 10 mm Hg from baselinet blood

pressure despite an increase in workload, in the absence of other evi­dence of ischemia

• ST or QRS changes such as excessive ST depression (>2 mm horizontalor downsloping ST-segment depression) or marked axis shift

• Arrhythmias other than sustained ventricular tachycardia, including mul­tifocal PVCs, triplets of PVCs, supraventricular tachycardia, heart block,or bradyarrhythmias

• Fatigue, shortness of breath, wheezing, leg cramps, or claudication• Development of bundle-branch block or intraventricular conduction

delay that cannot be distinguished from ventricular tachycardia• Increasing chest pain• Hypertensive response (systolic blood pressure of >250 mm Hg and/or

a diastolic blood pressure of > 115 mm Hg).

'See reference 1: Modified from Gibbons RJ, Balady GJ, Bricker JT, et al ACCIAHA 2002Guideline Update for Exercise Testing; a report of the American College ofCardiology/American Heart Association Task Force on Practice Guidelines Committee onExercise Testing, 2002. American College of Cardiology web site:www.acc.orglclinical/guidelineslexercise/dirlndex.htm

tBaseline refers to a measurement obtained immediately before the test and in the sameposture as the test is being performed.

106

SUBJECTIVE RATINGS AND SYMPTOMS

The measurement of perceptual responses during exercise testing can provideuseful clinical information. Somatic ratings of perceived exertion (RPE) and/or

Because of the inaccmacies associated \\~th estimating o>;ygen consumption andMETs from work rate (i.e., treadmill speed and grade), many laboratories directlymeasure expired gases. The direct measurement of \'02 has been shown to bemore reliable and reprod"cible than estimated values from treadmill or cycle

BLOOD GASES

INDICATIONS FOR EXERCISE TEST TERMINATION

109

I' •

CHAPTER 5/ CLINICAL EXERCISE TESTING

• Knowledge of appropriate indications for exercise testing• Knowledge of alternative physiologic cardiovascular tests• Knowledge of appropriate contraindications, risks, and risk assessment

of testing• Knowledge to promptly recognize and treat complications of exercise

testing• Competence in cardiopulmonary resuscitation and successful comple-

tion of an American Heart Association-sponsored course in advance

cardiovascular life support and renewal on a regular basis• Knowledge of various exercise protocols and indications for each• Knowledge of basic cardiovascular and exercise physiology, including

hemodynamic response to exercise• Knowledge of cardiac arrhythmia and the ability to recognize and treat

serious arrhythmias• Knowledge of cardiovascular drugs and how they can affect exercise

performance, hemodynamics, and the electrocardiogram• Knowledge of the effects of age and disease on hemodynamic and the

electrocardiographic response to exercise• Knowledge of principles and details of exercise testing, including proper

lead placement and skin preparation• Knowledge of endpoints of exercise testing and indications to termi-

nate exercise testing'See reference 35: Adapted from Rodgers GP, Ayanian JZ, Balady GJ, et al AmericanCollege of Cardiology/American Heart Association c1il1lcal competance statement on stress

testing. Circulation 2000; 102: 1726-1738.

record about 10 seconds o[ ECG data while the patient is in the upright positionimmediately after exercise [or ECG clarity at peak exercise heart rate. Ha\1ng thepatient perform a cool-down walk after the test may decrease the risk of hypoten­sion but can attenuate the magnitude of ST-segment depression. \!\Thcn the testis being performed for nondiagnostic purposes, an active cool-down usually ispreferable; for example, slow walking (1.0-1.5 mi·h -I) or continued cyclingagainst minimal resistance. Monitoring should continue for at least 5 minutesafter exercise or until ECG changes return to baseline and significant signs andsymptoms resolve. Hemodynamic variables (heart rate and blood pressure) alsoshould return to ncar-baseline levels berore discontinuation of monitoring. ST­segment changes that occur only during the postexercise period are currentlyrecognized to be an important diagnostic part of the test.:

15In addition, the rate

in which heart rate recovers from exercise recently has been demonstrated to bean important prognostic marker and is discllssed in Chapter 6.:

36.3

, In patientswho are severely dyspneic, the supine posture may exacerbate the condition, and

sitting may be a more appropriate posture.

•SECTION II/EXERCISE TESTING108

ergometer work rate. Peak \102 is the most accurate measurement of functionalcapacity and IS a !Iseful index of overall cardiopulmonmy healthS In addition, themeasurement ofV02 carbon dioxide (VC02) and the subsequent calculation of therespiratory exc!1ange ratio (RER) can be used to determine total energy expendi­tu.re and specIfic substrate contribution during physical acti\1ty. The measurementof mmute ventilation also should be collected whene\'er gas exchange responses aremeasured. Measurement of gas exchange and ventilation is not necessmy for allc1l11lcal exerCise testmg, but the additional information can provide useful physio­logIC data. Because h~art and hll1g diseases frequently manifest as ventilatory or gasexchange abnormahttes dunng exercise, an integrated analysis of these measurescan be useful for differential diagnosisS F11Ithennore, collection of gas exchangeand ventilatOlY responses arc increasingly being lIsed in clinical tlials to objective­ly assess the response to specific interventions. Situations in which gas exchangeand ventilatlOn measurements are appropriate include the following: I

• \"!hen a precise cardiopulmonmy response to a specific therapeutic interven­tion is required

• When the etiology of exercise limitation or dyspnea is uncertain• When evaluation of exercise capacity in patients with heart failure is used to

assist in the estimation of prognosis and assess the need for transplantation• \"!hen a precise cardiopulmonary response is needed within a research con­

text• When assisting in the development of an appropliate exercise prescription for

cardiaC and/or pulmonaty rehabilitation

Pulmonary disease should be considered in patients who exhibit \\~th dyspnea onexertIOn. As such, It IS also ImpOltant to measure gas pmtial pressures in thesepattents because oxygen desaturation may occur during exertion. Although meas­urement of P,,02 and P"C02 from arteJial blood has been the standard in the past,the avmlablhty of oximetry has replaced the need to routinely draw mterial blood inmost patlents. In patients \~th pulmonary disease, measurements of m,ygen satu­ration (S,,02) from oximetty at rest correlate reasonably well \~th S,,02 measuredfrom mterial blood (95% confidence limits are ± 3% to 5% saturation).:JlCarboxyhemoglobin (COHb) levels greater than 4% and black skin may adverselyaffect the accuracy of pulse oximeters,:l2.:3:3 and most oximeters are inaccurate at anS,,02 of 85% or less. AlteJial blood gases may be obtained if clinically warranted.

The absolute and relative indications for termination of an exercise test are listedin Box 5-3. Absolute indications are unambiguous, whereas relative indicationssometimes may be superseded by clinical judgment.

Postexercise PeriodIf maximal sensiti~ity is to be achieved with an exercise test, patients should beplaced supme dunng the postexercise period,:14 although it is advantageous to

EXERCISE ECHOCARDIOGRAPHY

EXERCISE NUCLEAR IMAGING

Exercise Testing With Imaging Modalities

111CHAPTER 5/ CLINICAL EXERCISE TESTING

PHARMACOLOGIC STRESS TESTING

ELECTRON BEAM COMPUTED TOMOGRAPHY

seen at rest suggest myocardial ischemia. Perfusion defects that are present dur­ing exercise and persist at rest suggest previous MI or scar. The extent and dis­tribution of ischemic myocardium can be identified in this manner.

The limitations of nuclear imaging inclnde the exposure to low-level ionizingradiation. Furthermore, additional equipment and personnel are required forimage acquisition and interpretation, including a nuclear technician to adminis­ter the radioactive isotope and acquire the images, and a physician trained innuclear medicine to reconstruct and interpret the images.

Patients unable to undergo exercise stress testing tor reasons such as decondition­ing, peripheral vascular disease,. orthopediC disabilities, neurologic disease, andconcomitant illness often benefit from pharmacologic stress testing. The two mostcommonly used pharmacolOgiC tests are dobutamine stress echocardiography anddipyridamole or adenosine stress nuclear SCintigraphy. Indications for these testsinclude establishing a diagnosis of CAD, determining myocardial viability beforerevascularization, assessing prognosis after MI or in chronic angina, and evaluatingcardiac risk preoperatively. Some protocols include light exercise in combinationv.ith pharmacologic infusion.

Dobutamine elicits wall motion abnormalities by increasing hemt rate andtherefore myocardial oxygen demand. It is infused intravenously and the dose isincreased gradually until the masimal dose or an endpOint is achieved. EndpOintsmay include new or worsening wall-motion abnormalities, an adequate heart rateresponse, serious arrhythmias, angina, Significant ST depression, intolerable sideeffects, and a Significant increase or decrease in blood pressure. Atropine may begiven if an adequate heart rate is not achieved or other endpOints have not beenreached at peak dobutamine dose. Hemt rate, blood pressure, ECG, and echocar­diographic images are obtained throughout the infusion. Echocardiographicimages are obtained similar to exercise echocardiography. A new or worsening wallmotion abnormality constitutes a positive test for ischemia40

Vasodilators such as dipyridamole and adenosine commonly are used to assesscoronary perfusion in conjunction v.ith a nuclear imaging agent. Dipyridamoleand adenosine cause maximal coronmy vasodilation in normal epicardial arteries,but not in stenotic segments. As a result, a coronary steal phenomenon occurs,v.ith a relatively increased flow to normal arteries and a relatively decreased flowto stenotic arteries. Nuclear perfusion imaging under resting conditions is thencompared v.ith imaging obtained after coronmy vasodilation 4o Interpretation issimilar to that for exercise nuclear testing.

Although not an exercise test per se, electron beam computed tomography(EBCT) is being used increasingly to screen asymptomatic and high-risk individ­uals to detect CAD. EBCT is highly sensitive for detecting coronmy artery calci­um; and the presence and extent of calcium is closely related to atherosclerosis.However, calcium also may stabilize plaque, particularly in elderly people, amongwhom it is most often noted. Although EBCT has been highly promoted in the

SECTION II/EXERCISE TESTING110

Exercise tests with nuclear imaging are performed with ECG monitoring. Thereare several different imaging protocols using only technetium (Tc)-99m or thal­lous (thallium) chloride-20l. A common protocol with technetium is to performrest images 30 to 60 minutes after intravenous administration of technetium fol­lowed by exercise (or pharmacologic stress) 1 to 3 hours later. Stress images areobtained 30 to 60 minutes after injecting technetium approximately 1 minutebefore completion of peak exercise. Comparison of the rest and stress imagespermit differentiation of thed versus transient perfusion abnormalities.

Technetium-99m permits higher dosing v.ith less radiation exposure thanthallium and results in improved images that are sharper and have less artifactand attenuation. Consequently, technetium is the preferred imaging agent whenperforming tomographiC images of the heart using single photon emission com­puted tomography (SPECT). SPECT images are obtained with a gamma camera,which rotates 180 degrees around the patient, stopping at preset angles to recordthe image. Cardiac images then are displayed in slices frolll three different axesto allow visualization of the heart in three dimensions. Thns, multiple myocardialsegments can be \iewed individually, \\ithout the overlap of segments that occurs\·vith planar imaging.:J9 Perfusion defects that are present during exercise but not

Imaging modalities such as echocardiography can be combined with exerciseECG in an attempt to increase the sensitivity and specificity of stress testing, aswell as to determine the extent of myocardium at risk as a result of ischemia.Echocardiographic images at rest are compared with those obtained during cycleergometry or immediately after treadmill exercise. Images must be obtainedwithin 1 to 2 minutes after exercise because abnorrmJ wall motion begins to nor­malize after this point.

Rest and stress images are compared side-by-side in a cine-loop display that isgated during systole f)'om the QRS complex. Myocardial contractility normallyincreases with exercise, whereas ischemia causes hypokinetic, dyskinetic, or aki­netic wall motion to develop or worsen in the affected segments.:J8 Advantages ofexercise echocardiography over nuclear testing include a lower cost, the absenceof exposure to low-level ionizing radiation, and a shorter amount of time for test­ing. Limitations include dependence on the operator for obtaining adequate,timely images. In addition, approximately 5% of patients have inadequateechocardiographic windows secondary to body habitns or lung interference,:J~

although sonicated contrast agents can be helpful to enhance endocardial detlni­tion in these conditions.

Cardiac imaging modalities are indicated when ECG changes from standardexercise testing are non diagnostic, it is important to quantify the extent and dis­tribution of myocardial ischemia, or a positive or negative exercise ECG needs tobe confirmed.

REFERENCES

Supervision of Exercise Testing

113CHAPTER S / CLINICAL EXERCISE TESTING

\Iorris CK. \I;ers J. Froelicher \'F. et al. :'\olllogralli ha\cd Oil Illt'tahoJjc eqlli\alellts and age I()I'

assessing aerohic exercist:' capacity in llleli. J Am Coli Cardinl HJ9:3::2:2: 11.5~ Ih2.American Thoracic Socie-h al1<1 AIlH.:'rican Collt'gt> of Cllest Ph;sidans. Alllcrican Thoracic

Society/Allwric<.l1l College oj' Chest _Ph~,siciallsSlaknwnl on Can..liopultl,ol1ar; E\er<:i,,>t-' Testing. Am

J Ikspir Crit Carl' "led 2003:167:211-277.Blair SN, Kohl 1111' :3rd. I)alrl'nbar~er HS Jr. et al. !'h,sil'al Ihne." and all-cause mortalit,. A

I'rospecti\'e Stllli: of health\ men and \\()llll'n. JAMA 1%\):262:2:3>J,5-2~O I.Blair S:\. Kohl 1111' :3rd, Barlow CL cl al. Chanl(l's in ph\sieal f1tne" and all-eausl' mortality. A

prospect in' ,tud\ of health\ and nnhealth\ men. JA\IA 1995:27:3: I09:3--1 O\)i>.

Vanhees I., Fagan} R, Thij') L. et al. Prognostic si~nificanceof peak t:'xerc.:ise capacit~ in patients with

coronalyarten diseas". J Am Coli Cardiol 1\)\)4:2:3::3.5i>-.36:"Myers i. Prak~\s" ~l. Froeliclwr \', et al. E\t'rcise capacity and mortc~ity among men referred for

exercise testinl(. N Enl(1 J "it'd 2002::346:79.3-801.Dum J, !\aughtoll J, 11ll<lJlwra n. d <11. Results of a 1l111lticenter randomized dinic:al trial of exercise

and long-tcrlll survival in lllvoci:lnJi<.tl infarction patiellts: the National Exercise and Ileart Disease

Project ('iF: II DP). Circnlali'on I999;lOO: i/64-176\).Ilambrel'hi HI', Schuler CC. ~Inth T, et al. Greater diagnostic sensitisit, of treadmill versus eyele

exercise testinl( of asymplomatic men with (1)ron",)' al1l'l) disease. Am J Cardiol J992;70: 141-146.

Myers J, Buchanan K Il'alsh D. l't al. Comparison of the ramp \'ersus slandard exercise protocols.

J Am Coli Cardioll\)\)1:17:1:3:34-I:342. .Pollock ML, II'ilmore J II, Fo, SM. Exercise in Health and Disease: Evaluation and Prescription for

Prevention and Hehabililation. Philadelphia: \\'B Saunders, 1990.Franklin BA. Exercise testin~, lraininl( and ann ergometry. SPOltS Med 19805;2:100-119.

l3alady GJ, Weiner DA, McCabe CH, et a!. Value of arm exercise testinl( in detectinl( coronary artelY

disease. Am J CardioI19805;55:.37-.39.Myers J, Buchanan ~, Smith D, et ill. lndh'idualized ramp treadmill. Observations on a new proto-

col. Cbesl 1992;10U.36S-24I S.Kaminsh' LA, \\'hale\ ~I H. E\·aluation of a new standardized ramp protoeol: the BS UlBruee Ramp

protocol~J Cardiopul:n HehabiI19\)8;J8:4.3H--444.Buchfuhrer \\J, Hansen JE, Hobinson TE, et al. Optimizinl( the exereise protocol for cardiopul­

monary assessment. J Appl Physioll!J8.3;.505: 1.5.58-1.564.Balady CJ, Weiner DA, Hose L, et al. Physiolo~ic responses to arm ergometry exercise relative to

a~e and l(ender. J Am Coil Cardiol 1990:16: 1.30-1.35.Hnllinl(swOlth V, Bendiek P, Franklin 13, et al. V,i1icuty of ann erl(ometer blood pressures immedi-

ately after exercise. Am J CardioI1990;6.5: 1.358-1.360. .Sheldalll L\I, \\'ilke 1\A, Tristani FE. E\,i1uation and traininl( for resumption 01 oc<:Upational and

leisure-tillle physical acti\;ties in patients after a Inajol' cardiae event. \Ied Exerc NlItr Health

1995:4: 27.3--289.Ainsworth BE, Ilaskell II'L, II'hitt MC. et al. Compendium of physieal acti\'ities: an update of aetiv-

ity eodes and MET intensities. "led Sei Spnrts Exere 2000;.32:S4\)8-So5 I(1.Wilke NA, Sheldahl LM, Dou~he,.ty SM, et ai. Baltimore Therapeutic Equipment work simulator:

eneriO' expendilure of work activities in eardiac patiellts. Arch Phys Med Hehabil 199.3;74:41\)-424.

Dubach P, Froeheher VF. Klein J. et al. Exereise-indueed hypotension in a male population.

Criteria, eauses, and prol(nosis. Cireulation l!J88:78:l:380-1.387.Mason HE, Uk"r 1. A new S\'stem of multiple-lead exercise electrocanuography. Am Heart J 1966;

71:196-20.5.Milliken JA, Abdollall H, Bur!(!(raf G\\'. False-positi\e treadmill exereise tests due to computer sig-

nal averagin!(- Am J Careliol 1\)\)0:6.5:\)4(;-948.Myers IN, Perception of clwst pain during exercise testing in patients with coronary artery disease.

Med Sci Sports Exerc l!J>J4:26:J082-108fi.Ries AL, Farrow JT, Clausen JL. Accuracy of Iwo t'ur oxitl1eters at rest and during t::'xerdse in pul­

monaIy patients. Am He\' Hespir Dis 1\)85;1:32:685-689.Zeb"lIos HJ, \\'eisman J\-\. Hehahilit\ of 1I0nil1\'asi\'e oximetry in black subjects durinl( exercise

and bypo,ia. Am He\' Ht'spir Dis l!J91:144:1240-1244.Orenstein D~I, Curtis SE. :\i\on PA. pi al. Accllrac; of three plll"it::' u\imeters during exercise and

hypoxemia in patients with c,stic fibrosis. Chest 199:3: 104: 11i>7-1190.Lachterrnan B, Lehmann KG, Abrahamson D. et al. "RecO\'e!)' only" ST-seglllt'nt depression and

the predietive accuracy of the exercise test. Ann Intern Med 19\)0; 112:11-16.

t.

S.

9.

10.

11.

12.

1.3.

14.

15.

16.

1718.

19.

20.

21.

22.

2.3.

24

2.5.

26.

27

28.

29.

.30.

31.

.32.

.3.3.

34.

1I

SECTION II / EXERCISE TESTING112

media, it has not been shO\\~l to produce test results that are superior to existinamodalities. In studies reviewed by a recent AIIA consensus writing panel,4~EBCT had an overall predictive accuracy (percentage of subjects correctly clas­sified) of approximately 70% for detecting CAD, which is no better than standardexercise testing. Because of this, the panel did not recommend the routine use ofE BCT [or screening individuals who are as\'mptomatic or suspected to be at riskfor CAD.

I. Cibbons HJ, Balady GJ. Bricker J. et al. ACC/AIIA 2002 l(uideune update for exercise testinl(: a

report of the Anleric..:an College of Cardiolog)-JAmerican Ileart Association Task F'oJ"{:e on Practice

Guitlclines (Committee un E\('ITise Testing). 2002. AlIlcrican Collegt' of Canliology \n"h site. avail­ahle at: \\'\\'\v.acc.orgidinicaVguiJelineslt-'\erdsl'/dirJ 11(1<:,\.hll11

2. \\'ilson P\\', O'Agostino R B, 1..£\)' 0, t-'t al. Prt'diction of coronary heart disease using risk Eldur cat­el(ories. Circulation ]\)\)8;97: 18.37-1847.

:3. Lcwis \VH, Ailisterdalll EA. F.\'aluation of the patiellt with 'rule out myocardial inEtrction.' ArchInterll Med 1\)96;156:41-45. .

4. Amsknlalll EA. Kirk JD, Diercks DB. t:'t al. IllIlIlewatt-' eM:rcise testing to ('valuak low-risk patients

presenting to the elllergt:'Jl(:) depmtlllent with chest pain. J Am Coli Cardiol 2002:40:251-2.56.

5. lark DB, Shaw L, Ilarrell FE Jr, t:'t al. Progllostie value of a treadmill c\en.:ise scorp in olilpatit:'nh

with suspected eoronary arten disease. :\ En~1 J ~Ied 1\)\)1:.3205:849-8.5.3.

6. Ashley E, "Iyers J, FroelidH.'J" V. Exereisp testing SCOrt-'S as an example of hetter dt-'cisions throughscienee. Med Sei Sports E,erc 2002;.34: 1:391-1.3\)8.

Although exercise testing generally is considercd a safe procedure, both acute MIand cardiac arrest have been reported and can be expected to occur at a com­bined rate of up to ] per 2.,500 tests. 1 Accordingly, individuals who superviseexercise tests must have the cognitive and technical skills necessary to be com­petent to do so. The American College of Cardiology, American HeartAssociation, and American College of Physicians with broad involvement fromother professional organizations involved with exercise testing (including theAmerican College of Sports Medicine) have outlined those cognitive skills need­ed to competently supervise exercise tests 35 These are presented in Box ,5-3, Inmost cases, exercise tests can be supervised by properly trained exercise physiol­ogists, physical therapists, nurses, physician assistants, or medical technicianswho are worhing under the direct supenision of a physician; that is, the physicianmust be in the immediate vicinity and available for emergencies.:3-5 Several stud­ies ha\'e demonstrated that the incidence of cardiovascular comI)lications durina

b

exercise testing is no higher with experienced paramedical personnel" than withdirect physician supervision 42,-I:J In situations where the patient is deemed to beat increased risk for an adverse event during exercise testing, the physician shouldbe physically present in the exercise testing room to personally supervise the test.Such cases include, but arc not limited to, patients undergOing symptom limitedtesting follo\\iug recent acute events (i.e., acute coronary syndrome or myocar­dial infarction \\ithin 7-] 0 days), severe left ventricular dysfunction, severe valvu­lar stenosis (e,g" aortic stenosis), or known complex arrhythmias,:J·5

Exercise Testing As aScreening Tool for Coronary Artery Disease

This chapter addresses the interpretation and clinical significance of exercise testresults, with spccific reference to screening for corOll<U)' aliel)' diseasc (CAD),hemodynamic electrocardiographic (ECG) gas cxchange and ventilatOlY respons­es, as well as the diagnostic and prognostic value of the exercise test.

CHAPTER

6•••••

Interpretation of ClinicalExercise Test Data

The probability of a patient having CAD cannot he estimated accurately from theexercise test result and the diagnostic characteristics of the test alone. It alsodepends on the likelihood of the patient having disease before the test is admin­istered. Bayes theorem states that the posttest probability of a patient hal1ng dis­ease is determined by the disease probability before the test and the probabilitythat the test \\111 provide a true result. The probability of a patient ha\1ng diseasebefore the test is related, most importantly, to the patient's chest pain character­istics, but also to the patient's age, gcnder, and the presence of major lisk factorsfor cardiovascular disease.

Exercise testing in individuals \\1th known CAD (plioI' myocardial infarction,angiographically documented coronary stenoses, anel/or prior coronmy revascular­ization) is not regularly used for diagnostic purposes. However, the description ofsymptoms can be most helpful among individuals in whom the diagnosis is inquestion. Typical or definite angina (substernal chest discomfOli that may radiateto the back, jaw, or arms; S)1nptoms provoked by exeliion or emotional stress andrelieved by rest <mel/or nitroglyce,in) makes the pretest probability so high that thetest result docs not dramatically change the probability of underlying CAD.Atypical angina (chest discomfort that lacks one of the mentioned charactelisticsof typical angina) generally indicates an intermediate pretest likelihood of CAD inmen more than :30 years old and women more than ,50 years old (see Table ,')-1 ).

The use of exercise testing in screening as}1nptomatie indi\1duals, p<uiicular­Iy among individuals \vithout diabetes or other lisk factors fell' coroll<l1Y <uteI')' dis­ease,' is problematic in view of the low to velY low pretest likelihood of CAD, evenamong symptom-free men and women more than 60 years old (see Table 5-1).Exercise testing as a pmt of routine health screening in apparently healthy indi­viduals is not recommended. I Such testing can have potential adverse conse­quences (e.g., psychological, work and insurance status, costs for subsequenttesting) by misclassifying a large percentage of those \vithout CAD as having dis­ease. Testing in asymptomatic persons with multiple risk factors may provide

115

114 SECTION II / EXERCISE TESTING

:3.5. Hodgt'rs GP, A~ani,-lIl JZ, Balady C, t't al. Allwric.:an College of Cardio)oh')/AIIlt'I·ic.:an Heart

Association Clinical Competence Statclllcnt on Stress Testing: A Heport urthe Alll<.'rican College of

Cardiology/AIllPriC<ln Heart AssociationlAmerican College of P!Iysic.:ialls-Anwrican Society of'

InIPrnal l\leuicin(' Task Force WI Clinical Competence. Circulation 2000, 102: 172(}.-1 738.

36. Cole CH. Blackstone Ell, Pashko\\' FJ. d a1. lIeart-raIP recmery immediatel} alier csercise as a pre­

uictoror mwt,Jil}. :\ Engl J ~Ied HJ99:341:1:3.51-1:3.57.

:37. Shetler K. \Ian:u'l H. Froeli<.:hcr VF', et al. Heart rate rec(wt'ry: \"aJidatioll and lIIl'thodologic issues.

J Am Coli CaruioI2(X11;:3IU%O-19b7.

:3H. Anllslrong \r. ~larcO\'itz PA. Stress t'chocardiograpliy. In: BraulI\vald E, ed. ileaI'I Disease

Updates. Plliladelphia: \\'B Saunders, I99:3:i-IO.

:3g, Ritchie JI '. Batt'lllclll T\L BOllow RO. Cuidelint-'s for clinical use of cardiac radiolllldide inwgillg.

Report ()(' tJle Anll'rican College of Cardioloh'y/Alnerk'all Ileart A~sociation Task Forct' on

AsseSSllH'llt or Diagnostic and Therapeutic Cardim"ascular Procedures (Collllllittee Oil Radiolluclide

Imaging. den~luped in conjunction with the American Socipt: of ::\udear CardioloL,')l J AnI Coll

Cardiol J995:,52 1-5-17.

40. Poldenllans D, F'iorctti PM, Forster T, l't al. Dohutarnine stress echocardiograph:' ICll' aSSeSSIIll'llt of

perioperative cardiac risk in patiellts lIndc:rgoing major vascular sllrgery. Circldatiun

1993;1>7: I,50(}-1.512.

... 1 a"Bourke HA, Brundage BU, Froelidwr \'F, et al. American College ofCardiolog:IAnlericall Ileart

Asso<..:iation Expert Consensus document on e1ectron-heam computed tomograph: Ic)r the diagnosis

and prognosis of coronary arter: dise"Lse. Circulation :?000;102: 1:?(i-140..,I:?,. FrankJin BA, Cordon S, Timlllis ce, et a!. Is direct physician SllpefYision of' exercise stress tf'sting

routinel} llecess'll)'? Chest 1997;111:262-26,5.

4,3. Knight JA, Lauhach CA Jr. Buteher HJ. et ,J. Supel"ision of clinical exercise I,'sling hy "",rcise

phssiologists. Alll J Cardiol 1995;75::)!J(h391.

44. Brubaker PH, Kalllinsky LA, \\'haley ~t H. Corol1<u-:' Artt'l-: Disei:L"iP. Challlpai~n. I L: I(ulllan

Kinetics.2(X12:1S2.

HEART RATE RESPONSE

Interpretation of Responses to Graded Exercise Testing

117

Clinical SignificanceAn abnormal ECG response is defined as 21.0 mm of

horizontal or downsloping ST J, at 80 msec beyond theJ point, suggesting myocardial ischemia

ST i in leads displaying a previous Q-wave MI almost

always reflects an aneurysm or wall motion abnormali­ty. In the abser:ce of significant Q waves, exercise­induced 5T i often is associated with a fixed high­

grade coronary stenosis.

Isolated atrial ectopic beats or short runs of 5VTcommonly occur during exercise testing and do notappear to have any diagnostic or prognostic signifi­

cance for CAD.

The suppression of resting ventricular dysrhythmiasduring exercise does not exclude the presence ofunderlying CAD; conversely, PVCs that increase infrequency, complexity, or both do not necessarily

signify underlying ischemic heart disease. Complexventricular ectopy, including paired or multiform PVCs,and runs of ventricular tachycardia (23 successivebeats), are likely to be associated with significant CADand/or a poor prognosis if they occur in conjunctionwith signs and/or symptoms of myocardial ischemia,or in patients with a history of sudden cardiac death,

cardiomyopathy, or valvular heart disease Frequentventricular ectopy during recovery has been found tobe a better predictor of mortality than ventricularectopy that occurs only during exercise.The normal HR response to progressive exercise is arelatively linear increase, corresponding to 10 ± 2beats·MEr' for inactive subjects. Chronotropic incom­

petence may be signified by:

1. A peak exercise HR that is >2 5D (>20 beats'min- 1)

below the age-predicted maximal HR for subjectswho are limited by volitional fatigue and are not

taking l3-blockers

2 A chronotropic index (CI) <0.8;39 where CI is calcu­

lated as the percent of heart rate reserve to percent

metabolic reserve achieved at any test stage ~

CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA

ST-segmentelevation (ST i)

Heart rate (HR)

Ventricular

dysrhythmias

Supraventricular

dysrhythmias

VariableST-segmentdepression (ST J,)

•SECTION II / EXERCISE TESTING116

some useful information, although this practice cannot be strongly recommend­ed based on available data. I It is likewise difficult to choose a chronological agebeyond which exercise testing becomes valuable as a screening tool prior tobeginning an exercise program because physiologic age often differs fromchronological age. In general, the guidelines presented in Table 2-1 are recom­mended if the exercise is more strenuous than brisk walking. The potential ram­ifications resulting from mass screening must be considered and the results ofsuch testing must be applied using the predictive model and Bayesian analyses.Test results should be considered as prohability statements and not as absolutes.

Before interpreting clinical test data, it is impOltant to consider the purpose ofthe test (e.g., diagnostic or prognostiC) and patient conditions that may influencethe exercise test or its interpretation. Medical conditions influencing test inter­pretation include orthopediC limitations, pulmonary disease, obeSity, neurologicdisorders, and significant deconditioning. Medication effects (see Appendix A)and resting ECG abnormalities also must be considered, especially resting ST­segment changes secondary to conduction defects, left ventricular hypertrophy,and other factors that may contlibute to spuriOUS ST-segment depression.

Although total body and myocardial oxygen consumption are directly related,the relationship between these variables can be altered by exercise training,drugs, and disease. For example, exercise-induced myocardial ischemia maycause left ventricular dysfunction, exercise intolerance, and a hypotensive bloodpressure response. Although the severity of symptomatic ischemia is inverselyrelated to exercise capacity, left ventricular ejection fraction does not correlatewell with exercise tolerance.2.3

The objective of exercise testing is to evaluate quantitatively and accuratelythe follOwing variables. Each is described in the following sections and summa­rized in Box 6-1:

• HemodynamiCS: assessed by the heart rate (HR) and systolic/diastolic bloodpressure (SBP/DBP) responses

• ECG waveforms: especially ST-segment displacement and supraventricularand ventricular dysrhythmias

• Limiting clinical signs or symptoms• Gas exchange and ventilatory responses (e.g., V02maX> VEl• Responses to exercise tests are useful in evaluating the need for and effec­

tiveness of various types of therapeutic interventions.

Maximal heart rate (HRmaJ may be predicted from age using any of several pub­lished equations 4 The relationship between age and HR max {or a large sample ofsubjects is well established; however, interindividual variahility is high (standarddeviation, 10-12 beats' min- l

). As a result, there is potential for considerableerror in the lise of methods that extrapolate sllhmaximal test data to an age-pre­dicted HRnmx• Aerobic capacity, anthropometric measures such as height andweight, and hody composition do not indepcndently influence HRm,lX' The inabil-

Aerobic fitness

Anginalsymptoms

Diastolic bloodpressure (DBP)

119CHAPTER 6 / INTERPRETATION OF CLINICAL EXERCISE TEST DATA

BLOOD PRESSURE RESPONSE

The normal blood pressure response to dynamic upright exercise consists of aprogressive increase in SBP, no change or a slight decrease in DBP, and a widen­ing of the pulse pressure. The following are key points concerning interpretationof the blood pressure response to progressive dynamic exercise:

• A drop in SBP (>10 mm Hg from baseline SBP despite an increase in work­load), or failure of SBP to increase with increased workload, is considered anabnormal test response. Exercise-induced decreases in SBP (exertionalhypotension) may occur in patients with CAD, valvular heart disease, car­diomyopathies, and serious dysrhythmias. Occasionally, patients without clin­ically signiflcant heart discas,e demonstrate exertional hypotension causedby antihypertensive thcrapy, prolonged strenuous exercise, and vasovagalresponses. However, exertional hypotension has been shown to correlate withmyocardial ischemia, left ventricular dysfunction, and an increased risk of sub­sequent cardiac events S

.9 In some cases this response is improved after coro­

nalY bypass surgely.10• The normal postexercise response is a progressive decline in SBP. During pas­

sive recovelY in an upright posture, SBP may decrease abruptly because ofperipheral pooling (and usually normalizes on resuming the supine position).SBP may remain below pretest resting values for several hours after the test.DBP also may drop dUJing the postexercise period.

• In patients on vasodilators, calcium channel blockers, angiotensin-convertingenzyme inhibitors, and (X- and f3-adrenergic blockers, the blood pressureresponse to exercise is variably attenuated and cannot be accurately predictedin the absence of clinical test data.

• Although maximal heart rates are comparable for men and women, men gen­erally have higher systolic blood pressures (~20 ::':: 5 mm Hg) dUJing maximaltreadmill testing. However, the gender difference is no longer apparent after70 years of age. A systolic blood pressure >250 mm Hg or a diastolic bloodpressure>115 mm Hg should result in test termination.

• The rate-pressure product or double product (SBP X HR) is an indicator ofmyocardial oxygen demand. ll Signs and symptoms of ischemia generallyoccur at a reprodUCible double product.

ELECTROCARDIOGRAPH WAVEFORMS

AppendiX C provides information to aid in the interpretation of resting and exer­cise electrocardiograms. Additional information is provided here with respect tocOlTIlTIon exercise-induced changes in ECG variables. The normal ECG responseto exercise includes the follOwing:

• Minor and insignificant changes in P wave morphology• SuperimpOSition of the P and T waves of successive beats• Increases in septal Q wave amplitude• Slight decreases in R wave amplitude• Increases in T wave amplitude (although wide vmiability exists among subjects)• Minimal shortening of the QRS duration

SECTION II/EXERCISE TESTING

Systolic blood The normal response to exercise is a progressivepressure (SBP) increase in SBP, typically 10 ::':: 2 mm Hg'MEr 1

, with

a possible plateau at peak exercise. Exercise testing­should be discontinued with SBP values of >250 mmHg. Exertional hypotension (SBP that fails to rise or falls[> 10 mm Hg]) may signify myocardial ischemia and/orLV dysfunction. Maximal exercise SBP of < 140 mm Hg

suggests a poor prognosis.

The normal response to exercise is no change or adecrease in DBP. A DBP of > 115 mm Hg is considered

an endpoint for exercise testing.

Can be graded on a scale of 1 to 4, corresponding toperceptible but mild, moderate, moderately severe, andsevere, respectively. A rating of 3 (moderately severe)

generally should be used as an endpoint for exercisetesting.

Average values of V02max, expressed as METs, expect­ed in healthy sedentary men and women can be pre­dicted from the following regressions Ao Men =

(57.8-0445 [age])/35; Women = (41.2-0.343[age])/35.

118

~ Box 6-1, continued

Also, see Table 4-8 for age-specific V02max norms.

Abbreviations: EC G, electrocardiographic; MI, myocardial infarction; SVT, supraventriculartachycardia; PVC, premature ventricular contraction; CAD, coronary artery disease; VT, ven­tricular tachycardia; HR, heart rate; MET, metabolic equivalent; SD, standard deviation; LV,

left ventricular; SBP, systolic blood pressure; DBP, diastolic blood pressure; VO'm", maxi­mal oxygen uptake.

ity to appropliately increase heart rate during exercise (chronotropic incompe­tence) is associated with the presence of heart disease and increased mortality.5.6A delayed decrease in the heart rate during the first minute of recovery « 12bpm decrease) after a symptom-limited maximal exercise test is also a powerfulpredictor of overall mortality.'

Achievement of age-predicted maximal heart rate should not be used as anabsolute test endpoint or as an indication that effort has been maximal, becauseof its high intersubject variability. The clinical indications for stopping an exer­cise test are presented in Box 5-2. Good judgment on the part of the physicianandlor supervising staff remains the most important criteria for terminating anexercise test.

ST-Segment Displacement

121CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA

ST-Segment Depression

• ST-segment depression (depression of the I point and the slope at 80 msecpast the I point) is the most common manifestation of exercise-induced

myocardial ischemia.• HOIizontal or downsloping ST-segment depression is more indicative of

myocardial ischemia than is upsloping depression.• The standard critelion for a positive test is 2:1.0 mm (1 mV) of horizontal or

downsloping ST segment 80 msec after the I point.• Slowly upsloping ST-segment depression should be considered a borderline

response, and added emphasis should be placed on other clinical and exercise

variables.• ST-segment depression does not localize ischemia to a specific area of

myocardium.• The more leads \'lith (apparent) ischemic ST-segment shifts, the more severe

the disease.• Significant ST-segment depression occurring only in recovery likely repre­

sents a true positive response, and should be considered an impOliant diag­

nostic finding. l6

• In the presence of baseline S1' abnormalities on the resting EGG, additionalST segment depression dUling exercise is less specific for myocardialischemia. In patients \\~th left bunule-branch block, ST-segment abnormali­ties that develop dUling exercise are uninte'1Jretable \vith respect to e\~dence

of myocardial ischemia. Ii In right bunule-branch block, exercise-induced ST­segment depression in the antelior precordial leads (VI, V2, and Vl) shouldnot be used to uiagnose ischemia; however, S1'-segment changes in the later­alleads (V4, \1.5, and V(;) may be indicative of ischemia even in the presence ofthis conduction abnormality. Ii

• Adjustment of the ST segment relative to the HR may pro~ue additional diag­nostic information. Thc ST/HR index is the ratio of the maximal ST segmentchange to the maximal change in HR from rest to peak exercise. An ST/HRindex of 2:1.6 is defined as abnormal. The ST/HR slope evaluates the maximalslope relating the amount of the ST segment depression to HR duling exer­cise. An ST/HR slope of >2.4 mVlbeatimin is defined as abnormal. Severalstudies have addressed the diagnostic value of these ST/H R vaJiables, 18-20 but

• ST-segment elevation (early repolaJization) may be seen in the normal restingEGG. Increasing HR may cause these elevated ST segments to return to the

isoelectric line.• Exercise-induced ST-segment elevation in leads displaying a pre~ous Q wave

infarction may be indicative of wall motion abnormalities or ventiicularaneurysm. 14

• Exercise-induced ST-segment elevation on an othenvise normal EGG (exceptin aVR or VI - 2) generally indicates significant myocardial ischemia, and local­izes the ischemia to a speciflc area of myocardium15

• ST-segment elevation indicates myocardial injUly (i.e., an acute transmuralinfarction) when followed by the evolution of significant Q-waves.

ST-Segment Elevation

NormalAbnormal

80 msec

,,- - - ... ... !*-'- - - 2.0 mm--,--

UpslopingClassic

... --------,

SECTION II/EXERCISE TESTING

, ..o....-...I--t7"-- L;.'-...:·~--...J.__jI__J.---_J_."L:...-~--~

2.0

4.0

15

5

20

l/l...Q)-Q) 10E

:iE

120

• Dcprcssion of the J pointHatc-rclated shortening of the Q1' interval

Howe\'er, some changes in EGG wave mOI1Jhology may be indicative ofunderl)~ng pathology. For example, although QRS duration tends to decreaseslightly \\~th exercise (and increasing HR) in normal subjects, it may increase inpatients with either angina or left vcntricular dysfunction. Exercise-induced Pwavc changes are rarely scen and arc of questionable significancc. Many factorsaffcct R-wave amplitudc; consequently, such changcs during cxercisc 'havc noindependent predictivc power. l2

S1'-scgment changes are \\~dely accepted criteria for myocardial ischemia andinjury. The interprctation of ST segments may be affected by the resting ECGconfiguration (e.g., bundle-branch blocks, left ventricular hypelirophy) and phar­macologic agents (e.g., digitalis therapy). There may bc I-point depression andtall pcaked T-waves at high exercise intensities and during recovelY in normalsubjccts. Depression of the I point that leads to marked ST-scgmcnt upsloping iscauscd by competition between normal repolarization and delayeu tcrminaldepolarization forces rather than to ischemia. 13 Exercise-induceu myocardialischemia may be manifesteu by different types of ST-segment changes on theEGG, as shown in Figurc 6-1.

FIGURE 6-1. ST segment changes during exercise. Classic ST segment depression (firstcomplex) is defined as a horizontal of downsloping ST segment that is 2: 1 mm belowthe baseline at 80 msec past the J point. Slowly upsloping 5T-segment depression (sec­ond complex) should be considered a borderline response, and added emphasis shouldbe placed on other clinical and exercise variables.

ST-Segment Normalization or Absence of Change

the findings have been inconsistent and preclude a strong recommendationregarding their utility.

• Ischemia may be manifested by normalization of resting ST segments. ECGabnormalities at rest, including T-wa\'(:, inversion and ST-segment depression,ma\' return to normal dming anginal S\'lllptOIllS and dming exercise in somepatients.:>·21

123CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA

LIMITING SIGNS AND SYMPTOMS

Although patients \~th exercise-induced ST-segment depreSSion can he asymp­tomatic, when concomitant angina occurs, the likelihood that the ECG changesresult from CAD is Significantly increased.22 In addition, angina pectOJis lcitholltischemic ECG changes may be as predictive of CAD as ST-segment changesalone.23 Both are currently considered independent vmiables that identifypatients at increased lisk for subsequent coronary events.

GAS EXCHANGE AND VENTILATORY RESPONSES

SECTION II / EXERCISE TESTING122

Dysrhythmias

Exercise-associated dysrhythmias occur in healthy subjects as well as patients\\~th cardiac disease. Increased sympathetic drive and changes in extracellularand intracellular electrolytes, pH, and oXYgen tension contribute to disturbancesin myocardial and conducting tissue automaticity and reentlY, which are majormechanisms of dysrhythmias.

Supraventricular Dysrhythmias

Isolated premature atrial contractions are common and require no special pre­cautions. Atrial flutter or atlial fibrillation may occur in organic heart disease' ormay reflect endocrine, metabolic, or drug efrects. Sustained supraventriculartach)'cardia occasionally is induced by cxercise and may require pharmacologictreatment or electroconversion if discontinuation of exercise fails to abolish therh)thm. Patients who experience parox;'smal atrial tachycardia may be evaluatedby repeating the exercise test after appropliate treatment.

Ventricular Dysrhythmias

Isolated premature vcntlicular complexes or contractions (PVCs) occur duringexercise in 30% to 40% of healthy subjects and in .50% to 60% of patients \\~th

CAD. The presence of ventlicular ectopy during exercisc testing was observed ina large series of patients undergOing exercise testing in a Single clinicallaborato­ry. Among 29,244 patients, 3% had frequent ventricular ectopy (>7PVCs/minute) only during exercise, 2% dllring exercise and rccoveJY, and 2%only during recovely. Frequent isolated PVCs were obselved in 3%, ventricularbigeminy in ]%, cach of ventricular trigeminy, couplets and triplet in <J %, non­sustained vcntrieular tachycardia «30 seconds in duration) in 0.6%, and sus­tained ventricular tachycardia (>30 seconds in duration) in 0.01 %24 In someindividuals, graded exercise induces PVCs, whereas in others it reduces theiroccurrence. Criteria for terminating exercise' te'sts based on ventricular ectopyinclude sustained ventricular tachycardia, as well as multiloeal PVCs, and tripletsof PVCs. The decision to terminate an exercise test should also he influenced I)\'simultaneous e\~dence of myocardial ischemia andlOl' adverse signs or symptom's(see Box .5-2).

Gas exchange and ventilatory responses should be used to assess patient effOltduring an exercise test, especially when a reduction in maximal exercise capaCityis suspected. Submaximal efforts from the patient can interfere \~th the inter­pretation of the test results and subsequent patient management. Jn the absenceof untoward signs or symptoms, patients should be encouraged to give their besteffort so that maximal exercise tolerancc can be determined. Maximal or peakoxygen uptake (V02peak) provides important information about cardiovascular fit­ness and prognosis. Population-specific nomograms (see Fig. .5-1) and/or popula­tion norms (see Table 4-8) may be Ilsed to compare \1021"'ak with the expectedvalue fiJI' a given age, gender, and activity status.

Various objcetive and subjective indicators can be used to confirm that a max­imal effort has been elicited during graded exercise testing:

• Failure of HR to increase \~th further increases in exercise intensity.• A plateau in oxygen uptake (or failure to increase oxygen uptake by 1.50

mL·min1) \~th increased workload. 2~ This criterion has f~lllen into somedisfavor because a plateau is inconsistently seen during continuous gradedexercise tests and is confused by vatious definitions and how data are sampledduring exercise.2,s

• A respiratOly exchange ratio> ] .1; however, there is considerahle interindi­\~dua] variability in this response.

• A postexercise venous lactic acid concentration of >8 mmol also has beenused; however, there is great interindi~dua]vmiability in this response.

• A rating of perceivecl exertion> 17 on the 6 to 20 scale or >9 on the 0 to 10scale.

Gas exchange and ventiiatOlY responses often are used in clinical settings as anestimation of the point where lactate accumulation in the blood ocelli'S, sometimesreferred to as the lactate or anaerobic threshold. Several different methods using?oth gas exchange and ventilatOlY responses have been proposed for the estima­tion of this point. These includc the ventiJatOlY equivalents method26.27 and the Vslope method.28 Whichever method is used, it should be remembered that the uscof any of these methods prO\~des only an estimation and the use of these methodsis eontroversiaJ.29

..30 Because exercise beyond the lactate threshold is associatedwith metabolic acidosis, hyperventilation, and a reduced capaCity to perform work,its estimation has evolved into a useful phYSiolOgiC measurement when evaluatinginterventions in patients \\~th heatt and puJmonmy disease as well as studying thelimits of performance in healthy individuals.

SENSITIVITY

Diagnostic Value of Exercise Testing

125

. I.

CHAPTER 61 INTERPRETATION OF CLINICAL EXERCISE TEST DATA

• Failure to reach an ischemic threshold• Monitoring an insufficient number of leads to detect ECG changes• Failure to recognize non-ECG signs and symptoms that may be associ­

ated with underlying coronary artery disease (CAD) (e.g., exertional

hypotension)• Angiographically significant CAD compensated by collateral circulation

• Musculoskeletal limitations to exercise preceding cardiac abnormalities

• Technical or observer error

PREDICTIVE VALUE

SPECIFICITY

The specificity of exercise tests refers to the percentage of patients \\1thout CADwho demonstrate nonsignificant (i.e., negative) ST segment changes. A true neg­ative test correctly identifies a person \\1thont CAD. Mam' conditions mav causeabnormal exercise ECG responses in the absence of significant obstructive coro­nary aIielY disease (Box 6-4). Reported valucs for the speCifiCity and sensitivity ofexercise ECG testing v,uy because of differences in patient selection, test proto­cols, ECG criteria for a positive test, and the angiographic def'inition of CAD. Instudies that controlled for these variables, the pooled results show a sensitivity of68% and a speciflcity of 77% I

determined coronary artery stenosis of 70% or more in at least one vessel. A truepositive exercise tcst reveals ST-segment depression of 1.0 mm or more and cor­rectly identifies a patient with CAD. False-negativc test results show no or non­diagnostic ECG changes and f~lils to identify patients with underlying CAD.

Common factors that contribute to r~tlse-negative exercise tests are summa­Jized in Box 6-3. Tcst sensitivity is decreased by inadequate myocardial stress,drugs that attenuate cardiac demands to exercise or reduce myocardial ischemia(e.g., f3-blockers, nitrates, calcium channel blocking agents), and insufficientECG lead monitoring. The use of right precordial leads along with the standardsix left precordial leads during exercise electrocardiography may improve thcsensitivity of exercise testing in the detection of CAD,:J2 although this has notbeen demonstrated consistently. Prcexisting ECG changes, such as left ventricu­lar hype'irophy, left bundle-branch block, or the preexcitation S)llllrome (Wolff­Parkinson-White syndrome), limit the ability to intel1Jret exercise-induced ST­segment changes as ischemic ECG responses.

The predictive value of exercisc testing is a measure of how accurately a testresult (positive or negative) correct!v identifies the presence or absence of CADin tested patients. For examplc, the predictive value of a positive test is the per­centage of those persons with an abnormal test who hm'e CAD. :--1e\'elthcless, atest should not be classiHed as "negative" unless the patient has attained an ade-

SECTION III EXERCISE TESTING124

Sensitivity = TP/(TP + FN) = the percentage of patients with CAD whohave a positive test

Specificity = TN/(TN + FP) = the percentage of patients without CAD whohave a negative test

Predictive Value (positive test) = TP/(TP + FP) = the percentage of patientswith a positive test result who have CAD

Predictive Value (negative test) = TN/(TN + FN) = the percentage ofpatients with a negative test who do not have CAD

Abbreviations: TP. true positive (positive exercise test and coronary artery disease [CAD]);FP, false positive (positive exercise test and no CAD); TN, true negative (negative exercisetest and no CAD); FN, false negative (negative exercise test and CAD).

In addition to estimating when blood lactate values begin to increase, maximalminute ventilation (VEmaJ can be used in conjunction with the maximal volun­taIy ventilation (MVV) to determine if there is a ventilatory limitation to maximalexercise. A comparison between the VEn"" and the MVV can be used when eval­uating responses to a graded exercise test. The relationship between these meas­ures, typically referred to as the ventilatOlY reserve, traditionally has beendefined as the percentage of the MVV achieved at maximal exercise (i.e., theVEm<"/MVV ratio). In most normal subjects this ratio ranges from 50% to 8.5%.3\Patients with pulmonary disease typically have values >8.5%, indicative of areduced ventilatOlY reserve and a possible pulmonary limitation to exercise.

The diagnostic value of conventional exercise testing for the detection of CAD isinfluenced by the principles of conditional probability (Box 6-2). The factors thatdetermine the predictive outcome of exercise testing (and other diagnostic tests)are the sensitivity and specificity of the test procedure and the prevalence ofCAD in the population tested. Sensitivity and specificity determine how effectivethe test is in making correct diagnoses in individuals with and without disease,respectively. Disease prevalence is an impOliant determinant of the predictivevalue of the test. Moreover, non-ECG criteria (e.g., duration of exercise or max­imal MET level, hemodynamiC responses, symptoms of angina or dyspnea)should be considered in the overall interpretation of exercise test results.

Sensitivity refers to the percentage of patients tested with known CAD whodemonstrate significant ST segment (i.e., positive) changes. Exercise ECG sensi­tivity for the detection of CAD usually is based on subsequent angiographically

COMPARISON WITH IMAGING STRESS TESTS

127

IPrognosis I IExerciseIAverage Exercise

5-year annual METssurvival mortality

20None 0.99 0,2%0.96 0.4% 17

0.95 1% 13Nonlimiting 0.93 1.5% 10

0.90 2%0.85 ~% 70.80 %

Exercise- 8~8 g~ 5limiting 0.55 9% 0

CHAPTER 6/ INTERPRETATION OF CLINICAL EXERCISE TEST DATA

FIGURE 6-2, Duke Nomogram uses five steps to estimate prognosis for a given individualfrom the parameters of the Duke score. First, the observed amount of ST-depresslon IS

marked on the ST-segment deviation line. Second, the observed degree of angina IS

marked on the line for angina, and these two points are connected. Third, the POll1twhere this line intersects the ischemia reading line is noted. Fourth, the observedexercise tolerance is marked on the line for exercise capacity. Finally, the mark on theischemia reading line is connected to the mark on the exercise capacity line, and theestimated 5-year survival or average annual mortality rate is read from the pOint atwhich this line intersects the prognosis scale.

1 mm

3mm

2mm

ST-Segmentdeviationduring

exercise

Omm

4mm

clinical factors contlibute to patient outcome, including severity and stability ofsymptoms; left ventricular function; angiographic extent and seventy of CAD;electlical stability of the myocardium; and the presence of other comorbld con­ditions, Unless cardiac cathetelization and immediate coronmy revasculanzatlOnare indicated, an exercise test should be performed in persons with known or sus-

t d CAD to assess lisk of future cardiac events, and to assist in subsequentpece 'df' h ,,'management decisions, As stated in Chapter 5, data denve ,r~m ,t e exelclsetest are most useful when considered in the context of other chl1lcalmformatlOn,ImpOltant prognostic vaJiables that can be delived from the exercise test are

summarized in Box 6-1.Use of the Veteran's Administration score36 (validated for the male veteran pop-

ulation) and the Duke nomogram37 (validated for the general population, includingwomen) (Fig, 6-2) can be helpful when applied appropIiately. Th;s Duke nomo­gram does not appear to be valid in patients more th,an 75 years old, Pa~ents whorecently have suffered an acute myocardial mfarcbon and receiVed tlliombolytic

I'

SECTION II/EXERCISE TESTING126

Risk or prognostic evaluation is an impOltant activity in medical practice on whichmany patient management decisions are based. In patients with CAD, several

The overall senSitivity and specificity of exercise echocardiography ranges from74% to 97% and 64% to 94%, respectively, \vith higher sensitivities observed inpatients with multivessel disease.33 Exercise with concomitant nuclear imagingusing technetium (Tc99m) agents has shown similar accuracy to those using thal­lous (thallium) chloride-20l agents in the detection of myocardial ischemia. Forplanar imaging, the sensitivity and specificity of technetium agents have beenmeasured at 84% and 83%, compared \vith 83% and 88% for thallium agents. InSingle photon emission computed tomography (SPECT) imaging, the sensitivitiesand specificities were 90% and 93% for technetium agents, compared with 89%and 76% for thallium agents. In addition, when normal, reversible, and nonre­versible segments scanned with technetium and thallium agents are compared,there is 88% agreement "vith planar and 92% agreement \vith SPECT imaging.The sensitivity and specificity are similar for planar and tomographic nuclearimaging.34 ,35

quate level of myocardial stress, generally defined as having achieved 85% ormore of predicted maximal heart rate during the test. Predictive value cannot beestimated directly from a test's specificity or sensitivity because it depends on theprevalence of disease in the population being tested.

• Resting repolarization abnormalities (e.g., left bundle-branch block)• Cardiac hypertrophy• Accelerated conduction defects (e.g., Wolff-Parkinson-White syndrome)

• Digitalis• Nonischemic cardiomyopathy• Hypokalemia• Vasoregulatory abnormalities• Mitral valve prolapse• Pericardial disorders• Technical or observer error• Coronary spasm in the absence of significant coronary artery disease

• Anemia• Female gender

'Selected variables simply may be associated with rather than be causes of abnormal testresults.

PROGNOSTIC APPLICATIONS OF THE EXERCISE TEST

•

REFERENCES

therapy and/or have undergone coronary revasculatization generally have a lowsubsequent cardiac event rate. Exercise testing still can provide prognostic infor­mation in this population, as well as assist in activity counseling and exercise pre­sCliption.

Gibbous HJ, Balach- GJ, Blicker J, et a1. ACC/AIIA 2002 guideline update for exercise testing: a repOlt

of the Amelican College ofCard..iolog;JAmer;can Ile<111 Association Task Force on Practice Cuidelines(Committee on Exercise Testing). 2002. Ameliean College of Cardiology weh site. a\ailahle at:

\\'\\'\v.at'C.orWc1i nicaVgu idelineslexercise/di r1ndex. ht 111.

2. ~Iyers J, Froelicher "F. Hemodynamic determinants of" t''\en..'ise eapadty in chronic hemi failure. Ann

Intem ~Icd 1991; 115:31'1--386.3. ~IcKimau ~I D, Sulli'>ln .\1, Jensen D, et a1. Treadmill perfonllanc~' and carchac functiou in selected

patients "oth coron<ll)' heart disease. J Am Coli Cardiol J9f;..l;3:25J-261.4. Londeree BH, ~Ioeschberger ~,I L. Influence of age and other factors on maximal healt rate. J Cardiac

Hchab J984;(4)44-49.5. Ellestad M II. Chronotropic incompetence. TIle ilnplications of heali rate response to exercise (COlll­

pens,'tOl)' parasympathetic h)1)eracti\oty?). Circlilation 19%;93: 1-18.5-1487.

6. Laller MS, Francis CS, Okin PM, et al. Impaired chronotropic respollse to exercise stress testing as a

predictor of mortality. JAMA 1999;281:.524-,529.

7. Cole CH, Blackstone EH, Pashkow F.I, et al. Heart-rail' recovel)' immecliately after exercise as a pre­

dictor of' mortality. N Engl.l Mcd 1999;341: 13.51-13.57.8. Cnmess KA, Fenster PE. Clinical implications of' tl", blood prcssure response to exercise. Carruolog)'

1981;68:233-244.9. Irving JB, Bnlce RA, DeRouen TA. Variations in and significance of systolic pressure during IIl,LXimal

exercise (treadmill) testing. Am J CardioI1917:39:841-848.10. Weiner DA, Mc-Cabe CII, Cutler SS, et al. Decrease in s),stolic blood pressure dUliug excreise testing:

reproducibility, response to coronary bypass surgel)' and prognostic significance. Am J Cardinl

1982;49: 1627-1631.

II. Kitamura K, Jorgensen CR, Gobel FL, et a!. Hemocl)llamic correlates of m),ocardial O\')'gen con­

sumption dllling uplight exercisc. J Appl Ph)'siol 1972;32:516-522.12. Myers J, Ahn\'e S, Froelicher \', et al. Spatial R wmoe amplitude changes dllling exercise: relation with

left ventricular ischemia and function. J Am Coli Cardiol 1985;6:603-608.

13. Mil"is D~I, Hamanathan KB, Wilson JL. Hegional blood flow correlates ofST segment depreSSion in

tachycardia-induced mvocanlial ischemia. Circulation 1986;7,3:36.5-.373.

14. Bruce HA, Fisher LD, Pettinger ~I, et al. ST segment ele\'ation "oth exercise: a marker for poor \'en­tIicular function and poor prognosis. Coron",,, AI1er)' SurgeI')' Study (CASS) connrmation of Seattle

Ilel1lt Watch results. Circulation 1988;17:897-90.5.

15. :-Jostratian F, Froelicher "F. ST ele""tinn dllling exercise testing: a re\iew. Am J Carchol 1989;

63:986-988.16. Lachterman B, Lehmann KG, Detrano H, et aL Comparison of ST segment/hemt rate index to stan­

danl ST cJiteJia for analysis of exercise electrocardiogram. Circulation 1990;82:44--.50.

17. WhinnelY JE, Froelicher VF Jr, Longo ~IH Jr, et al. The electroearcliographie responsc to IIl'Lxilllaltreadmill exereixe of asymptomatic men with light bundle branch block. Chest 1917;71 :33.5--340.

18. Froelicher VF, Fearon WF, Ferguson CM, et al. Lessons learned from studies of the stanclard ex!'l'­cise ECG test. Chest 1999;116:1442-14.51.

19. Okin PM, Klignelcl P. lIel1lt rate adjustmcnt ofST segmc'nt depression and pcrformance of'the exer­

cise electrocardiogram: a critiC'll1 evaluation . .1 Am Coli Cardiol 1995;25:1726-]73.5.

20. Morise AP. Accuracy of healt rate-adjusted ST segments in populations with and without postlestrcferral bias. Am Ileart J I997;l::>4(4):647-6S.5.

21 Lavie Cj, Oh JK, Mankin HT, ct a!. Signillcance ofT-wave pseudouonnalization during exercisl'. A

rachonuclidl' angiographie study. Chest 1988;94:.512-.516.

22. Weiner DA, Byan Tj, McCahe CIl, ct ,J. Exercise stress testing Correlations among histon' of a"gi­na, ST-segment r(-'sponse and prevalence or coronary-artery disease in the Coronary Altery Surgery

Study (CASS). :-J Engl J Med 1979;301:23(}-2:}5

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23. Cole JP, Ellestad MH. Signincance of chest ["tin during treadmill exercise: eorrelation with eoronal)'

events. Am .I CarruoI1978;41:227-232.24. Taylor HI., Buskirk ER, Hensehel A. Maximal oxygen uptake as an objective measure of carruores­

piratory performance. J Appl Physiol 1955;8:73-80.25. :-Joakes TO. Challenging beliefs: ex Africa semper aliquid nO\o. Med Sci Sports Exere 1997;

29;5/1-590.26. Wasserman K, Whipp BJ, Ko)'1 SN, et aJ. Anaerobic threshold and respiratOl)' gas exchange during

exercise. J App! Physiol 1973;35:236-243.27. Cai07,z0 Yj, Davis JA, Ellis .IF, et al. A comparison of gas exehange inruees osed to detect the anaer­

obic threshold. J Appl Ph)siol 1982;53:118+-1189.28. Beaver WL, Wasserman K, Whipp B.I. A new method for detecting anaerobic threshold by gas

exchange. J Appl Physiol 1986;60;2020-2027.29. Brooks GA. Anaerobic threshold: review of the concept and cbrections for future research. Med Sei

Sports Exerc 198.5;17:22-34.30. Sue DY, Wasserman K, Moricca RB, et pJ. Metabolic aeidosis during exereise in patients with duon­

ic obstructive pulmonary rusease. Use of the V-slope method for anaerobic threshold determination.

Chest 1988;94:931-938.31. American Thoracic Society and American College of Chest Physicians. ATS/ACCP Statement on

cardiopulmonal)' exercise testing. Am J Respir Crit Care Med 2003;167:211-277.32. Michaelidcs AI', Psomadaki ZD, Dilaveris PE, et al. Improved deteetion of coronal)' artel)' rusease

by exercise electrocarruography with the use of right preeordial leads. N Engl J Med 1999;340:

340--34533. Chetlin MD, Alpert IS, Armstrong WF. ACC/AHA gUidelines lor the dinieal application of echocar­

diography: a rcport of the American College ofCardiology/Ameriean Heart Association Task Foree

on Practice Guidelines (Committee on Clinical Applieation of Eehocarruography). J Am Coil Cardiol

1.997;29;862-S79.34. Berman OS, Kiat H, Leppo J. Technetium-99m myoeardial perfUSion imaging agents. In: Marcus

ML, Schelbert HR, Skorton OJ, eds. Carchac Imaging: A Companion to Baunwald's Heart Disease.

Philadelphia; WB Saunders, 1997:1097-1109.35. Ritchie .IL, Bateman TM, Bonow RO. Guidelines for dinical use of carruac raruonudide imaging.

HepOlt of the American College of CarruologylAmelican Heart Association Task Force on Assessment

of Diagnostie and Therapeutic Carruovascular Procedures (Committee on Raruonoclide Imaging). J

Am Coli Carruol 1995;2.5(2):521-554.36. ~IOITOW K, Morris CK, Froelicher VF, et aJ. Precliction of eardiovascular death in men undergOing

noninvasive evaluation for eoronary artel} rusease. Ann Intem Med 1993;118:689-695.

37. Mark DB, Hlatky MA, Harrell FE J1', et a!. Exercise treadmill score for preructing prognOSiS in coro­

nary artel)' rusease. Ann Intem ~Ied 1987;106:793-S00.38. Kwok .1M, Miller TO, Hodge DO, et al. PrognostiC value of the Duke treadmill score in the elder­

Iv. J Am Coil Carruol 2002;39:1475-1481.39. \Vilkoff B, Miller R. Exercise testing for chronotropiC assessment. Cardiol Clin 1992;10:705-717.

40. Bruce RA, Kusumi F, Hosmer D. M'Lximal oxygen intake and nomographiC assessment of function­

al aerobic impairment in cardiovascular disease. Am Heart .11973;85:546-562.

SECTION II/EXERCISE TESTING128

Exercise Prescription

SECTION

III

133

The prin1alY focus on achic\'ing health-related goals has been on prescribingexercise for improvements in cardiorespiratory (CH) fitness, body composition,and muscular fitness. To hlcilitate change, the Centers for Disease Control(CDC) and American College of Sports \ledicine (ACSM) recommended that alladults in the United States should accumulate 30 minutes or more of moderate­intensity physical activity on most, and preferably all, days of the week I Thesuccess of exercise implementation is predicated on a willingness and readinessto change behavior. See the latter section of this chapter and Section 12 of theACSM's Resource Manual for Guidelines for Exercise Testing and Prescription(5th ed,) for additional information on behavior modification.

[n 1996, the United States Office of the Surgeon General (SGH) issued the firstreport on physical activity and health. This report concurred \\~th the CDC/ACSMrecommendations and concluded that people of all ages benefit from regularphysical activit)', I The SGH indicated that although health benefits improve \vithmoderate amounts of physical activity (1.5 minutes of running, 30 minutes of bliskwalking, or 45 minutes of pla)ing volleyball), greater benefits are obtaincd withgreater amounts of ph)'sical activity." [n October 2000, an international consensuscommittee conducted an evidence-based symposium that examined the dose­response of phvsical acti\~ty and health. The proceedings for this symposiumindicate ample e\~dence to suppOJi the beneficial effects of regular physical activi­ty on more than a dozen health outcomes.3 See Table 1-2 for a summary of thedose-response evidence, The panel suggested that, when assessing dose-response,consideration be given to not only the dose that induces the greatest health bene­fit, but also the potential risk in a particular population, They noted that the greaterintensity and volume of exercise, the greater the risk of injUly, especially muscu­loskeletal injury in general, and cardiovascular injul)' for those \\~th disease4

Hegular physical acti\~ty to enhance health benefits for all popillations is support­ed by numerous organizations and research. The Physical Activity Pyramid hasbeen suggested as one way to facilitate this objective (Fig. 7-1).

Some fitness profeSSionals \~ewed this recommendation as a major departurefrom the traditional ACSM exercise programming recommendations publishedin earlier editions of this text and various ACSM position stands. Others saw thenew recommendation as part of a continuum of physical activity recommenda­tions that meets the needs of almost all individuals to improve health status, Thelower end of the moderate intensity scale (40%-59% of heart rate reserve) can

CHAPTER

7General Principles ofExercise Prescription

Principles of Training

FIGURE 7-1. The Activity Pyramid. analogous to the USDA's Food Guide Pyramid, hasbeen suggested as a model to facilitate public and patient education for the adoptionof a progressively more active lifestyle. (The Activity Pyramid © 2003 Park NicolletHealth Innovations, Minneapolis, U.S.A. 1-888-637-2675. Reprinted with permission.)

improve fitness for many sedentary, overweight, or low-fitness indi\~duals. Thecombined ACSM/CDC and traditional ACSM recommendations represent a truecontinuum for one of the primary variables in exercise prescription; that is, theintensity of exercise. Those who follow the more recent recommendation L eX1Je­rience many of the health-related benefits of physical acti~ty, and if they areinterested in achieving higher levels of fitness, they \\~Il be ready to do so. Thischapter describes how to structure exercise prescriptions to achieve and maintainhealth and fitness goals.

135CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

Overview of the Exercise PrescriptionExercise prescriptions are designed to enhance physical fitness, promote healthby reducing risk factors for chronic disease (e.g., high blood pressure, glucoseintolerance), and ensure safety during exercise participation. Based on individualinterests, health needs, and clinical status, these common purposes do not carryequal or consistent weight. For the sedentm)' person at risk for prematurechronic disease, adopting a moderately active lifestyle (i.e., the ACSM/CDC rec­ommendation) may prO\~de important health benefits mld represent a moreattainable goal than achievement of a high VOZ•mv However, enhancing physicalfitness, whenever possible, is a desirable feature of exercise prescriptions. In allcases, specific outcomes identified for a particular person should be the ultimatetarget of the exercise prescription.

The essential components of a systematic, indi~dualized exercise prescriptioninclude the appropriate mode(s), intensity, duration, frequency, and progressionof physical acti~ty. These five components apply when developing exercise pre­scriptions for people of all ages and fitness levels, regardless of the individualhealth status. The optimal exercise prescription for an individual is determinedfr9m an objective evaluation of that person's response to exercise, includingobservations of heart rate (HH), blood pressnre (BP), subjective response to exer­cise (RPE), electrocardiogram (ECG) when applicable, and VOZmax measureddirectly or estimated during a graded exercise test. As discussed in Chapter 2, ahealth/medical screening helps determine the necessary or recommended evalu­ation before beginning a physical conditioning program. However, the exerciseprescription should be developed with carcful consideration of the individual'shealth status (including medications), risk factor profile, beha\~oral characteris­tics, personal goals, and exercise preferences.

the interaction of these variables results in the cumulative overload to which thetissue or organ must adapt.

The principle of specificity states that training effects derived from an exerciseprogram are specific to the exercise performed and muscles involved. For example,running improves VOZm"x through both central circulation and peripheral muscleadaptations; however, this results in limited carryover for s\\~m performance.5

AJthough numerous modes of aerobic exercise can prO\~de a general adaptation ofthe myocardium, changes in oxygen extraction and delivel)' at the muscle site arespecific to the muscle recruited and intensity of exercise6 The training effect, spe­cific to the muscles recruited, is exemplified bv different modes of aerobic exercisethat produce different outcomes, despite exercising at the same percentage ofVOZIll"x or rating of percei\'ed exeltion (RPE)' Consequently, a fitness programthat involves a wide variet)' of exercises and recruits most of the m,~or musclegroups increases the likelihood that the training effect may transfer to vocationaland recreational acti~ties. Conversely, if the goal is to improve one specific acti\~­

ty, the physical acti~ty should focus on that acti~ty.

The individual rate of progression in response to similar stimuli can val)'significantlyS Gcnetic characteristics and hcalth status are responsible for thedifferent response rates. Some individuals may be classified as responders versllsnonresponders based on different changes to similar stimuli.

ENJOY RECREATIONALSPORTS• tennis

• racquetball• basketball

DO AEROBIC ACTIVITIES• long walks

• biking• swimming

I EVERYDAY I• take extra steps in your day

• walk the dog• take the stairs instead ot the elevator• park your car farther away and walk

SITSPARINGLY• watch TV

• play computer

" games

12-3 TIMESIWEEK IENJOY LEISURE STRETCH!

ACTIVITIES STRENGTHEN• golf • curl-ups

'\. • bowling • push-ups" • ,;,.ya"Trd_w_o_rk__.l.,-_.w..e..ig;:.hrt_Iift_in..:;g _

13-5 TIMESIWEEK I

THE ACTIVITYPYRAMID

Start your weekly activity plan with the daily activities at the base of the pyramid.Enhance your fitness by choosing other activities on the pyramid. Move more, sit less.

\

SECTION III / EXERCISE PRESCRIPTION134

The health-related physical fitness components identified and evaluated inChapter 4 included body composition, CR fitness (VOZm",), muscular strength,muscular endurance, and flexibility. Improvements in the final four componentsfollow the two major principles of training progression: overload and specificity.The principle of progressive overload states that for a tissue or organ to improveits function, it must be exposed to a stimulus greater than it is normally accus­tomed to. Repeated exposure is associated \\~th an adaptation by the tissue ororgan that leads to improved functional capacity and/or efficienc),. An exerciseprescription specifies the mode, intensity, duration, and frequency of training;

The Art of Exercise Prescription

Components of the Training Session

137

yStop

exercise5040302010

HRR 85% = 155 beats,min-1

: Warm-up l'l:.f---- Endurance ----l.~:Cooldown: Recovery,(10-20 min), (20-60 min) 1(5-10 min),I I I I

, , Maximum =170 beats·min-1 , 1

Startexercise

Resting

CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

200

- 180,....l:::E 160

III- 140COQ).0- 120Q)-CO"- 100-"-COQ)

J: 80

60

The sequence of performing endurance or resistance training is a personal prefer­ence \\~thout a scientific mandate,

WARM-UP

Minutes of exerciseFIGURE 7-2, Format of a typical aerobic exercise session illustrating the warm-up,endurance, and cool-down phases along with a representative heart rate response, Atthe conclusion of warm-up, heart rate approached the lower limit of the target zonefor training, corresponding to 70% to 85% of the peak heart rate reserve achievedduring maximal exercise testing,

Warm-up facilitates the transition from rest to exercise, stretches postural mus­cles, augments blood flow, elevates body temperature, dissociates more oxygen,and increases the metabolic rate from the resting level (1 MET) to the aerobicrequirements for endurance traininglO A warm-up may reduce the susceptibilityto musculoskeletal injury by increasing connective tissue extenSibility, impro~ngjoint range of motion and flmction, and enhanCing muscular performance,llA preliminary warm-up also may have preventive value, decreasing the occur­rence of ischemic ST-segment depression, 12.1,3 threatening ventricular dysrhyth­mias, and transient global left ventricular dysfunction follo\~ng sudden strenuousexertion14

,15 However, studies in healthy subjects and postmyocardial infarctionpatients who were taking l3-blockers have failed to confirm these cardiovascularabnormalities during sudden strenuous exercise,lo,n

The exercise session should begin with 5 to 10 minutes of low-intensity largemuscle activity (10% to 30% \'02R) and progress to an intensity at the lower limitprescribed for endurance training, For example, participants who use brisk walk­ing during the endurance phase might conclude the warm-up period with slowwalking, Similarly, brisk walking serves as an ,ideal warm-up to for participantswho jog slowly dUJing the endurance phase, The stretching acti~ties may be

SECTION III/EXERCISE PRESCRIPTION136

The guidelines for e:o.ercise prescription presented in this book are based on asolid foundation of scientific information, Gi\'en the di\'erse nature and healthneeds of the population, these guidelines cannot he implemented in an overlyrigid f~lshion by simply applying mathematical calculations to test data, The red­oml1lendatiolls presented should be used \\~th carcful attention to the goals of theindividual. Excrcise prcscriptions recluirc modification in accordanc:e \I~th

observed individual respouses and adaptations because of thc following:

• Physiologic and perc:eptwJ resjJonses to acute exercise l'aJY amona indi\'idu-/ b

als and within an indi\idual performing differcnt t\1Jes of exercise, There is aneed to adjust the intensit\' and duration of exercise and monitor lIR BPHPE, and, whcre appropri,~te, ECG responses to achie\'e a safe and eH;cti\'~e:o.ercise stimulus,

• Adaptations to exercise training vary in terms of magnitude and rate of devel­opment, and are dependent on health status and genetic potential. Progresssl~ould be monitored by checking HH and HPE responses to allow finc-tuningof the exerc:ise stimulus,

• Desired outcomes based on individual nced(s) may be achieved with exerciseprograms that vary considerably in structure, so onc should address individualinterests, abilities, and limitations in the deSign of thc program,

A fundamental objecti\'e of excrcise prescription is to bring about a change inpersonal health behmior to include habitual phYSical acti\'ity, Thus, the mostappropriate exercise prescription for a particular indi\idual is the onc that is mosthelpful in achie\ing this behmioral change, The art ofexercise prescription is theslicces,ljlll integration ofexercise science leith behal)ioral techniqlles that resliit in

long-term program compliance and attainment of the indil)idllal's goals, As such,knowledgc of methods to change hcalth behaviors is essential and is addressedlater in this chapter, Although an abllndance of Iitemture exists on this topic, anexcellcnt source is Section ,5 of the ACSM's Resource Manllal for GllidelinesforExercise Testing and Prescription (.5th eel.)9

Once the exercise prescription has been fonnniated, it is integrated into a compre­henSl\'e phYSical conditioning program, which generally is complemented by anm'erall health impro\'ement plan, The format for the exercise scssion shouldinclude a warm-up period (approximatcly ,5 to 10 minutes), a stimulus or condi­tioningphase (CR, Oexibility, resistance tmining) (20 to 60 minutcs), an optionalrccreatlonal game (proVides variety), ane! a cool-down period (5 to 10 minutcs)(Fig, 7-2), All tmining (p,g" CR, resistance, flexibility) should be prescribed inspeCific terms of in~cnsity (how difflcnlt), duration (how long), frequency (howoften), and t:1Je of acti\ities,~ FleXibility training can be included as part ofth,e warm-up or cool-do\\~l, or undertakcn at a separate time, Resistance trainingoften IS performed on aitelllate da,'s when endurance tminina is not' however both

~ h"

acti\ities can be combined into the same workout, Cardiorespiratory, Oexibilitv, andresistance training should be integral parts of a comprehensi\'e tr:aining pra'gram,

138 SECTION III/EXERCISE PRESCRIPTION

conducted after the initial large muscle warm-up and should stretch the majormuscle groups using static techniques. Dynamic stretching or modified proprio­ceptive neuromuscular bcilitation techniqlles or combinations thereof also canbe incorporated into the latter portion of the warm-1lpIl Generally low-intensitystretching is preferred before vigorous endurance activity. Stretching (flexibility)exercises performed as part of the warm-up may primarily have an acute effect,whereas flexibility performed during the cool-down may provide a more long­term benefit. Stlldies to confirm this hypothesis are lacking.

STIMULUS OR CONDITIONING PHASE

The stimulus (conditioning) phase includes CR (endnrance), resistance, andflexibility programming. Depending on the individual's goals or outcomes; one,two, or all program areas can be included. A comprehensive program shollldinclude all three conditioning components. Figure 7-2 depicts a typical exercisetraining session with the CR phase exemplified. Later sections of this chapterfocus on exercise programming by CR conditioning, resistance training, andflexibility training.

RECREATIONAL ACTIVITIES

Activities like golf are unlikely to elicit a cardiovascular training effect for fltindividuals, but are enjoyable, have definite recreational value, and may yieldhealth-related benefits. The inclusion of enjoyable recreational activities dming(or immediately after) the endurance phase may enhance adherence. However,game rules may be modified to decrease skill requirements, competition, energycost, and heart rate responses to play. Game modifications should maxlImze theexperience of successful participation; winning or losing should be of lesserimportance. 18 Because of a potential discordance between RPE and IIR dnringgame activities, the latter should be monitored periodically to adjust the intensi­ty of play. The imaginative exercise leader may suggest a smaller court Size,lowered net height, freqllent player-position rotation, intermittent rest periods,minor rule changes, and adjusted scoring. For example, playing volleyball whileallowing one bounce of the ball per side facilitates longer rallies, pro.vides addi­tional fun, and reduces the skill required to play the game sllccessllllly. Ma.IlYother team games and individual sports can be modified in a similar fashion. IH

COOL-DOWN

The cool-down period provides a gradual recovery from the endurance/gamesphase and includes exercises of diminishing intensities; for example, approximate­ly.5 minutes of slower walking or jogging, cycling and approximately .5 minutes ofstretching exercises, and in some cases, alternate activities (e.g., yoga, tai chi, relax­ation training). The cool-down is critical to attenuate the exercise-induced circula­tOlY responses and return HR and BP to near resting values; maintain adequatevenous return, thereby reducing the potential for postexercise hypotension and.dizziness; hlCilitate the dissipation of body heat; promote more rapid removal 01lactic acid than stationaJy recovely; and combat the potential, deleteriolls effectsof the postexercise rise in plasma catecholamines. 18 The attenuation of the

CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 139

catecholamine response, especially in patients with heart disease, may reducc thelikelihood of threatening ventricular dysrhythmias, which are potential harbingersof sudden cardiac death.

Omission of a cool-down in the immediate postexercise period theoreticallyincreases the opportunity for cardiovascular complications. Presumably, the sud­den termination of exercise results in a transient decrease in venous return,possibly reducing coronary blood flow when HR and myocardial oxygen demandsstill may be high. Conseqnences may include ischemic ST-segment depreSSIOn,with or without anginal symptoms (e.g., back pain, diffuse ann pain, throat pain),serious ventricular dysrhythmias, or combinations thereof. Cool-down is a criticalingredient of a comprehensive, safe program for both healthy participants, as wellas patients with disease.

Cardiorespiratory Exercise PrescriptionThis phase develops CR and local muscle fltness. CardiorespiratOlY fitness, V02m""

aerobic capacity, and cardiovascular fltness are used synonymously. These termsrefer to the maximal capacity to produce energy aerobically and usually areexpressed in METs or mL Oz·kg- J ·min- 1 CardiorespiratOlY endurance, aerobicendurance, or cardiovascular endmance refers to the ability to persist or continuein strenuous activity reqlliring large-muscle groups for prolonged time.

Improvements in the ability of the heart to deliver (J},ygen (Oz) to the workingmuscles and in the muscle's ability to generate energy with Oz result in increasedCR fitness. Alteration in CR fitness is measured by assessing the change in VOZn"",

which is related to a minimal threshold of frequency, duration, intensity, and vol­ume of exercise.H.ZO.ZI Because of heterogeneity in the response to an exercisestimulus, aerobic endurance training below a minimal threshold (20% HRR or .50%max HR) may be sufflcient for developing aerobic fitness in healthy adults, whohave a low V02m"x «30 mL'kg- J 'min- J )2Z The training-induced increase inVOZ,m1x, which generally ranges from .5% to 30%, may be proportional to the qual­ity of the stimulus above the minimal threshold. Genetics also influence the mag­nitude and rate of change. Indi\~duals \\~th low initial levels of fitness, such as car­diac patients and those experiencing concomitant reductions in ?ody weight and fatstores, generally demonstrate the greatest percent increase in VOZon",. In contrast,more modest increases occur in healthy individuals V\~th high initial levels of fitnessand in those whose body weight remains unchanged. I I

MODE OF EXERCISE

Exercises for the endurance phase employ large muscle groups in activities thatate rhythmiC or dynamiC in nature. Sports such as tennis, racquetball, handball,and basketball also have aerobic conditioning potential if they are pursued for asufficient duration and intensity. Using a constant mode (type) of exercise forboth testing and training provides ideal speCifiCity, and is the most a~curate

measure of change in oxygen consll1nption. The greatest improvement in V02n ""

occurs when exercise involves the use of large muscle groups over prolongedperiods in activities that are rhythmic and aerobic in nature (e.g., walking, hiking,running, machine-based stair climbing, swimming, elliptical activity, cycling,

Group 2Activities in which the rate of energy expenditure is highly related to skill,but can provide a constant intensity for a given individual. Such activities alsomay be useful in the early stages of conditioning, but individual skill levelsmust be considered. Examples include swimming and cross-country skiing.

141CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

EXERCISE INTENSITY

Intensity and duration of exercise determine the total caloric expenditure duringa training session, ancl are inversely related. for e,ample, imprm'ements in healthrelated benefits may be achieved by a low-intensity, longer-duration regimen,whereas improvemcnts in CR fitness (\102maJ are associated with a higher­intensity, shorter-duration program. 12 The risk of orthopediC injury is purportedto be il;creased with the latter; however, programs emphaSizing moderate to \~g­

orous exercise with a longer training duration (>20 minutes) are recommendedfor most individuals." Improvements in \102ma.\ can occur with a high-intensitystimulus and low duration «10 minutes),20 21 but this training should bereserved for asymptomatic, apparently healthy, and highly motivated individuals.The ACSY[ recommends an intensity of exercise corresponding to 40% and 50%(40%/50%) to 850/< of' Q;\'\'gen uptake reserve (\'02R) or heart rate reserve (I-IHR),

, . () 1129 1'\or 64% and 70% (64%170%) to 94% of maxunum heart rate I-IRma\,' 1eVO,H is the diff'erence between V02""" and resting V02. Similarly, the HHR isthe-difference between HRma\ and resting HI\. \Vhen exercise intensities arc setaccording to \102R, the percent values are apprOXimately equal to the percentvalues for the HRR, 11,:30 Consequently, use of the V02H improves the accuracyof calculating a target V02 from a HRH prescription, especially for low-fit clients,but does not alter the current methods of calculating target heart rates.

The intensity range to increase and maintain CH fitness is intentionally broadand reflects the fact that low-fit or deconditioned indi\~duals may demonstrateincreases in CH fitness with exercise intensities of only 40% to 49% I-lRR or 64%to 70% HR m,,,. For inchiduals with \'02m,,, below 40 mL' kg "min ~ I, a mini malint.ensity of 30% \102R can elicit impro\'ement in \'02m,,,· In contrast, indi\idualswith greater CH fltness (>40 mL'kg I 'min-I) require a minimal threshold of45% V02R.22 Those who are already physically active (in aerobic actiVity) requireexercise intensities at the high end of the continuum to further augment their CRfitness. For most indi\~duals, intensities \\~thin the range of 60% to 80% HRH. or77% to 90% HHn"C\ are sufficient to achieve improvements in CR fitness whencombined \\~th an appropriate frequency and duration of training. These rangesof exercise intensities have been successful for increasing \'02",a\ in participantsin primaly and secondmy prevention programs.:ll ·:33

50% IlRR or 70% HR max in oldcr adults (>50 \'ears of age).27.2" Manvindi\'iduals might logically progress through walking and jogging programsbefore engaging in group 2 and 3 activities.

The risk of injury associated with high-impact activities or highly repetitivetraining also must be considered when prescribing exercise modalities, especial­ly for the o\'crweiaht or no\'ice exerciser. It m<l\' he desirable to ha\'e the indi\'id-o .ual cross train (engage in se\'eral different acti\'ities) to reduce repetith'eorthopediC stresses and involve the greatest nu mber of' muscle groups. Becauseimpro\'ement in muscular function is largeh- speCific to the muscles in\uh-ed inexercise, it is important to consider uniquc \'oeational or recreational objecti\'esof the exercise program when recommending activities. Finally, if' pOSSible, oneshould deSign programs to eliminate or attenuate barriers that might decrease thelikelihood of compliance with, or lldherence to, the e,ercise program.

, I

SECTION III / EXERCISE PRESCRIPTION

, '.....':liBOX 7-1 Grouping!of

~ :·il'

140

Group 1Activities that can be readily maintained at a constant intensity and interindi­vidual variation in energy expenditure is relatively low. Desirable for moreprecise control of exercise intensity, as in the early stages of a rehabilitationprogram. Examples of these activities are walking and cycling, especiallytreadmill and cycle ergometry.

Group 3Activities where both skill and intensity of exercise are highly variable. Suchactivities can be very useful to provide group interaction and variety in exer­cise, but must be employed cautiously for high-risk, low-fit, and/or sympto­matic individuals. Competitive factors also must be considered and mini­mized. Examples of these activities are racquet sports and basketball.

rowing, combined upper and lower body ergometry, dancing, skating, cross­country skiing, endurance games). Clearly, this wide range of activities providesfor individual variability relative to skill and enjoyment, factors that influencecompliance to the exercise program and thus desired outcomes. Box 7-1 groupscommonly prescribed activities by the consistency of the exercise intensity. In thedevelopment of the exercise prescription for the novice exerciser, it may be use­ful to begin with group 1 activities and progress depending on the individual'sinterest, adaptation, and clinical status.

Walking may be the activity of choice for many individuals because it isreadily acceSSible, offers tolerable exercise intensity, and is an easily regulatedexercise for improving health outcomes and CR fitness. Even extremely slowwalking «2 mph) approximates 2 METs and may impose metabolic loads suf­ficient for exercise training in lower-fit subjects. 23 Brisk walk training programsproVide an activity intense enough to increase aerobic capacity and decreasebody weight and fat stores in previously sedentary, middle-aged men.24

Variations of conventional walking training, including walking with a3- to 6-kg backpack load25 and swimming pool walkini6 offer additionaloptions for those who wish to reduce body weight and fat stores, improve CRfitness, or both. Brisk walking (2.9 to 3.9 mph), which can be attained byhealthy, habitual walkers can elicit an aerobic training stimulus comparable to

Intensity Prescription by \/02

Factors to consider before determining the level of exercise intensity includethe following:

• Low-fit, sedentary, and clinical populations can improve fitness with lower­intensity, longer-duration exercise sessions, Higher fit individuals need towork at the higher end of the intensity continuum to improve and maintaintheir fitness, Athletes may frequently train at intensities in excess of 90%V02R to achieve improvements in performance,

• Medical conditions, such as musculoskeletal disorders, asthma, or metabolicconditions,

• Medications (see Appendix A) that may influence HR require special atten­tion when defining the initial target HR range and when the dose or timing ofmedication is changed,

• Risk of cardiovascular and orthopedic injuries is higher and adherence islower with higher-intensity exercise programs,

• Individual preferences for exercise must be considered to improve the likeli­hood that the individual will adhere to the exercise program,

• Individual program objectives (lower BP; lower body fatness; increasedV02mnJ help define the characteristics of the exercise prescription,

143CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

220-... 2101:::'E 200III..-

190ellQ).0- 180Q)..-ell 170.....-...

160ellQ)J: 150(ijE 140 0><

0ell 130:2E 0

120

10 20 30 40 50 80

Age (years)

Heart Rate Methods

Heart rate is used as a guide to set exercise intensity because of the relatively lin­ear relationship between HR and V02, It is best to measure maximal HR (HR,mc,)dUling a progressive maximal exercise test whenever possible because HRmaxdeclines with age (e,g" estimated HRma, = 220-age) and the vanance for any glVenage is considerable (1 SO :±: 10-12 beats'min-1) (Fig, 7-3). Currently, all

FIGURE 7-3. The relationship between age and maximal heart rate for mendemonstrates a high SEE, which is similar for women, Note: y = 213,6-0789 (age);r =-0.603; SEE = 10,7; P <.0001, (Reproduced with permission from Whaley MH,Kaminsky LA. Dwyer GB, Predictions of over- and underachievement of age-predictedmaximal heart rate, Med Sci Sports Exerc 1992;24(10):1173-1179.)

• The caloric cost of activities can provide a starting point for prescribingexercise intensity for individuals with cardiac andlor pulmonary disease, andfor individuals with low functional capacities, but the load should betitrated depending on the physiologic responses, perceived exertion, andsymptoms,

• The caloric cost of an activity does not take into consideration the effect ofenvironment (e.g" heat, humidity, altitude, pollution), level of hydration,and other variables that can alter the HR and RPE responses to exercise,The ability of individuals to undertake exercise successfully at a givenabsolute intensity is directly related to their relative effort as reflected byHR and RPE.

Consequently, the most comm~n methods of setting the intensity of exercise toimprove or maintain CR fitness use HR and RPE.

SECTION III / EXERCISE PRESCRIPTION142

Traditionally, the range of exercise training intensities (mL'kg- J 'min -J or inMETs) has been based on a straight percentage of V02mn" For example, if anindividual had a measured \102ma, of 40 mL'kg-1'min -I, the prescribed intensi­ty could be set at 24 to 32 mL'kg-"min- l

, corresponding to 60% and 80% ofV02mm" respectively. In the ACSM position stand, the exercise intensity has beenexpressed as a percentage of oxygen uptake reserve (%\102R), II To calculate thetarget \102 based on V02R, the following equation is used:

Target V0 2 = (V02max - V02,est) (exercise intensity) + V02,es!

This equation has the same form as the heart rate reserve (HRR) calculation oftarget heart rate (see the fo]]owing), In the target \102 equation, V02 "es( is 3.5mL·kg-1·min- 1 (l MET) and the exercise intensity is 50% to 85% (or as low as40% for velY deconditioned individuals), Intensity is expressed as a fraction in theequation, For example, what is the target \102 at 40% of V02R for a person witha \102n"" of 17,5 mL'kg-r'min -1 (5 METs)?

Target V02 mL'kg- I 'min- 1 = (175 - 35) (040) + 3.5

Target V02 mL'kg- 1 'min- 1 = (140) (040) + 3.5

Target V02 mL'kg- r 'min- 1 = 5,6 + 3.5

Target V02 mL'kg- r 'min- 1 = 9,1 mL'kg- I 'min- 1

Once a V02 (MET) target level is identified, a corresponding work rate maybe calculated through the use of metabolic equations (see Appendix 0) or byselecting an activity with a corresponding MET level from published tables,,34However, there are limitations to the use of \102 iu prescribing exercise:

• The caloric cost for activities in groups 2 and 3 (see Box 7-1) are quite vari­able and depend on the skill of the participant andlor the level of competition,

Direct Method

HR Reserve Method (Karvonen)

145

180

170-~ 160

.~ 150Ul-m140.0-; 130-1-------7-eu... 120­...m110::I:

100

90

CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

HH is ISO, then: ISO beats'min-1 minus 60 beats-min- 1 = 120 beats'min- I Onethen takes 60% andSO% of the HHH and adds each of these values to resting HRto obtain the target HR range:

Target HR range = ([HRmarHRrestl x percent intensity) + HRre51

Target HR range of 60% intensity = ([180 - 60] x 0,60) + 60 = 132 beats-min- 1

Target HR range of 80% intensity = ([180 - 60] x 0,80) + 60 = 156 beats-min- 1

The HHH method yields a target HR range of 132 to 1.56 beats' min -1 for.this sub­ject, similar to the target HR range calculated by the percent of maximal HRmethod. Sixty to eighty percent of the EHR is equal to about60% to 80% ofV02'~"lX

for most fit individuals, but is more closely linked to the %V02H across the entirerange of fitness levels. The latter point is most impOitant when working with low­fit clients.

The target HR range for the %HH,mx and the HHR methods are diffel:entbec;use different resting heart rates are used in the target HH calcul.ation,The systematic difference between the hvo HR methods is reduced as the mten­sity increases. Either method can be used to approximate the range of exercise

5 10 15 20 25 30 35 40

V02 (mL·kg-1·min-1)

FIGURE 7-4. A line of best fit has been drawn through the data points on this plot ofheart rate and oxygen consumption data observed during a hypothetical maximalexercise test in which \102max was observed to be 38 mL'kg- 1 'min- 1 and maXimalheart rate was 184 bpm- 1, A target heart rate range was determined by finding theheart rates that correspond to 50% and 85% of V02max, Forthis individual, 50% of\102max was approximately 19 mL-kg- 1 -min- 1

, and 85% of V02max was approximately32 mL'kg- 1 'min- 1, The corresponding target heart rates are approximately 130 and168 beats-min- 1,

SECTION III/EXERCISE PRESCRIPTION144

prediction fOrl1l1llae for ma"imal heart rate contain large standard errors of esti­mate, which ma\' result in inaccurac\' when applied to general populations,:l5Prediction equations, which are population specific (e,g" smokers, obese, aged,those with elevated resting HR), may prO\~de more accurate estimates of maximalHIt·

1B,:), Specific medications (l3-bloekcrs) preclude the use of a predicted maximal

HR; thus other methods of monitoring intensity are necessary (e.g., RPE, ~lETs).

The actual maximal HR is specific to the mode of exercise and may differ \\~th­in populations of the same age and sex. Until a multivariate regression equation isdeveloped that accurately predicts maximal HR, obtaining the actual maximal HRthrough a maximal exercise test is preferred. In the absence of a tnle determina­tion of maximal IIR, the traditional, empirically based, easy-to-use (220-age) is stiJi~able, despite the large standard error. Dnring an exercise session, the assumptionis that the indi\idual \\~11 achie\'e a steady-state HR response in the prescribedrange; in reality (and celtainly dming discontinllOus exercise) IIR is likeh- to beboth above and below the prescribed intensity. The goal slHJIlld be to maintain anaverage IJR close to the midpoint of the prescribed range, There are severalapproaches to determining a teu'get HR range for prescriptive pU!1)oses,

Percent of HRmax (Zero to Peak Method)

The direct method of obtaining the target FIR range im'oh-es plotting measuredHR against either measured \'02 (Fig, i -4) or exercise intensity (as discllssed inChapter 4). If BPE data are available, the IIH-\f02 relationship can be evaJnat­ed further in relation to the individual's RPE, which is helpful in monitoring theexercise intensity, This method is appropriate for setting exercise intensity forpersons \\~th low fitness levels, those with cardiovascnlar anellor pulmonary dis­ease, and those taking medications (e.g" l3-blockers) that affect the EH rcsponseto exercise. The direct method allows one to prescribe an appropriate trainingHR range below the point of ackerse signs or symptoms experienced b\' the incli­vidual during exercise testing,

One of the oldest methods of setting the target HR range uses a straight percent­age of the I-IH""". Early researchers and clinicians used 70% to S.5% of an indi\~d­ual's HH",,,, as the preselibed exercise intensih', This range of' exercise intensitiesapproximates .50% to iO% \'02",,,,:)'> and prO\ides the stimulus needed to imprO\'eor maintain \'02m", in individuals exercising in clinical and adnlt fitness set­tings,:)I-:J:J It is also simple to compute. If' an indi\~dual's HH",,,, is ISO beats'min -I,the target HB range is 126 to 153 beats' min-I, This is a conservative approach thatis vel)' inaccurate at low intensity target zones, For example, prescribing a cooldO\\~l intensity of' 30% IIR""" for an indi\~dl!CtI \\~th a maximal EB of ISO yields atarget HH 01'.54 (.30 X ISO = .54), which is often below the resting lIIt

The HR reserve (HHR) method is also known as the Karvonen method,·l~ In thismethod, resting heart rate (IIRr~\() is subtracted from the maximal heart rate(HR"",,) to obtain EBR. For example, if the resting HR is 60 and the maximal

146 SECTION III/EXERCISE PRESCRIPTION

intensities kno\\'n to increase or maintain \102011 <,,; however, the IIRR methodmore accurately depicts the intensity relative to oxygen consumption. As "the artof exercise prescription" suggested earlier, the target IlR range is only a guide­line used in setting the exercise intensity:

• Some individuals prefer to exercise at the low end of the target HR range andfocus on long dmation (>40 minutes) to accomplish fitness goals, althoughthe e\idence is weak to suggest that a longer omation further enhances\'02ma" As the duration increases the opportunity for cardiOl'ascular drift(e.g., a rise in HR over time from increased core temperature, dehnlration,and blood redistribution) is increased; thus, a reduction in the \\'orkioad maymaintain the target HR range. '

• Because of the specificity of training and the fact that measu red m,Lximal heartrate is oifferent for different modes of exercise, an indi\idual's perception ofeffort \Iill vary among exercise modes when exercising at exactly the same lIB.7

• Conversion of a %HR 01"" value to a %\'0201"" value carries with it a stanoarderror of esti mate of ± .5.7% \102m<L\':'~

• If an estimate of HR max (e.g., 220-age) is used in the preceding calculationsrather than measured HR, the error inherent in that estimate is carried overto the calculated target HR range (see Fig. 7-3). This must be considereowhen an individual begins an exercise program. The RPE can be helpful inadjusting the exercise intensity in such situations.:lu

Rating of Perceived Exertion

Commonly useo RPE scales are found iu Chapter 4. Use of Il.PE is consideredan adjunct to monitoring HR because RPE determined during a gradeo exercisetest may not consistently translate to the same intensity during an exercise sessionor for different modes of exercise,AoAI Howel'er, the Il.PE has prol'ed to be avaluable aid in prescribing exercise for indi\iduals who have difficulty with H Rpalpation, and in cases where the HIl. response to exercise may hm'e b~en alteredbecause of a change in medication. The average RPE range a~soeiated \lith phys­iologic adaptation to exercise is 12 to 16 (in the range of "somewhat hard" to"hard") on the Borg scale (see Chapter 4). 110wever, because of significantinterindil'idual variability in the psychophysiologic relationship, one should suitthe Il.PE to the individual on a specific mode of exercise and not expect an exactmatching of the RPE to a %HR 01"" or %lIIl.R.42 Consequently, the RPE shouldbe used as a guideline in setting the exercise intensity. It is important to establishthe target HPE within the training environment.

In the final analysis, the appropriate exercise intensity is one that is safe,enhances aerobic capacity (\102ma\), conlpatiblc with a long-term active lifestylefor that individual, and achieves the desired caloric output aiven the time con-straints of' the exercise session. b

EXERCISE DURATION

The duration of an exercise session interacts \lith the intensity to result in theexpenditure of a sufficient number of calories to achieve health and fitnessgoals such as improved body composition. The CH phase usuallv includes 20 to

CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 147

60 minutes of continuous or intermittent activity (lO-minute bouts accumulatedthroughout the day). The ACS~1 position stand recommends a minimum of 20minutes of cardiOl'ascular exercise f'or improvement in aerobic capacity. I I

Significant improvcment in \'02011<1\ has been demonstrated \lith multiple shOltbouts (l0 minutes) of exercise equivalent to the total duration of a single longbout (:30 minutes) of exereise.4.1-l5 People training at low intensity should con­duct the exercise sessions O\'er a longer period of time (30 minutes or more), and,eOl1\'erselv, indiliduals training at higher le\'els of intensitv m<1\' train for 20 min­utes or le~s. Consequently, exercising at 60% to 80% HRR or 77o/c to 90% I-Tl'l.01l<L\for 20 to 30 minutes, excluding time spent warming up and cooling down, enablesmost indi\iduals to fulfill their goals.4

Tn addition, limited data on short bouts (12 minutes at high intensity)20 orinterval training (six to seven bouts of 20 seconds at > 170% \'02,"aJ21 havedemonstrated improvements in \102IlHL\, Although fitness may improve throughshort duration, high -intensity exercise, scientific evidence to support the healthbenefits of short duration exercise is lacking. High-intensity exercise is associat­cd with an increased risk of orthopedic injury, cardiovascular incidence, andlower compliance.4(i Thcrefore, moderate intensity, moderate duration (20 to 30minutes) cxercisc is recommended for improving aerobic capacity (\T02IlJaxl ofmost adults. Duration is inversely related to the intensity of the activity. Lowcr­intensity activity should be done for a longer period of time (30 minute's or more).

Consistent with the manner in which the intensity of a session is graduallyincreased over wecks of training, the duration (e.g., 30 minutes) can begin with aslittle as multiple (4 to 10), 2-to 5-minute bouts with rest pCliods between bouts forthose \\ith low levels of CR fitness. The duration of the exercise bout can be extend­ed until the goal is achieved. Increases in cxercise duration should be made as theindi\idual adapts to training \lithout e\idence of undue fatigue or injlll)'.

Exercise Frequency

The ACSlvI recommends an exercise frequency of 3 to.') ehvk- ' . For those exer­cising at 60% to 80% IIRR or 77% to 90% HIl.01m, an exercise frequency of3 d'wk- ' is sufficient to improve or maintain \'02m<L\' For those exercising at thelower end of the intensity continuum, exercising more than 3 chvk- ' may beneeded to achicvc the caloric expenditure associated with weight loss and fitnessgoals. Patients with functional capacities of fewer than 3 MEl's may benefit f'rommultiple brief daily exercise sessions; one to two shOlt sessions per day are appro­pliate for those with 3 to .5 MET capacities; and three to five sessions per weekare recommended for individuals \lith a functional capacity of >5 METs.

.' Although deconditioned persons may improve CH fitness with only twice­weekly exercise, greater improvement is achieved with a frefluency of threeto five sessions per week, hut improvements generally plateau within the 3to 5 d'wk- 1 frequency47 Additional bcnefits of training 6 or more chvk- I

appear to be minimal, and should be reserved for the performance orientedindividuals or competitive athletes. The risk of musculoskeletal injllry increas­es abruptly with increased frequency of training beyond 6 d ·wk- I

. Vigoroustraining 7 d'wk- 1 is not recommendcd; however, 30 minutes or more of mod­erate intensity physical activity is preferable on most days of the week for

Energy Expenditure Goals

health-related benefits. Clearly, the number of exercise sessions per weekvaries depending on the caloric goals, participant preferences, and limitationsimposed by the participant's lifestyle. The optimal training frequency is stillelusive.

The interaction of physical activity intensity, duration, and frequency determinesnet caloric expenditure from the activity. It is generally accepted that many of thehealth benefits and training adaptations associated with increased physical activ­ity are related to the total amount of work (volume) accomplished during train­ing.1.2.48 However, the caloric thresholds necessmy to elicit significant improve­ments in V02m,~x, weight loss, or a reduced risk of premature chronic disease maybe different. Therefore, individualized exercise prescriptions should be deSignedwith energy expenditure goals in mind.

The ACSM recommends a target range of 150 to 400 kcal of physical activityand/or exercise energy expenditure per day.2.48 The lower end of this range rep­resents a minimal calO1ic threshold of ~1,000 kcal'wk- 1 from physical activity,which is associated with a significant 20% to 30% reduction in risk of all-causemortality,2.48.49 and this should be the initial goal for previously sedentmy indi­viduals. Based on the dose-response relationships between physical activity andhealth and fitness, individuals should be encouraged to move toward attainmentof the upper end of the recommended range (e.g., 300 to 400 kcal'day-l fromactivity) as their fitness levels improve during the training program. The applica­tion of the 1,000 kcal threshold (150 kcal'day-I X 7 d'wk- I

) for weight loss andweight loss maintenance may be insufficient for effective control.50.51 Recentreports suggest that 60 minutes or more per day may be necessary for weight lossand maintenance, which is double the current recommendation for health­related physical activity.50-52 Physical activity and/or exercise energy expenditurein excess of 2,000 kcal'wk- l have been successful for both short- and long-termweight control.53

Estimating caloric expenditure dUling exercise has been problematic for exer­cise profeSSionals, and developing an exercise plan based on caloric thresholdsshould not be viewed as an exact science. Interindividual differences in skill,coordination, and exercise economy (the V02 at a given submaximal work rate)and the variable intensities within each available activity strongly influence esti­mation of caloric eX1Jenditure during exercise. Accelerometers have been used toestimate calO1ic expenditure during v,uious recreational and household activities.The energy expenditure associated with walking can be predicted with reason­able accuracy, but other activities, such as golf and household activities may beunderestimated by 30% to 60%.54 Accelerometers provide a general estimate ofcaloric expenditure and may be more valuable on a relative (pre-, post-) compar­ison within the same individual. Any attempt to quantify energy expenditure byaccelerometly must be viewed cautiouslyS5 Another useful method to approxi­mate the caloric cost of exercise is by using the follO\ving equation based on theMET level of the activity:

(METs x 3.5 x body weight in kg)/200 = kcal'min- 1

149

Exercise Frequency Exercise Intensity Exercise Duration(sessions'wk ') (%HRR) (min)

3 40-50 15-203-4 40-50 20-253-4 50-60 20-253-4 50-60 25-303-4 60-70 25-303-4 60-70 30-353-4 65-75 30-353-5 65-75 30-353-5 70-85 35-403-5 70-85 35-40

3-5 70-85 20-6024+

Week

1234

5-78-10

11-1314-1617-2021-24

CHAPTER 7 I GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

The recommended rate of progreSSion in an exercise program depends on func­tional capacity, medical and health status, age, indi\idual activit)' preferences andgoals, and tolerance to the current le\'el of training. For healthy adults, theendurance aspect of the exercise prescription has three stages of progression: ini­tial, improvement, and maintenance (Table 7-1). Exercise profeSSionals should

Rate of Progression

This formula helps an indi\idual understand the components of the exerciseprescription and the \'olume of exercise necessary to achieve the caloric goalsofthe program. Consider the follO\\ing example. The weekly goal of th.e exerClseprogram has been set at a net caloric expenditure of 1,000 kilocalories for an indi­vidual who weighs 70 kg, and the MET level of the prescribed activity is 6 MEl's.In this example, the net calolic expenditure from the exercise is.5 MEl's because1 MET of the activit)' represents resting metabolic rate. Therefore, the lIet calOlicexpenditure from the exercise is 6 kcal'min -I, which requires 167 minutes perweek to attain the 1,000 kilocalorie threshold. Gi\'en a -l chvk- I program, theindividual would require approximatel~'42 minutes per day to achieve the 1,000kcal goal (or 33 minutes per day, 5 d·wk- l

). Working back'ward from the caloricgoal to determine the volume ?f exercise needed to reach the goal is useful indetermining the appropriate exercise prescription components. If the goal was amore aggressive 2,000 kcahvk- 1 for long-term weight control, the net caloricexpenditure of 6 kcaJ'min - L would require 333 minutes per week or ~48 min­utes per day on all days of the week. For information on ~IET values for over 500physical activities, see Ainsworth et al.:34 or the ACS.'Irs Resource ,\[an//a! forExercise Testing and Prescription (.5th ed.).

MaintenanceStaget

TABLE 7-1. Training Progression for the Sedentary Low-Risk*Participants

Program Stage

Improvementstage

Initial stage

'Defined as the lowest risk categones In Table 2-4 and Boxes 2-1 and 2-2

tDepending on long-term goals of program. the IntenSity. frequency. and duration may vary.

Abbreviations: HRR, heart rate reserve; It is recommended that low-risk cardIac patients train at the lower end ofthese ranges.

SECTION III I EXERCISE PRESCRIPTION148

INITIAL CONDITIONING STAGE

IMPROVEMENT STAGE

recognize that recent physical acti\~ty recommendations from the ACSM/CDC1

and the Surgeon General2 include 30 minutes of moderate intensity physicalacti\~ty on most, if not all, days of the week for health-related benefits. Althoughsome apparently healthy but sedentm)' indi\~duals may not be able to attain thisinitial level of activity, they should be encouraged to progress to this goal dUtingthe first few weeks of the training program.

151CHAPTER 7 I GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

MAINTENANCE STAGE

Training Specificity

The goal of this stage of training is the long-term maintenance of CR fitness devel­oped dUling the improvement stage. This stage of the exercise program usuallybegins after the pmticipant has reached preestablished fitness goals. DUling thisstage, the lxuticipant may no longer be interested in further increasing the condi­tioning stimulus. FUlther improvement may bc minimal, but continuing the sameworkout routine enables indi~duals to maintain their fitness levels. At this point,the goals of the program should be reviewed and new goals set. The goal of eachpmticipant should be to reach a minimum of the 50th percentile in all health-relat­ed fitness parameters. To maintain CR fitness, an exercise prescliption shouldincollJorate an intensity, frequency, and duration consistent \~th the palticipant'slong-term goals, and should also meet, and preferably exceed, the minimal calOlicthresholds identified earlier in the chapter. If there is the need for fmther weightloss dUling this phase of the program, a calOlic restJiction combined \~th a moder­ate intensity exercise program that results in a significant negative calOlic balance(500 to 800 kcal .day-I) is recommended. However, such programs usually areassociated \,~th increased exercise duration, frequency, or both. It is important toinclude exercises and recreational activities (see Box 7-1, group 3 activities) that theindividual finds enjoyable. It is also helpful to pro~de valiety \~thin and betweeneach exercise session to mai ntain pmticipant interest.

Tumerous studies have investigated the CR and metabolic responses of trainedversus untrained muscles to chronic aerobic conditioning. For example, upperextremity or lower extremity training resulted in only minor improvements insubma,ximal and maximal lower extremity or upper extremity exercise responses,respectively. Thus, subjects trained by lower extremity exercise failed to demon­strate a conditioning bradycardia during upper extremity work, and vice versa(Fig. 7_5).57 Similar differences in muscle-speCific adaptations have been shownfor blood lactate58 and pulmonm)' ventilation S9 The use of arm training during adetraining phase failed to maintain the gains accrued during leg training, thusconfirming the specificity of training. GO These findings suggest that a substantialpOltion of the training effect derives from peripheral rather than central changes,including cellular and enzymatic adaptations that increase the oxidative capacityof chronically exercised skeletal muscle 61

. Some transfer-oftraining effects have been repOlted, including increasedV02m,~x or reduced submaximal heart rate \\ith untrained limbs, thus providinge~d~nce for central circulatOl)' adaptations to chronic endurance exercise62

,63

It has been suggested that approximately half of the increase in trained limb per­formance results from a centralized training effect and half from peripheraladaptations, speCifically alterations in trained skeletal muscle64 However, thepelipheral adaptations may predominate in some patient subsets, for example,cardiac patients with left ventlicular dysFunction.55 Although the conditionsunder which the interchangeability of arm and leg training effects may val)',there is evidence to suggest that the initial fitness of the subjects as well as the

SECTION 1111 EXERCISE PRESCRIPTION150

The initial stage should include an extended warm-up (10 to 15 minutes), mod­erate intensity aerobic activities (40% to 60% of HRR) in an intelval format; low­intensity muscular fitness exercises that are compatible \~th minimal musclesoreness, discomfort, and injm)'; and an extended cool-down (10 to 15 minutes)\~th the majority of cool-down time devoted to stretching. Exercise adherencemay decrease if the program is initiated too aggreSSively. This stage may last 1 to6 weeks, but the length depends on the adaptation of the indi~dual to the exer­cise program. The duration of the exercise session during the initial stage maybegin with approximately 15 minutes of the cardiovascular stimulus phase andprogress to 30 minutes. It is recommended that individuals who are starting amoderate-intensity conditioning program should exercise three to four times perweek. This initial conditioning stage should prepare the palticipant for the novelactivities and develop an OIthopedic tolerance to the exercise stress. Individualgoals should be established early in the exercise program and must be realistic,\-~th a system of rewards.

The goal of this stage of training is to provide a gradual increase in the overallexercise stimulus to allow for significant improvements and adaptations in CRfitness. The improvement stage of the conditioning program differs from theinitial stage in that the palticipant is progressed at a more rapid rate. This stagetypically lasts 4 to 8 months, during which intensity is progressively increased\~thin the upper portion of the target range of 50% to 85% of HRR. Duration isincreased consistently, \~th increments of no more than 20% each week untilpalticipants are able to exercise at a moderate to ~gorous intensity continuouslyfor 20 to 30 minutes. The frequency and magnitude of the increments are dic­tated by the rate at which the participant adapts to the conditioning program.Increases of duration andlor frequency usually precede increases in intensity.Once the target duration and frequ ncy are achieved, adjustments in intensity ofno more th.an 5% of HRR evel)' sixth exercise session are well tolerated. The pro­gression of intensity also can be achieved through intelval training incorporatingextended higher-intensity work intervals or by adding one higher-intensity exer­cise session each week until the target intensity is achieved. Deconditionedindi~duals should be permitted more time for adaptation at each stage of condi­tioning. Age also should be taken into consideration when progressions are rec­ommended; experience suggests that adaptation to conditioning may take longerin older individuals. I I

FIGURE 7-5. Importance of peripheral adaptation to training of the arms (top) and legs(bottom). Arm training on the cycle ergometer reduced the heart rate during armwork but not during leg work. Similarly, leg training was associated with a lower heartrate response during leg exercise but not during arm exercise. (Adapted from ClausenJP, Trap-Jensen J, Lassen NA. The effects of training on the heart rate during arm andleg exercise. Scand J Clin Lab Invest 1970;26:295-301.)

153CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

intensity, frequency, and duration of training may be impOltant variables indetermining the extent of cross-training benefits.66

The limited degree of cardiovascular and metabolic crossover benefits oftraining from one set of limbs to another appears to discredit the general prac­tice of limiting exercise training to the lower extremity alone. Many recreation­al and occupational activities require sustained arm work to a greater extentthan leg work. Consequently, individuals who rely on their upper extremitiesshould be advised to train the upper as well as the lower extremities, with theexpectation of improved CR, and hemodynamic and perceived exertionresponses to both forms of effort. Such programs should serve to maximize theconditioning response through increased crossover of training benefits to real­life situations.

SUMMARY OF GUIDELINES FOR CARDIOVASCULARSTIMULUS PHASE

• The goal of each palticipant should be to reach a minimum of the 50th per­centile in all health-related fitness parameters.

• The ACSM recommends an intensity of exercise corresponding to 40% and50% (40%/50%) to 85% of oxygen uptake reserve (V02R) or hemt rate reserve(HRR), or 64% and 70% (64%170%) to 94% of maximum healt rate. HRR andV02R can be used interchangeably.

• Aerobic endurance training below a minimal threshold (20% HRR or 50%HRm'LJ may be sufficient for developing aerobic fitness in healthy adults, whohave a low\T02llULx «30 mL·kg-1·min-1).

• For people with \102max below 40 mL·kg-1·min-\ a minimal intensityof30%V02R can provide for improvement in V021llax'

• For most individuals, intensities within the range of 60% to 80% HRR or 77to 90% HRIll'LX are sufficient to achieve improvements in CR fitness, whencombined witl1 an approptiate frequency and duration of training.

• Athletes may frequently train at intensities in excess of 90% V02R to achieveimprovements in performance.

• The HRR method is recommended for prescIibing exercise intensity rathertl1an the HRIll'LX method because the HRR method more accurately depictsthe intensity relative to oll.ygen consumption.

• The CR phase usually includes 20 to 60 minutes of continuous or intermittent(lO-minute bouts accumulated throughout the day) activity.

• Although deconditioned persons may improve CR fitness with only twice­weekly exercise, greater improvement is achieved "vith a frequency of 3 to5 d'wk- 1, but improvements generally plateau within the 3 to 5 d'wk- 1

frequency.

• Progression of the CR stimulus: Duration is increased consistently, with incre­ments of no more than 20% each week until participants are able to exerciseat a moderate to vigorous intensity for 20 to 30 minutes continuously.Increases of duration and/or frequency usually precede increases in intensity.Once the target duration and frequency are achieved, adjustments in intensi­ty of no more ilian 5% of HRR evelY sixth exercise session are well tolerated.

High

High

High Low

Workloads

High Low

Workloads

Low

Low

Arm Training

Leg Training

r- Arm work-----,I r---- Leg work~

r- Arm work----,I r---- Leg work~

SECTION III/EXERCISE PRESCRIPTION

­~C: -40

EVI-caC1l -30.0-C1l-ca~_ -20~

caC1l.r;

c:.- -10

C1lVIcaC1l~

lrl 0Cl

­~C: -40'EVI-m-30.0-C1l-ca~_ -20~

caC1l.r;c:.- -10C1lVIcaC1l~

lrl 0Cl

152

Resistance Exercise Prescription

• A target range of 1.50 to 400 kcal of physical activity and/or exercise energye~penditure per day or a minimal caloric threshold of approximately 1,000kcahvk-I from physical acti\~t)' is recommended. -

• Physical aeti\~ty and/or exercise energy expenditure in excess of 2000 kcal'wk- I

have been successful for both short- and long-term weight control.

Muscular strength and muscular endurance directly impact on activities of dailylh~ng (ADLs) because daily Ii\~ng activity rcquires a given percentage of one'smuscular capacity to perform common tasks. The enhancement of muscularstrength and endurance enables an individual to pcrform such tasks \vith lessphYSiologic stress and aids in maintaining functional independence throughoutthe life span. Even the cardiovascular stress of lifting or holding a given wCight(objcet) is proportional to the percentage of maximal strength invoked.Improving muscular function t~1rough resistance training (weight training) mayaccrue health-related benefits 6

' A reduction in the risk of osteoporosis, low backpain, hypertension, and diabctes are associated with resistance training6S- 70 Inaddition, the benefits of increased muscular strength and endurance, bone den­sity, enhanced strength of connective tissue, and the increase or maintcnance oflean body weight also may occur. These adaptations are beneficial for all ages,including middle-aged and older adults, and, in particular, postmenopausalwomen who may expelience a more rapid loss of bone mineral density. 71

Although resistance training may ele\·ate healt rate because of sympatheticacth'it)' and ca_te;holamine responses, the heart rate is disproportionate to m,ygenconsumption. ,2.>-3 Heart rate should not be used as a measure of intensity dUlingresistance training. Resistance training does little to increase the \TO? .. 70although resistance training may improve cardiovascular endurance. For ~:~~~~_pie, when cardiovascular endurance is dcfined as the length of time a person canwalk on a trcadmill during a graded exercise test protocol, resistance training maypermit one to extend the duration of the exercisc because of increased muscularstrength and muscular endurance \\~thout increasing V02",,",.7-1 Circuit weighttraining (a series of resistance exercises, performed one after another, with littlerest between exercises) results in an average improvement in \IO? . of about6%. Thus, it is not generally recommended as an activity for in~';';'~ving CRendurance. il

The use of resistance training as a primary mode for weight and bod\' fat lossis controversial. Although successful fat loss is associated with a caloric deIlcitachieved through a combination of dietary restriction and caloric expcnditure,resistance training per se expends only moderate amounts of calories. Energyexpenditure estima!;: r~nge from 4 to ]Q kcahnin -I while engaged in actualresistance training. ,~.,.'.I.5 This does not include rest intervals and is propor­tional to the amount of muscle mass involved. Moderate aerobic exerciseexceeds the energy expenditure of resistance exercise and a cardiovascularstimulus can be maintained for a longer duration. Thus, for a given length o[time, more calories can be expended in aerobic exercise compared to resistancetraining. For example, a 70-kg person jogging [or 30 minutes at 6.0 mph(161 m'min-

I) would typicaJl)' demonstrate a net caloric expenditure of 338

155CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

kcal; whereas a half hour resistance training session, of which 1.5 minutes is lift­ing and 15 minutes is recovelY, accounts for a net caloric expenditure of 60 to150 kcal.

A small increase in caloric expenditme occurs dUling recovelY [rom bothaerobic and resistance training but it is transient and usually dissipatcs \vithin2 hours postexercise.7fi,77 Reports of elevations in resting metabolic rate (HMR)following a bout o[ resistance training have generally accounted for less than 100net calories over 24 hours,7,~ \vith several studies repOlting a net expenditure ofonly 19 to .50 kcal in the 2-hour postexercise period. 78

-ii1

Resting metabolic rate may be influenced by a greater amount of fat-freemass;82 however, resistance training studies suggest that the relative metabolicrate (kcal'kg FFM- i) does not change.s".'>-1 One study even revealed no alterationof sleeping metabolic rate despite a 1.1-kg increase in fat-free mass after12 weeks of resistance training.H.5 To raise the resting metabolic rate throughresistance training requi res increases in the quantity of lean tissue. Typicalincreases in Ican body mass (LBM) in up to 6 months of resistance training rangefrom 0.3 to 2.0 kg, \\~th the greatest improvement in malesgJ·sfi Increases inLBM that were similar between resistance training programs lasting 12 to 24weeks, suggest that additional increase in LBM after 12 weeks of training may besomewhat limited for the general population g6 Although not well studied, theability to increase LBM is linked to genetic factors.S7 Responses to resistancetraining may be subjcct to indi\~dual heterogeneity&7 similar to responses to car­diovascular exercise training.H The ability to demonstrate large increases in LBMappears limited in the general population.

Resistance training (i.e., sufficient to develop and maintain muscular fitnessand fat-free mass or reduce the normal decrease in fat-free mass associated \vithaging) should be an integral palt of prima,y and seconchuy prevention programs.Unlike cardiovascular activity, intensity for resistance cxercise is not easily deter­mined. The common use of a percentage of the 1 RM (repetition maximum) toestimate intensity does not portray a true intensity and is only used as a generalguideline. The number of repetitions performed at a given percentage of 1 HMdiffers between muscle groups (e.g., bench press versus leg curl) as well asbetween individualsg&·'>H This variability in the number of repetitions performedat a percentage of 1 RM precludes its use as an accurate measure of intensity.Intensity can be defined as the effort or how difficult the training stimulus orexercise is. A resting muscle represents minimal intensity, whereas moment<Uymuscular fatigue (failure) in the concentlic pOltion of an exercise performed instrict form represents high intensity. All other levels of muscle activity arc some­where between these two extremes. A 3 HM, 10 RM, and 15 RM result in a sim­ilar intensity as defined hy the repetition maximum. The HM indicates that themuscle has reached a point of fatigue or failure in which the force-generatingcapacity falls below the required forcc to shorten thc muscle against the imposedresistance. At this point, the progressive recruitmcnt of muscle fiber motor unitshas occurred and the muscle is at high intensityml \Vith each repetition, there isa progreSSive increase in active musclc mass, until a maximal voluntarv contrac­tion is achieved. Thus, high intensity can he reached by performing a f~w repeti­tions (e.g., three to six) \vith a heavier resistance or several repetitions (e.g., 8 to12) \~~th a lighter resistance.

SECTION III / EXERCISE PRESCRIPTION154

The progressive increase in muscle fiber recruitment parallels increases inblood pressure, regardless of the size of the muscle mass involvedHl.92 The magni­tude of the blood pressure response depends on the degree ofeffOlt (intensity), notthe absolute force of contractionHl .92 A similar blood pressure is evident at thesame relative degree of effOlt despite significant differences in absolute force pro­duction.

9l.92

If high intensity is achieved (momentmy muscular fatigue), whetherby small versus large muscle groups, or few versus several repetitions, the resultsare similar; the muscle has been stimulated to a high degree. The elevation in bloodpressure associated with this high intensity is extreme even when recruiting a smallmuscle mass.

92For a healthy, asymptomatic population, the briefexposure to these

high blood pressures is considered inconsequential. Individuals with hypertension,diabetes, at risk for stroke, or at other medical lisk from exposure to high bloodpressures should avoid high-intensity resistance training. They can engage in lower­intensity resistance training, by terminating lifting before fatigue. Although unde­fined, a threshold for improvements in muscle strength and endurance is evidentbelow momentary muscular fatigue (high intensity)69.93.94 Submaximal training canoccur by terminating the exercise when the participant demonstrates an obviousunintentional increase in concenbic repetition duration (e.g., slower speed ofmovement), or when one to three more repetitions could still be performed or byusing the RPE scale as an index of intensity. An initial goal of 12 to 13 and a Hnalgoal of 15 to 16 on the RPE scale has been recommended {or submaximal train­ing.

9.5-97 A target of 19 to 20 on the RPE scale is synonymous with high-intensity

strength stimuli for healthy populations.

. The theory of a strength-endurance continuum producing specific adapta­bons related to the number of repetitions has limited scientiHc support.98

Muscular strength and endurance can be developed simultaneously within a rea­sonable range of repetitions (3 to 6, 6 to 10, 10 to 12, etc.)69.94.99-103 If the resist­ance training stimulus is generally less than 90 seconds to fatigue per exercise,both muscular strength and absolute muscular endurance (number of repetitionsperformed at a specific amount of resistance) increase, but not necessmily to thesame degree. For example, doubling the number of repetitions performed at agiven resistance does not mandate the performance of twice the resistance for1 RM. Successful resistance training typically increases strength and absolutemuscular endurance, yet relative muscular endurance (a speciHc percentage ofthe 1 RM adjusted {or both pre- and post-training) remains stable86.104

Thus, for any common range of repetitions (3 to 6, 6 to 10, 10 to 12, etc.)there is little evidence to suggest a specific number of repetitions will providea superior response relative to muscular strength, hypertrophy, or absolutemuscular endurance. However improvements in bone mineral density have~een associated with lower (7 t~ 10) repetitions versus higher (14 to 18) repe­tI.tlOns 111 older populations. 68.lOo ,106 This may provide insight for training indi­VIduals prone to osteopenia or osteoporosis. Women who may have a predispo­sltlOn to osteoporosis should be advised to resistance train with higher resist­ance with fewer repetitions and a variety of exercises to benefit from site­specific bone improvement, without a fear of muscular hypertrophy. To elicitimprovement in both muscular strength and endurance, 8 to 12 repetitions at ahigh intensity (approximate momentaly muscular fatigue) is recommended forhealthy populations,

Any overload beyond a minimal thrcshokl results in strength development. Ahigher-intensity effort at or near maximal effort produces the grcatcst sti.mulus,but may not produce any greater adaptation, Thc increase 01 intensity ot resist­ance training can be manipulated by valying any onc of the follo\ving variables,while keeping all the other variablcs constant:

• The weight (resistance)• The numbcr of repetitions• Rcducing momentum by increasing the repetition duration (reducing specd

of movement)• Maintaining muscular tcnsion versus "locking out" the joint when performing

multiple joint exercise (e,g., bench press, militcuy prcss, leg press, squat)

An overload or progression can occur with any exercise by requiring anincreased intensity with controlled repetition duration (movement speed). Theinitial repetition is typically least difficult and cach subsequent repetition pro­gresses in intensity until the terminal repetition, All muscle groups can be trainedthrough a variety of exercises, which can prOl'ide novel or different stimuli to themuscle and bone. A variety of exercises for cach muscle group also may maintainparticipant adhercnce and interest in the exercise program. Develop a menu ofexercises for each muscle group and choose one for cach exercise session. Thereis no evidence to suggest there is an absolute best exercise for any specific musclegroup, but cach is specific in its purposc, Some exercises may be more difficultto perform (stability ball activity) because of increased neuromuscular com'dina­tion or balance, but there is no evidence to indicate these activities are better interms of muscle strcngth or endurance. They arc simply different. For example,performing a bench prcss exercise on a flat bench versus a stability ball is differ­ent. There is no evidence to show one form of bench press is superior to theother. Moditlcations such as a change in the length of the external moment arm(e,g" bicep curl move from a position of the upper arm vertical to a preacher curlposition) or the basc of support (e.g., stability ball) or other variables (e,g" stand­ing curl versus machinc curl) can change thc difficulty of the exercise; therefore,the exercise activity has been changed.

A few researchers repmt a supelior response {i'om multiple set resistance train­ingJ07-111 However, the preponderance of evidence reports similar responses ofmuscular strength, hypettrophy, and muscular endurance between single and mul­tiple set resistance training programs,11.9,5-97.102.112-12.3 Single set programs requireless time and are eftlcient.u'97,122 In addition, an effective resistance training pro­gram conducted \\rithin a limited time commitment may improve exercise compli­ance. Caution is advised for training that emphasizes accentuated lengthening(eccentIic) muscle actions, compared to shOltening (concentlic) or isometlic mus­cle actions, because the potential for acute delayed onset of muscle soreness isaccentuated and the outcome is similar. The soreness may discourage exercise par­ticipation, Muscular strength and endurance can be developed by means of staticor dynamic exercises, Although each type of training has advantages and limita­tions, dynamic resistance exercises are recommended for most adults. Resistancetraining for the average pmticipant should be rhythmic, performcd at a moderaterepetition duration (-3 seconds concentJic, -3 seconds eccentric), involve a fullrange of motion, and not interfere with normal breathing. High-intensity exercise

156 SECTION III / EXERCISE PRESCRIPTION CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 157

Flexibility Exercise PrescriptionOptimal musculoskeletal function requires that an adequate range of motion bemaintained in all joints. Therefore, preventive and rehabilitative exercise pro­grams should include activities that promote the maintenance of flexibility.Reductions in flexibility often are evident by the third decade of life and progress'Nith aging. A lack of flexibility combined with a reduced musculoskeletal strengthin elderly persons often contributes to a reduced ability to perform activities ofdaily living. Accordingly, exercise programs for elderly persons, as well as otherpopulations, should emphasize proper stretching for all the major joints, espe­cially for areas affected by a reduction in range of motion. Flexibility is highly

combined with the Valsalva maneuver (forced expiration against a closed glottis)can cause a dramatic, acute increase in both systolic and diastolic blood pres­sures.

91.92 Currently there is little scientific evidence to indicate that the stimulus

for improving muscular strensrth and muscular endurance in resistance-trainedpopulations is different than for the untrained healthy adult populations.

The following resistance training guidelines are recommended:

• Choose a mode of exercise (hee weights, bands, or machines) that is com­fortable throughout the full pain free range of motion.

• Perform a minimum of 8 to 10 separate exercises that train the major musclesof the hips, thigh, legs, back, chest, shoulders, anm, and abdomen. A plimarygoal of the program should be to develop total body strength and endurancein a relatively time-efficient manner. Total exercise training programs lastinglonger than 1 hour per session are associated with higher dropout rates.

• Perform one set of each exercise to the point of volitional fatigue for healthyindividuals, while maintaining good form.

• While the traditional recommendation of 8 to 12 repetitions is still appropri­ate, choose a range of repetitions between 3 and 20 (e.g., 3 to 5,8 to 10, 12 to15) that can be performed at a moderate repetition duration (~3 sec concen­tric, -3 sec eccentric).

• Exercise each muscle group 2 to 3 nonconsecutive days per week and if pos­sible, perform a different exercise for the muscle group every two to three ses­sions.

• Adhere as closely as possible to the specific techniques for performing a givenexercise.

• Allow enough time between exercises to perform the next exercise in properform.

• For people with high cardiovascular risk or those with chronic disease (hyper­tension, diabetes), terminate each exercise as the concentric portion of theexercise becomes difficult (RPE 15 to 16) while maintaining good form.

• Perform both the lifting (concentric phase) and lowering (eccentric phase)pOltion of the resistance exercises in a controlled manner.

• Maintain a normal breathing pattern; breath-holding can induce excessiveincreases in blood pressure.

• If possible, exercise with a training partner who can provide feedback, assis­tance, and motivation.

159CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

individual, specific to each joint, and affected by many factors, including muscu­lar strength and disease (e.g., carpal tunnel syndrome, arthlitis)124

Stretching can be defined as the systematic elongation of musculotendinousunits to create a persistent length of the muscle and a decrease in passive tension.Musculotendinous units are considered the limiting structures preventing greaterranges of motion about the joint. 125 Muscles have viscoelastic properties; that is,elasticity indicates that length changes are directly proportional to the appliedforce, and viscous properties indicate that the rate of muscle deformation isdirectly proportional to the applied force. The muscle's viscoelastic propelty per­mits a gradual decrease in tension or force within the muscle at a given length.The attenuation of muscular tension over time is termed stress relaxation.126 Theapplication of stretching can resul~ in a continued deformation (longer length) ofthe muscle at a lower tension, which is commonly known as improved fleXibility.

Although flexibility can improve acutely, there is a lack of scientific evidenceas to how long the effect may last. Many experts recommend frequent (daily)stretching because flexibility is believed to be transient. Different types ofstretching techniques (e.g., static, dynamic, proprioceptive neuromuscular facili­tation [PNFJ) can be performed. Static stretching involves slowly stretching amuscle to the end of the range of motion (point of tightness without invoking dis­comfort) and then holding that position for an extended peliod of time (usually15 to 30 seconds). The greatest change in flexibility has been shown in the !irs~

5 d f· I' I . 'f' t . t ft 30 d 121.1281 secon s 0 a stretc 1 WIt 1 no slgm lcan 11llprOVemen a er secon s.The optimal number of stretches per muscle group is two to four, because no sig­nificant additional improvement in muscle elongation is evident in repeatedstretching of five to ten repetitions. 126 The risk of injury is low, requires littletime and assistance, and is quite effective. For these reasons, static stretching isrecommended.

The follOwing two types of stretching techniques are not recommended for thegeneral population; however, certain circumstances (e.g., past histOly, specificgoals, speciHcity of training) may warrant their use for specific populations.Dynamic stretching uses the momentum created by repetitive bouncing move­ments to produce muscle stretch. The strain in the muscle has a fast onset and tllemuscle tension reaches relatively high values. There is a greater risk of strain injUlybecause the muscle is not held at the higher tension to allow the time-dependentstress relaxation response to occur. This type of stretch can result in muscle sore­ness or injUly if the forces generated by the dynamic movements are too great.PNF stretching involves a combination of alternating contraction and relaxation ofboth agonist and antagonist muscles through a designated series of motions. Forexample, PNF can be applied to a hamstJing stretch by allowing a paltner to flexthe hip with the knee straight until the pmticipant reports muscle tightness. Thepalticipant then actively extends the hip against the pmtner's resistance. Finally,the participant relaxes the hamstling and allows the paItner to passively stretch thehamstring to a greater range of motion by flexing the hip. PNF typically requires apartner trained in tlle technique, may cause some degree of muscle soreness, andis more time consuming than alternative methods.

Properly performed stretching exercises can aid in improving and maintainingrange of motion in a joint or selies of joints. Flexibility exercises should be per­formed in a slow, controlled manner with a gradual progression to greater ranges

SECTION III/EXERCISE PRESCRIPTION158

Maintenance of the Training Effect

For additional information on the topiC, refer to thc ACSM's Resource Manualfor Guidelines for Exercise Testing and Prescription (5th ed.).

Numerous studics have investigated the phYSiologic consequenccs of a reducedexercise dosage or complete cessation of training in phYSically conditioned peo­ple. A significant reduction of 5% to 10% in 'i'02,mL' has been reported within 3weeks of stopping intense endurance training, 1:31 \\~th most of the reductionattJibuted to dccreased blood volume. The rapid reduction in maximal ox)'genconsumption plateaus relatively soon, \\~th a total reduction of only 16% after 12weeks of detraining. 13] Participants may return to pretraining levels of aerobic

161CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

fitness in apprOXimately 10 weeks132 to 8 months of detraining133 or decreasetheir gains by half after only 4 to 12 weeks Of134 complete cessation of training.Maintenance of the training effect generally shows a direct relationship to thelength of time in training; 131 that is, the longer one remains in a trained state thelonger it takes to return to baseline levels, and may be modulated by the level offitness, age, intervening illness or injury, and speCific conditioning practices.

A related series of studies examined the relative effects of decreased exer­cise frequency,135 duration,I.36 or intensiti37 on the maintenance of V02m 'LX

during a period of reduced training. All three studies trained young men andwomen for 40 minutes, 6 d'wk- 1 for 10 weeks at a moderate to high exerciseintenSity, followed by 15 weeks of reduced training at one-third and two-thirdreductions in the frequency, duration, or intensity of training. Only when theintensity of training was reduced was there a significant decrease in V02max;

moreover, most of the reduction occurred within the first 5 weeks of reducedtraining.137 In contrast, decreasing the frequency or duration of training had lit­tle influence on the postconditioning V02111ax> prOVided that the intensity wasmaintained. Similarly, restricted walk training resulted in rapid deconditioningin cardiac patients who had been jogging, despite an unchanged exercise fre­quency and duration. '38 Collectively, these findings indicate that exerciseintensity is the most impOltant exercise prescription variable to maintain a car­diovascular training response.

The preservation of resistance training effects also has been examined relativeto a reduced exercise frequency. In these studies, strength gains were maintainedfor 12 weeks vvith one training session per week '39 and only one training sessionevelY 2 to 4 weeks, 140 prOvided that the resistance training loads remained con­stant. Thus, it appears that a reduced training frequency or duration does notadversely affect V0211l 'LX or muscular strength if the training intensity ismaintained.

Additional evidence, relevant to the maintenance of training effects, suggeststhat upper body training per se has little influence on the retention of lower bodytraining effects,141 further reinforcing the principle of training specificity.However, an alternate training modality augments energy expenditure and servesto maintain health benefits.

Program SupervisionInformation from health screening, medical evaluation, and exercise testing a]]o\Vthe exercise profeSSional to determine those individuals for whom supervisedexercise programs are suggested. Exercise profeSSionals should recognize thatmost individuals can exercise safely at a moderate intensity without supervision.However, for those who \\~sh to maintain or increase their fitness levels byfollo~ng the exercise prescliption guidelines \vithin this chapter, Table 7-3 pro­vides general guidelines for exercise program supervision.

Table 7-3 represents a hierarchy of supervision. To use this table, determinethe health status of the participant through risk stratification, and in conjunction~th the palticipants' functional capaCity, determine the level of supervision

Alternative StretchSeated toe touch or modified hurdlcr'sstretchScated toc touch or modified hurdler'sstretchModified hurdler's stretch

on-twisting directional stretchKneeling hip and thigh stretchSeated toe touch

SECTION III/EXERCISE PRESCRIPTION

Barre stretch

High-Risk StretchStanding toe touch

Hurdler's stretchNeck circlesKnee h)1JerflexionYoga plow

160

of motion. A gcneral exercise prcscription for achieving and maintaining flexibil­ity should adhere to the following gUidclines: 12H

• Precede stretching with a warm-up to ele\'atc muscle temperature• Do a static stretching routine that exercises the major muscle tendon units

that (ocuses on muscle groups (joints) that havc reduced range of motion• Perform a minimum of 2 to 3 chvk- I

, ideally 5 to 7 chvk- '• Stretch to the end of the range of motion at a point of tightness, without

inducing discomfOlt• Hold each stretch for 15 to .30 seconds• Two to four repetitions for each stretch

A series of easy-to-understand stretchcs are available from various publica­tions that can provide the basis for a prudent flexibility program. 1:lO Yoga, tai chi,and Pilatcs movements also may be used to improve flexibilitv when appropliate.Stretching exercises can be effecti\'ck included in the warm-up and/or cool-downperiods that precede and follow the aerobic conditioning phase of an exercise ses­sion. Jt is recommended that an active warm-up precede stretching exerciscs.Some com monly employed stretching exerciscs may not be appropriate for somepmticipants who may be at greatcr risk for musculoskeletal injuries bccause ofplioI' injul)', joint insufHciency, or other conditions. Although research concern­ing the risks of speCific exercises is lacking, those activities that require substan­tial flexibility, skill, or position the joint in a range of motion that stretches liga­ments or nerves are not recommended. For cxample, the follOWing is a list ofhigh-risk stretches (danger to the joint) and safer alternativcs. 129

CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 163

TABLE 7-3. General Guidelines for Exercise Program Supervision

Methods for Changing Exercise Behaviors

High risk (from Table 2-4)with recent onset ofCPM that have beencleared by a physicianfor participation inexercise regimen.

<7 METs§

Clinically SupervisedtProfessionally Supervised*

Level of Supervision

Moderate risk (fromTable 2-4)

OrHigh risk (from Table 2-4)

but with well-controlled,stable CPM disease

> 7 METs

Health Status Low risk (fromTable 2-4)

Unsupervised

Functional:l: >7 METscapacity

*Professionally supervised means supervision by appropriately trained personnel who possess academic training and

practical/clinical knowledge, skills, and abilities c~mmensurate with any of the three credentials defined in Appendix

F (I.e" ACSM Health/Fitness Instructor. ACSM Exercise SpeCialist, ACSM RCEP), the ACSM Program Director, or

ACSM Health/Fitness Director

tC.inically supeIVised means supervision by appropriately trained personnel who possess academic training and

practical/clinical knowledge. skills. and abilities commensurate With the ACSM Exercise Specialist or ACSM RCEP

credentials defined ,n Appendix F, or the ACSM Program Director.

>A functional capacity of,;7 METs IS well below the 10th percentile for apparently healthy men. and either at or

below the 10th percentile for most apparently healthy women from the AerobiCS Center Longitudinal Study (see

Table 4·8). Apparently healthy indiViduals within the ACLS cohort would be inclUSive of indiViduals within the

ACSM Low and Moderate Risk categones (see Table 2·4).

§For functional capacity of <5 METs, a small staff-to-patient ratio (I.e., one clinical staff member for every five to

eight patients) also is recommended

Abbreviation: (PM, cardiovascular, pulmonary, and/or metabolic disease

Despite nearly three decades of the so-called "exercise revolution," structmedexercise programs have been only marginally effective in getting people to bemore phYSically active. Fitness and cardiac exercise programs have typicallyreported dropout rates ranging from 9% to 87% (mean, 4.5%), highlighting thecompliance problem among those who initiate phYSical conditioning pro­gramsI4:3.144 Dropout rates are generally high in the first 3 mouths, increasing to

approximately .50% within 1 year. Thus, it appears that exercise is not unlikeother health-related behaviors (e.g., medication compliance, smoking cessation,weight reduction) in that typically half or less of those who initiate the behaviorwill continue, irrespective of initial health status or type of program.

To understand why people sometimes lack the motivation for regular physicalactivity, one must acknowledge a simple yet important fact: Exercise is voluntaryand time consuming; therefore, it may cxtend the day or compcte \\ith other val­ued interests and responsibilities of daily life. According to one recent repmi, newmembers of fitness centers typically use these facilities less than t\\ice a month. 14.5

In another study, patients undergoing gymnasium-based exercise training spentmore time in their cars going to amI from the programs than paticnts in a home­training comparison group spent on their cycle ergometers. J46 The traditionalapproach to the exercise compliance problem has involved attempting to persuadcdropouts to become reinvolved. However, an alternative approach involves the

TABLE 7-2. Summary of General Exercise Programming

Componentsof Training Frequency Intensity Duration ActivityProgram (sessions'wk ')

Cardiorespiratory 3-5 d·wk- 1 40%/50%-85% 20-60 min Large muscleHRR or V02 R groups55%/65%- Dynamic

90% HRmax activity12-16 RPE

Resistance 2-3 d'wk- 1 Volitional 1 set of 3-20 8-10 exercisesfatigue repetitions Include(MMF) (e.g., (e.g., 3-5, all major19-20 RPE) 8-10,12-15) muscle

Or groupsStop 2-3 reps

before voli-tional fatigue(e.g., 16 RPE)

Flexibility Minimal Stretch to tlght- 15-30 Static stretch2-3 d·wk- 1 ness at the seconds all major

Ideal end of the 2-4 x/stretch muscle5-7 d-wk- 1 range of groups

motion butnot to pain

Abbreviations: HRR, heart rate reserve; V0 2R, maximal oxygen uptake reserve; MMF, momentary muscular fatigue

162 SECTION III/EXERCISE PRESCRIPTION

recommended. For cxample, if a pcrson's health status is classified as modcraterisk, but he or she has a functional capacity of.5 METs, then the clinical profes­sional should supervise the excrcise program. If a person is of low risk, but has afunctional capacity of <7 METs, then a professional (Table 7-3) should supervisethe exercise program. It should be notcd that a functional capacity of ~7 METsis wcll below the 10th pcrcentile for apparently healthy men, and either at orbclow the 10th percentile [or most apparently bealthy women from the AcrobicsCenter Longitudinal Study (see Tahle 4-8). Apparently healthy individuals with­in the ACLS cohort would be inclusive of individuals within the ACSM Low andModerate Risk categOlics (see Table 2-4).

Supervised exercise programs are recommended for patients \vith symptomsand cardiorespiratOlY disease who are considcrcd by their physicians to bc clini­cally stable and who bave been medically clem'ed for participation in such pro­grams. It is recommended tbat supervised exercise programs for sucb individualsbe under the combined overall guidance of a physician; appropriatc nursing staff,and an ACSM-certified Program Director, ACSM Exercise Specialist, or ACSMRegistered Clinical Exercise Physiologist (see Appendix F). However, directsupervision of each scssion by a physician is not necessarily rcquired to ensuresafcty.142 These programs can be useful for those who need instruction in prop­er exercisc techniqucs. For some participants, direct supclvision may enhancecompliance \\ith an exercise program.

FIGURE 7-6. Self-motivation assessment scale to determine likelihood of exercise com­pliance. (Copyright 1978, Dishman RK, Ickes W, Morgan WP. Self-motivation andadherence to habitual physical activity. J Appl Social Psychol 1980; 10: 115-132. FromFalls HB, Baylor AM, Dishman RK. Essentials of fitness. Philadelphia: Saunders College,1980:Appendix A-B. Reproduced by permission of the copyright holders.)

Directions: Circle the number beneath the letter corresponding to the alterna­tive that best describes how characteristic the statement is when applied to you.The alternatives are:

A. extremely uncharacteristic of me.B. somewhat uncharacteristic of me.C. neither characteristic nor uncharacteristic of me.D. somewhat characteJistic of me.E. extremely characteristic of me.

Scoring: Add together the seven numbers you circled. A score ~ 24 suggestsdropout-prone behavior. The lower the self-motivation score, the greater thelikelihood toward exercise noncompliance. If the score suggests dropout prone­ness, it should be viewed as an incentive to remain active, rather than a self­fulfilling prophecy to quit exercising.

165

Precontemplation Enter

~-Contemplation

Preparation

Maintenance Relapse

~ermanenteXit

,,\ ~

Action

CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

umerous inter\'entions aimed at increasing phYSical acti\ity levels using behav-. I . I' a 11'lve l)ee[l described preViously \vith mixed results,lOr c lange counse In b " .

Nevertheless, the fen'or of the primary physicians' recommendatlOn appears tobe one of the most powerful predictors of the patient's participation In exer­cise/5 [ espeCially if a baseline fitncss assessment and an exercise prescnptlon areprOvided at the point of care. \.52 Research and cmpmc expenence suggests tl1,lt

1 . t' It· t a'es m'l)' enlnnce l)artlcl-certain program modi fications ant motlva JOna s 1a ebl , ,

pant interest and compliance, as shown in Box 7-3.

STRATEGIES FOR INCREASING EXERCISE ADHERENCE

Over the last decade, researchers have re-evaluated the scientific evidence link­ing physical inactivity \vith a variety of chronic diseases. These analyses suggest

ENCOURAGE LIFESTYLE PHYSICAL ACTIVITY

exercisina for a variet\' of reasons (e.g., job change andlor move, intercurrent ill­ness or i~jl1tY, perso~al convenience bctors, competing priorities [w~rk dead­lines]). Snch indi\~duals should be taught to deal WIth InactIve lapses 01 Ielapses,re-entered at the appropriate stage, and counseled that these behavlOrs are not

necessarily tantamount to failure.

Temp"", ,',....l1lI(eXit ~I ~

FIGURE 7-7. Progressive stages of readiness for behavior change, with specific reference

to temporary and permanent exits and relapse. (Adapted from Prochaska J,DiClemente C. Transtheoretical therapy, toward a more IIltegratlve model of change.

Psych Theory Res Prac 1982; 19:276-288.)

1. I get discouraged easily.2. I don't work any harder than I have to.3. I seldom if ever let myself down.4. I'm just not the goal-setting type.5. I'm good at keeping promises, especiaJly the ones I make

myself.6. I don't impose much structure on my activities.7. I have a very hard-driving, aggressive personality.

SECTION III/EXERCISE PRESCRIPTION164

ABCDE5 432 15 432 11 234 55 432 11 234 5

5 432 11 234 5

identification and subsequent monitOling of "dropout-prone" individuals, \vithan aim toward preventing recidivism. A brief questionnaire designed to assess"self-motivation" can be used along with measures of intention and self-efficacy, topredict male and female dropout-prone behavior (Fig. 7_6).147

Readiness for change theory has received \vide acceptance by health carepractitioners in assisting individuals to make permanent lifestyle changes,14~

including regular exercise. 149,1.50 A preliminmy interview/orientation provides anopportunity to identify the client's expectations (realistic or unrealistic), copingtechniques/defense mechanisms, belief systems and values, social support sys­tems, and stage of readiness for change (Fig. 7-7). Box 7-2 describes each of thesestages. Stage-specific interventions using varied approaches (e.g., structuredgroup programs versus home-based exercise), community resources, and serialmonitoring andlor communication should be employed. The latter may includeregular telephone contact, Illail (e.g., completion of activity logs), fax, videorecording, Internet, and transtelephonic ECG monitoring. Unfortunately, someindividuals may "exit" from the "preparation phase," and essentiaJly discontinuetheir sporadic activity patterns. Other persons in the "action" stage also may stop

that the intensity of exercise needed to achieve health-related benefits is prob­ably less than that required to improve CR fitness. Thus, frequent bouts ofmoderate-intensity activity (e.g., brisk walking, household chores, gardening,recreational activities) may serve as an alternative to vigorous exercise, provid­ed that the total energy expenditure is comparable. 15:) Recent randomized tri­als have shown that a lifestyle approach to physical activity among previouslysedentary adults is feasible and has similar effects on aerobic fitness, body com­position, and coronary risk factors as compared with a traditional structnredexercise program. 1.;0,154 Another recent study showed that lifestyle interven­tion, including at least ]50 minutes of physical activity per week, was even moreeffective than pharmacologic treatment, in reducing the incidence of type 2diabetes. 15.; Collectively, these findings have important implications for publichealth. 156

Although lifestyle exercise is not being suggested to replace traditional struc­tured exercise programs, it provides an effective complement to any health andfitness regimen. Accordingly, exercise profeSSionals should consider broadeningtheir client's recommendations beyond the frequency, intensity, duration, andmodes of training that are associated with structured programs, by encouraging

167

. I ••

CHAPTER 7 / GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION

• Recruit physician support of the exercise program.• Provide exercise facilities and changing facilities that are appropriately

maintained.• Clarify individual needs to establish the motive to exercise.

• Emphasize short-term, realistic goals.• Minimize injuries and/or complications with a light to moderate exercise

prescription.• Encourage group participation• Emphasize variety and enjoyment in the exercise program.• Employ periodic fitness testing to assess the client's response to the train-

ing program.• Recruit support of the program among family and friends• Include an optional recreational game to the conditioning program

format.• Establish regularity of exercise sessions.• Use progress charts to record exercise achievements.• Recognize participant accomplishments through a system of rewards.• Provide qualified, personable, and enthusiastic exercise professionals.

them to increase physical activity in daily living. To assist with this objective, afive-step counseling plan has been suggested to help clients initiate and maintain

a more physically active lifestyle:

1. Ask clients about their current structured excrcise and activity habits to deter­mine whether those activities are sufficient to confer health andlor fitness

benefits.2. Provide clients with a traditional exercise prescription.3. Brainstorm opportunities to increase physical activity in daily living (e.g.,

increase routine activity by taking the stairs rather than the elevator, increasetransportation-related physical activity by walking or cycling versus automo­bile, and find more convenient forms of leisure physical acti\~ty in parks, hIk­

ing trails, and bike paths).4. Emphasize the short- and long-term benefits of these varied approaches.5. Plan regular follow-up contact to reinforce efforts and devise ways to over­

come barriers to regular physical activity.

The Activity Pyramid has been suggested as one way to facilitate these objec­tives (see Fig. 7_1).157 In addition, despite a lack of scientific evidence,accelerometers or pedometer use may assist clients in tracking their daily activi­ties 158,1.;9 and facilitate exercise adherence.

• I'

SECTION III/EXERCISE PRESCRIPTION166

1. Precontemplation: Patients express lack of interest in making change.Moving patients through this stage involves use of multiple resources tostress the importance of the desired change. This can be achievedthrough written materials, educational classes, physician and family per­suasion, and other means.

2. Contemplation: Patients are "thinking" about making a desired change.This stage can be influenced by helping patients define the risks and ben­efits of making or not making the desired change (e.g., starting an exer­cise program).

3. Preparation: Patients are doing some physical activity but not meetingthe recommended criteria; that is, 30 minutes of moderate intensityphysical activity 5 d·wk- 1 or 3 to 5 d·wk- 1 of vigorous intensity activityfor 20 minutes.

4. Action: Patients are meeting the referenced (preparation) criteria on aconsistent basis but they have not maintained the behavior for 6 months.

5. Maintenance: Patients have been in action for 6 months or more.

*From Dunn AL, Marcus BH, Kampert JB, et al. Reduction in cardiovascular disease risk fac­tors: 6-month results from Project Active. Prev Med 1997;26:883-892; Dunn AL, MarcusBH, Kampert JB, et al. Comparison of lifestyle and structured interventions to increasephysical activity and cardiorespiratory fitness: a randomized trial. JAMA1999;281327-334.

tModified for physical activity interventions.

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2. Uoit"d States Departmellt of Health and JIllman S"n iccs. Plnsical atth'ih' ,lIld health: a rcport ofthe Sur!(eon CCllcral. 199f;.

:3. Bouchard C. Ph~'~i('aJ adi,it:" and health: introduction to the <!ost'-rcspollse symposiulIl . .\I(-'d SciSports Ewrc 2001 ::3:3:S34,--:3.50.

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prolonged intense endurance training. J Appl Physiol 1984;57:JI;57-1864.132. Fringer MN, Stull CA. Changes in cardiorespiratory parameters during periods of training and

detraining in yoong adolt lemales. ~Ied Sci Sports 1974;6:20-25.133. Knuttgen HC, i\ordesjo LO, Ollander B, et al. Physical conditioning through inten'al training with

young male adults. Med Sci Sports J973;5:220-226.134. Kendrick ZV, Pollock ML, Hickman TN, et al. Effects of training and detraining on cardiovascular

effiCiency. Am Correct Ther J 1971 ;2S:79-83.135. Hickson HC, Hosenkoetter MA. Reduced training frequencies and maintenance of increased aer­

obic power. Med Sci SPOltS Exerc 1981;13: 13-16.136. Hickson RC, Kanakis C Jr, Davis JR, et a\. Reduced training duration effects on aerobic power,

endurance, and cardiac growth. J Appl Physiol 191;2;5:3:225-229.137. Hickson RC, Foster C, Pollock ~I L, et al. Heduced training intensities and loss of aerobic power.

endurance, and cardiac growth. J Appl Physiol 1985;S8:492-499.

CHAPTER 7/ GENERAL PRINCIPLES OF EXERCISE PRESCRIPTION 173

138. Dressendorfer HII, Franklin 13A. Smith JL, et al. Hapid cardiac dcconditioning in joggers restrict­ed to walking: training heali rate and ischemic threshold. Chest 1997: 112:1107-1I II.

139. Craves JE, Pollock ML, Leggett 511, et a\. Effect of reduced training freejuenc;' on muscularstrength. Int J SpOJis Med 1988;9:3J 6-,3J 9.

140. Tucci JT, Carpenter DM. Pollock ML, d al. Effect of reduced frequency of traiuing aud detrain­ing on lumbar extension strcngth. Spine 1992; 17: 1497-1501.

141. Pate RH, Ilughes RD, Chandler JV, et al. Effects of arm training on retention of training eff'ectsderived from leg training. '"Ied Sci Sports 1978;10:71-74.

142. Franklin BA, Bonzheim K, Cordon 5, et al. Safety of medically superviscd outpatieutcarrliac reha­bilitation exercise therapy: a Ifi-year follow-up. Chest 1998;114:902-906.

143. Franklin BA. Program fadors that influence exercise (lCUlf:'H:'nce: practical adherence skills for

clinical staff. In: Dishman 13, ee\. Exercise Auherence: Its Jmpact on Public Health. Champaigu, JL:Human Kinetics, J91;8:237-258.

144. Oldridge, N B. Compliance with exercise rehabilitation. In: Dishmau 13, ed. Exercise Adherence:Its Jmpact on Public Health. Champai~n, IL: Human Kinctics, .1988:28:3-304.

145. Franklin 13A, Conviser J~I, Ste\\art B. The challenge of euhancing exercise compliance. J Am CoilCan.lioI200J;37:170A.

146. DeBusk HF, l-IaskellWL, Miller NH, et a\. '''!edica!ly directed at-homc rchabilitation soon afterdinically uncomplicated aClltc myocardial infardion: a lIew model f(}r patient care. Am J CarcUo!198.5;55:2S1-2.57

147. Falls liB, Baylor AM, Dishman 13K. Essentials for fitness. Philadelphia: Saunders College, 1980:Appendix A-13.

148. Prochaska J, DiClemente C. Transtheord ical therapy, toward a Inore integrative model of change.Psvch Theon' Hes Prac 1982;19:276-288.

149. D;lI1n AI" ~,iarcus BII, Kampert J13, et al. Heduction in cardiovascular disease risk f,wtors: 6-monthresults from Project Active. Prev ~Ied 1997;26:883-892.

150. Dunn AL, Mar~us BII, Kampelt J13, et al. Comparison of lifestyle and structured interventionsto increase physical activity anu caruiorespiratolY fitness: a randomized trial. JAMA 1999;281:327-3:34.

151. Aues PA, Waldmann ML, ~kCann WJ, et a1. Prechctors of cardiac rehahilitation participation inoluer coronalY patients. Arch Intern Med 1992; 152:1033-1035.

152. Petrella HJ, Koval JJ, Cunningham DA, d al. Can primary care doctors prescribe exercise toimprove fitness? The Stcp Test Exercise Prescription (STEP) project. Am J Prev '"Ied 2003;24:316-322.

J53. Cordon 1'\F, Kohl Ill, Blair SN. Life style exercise: a new strategy to promote physical activity forauults. J Cardiopulm Hehabil1993; 13:161-163.

154. Andersc'n HE, Wadden TA, Bartlett Sj, et a\. Effeds of lifestyle" activity vs structured aerobic cxer­cise in obese women: a randomized tria\. JAMA 1999:281:335-340.

155. Knowler WC, Barrctt-Connor E, Fowler SE, et al. Heduction in the incidence of t)l'" 2 diabeteswith lilestyle intervention or metlurmin. 01 Engl J Med 2002;346:393-403.

156. Pratt M. Benefits of lilestyle activity vs structured exercise. JAMA 1999;281:375-376.157. Leon AS, Norstrom J. Evidence of the role of physic,u activity and cardiorespiratory fitness in the

prevention of wronalY heart disease. Quest 199.5;47:311-319.158. Bassett DR Jr, Strath SJ. Use of pedometers in assessing physical activity. In: Welk CJ, ed. Physical

Activity Assessments for Health-Helated Research. Champaign, j L: Human Kinetics, 2002:163-177.

159. Tudor-Locke C. Taking steps toward increased physk:al activit)': using pedometers to measure and

motivate. Research Digest, President's Council un Physical Fitness and SPOIts 2002: 17:1-8.

174

Inpatient Rehabilitation Programs

CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 175

• Enabling patients to more safely return to activities of daily liVing within thelimits imposed by their disease

• Preparing the patient and support system at home to optimize recoveryfollo""ring hospital discharge

Before beginning formal phYSical activity in the inpatient setting, a baselineassessment should be conducted by a health care provider who possesses theskills and competencies necessary to assess and document heart and lung sounds,peripheral pulses, as well as musculoskeletal strength and flexibility. J Initiationand progression of phYSical activity depends on the findings of the initial assess­ment and varies with level of risk, thus inpatients should be risk-stratified as earlyas pOSSible follov-ring their acute cardiac event. The AACVPR or ACP risk strati­fication models (see Chapter 2) are useful because they are based on overallprognosis1 Furthermore, the clinical indications and contraindications for car­diac rehabilitation (inpatient or outpatient) are listed in Box 8-1; however, excep­tions should be considered based on clinical judgment.

Traditional inpatient programs with multiple steps for increasing activity are nolonger feasible because of the decreased length of hospital stay for most cardiacpatients. In many instances, uncomplicated patients are now seen for only 3 to 4days before hospital discharge. Activities during the first 48 hours followingmyocardial infarction (MI) and/or car'diac surgery should be restlicted to self-careactivities, arm and leg range of motion, and postural change. Simple eA'P0sure toorthostatic or gravitational stress, such as intermittent sitting or standing duringhospital convalescence, may reduce much of the detelioration in exercise perform­ance that generally follows an acute cardiac event4 Structured, formalized, in­hospital exercise programs after acute MI appear to offer little additional phYSiO­lOgiC or behavioral (self-efficacy) benefits over routine medical care.5

,6 Patients mayprogress from self-care activities, to walking sholi-to-moderate distances (50--500feet) start with minimal or no assistance, three to four times per day, to independ­ent ambulation on the unit. The optimal dosage of exercise for inpatients dependsin pari on their medical history, clinical status, and symptoms. The rating ofperceived exertion (RPE) provides a useful and complementary gUide to hemi rate(HR) to gauge exercise intensity. In general, the criteria for terminating an inpa­tient exercise session are similar to or slightly more conservative than those forterminating a low-level exercise test. Box 8-2 lists potential adverse responses thatshould result in cliscontinuation of an inpatient exercise session.

Recommendations for inpatient exercise programming include the follOWing;

Intensity

• RPE <13 (6-20 scale)• Post-MI: HR <120 beats'min- l or HRres ! + 20 beatS'min- 1 (arbitrmy upper

limit)• PostsurgelY: HRres! + 30 beats'min- I (arbitrmy upper limit)• To tolerance if asymptomatic

Duration

• Begin ""rith intermittent bouts lasting 3 to 5 minutes, as tolerated• Rest periods can be a slower walk or complete rest at patient's discretion;

shorter than exercise bout duration; attempt to achieve 2:1 exercise/rest ratio

••e•• Exercise Prescription• Modifications for

Cardiac Patients

CHAPTER

8

Contemporary cardiac rehabilitation programs provide several important corecomponents, including baseline patient assessment, nutrition counseling, risk fac­tor management, psychosocial management, and activity counseling. However,appropnately prescribed exercise therapy remains the cornerstone of these pro­grams. CardIaC rehabilItation programs traditionally have been categorized asphase I (mpatient), phase II (up to 12 weeks of electrocardiographic [ECe] mon­itored exercise and/or education following hospital discharge), phase III (variablelength program of intermittent or no ECe monitoring under clinical supervi­s1On), and phase IV (no ECe monitoring, professional supervision). New theoriesof risk stratification, recent data on the safety of exercise, and pressures in the eraof managed, capitated health care have contributed to a shortening and acceler­atlOn of these phases. There is now movement toward a continuum whereinpatients follow a regimen of exercise specific to their vocational and recreationalneeds, with more individualization of the length of program, degree of EcemOl1ltoru~g, and level of clinical supelvision.,,2 Outcome analysis is an importantpart of thIS evolut1On and includes not only clinical parameters and quality of life,but also recurrent cardiac events as well as physiologic, functional, and healthoutcomes.3

FollOWing a documented physician referral, patients hospitalized after a cardiacevent or procedure should be prOvided with a program consisting of early mobi­hzatlon, IdentiflcatlOn, and education of cardiovascular disease risk factors'assessme~t of the patient's level of readiness for phYSical activity; and compre~hensl~e dIscharge planning that includes referral to an outpatient cardiac reha­blhtatIOn program. ~he benefits of early mobilization and the other componentsof the mpatlent cardrac rehabilitation program include:

• Offsetting the deleterious psychological and physiologic effects of bed restduring hospitalization

• Providing additional medical surveillance of patients

• IdentifYing patients with significant cardiovascular, physical, or cognitiveimpairments that may influence prognOSis

CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 177

'. ft.I.

Outpatient Exercise Programs

Frequency

• Early mobilization: three to four times per day (days 1-3)• Later mobilization: two times per day (beginning on day 4) with increased

duration of exercise bouts

• Diastolic BP 2: 11 0 mm Hg• Decrease in systolic BP > 10 mm Hg• Significant ventricular or atrial dysrhythmias

• Second- or third-degree heart block• Signs/symptoms of exercise intolerance, including angina, marked dysp-

nea, and electrocardiogram changes suggestive of ischemia

See reference 1: Reprinted, by permission, from the American Association ofCardiovascular and Pulmonary Rehabilitation, 2004. Guidelines for Cardiac Rehabilitationand Secondary Prevention Programs, 4th ed. (Champaign, IL: Human Kinetics), 36 and 119

Progression

• When continuous exercise duration reaches 10 to 15 minutes increase inten­sity as tolerated

By hospital discharge, the patient should demonstrate an understanding ofphYSical activities that may be inappropriate or excessive. Moreover, a safe, pro­gressive plan of exercise should be formulated before they leave the hospital.Until the patient is evaluated with a submaximal or maximal exercise test, theupper limit of exercise should not exceed levels observed during the inpatientprogram. The patient also should be apprised of outpatient exercise programoptions and proVided with information regarding the use of home exercise equip­ment. Selected moderate- to high-risk patients should be encouraged strongly toparticipate in clinically supervised outpatient rehabilitation programs and, at aminimum, be counseled to identify abnormal signs and symptoms, suggestingexercise intolerance and the need for medical review. Although not all patientsmay be suitable candidates for inpatient exercise, virtually all benefit from somelevel of inpatient intervention, including risk factor assessment, activity counsel­ing" and patient and family education.

Presuming that the goals for inpatient cardiac rehabilitation are met, the goals foroutpatient programs are as follows:

• Provide appropriate patient monitoring and supervision to detect deteriora­tion in clinical status and provide ongoing surveillance data to the referringphySICIan to enhance medical management.

Indications• Medically stable postmyocardial infarction

• Stable angina• Coronary artery bypass graft surgery

• Percutaneous transluminal coronary angioplasty (PTCA) or other tran-scatheter procedure

• Compensated congestive heart failure

• Cardiomyopathy• Heart or other organ transplantation

• Other cardiac surgery including valvular and pacemaker insertion(including implantable cardioverter defibrillator)

• Peripheral arterial disease

• High-risk cardiovascular disease ineligible for surgical intervention• Sudden cardiac death syndrome• End-stage renal disease

• At risk for coronary artery disease, with diagnoses of diabetes mellitus,dyslipidemia, hypertension, etc.

• Other patients who may benefit from structured exercise and/or patienteducation (based on physician referral and consensus of the rehabilita­tion team)

Contra indications• Unstable angina

• Resting systolic blood pressure of >200 mm Hg or resting diastolic bloodpressure of > 110 mm Hg should be evaluated on a case-by-case basis

• Orthostatic blood pressure drop of >20 mm Hg with symptoms• Critical aortic stenosis (peak systolic pressure gradient of >50 mm Hg

with an aortic valve orifice area of <0.75 cm2 in an average size adult)• Acute systemic illness or fever• Uncontrolled atrial or ventricular dysrhythmias• Uncontrolled sinus tachycardia (> 120 beats'min- 1)

• Uncompensated congestive heart failure• 3-degree AV block (without pacemaker)• Active pericarditis or myocarditis• Recent embolism• Thrombophlebitis• Resting ST segment displacement (>2 mm)

• Uncontrolled diabetes (resting blood glucose of >300 mg·dL-1) or>250 mg'dL-1 with ketones present

• Severe orthopedic conditions that would prohibit exercise• Other metabolic conditions, such as acute thyroiditis, hypokalemia or

hyperkalemia, hypovolemia, etc.

176 SECTION III/EXERCISE PRESCRIPTION

........_I.''"I:~,~~~

Patients at lowest risk for exercise participation ,.• Direct staff supervision of exercise should occur for a minimum of 6 to

18 exercise sessions or 30 days postevent or postprocedure, beginningwith continuous ECG monitoring and decreaSing to intermittent ECGmonitoring as appropriate (e.g., at 6-12 sessions) , , ,

• For a patient to remain at lowest risk, ECG and hemodynamiC findingsshould remain normal, there should be no development of abnormalsigns and symptoms either within or away from the exerCise program,and progression of the exercise regimen should be appropriate.

Patients at moderate risk for exercise participation .• Direct staff supervision of exercise should occur for a minimum of 12 to

24 exercise sessions or 60 days postevent or postprocedure, beginningwith continuous ECG monitoring and decreasing to intermittent ECGmonitoring as appropriate (e.g., at 12-18 sessions)

• For a patient to move to the lowest-risk category, ECG and hemodynam­ic findings should remain normal, there should be no development ofabnormal signs and symptoms either within or away from the exerCIseprogram, and progression of the exercise regimen should be appropriate.

• Abnormal ECG or hemodynamic findings dUring exerCise, the develop­ment of abnormal signs and symptoms either within or away from theexercise program, or the need to severely decrease exerCISe levels mayresult in the patient remaining in the moderate-risk category or evenmoving to the high-risk category.

Patients at highest risk for exercise participation . . 0

• Direct staff supervision of exercise should occur for a minimum of 18 t36 exercise sessions or 90 days postevent or postprocedure, beginningwith continuous ECG monitoring and decreasing to Intermittent ECGmonitoring as appropriate (e.g., at 18, 24, or 30 sessions).

• For a patient to move to the moderate-risk category, ECG and hemody­namic findings should remain normal, there should be no developmentof abnormal signs and symptoms either within or away from the exerCiseprogram, and progression of the exercise regimen should be appropriate.

• Abnormal ECG or hemodynamic findings dUring exerCIse, the develop­ment of abnormal signs and symptoms either within or away from the!,xercise program, or significant limitations In the patient's ability to par­ticipate in the exercise regimen may resultm discontinuation of theexercise program until appropriate evaluation, and intervention wherenecessary, can take place.

, CI" f N th America V19(3) Williams,See reference 94: Reprinted from Cardiology !nICS 0 or., ,M.A. Exercise testing in cardiac rehabilitation: Exercise prescription and beyond, 415-431,© 2001, with permission from Elsevier.

178 SECTION "' / EXERCISE PRESCRIPTION

• Contingent on patient clinical status, return the patient to premorbid voca­tional and/or recreational activities, modify these activities as necessaJy, orfind alternate activities.

• Develop and help the patient implement a safe and effective formal exerciseand lifestyle activity program.

• Provide patient and family education about comprehensive cardiovascular riskreduction therapies and serial outcome assessments to maximize secondalYprevention.

As presented in Chapter 1, exercise training is relatively safe for the vast major­ity ofappropriately assessed cardiac patients. Althougb not completely preventable,the risk of exercise-induced events can be reduced through appropriate assess­ment, lisk stratification, patient education, and adberence to established recom­mendations.

1Prior to starting outpatient exercise rehabilitation, all cardiac patients

should be stratified based on their risk for a cardiovascular event during exercise(see Chapter 2). Current risk stratification models for cardiac patients, sucb as theones presented in Chapter 2 (see Boxes 2-1 and 2_2),1.2 allow categorization to asingle risk class (e.g., low, moderate, high). Patients who have not undergone exer­cise testing before entering a program or those with nondiagnostic exercise testsmay be inadequately categorized using this approach. Such patients may receive amore cautious approach to risk stratification at program entry and a more conser­vative exercise prescription. However, risk stratification should be only one factorto consider when making recommendations for outpatient medical supervision andthe need for continuous or instantaneous ECG monitoring during exercise.Recommendations for the intensity of supervision and monitoring related to therisk of exercise participation are described in Box 8-3.

The formation of exercise intervention plans for cardiac patients must not onlyconsider safety but also should consider as the patients' vocational and avoca­tional requirements, orthopedic limitations, premorbid and current activities, aswell as personal health and fitness goals of the patient. Prescriptive techniquesfor determining the exercise dosage (i.e., intensity, frequency, and duration) forthe general population are detailed in Chapter 7. Generally, the guidelines forappropriate exercise duration and frequency described in Chapter 7 can beapplied safely to most Jow- to moderate-risk cardiac patients. The remainder ofthis chapter considers specific modifications of the exercise prescription for car­diac patients participating in an outpatient rehabilitation setting, witb particularemphasis on intensity because this may be the most critical variable with regardto the safety and effectiveness of exercise training.

EXERCISE INTENSITY FOR THE CARDIAC PATIENT

The prescribed exercise intensity for a cardiac patient should be above a minimallevel required to induce a "training effect," yet below the metabolic load thatevokes abnormal clinical signs or symptoms7

- 9 Setting the safe upper limit forexercise intensity should be a foremost consideration, regardless of the methodsemployed, and should be established in order to prevent the signs and symptomslisted in Box 8-4. For most deconditioned cardiac patients, the minimal effectiveintensity for improving cardiorespiratOlY fitness approximates 45% of the

CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

• '.,. I •.' I I

179

• Onset of angina or other symptoms of cardiovascular insufficiency• Plateau or decrease in systolic blood pressure, systolic blood pressure of

>250 mm Hg or diastolic blood pressure of >115 mm Hg• ;::,1 mm 5T-segment depression, horizontal or downsloping• Radionuclide evidence of left ventricular dysfunction or onset of moder­

ate to severe wall motion abnormalities during exertion

• Increased frequency of ventricular dysrhythmias• Other significant ECG disturbances (e.g., 2- or 3-degree atrioventricular

block, atrial fibrillation, supraventricular tachycardia, complex ventrIcu­

lar ectopy, etc.)• Other signs/symptoms of intolerance to exercise

'The peak exercise heart rate generally should be at least 10 beats'min-' below the heartrate associated with any of the referenced criteria. Other variables (e.g., the correspondingsystolic blood pressure response and perceived exertion); however, also should be consid­

ered when establishing exercise intensity.

181CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

MODES OF EXERCISE FOR CARDIAC PATIENTS

perceived exeltion of 14 to 16 may be appropliate provided there are no signs orsymptoms of ischemia or serious dysrhythmias. However, there is considerableintelindividuaJ variation among patients with regard to the relationship betweenRPE and heatt rate or oxygen consumption17 One stud/" using cardiac patientsin an early outpatient program, observed a wide range in actual physiologicdemand (39%-92% of V02R) during an exercise session when patients wereinstructed to use an RPE of 11 to 13 to regulate exercise training intensity.Consequently, clinicians using RPE exclusively to regulate exercise intensity incardiac patients should be aware of the intersubject vmiability of this approach.

It is impOltant to know when myocardial ischemia occurs for cardiac patientswith exercise-induced ischemia, so that patients can exercise below the angina orischemic ECG threshold. Such patients may wish to consider using a healt ratemonitor that is highly accurate and offers the advantage ofalarms for the upper andlower limits of training, thereby potentiaJJy increasing the safety and effectivenessof exercise. A peak exercise training hemt rate 10 beats'min-1 or more below thethreshold has been suggested, because silent myocardial ischemia has been identi­Bed as a link between lack of premonitOling symptoms and increased lisk of car­diac arrest dUling physical stress19 An altemative is to use heart rate obselved atthe highest "safe" (i.e., no evidence of ischemia, significant dysrhythmia, hemody­namic abnormalities, or symptoms) workload achieved on an exercise test. It is alsoimpoltant to consider medication effects (see Appendix A), especially (3-blockers.For example, at a fixed extema! work load, patients taking a single moming dose ofa (3-blocker are more likely to e>'1Jelience tachycardia and ischemic ST-segmentdepression during late afternoon than during morning exercise bouts. 2o

Accordingly, prescribed healt rates for training should be based on an exercise testconducted under conditions as similar as possible, with respect to the timing ofmedications, to those under which the subject will be exercising.21

In two analyses,10,22 including individuals with and \vithout hemt disease,training at higher intensities resulted in greater percentage improvements inaerobic capacity than training at lower intensities, even when the lower-intensityactivity was compensated for by an increased exercise duration, frequency, orboth, to accomplish the same total amount of work. This finding is clinicallyrelevant in view of epidemiologic data showing lower all-cause mortality for thoseexercising at vigorous versus moderate intensities, and moderate versus lightintensities.2:3 Although some studies suppOlting the added cardioprotective effectof vigorous activity were plagued by methodologic limitations (e.g., a one-timeassessment of exercise habits and/or failure to control for the total caJOIicexpenditure),24 several welJ-designed intelventions have come to a similarconclusion.25-27 Collectively, these data suggest that physicians and allied healthprofessionals should encourage their patients with coronalY disease to improvetheir exercise capacity by initiating a moderate-intensity physical conditioningprogram and, if possible, stlive for the goal of more vigorous exercise, providedthere are no contraindications.28,29

Whenever possible, patients should be encouraged to engage in multipleactivities to promote total physical conditioning (i.e., treadmills, cycle and arm

I' .

SECTION III/ EXERCISE PRESCRIPTION

maximum o>.')'gen uptake reserve (V02R).10 Improvement in V02m,,, with light­to-moderate training intensities suggests that a decrease m thc mtenslty may bepaltially or totally compensated for by increases in the exercIse duration orfrequency, or both u As desClibed in Chapter 7, becal.lse healt rate and o>.')'genconsumption are linearly related dUling dynamic exercIse I1lvolvmg large musclegroups, a predetermined training or target healt rate (THR) has become WIdelyused as an index of exercise intensity in a valiety of clinical populatIOns, mcludmgcardiac patients8 The heart rate reselve method appears to closely approx.imatel;l~~same percentage of the oxygen uptake reserve (%V02R) m cardiac patients, .including those taking (3-blockers1.3 and diabetics with and \\~thout autonOlnlCneuropathy14 However, one cannot simply rely on these metabolic or healt rateformulas when prescribing exercise intensity for clinical populatIOns because othervariables (e.g., ischemic ST-segment depression, angina symptoms, dysrhythmlas,blood pressure responses, perceived exeltion) also should be consIdered. .

RPE, when properly explained and practiced, can provide a useful anduTIpor­tant adjunct to hemt rate as an intensity guide for exercisc training.

15PerceIved

exeltion is pmticularly valuable when patients enter an exercise-based rehablhta­tion program without a preliminm')' exercise test, or when clinical status ormedical therapy changes. Although perceived exertion generally correlates wellwith exercise intensity, even in patients taking (3-blockers,16 ischemic ST-scg­ment depression and selious ventricular dysrhythmias can occur at low heartrates and/or ratings of perceived effort. Generally, exercisc rated as 11 to 13(6-20 scale), between "fairly light" and "somewhat hard," correspo.nds to theupper limit of presclibed training healt rates during the early stagesof outpatientcardiac rehabilitation. For higher-intensity levels of exercIse tral11mg, ratl11g of

180

PROGRESSION OF EXERCISE FOR THE CARDIAC PATIENT

The recommended rate of progression in a physical conditioning programdepends on several variables, including the individual's functional capacity, Oltho­pedic and musculoskeletal status, comorbid conditions (e.g., obesity, diabetes),and their activity goals and preferences. Nevertheless, physical activity progressioncan be facilitated by gradual increases in the presclibed intensity, frequency, dura­tion, or combinations thereof. Using a presclibed THR provides a built-in regula­tor for improvements in cardiorespiratOlY fitness. As the patient becomes more fit,as velified by a conditioning bradycardia, the training work rate must be subtlyincreased over time to maintain the presclibed heart rate range.

For the low-risk cardiac patient, the endurance component of the exerciseprescription generally has tllree stages of progression: initial, improvement, andmaintenance (refer to Table 7-1). The initial phase of structured exercise trainingshould begin with a low total volume of exercise and include only modest increas­es in frequency, intensity, and duration over the first month. The first week oftraining might include three sessions at a moderate intensity for only 15 to 20minutes of continuous or intermittent activity (minimum of 10-minute boutsaccumulated throughout the day). For most previously sedentmy patients, theinitial intensity might range from 2 to 4 METs, corresponding to walking on levelground at a 1.5- to 3.5-mph pace, or stationary cycle ergometry at -150 to 300kg'm'min- 1 (25-50 W), depending on body weight. The improvement stage,

183CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

As desclibed in Chapter 7, the total dose or volume of exercise can be quantifiedand subsequently prescribed to target a specific level of energy expenditure. For

which includes months 2 through 6, begins with three to four exercise sessionsper week, 25 to 30 minutes per session (excluding warm-up or cool-down peli­ods), at a moderate to hard exercise intensity. Depending on the individual'sprogress, tl1ere are systematic increases in the frequency (up to five sessions perweek), intensity (up to 85% heart rate reserve or V02R), and duration (up to 40minutes per session) of training at 6 months. Thereafter, during the maintenancestage, the duration may be lengthened to 60 minutes or Jonger,36 especiaJly ifweight management is a primmy objective, and additional lifestyle activities maybe used to complement the conditioning regimen. Clinically stable higher-riskpatients, such as those with congestive heart failure, may require an intermittentformat of exercise and should be progressed according to symptoms and clinicalstatus. Intensity should be kept low until a continuous duration of 10 to 15 min­utes is achieved. An example of a progression from intermittent to continuousexercise is presented in Table 8-1. However, moderate- to high-lisk cardiacpatients may require more gradual increases in exercise dosage over time.

A scientific statement on preventing hemt attack and death in patients withatherosclerotic cardiovascular disease extolled the importance of a minimum of30 to 60 minutes of moderate-intensity activity three or four times weekly sup­plemented by an increase in daily lifestyle activities (e.g., walking breaks at work,using stairs, garde?ing, household chores); 5 to 6 hours a week was suggested foroptimal benefits.31

RECOMMENDED TOTAL DOSE OR VOLUME OF EXERCISE FORCARDIAC PATIENTS

TABLE 8-1. Example of Exercise Progression using Intermittent Exercise

Functional Capacity (FC) >4 METsWk %FC Total Min Min Min Rest Reps

at %FC Exercise

1 50-60 15-20 3-5 3-5 3-42 50-60 15-20 7-10 2-3 33 60-70 20-30 10-15 Optional 24 60-70 30-40 15-20 Optional 2

FC,,;4 METsWk %FC Total Min Min Min Rest Reps

at %FC Exercise

1 40-50 10-15 3-5 3-5 3-42 40-50 12-20 5-7 3-5 33 50-60 15-25 7-10 3-5 34 50-60 20-30 10-15 2-3 25 60-70 25-40 12-20 2 26 Continue with two repetitions of continuous exercise, with one rest

period or progress to a single continuous bout

SECTION III/ EXERCISE PRESCRIPTION182

ergometers, stair-climbers, and rowing machines), including range-of-motionexercises and resistance training, if medically appropliate, to maximize thecarryover of training benefits to real-life activities.

Physical activity programs initiated early can enhance self-confidence of car­diac patients, without increasing the risk of death, recurrent infarction, or othercomplications. The inherent neuromuscular limitations to the speed of walking(and, therefore, the rate of energy expenditure) establish it as an appropriatemode of activity for early-unsupervised exercise for coronary patients. Evenextremely slow walking «2 mph) approximates 2 METs and may impose meta­bolic loads sufficient for exercise training in lower-fit subjects.30 The CR adapta­tions to walking are well documented in persons \vith and \vithout coronary mterydisease. Blisk walking programs provide an activity intense enough to increaseaerobic capacity and decrease body weight and fat stores in previously sedentary,middle-aged men.31 Coronary patients undergoing a walking program demon­strated decreases in the rate-pressure product and somatic oxygen requirementsat a fixed submaximal work load, suggesting increased mechanical efficiency.32Vmiations of conventional walking training, including walking \\lith a 3- to 6-kgbach'Pack load33 and swimming pool walking34 offer additional options for thosewho \\Iish to reduce body weight and fat stores, improve cardiorespiratory fitness,or both. One study sought to determine if men and women \\lith coronary arterydisease could achieve an exercise intensity during a brisk I-mile walk on a flattrack sufficient to induce a training heart rate (THR), arbitrarily defined as ~70%of measured HRmax .

35 These findings suggest that brisk walking is of a sufficientintensity to elicit a THR in all but the most highly fit patients with coronary dis­ease.

CHAPTER 8 / EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 185

TABLE 8-2. Guidelines for Exercise Prescription for Cardiac PatientsWithout an Entry Exercise Stress Test

*Resistance training consisting of 10 to 15 repetitions per set, one set of 8 to 10 exercises, 2 d'wk 1

tFor patients who tolerate more than 5 minutes, allow up to 10 minutes on each exercise device for a cumulativeexercise duration of 30 to 45 minutes.

*Use of these techniques may result in significant intersubject variability in exercise intensity as defined by percentof actual HRR or VO,R (Joo KC, Brubaker PH. MacDougall AS. et al. Exercise prescrrption using heart rate plus 20 orperceived exertion in cardiac rehabilitation. J Cardlopulm Rehabil 2004;24: 178-186).

§Treadmill. 1 to 2.5 mph, 0% grade; leg ergometer (25-50 W. depending on the patient's body weight);arm ergometer, <25 W.

Abbreviations: ROM, range of motion exercise; MI, myocardial infarction; CABG, coronary artery bypassgraft surgery; RHR. resting heart rate; RPE, rating of perceived exertion.

10-20 minutes, 2 d-wk- 1

Initial Recommendations

5-10 minutes

5-10 minutes

1-2 bouts per day, 5 d'wk- 1

MI: 30-45 minutesCABG: 30-45 minutesRHR +20 beats'min- 1

RPE: 11-13Treadmill, leg ergometer, arm ergometer,

ROM, stairsType of activities§

Component

Intensity:t:

Warm-upStretching, low-level calisthenics(ROM)

Muscular fitnessResistance exercise: * all major musclegroups

Cardiorespiratory fitnessFrequencyDurationt

Cool-downLow-level aerobic exercise, stretching

Initial exercise intensities can be determined according to the length of timefrom the acute cardiac event and associated complications, duration since hospitaldischarge, and the information obtained during the patient's preliminary outpatientassessment (e.g" activities of daily living, current home walking program, associat­ed signs and symptoms). Patient questionnaires, such as the Duke Activity StatusIndex (Fig. 8_1)42 can be used to estimate an individual's activity status and func­tional capaCity in the absence of a preliminaly exercise stress test. Nevertheless,initial exercise intensities usually range from 2 to 3 METs, corresponding to 1 to3 mph, 0% grade on the treadmill, or 100 to 300 kg'm'min- 1 (or 12.5-50 W) onthe cycle ergometer, depending on body weight, with gradual increments of 0.5 to1.0 M'ETs as tolerated.1.2 The THR can be set at an arbitraly level of approximate­ly 20 beats'min- 1 above standing rest, and gradually increased using perceivedexertion in the absence of symptoms, abnormal hemodynamiCS, threatening ven­tricular dysrhythmias, or ECG changes Signifying myocardial ischemia. If ECG­telemetry monitOJing suggests new-onset ST-segment depression, this should beconfirmed with 12-lead electrocardiography during a simulated exercise session.Use of arbitrarily determined heart rate levels and/or subjective ratings of exertionshould be done with caution, because there is Significant intersubjective vmiability

stable cardiac patients generally it is prudent to progress over a 3- to 6-month peli­od to a total dose or volume of physical activity energy expenditure of more than1,000 kcal'wk- I because activity below this level was associated with coronaryartely progression in one study.'38 Higher levels of physical activity and/or exerciseenergy expenditure, corresponding to 1,533 ± 122 and 2,204 ± 237 kcal'wk-1,were associated with either no change or a reversal of coronary atheroscleroticlesions, respectively38 These goals would require walking approximately 24 and 32km (15 and 20 miles) per week for most patients. Several investigations haveobserved that the estimated phYSical activity energy expenditure of a typical cardiacmaintenance program palticipant is <300 kcal per session39

,4o Fmthermore, phys­ical activity energy expenditure on "nonprogram days" for cardiac rehabilitationpmticipants averaged <200 kcal·d- 140 Although weekly amounts of phYSical activ­ity of these cardiac rehabilitation pmticipants in one study averaged 1,600kcal'wk-I, there was Significant behveen-subject variability, with a standard devia­tion of 846 kcal'wk-1 and a range of 397 to 4,557 kcal'wk- 140 Consequently, only43% and 19% of participants achieved the target levels of 1,500 and 2,100kcal'wk -1, respectively. To maximize the potential for coronmy artery disease sta­bility and/or regression, patients should focus on achieving a total volume of phys­ical activity of 1,500 to 2,100 kcal 'wk-138 Clinicians need to recognize and conveyto program participants that three traditional (30--40 minutes of moderate-intensi­ty exercise) sessions per week will fall short of these goals and that phYSical activityoutside of the center-based program is necessaly40

Exercise Prescription Without aPreliminary Exercise Test

184 SECTION III/EXERCISE PRESCRIPTION

In patients with known or suspected coronary disease, a pharmacologic stress testmay have been recently performed; however, these tests may prOvide insufficientdata to formulate a traditional exercise prescliption. Furthermore, symptom­limited exercise testing may be inappropriate for some patients at or soon afterhospital discharge, including those with extreme deconditioning, orthopedic lim­itations, or those with left ventricular dysfunction who are limited by shortness ofbreath 41 An initial exercise prescription for patients with no preliminaly exercisestress test is shown in Table 8-2. Exercise programs for such patients should beimplemented conservatively \vith close medical surveillance; moreover, a periodof continuous ECG-telemetry monitoring is highly recommended. The patientshould be observed closely for signs and symptoms of exercise intolerance, andexercise blood pressure measurements should be obtained regularly,

In some instances, dobutamine testing may evoke a considerable rise in heartrate, This is particularly true if atropine is infused at the end of the dobutamineinfusion protocol. If the echocardiogram or myocardial perfusion imaging resultsare negative for ischemia, the highest healt rate obtained may be used as a guideto determine the presclibed THR. However, an abnormal test may signify theneed for coronary revascularization, more aggressive medical management (e.g.,drug therapy), or both, before initiating an exercise training program. Becausethese test results may not necessarily define the ischemic ECG threshold, othercomplementmy methods (e.g., symptoms, Holter monitoring, ECG-telemetry,heart rate monitor [watches)) should be used in conjunction with conservativehealt rate guidelines to determine the exercise intensity.

Types of Outpatient Exercise Programs

FIGURE 8-1. Duke Activity Status Index (QASI). Sum the weights for each "yes" replyand enter into the following equation: V02peak (mL·kg- 1·min 1) = 0.43 x DASI + 9.

187

..• III •

CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

• Estimated functional capacity of 2:7 METs (or measured 2:5 METs) ortwice the level of occupational demand

• Appropliate hemodynamiC response to exercise (increase in systolicblood pressure v.ith increasing work load) and recovery

• Appropriate ECG response at peak exercise with normal or unchangedconduction, stable or benign dysrhythmias, and nondiagnostic ischemicresponse (i.e., <1 mm ST-segment depression)

• Cardiac symptoms stable or absent• Stable ancIJor controlled baseline heart rate and blood pressure• Adequate management of Jisk factor intervention strategy and safe

exercise paliicipation such that the patient demonstrates independentand effective management of lisk factors with favorable changes inthose lisk factors

• Demonstrated knowledge of the disease process, abnormal signs andsymptoms, medication use, and side effects

for some pcriod of time to facilitate both exercise and lifestyle managementchanges. Advantages to cxercising in a structured program include group sup­poli, profeSSional feedback and monitOJing, increased access to varied trainingmodalities, recreational opportunities, and the availability of direct medicalsurveillance and emergency suppmt. Outpatient cardiac rehabilitation programstraditionally havc been divided into phases II and III, often scparated arbitrar­ily based on length of participation or number of exercise sessions attended. Inthe current era, the outpatient rehabilitation process is viewed more on acontinuum from carly outpatient to long-term (lifelong) maintenance. l

Movement along this continuum should be individualized to the patients' med­ical and psychosocial needs and not Simply hased on length of participation.Guidelines for the intensity of supervision and dcgree of monitoring arcdescribed in Box 8-3. The decisiqn to progress a patient from a clinically ancIJorprofeSSionally supenised program to a nonsupervised environment is best madeby the physician with input from the rehabilitation team. Gcneral criteria forsuch decisions are presentcd in Box 8-05.

Not all patients are able to, or wish to, participate in a supervised rehabil­itation program. Accordingly, home exercise rehabilitation should be promulgat­ed as an alternative, hecause of its lowcr cost, convenience, and potential topromote independence and sclf-responsibility4.5 For low-risk patients, medicallydirected, home-based rehabilitation and supervised group programs have showncomparable safety and efficacy. Smoking cessation programs and dyslipidemiamanagcment also can be successfully achieved in a home-based rehabilitationsetting.4fi A variety of techniques may be used to facilitate monitoring ancIJorcommunication hetween patients managed at home and rehabilitation staff,

•

8.00

7.50

4.50

5.25

6.00

SECTION III/ EXERCISE PRESCRIPTION

1- Take care of yourself, that is, eat, dress, bathe, or use the toilet?

2- Walk indoors, such as around your house?

3- Walk a block or two on level ground?

4- Climb a flight of stairs or walk up a hill?

5- Run a short distance?

6- Do light work around the house like dusting or washing dishes?

7- Do moderate house work around the house like vacuuming,sweeping floors, or carrying groceries?

8- Do heavy work around the house like scrubbing floors or lifting ormoving heavy furniture?

9- Do yard work like raking leaves, weeding, or pushing a power mower?

10- Have sexual relations?

11· Participate in moderate recreational activities like golf, bowling,dancing, doubles tennis, or throwing a baseball or football?

12- Participate in strenuous sports like swimming, singles tennis, football,basketball, or skiing?

Can you:---'----------------------- Weight

2.75

1.75

2.75

5.50

8.00

2.70

3.50

186

with these approaches. IS Nonetheless, one study compared the rehabilitation out­comes in 229 post-MI and coronalY artely bypass patients who had undergone pre­limimuy symptom-limited exercise testing with 271 matched patients who didnot4:3 Program prescliption and progression for the fonner group involved con­ventional intensities (70%---85% HRm"" HPE 11-14), whereas the latter group ini­tiated training at approximately 2 to 3 METs and, in the absence of abnormalsigns/symptoms, progressed using heart rate and perceived exeltion. The programlasted 12 weeks, and all patients underwent continuous ECG telemetry monitmingfor the first 3 to 6 wceks. Both groups showed similar physiologic improvements,and there were no cardiovascular events in either group.

Although traditional supervised group programs are associated with increasedcost and extended travel time,3 considerable data are available regarding thesafety, efficacy, and cost effectiveness of this model.44 Such programs also aremore appropriate for the growing medical complexity of candidates who may beat increased risk for future cardiac events, as well as those unable to self­regulate, or those whose adherence depends heavily on group support. Ideally,most cardiac patients should participate in a supenised rehabilitation program

Potential Cardioprotective Effects of Regular Physical Activity

189CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

ELIGIBILITY AND EXCLUSION CRITERIA FORRESISTANCE TRAINING

Resistance Training for Cardiac PatientsMany cardiac patients lack the physical strength and/or self-confidence toperform common activities of daily living. Resistance training provides an effec­tive method for improving muscular strength and endurance, preventing andmanaging a variety of chronic medical conditions, modifying coronmy risk fac­tors, and enhancing functional independence62 Resistance training also appearsto decrease cardiac demands (i.e., reduced rate pressure product) during dailyactivities like carrying groceries or lifting moderate to heavy objects, while simul­taneously increasing endurance capacity63

aerobic requirements at any given oxygen uptake or submax.imal workload, evenwhen low to moderate exercise training intensities are used.54 The beneficial effectsof exercise training on myocardial perfusion and/or indices of myocardial ischemiainclude less ST-segment depression dming exercise testing, reduced anginal symp­toms, and resolution of reversible myocardial perfusion abnormalities.55,56Additionally, short-term aerobic exercise training has now been shown to improveendothelium-dependent vasodilation both in epicardial coronmy vessels and inresistance vessels in patients with asymptomatic coronmy atherosclerosis.57 Finally,it has been suggested that exercise training improves hemostatidfiblinolytic param­eters in patients with and without coronary altery disease, reducing the potentialfor thrombosis and plaque expansion, and simultaneously elevating red blood celltransport efflciency,58 Ischemic preconditioning; that is, bliefperiods of myocardialischemia before coronmy occlusioh,"9 also may help to reduce infarct size and/orthe potential for threatening venllicular dysrhythmias 60 Although enduranceexercise training has been shown to increase baroreflex sensitivity and heart ratevariability in patients with coronary artely disease,61 reports that described changesin venllicular dysrhythmias related to exercise-based cardiac rehabilitation haveyielded inconsistent results44

Many low- to moderate-risk patients should be encouraged to incorporate resist­ance training into their physical conditioning program, especially those who rely ontheir upper extremities for work or recreational pursuits. Box 8-6 lists criteria andtime course recommendations for resistance training in low to moderate riskcardiac patients. The safety and effectiveness of resistance training in higher riskcat:diac patients (i.e., those with severe left ventricular dysfunction, severe valvulardisease, uncontrolled dysrhythmias, uncontrolled hypertension, or unstable symp­toms) have not been well studied.44 Accordingly, these patient subsets may requiremore careful evaluation, initial monitOling, and progression. General absolute andrelative contraindications to resistance training are similar to those used for theaerobic component of cardiac exercise programs (see Box 8-1) and should beevaluated in each patient. Palticipation in resistance training ultimately should becontingent on approval of the medical director and/or the patients' personal physi­cian. Box 8-6 lists the general guidelines of resistance training for cardiac patients.

HR variabilit)

Vagal toneMyocardial02 demand

Coronary flow I Adrenergict activityFibrinolysis

Plateletadhesiveness

I Endothelialt dysfunction

t Blood viscosity

Depression

Stress

t Social support t Fibrinogen

SECTION III/EXERCISE PRESCRIPTION

t Adiposity

BPs

t Insulinsensitivity

t Inflammation

Improvedlipids

188

including regular telephone contact, mail (e.g., completion of activity logs), fax,video recording, Internet, and transtelephonic ECG monitoring.

Benefits of Endurance Exercise Training in Cardiac PatientsThere are multiple physiologic and psychosocial mechanisms by which moderate tovigorous physical activity may decrease morbidity and mOttality rates associatedwith the secondary prevention of cardiovascular disease (Fig. 8-2). Aerobic exercisetraining programs can reduce stress and depression and promote decreases in bodyweight and fat stores, blood pressure (particularly among hypertensive individuals),total blood cholesterol, sel1lm triglycerides, and low-density lipoprotein choles­terol, and increases in the "antiatherogenic" high density lipoprotein subfraction47

The beneficial effect ofexercise on a variety oflipid and lipoprotein variables, inde­pendent of changes in body weight, is seen most clearly with higher amount, high­er intensity regimens 48 Considerable data now strongly SUpp01t the role of aerobicfitness and regular physical activity in improving both glucose and insulin home­ostasis49.50 Moreover, recent cross-sectional studies have reported an inverse rela­tionship benveen C-reactive protein, a marker of inflammation, and CR fitness inmen5l and womenS2 The effects of chronic exercise training on the autonomicnervous system act to reduce heart rate at rest, during exercise and in recovely..,3Vagal tone appears to be increased at rest, whereas sympathetic drive (circulatingcatecholamines, particularly norepinephline) is decreased dming exercise. Theresult is a reduction in the healt rate-blood pressure product and myocardial

FIGURE 8-2. A structured endurance exercise program sufficient to maintain andenhance cardiorespiratory fitness may provide multiple mechanisms to reduce nonfataland fatal cardiovascular events.*Moderate to vigorous exercise intensities (i.e, 2':55% HR max, 2': 12-13 rating of per­ceived exertion (6-20 scale). Abbreviations: SP, blood pressure; HR, heart rate.

TIME COURSE FOR RESISTANCE TRAINING

RESISTANCE TRAINING PRESCRIPTION FOR CARDIAC PATIENTS

191CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

Exercise Training for Return to Work

should not exceed that during prescribed endurance exercise, and perceivedexertion should range from 11 to 13 ("light" to "somewhat hard") on the BorgcategOlY scale. 15 AdditionaJIy, patients should be counseled to raise weightswith slow, controlled movements to full extension, exhale during the exertionphase of the lift, avoid straining and the Valsalva maneuver, and stop exercisein the event of warning signs and symptoms.! Tight gl;pping of the weighthandles or bar should be avoided to prevent an excessive blood pressureresponse to lifting.

Failure to return to work after a cardiac event can stem from a variety of factors,including low functional capacity, poor prognosis, reduced self-efficacy, or inap­propl;ate perceptions of actual job demands.65 Exercise training may enhance thereturn to work decision and long-term employment by helping selected patientsto improve their work capacity and self-efficacy for physical work. Nevertheless, itappears that exercise-based cardiac rehabilitation exelis less of an influence on therates of return to work than many nonexercise variables, including employer atti­tudes, pl;or employment status, and economic incentives.44

In addition to enhancing work capacity, exercise training may help patients gaina better appreciation of their ability to perform physical work within reasonable lev­els of safety. Monitoring the physiologic responses to a simulated work environ­ment also may be helpful in this regard. Enhanced self-efficacy, in tum, may leadto a greater \villingness on the pmi of patients to resume work and/or more wiJI­ingness to remain employed long-term follO\ving a cardiac event. Patients who planto resume work combined \vith environmental heat stress should consider a grad­ual exposure to an outdoor exercise program during convalescence rather thanrestticting all exercise to an air-conditioned environment.65 A few days of relative­ly short periods of mild to moderate exercise in a warm environment can enhancethermoregulation that, in tum, can lower the cm'diovascular demand of work com­bined with heat stress.66 Refer to Appendix E for further discussion of the impactof environmental factors on vocational requirements.

Cardiac patients who have specific needs to consider when formulating theexercise prescription include those with history of myocardial ischemia, conges­tive heali failure, pacemakers, and/or implanted cardioverter defibrillators(ICDs), cardiac transplantation, as well as revascularization or valve surgelY. Amore comprehensive deSCription of exercise testing and training protocols forthese patient subsets is available elsewhere67 A brief description of each popula­tion and specific modifications to the exercise prescription is provided.

MYOCARDIAL ISCHEMIA

Special Cardiac Patient Populations

Ischemia generally occurs when clinicaJIy significant lesions (i.e., 70% or moreof the vessel's cross-sectional area) result in blood flow inadequate to meet

•• t I

SECTION III/EXERCISE PRESCRIPTION190

• Minimum of 5 weeks after date of MI or cardiac surgery, including 4weeks of consistent participation in a supervised CR endurance trainingprogram:j:

• Minimum of 3 weeks following transcatheter procedure (PTCA, other),including 2 weeks of consistent participation in a supervised CRendurance training program:j:

• No evidence of the following conditions:o Congestive heart failureo Uncontrolled dysrhythmiaso Severe valvular diseaseo Uncontrolled hypertension. Patients with moderate hypertension (sys­

tolic BP > 160 mm Hg or diastolic BP > 100) should be referred forappropriate management, although these values are not absolutecontraindications for participation in a resistance training program

o Unstable symptoms

'Reprinted, with permission, from the American Association of Cardiovascular andPulmonary Rehabilitation, 2004. Guidelines for Cardiac Rehabilitatoin and SecondaryPrevention Programs, 4th ed. (Champaign, IL: Human Kinetics). 36 and 119.

tin this box, a resistance exercise program is defined as one in which patients lift weights50% or greater of 1 RM. The use of elastic bands, 1- to 3-lb hand weights, and light freeweights may be initiated in a progressive fashion at phase II program entry, provided noother contraindications exist.

*Entry should be a staff decision with approval of the medical director and surgeon asappropriate.

Many patients can safely perform static-dynamic activity equivalent to carryingup to 30 pounds by 3 weeks after acute MI.64 Thus, it is possible that resistanceexercise could be initiated sooner if a continuum of modalities is employed. A tra­ditional resistance training program has been defined as one in which patients liftweights corresponding to 50% or more of the maximum weight that could beused to complete one repetition (i.e., 1 repetition maximum, 1 RM)l However,the use of elastic bands, light (1- to 5-lb) cuff and hand weights, light free weights,and wall pulleys may be initiated in a progressive fashion at immediate outpatientprogram entty (i.e., phase II) in the absence of contraindications.

The cardiac patient should start at a low weight and perform one set of 10 to 15repetitions to moderate fatigue using 8 to 10 different exercises. Weight isincreased slowly as the patient adapts to the program (approximately 2 to 5Ibs'wk- ' for arms and 5 to 10 Ibs'wk- I for legs). The rate-pressure product

192 SECTION III/ EXERCISE PRESCRIPTION

myocardial oxygen demands, causing significant ST-segment depression, anginapectoris, transient myocardial perfusion abnormalities, or combinations thereof.vVhen ischemic ECG changes occur in the absence of symptoms It IS referred toas silent ischemia. For a given patient, stable angina predictably occurs with pro­gressive exercise at approximately the same rate-pressure product. .In contrast,unstable angina may be charactelized by an abrupt increase in the frequency ofangina, angina at rest, or both. This acceleration of symptoms may herald animpending cardiovascular event, selves as a contraindication to exerCIse, and

requires immediate medical attention. .Exercise training can decrease the sevelity of angina at subm<1,xlImillevels of

exertion by reducing heart rate, systolic blood pressure and subsequent myocar­dial oxygen consumption (MV02). In addition to the reduction in myocardialdemand, exercise training may improve myocardial blo<:? supply throughchanges in endothelial function and vascular smooth muscle.'"

Exercise Prescription and Training Considerations for theAngina Patient

• Exercise may be inappropriate for those who e:l:perience exeliional angina ataerobic requirements of <3 METs.

• The plimary goal for persons with angina is to increase the anginal andischemic ECG threshold by decreasing the rate-pressure product at any gwenlevel of submaximal exeliion.

• Patients should be taught to recognize the symptoms that may represent clas­sic angina pectOlis, such as substernal pressure radiating across the chestand/or down the left arm, back, jaw, or stomach, or lower neck pain or dis­

comfort.• The exercise session should be discontinued, or at least decreased in intensi­

ty, when the discomfOli reaches a moderate level (i.e., >2 on 1--4 scale) level.• The exercise session should include a prolonged warm-up and cool down

(~10 minutes), both of which may have an antianginal effect, and consist ofrange of motion, stretching, ancllow-level aerobic activities.68 The goal of thewarm-up is to gradually raise the heali rate response within 10 to 20beats'min- 1 of the lower limit presclibed for endurance training.

• Because symptomatic or silent ischemia may be arrhythmogenic,19 the THRfor endurance exercise should be set safely below (~1O beatS'min -I) theischemic ECG or anginal threshold. Alternatively, the upper heali level canbe set as the highest "nonischemic" workload from the GXT.

• Patients ,vith stable angina should be counseled regarding the potentialexacerbation of symptoms while exercising in the cold.

• Upper body exercises may precipitate angina more readily than lower bodyexercises because of a higher pressor response.

• Patients ,vith stable angina may, in selected cases, also benefit from pro­phylactic (preexercise) nitroglycerin. However, the lise of prophylactic nitro­glycelin should be cleared \vith the supelvising physician ancl!or refening

physician.• Blood pressure should be checked routinely before and after the administra­

tion of nitroglycerin to reduce the potential for hypotensive sequelae.

CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 193

• Intermittent, shOlier duration-type exercise on a more frequent basis (e.g.,4-6 d'wk- 1 ,vith 5 to 10 minutes per session and two or three sessions perday)68 may be useful.

• Any increase or change in anginal symptoms should be recorded and receiveimmediate medical attention as it may reflect a change in coronary status.

• If anginal symptoms are not relieved by termination of exercise or by the useof three sublingual nitroglycerin tablets (one taken every 5 minutes), thepatient should be transported to the nearest hospital emergency center.

CONGESTIVE HEART FAILURE

Congestive heart failure (CHF) is characterized by the inability of the heart toadequately deliver oxygenated blood to metabolizing tissue, secondary toimpairment in cardiac output. Impaired left ventricular systolic function ancl!ordiastolic dysfunction can result in abnormalities in skeletal muscle metabolismand morphology, vascular function, neurohormonal responses, or pulmonaryfunction 69 Although treatment with bed rest and restricted physical activity isstill appropriate for acute or unstable conditions, exercise can be safe and ben­eficial for those with chronic heart failure 70 Previous concerns71 regarding thepotential deleterious effects of early exercise training in patients recoveringfrom large anterior wall MI, causing abnormal ventricular remodeling andinfarct expansion, now have been resolved. Two randomized controlled trials inpatients with anterior Q-wave MI and decreased ejection fraction showed nosignificant difference in left ventlicular dysfunction between exercise trainingand controI patients .'2.73

Physical conditioning in patients ,vith heart failure and moderate to severeleft ventricular dysfunction results in improved functional capacity and qualityof life, and reduced symptoms74

.75 Peripheral adaptations (increased skeletal

muscle oxidative enzymes and improved mitochondrial size and density) arelargely responsible for the increase in exercise tolerance. 7o Whether thesephysiological adaptations will ultimately decrease fatal and nonfatal cardiovas­cular events is yet to be determined by a large prospective trial, although thereis at least one small trial that showed a reduction in hospital admissions andimproved I-year sUlvival74 A large prospective randomized trial, Heart Failureand A Controlled Trial Investigating Outcomes of Exercise TraiNing(HF-ACTION), funded by the ational Institutes of Health, is underwaycurrently. This trial proposes to randomize patients with CHF to a formalexercise training program (12 weeks), followed by home-based exercise (-3years), or usual care, ,vith the primary endpoints of all-cause mortality orall-cause hospitalizations.

Exercise Prescription and Training Considerations for HeartFailure Patients

• CHF patients who are selected for exercise training should be stable onmedical therapy without absolute contraindications (particularly obstructionto left ventricular outflow, decompensated CHF, or threatening dysrhyth­mias) and have an exercise capacity of more than 3 METs.

194 SECTION III/ EXERCISE PRESCRIPTION

• If possible, peak oxygen consumption should be determined by direct gasexchange measurements because aerobic capacity may be markedly overesti­mated from treadmill exercise time in this patient subset.6'J

• Many of these patients also may be taking multiple medications, includingdigoxin, diuretics, vasodilators, ACE inhibitors, f3-blockers, and antiarrlwth­mics, which have the potential to influence the ECG and hemodym{micresponse to exercise. Moreover, hypokalemia commonly results from chronicdiuretic therapy.

• Because malignant ventticular dysrhythmias are the most common cause ofsudden cardiac death in CHF patients, supe/visol)' staff should be especiallyvigilant of worsening signs and!or symptoms (e.g., increasing fatigue, worse­than-usual dyspnea or shOttness of breath or angina on exeltion, edema,sudden weight gain, or malignant ventricular dysrhythmias) that mav suggestdetelioration in clinical status. Serial ECG and blood pressure monitOlingmay be helpful in this regard.

• Exercise intensity should be based on a symptom-limited treadmill or cycleergometer evaluation, using a THR range corresponding to approximately40% to 75% V02"""" 3 to 7 d'wk- l, 20 to 40 minutes per session fi9

• If possible, ancillaty study data (e.g., exercise echocardiogram, radionuclidestudies, gas analysis) may be helpful when formulating the exercise intensityto avoid work rates that produce ischemic wall motion abnormalities, 19 a dropin ejection fraction, a pulmonaJy wedge pressure greater than 20 mm Hg, ora response exceeding the ventilatOty threshold69

• Warm-up and cool-down peliods should be lengthened to a minimum of 10to 15 minutes each, and patients should be advised to avoid isomettic exertion.

• Training sessions initially should be brief (e.g., 10-20 minutes), includingexercise for intervals of 2 to 6 minutes separated by 1 to 2 minutes of rest, andprogressively lengthened as the patient's tolerance improves. Interval exercisetraining has been used in patients with chronic CHF, applying shOtt bouts ofintense muscular loading, \vith good clinical results and accelerated rehabili­tation outcomes'6

• \Valking, stationary cycling, and other aerobic activities, including ann exer­cise training, generally are recommended. These moderate-intensity activitiesmay be safely and effectively complemented by a resistance training programin patients \vi!~ stable CHF to improve symptoms of fatigue, dyspnea, andquality of life."

• Because the chronotropic response may be impaired, perceived exertion anddyspnea may be used preferentially over heart rate or workload targets.Perceived exertion ratings of 11 to 14 (on the 6-20 scale) are useful guides.

PACEMAKERS AND IMPLANTABLE CARDIOVERTERDEFIBRILLATORS

Patients with a histOly of resuscitated sudden cardiac death, threatening vcntlicu­lar dysrhythmias, or disease of the sinus node or conduction system vvith permanentpacemakers or an lCD, are being increasinaly referred to exercise-based cardiacrehabilitation programs'S Although these p;ticnts traditionally werc cautioned toavoid vigorous physical activity because of the pacemaker's ILxed rate, advances in

CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 195

technology now enable dual chamber pacing with atrioventricular (AV) synchronyas well as dynamic adjustment of the hemt rate to match increasina levels of meta-

~ . bbolic demand. I Moreover, the safety and effectiveness of exercise training in thispatient subset now has been demonstratedhO

Because some upper body movements may clislodge implanted leads, there is ablief period (-2--3 weeks) following pacemaker imIJlantation dUlina which the

. bpatient should avoid raising the ann on the affected side above the shoulder.Thereafter, patients may participate in physical activities that are compatible withtheir functional capacity. Although vigorous upper body activities and contactsports are not advised for patients with pacemakers, most physicians permit routineacti~ties involving the upper extremities. Initial ECG telemetlY monitoring may beuseful to ensure proper functioning of the pacemaker dUling progressive physicalactivity. Particularly impOttant is maintenance of the proper emergency and resus­citation equipl~lent, including a cardioverter/defibrillator v\~th R-wave synchroniz­ing capability. ,9 The NOtth American Society of Pacing and Electrophysiology(NASPE)/British Pacing and Electrophysiology Group (BPEG) have developed astandard international five-letter code to provide a universal description of pace­maker characteristics (Table 8-3). Pacemakers are categOtized by these codes (e.g.,AAI, VVI, DDD, WIR, and AATOP). The first letter position represents thechamber(s) paced, the second letter position describes the chamber(s) sensed, andthe third letter position signifies the response of the pacemaker to a sensed event.The fourth letter represents rate-responsive propelties, and the fifth positiondenotes any antitachyarrhythmia function of the pacemaker.

Considerations for Patients with Fixed Rate Pacemakers

For many patients, the pacemaker is programmed in WI to manage ventricularbradycardias effectively.'>l However, limitations of WI pacing include the lack ofAV s)'llchronization, absence of an atrial contribution to end-diastolic volumeand intermittent valvular regurgitation. Consequently, the patient demonstrate~an attenuated rise in cardiac output during physical activity, and functional capac­ity may be severely compromised. Other individuals vvith WI pacemakers mayhave little or no chronotropic reserve. Although previously it was believed thatexercise training programs were ineffective for patients \\~th a fixed heart rateresponse, it appears that these patients adapt to physical conditioning in amanner similar to patients \\~th coronary artet), disease who are heart rate­r~sponsive.82 Exercise prescription and training considerations for patients \\~th

ftxed rate pacemakers include the follOwing:

• Because of the nonlinear relationship between oxygen consllmption and heartrate, in patients without rate-adaptive pacemakers, adjunctive target METlevels and perceived exertion limits should be provided

• Exercise intensity can be determined by modifying the Karvonen8:J equation

from heart rate to systolic blood pressure (SBP), as follows (modifiedKarvonen formula):

TSBP = (SBPmax - SBP,est) (50% to 80%) + SBP,est

where TSBP equals training systolic blood pressure.

Considerations for Patients with Rate Responsive Pacemakers

• Systolic blood pressure should be monitored throughout exercise to ensuresafe and effective exercise intensity.

• Extended warm-up and cool-down periods are recommended.• Such patients also should work at a markedly reduced intensity for the first

few minutes of exercise to avoid dyspnea or premature fatigue,Sl• Finally, it should be emphasized that without rate adaptive pacing, the func­

tional capacity of WI-paced patients may be greatly reduced when comparedwith those with rate modulation and AV synchrony.

Rate responsiveness to exercise can be achieved in patients with chronotropicincompetence with WIR or DDD pacing. The pacing rate for these modalitiesis determined by physiologic variables or atrial tracking. Various rate-responsivesensors have relative advantages and disadvantages. Exercise recommendationsfor patients with nonphysiologic sensors, such as a motion sensitive piezoelectriccrystal device or accelerometer, should be designed carefully with respect to thetype and intensity of activity. For example, treadmill exercise should use speedincrements more than gradient changes because these units may respond at aninappropriately slower rate during uphill walking, despite comparable aerobicrequirements. Similarly, stationary cycle ergometry may not produce sufficientmotion of the thorax to yield an adequate rise in heart rate. A combined <Hm-legergometer that uses the levers and pedals simultaneously may elicit a moreappropriate chronotropic response81

For patients with adequate sinus node function but high-grade AV block, theDDD pacemaker offers the advantage of AV synchrony as well as rate respon­siveness during activity via atrial tracking. Pacing in the WIR mode provides rateresponsiveness to activity, but without AV synchrony. Nevertheless, it shouldaugment cardiac output during activity in appropriately selected patients. Finally,the DDDR pacemaker most closely resembles the normal heart's conductionsystem because it provides AV synchrony and uses sinus rhythm for the sensor­driven heart rate. The R in the pacemaker coding system indicates that physio­logic or nonphysiologic sensors are used for rate modulation.

Exercise intensity for pacemaker patients should approximate 50% to 85% ofHRR, 4 to 7 d'wk-l, 20 to 60 minutes per session.'s Exercise intensity forpatients with rate-modulating pacemakers can be prescribed using the follo\vingmethods, alone or in combination:Sl

197

V

Antitachyarrhythmia Functioning

0= NoneP = Pacing (antitachyarrhythmia)S = ShockD = Dual (P and S)

IV

CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

Programmability and Modulation

0= NoneP = Simple programmableM = MultiprogramC = CommunicatingR = Rate modulation

• Maxi mal hemt rate reserve method of KarvonenS:1

• A fixed percentage of the maximal heart rate9

• Rating of perceived exertion15

• METs

Considerations for Patients with Antitachycardia Pacemakers andImplanted Cardioverter Defibrillators

If either of the heart rate methods is used, consideration should be given tothe upper- and lower-rate limits of the pacemaker device. If signs or symptomsof myocardial ischemia occur during exercise, the upper limit for prescribedheart rate in DDD and WIR pacemakers should be set at 10 beats'min- I ormore below the person's ischemic threshold. Reprogramming of maximum heartrate below the ischemic threshold also should be considered.

CARDIAC TRANSPLANT RECIPIENT

Antitachycardia pacemakers and ICDs are commonly used to manage tachydys­rhythmias (usually with burst pacing or shock), An ICD consists of a cardioverterdevice and a lead system. The unit is designed to recognize rapid rhythms andrespond in a tiered fashion. Because the device is programmed to detectdysrhythmias using heart rate and intervals as the main criteria, it is critical toknow the cutoff rate. Persons with ICDs are at risk of receiving inappropriateshocks during exercise if the sinus heart rate exceeds the programmed thresholdor the patient develops an exercise-induced supraventricular tachycardia.'s Forthis reason, patients with ICDs should be closely monitored using continuous orinstantaneous ECG telemetry monitOling, pulse palpation, or both, to titrate asafe and effective exercise dose, A magnet should be readily available to overrideor inactivate the device should it malfunction.

Cardiqc transplantation represents a therapeutic alternative for nearly 3,000patients each year with end-stage heart failure. Moreover, 1- and 3-year survivalrates for transplant recipients now approximate 86% and 80%, respectivelyS4Despite surgelY, cardiac transplant patients continue to experience exercise intol­erance because of extended inactivity and convalescence, associated skeletalmuscle derangements, loss of muscle mass and strength, and the absence(complete or partial) of autonomic cardiac innervation. Because of the adverseside effects of immunosuppressive drug therapy (cyclosporine and prednisone),such as dyslipidemia, hypertension, obesity, and diabetes, these individuals are at

III

Response to Sensing

0= NoneT = TriggeredI = InhibitedD = Dual (T and I)

II

Chambers Sensed

0= NoneA = AtriumV = Ventrcular-D = Dual (A and V)

0= NoneA = AtriumV = VentricularD = Dual (A and V)

Chamber(s) Paced

SECTION III/EXERCISE PRESCRIPTION196

Position

TABLE 8-3. NASPE/BPEG Generic Pacemaker Code

Category

Exercise Prescription and Training Considerations for CardiacTransplant Patients

• The exercise prescription for the cardiac transplant recipient should be basedon data derived from exercise testing to volitional fatigue, using "graded" pro­tocols with 1 to 2 MET increments per 3-minute stage84

• Although isolated cases of chest pain have been reported in cardiac transplantrecipients, generally there is an absence of anginal symptoms because ofpartial or complete denervation.

• The sensitivity of the exercise ECG in this patient subset is extremely lowrelative to the detection of myocardial ischemia. Consequently, radionuclidetesting or exercise echocardiography may be more appropriate in assessingatherosclerotic heart disease.

• Exercise intensity in cardiac transplant recipients can be established using thefollowing methods:o 50% to 75% V02pcak

o Rating of perceived exertion (11-15 on the 6-20 scale)o Ventilatory thresholdo Dyspnea

199CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

Because the initial heart rate response is attenuated and may not correspondwith exercise intensity, predetermined work rates or MET loads may be pre­ferred, using perceived exertion and dyspnea ratings as adjunctive guides fortraining. However, large interindividual variations in RPE at a given oxygenuptake have been reported in this patient population 88 With continued exerciseit is not uncommon for cardiac transplant patients to approach or exceed the max­imal heart rate achieved on a previous exercise test.84 Longer periods of warm­up and cool-down are indicated because the physiologic responses to exercise andrecovery take longer. Cardiac transplant recipients should perform aerobic exer­cises 4 to 6 d 'wk-1 while progressively increasing the duration of training from15 to 60 minutes per session84 Low- to moderate-intensity resistance trainingand range-of-motion activities performed 2 to 3 d'wk- 1 may be used to comple­ment this regimen. Moreover, 6 months of resistance training prevents glucocor­ticoid-induced myopathy in heart transplant recipients and restores fat-free massto levels greater than before transplantation surgely89

Surveillance of the transplant patient during exercise training should focus onresting and exercise blood pressures, possible adverse effects of immunosup­pressive drug therapy, and evidence of rejection. Blood pressure should be mon­itored carefully because hypertension is a common side effect of cyclosporin.Moreover, prednisone therapy may result in numerous side effects, includingsodium and fluid retention; loss of muscle mass; glucose intolerance andlor dia­betes mellitus; osteoporosis; fat redistribution from the extremities to the torso'gastric irritation; increased appetite; increased susceptibility to infection; predis~position to peptic ulcers; and increased potassium excretion. Finally, knowledgeof the most recent cardiac biopsy score is important because rejection exacer­bates exercise intolerance. If evidence of rejection is present, the prescribedexercise regimen should be discontinued until this is reversed.

CARDIAC SURGERY AND PERCUTANEOUS TRANSLUMINALCORONARY INTERVENTION

The two most common approaches to revascularize occluded coronaty arteries arecoronmy artery bypass graft surgelY (CABGS) and percutaneous transluminal coro­nalY interventions (PTCIs) which include angioplasty (PTCA) andlor intracoronarystenting. In the United States alone, more than 519,000 CABGS and 561,000PTCIs were performed in 2000.90 Valve replacements/repairs are also commonlypelformed, particularly for aortic and mitral valve disease. 91 Generally, the uncom­plicated PTCI patient is discharged in 24 hours, whereas cardiac surgelY patients(CABGs or valvular) are hospitalized for 4 to 6 days. To counteract the deleteriouseff~:ts of bed rest and complications associated with the cardiac surgelY, range-of­motIon activities and velY light (i.e., 1- to 3-pounds) hand weights, as well as mobi­lization are initiated while in the hospital or in the early outpatient setting.Stretching or flexibility activities can begin as early as 24 and 48 hours after bypasssurgery or uncomplicated MI, respectively. Patients may be seen once daily andperform 10 to 15 repetitions of each exercise. However, as outlined in Box 8-7,postsurgery patients should avoid traditional resistance training exercises (withmoderate to heavy weights), until the sternum has healed suffiCiently, generally by3 months

62Surgery patients who experience sternal movement or wound compli-

SECTION III/EXERCISE PRESCRIPTION198

increased risk of developing coronary atherosclerosis of the donor heart. As aresult, increasing numbers of patients are being referred to exercise rehabilita­tion early after cardiac transplantation to improve functional capacity, coronaryrisk factors, and quality of life.8.s

Because of the surgical procedure, the transplanted heart essentially is dener­vated, although some evidence for partial reinnervation exists86 As a result of thedenervation, there are numerous differences in the cardiorespiratory, ECG (e.g.,two separate P waves may be apparent), hemodynamic, and neuroendocrineresponses at rest and during exercise when comparing transplant recipients withage- and gender-matched healthy individuals. Resting sinus tachycardia (90-110beats'min -1) is common, and systolic and diastolic hypertension may result fromelevated catecholamine levels, the effects of immunosuppressive medications,altered baroreceptor sensitivity, or combinations thereof. In the normally inner­vated heart, the increase in cardiac output during exercise is elicited by a signifi­cant increase in heart rate, and, to a lesser extent, in stroke volume. In thedenervated heart, the cardioacceleratory response to exercise is delayed, yetcardiac output increases to support the metabolic demand. Studies in cardiactransplant recipients have shown that the initial increase in cardiac output withsubmaximal exercise is achieved by an increase in stroke volume via the Frank­Starling mechanism because immediate cardioacceleratory stimulation is lacking.However, at higher work rates the myocardium responds with tachycardia tohumoral adrenergic stimulation, largely to rising plasma norepinephrine levels87

Postexercise heart rates often rise or remain elevated longer than normal becauseof the continued presence of norepinephrine andlor the lack of parasympatheticinnervation. Peak oxygen consumption in untrained cardiac transplant recipientsgenerally is 50% of normal and ranges from 10 to 22 mL'kg~1'min-184

Collectively, these data indicate an earlier onset of anaerobiosis in transplantrecipients than in healthy individuals.

cations should perform lower extremity exercises only. Nevertheless, significantsoft-tissue and bone damage of the chest wall can occur during surgery. If this areadoes not receive range-of-motion exercise, adhesions may develop and the muscu­lature can become weaker and shorten, accentuating postural problems and hin­dering strength gains. Aerobic exercise training for the postsurgical inpatient can beguided initially using resting HR + 30 beats' min ~ I (or other techniques describedin the inpatient section of this chapter) until more objective data from a symptom­limited exercise test is generated. Valve surgery patients generally can follow thesame exercise prescription guidelines as the CABGs patient, although thesepatients may have had greater activity restrictions and/or longer periods of symp­toms prior to surgery. The resulting low functional capacity, as well as advancedage, may require valve surgery patients to start and progress at a slower rate.92

For PTCI patients, aerobic and resistance training can begin almost immedi­ately as long as the catheter access site has healed properly. The exercise

• To prevent soreness and minimize the risk of injury, the initial loadshould allow 12 to 15 repetitions comfortably. If a 1 RM pretest isused, this load would be approximately 30% to 40% 1RM for theupper body and 50% to 60% for hips and legs. Low-risk-stratified,well-trained patients may progress to higher relative loads dependingon program goals.

• Perform one set of 8 to 10 exercises (major muscle groups) 2 to 3days/week. An additional set may be added, but additional gains arenot proportionate.

• Some specific considerations are as follows:o Exercise large muscle groups before small muscle groups.o Increase loads by 5% when the patient can comfortably lift 12 to 15

repetitions.o Raise weights with slow, controlled movements; emphasize complete

extension of the limbs when lifting.o Avoid straining.o Exhale (blowout) during the exertion phase of the lift (e.g., exhale

when pushing a weight stack overhead and inhale when lowering it)o Avoid sustained, tight gripping, which may evoke an excessive BP

response to lifting.o An RPE of 11 to 13 may be used as a subjective guide to efforto Stop exercise if warning signs or symptoms occur, especially

dizziness, dysrhythmias, unusual shortness of breath, or anginaldiscomfort

Reprinted, by permission, from the American Association of Cardiovascular and Pulmonary

Rehabilitation, 2004. Guidelines for Cardiac Rehabilitation and Secondary Prevention

Programs, 4th ed. (Champaign, IL: Human Kinetics), 182

201CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS

1. Alilerican Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for CardiacHehabilitation and Secondary Prevention Programs, 4tb ed. Champaign, IL: Human Kinetics, 2003.

2. Fletcher GF, Balauy Gf, Amsteruam EA, et al. Exercise Standards lor testing and training: a statementfor healthcare professionals from the American Heart Association. Circulation 2001;104:1694-1740.

3. Franklin BA, Hall L, Timmis Gc. Contempora,y caruiac rehabilitation services. Am J Cardiol1997;79:1075~1077.

4. Convertino VA. Effect of orthostatic stress on exercise performance after bed rest: relation to in-hos­pit,u rehabilitation. J Cardiac Rehab 1983;3:660-663.

5. Sivarajan ES, Bruce RA, Almes Mf, et al. In-hospital exercise after myocardial infarction does notimprove treadmill performance. N Engl J MedI981;305:357-362.

6. Oldridge NB, Hogowski BL. SeH~efficacy anu in-patient cardiac rehabilitation. Am J Cardiol1990;66:362~365.

7. Franklin BA, Cordon S, Tillllllis ce. An10unt of exercise necessary for the patient with coronal)'artely disease. Am J Carcliol 1992;69:1426-1432.

8. Wilmore JH. Exercise prescription: role of the physiatrist and allied he,uth professional. Arch PhysMed Hehabil 1976;57:315-319.

9. American Heart Association. Exercise testing and training of individuals with heart disease or at highrisk for its development: a handbook for physicians. Dallas, 1975.

10. Swain DR, Franklin BA. [s there a threshold intensity for aerobic training in cardiac patients? MedSci Sports Exerc 2002;34:1071-J075.

J1. Pollock MI., Gaesser GA, Butcher JD. The recommended quantity and quality of exercise for devel­oping and maintaining caruiorespiratory and muscular fitness, and flexibility in healthy adults. MedSci Sports Exerc 1998;30:975-991.

12. Franklin BA, Swain DP. New insights on the threshold intensity for improving cardiorespiratoryfitness. Prev Cardiol 2003;6: 118-1.21.

13. Brawner CA, Keteyian SJ, Ehrman JK. The relationship of heart rate rese,ve to V02 reserve inpatients with heart disease. Med Sci Sports Exerc 2002;34:418-422.

14. Colberg SH, Swain DP, Vinik AI. Use of heart rate reserve and rating of perceived exer­tion to prescribe exercise intensity in diabetic autonomic neuropathy. Diabetes Care2003;26:886-990.

15. Borg GAV. Borg's Perceiveu Exertion and Pain Scales. Champaign, II.: Human Kinetics, 1998.16. Pollock ML, Lowenthal DT, Foster C. Acute and chronic responses to exercise in patients treated

with beta-blockers. J Cardiopulm Rehabill991;IJ :132-144.17. Whaley MH, Brubaker PH, Kaminsky LA, et al. Validity of rating of perceived exertion during

graded exercise testing in apparently healthy adults and cardiac patients. J Cardiopulm Rehabil1997;17:261-267.

18. Joo, KC, Brubaker PH, MacDougall AS, et al. Exercise prescription using hea,t rate plus 20 orperceived exertion in cardiac rehabilitation. J Cardiopulm Rehabil2004;24:178-186.

19. Hoberg E, Schuler G, Kunze B, et al. Silent myocardial ischemia as a potential link between lack ofpremonitoring symptoms and increased risk of can.liac arrest during physical stress. Am J Cardiol1990;65:583-589.

20. Franklin BA, Gordon S, Timrnis ce. Diurnal variation of ischemic response to exercise in patientsreceiving a once-daily dose of beta-blockers. Implications for exercise testing and prescription ofexercise and training heart rates. Chest 1886; 108:253-257.

21. Wilmore JI-!, Freund BJ, Joyner MJ, et al. Acute response to submaxin"u and maximal exerciseconsequent to beta-adrenergic blockacle: implications for the prescription of exercise. Am J Cardiol1985;55:135D(141D.

prescription for PTCIs is similar to other cardiac patients although these patientsmay be able to progress more rapidly if there was no myocardial damage and lessinactivity preprocedure and postprocedure. In the current era of stenting andaggressive pharmacotherapy, the risk for restenosis in PTCI patient is reducedconsiderably from early experiences with PTCA alone. However, the PTCIpatient should still be observed closely in the exercise program for potentialrecurrence of ischemic signs and symptoms D3

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SECTION III/ EXERCISE PRESCRIPTION200

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CHAPTER 8/ EXERCISE PRESCRIPTION MODIFICATIONS FOR CARDIAC PATIENTS 203

Arthritis

A~though the general plinciples of exercise prescription apply to persons \\~th and:~thoutchromc dIsease, certain ,dinical conditions may require differences in pro­b'<1mmll1g to maXUTIlze effectiveness and avoid complications, This chapterextends the general exercise prescription guidelines presented in Chapter 7 forpers~ns \\~th, one, or more of the follo>\~ng conditions: arthritis, diabetes, dyslipi­dem1<l, hypeltenslOn, obeSity, metabohc syndrome, immunologic disorders, osteo­POroSIS, penpheral arterial disease, pulmonary disease, and pregnancy, Eachcondition IS h1gh hghted Wlth a bnef overview of pathophysiology, divergence forexercls~ test~ng and exercise prescription relative to the general exercise prescrip­tIOn (Table 9-1), and speCIal conSiderations to ensure safety, If modil'ications ofexercise testll1g and exercise prescriptions are not noted, the guidelines from theprecedll1g chapters apply, Refer to the ACSM Resource Manual (Section 4) for acomprehensive and detailed analysis of each condition.

Arthritis and rheumatoid disease typically affect almost 14% of Americans andcause muscle weakness, fatigue, and pain, stiffness, and swelling in joints andother supportmg structures of the body such as muscles, tendons, ligaments,and bones. The two most common conditions of arthritis and rheumatic dis­eases are osteoarthritis and rheumatoid arthritis, Osteoarthritis is a deaenera­tive joint disease t,hat typically impacts the knees, hips, feet, spine, and\ands.Rheu~nat01d arthntls lS a chronic, systemic inflammatory disease affecting thesynovIa! membrane of Jomts, The complications of arthritis may lead to a lessactive hfestyle. However, individuals with either inflammatory or degenerativeJOll1t dIsease g;nerally are able to engage in regular exercise to improve theirhealth status: fhe goals for many ~rthritis patients are to engage in normaleveryday actIVItIes w1thout undue fatigue and pain, improve cardiovascular,musc,ular, and flexibility fitness, enhance functional status, and decrease jointswelllllg and pain.

TI~~.ACSM makes the follOWing recommendations regarding exercise testingand tJ,ul1lng for patients w1th arthritis,

CHAPTER

9•••••

Other Clinical ConditionsInfluencing ExercisePrescription

73. Giannuzzi P, Temporelli PL, Ta\"azzi L, et al. EAM l--exercise training in anterior myucanlialinfarction: an ongoing multicenter randomized study. Preliminary results on left: ventricular function

and remodeling. The EAMI Study Group. Chest 1992;10l:3155(3215.74. Belardinelli H, Georgiou D, Cianci G, et al. Handomized, c'ontrolled trial of long-term moderate

exercise training in chronic heart failure: effeds un fundional capacity, quality of life, and dinical

outcome. Circulation 1999;99:1173--1182.75. McKelvie RS, Teo KK, Roberts R, et aI. Effects of exercise training in patients with heart failure;

the Exercise Rehabilitation Trial (EXEHT). Am Heali J 2002; 144:23--30.76. Meyer K. Exercise training in heart failure: recommendations based on current research. ~Ied Sci

Sports Exerc 2001;33;525-531.77. Oka HK, De Marc'O T, Haskell \\'L, et aI. Impact of a home-based walking and resistance training

program on quality of life in patients with heart failure. Am J Cardiol 2000;85:365--369.78. West NI, Roberts SO. Pacemakers and implantable cardioverter defibrillators. In: Durstine JL,

Moore GE, eds. American College of Sports Medicine's Exercise Management for Persons withChronic Diseases and Disabilities, 2nd I'd. Champaign, IL: Human Kinetics, 2003:52-57.

79. Schweikert HA, Pashkow FJ, Wilkoff BL. Hehabilitation of patients with arrhythmias, pacemakers,and defibrillators. In: Pashkow FJ, Dafoe WA, eds. Clinical Cardiac Rehabilitation: A Cardiologist's

Guide, 2nd eel. Baltimore; Williams & Wilkins, 1999:192-203.80. Vanhees L, Schepers 0, Heidbuchel H, et al. Exercise performance and training in patients with

implantable cardioverter-deflbrillators and coronary heart disease. Am J CardioI2001;87:712-715.81. Sharp CT, Busse EF, Burgess JJ, et al. Exercise prescription for patients with pacemakers. J

Cardiopulm Hehabil 1998;18:421-431.82. Superko HH. Effects of cardiac rehabilitation in permanently paced patients with third-degree heart

block. J Carcliac Hehab 1983;3:561-568.83. Kalvonen M, Kentala K, Mustala O. The effects of training on heart rate: a longitudinal study.

Annales Medicinal' Experimentalis et Biological FenniaI1957;35(3):307--315.84. Keteyian SJ, Brawner C. Cardiac transplant. In: Durstine JL, Moore GE, eds. American College of

Sports Medicine's Exercise Management for Persons with Chronic Diseases and Disabilities.

Cbampaign, IL: Human Kinetics, 1997:70-75.85. Kobashigawa JA, Leaf DA, Lee N, et aI. A controlled trial of exercise rehabilitation after hemi trans-

plantation. N Engl J Med 1999;340:272-277.86. Kaye OM, Esler M, Kingwell B, et al. Functional and neuralchemical evidence for paliial cardiac

sympathetic reinnervation after cardiac transplantation in humans. Circulation 1993;88:1110-1118.87. Shepard RJ. Hesponses of the cardiac transplant patient to exercise and training. Exerc Sport Sci Rev

1992;7:297--320.88. Shephard HJ, Kavanagh T, Mertens OJ, et aI. The place of perceived exertion ratings in exercise pre-

scription for cardiac transplant patients before and after training. Br J Sports Med 1996;30:116-121.89. Braith H\\', Welsch MA, Mills HM Jr, et al. Hesistance exercise prevents glucowrticoid-induced

myopathy in heart transplant recipients. Med Sci Sports Exerc 1998;30:483--489.90. American Heart Association. Heart Disease and Stroke Statistics, 2003 Update. 2002.91. Canulette M, Gitkin A, Friedman D. Valvular heart disease. In: Durstine JL, Moore GE, eds.

American College of Sports Medicine's Exercise Management for Persons with Chronic Diseases

and Disabilities. Champaign, IL: Human Kinetics, 2003:58-63.92. Stewart KJ, Badenhop 0, Brubaker PH, et aI. Cardiac rehabilitation following percutaneous revas­

cularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest 2003;123:

2104-2111.93. Franklin B. Coronal)' artel)' bypass surgery and perc;utaneous transluminal coronal)' angioplasty. In:

Durstine JL, Moore GE, eds. American College of Sports Medicine's Exercise Management forPersons with Chronic Diseases and Disabilities. Champaign, IL: Human Kinetics, 2003:32-39.

94, Williams MA. Exercise testing in cardiac rehabiliatation: exercise prescription and beyond. Cardiol

Clin 2001;19:4 15-431.

204 SECTION 1111 EXERCISE PRESCRIPTION

205

Abbreviations: HRR, heart rate reserve; V02R, maximal oxygen uptake reserve; MMF, momentary muscular fatigue.

EXERCISE TESTING

207CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

• Hydrotherapy may attenuate pain and stiffness and reduce reliance on nons­teroidal antiinflammatOly drugs (NSAIDs).

• Regular use of NSAIDs may cause anemia because of gastrointestinal bleed­ing and mask the musculoskeletal pain.

• Contraindications to exercise include vigorous, highly repetitive exercise \vithunstable joints, overstretching and bypennobility, and morning exercise \vithrheumatoid arthritis because of significant morning stiffness.

• Morning exercise often is avoided for rheumatoid arthritis patients, who havesignificant morning stiffness. However, some patients may benefit from theenhanced circulation.

• Perform flexibility exercise one to two times daily, using the pain-free rangeof motion as an index of intensity. I

• Perform cardiovascular exercise initially in short bouts (~1O minutes). Add 5minutes per session up to 30 minutes and progress with duration versus inten­sity. Aquatic, walking, and cycling activities are preferredJ

• Perform resistance training (free weights, machines, elastic bands, isometrics)of two to three repetitions progressing to 10 to 12 repetitions, 2 to 3 d'wk- 1

using pain thresbold as an index of intensity.1• Functional activities (e.g., climbing stairs, sit to stand) should be performed

daily.

• Use low-intensity and low-duration during the initial phase of programming.Discontinuous exercise bouts of 5 to 10 minutes may be necessary withdeconditioned patients.

• Alternate exercise modes or cross-training should be incOlvorated in the pro­gram.

• Avoid exercise during a1ibritic flare-up.

• Conditions for exercise termination include unusual or persistent fatigue,increased weakness, decreased range of motion, increased joint swelling, andcontinuing pain that lasts more than 1 hour after exercise.

Diabetes Mellitus

SPECIAL CONSIDERATIONS

Diabetes mellitus is a group of metabolic diseases resulting from defects ininsulin secretion, insulin action, or both. Since 1997, the types of diabetes havebeen classified by the etiologic origins. Type 1 diabetes is caused by the autoim­mune destruction of the insulin producing f3 cells of the pancreas. Absoluteinsulin defiCiency and a high propensity for ketoacidosis are the common charac­teristics of type 1 diabetic patients. Type 2 diabetes (NIDDM) is caused bymsulm resistance with an insulin secretory defect. Approximately 90% to 95% ofall diabetics are type 2.2 Although type 2 diabetes is associated with excess bodyfat, the primary feature is an upper body fat distribution regardless of the amountof total body fat. In contrast to type 1 diabetes, type 2 diabetes often is associat­ed with elevated insulin concentrations.

Large musclegroups

Dynamicactivity

Activity

8-10 exercisesInclude

all majormusclegroups

Static stretchall majormusclegroups

Duration

1 set of 3-20repetitions(e.g., 3-5,8-10,12-15)

15-30seconds2-4 xlstretch

40%/50%-85% 20-60 minHRR or V02 R55%/65%-

90% HRmax

12-16 RPE

Volitionalfatigue(MMF) (e.g.,19-20 RPE)

OrStop 2-3 reps

before voli­tional fatigue(e.g., 16 RPE)

Stretch to tight­ness at theend of therange ofmotion butnot to pain

Frequency Intensity(sessions'wk- 1j

Minimal2-3 d·wk- 1

Ideal5-7 d'wk- 1

2-3 d·wk- 1

SECTION III/ EXERCISE PRESCRIPTION206

• Assessment of physiologic function should inc:lude cardiopulmonary capacity,neuromuscular status, and fleXibility.

• Modifications of traditional protocols may be warranted depending on func­tionallimitations and an early onset of fatigue.

• Choose a mode of exercise based on the most pain-free method for exercise.Although treadmill and cycle ergometer protocols can be tolerated, cycle test­ing or combined arm and leg ergometry may provide a more accurate meas­urement of cardiopulmonary function if the patient is less limited by pain.

• Most patients are able to perform a symptom-limited graded exercise test.

• Tbe recommended mode, intensity, frequency, duration, and overload gener­ally are consistent with those in Chapter 7 for cardiorespiratOly, resistance,and flexibility exercise stimuli (see summary in Table 9-1).

• Focus on improvement of both functional status as well as physical fitness.• In a single exercise session, progress from flexibility exercises (affected joints),

to neuromuscular muscle function exercises (strength and endurance), to aer­obic activities (weight-bearing and/or non-weight bearing).

EXERCISE PRESCRIPTION

Resistance

TABLE 9-1. Summary of Exercise Programming

Cardiorespiratory 3-5 d·wk- 1

Componentsof TrainingProgram

Flexibility

EXERCISE PRESCRIPTION

EXERCISE TESTING

• Prior to beginning an exercise program, diabetic patients should undergo anextensive medical evaluation particularly for the cardiovascular, nervous,renal, and visual systems because they are related to diabetic complications

6

• Some patients, who exhibit nonspecific electrocardiographic (ECG) changesin response to exercise or who have nonspecific ST and T wave changes onresting ECG, may require additional radionuclide stress testing to rule out

atherosclerotic hemt disease.'• Simple cardiovascular tests of resting heart rate (tachycardia) as well as heart

rate and blood pressure response to orthostatic challenge, deep breathing, andValsalva can provide information on the extent of autonomic neuropathy.~

209

ApathyBlurred visionConfusionDelusionDouble visionLoss of ConsciousnessConvulsionsHeadacheInability to concentrateNervousnessSlurred speechSomnolencePoor coordination

Hypoglycemia«80 mg'dL-1 or a rapid drop in glucose)

CryingDrowsyFainting or feeling faintHand tremorsSweatDizzinessExcessive hungerFatigueIrritabilityUnsteady gait

CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

amounts of caloric expenditure (2:2000 kcal 'wk-1), including daily exercise, maybe required if weight loss is a goal.• For resistance training, lower resistance (40%-60% of one repetition ma'\i­

mum [RMJ), and lower intensity (avoiding MMF) is recommended.

• One set of exercises for the major muscle groups with 10 to 15 repetitions;progress to 15 to 20.

• The minimum frequency is hvo per week, with at least 48 hours behveensessions.

• Proper technique, including minimizing sustained gripping, static workand Valsalva are essential to prevent a hypertensive response13

• Hypoglycemia is the most common problem for diabetics who exercise. SeeTable 9-2 for common symptoms associated ,~th hypoglycemia.

• Hyperglycemia during exercise is a risk, particularly for type 1 diabetics, whoare not in glycemic control. See Table 9-2 for common symptoms associatedwith hyperglycemia.

• Because of the increase of glucose uptake during exercise, the risk of hypo­glycemia exists during and after exercise. Hypoglycemia, usually considered<80 mg'dL -1 is relative. Rapid drops in blood glucose also can cause thesigns and symptoms of hypoglycemia in elevated glycemic states.

• Hypoglycemia, associated with exercise, may last as long as 48 hours afterexercise. 14 To prevent postexercise hypoglycemia, monitor plasma glucoselevels and ingest carbohydrates as needed.

• For diabetic patients with retinopathy, exercise that produces high arterialpressures may increase the risk of retinal detachment and vitreous hemor­rhage. 15 Diabetic patients with ovelt nephropathy often have a reducedcapacity for exercise6

• Peripheral neuropathy may result in balance and gait abnormalities duringexercise16 as well as foot ulceration and fracture. 6

Hyperglycemia(>300 mg'dL-1)

TABLE 9-2. Signs and Symptoms of Hyperglycemia and Hypoglycemia

WeaknessIncreased thirstDry mouthSoft eyeballsFrequent, scant urinationDecreased appetiteNauseaVomitingAbdominal tendernessAcetone breathKussmaul respirations

SECTION III/ EXERCISE PRESCRIPTION

• Exercise is effective in glucose control because exercise has an insulin-like effectthat enhances the uptake of glucose even in the presence of insulin defiCiency.

• Outcomes of exercise treatment in diabetes include improved glucose toler­ance, increased insulin sensitivity, decreased glycosylated hemoglobin, anddecreased insulin rcquirements.8 Additional benefits of exercise for diabeticpatients include improved lipid profiles, blood pressure reduction, weightmanagement, increased physical work capacity, and improved well-being. '0-12

• The basic elements of a cardiorespiratory exercise prescription'

• Frequency: 3-4 d'wk- 1

• Duration: 20-60 minutes• Intensity: 50%-80% \T02R or heart rate reserve (HRR)

Within this recommended prescription, patients with type 2 diabetes shouldstrive to accumulate a minimum of 1,000 kcahvk- I of physical activity.8 Greater

The treatment goal for diabetes is glucose control, which includes diet, med­ications, and excrcise. Intensive treatment to control blood glucose has been doc­umented to reduce the risk of progression of diabetic complications 50% to 75%in type 1 diabetic adults:l and has been considered to be of similar efficacy in type2 diabetic adults.~ The 2003 report from the ADA Expert Panel on Diagnosis of

Diabetes :Vlellitus includes the following:5

• ~onnal fasting plasma glucose <100 mg·dL-1 (5.6 mmo]' L-I)

• Cutpoint between non-diabetic and diabetic is fasting plasma glucose 2:126mg.dL-I (7.0 mmol.L 1)

• Fasting plasma glucose "alues between 100 and 125 mg'dL-I indicate

impaired fasting glucose (IFG)• 2-Hour plasma glucose level in an oral glucose tolerance test (OGTI) <200

mg.dL I (11.1mmol·L- 1)

• The use of HbA Ic as a diagnostic test for diabetes is not recommendedbecause of a lack of standardizcd methodologies

ACSM makes the following recommendations rcgarding exercise testing aud

training for patients ,\~th diabetes.

208

210 SECTION III / EXERCISE PRESCRIPTION

• Autonomic neuropathy may cause chronotropic incompetence, blunted sys­tolic blood pressure response, blunted oxygen uptake kinetics, and an hydro­SiS fi ,17,IR Consequently, RPE may be needed to regulate exercise intensity.

• Dehydration resulting from polyuria contributes to compromised thennoreg­ulation,19

• Sudden death and silent ischemia during exercise also are associated withautonomic neuropathyfi The incidence of silent myocardial infarction is sixto seven times greater in the diabetic population, 19 Cardiac patients report­ed angina during exercise approximately 50% more often than diabeticcardiac patients with similar thallium scintigraphy,20 Sudden death duringexercise may be attributed to sympathetic imbalance and prolonged QTinterval. 21

SPECIAL CONSIDERATIONS

• Glycosylated hemoglobin (HbAld should be an additional blood chemistrytest, because this measure provides information on long-term glycemic con­trol.9 As mentioned, HbAJ(; is not recommended as a screening tool fordiabetes,

• Hyperglycemia, common to diabetes may cause polyuria, polydipsia, weightloss (sometimes with polyphagia), and blurred vision.

• Brittle diabetic patients must be in glycemic control before starting an exer­cise program to prevent hypoglycemiC and hyperglycemic events,7

• Exercise with a partner or under supervision to reduce the risk of problemsassociated with hypoglycemiC events.

• Monitor blood glucose to prevent hypoglycemia or hyperglycemia associated\vith exercise, especially if taking insulin or oral hypoglycemic agents thatincrease insulin production,• Monitor blood glucose prior to exercise and follOWing exercise, espeCially

when beginning or modifYing the exercise program,• A late-onset hypoglycemia can OCCllr up to 48 hours follOWing exercise,

especiaJly when beginning or modifying the exercise program.• See Table 9-2 for signs and symptoms of hyperglycemia and hypoglycemia.• Avoid physical activity if fasting gillcose >2.50 mg'dL-I and ketosis are pres­

ent, and use caution if glucose >300 mg·dL-I and no ketosis is present.'• Adjust carbohydrate intake or insulin injections prior to exercisc based on

blood glucose and exercise intensity to prevent h)1Joglycemia associated\vith exercise. Twenty to thirty grams of additional carbohydrates shouldbe ingested if preexercise blood glucose is <100 mg'dL-I.

• To lower the risk of hypoglycemia associated with exercise, 18,22 avoid inject­ing insulin into exercising limbs; an abdominal injection site is preferred,

• vVhen exercising late in the evening, an increased consumption of carbo­hydrates may be required to minimize the risk of nocturnal h)1Joglycemia.

• Tlllcllse resistance exercise often produces an acute hyperglycemic effect,whereas postexercise hypoglycemia in the hours follOWing basic resistancetraining is an increased risk for patients on insulin or oral hypoglycemiCagents. 1:3

CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 211

• For diabetic patients 'vith retinopathy, prevent retinal detachment and vitre­ous hemorrhage associated with exercise: 1.5

• For moderate nonproliferative diabetic retinopathy, avoid activities thatdramatically elc\'ate blood pressure.

• For severe nonproliferative diabetic retinopathy, avoid exercise thatincreases systolic blood prcssure > 170 mm Hg.

• For proliferative diabetic retinopathy avoid strcnuous activities, Valsalvamaneuvers, or activities of pounding or jarring

• For diabetic patients \\~th autonomic neuropathy:6,19

• Monitor for signs and symptoms of h\1Joglycemia because of the inabilityof the patient to recognize them.

• Monitor for signs and symptoms of silent ischemia becausc of the inabilityto perceive angina.

• Monitor blood prcssure follmving exercise to manage hypotension andhypertenSion associated \\~th \~gorous exercise J9

• Understand that the hemt rate and blood pressure response to exercisemay be blunted and that the use of perceived exeltion may help guideexercise intensity. 19

• Use precautions for poor thermoregulation in both hot and cold environ­ments.

• For the patient \\~th peripheral neuropathy:"• Take proper care of the feet to prevent foot ulcers,2:3• Limit weight-bearing exercise for patients \vith significant peripheral neu­

ropathy.• For the patient \vith nephropathy:6

• Limit exercise to low to moderate intensities and discourage strenuousintensities when physical work capacity is low,

DyslipidemiaDyslipidemia, or abnormalities in blood lipid and lipoprotein concentrations, is amajor modifiable cause of coronmy heart disease (CHD) and a \videspread prob­lem, For example, 49% of adult men and 43% of adult women in the UnitcdStates have elevated low-denSity lipoprotein cholesterol (LDL-C) concentrations(e.g., ;;::130 mg·dL -1).24 Elevated blood LDL-C and triglyceride (TG) concen­tratIOns and low high-denSity lipoprotcin cholesterol (HDL-C) concentrationsare all independent risk factors for CHD.2

.5 The National Cholesterol EducationProgram's classifications for cholesterol and TG measurements are presented inTable .3-2. Current dctection, evaluation, and treatment guidelines for dyslipi­demla are avaIlable '\~thin the NCEP ATP rn report,2.5 The ATP III repOltrecogn~es the impOltance of lifestyle modification in the treatment of dyslipi­demIa. These recommendations include increased physical acti\~tv and weightreduction, if needed. -

A recent review of 28 randomized clinical trials involving over 4 700 [J'lrtic-. 26 1 ' (:Ip~nts revea ed that aerobic exercise training has varying influences on bloodhplds and hpopr~teins, The most common lipoprotein adaptation, observed in40% of the studIes, was a 4.6% increase in IIDL-C, which occurred in both

EXERCISE TESTING

EXERCISE PRESCRIPTION

SPECIAL CONSIDERATIONS

213CHAPTER 9 / OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

HYPERTENSION

Hypeltension is defined clinically as an elevation in <utcrial blood pressurc equalto or exceeding a systolic blood prcssure of 140 mm Hg and/or a diastolic bloodpressure of 90 mm I-Ig. The Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of I-Iypettension (JNC7) clas­sification system for hypertension is presented in Table 3_1.29 Hypertension isone of the most prevalent forms of cardiovascular disease affecting approximate­ly 50 milJion Americans and approximately 1 billion individuals worldwidc.29 Theprevalence of hypertension increases with advanCing age and is higher in menthan women and in blacks than in whites 30 Hypeltension is the major contribu­tor to the more than 700,000 strokes and 280,000 stroke deaths annually in theUnited States and is a major factor contributing to the more than 1 million heattattacks and 500,000 heart attack deaths annualJy.24 Hypertension is also animpOltant lisk factor for congestive heart failure, pelipheral vascular disease, andkidney failure. 24 Furthermore, the risk of many of these diseases increases at lev­els of blood pressure well below the diagnostic threshold of 140/90 mm Hg.·1 !

Therefore, lowering blood pressure may benefit individuals with any elevationabove optimal levels. In addition, the association between obesity and hyperten­sion is well established. Risk estimates from the Framingham Heart Study sug­gest that approximately 75% and 65% of the cases of hypertension in men andwomen, respectively, are directly attributable to overweight and obesity.:J2

Although advances in the detection, treatment, and control of hypettensionhave taken place over the past few decades, control rates (SBP <140 mm Hg andDBP <90 mm Hg) are still well below the Healthy People 2010 goal of 50%; andapproximately 30% of hypettensive individuals remain undiagnosed.29 The goal ofhypettension prevention and management is to reduce morbidity andmOltality bythe least intrusive means possible. This may be accomplished by achieving andmaintaining blood pressure <140/90 mm Hg or lower if tolerated, while control­ling other cardiovascular disease tisk factors. 29 Persons ~ith systoliC blood pressure120 to 139 mm Hg and/or diastolic blood pressure of 80 to 89 mm Hg are classi­fied prehypeltensive and should also engage in lifestyle modifications to preventcardiovascular disease.29 Table 9-3 presents lifestyle modifications recommendedalone, or in combination with pharmacologic treatment by JNC 7.29 Regular phys­ical activity and weight control are at the core of current recommendations for boththe primaty prevention and treatment of high blood pressure.29.33

Recent meta-analyses34,35 from over 54 randomized clinical trials, involVingmore than 2,600 subjects indicate that aerobic exercise training vvilJ elicit averagereductions of 3 to 4 mm Hg and 2 to 3 mm Hg for systolic and diastolic pressure,respecttvely. However, the reductions subsequent to aerobic training appear tobe more pronounced in hypertensive subjects (i.e., -7.4 and -5.8 mm Hg for sys­tolic and diastolic pressure).:J·5 With respect to training protocols, changes inblood pressure follOwing aerobic training appear to be similar with training inten­sities between 40% and 70% of V02Illax> for training frequencies 3 to 5 d'wk-t,and for training durations of 30 to 60 minutes.:J5 Reductions in blood pressure fol­lOWing aerobic exercise training appear to be independent of both baseline obe­sity status and weight loss during training.:J4

ACSM makes the following recommendations regarding exercise testing andtraining of persons with hypeltension.:J6,:J7

SECTION III/ EXERCISE PRESCRIPTION212

men and women and across all age groups. Changes in HDL-C were inverselyrelated to the baseline concentrations, and were associated, in part, withchanges in body and fat mass. Changes in LDL-C (-5.0%), triglycerides(-3.7%), and total cholesterol (-1.0%, nonsignificant) occurred less consis­tently than the changes in HDL-C. The available studies that evaluated a dose­response relationship between training intensity and lipid changes provide con­flicting results.

Based on the known therapeutic effects of habitual physical activity, ACSMmakes the following recommendations regarding exercise testing and training ofpersons with dyslipidemia.26,27

• Individuals with dyslipidemia should be screened and stratified prior to exer­cise testing (see Table 2-4).

• Standard exercise testing methods and protocols are approptiate for use withdyslipidemic patients cleared for exercise testing. Special considerationshould be given to the presence of other conditions (e.g., obesity, hyperten­sion) that may require modifications to standard exercise testing protocols andmodalities.

• Alternative testing modes may be required if the individual has xanthomasthat cause biomechanical problems.

• The recommended mode, intensity, frequency, duration, and overload gener­ally are consistent with those in Chapter 7 for cardiorespiratory, resistance,and flexibility exercise stimuli (see summary in Table 9-1).

• Primary mode should be large muscle group aerobic activities.• Exercise intensity between 40% to 70% of V02R or HRR• Frequency of training: 5 or more days per week to maximize caloric expendi­

ture• Duration of training session: 40 to 60 minutes (or two sessions per day of 20

to 30 minutes)• This prescription is consistent with recommendations for long-term weight

control (e.g., 200 to 300 min'wk-t, ~2,000 kcal·wk- 1).28

• Consideration should be given to the presence of other conditions, such asobesity and hypertension, which may necessitate modification in the exerciseprescription (see relevant sections in this chapter).

• Consideration should be given if the individual takes lipid-lowering medica­tions (e.g., HMG CoA reductase inhibitors, fibric acid) that have the potentialto cause muscle damage.

• Improvement in blood lipids/lipoproteins with aerobic exercise training maytake several weeks or months, depending on the blood lipid/lipoprotein ofinterest and the weekly caloric expenditure.27

EXERCISE TESTING

TABLE 9-3. Lifestyle Modifications to Manage Hypertension*

215CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

• The recommended mode, duration, and overload are consistent \villi those inChapter 7 for cardiovascular, resistance, and flexibility exercise stimuli (seesummalY in Table 9-1).

• Plimary mode should be large muscle group aerobic activities.• Exercise intensity 40% to 70% \T02R or HRR appears to reduce blood pres­

sure as much as, If not more than, exercise at higher intensities.35 This may beespeCIally Important for specific hypertensive populations, such as the elderlyand obese.

• Frequency of aerobic training: 3 to 7 d'wk- 1 are effective in reducing BP.H~wever, because of the acute reduction in BP that may last many hours aftera slllgle bout of aerobic exercise, daily exercise may provide more optimal con­trol of BP.37,38

• Duration of aerobic training session: 30 to 60 minutes• Resistance training is not recommended as the primary form of exercise train­

ing for hypeltensive individuals, but should be combined with aerobic train­ing. Resistance training regimens should incorporate lower resistance \vithhigher repetitions.

SPECIAL CONSIDERATIONS

necessity for appropliate lifestyle counseling to ameliorate this increase.Medication changes may be appropliate in certain instances.

EXERCISE PRESCRIPTION

• Do not exercise if resting systolic BP >200 mm Hg or diastolic BP > 110 mmHg (see Box 3-5).

• I3-BJockers attenuate heart rate response dUling submaximal and maximalexercise and may decrease exercise capacity, patticularly in patients withoutmyocardial ischemia (see Appendix A).

• I3-Blockers and diuretics may impair thermoregulation during exercise in hotand/or humid environments. Hypertensive patients taking these medicationss~ould be well informed about signs and symptoms of heat intolerance, alongWilli prudent modifications in the exercise routine to prevent heat illness (seeAppendix E).

• (XrBlockers, (X2-blockers, calcium channel blockers, and vasodilators may pro­vok~ postexettion hypotension so emphasize a gradual cool-dovm peliod fol­lOWing the exercise session.

• ?iuretics may cause a decrease in [K+j, potentially leading to cardiac dys­lhytllmlas and a false positive exercise ECG (see Appendix A).

• Altllough BP termination clitelia for exercise testing are established at>250/115 mm Hg, lower BP thresholds for termination of an exercise train­ing ~ession may be prudent (i.e., >220/105 mm Hg).37

: Avo,ld Valsalv~ maneuvers dUling resistance training.IndiVlduals With more marked elevations in BP (i.e., ~160/100) should addendurance exercise training to their treatment regimen only after initiatingpharmacologic therapy37 Exercise may reduce their BP further ·and, tllus,allow tllem to decrease tlleir antihypeltensive medications and attenuate theirlisk for premature mortality.

2-4 mm Hg (110)

2-8 mm Hg (106-108)

Approximate SBPReduction (range)

4-9 mm Hg (34.109)

5-20 mm Hg per 10 kgweight loss (104.105)

8-14 mm Hg (106. I 07)

Recommendation

Maintain normal body weight(BMI 18.5-24.9 kg m-2

)

Consume a diet risk in fruits,vegetables, and low-fatdairy products with areduced content ofsaturated fat

Reduce dietary sodium intaketo no more than 100 mmolper day (2.4 g sodium or 6 gsodium chloride)

Engage in regular aerobicphysical activity such as briskwalking (at least 30 min perday, most days of the week)

Limit consumption to no morethan 2 drinks (1 02 or 30 mLethanol; e.g., 2402 beer, 1002 wine, or 3 02 80-proofwhiskey) per day in mostmen and to no more thanone drink per day in womenand lighter-weight persons

SECTION III/ EXERCISE PRESCRIPTION

Dietary sodiumrestriction

Physical activity

Moderationof alcoholconsumption

Weightreduction

Adopt DASHeating plan

Modification

214

• Medical clearance of hypertensive persons is advised before maximal exercisetesting or plioI' to tlleir palticipation in vigorous exercise (see Table 2-1).

• Standard exercise testing methods and protocols are appropliate for use \vithhypettensive patients cleared for exercise testing. Other comorbidities (e.g.,obesity) or concerns (e.g., advanced age) may dictate modifications to the test­ing procedures.

• Medications should be taken at the usual time relative to the exercise bout.• Carefully monitor blood pressure for exaggerated response (systolic >260

mm Hg or diastolic>115 mm Hg are indications for test termination).• Mass exercise testing is not advocated to determine those individuals at high

risk for developing hypertension in the future as a result of an exaggeratedexercise blood pressure response. However, if exercise test results are avail­able and an individual has a hypertensive response to exercise, this informa­tion does provide some indication of risk stratification for that patient and the

Abbreviations: DASH. Dietary Approaches to Stop Hypertension; BMI. body mass index; SBP, systolic blood pressure;

g, gram; OZ, ounce.

'See reference 29: Reprinted with permission from National High Blood Pressure Education Program. The SeventhReport of the Joint National Committee on Prevention. Detection. Evaluation. and Treatment of High Blood

Pressure (JNC7). 2003. 03-S233. National Heart. Lung. and Blood Institute U.S. Department of Health and Human

Services.

Obesity is a serious and common public health problem in the United States andother indushialized countlies. DUling the past dccade the number of overweight(BMI ~2.5 to <30 kg·m -2) and obese (EMI ~30 kg·m-2) indi\~dllals has increaseddramatically. According to the most recent ational Health and utJitionExamination SlIIvey (NHANES II!), -6.5% of Americans are overweight and 31%are obese.,'9 An excess accumulation of fat, particularly in the intraabdominalregion, is associated with an increased lisk of a number of chronic diseases includ­ing h)1)eltension, coronal)' healt disease, and type 2 diabetes and reduced lifeeJ\'Pcctancy and early mOltality40Ar In tum, obesity places a significant burden onthe economy by increasing rates of health care usage and associated costs.

Obesity is caused by a complex interplay between genetic and ell\~ronmental

factors. 41 Ultimately, a cumulative positive energy balance causes obesity. Energybalance is determined by the difference between energy intake (calmies consumed)and energy eJ\'Penditure (calories eJ\'Pended through resting energy metabolism, thethermic effect of food, and physical activity). Therefore, weight gain occurs whenenergy intake exceeds energy eJ\'Penditure (i.e., positive energy balance) and bodyweight is lost when the opposite occurs (i.e., negative energy balance). One poundof fat is equivalent to approximately 3,.500 kcal of energy (1 kg is approximatelyequal to 7,700 kcaI). The modem environment is dliving the current obesity epi­demic by favoling sedentmy behavior and overconsumption;42 therefore, physicalactivity and sound nutJition fonn the basis of obesity prevention and treatment.

A failure to fully appreciate the eJ\'Pected weight loss following exercise train­ing has led to disappointment on the palt of many palticipants and, in some cases,health care providers. This could selve to discourage health care providers frommaking physical activity recommendations to their obese patients. Results fromrecent meta-analysis43 of short-term exercisc intervention studies (i.e., S16weeks) in which suhjects consumed an isocalOlic diet revealed that physical activ­ity was associated with reductions in total body fat in a dose-response manner,\vith an average weight loss of 0.26 kg'wk- ' and fat loss of 0.2.5 kg'wk- 1 Longerduration studies repOlted a smaller effect (i.e., 0.06 kg'wk-I reduction in bodyweight and total ht). However, the above results were delived from studies that:1) incor1)orated isocaloric diets to isolate the "exercise effect," and 2) reported anaverage energy expenditure typically less than 1.500 kcal ·wk- r. Intervention pro­grams that incorporate dietary modification and greater energy expenditurewould likely produce greater weight and hlt losses.28 Overall, reductions in bodyweight and fat resulting from increased cxercise appear to be propOltional to theamount of aerobic exercise performed. 28,43

However, it is important to emphasize that there is considerable intelindi\~dual

valiability in the magnitude of weight loss produced by exercise. Some individualsactually may gain small amounts of weight, whereas others eJ\'Pelience dramaticweight loss. The degree to which an individual compcnsates with changes in ener­gy intake anclJor physical activity dming the remaining nonexercise pmuons of theday is an impOltant determinant of the degree ofweight loss experienced \vith exer­cise. For example, if two individuals eJ\'Pend 300 kcal·d -I \vith exercise and one ofthese individuals reduces their activity dming the remainder of the day by 1.50 kilo­calOlies (or consumes an additional 1.50 kcal) then the difference in weight loss

EXERCISE TESTING

217CHAPTER 9 / OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

between these individuals over time could be considerable (i.e., approximately 30lbs versus 1.5 Ibs in 1 year). Therefore, it is impOttant to emphasize the concept ofenergy balance in both causing and treating obeSity.

Obesity often canies a negative social stigma and obese individuals are almostinvariably sedentmy, have low physical work capacities, and many have had nega­tive eX'Periences with exercise in the past. The exercise profeSSional should inter­view the obese palticipant to determine goals, past exercise histOty, perceivedbarriers to exercise palticipation, and the locations where exercise might be per­formed (e.g., sports club, home, street, school gym, or track). This may increaseadherence to an agreed-on exercise program. In addition, because reduction in adi­posity is often a goal and need of many obese exercise program participants, exer­cise prescriptions should be designed to aid in accomplishing this objective.However, normalization of body weight and composition is not a realistic goal formost obese clients. In this regard, it is impOttant to emphasize that it is not neces­sary to achieve an optimal body weight to eJ\'PeJience health benefits. Even modestlevels ofweight loss (.5% to 10% reduction in body weight) are associated \vith clin­ically significant reductions in blood pressure, increases in insulin sensitivity, ar1dimprovements in lipid and lipoproteins concentrations.28 The prevention of fUttherweight gain should be the first primity for obese individuals. Subsequently, theobese patient should be encouraged to focus on gradual but permanent weight loss,improving cardiorespiratory fitness and reducing overall cardiovascular disease risk.

ACSM makes the follOWing recommendations regarding exercise testing andtraining of overweight and obese persons.28,44

• Although standard exercise testing methods and protocols are generallyappropriate with obese patients cleared for exercise testing, the level ofdeconditioning typically obselved \vithin this population \viII necessitate a lowinitial workload (2 to 3 metabolic equivalents [METsJ) and small workloadincrements per test stage (0..5 to 1.0 METs).

• Other comorbidities (e.g., hypertension other chronic diseases) or concerns(e.g., olthopedic limitations or elderly) may dictate modifications to the test­ing procedures.

• Use of leg or arm ergometry may enhance testing performance.• Medications should be taken at usual time relative to the exercise bout.• For those who have difficulty adjusting to the exercise equipment, the initial

stage may need to be extended, the test restarted, or the test repeated,• Special attention to proper cuff size is necessary for accurate blood pressure

measurements.

EXERCISE PRESCRIPTION

• The recommended mode, intensity, duration, and overload are consistent\vith those in Chapter 7 for cardiovascular, resistance, and flexibility exercisestimuli (see summary in Table 9-1). However, modifications should be madeto encourage greater overall energy eJ\'Penditure \vitl1in the program for theobese individual.

SECTION III/ EXERCISE PRESCRIPTION216

Obesity

219CHAPTER 9 / OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

Metabolic Syndrome

is one that combines a mild caloric restJiction \vith regular endurance exercise.ACSM makes the foIlO\\~ng recommendations for weight loss programs:z'>

• Targets a long-term reduction in body weight of at least .5% to 10%• Includes the exercise recommendations outlined in the preceding section• Includes a reduction in dietary fat intake to <30% of total energy intakc and

emphaSizes fruits, vegetables, whole grains, and lean sources of protein• Includes foods that are acceptable in terms of sociocultural background. pref­

erences, costs, and ease in acquisition and preparation• Provides in a negative energy balance of .500 to 1,000 kcahl- \ resulting in

gradual weight loss of 0.5 to 1 kg'wk- ' (l kg approXimately equal to 7,700kcal)

• Includes the use of behavior modification techniques including relapse prc­vention

• Pro\~des phYSical acti\~ty and dietaly habits that can be continued for life tomaintain the achieved lower body wCight

The metabolic svndrome also referred to as syndrome X or the insulin resistancesyndrome, desc:ibes a c;ndition in which several coronary hemi disease (CHD)risk factors (e.g., dyslipidemia, insulin resistance, elevated blood pressure,impaired fibrinolYSiS, and chronic low-grade inflammation) are clustered togeth­er46 Visceral obesity (e.g., increased intra-abdominal adipose tissue) appears tobe a central feature of this syndrome.4

' The prevalence of the metabolic syn­drome has been estimated to be approXimately 22% in the United States, whichcorresponds to about 47 million adults.4.'> The lisk factors associated \\~th this syn­drome act synergistically to increase cardiovascular disease morbidity and mor­tality.49

Several mechanisms havc been proposed to explain how \~sceral obeSity mightlead to insulin resistance and the other abnormalities associated vvith the syn­drome. Visceral adipose tissue secretes factors including PAl-I, cytokines (e.g.,IL-6, T F-ct), and angiotensinogen that are associated \vith one or more featuresof this syndromeso In addition, visceral adipose tissue, which is drained by theportal vein, is highly lipolytically active, thereby increasing non-esterified fattyacid (NEFA) flux to the liverso Increased hepatiC NEFA uptake may lead tohyperglycemia, h)1)erinsulinemia, and hypeliliglyce,idemiaso

Diagnosis of the mctabolic syndrome is made when threc or more of the riskdeterminants shown in Table 9-4 are present.2.5 However, abdominal obeSity, asassessed by waist circumference, is more highly correlated \\~th metabolic liskfactors than is an elevated body mass index (BMI).Z5 Therefore, waist circumfer­ence should be used as the plimary anthropometriC marker of the metabolic syn­drome. Some male patients exhibit metabolic Jisk factors \vith lower levels ofabdominal obesity (e.g., waist circumference 01'94-102 cm [37-40 in.].z5 Thesepatients are thought to have strong genetic contribution to insulin resistance.z.5

There are two major objectives for the clinical management of the metabolicsyndrome: 1) reduce underlying causes of the disorder (e.g., obesity and phYSicalinactivity), and 2) treat the associated lisk factors. z5 Thus, the initial treatment

SECTION III/EXERCISE PRESCRIPTION218

• The needs and goals of the obese subject must be indiVidually matched withthe proper exercise program to achieve long-term weight management.

• Primmy mode should be large muscle group aerobic activities.• The initial exercise training intensity should be moderate (e.g., 40% to 60%

VOzR or HRR) with more emphaSiS placed on increased duration and fre­quency. Eventual progression to higher exercise intensities (50% to 75%\10zR or HRR) allows for further increases in \/OZm.." which in tum allows fora more efficient exercise session (i.e., attainment of goal energy expenditurein reasonable amount of time).44 However, for some (espeCially older) obesesubjects, a walking or other moderate-intensity exercise program may be allthey desire, and movement toward a more intense program may not be war­ranted.

• Frequency of training: 5 to 7 d'wk- I

• Duration of training session: 45 to 60 minutesZIl.44• Volume of training: Initial training volume should follow the progressions out­

lined in Table 7-1, focusing on attainment of 150 minutes of moderate inten­sity exercise weekly. However, the optimal maintenance dose of phYSicalactivity is 2:2,000 kcahvk- I (200-300 minutes per week [or most).ZI>.44

• Obese individuals benefit from additional resistance exercise training in amanner similar to othenvise healthy adults. However, the addition of resist­ance exercise to endurance exercise and diet modification does not appear tominimize the loss of fat-free mass or resting energy expenditure compared tothat observed with diet modification alone, or the combination of diet modi­fication and endurance exercise training.zI>

SPECIAL CONSIDERATIONS

• vVhen the exercise component of a weight loss program is deSigned, the bal­ance between intensity and duration of exercise should be manipulated topromote a high total calOlic eX'Penditure.

• Obese individuals are at an increased Jisk for olihopedic injUly, and this mayrequire that the intensity of exercise be maintained at or below the intensityrecommended [or improvement of CR fitness.

• lon-weight-bearing activities (,mcl!or rotation of exercise modalities) may benecessary, and frequent modifications in frequency and duration also may berequired.

• Obese individuals have an increased Jisk of hyperihermia during exercise.• Equipment modifications may be necess,uy (i.e., wide seats on cycle ergome­

tel's and rowers)4.5

• It should be emphaSized that increases in phYSical acti\~ty, cven in theabsence of weight loss, can reduce the risk of cardiovascular disease in obesesubjects.

• Physical activity is the best predictor of long-term weight maintenance 40

RECOMMENDED WEIGHT LOSS PROGRAMS

UnfOliunately, there is little evidence that exercise alone or in combination \vithdietaly energy restriction produces magnitudes of weight loss achieved \vithdietmy energy restriction alone.'lo However, the optimal approach to weight loss

EXERCISE TESTING AND PRESCRIPTION

221

Very highModerateSedentary

CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

Belowaverage

Immunology

EXERCISE AND UPPER RESPIRATORY TRACT INFECTIONS

Aboveaverage

i=a:::;)-o~ AverageIIIa:

The generally accepted 'J' cUlve model proposes a relationship between theamount and intensity of exercise and susceptibility to URTI (Fig. 9_1),-56 Thismodel proposes that moderate cxercise training reduces the risk of developingURTI below that of a sedenta,y person, whereas the risk rises to above-averagelevels after intense exercise, Epidemiologic studies have demonstrated a higherincidence of self-reported symptoms of URTI in endurance athletes after bothcompetition (e.g., marathon) and intensified training relative to the gcneral pub­lic,56-,S8 Moderate exercise training (e.g., brisk walking) in untrained healthy indi­viduals on the other hanu, may reduce the incidence and/or the duration of URTI

The majOlity ofhuman research in exercise immunology has focused on the influ­ence of exercise on susceptibility to upper respiratOly tract infections (URTls;e,g., common cold or influenza [flu)). Thus, this section focuses on the relation­ship between exercise and URTI symptomatology and on basic immune respons­es to exercise, from which recommendations for exercise testing and prescriptionare delived. For more detailed information on exercise immunology, pmticularlyas it relates to cancer patients/survivors and people infected with a humanimmunodeficiency virus (HIV), consult other publications.'s2-.55

Amount and intensity of exerciseFIGURE 9-1. Proposed relationship between the amount and intensity of exercise andsusceptibility to upper respiratory tract infections. (Reprinted with permission fromNieman DC. Exercise, upper respiratory tract infection, and the immune system. MedSci Sports Exerc 1994;26: 128-139.)

<40 mg·dL- 1

<50 mg·dL- 1

~ 130/~85 mm Hg~110 mg·dL- 1

Waist circumference:j:>102 cm (>40 in.)>88 cm (>35 in.)~150 mg·dL- 1

Defining levelRisk Factor

tThe ATP III panel did not find adequate evidence to recommend routine measurement ofinsulin resistance (e.g., plasma insulin), proinflammatory state (e.g., high-sensitivity C-reactive

protein), or prothrombotic state (e.g., fibrinogen or PAI-1) in the diagnosis of the metabolic

syndrome.

*Some males can develop multiple metabolic risk factors when the waist circumference is only

marginally increased (e.g., 94-' 02 cm [37-39 in.]). Such persons may have a strong geneticcontribution to insulin resistance. They should benefit from changes in life habits, similar to

men with categorical increases in waist circumference.

Abdominal obesityMenWomen

TriglyceridesHigh-density lipoprotein cholesterol

MenWomen

Blood pressureFasting glucose

TABLE 9-4. Clinical Identification of the MetabolicSyndrome*.t

SECTION III/ EXERCISE PRESCRIPTION

'See reference 2S: From the National Cholesterol Education Program. Third Report of theNational Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and

Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II!). 2002. NIH

Publication No. 02-S215.

220

Standard exercise testing methods and protocols are recommended for individu­als with the metabolic syndrome. However, consideration should be given to spe­cific elements of the syndrome (e.g" hypertension, diabetes, and obesity), whichmay necessitate alterations in standardized testing methods (see appropriate sec­tions of this chapter for testing considerations).

Because obesity is at the core of the metabolic syndrome, exercise prescrip­tion guidelines should be based on those for obese patients (see preceding sec­tion on obesity). However, as the syndrome represents a clustering of metabolicdisorders, the exercise guidelines related to the other components of the syn­drome (i.e., dyslipidemia, hypeltension, and if necessary, diabetes) also should betaken into consideration, Furthermore, as the metabolic syndrome has been asso­ciated with both sedentary Iifestyle2.s and low CR fitness;Sl the eventual exerciseprogression should incorporate an increased training intensity (50% to 75%V02R or maximal HR reselve) to provide the stimulus to improve cardiorespira­tOlY fitness and allow for more efficient exercise sessions (i.e., attainment of goalenergy expenditure in reasonable amount of time)44

approach is weight reduction and increased physical activity. Even a modest 5%to 10% reduction in body weight results in significant improvements in metabol­ic risk factors 47 Treatment of risk factors also may involve treatment of hyper­tension, aspitin use in patients with CHD, and the treatment of elevated TG andlow HDL-C concentrations.25

EXERCISE TESTING

IMMUNE RESPONSES TO EXERCISE

symptomatology.·55..5s.59 Shmt-term 00 days) moderate exercise training (55% ofHRR) does not appear to increase the severity of mild symptoms associated witha rhinovirus-induced URTI (-50% of URTI are caused by rhinoviruses) nor neg­atively affect resting pulmonalY function, subma,...imal exercise responses, or max­imal exercise performance.50,51

223CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

infection could increase the virulence of some viruses, lead to severe dehydra­tion, exacerbate existing conditions (e.g., pulmonaIy or cardiovascular disease),and increase the risk of developing secondaIY complications (e.g., bronchitis,chronic fatigue syndrome, and exacerbations of cardiopulmonary conditions).Persons aged 65 years and older, pregnant women, HIV-infected individuals,and people of any age \vith chronic medical conditions are more likely to e>:pe­lience secondary complications (e.g., pneumonia, myocarditis) from tlle flu s2

• Prescribed or over-the-counter medications should be taken into accountbecause they may affect cardiovascular responses to testing and exercise per~formance.

EXERCISE PRESCRIPTION

SPECIAL CONSIDERATIONS

• Healthy individuals mth symptoms of a URTI could follow the above the neckrule. 53 That is, if the symptoms of a URTI are mild and limited to the mouth,nose, and throat (above the neck) exercise could be performed, albeit at alower intensity and volume. Exercise should be discontinued if symptomsworsen. If the symptoms are moderate to severe anellor indicate a systemicinvolvement (e.g., fever, tiredness, diarrhea, and myalgia), then exerciseshould be postponed until the symptoms have resolved.

• Resumption of training after URTI should begin at a modest level and theprogression should be gradual.

• Clients "vith a mild URTI should be encouraged not to exercise in a groupexercise setting to prevent the spread of their infection to other clients.

• Closely monitor exercise tolerance to avoid overtraining and chronic fatigue.

• Encourage clients to get adequate rest, maintain a well-balanced diet, ingestample fluids, and minimize psychological stress, particularly dUling peliods ofintense training.

• To reduce viral self-inoculation, encourage clients to wash hands with warmsoapy water and minimize hand-to-eye and hand-to-nose contact, paIticularlydUling tlle cold and flu season.

• Clients should minimize their exposure to individuals \vith a URTI becauseURTI is spread from person to person plimaIily through coughing and sneez­ing of infected persons.

• Clients should be encouraged to consult "vith their physician on the appropri­ateness and timing of receiving a flu vaccine, paIticularly those at high risk fordeveloping secondary complications from the flu (persons aged 65 years andolder, pregnant women, and people of any age "vith chronic medical condi­tions).52 Clinicians who have frequent contact mth these high-risk popula­tions should obtain a flu vaccine,52

OsteoporosisOsteoporosis is defined as a systemic skeletal disease characterized by low bonemass and microarchitectural detelioration of bone tissue \villi a consequentincrease in generalized skeletal fragility, such that fractures occur \vith minimal

SECTION III/ EXERCISE PRESCRIPTION222

Reductions in selected measures of immune function dming recovery fromendurance exercise may provide an "open window" for viruses and bacteria to gaina foothold.53,56 Vigorous (e.g., >80% HRR), but not moderate, intensity exercisemay increase the probability of developing a subclinical (i.e., ,,~tllout symptoms) ora clinical (i.e., \\~th symptoms) infection 1 to 4 days after the exercise.

Changes in immune function after a Single bout of intense endurance exerciseor after intense training does not appear to chronically enhance nor suppressimmunity in the resting state.53,54 In addition, no studies have demonstrated thatendurance athletes during intensified training are clinically immune deficient.Similarly, moderate endurance training and resistance training in healthy indi­viduals does not appear to chronically influence immune function in the restingstate:53,.54,52 Larger long-term prospective studies are needed to confirm the 'T'curve model and the "open mndow" hypothesis. In addition to exercise, theimmune system is influenced by many factors, including psychological stress,underlying disease, nutrition, medications, smoking, alcohol consumption, obesi­ty, weight loss, aging, allergies, socioeconomic factors, and environmental condi­tions.53.54 ,63.6.J Thus, clinicians should not confuse the apparent associationbetween acute and chronic exercise and altered susceptibility to URTI with cau­sation. Changes in URTI symptomatology may occur in the absence of exercise.Because clinical populations (e.g., cardiovascular diseased, cancer patients/sur­vivors, HIV-infected individuals, and elderly people) exhibit mallY of the afore­mentioned factors, the immune response to exercise may be different from theresponses observed in healthy or younger individuals.55

,65,66 Thus, the overallhealth status of the client must be taken into account when assessing the impactof exercise on immunity.

ACSM makes the follo,,\~ng recommendations regarding exercise testing andtraining for patients \vith URTI.

• It is probably safe to test clients at a submaximal intensity, whose symptoms aremild and limited to the upper respiratOly tract (e.g., common cold symptoms ofa runny or congested nose, sneezing, anellor sore throat). Maximal testing ofsubjects exllibiting URTI symptoms does not elicit diminished performance,and tllUS it is not necessaIy to postpone testing60

,61 However, for the comfOlt ofthe patient and because of a lack of information regarding long-term effects, itis prudent to delay maximal testing until tlle symptoms have resolved.

• Exercise testing should be postponed in clients who demonstrate symptoms ofsystemic involvement (e.g., fever, tiredness, diaIThea, and myalgia) until thesymptoms have resolved (generally 1 to 2 weeks). Exercising with a systemic

EXERCISE TESTING

EXERCISE PRESCRIPTION

°NationaJ Institutes of Health, Osteoporosis and Related Bone Diseases National Resource Center

(\\~\~v.osteo.org).

225CHAPTER 9 / OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

Peripheral Arterial Disease

• Contraindicated exercises include explOSive movement and high-impact load­ing activities to the skeleton, such as jumping, running, or jogging68

• Dynamic abdominal exercises (e.g., Sit-ups), excessive trunk flexion, and twist­ing movements can be dangerous. Exercises that require bending forward atthe waist or excessive twisting at the waist (golf swing) produce high com­pressive forces in the spinal area and increase the vulnerability to fracture.Daily activities such as sitting and bending to pick up objects can cause verte­bral fracture.

by pain, the physician should be consulted prior to exercise pmiicipation.• ~erform cardiovascular exercise (aquatic, walking, cycling) at 40% to 70% of

VOzH or HHR69

• Perform resistance exercise (free weights, machines, calisthenics, elastic bands)with the load directed over the long axis of the bone, 2 d 'wk-t for 8 to 10 rep­etitions at a submaximal intensity (HPE 13-15) for one to two sets69 Avoid exer­cises with spinal flexion and pelform all exercises in an upright posture.

• Perform flexibility exercise 5 to 7 d'wk- 169

• Perform functional exercise activities (chair exercise, chair sit and stand, vig­orous walking) 2 to 5 d'wk- t 69

Peripheral artetial disease (PAD) is a manifestation of systemic atherosclerosisthat affects approximately 8 to 10 million people in the United States.7Z,73 PADdiminishes blood flow to the lower extremities, which leads to a mismatch of oxy­gen delively and metabolic demand dUring physical activity. Claudication is theprimaly symptom of PAD and is charactetized as walking-induced pain in one orboth legs that does not go away with continued walking and is relieved by rest.Claudication ptimarily affects the calves but may begin in the buttock region andradiate down the leg. The symptoms commonly are desctibed as burning, sear­ing, aching, tigh!ness, or cramping. Claudication is present in 15% to 40% of per­sons with PAD. '4 To avoid leg discomfOli, patients with claudication alter theirgait by decreasing their ambulatOlY pace and distance. Daily physical activity andmaximal oxygen uptake are reduced by 50% in those with claudication comparedto healthy subjects of similar age. Many affected patients are so deconditionedthat they become housebound or dependent on others.'5 In more advancedcases, ischemic limb symptoms can occur at rest ("critical limb ischemia") andoften requires surgery or amputation.

The goals of treatment for patients with claudication are to relieve their exer­tional symptoms, improve their walking capacity and quality of life, and reducetheir atherosclerosis tisk burden./(; Patients are treated initially with cardiovascu­lar dIsease risk factor modification, exercise training, and medications. The goalsfor rIsk factor modification in patients with petipheral alierial disease are similarto those in patients with coronaty aliery disease.

.A~SM makes the following recommendations regarding exercise testing andtrammg for patients with PAD.

SPECIAL CONSIDERATIONS

SECTION III/ EXERCISE PRESCRIPTION224

• Physician approval is warranted plior to graded exercise testing to determinethe risk! benefit ratio of testing.

• The patient should maintain an up,ight posture at all times, as any SOli ofspinal flexion is contraindicated. A cycle ergometer protocol is preferred.

• Premature termination may occur from osteoporotic pain.• Severe kyphosis, which can exist as a functional limitation imposed by multi­

ple veliebral fractures, may result in compromised ventilatory capacity and afOlward shift in center of gravity.

• Care must be taken to ensure the patient does not trip or fall if a traditionaltreadmill exercise test is performed. Additional testing may include balance,muscular strength, and gait biomechanics.

trauma.67 Osteoporosis involves reductions in both bone mineral density (BMD)and bone quality. Osteopenia is dcfined as a bone density between1 and 2.5 standard deviation units below average and places the individualat greater lisk for osteoporosis.6B The risk of fracture increases with age forthe osteopenia patient. An estimated 44 million Amelicans are at risk ofosteoporosis, with 10 million displaying the disease and 34 million having lowbone mass."

Osteoporosis has a debilitating effect on independence and quality of life. Hiskfactors for osteoporosis are family histolY, female gender, estrogen deficiency,low weight, dietmy factors, prolonged use of corticosteroids, smoking, and phys­ical inactivity69 Exercise therapy, paliicularly resistance-based and weight-bear­ing activity may increase bone material and modify several tisk factors for osteo­porotic fracture, including muscle strength, bone-mineral density, and dynamicbalance.68.

7o Bone mass attained early in life is perhaps the most important deter­minant of lifelong skeletal health.'t Nutrition, exercise, and body composition allplaya key role in bone density. Exercise can positively affect peak bone mass inchildren and adolescents, maintain or even modestly increase bone density inadulthood, and assist in minimizing age-related bone loss in older adults.Therefore, exercise programming should be presented to optimize bone healthand to safely prescribe exercise for individuals with existing low BMD.

ACSM makes the following recommendations regarding exercise testing andtraining for patients 'vith osteoporosis.

• Consider pain status of patient. If the patient is relatively pain-free, aerobicweight bearing activity (4 d'wk- I) and resistance training (2-3 d'wk- I

) is rec­ommended.

• Specific exercises focusing on improving balance and modifYing activities ofdaily living are recommended.'o

• ImprOving muscle strength helps to conserve bone mass and enhance dynam­ic balance.'o Wben prescribing exercise for patients who are severely limited

226 SECTION III/EXERCISE PRESCRIPTION

EXERCISE TESTING

• Patients with PAD generally are classified as high risk; thus, exercise testingshould be conducted in the presence of a physician.

• Because of the high Iisk of cardiovascular disease in this population, exercisetesting with ECG monitoring should be performed so that ischemic symp­toms, ST-T wave changes, or dysrhythmias may be IdentIfied.

• Graded treadmill protocol at 2 mph with modest increases in grade of 3.5%every 3 minutes or 2% eveI)' 2 minutes or a gradual ramp protocols may beused." Record time or distance to the onset of claudication pain (see Chapter5 for claudication scale) and the maximal walking time or distance.

• Arm ergometry or pharmacologic stress testing can be used in patients whocannot perform leg exercise to assess cardiovascular status. .

• Questionnaires are ': u:~£ul adjunct to exercise testing to assess commumty­based activity levels. ,.5.'S.,,)

EXERCISE PRESCRIPTION77.80.81

• The recommended mode, frequency, duration, and overload generally arcconsistent with those in Chapter 7 for cardiorespiratory, resistance, and flexi­bility exercise stimuli (see summaI)' in Table 9-1).

• Initial enrollment in a medically supcrvised program with ECG, healt rate,and blood pressure monitoring is encouraged (see Table 7-3).

• \"!arm-up and cool down period of 5 to 10 minutes each.• Treadmill and track walking are the most effective approaches to reduce clau­

clication and should be performed 3 to 5 d·wk- 1s2

• Initial treadmill workload is set to elicit claudication symptoms within 3 to 5minutes. Patients walk at this workload until they reach claudication of mod­erate sevelity (level 3). This is followed by a brief peliod of standing or sittingto allow symptoms to resolve.

• The exercise-rest-exercise pattern is repeated throughout the exercise session.The initial duration is a total of 3.5 minutes of intermittent walking, andincreased by 5 minutes each session until 50 minutes of intermittent walkingcan be completed. Ultimately, 35 to 50 minutes of continuous walking is

desired.• Cardiac signs and symptoms may appear as patients increase their exercise

capacity and reach higher heart rates and blood pressure.• Resistance training and/or upper body ergometry is complementary to but not

a substitute for walking.

SPECIAL CONSIDERATIONS

• The most common procedure for assessing the pelipheral circulation is theratio of ankle to arm systolic blood pressure (ankle-hrachial index [ABI])

• Normal: 0.91 to 1.30• Mild to moderate PAD: 0.41 to 0.90• Severe PAD: 0.00 to 0.40• oncompressible, calcified vessel: >] .30

CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 227

• Ankle systolic BP and ABI are further reduced after exercise because bloodflow is shunted into the proximal leg musculature at the expense of theperiphe,)' and distal circulation in the leg.

• Although serial measurements of ABI are used for assessing progression indisease severity, an increase in leg blood flow is not a common response toexercise training. Hence, ABI is not useful for assessing the efficacy of inter­vention.

• Time to onset of intermittent claudication on exercise test is valuable outcomemeasure.

Pulmonary DiseasesPulmonal)' diseases typically result in dyspnea or shOltness of breath with

exertion. As a result of this dyspnea, pulmonary patients limit their physical activ­ity, and deconditioning results. Consequentially, pulmonal)' patients experienceeven greater dyspnea with even lower levels of physical exertion. Unless thisvicious cycle can be broken, the pulmonat)' patient eventually becomes disabledand functionally impaired. Exercise has been shov.'n to be an effective interven­tion that can break this cycle and prevent disability and functional impair­ment.S:,.S4

Pulmonal)' function abnormalities often are divided into restrictive andobstructive dysfunction. Restrictive lung dysfunction is an abnormal reduction inpulmonary ventilation that may be the result of many different diseases, trauma,radiation, or certain drugs. In contrast, chronic obstructive pulmonary disease(COPD) is defined as a permanent diminution of airflow, usually associated withchronic bronchitis, emphysema, and asthma. Current evidence suggests thatstandard principles of exercise prescription (mode, frequency, intensity, andduration) generally can be applied to patients with pulmonat)' diseases. However,the majority of published data on exercise testing and prescription in this popu­lation have been obtained from those with COPD b

.5.'>r, Individuals with well­controlled asthma can exercise follOWing the general guidelines presented inChapter 7. However, patients with asthma, particularly those with exercise­induced asthma (EIA), should pay special attention to avoiding environmental"triggers" such as cold, dry, dusty air and/or inhaled pollutants, chemicals.Individuals suffering from acute asthma should not exercise until symptoms havesubsided.

ACSM makes the follOWing recommendations regarding exercise testing andtraining for patients with pulmonar)' disease.

EXERCISE TESTING

• Assessment of physiologic function should include cardiopulmonaty capacity,pulmonal)' function and determination of arterial blood gases and/or arterialoxygen saturation (5,.02)'

• Modifications of traditional protocols (extended stages, smaller increments,slower progression) may be warranted depending on functional limitationsand the early onset of dyspnea.

• Exercise testing may be terminated because of atterial oxygen desaturation.

EXERCISE PRESCRIPTION

• The exercise testing mode is typically walking or stationary cycling. If anTIergometry is to be used, it is important to remember that upper extremity aer­obic-type exercise can result in increased dyspnea that can limit the durationof the activity87

• The recommended mode, frequency, duration, and overload generally areconsistent with those in Chapter 7 for cardiorespiratory, resistance, and flexi­bility exercise stimuli (see summary in Table 9-1).

• Walking is recommended strongly as the mode of exercise because it isinvolved in most activities of daily living. Stationary cycling may be used as analternate mode of training. As with testing, upper extremity aerobic exercisetraining can result in increased levels of dyspnea.

• The recommended minimal goal for exercise frequency is 3 to 5 d·wk- 1.

Individuals with a reduced functional capacity may require more frequent(i.e., daily) exercise training for optimal improvement.

• At present, there is no consensus as to the "optimal" intensity of exercise train­ing for pulmonary patients. Two major approaches that have been evaluatedare to exercise at 50% of peak \102 or at maximal limits as tolerated by symp­toms84.88.89

• 0 matter what the prescribed intensity, the exercise professional shouldclosely monitor initial exercise sessions and be ready to adjust intensity andlorduration according to patient responses. In many cases, the presence of symp­toms, particularly dyspnealbreathlessness supersedes objective methods ofexercise prescription.

• The traditional method for monitoring the training intensity has been heartrate. An alternative approach is to use a dyspnea rating obtained from a GXTas a "target" for exercise training. Most patients with COPD can accuratelyand reliably produce a desired exercise intensity using a dyspnea target of 2 to3 (on 4-point scale) or between 3 and 5 ("moderate to severe") on the 0 to 10category-ratio scale during submaximal exercise of 10 to 30 minutes' dura­tion.90

•9i It is probably unrealistic for most patients vvith a chronic respiratOly

disease to perform 20 to 30 minutes of continuous exercise at the start of aphysical training program. Therefore, some patients may be able to exerciseonly at a speCified intensity for a few minutes. Intermittent exercise, that is,repetitive exercise-rest periods, may be necessary for the initial training ses­sions until the patient can achieve sustained higher intensities.

• It is now recognized that respiratory diseases, COPD in particular, not onlyaffect the lungs but skeletal muscle as well. As such, resistance training ofskeletal muscle should be an integral part of pulmonary rehabilitation pro­grams. 92-94 The exercise prescription for resistance training with pulmonarypatients should follow the same principles as those with older healthyadults.94-96

• Because respiratory disease patients can experience greater dyspnea whileperforming activities of daily living involving the upper extremities,S7 it maybe beneficial for these patients to focus on the muscles of the shoulder girdlewhen performing resistance exercises.

229CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION

Pregnancy

• Unlike healthy individuals and heart disease patients, pulmonmy diseasepatients may exhibit arterial m;ygen desaturation with exercise. Therefore,some measure of the blood oxygenation, either the partial pressure of arte­rial oxygen (P,,02) or percent saturation of arterial oxygen (S,P2), should bemade during the initial GXT. In addition, oximetry is recommended for theinitial exercise training sessions to evaluate possible exercise-induced O2desaturation.

• Based on the recommendations of the Nocturnal Oxygen Therapy Trial/ oo

supplemental O2 is indicated for patients with a P,,02 of 55 mm Hg or less, oran S,P2 of 88% or less while breathing room air. These same guidelines applywhen considering supplemental m,ygen during exercise training.

SPECIAL CONSIDERATIONS

• InspiratOlY muscle weakness has been identified as a contributor to exerciseintolerance and dyspnea97

.9& As such, trai.ning of these muscles has the poten­tial to reduce dyspnea and improve exercise capacity. RespiratOlY musclestrength andlor endurance can be speCifically increased with inspiratOly mus­cle training. Although positive benefits from inspiratory muscle training havenot been demonstrated conclusively, there is emerging evidence to suggestthat inspiratory muscle training does have positive effects in those patientspresenting with inspiratOly muscle weakness 8 .5.99

• Guidelines for inspiratOly muscle training for individual patients include: aminimum frequency of 4 to 5 chvk-\ an intensity of 30% of maximal inspira­tory pressure measured at functional residual capacity, and a duration of 30minutes a day or hvo I5-minute sessions per day.

The physiologic changes associated with pregnancy warrant evaluation of obstet­ric and medical risks prior to engaging in regular physical exercise. Concernsregarding the possible adverse effects of exercise participation have focused on:1) inadequate availability of oxygen or substrate for mother and fetus, 2)hypothermia-induced fetal distress or birth abnormalities, andlor 3) increaseduterine contractions. However, current studies indicate that healthy women withuncomplicated pregnancy do not need to limit their exercise for fear of adverseeffects. WI Generally, participation in a wide range of recreational activitiesappears safe during and after pregnancy. \Vomen should be encouraged toengage in a consistent, moderate-intensity physical activity to reap the health­related benefits associated with exercise. Overly vigorous activity in the thirdtr.imester, activities that have a high potential for contact, or activities vvith a highrIsk of falling should be avoided. In addition, during pregnancy refrain from activ­ItIes with a risk of abdominal trauma, exertion at altitude greater than 6,000 feet,and scuba diving. lOi Interestingly, the benefits of chronic exercise reside with themother, whereas the risks of overexercise predominantly affect the fetus.

The American College of Obstetricians and Gynecologists (ACOG)WIhave established relative and absolute contraindications (Box 9-1) for exerciseduring pregnancy. If the aforementioned contraindications do not preclude

SECTION III/EXERCISE PRESCRIPTION228

230 SECTION III / EXERCISE PRESCRIPTION CHAPTER 9/ OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 231

• The recommended mode, frequency, duration, and overload generally areconsistent with those in Chapter 7 for cardiorespiratOlY, resistance, and flexi­bility exercise stimuli (see summary in Table 9-1).

• In the absence of either medical or obstetric complications, 30 to 40 minutesor more of moderate physical activity on most, if not all, days of the week isrecommended.

• Regular exercise (e.g., at least 3 d'wk- 1) is preferable to intermittent

activity.

• Monitor exercise intensity by use of ratings of perceived exertion (RPE 11-13)(light to somewhat hard), rather than heart rate.

• Women who were sedentary or relatively inactive prior to pregnancy shouldbegin v,rith light-intensity (20%-39% HRR), low- (or non-) impact activities,such as walking and swimming.

• Avoid exercise in the supine position after the first trimester because mildobstruction of venous return attenuates cardiac output and may facilitateorthostatic hypotension.

EXERCISE TESTING

• Unless a clinical condition dictates ma"imal exercise testing, it is not recom­mended for pregnant women, and only under the supervision of a physician.

• Submaximal testing can be performed vvith an endpoint of <75% heart ratereserve.

• Women who were less active or sedentmy prior to pregnancy should seek theapproval of a physician prior to engaging in physical activity.

EXERCISE PRESCRIPTION

ated with maternal complications, the rate of return to prepregnancy levels dif­fers among individuals. 102 Moderate weight reduction while nursing is safe anddoes not compromise neonatal weight gain.

ACSM makes the following recommendations regarding exercise testing andtraining during and follov,ring pregnancy.

SPECIAL CONSIDERATIONS

• Pregnancy requires an additional 300 kcal·d- 1 to maintain metabolic home­ostasis. L03 Therefore, ingest additional calories to meet the needs of exerciseand pregnancy.

• Motionless standing results in venous blood pooling, so it should be avoided.• He~t dissipation is impotiant throughout pregnancy. Appropriate clothing,

en~ronmental considerations, and adequate hydration should be prioritiesdunng the exercise program to prevent the possibility of hyperthermia andthe corresponding risk to the fetus. Drink ample water to prevent dehydra­tIon. Avoid brisk exercise in hot, humid weather or when you have a fever.

• Matet:nal hypoglycemia may be associated vvith strenuous exercise during thelast tnmester of pregnancy. The reduction in blood glucose lllay result frommcreased glucose uptake by the fetus and mother, decreased maternal liverglycogen stores, or reduced maternal liver glycogenolysis. 103 Attenuate the

Contraindications for Exercis~ng During Pregnancl*

Relative• Severe anemia• Unevaluated maternal cardiac dysrhythmia

• Chronic bronchitis• Poorly controlled type I diabetes

• Extreme morbid obesity• Extreme underweight (BMI < 12)• History of extremely sedentary lifestyle• Intrauterine growth restriction in current pregnancy

• Poorly controlled hypertension

• Orthopedic limitations• Poorly controlled seizure disorder• Poorly controlled hyperthyroidism

• Heavy smoker

Absolute• Hemodynamically significant heart disease

• Restrictive lung disease• Incompetent cervix/cerclage• Multiple gestation at risk for premature labor• Persistent second- or third-trimester bleeding

• Placenta previa after 26 weeks of gestation• Premature labor during the current pregnancy

• Ruptured membranes• Preeclampsia/pregnancy-induced hypertension

*See reference 101. From American College of Obstetricians and Gynecologists. Exercise

during pregnancy and the postpartum period. ACOG Committee Opinion No. 267. Obstet

GynecoI2002;99:171-173.

participation, guidelines for safe exercise participation for women with no riskfactors for adverse maternal or perinatal outcomes are suggested. Women whocurrently participate in exercise can continue their exercise program withoutmajor moditlcations. However, many active women modify their program basedon symptoms, discomfort, and risk associated 'Nith joint laxity and body mass gain.Precautions may include using a treadmill or track for walking or running insteadof exercising along the sidewalks or roadways. Exercising indoors may providemore environmental control to avoid excess heat, cold, or air pollution.

Lactation is an energy-demanding physiologic process; however, exercise hasno detrimental effects on lactation for milk composition, milk volume, or mater­nal health. Many of the physiologic changes associated with pregnancy persist 4to 6 weeks postpartum. Prepregnancy exercise programs should be resumedgradually depending on birth complications (i.e., Caesarean section) and physicalsymptoms. Although there is no evidence that a rapid return to training is associ-

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illness on pulmonary function test ami e\ercise responses. ~Ied Sci Sports E,erc 1997;29(5Hi04--6JO.\reidner TC, Cranstoll T. Schurr T, et al. The (...ned of e\:ercise training on the se\-erit~' and dura­

tion of a viral upper respirat,,,), illness. Mecl Sci Sports Exerc J991>;30: I.571>- I,51>3.

Flynn ~IG, Fahlman :\/1, Braun \VA, et al. Effect or resistance training Oil selected indexes of

immune fundion inclderls \\omen. J Appl Physiol 1999;86(6): 190,5-19 J:3.Irwin M. Psyc!lollcuroimlllunologJ of deprt'ssion: clinical illlplications. Brain Beha\' lmmuilol

2002;16:1-16::\ielllan DC, \'ehlsen-Cannarella St., Ilenson DA, et al. immune response to e\:ercise training

aneVor t'nerh'y restriction in ohese women. \Ied Sci Sports Excrc 1998;:30:679-686.

Brllllllsgaard II, Pedersen 13K. EfTcd of exercise on the illlJl1111H.' Systl'tll in the elderly populatiou.

1IIIIIIulloi Cell Bioi 2000;78:,52:3-531.

66.

67.

68

69.

70.

71.

72.

73.74.

7,5.

76.

77 .

78.

79

80.

81.

82.

83.

84.

8.5.

86.

87.

88.

89.

90.

91.

CHAPTER 91 OTHER CLINICAL CONDITIONS INFLUENCING EXERCISE PRESCRIPTION 235

237

CLINICAL LABORATORY TESTING

A number of issues have prompted specific interest in physical actil'ity and fitnessin the pediatric population, including: 1) recognition of the role of regular exer­cise in the present and future health of youth, especially childhood obesity; 2) thegrowing number of children participating in elite-level sports competition; and 3)a growing awareness of the role of exercise testing and intervention in childrenand adolescents with chronic diseases. The growing body of research informationsurrounding these issues has identified a number of biological responses to exer­cise that are unique to physically immature individuals (Table 10-1). These haveprovided evidence that, phYSiologically, children are not simply smaJl adults. it isimportant that these features be considered when performing clinical exercisetesting or physic<J fitness testing in children as well as in designing exercise pro­grams for young subjects.

CHAPTER

10•••••

Children

Exercise Testing andPrescription for Childrenand Elderly People

The basic prcmise for treadmill or cycle testing of young persons is not differentthan that for adults-to assess symptoms, tolerance, and cardiopulmonatyresponses to high-intensity exercise in a controlled setting. In gencral, satisfacto­ry testing of children can be conducted equally well as in adults, even in subjectsas young as 3 to 4 years. However, a number of particular featmes need to beappreciated when dealing with this age group. I Most importantly, children areemotionally immature and need encouragement and positive support by an expe­rienced testing staff to achieve an adequate exercise effort.

The indications for exercise testing of children and adolescents are morediverse than for adults. Experience in pediatric exercise testing laboratories indi­cates that tests are most commonly performed [or: 1) evaluating individuals whoexperience symptoms (e.g., chest pain, shortness of breath, syncope, palpitations)during.sports or physical activity, 2) assessing cardiopulmonmy functional capac­ity, 3) identifying myocardial ischemia (most commonly in patients with aorticvalve stenosis or Kawasaki disease), 4) examining responses of heart rate, andrhythm (changes in ventricular ectopy, rate increases with complete heart block),and 5) assessing response to cardiac and pulmonaty rehabilitation programs.

Both cycle and treadmill protocols have been used for exercise testing of chil­dren. However, use o[ the treadmill is more appropl'iate when testing very young

236 SECTION III/ EXERCISE PRESCRIPTION

92. American Thoracic Societ) and America!l College of (~he~t PII.'~i<:i<llIS. ATS/ACCP Statement oncardiopulmonary t'wrcise tt'sting. Am J Ht'spir Crit Car" \tt'd 2(Xl:3;167:211-277.

9:3. American Thoracic Societ.'" ana European Hespirato,:, So(.'iet.'. Skeletal muscle dysfunction in

chronic obstructi,t' pulmOl"uY dist'a.>t'. Am J Ht'spir Crit Cart' \It'd 1999:\.59:S1-S~0.

9..1. Lake FH, I-Iendersoll K. Brin~l T. ct al. Uppt'r-lilllh alld (mer-limh t''Xercist' training in patit'l1b

with chronic airflow ohstruction. Ch"sl 1990;97: 1017-101>2.95. Simpson K, Killian K, McCarliw, :'oJ, d ai. Handomiwd "ontrolled trial of\\'t'ightlif\ing exercist' in

patients with chronic airflow limitation. T!lorcL\ 1992;47;70-7.5.

96. Spruit MA, Gosst-'Iin H, Troosters T, t>t <\1. Resistance versus (-'IHluranct' training in patients with

capo and peripheral musclt' wt'akness. Eur Ht'spir J 2002;19:1012-1071>.97. Killian KJ, Jont's NL. Hespiratnry nluscles and dyspnt'a. Clin Chest Med 1988;9;237-248.98. Mahler DA. \\'t'lis CK. E,·,Juation of clinical methods li,r rating dyspnea. Clwst 1988;93:580~586.

99. Lotters F, 'an Tol B. Kwakkel G, pt ai. Effects of controlled inspiratory musclt' training in pati"ntswith capo: a meta-analysis. Eur Respir J 2<Xl2:20:570-51fi.

100. Nex:.:tunlal O'\ygen Therapy Trial Croup. Continuous or nocturnal o\"ygen therapy in h:poxemic

chronic obstrudive lung disease: a dinical trial. :"Jocturnal Oxygen Therapy Trial Croup. Annlntern ~led 1980:9:3::391-:398.

lOt. American College of Ohstetricians and C:l1ecologists. Exercise dllring pregnanc), and the postpar­

tum pt'riod, ACOG Committee Opinion :\0. 267. Obstet CY11t'col 2002;99: l71-173.102. Hale m\·. \lilne L. The elite athlete and t'xt'rcise in pregnancy. Semin Perinatol 1996:20:217-284.103. \1'011' LA, Br"nnt'r JK, Mottola MF. Matt'rnal ext'rcist', letal wcll-bringand pr"gnancyoutcome. In:

Holloszy JO, ed. Exercise & Sports Scienct's neviews. Baltimort': Williams & \l'ilkins, 1994:145-194.

104. The Trials of Hypertension Prevention Collaborative Research Group. Effeds 01' weight loss andsodium redudion intervention on blood pressure and hypertension incidence in overweight peoplewith high-normal blood pressure. Arch lnt Med 1997;157;657-667.

105. He J, Whelton P, App,,1 L, et al. Long-krm effects of "'t'ight loss and di"tary sodium reduction onincidence ofhYl)ertension. Hypertension 2000;35:5"[4-~9.

106. Sacks F, S"etkey L, \'ollmer \1', et al. Effects on blood pressure of redoced dietary sodium and theDietHl}' Approach"s to Stop Hypert"nsion (DASH) dit't. DASH-Sodium Collaborati"e ResearcbGroup. :\ Engl J ~Ied 2001;344:3-10.

107. Vollmer \1', Sacks F, Ard J, "t al. Effects or diet and sodium intake on blood pressure: Subgroupanalysis of the DASH-sodium trial. Ann Intern \·Ied 2oo1;J35: 1019-1028.

108. Chobanian A, Hill M. National Heart, I,ung, and Blood [nstitutt' \ I'orkshop on Sodium and BloodPressure: A critical review of the current scientific eyiden<:e. 1-I:11ertension 2000;35:858-863.

lO9. Kefley GA, Kt'lley KS. Progrt'ssive resistallce exercise and resting hlood pressur,,: a meta-analysisof randomized controlled trials. Hypertt'nsion 2000;35:831>-843.

110. Xin X, He J, Frontini MG, et aI. Effeds or alcohol reduction on blood pressur<e: a meta-analysis orrandomized, controlled trials. Hl1)ertensioll 2001:38:1ll2-1117.

TABLE 10-1. Unique Physiologic Responses of Children Relative toAdults*t

*See references 1, 31. 32, and 33: Developed from Rowland TW Aerobic exercise tes\lng protocols In Rowland

TW, ed. Pediatnc Laboratory ExerCISe Testing: Clinical GUidelines. Champaign, IL: Human Kinetics, 199319-42; Bar­

Or 0 Pediatric Sports MediCine for the Practitioner. New York: Springer-Verlag, 1983:315-338; Rowland TW,

Straub JS, Unnlthan VB, et al. Mechanical efficiency during cycling In prepubertal and adult males Int J Sports Med

1990; 11 :452-455; Washington RL. Measurement of cardiac output. In: Rowland TW, ed. Pediatric Laboratory

Exercise Testing: Clinical GUidelines. Champaign, IL: Human Kinetics, 1993: 133.

tComparisons are based on exercise responses in a male child between 8 and 12 years of age compared with anapparently healthy young adult male.

*Submaximal exercise responses are referenced to the same absolute work rate.

children, because this modality requires that the subject maintain the pace of thebelt rather than provide the volitional effort to maintain a cycling cadence withincreased workloads. Electronically braked cycle ergometers reduce the depend­ence on a specific cadence by allowing a range of cadence to achieve the sameworkload. However, appropriate small size cycle ergometers are not available inmost laboratories. Seat height, handlebar height and position, and pedal cranklength may have to be modified for cycle ergometer testing to accommodate chil­dren. Most children who are 125 cm (50 in.) tall or taller can be tested on a stan­dard cycle ergometer. The greater potential for accidental falls on the treadmillrequires greater attention by the testing staff. Regardless of the mode or proto­col, children must be familiarized vvith all testing procedures to ensure the oppor­tunity for a successful evaluation.

Because of the wide ranges of ages and testing indications, no Single standardtesting protocol has been used for children (Table 10-2). Most laboratories usethe Bruce treadmill protocol for pediatric subjects, often modified to 2-minutework stages. In addition, various modifications of the Balke protocol commonlyare employed in pediatric research studies and in some clinical laboratories. Thisprotocol allows a constant comfortable speed (usually walking 3.0-3.5 mph orrunning at 5.0 mph), minimal slope elevation (2% per stage), and appropriate testduration (about 8-10 minutes). Its disadvantage is that, in contrast to the Bruceprotocol, this protocol provides no standard norms for test duration to age as anindicator of phYSical fitness. Adjustments to the protocol speed may be necessaryto accommodate for differences in stature and fitness levels. A number of differ­ent cycle testing protocols have been lISed for young subjects, most commonlythe McMaster and James protocols. These are outlined in Table 10-2.

239

TABLE 10-2. Cycle Ergometer Protocols for Children*

CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

Protocol Cadence Body Size Initial Increment Stage

(RPM) Load per Stage Duration

(min)

McMaster 50 Height (cm) Watts Watts<120 12.5 12.5 2120-140 12.5 25 2140-160 25 25 2>160 25 25 (female) 2

50 (male)

James 60-70 Body Surface kg·m·min- 1 kg·m·min- 1

Area (m 2)

<10 200 100 31.0-1.2 200 200 3>1.2 200 300 3

*See references 31 and 34: Adapted from Bar-Or O. Pediatric Sports Medicine for the Practitioner. New York:

Springer-Verlag, 1983:315-338; James f, Kaplan S, Glueck C, et al. Responses of normal children and young adults

to controlled bicycle exercise. Circulation 1980;61 :902-912

Abbreviations: RPM, revolutions per minute; em, centimeters; min, minute.

Certain phYSiologiC features can be anticipated during exercise testing of chil­dren. 2 The heart rate at rest, and both submaximal and maximal exercise arehigher in young subjects compared with adults. Although the heart rate at restand at a given workload progressively decreases as a child grows, maximal heartrate does not change. Heart rate at exhaustion in a progressive test remains sta­ble for both boys and girls during the growing years, and does not begin todecline until about age] 6 years. Consequently, formulae for estimating maximalheart rate (e.g., 220-age) are inappropriate for children and young adolescents.The achievable peak heart rate in young subjects depends on testing modality andprotocol. During treadmill running the maximal rate is typically 200 bpm, where­as walking or cycling protocols usually elicit a peak rate of approximately 195bpm. However, it should be recognized that vvide interindividual variability existsin such values, and peak rates of ] 85 to 225 bpm are consistent with exhaustiveexercise efforts in individual subjects.

Blood pressures at rest and during exercise are lower in children comparedwith adults. 3 At maximal exercise, a child 'with a body surface area (BSA) of 1.25m2 demonstrates a systolic blood pressure of about 140 mm Hg, whereas 160 mmHg i,s expected in a subject with a BSA of 1.75 m2

.

Endurance time with a given exercise testing protocol progreSSivelyimproves as a child ages. Mean duration times for males are greater than forfemales. Age-related norms for subjects during treadmill testing with the Bruceprotocol have been published and used to assess cardiopulmonary fitness inchildren (Table 10_3)4,.5 However, it should be recognized that endurance timeduring exercise testing in children might differ between laboratories, even withthe same protocol, because it is influenced by factors such as testing experienceand level of encouragement by the testing staff.

Maximal Exercise

LowerHigher or equalHigherLowerLowerLowerLowerLowerLowerHigher

Submaximal Exercise:!:

LowerHigherHigherLowerLowerLowerLowerLowerLowerHigher

SECTION III/EXERCISE PRESCRIPTION238

Variable

1;02 (L·min- 1)

1;02 (mL'kg- 1'min- 1)

Heart rateCardiac outputStroke volumeLactate concentrationTidal volumeVentilationRERI;E/I;0 2

FITNESS TESTING

Measurement of physical fitness and health in children and adolescents is a com­mon practice in school-based physical education. Such testing also has been usedin recreational programs, public health assessments, and clinical settings.

Electrocardiographic changes during exercise testing in children are similar tothose observed in adults. An increase in R-wave voltage has been considered amarker of myocardial ischemia in adults but often is observed in health\' children.The traditional ST-segment indicators of myocardial ischemia in adults with coro­nary artery disease have been interpreted similarly in pediatric subjects.However, thc v"lidity of these changes as markers of coronmy insufficiency inimmature subjects is not certain.

Other physiologic features in children may not have a direct influence on clini­cal exercise testing but need to be appreciated by the testing staff. Children exhib­it a much more rapid recovelY of healt rate, blood pressure, and other physiologicvmiables after exercise testing compared with adults. The sweating rate of childrenis less than adults because of a dccreased capacity per glandfi Young subjects havelower exercise economy dnring walking or running than adults, such that oxygenuptake (and heat production) per kg body mass at a given treadmill work rate isgreater in children. Compensating for this, children have a larger ratio of body sur­face area to mass than adults. As a result, heat loss in a thermoneutral environmentis comparable in the two populations. However, heat loss by the rclativcly greaterbody surf~lce area of the child may be impaired at velY high ambient temperatures.

241

Field Test

l-mile walk/runCurl-up testPull-up/push-up testSit and reach testBody mass index or skin folds

TABLE 10-4. Field Tests for Children

Health Fitness Component

Cardiorespiratory fitnessMuscular fitness

FlexibilityBody composition

CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

Typically, a battely of simple field tests (generally four to six tests) are adminis­tered to evaluate different components of fitness ancl!or health7~\J Two of themost commonly administered test batteries are the FITNESSGRAM' and thePresident's Challenge Test.~ Each provides criterion-referenced standards forinterpretation of results. Table 10-4 provides a list of common field tests of phys­ical fitness for children, with specific reference to the five components of physi­cal fitness. Some communities, schools, and SUlyeys develop their own battery oftests and standards of performance.\! Questionnaires also have been used toassess physical activity patterns of young people. 1o

EXERCISE PRESCRIPTION

Regular exercise in children and adolescents can pay immediate health benefits(e.g., reduction of body fat, diminished mental stress), and, if persistent, can reducethe risk of future adult disorders such as atherosclerotic disease, osteoporosis, andsystemic hypertension. For this reason, promotion of exercise in youth should bedesigned to introduce exercise habits that will serve as the basis for a long-term lifestyle of regular physical activity. Although children are the most physically activeage group, a significant minority is considered to have inadequate levels of regularexercise. Survey data suggest that only about 50% ofAmerican youth aged 12 to 21are vigorously active on a regular basis. Daily enrollment in physical educationclasses also has declined in high school students from 42% in 1991 to 25% in1995. 11 Physical acti\~ty typically declines through pubelt)', especially for girls, andthe development of appropriate intervention strategies is impOltant. Currentresearch data do not allow recognition of a certain minimal level of daily physicalactivity in children necessary for long-term health benefits. However, a number ofconsensus groups have considered this issue and have concluded that a reasonablegoal is for each child to engage in at least a moderate level of physical activity 30 to60 minutes on most days of the week. 12.1.3 Such activity should include blief peri­ods of rest and recovelY as needed. Recently, the National Association for SPOltand Physical Education released a position statement for children ages 5 to 12 thatincludes the following guidelines: 14

• Children should accumulate at least 60 minutes, and up to several hours, ofage-appropriate physical acti\~ty on all or most days of the week. This dailyaccumulation should include moderate and vigorous physical activity \\~th themajority of the time being spent in activity that is intermittent in nature.

• Children should participate in several bouts of physical activity lasting 15 min­utes or more each day.

90

12712314.614.414.614.9

11.212013613.813011.4

50

10.111.011.2118132132

9.510.210.511010.810.0

Percentiles

5.98.28.6928.281

10

8.67.98.99.599

10.7

TABLE 10-3. Endurance Time (Minutesl by Gender andAge Group with the Bruce Treadmill Protocol*

MalesAge (years)4-56-78-9

10-1213-1516-18FemalesAge (years)4-56~7

8-910-1213-1516-18

"Treadmill tImes represent the average for a given gender-age group across twostudles.4.5 Data were derived from two pediatric cohorts referred for clinICal exerCIsetesting. Subjects were not allowed to use handrail support dUring the exercise test.

SECTION III/EXERCISE PRESCRIPTION240

The Adult Prescription Model

By this traditional approach, a particular activity (usually walking) is recom­mended, to be performed by the child for a certain number of minutes (begin­ning at 15 minutes), three to five times per week, and then increasing durationand frequency to eventually reach the activity guidelines described pre\~ously.

',Valking can be done in interesting places to avoid boredom (e.g., at a zoo, muse­um, or maJl) and in the company of family, friends, or pets. If the weather

• Children should participate in a variety of age-appropriate physical activitiesdesigned to achieve optimal health, weJlness, fitness, and performancebenefits.

• Extended periods (periods of 2 hours or more) of inactivity are discouragedfor children, especially during the daytime hours.

Counseling efforts to improve level of activity have bcen applied to young per­sons who are identified as having a sedentary lifestyle. In addition, there are spe­cific disease entities in which exercise intervention is considered an importantcomponent in management, including patients with familial hypercholes­terolemia, type 2 diabetes, obesity, and essential h)1)crtension. As in adults, theemphasis has shifted from improving physical fitness in youth to encouraging anincrease in levels of habitual physical activity. Such activities should be wellrounded, inclu<.ling those that t,1-",( the cardiovascular system (swimming, cycling),provide weight-bearing stress to bones (jumping, running), and improve musclestrength (calisthenics, lifting). Promotional efforts to maintain or improve habitsof physical activity in children are most effective if multifactorial, includingschool physical education classes, commllnity recreation programs, family-basedactivities, and counseling by health professionals.

Little research has been performed in the pediatric population to determine themost effective means of stimulating regular physical activity. For instance, it is notclear if psychosocial constructs used in programs designed to alter exercise behav­ior in adults, such as the transtheoretical model and social cognitive theory, areapplicable to children. Studies examining the effect of physical activity interven­tions on youth in school and community settings indicate that motivational factorsfor exercise are likely to vary according to a child's developmental age. 1.5 However,certain components ofa successful exercise intervention program for children seemevident, including the necessity for fim, lack of embarrassment, limited competi­tion, peer and family support, and recognition of success. Unsafe neighborhoods,lack of proximity to playgrounds, and inability of parents to transport representenvironmental barIiers that also may modify the plan. The use of school recess andafter school activities such as intralllllrais and activity-based latch-key programsmay permit children to enhance physical activity.

At the present time there exists no evidence-based standard approach toimproving the physical activity habits of children. The development of sucb stan­dards is hampered by variations in age, motivation, and degree of parental sup­pOli, as well as tbe vmying influences of geographic location, socioeconomiclevel, and availability of recreational facilities. A number of different activitycounseling models can be considered because no single exercise plan is likely tofit all children.

243CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

The Exercise "Menu"

This approach does away \vith structured activities altogether and attempts toincrease the child's ca101ic expenditure in his or her usual daily activities. Thismay be more attractive than a more formal schedule of regular exercise for youngpersons who are pmiicularly sedentary or obese. The child can be instructed onspecific ways of accomplishing this: Use stairs instead of the escalator, walkinstead of riding in the car, do specific chores around the home, stand while talk­ing on the telephone, don't stand still, or use a rocking chair while watching tel­evision. Acti\~ty lists can be checked as they arc accomplished and signed by theparents, with a small reward (e.g., sports tickets, t-shirt) for a certain total.

Increasing Lifestyle Activities

In this model, the child is presented \\~th a list of possible acti\~ties to begin,which he or she can help compile, based on those feasible in a paliicular com­munity. This widens the possibilities of exercise interventions to those invoh~ng

team spolis, recreational programs, and activity clubs. It offers the possibility ofmore social interaction and allows the child to select activities that are individu­ally attractive; and, imporiantly, it permits the child a greater degree of autono­my in de\~sing the exercise program. An exercise menu is only limited by one'simagination and resources, and may include acti\~ties such as soccer, dance,.i umprope, karate, broom ball, skateboarding, hide and go seek, and pick-up basketball.

becomes inclement, the activity can be moved indoors (e.g., exercising on a sta­tionary cycle while watching television).

This model has ceriain advantages for youth. It does not necessitate any ath­letic skill or special equipment, it requires no transpOliation by parents, it can beperformed \vith or \vithout company, and it is not physically taxing to the point ofbecoming uncomfortable. On the other hanel, it might be expected to ultimatelyprove boring for an unmotivated child over an extended period of time.

Decreasing Sedentary Time

Recognizing the impOliance of regular exercise for the physical and emotionalhealth of children has been coincident \\~th concern that youth are spending anincreasing amount of time in sedentary pursuits. In fact, sedentmy habits maytrack or persist more as a child grows into adulthood than levels of physical acti\"­lty. For this reason, reducing time spent watching tele\~sion, in front of a com­puter, or playing video games can be a p,ui of any prescription for sedentaryyouth

16Because physical activity experiences in childhood may be pivotal in

terms qf adult activity, health agencies have stepped up their efforts to encour­age schools, families, and communities to promote positive childhood and youthphysical activity expetiences. 17- 20

Schools are encouraged to:

• Offer daily physical education classes at each grade.• Increase time being physically active in physical education classes.• Discuss health benefits of physical activitv.• Eliminate or shalply decrease exemption~ for physical education.

SECTION III/EXERCISE PRESCRIPTION242

Parents should:

• Set a good example by being physically active.• Offer praise, interest, and encouragement.• Get involved in school and/or community activity programs.• Encourage children to be active around the home.• Provide needed transpOltation.

Schools and communities should:

• Provide enjoyable, lifetime physical activities.• Meet diverse ethnic and gender activity interests.• Promote self-efficacy and skill development.• Provide opportunities for all skill levels.• Not limit activities exclusively to team-oriented sports.• Provide safe facilities outside school hours.

Cardiorespiratory Training

Sustained cardiorespiratory endurance activities such as distance running,cycling, and s\vimming are not typical of the normal activity patterns of children.Still, issues of athletic training and responses to cardiac and pulmonalY rehabIlI­tation programs in youth have stimulated an interest in the aerobic charactens-

tics of the pediatric age group. '.Children have higher levels of maximal oxygen uptake (V02m".xl relatIVe to

their body mass than at any other time in life. A typical V02max value in boysls-52 mL·kg-l·min -1, which remains constant over the growing years .. Little dif­ference is seen in \l02max betv,Ieen young boys and girls, b~t values 111 girls dechneduring childhood to ~40 mL·kg-1·min-I by age 16 years.-1 The V02m"x of a pre­pubeltal child does not increase with endurance training to the same degree as ISobserved in young adults. 2 A previously sedentalY adult placed in a progra.m ofendurance exercise of sufficient intensity, frequency, and duratIOn typicallydemonstrates an improvement in \10 2m"" of approximately 15% to 30%.Children, on the other hand, are unlikely to increase their V02m"x in similarprograms by more than 10%. The mean value of increase in m~imal aerobicpower in a meta-analysis of training programs in children was 5%,-- and 111 somerepOlts no change at all is observed. No gender differences have been obselvedin aerobic trainability in the pediatric age group. It appears that any aerobictraining adaptations that occur in children can be elicited by the same frequencyand duration training cliteria as those recommended in adult programs. :0improve \l0 2max, training intensity in children should produce a healt rate of 1/0

to 180 bpm. .The explanation for the limited rise in maxima] aerohic power in children fol-

lowing endurance training is not known, but may result from a high innate levelof activity anellor less effective training regimens. However, it is more likely thatbiological factors, possibly related to hormonal changes at puberty, are responSI­ble. It is currently not clear if the dampened response of phySIOlogIC aerobICtrainability in children also reflects a blunted improvement with training in per­formance in endu rance events.

245CHAPTER 10 I EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

In young children, emphasis should be directed at acti\'(;' play (instead ofexercise) and othcr activities of intermittent houts of pln'sical activitv.l~ In olderchildren, 20 to 30 minutes of vigorous exercise at least::3 d'wk- ' is I~ecommend­ed13 Increased duration (i.e., 30-60 minutes) and frequency (i.e., 6-7 d'wk- ' )of exercise are recommended to reduce overweight and obeSity. Children do notgenerally require heart rate monitoring because of their low cardiac risk andtheir ability to adjust exercise through rating of perceived exertion and/ortolerance.

Resistance Training

Previously it was assumed that muscular strength could not be improved \\~th

resistance training in prepubelial subjects because of their lack of circulatingtestosterone. However, a selies of' recent studies has indicated clearly thatstrength can be effectively increased \\~th training in both boys and girls beforethe age of puberty. 2.1 In tact, the relative magnitudc of these increases in strengthhas been similar to that obselved in training programs in adult subjects.Moreover, these repOlis indicate that age-appropliate, supen~sed resistancetraining programs can he conducted safely in children. Most studies have demon­strated that improvements in strength from resistance training in children are notaccompanied by increascs in muscle bulk. This observation has lent credence tothe concept that neural adaptations can playa key role in the development ofmuscle strength with resistance training.

The role of resistance training in young subjects remains to be clHlified.,,yhether strength improvements in children and adolescents can serve to protectagainst athletic injUlY, improve performance in strength-related spOlis, or have along-term saluta,)' influence on infirmities such as back disease and osteoporosiscurrently is being studied. Guidelines for resistance training in children are sim­ilar to those for adults (sec Chapter 7); howevcr, specific guidelines are noted: 13

• The intcrmittent nature of resistance training is compatible \vith a child's nat­ural physical activity pattems.

• Resistance training should be carefully supervised by a competent instructor.• Avoid overly intense or maximal (IRM) resistance training. Gradual progres­

sion is impOliant to avoid excessively demanding programs, which may dis­courage young subjects.

• Training equipment should be v<uied and appropliate to the size, strength,and degree of maturity of the child.

• Training should be a comprehensive program to increase motor skill and fit­ness level.

• The child should perform 8 to 1.5 repetitions per exercise. Resistance orweight should be increased only when the child can perform the desired num­ber of repetitions \vith good form.

• Focus on participation and proper technique rather than the amount ofresistance.

• If a prepubescent child cannot perform a minimum of eight repetitions ingood form, the resistance is too heavy and should be reduced.

• A repetition range below eight should be reselved for adolescents (Tannerstage 5) of sufficient matlllity.

SECTION 1111 EXERCISE PRESCRIPTION244

EXERCISE TESTING

Elderly People

TABLE 10-5. Effects of the Aging Process on Selected Physiologicand Health-Related Variables

247CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

There is a \\~de selection of test protocols using a variety of modalities thathave been used for testing the elderly population, either in their standard formor with slight modifications. Protocols are available for those who are highlydeconditioned or phys!cally limited. The follo~ng are special considerations fortesting elderly people:-6

• The initial workload should be low (2-3 metabolic equivalents [METs]) andworkload increments should be small (0.5-1.0 METs) (e.g., Naughton proto­col) for those with expected low work capacities.

• A cycle ergometer may be preferable to a treadmill for those \\~th poor bal­ance, poor neuromuscular coordination, impaired vision, senile gait patterns,welght-beanng lnmtatlOns, and/or foot problems.

• Added treadmill handrail support may be required because of reduced bal­ance, decreased muscular strength, poor neuromuscular coordination, or fear.However, handrail SUppOlt for gait abnormalities can reduce the accuracy ofestnnatll1g peak MET capacity based on exercise duration or peak workloadachieved.

• Treadmill speed may need to be adapted according to walking ability.• For those who have difficulty adjusting to the exercise equipment, the initial

stage may need to be extended, the test restaJted, or the test repeated.• Exercise-induced dysrhythmias are more frequent in elderly people than in

people in other age groups.• Presclibed medications are common and may influence the electrocardio­

graphic and hemodynamic responses to exercise.• The exercise electrocardiogram has higher sensitivity (~84%) and lower

specificity (~70%) than in younger age groups. The higher rate offalse-posi­tIve outcomes may be related to tile greater frequency occurrence of left ven­tricular hypertrophy and the presence of conduction disturbances.

There are no specific exercise test termination criteria that are necessalY forthe elderly population beyond those previously presented (see Box .5-2).However, the probable attainment of a lower peak V02 and/or the increasedprevalence of cardiovascular, metabolic, and orthopedic problems25 in elderlype~ple often leads to an earlier test termination than in the young adult popu­latIOn.. To avoid. underestimating the level of stress imposed during gradedexercIse testmg, It should be understood that many elderly subjects exceed themaXimal heart rate predicted from the 220-age formula during a maximal exer­cise test.27

EXERCISE PRESCRIPTION

The'general principles of exercise prescription (see Chapter 7) apply to adults ofall ages. The .relative adaptations to exercise also are similar to other age groups.The percent Improvement in V02Jn 'LX in elderly persons can be comparable to thatreported m younger populations. Unfortunately, low functional capacity, muscleweakness, and deconditioning are more common in elderly persons than in anyother age group and can contribute to loss of independence in advanced age. 17

T!le pa~lcularl~ Important components of the exercise prescription include car­dIOrespiratory fItness, resistance training, and fleXibility.

Change

UnchangedLowerLowerHigherLowerHigherLowerSlowerLowerLowerLowerLowerHigherLowerLonger

SECTION III/EXERCISE PRESCRIPTION

Resting heart rateMaximal heart rateMaximal cardiac outputResting and exercise blood pressuresMaximal \;02 (L'min- 1 and mL·kg- 1·min- 1)

Residual volumeVital capacityReaction timeMuscular strengthFlexibilityBone massFat-free body massPercent body fatGlucose toleranceRecovery time

Variable

246

There is increasing recognition that the term "elderly" is an inadequate generaliza­tion that obscures the variability of a broad age group. Physiologic aging does notoccur uniformly across the population. Therefore, it is not satisfactOty to define"elderly" by any specific chronologie age or set of ages. Individuals of the samechronologie age can differ dramatically in their physiologic age and response to anexercise stimulus. In addition, it is difficult to distinguish the effects of aging per seon physiologic function from that resulting from deconditioning and/or disease.Although aging is inevitable, both the rate and magnitude of decline in physiologicfunction may be amenable to, and even reversible \\~th, exercise/activity interven­tion. ImpOttantly, the possibility that an active or latent disease process may bepresent in the elderly individual always should be considered.

The safe and effective performance of exercise testing and the developmentof a sound exercise prescription requires a thorough knowledge of the effects ofaging on physiologic function at rest and during graded exercise.2~.25 It should benoted that exercise training may attenuate some of the observed changes in aging.A list of key changes is provided in Table 10-5.

The prevalence of coronaJy healt disease increases with advancing age; thus, thejustification for exercise testing in elderly people may be even greater than thatof the general adult population.26 In accordance ~th Tables 2-1 and 2-4, med­ical clearance of older adults is advised before maximal exercise testing or priorto their participation in vigorous exercise. The assessment of cardiorespiratOtyfunction for elderly adults may require subtle differences in protocol, methodol­ogy, and dosage than that used for younger and middle-aged persons.

Mode

Intensity

• Tbc exercise modality should be one that does not impose excessive orthope­

dic stress.• Walking is an excellent mode of exercise for many elderly people.• Aquatic exercise and stationary cycle cxercise may be especially advantageous

for tbose with reduced ability to tolerate weight-bearing activity.• The activity should be accessible, convenient, and enjoyable to the pmtici­

pant, all factors directly related to exercise adherence.• A group setting may prOvide impOltant social reinforcement to adherence.• The wide range of health and fitness levels observed among older adults may

require special considerations in terms of integrating intensity, fre(luency, andduration into an exercise plan. II

249CHAPTER 101 EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY

• Physical activity performed at a moderate intensity should be performed mostdays of the week.

• If exercise is undeltaken at a vigorous level, it should be performed at least 2 to3 d'wk- I

, with exercise and no exercise or (Iow- to moderate-intensity) exercisedays alternated.

• Exercise duration need not be continuous to produce benefits; thus, thosewho have difficulty sustaining exercise for 30 minutes or who prefer shorterbouts of exercise can be advised to exercise for lO-minute periods at differenttimes throughout the day.

• To avoid injury and ensure safety, older individuals should initially increaseexercise duration rather than intensity.

Duration

Frequency

in persons more than 6.5 years of age and their greater lisk of underlying coro­nary mtely disease.

• Elderly persons are more likely than young persons to be taki ng medicationsthat can influence hemt rate.

Resistance Training

Muscular strength declines \vith advanCing age at least in palt because of reduc­tions in muscle mass.25.2H The reduction in muscle strength contIibutes to adecline in functional capacity. Resistance training increases muscular strength,power, and endurance (muscular fitness) in elderly individuals25.28.29 and in turnhas the potential to deter the untoward effects of frailty by improving 'mobili~and preventing falls and fi-actures. ImpOltantly, improved muscular fitness mayallow the elderly adult to perform activities of daily living with less effort28 andextend their functional independence by living the latter years in a self-sufficient,dignified manner. Therefore, resistance training should be an impOltant focus ofany exercise program, patticularly for elderly people. Tbe guidelines for resist­ance training for adults found in Chapter 7 generally apply to the older adult;however, some comll1on sense guidelines are specific to elderly people:30

• The first several resistance training sessions should be closely superVised andmonitored by trained personnel who are sensitive to the speCial needs andcapabilities of elderly people.

• Begin (the first 8 weeks) \vith minimal resistance to allow for adaptations oftl?e connective tissue elements.

• Perform one set of 8 to 10 exercises that use all the major muscle groups.• A set should involve 10 to 15 repetitions that elicit a perceived exertion rating

of 12 to 13 (somewhat hard).• As a training effect occurs, achieve an overload initially by increasing the num­

ber of repetitions, and then by increasing the resistance.• When returning from a layoff of more than 3 weeks, start \vith resistances of

50% or less of previous training intenSity, and then gradually increase theresIstance. The major goal of the resistance-training program is to develop

SECTION 1111 EXERCISE PRESCRIPTION

• The intensity gUidelines and precautions establishcd for adults (see Chapter7) for aerobic exercise training generally apply to elderly people.

• To minimize medical problems and promote long-term compliance, exerciseintensity for inactive elderly people should start low and indiVidually progressaccording to tolerance and preference. Initiating a program at less than 40%

\I02R or HRR is not unusual.• Many older persons suffer from a valiety of medical conditions; thus, a con­

servative approach to increasing exercise intensity may be warranted initially.• Exercise need not be vigorous and continuous to be bcneficial; a daily accu­

mulation of 30 minutes of modcrate-intensity phYSical activity can prOvide

health benefits.• Longer-duration or higher-aerobic intensity offers additional health and fit­

ness benefits, although it can lead to greater lisk of cardiovascular and mus­culoskeletal problems and lower compliance to a long-term exercise plan.

• A measured peak hemt rate is preferable to an age-predicted peak hemt ratewhen prescribing aerobic exercise because of the variability in peak heart rate

Cardiorespiratory Fitness

Elderh- people sbould be encouraged, whene\'er possible, to llleet tbe popula­tion-wide recOlllmendation to accumulate at least 30 minutes of moderate-inten­sity physical activity on most and preferably all days of tbe week. This can beaceomplisbed with activities sucb as brisk walking, gardening, yard work, house­work, cli mbing stairs, and active recreational pursuits (see Fig. 7-1, The ActivityPyramid). For those achieving this level, additional benefits may be obtained withlonger-duration, moderate-intensity phYSical activity or by substituting moderate­with higber-intensity phYSical activity. Importantly, activities performed at agiven MET value represent greater relative effOlt in elderly than young peoplebecause of the decrease in peak METs with age (Table 1-1). Elderly peopleshould consult a physician before progressing to a vigorous exercise program.

The optimal mode of exercise for elderly persons can be influenced by phYSi­ologiC and psychosocial variables, such as work capacity, OIthopedic problems,

poor balance, and travel limitations.

248

250 SECTION III/ EXERCISE PRESCRIPTION CHAPTER 10/ EXERCISE TESTING AND PRESCRIPTION FOR CHILDREN AND ELDERLY 251

sufficicnt muscular fitness to cnhance an individual's ahility to live a physical­ly independent lifestyle.

• Instruct pmticipants to maintain their normal breathing pattern while exer­cising.

• Stress that all exercises should be performed in a manner in which themomentum is controlled. Avoid explosive movements.

• Perform the exercises in a range of motion that is within a "pain-free arc" (i.e.,the Imu.1mum range of motion that does not elicit pain or discomfOlt).

• Perform multi-joint (as opposed to single-joint) exercises.• Given a choice, use machines to resistance train, as opposed to free weights.

Machines generally require less skill to use. They also protect the back by sta­bilizing the user's body position, and allow the user to more easily control theexercise range of motion.

• Allow participants ample time to adjust to postmal changes antI balance dur­ing the transition between resistance training exercises.

• Discourage palticipation in strength training exercises during active periodsof pain or inflammation for aJthritic patients.

• Engage in a year-round resistance-training program.• Routine activities (e.g., domestic work, gardening, walking) may help to main­

tain muscular strength.

Flexibility

An adequate range of motion in all body joints is impOitant to maintaining anacceptable level of musculoskeletal function, balance, and agility in older adults.What is almost universally accepted, although not documented, is the fact thatmaintaining adequate levels of fle:dbility enhances an indi\~dual's functional capa­bilities (e.g., bending and ffi~sting) and reduces injUly potential (e.g., risk of mus­cle strains, low back problems, and falls) palticularly for aged people. Exercisesshould be presc'ibed for evelY major joint (hip, back, shoulder, knee, upper trunk,and neck regions) in the body. A well-rounded program of strctching can counter­act thc usual decline in flexibility of elderly people and may improve balance andagility. Yoga and tai chi movements may be helpful in this regard. Therefore, it isclitical that a sound stretching program be included as pmt of each exercise sessionfor older adults. Consider devoting an entire exercise session to fleXibility fordeconditioned older adults who are beginning an exercise program. Older adults.should follow the recommendations for flexibility training found in Chapter 7.

REFERENCES

1. Howland n\!. Aerobic cxercise tcsting protocols. lu: Howland n\!, ed. Pediatric LaboralOlY

Exercise Tesling: Clinical Cuidelines. Cliampaign, TL: Iluman Kinetics, 199:3: 19-42.

2. Howland TW. Developmental Exercise Ph)'siology. Champaign, IL: Human Kinetics, 1997.

.3. Hiopel DA, Tador AB. Holin AH. Blood pressurc. hearl rate, pressure-rail' product and electrocar­diographiC changes in healthy children during treadmill exercise. Am J Cardiol 1979;-14:697-70-1.

4. Cumming CH, Everatt 0, Ilastm<ln L. Bruce treadmill test in children: norlllal values in a clinic

population. Am J Cardiol 1978;41:69-7.5.5. Wessel HU. Strashurger JF, Mitclicll BM. New standards for the Bruce treadmill protocol in chil­

dren and adolescents. Pediatr Exerc Sei 2001:1.3:.392-401.6. Falk B. Temperature regulation. In: Armstrong :"1, vall ~1e<:hclcn \V, eds. Paediatric Exercise

Scienee and ~Iedicine. Oxford. UK: Oxford Uni"ersit" Press. 2000:22:3-2.39.

7. The Cooper Institute for Aerobics Hesearch. I'ITNESSCRAM. Champaign. IL: Human Kinetics.1999

8. President's COllncil on Ph),sical Fitness and Sports. Cet Fit: A Handbook for Youth Ages &--17.Washington. DC: President's Council on Physical Fit",'ss and Sports. 1998.

9. Ross Je. Evaluating fitness and aClivity assessments from the National Children and Youth Fitnf"ssStudies J and U. In: Assessing Physical Fitness and Physical Activit.'" in Population-based Surveys.

Hockville, M D: United States Departmellt of Ilealth and Human Selvices. 1989.

10. Pereira MA. Fitzgerald SJ. Gregg EW. et al. A collection of ph)'sical actiVity qllestionnaires forhealth-related research. ~Ied Sci Sports Exerc 1997;29:S170-189. S201-205.

11. Centers for Diseasc Control ancl Prevention. Youth risk beha,ior sUlyeiliance: nited States. 1999.MMWR 2000;49: 1-94

12. Cavill N, Biddle S, Sallis JF. Hcalth enhanCing physical activity for young people. Statement of theUnited Kingdom Expert Cons('nsus Confcrenee. Pedialr Exerc Sei 200]: 1:3:12-2.5.

1.3. SalliS JF. Patrick K. PI"'sical acti,ity guidelines for adolescents: consensus statement. Pediatr ExercSci 199-1:6::302-:314.

14. National Association for SPOlt and Physical Education. PI"'sical aethit)' for children: A statement ofguidelincs, 2nd ed. Heston, VA: NASPE, 2004.

15. Pender NJ. Motivation for phYSical activity among childrcn and adolescents. Annn Hev Nul'S Res1998; 16: 1:39-172.

16. COli maker SL, Must A, Sobol A~L et al. Tek',"ision vie\\~ng as a cause of increasing obeSity amongchildren in the United States: 198&--1990. Arch Pediatr Adolesc ~Ied 1996;150:.356-362.

17. Physical activit" and health. A repOlt of the Surgeon Ceneral. Washington, DC: United StatesDeparlmcnt of Health alld Uuman Selvices, 1996.

18. Pnblic Health Service. Health)' People 2000: National Health Promotion and Disease PreventionObjectives. Washington, DC: DHHS Publication (PHS) 91-50212,1991.

19. Pate HR. Pratt ~I, Blair SN. et al. Physical activity and publiC health. A recommendation from theCenters for Disease Control and Prevention and the American College of Sports Medicine. JA~IA1995;27:3:402-407.

20. United States Department of Health and Human Selvices. Cuidelines for school and communityprograms to promote hfelong phYSical actiVit)' among young people. MMWR 1.997;46: 1-46.

21. Armstrong N. Weisman JE. Aerobic /Itness. In: Armstrong N. Van Mechelen W, eds. PaediatricExercise Science and Medicine. Oxford. UK: Oxford niversitv Press. 2000:17.3-182.

22. Payne VG, l\·lorrow JR. The effect of ph."sical training on prelJtlbescent V02rnax: a meta-analysis.Res Q Exerc Sport 199.3;64:.30.5_31.3.

23. Falk B, Tenenbaulll C. The effectiveness of' resistance training in children. A meta-analysis. SportsMed 1996;22: 17&--]86.

24. American College of SPOltS Medicine. Position Stand: Exercise and phYSical activity for older adults.~Ied Sci Sports Exerc 1998:.30:992-1008.

25. Masoro E. Aging. In: lIandbook ofPh),siology. American PhYSiological Society, Masoro E, ed. NewYork: Oxford University Press. 199.5:681.

26. Cibhons HJ. Baladv CJ. Blicker J. et al. ACC/AlIA 2002 gUideline update for exercise testing: areporl of the American College of Cardiology/American Heart Association Task Force on PracticeGuidelines (Committee on Exereise Testing). American College of Cardiology. 2002. Website avail­able at: www.acc.orgidinicaVguidelineslcxercise/djr[ndex.htm

27. Tanaka 11, Monahan KD. Seals DR Age-predicted maximal heart rate revisited. J Am Coli Cardiol2001;.37:15.3-1.56.

28. Roubenoff R. Sareopenia and its implications for the elderly. Eur J Clin NutI' 2000:.54(suppl .3):S40-47.29. Fiatarone MA, O' 'eill EF, Ryan ND. et al. Exercise training and nutritional supplementation for

phYSical frailty in vel)' elderly people. N Engl J Med J994;.3.30:J 769-1775.30. American College of Sports Medicine. Position Stand: The recommended quantity and quality of

exercise for developing and maintaining cardiorespiratOly and mllscular ntness, and flexibility inhealthy adults. Med Sci Sports Exerc 1998;:30:975-99 I:

.31. Bar-Or O. Pediatric SPOltS Medicine for the Practitioner. New York: Splingcr-Verlag, 19B.3:.31:h.l.3H.32. Howland n\', Straub JS, nnithan VB. et al. Mechanical efflcienc), during c"cling in prepllbertal

and adult males. Int J SPOltS Med 1990: II :4.52-4.55..3.3. Washington RL. Measurement of cardiac oulput. In: Howland n\', ed. Pediatric Lahoratory

Exercise Testing: Clinical Guidelines. Champaign, IL: I luman Kinetics, 199:3: 1.3:3.

.34. James F, Kaplan S, Glueck C, et al. Hesponses of normal children and yoong adnlts to controlledbicycle exercise. Circulation 1980;61 :902-912.

SECTION

IVAppendices

Appendix A Common MedicationsAppendix B Emergency ManagementAppendix C Electrocardiogram (ECG) InterpretationAppendix 0 Metabolic CalculationsAppendix E Environmental ConsiderationsAppendix F American College of Sports Medicine

Certifications

TABLE A-1. Generic and Brand Names of Common Drugs by Class

continued255

Central 0I2-Agonists and Other Centrally Acting Drugs

Clonidine Catapres, Catapres-TIS (patch)Guanfacine TenexMethyldopa AldometReserpine Serpasil

APPENDIX

A•••••BRAND NAME*

Sectral**TenorminKerloneZebetaBreviblocLopressor SR, Toprol XLCorgardLevatol* *Visken**InderalBetapaceBlocadren

TenoreticZiacInderideLopressor HCTCorzideTimolide

CoregNormodyne, Trandate

CarduraMinipress, MinizideHytrin

Common Medications

{J-Blockers

Acebutolol* *AtenololBetaxololBisoprololEsmololMetoprololNadololPenbutolol * *Pindolol**PropranololSotalolTimolol

**f3-Blockers with intrinsic sympathomimetic activity.

GENERIC NAME

a- and {J-Adrenergic Blocking Agents

CarvedilolLabetalol

{J-Blockers in Combination With Diuretics

Atenolol + chlorthalidoneBisoprolol + hydrochlorothiazidePropranolol LA + hydrochlorothiazideMetoprolol + hydrochlorothiazideNadolol + bendroflumethiazideTimolol + hydrochlorothiazide

OIt-Adrenergic Blocking Agents

DoxazosinPrazosinTerazosin

Central 0I2-Agonists in Combination With Diuretics

Methyldopa + hydrochlorothiazide AldorilReserpine + chlorothiazide DiupresReserpine + hydrochlorothiazide Hydropres

continued

257

Lotensin HCTCapozideVasereticPrinzide, ZestoreticUnireticAccuretic

BRAND NAME>

AtacandTevetanAvaproCozaarBenicarMicardisDiovan

Diuril

Microzide, HydroDiuril, OreticReneseLozolMykron, Zaroxolyn

BumexEdecrinLasixDemadex

MidamorDyrenium

InspraAldactone

Diuretics

ACE Inhibitors in Combination With Diuretic

Benazepril +hydrochlorothiazideCaptopril + hydrochlorothiazideEnalapril + hydrochlorothiazideLisinopril + hydrochlorothiazideMoexipril + hydrochlorothiazideQuinapril + hydrochlorothiazide

GENERIC NAME

TABLE A-l. continued

Angiotensin II Receptor AntagonistsCandesartanEprosartanIrbesartanLosartanOlmesartanTelmisartanValsartan

ACE Inhibitors in Combination With Calcium Channel BlockersBenazepril + Amlodipine LotrelEnalaprli + felodipine LexxelTrandolapril + verapamil Tarka

APPENDIX A / COMMON MEDICATIONS

Angiotensin II Receptor Antagonists in Combination With Diuretics

Candesartan + hydrochlorothiazide Atacand HCTEprosartan + hydrochlorothiazide Teveten HCTIrbesartan + hydrochlorothiazide AvalideLosartan + hydrochlorothiazide HyzaarTelmisartan + hydrochlorothiazide Micardis HCTValsartan + hydrochlorothiazide Diovan HCT

continued

Thiazides

ChlorothiazideHydrochlorothiazide (HCTZ)PolythiazideIndapamideMetolazone

"Loop" Diuretics

BumetanideEthacrynic AcidFurosemideTorsemide

Potassium-Sparing DiureticsAmilorideTriamterene

Aldosterone Receptor BlockersEplerenoneSpironolactone

BRAND NAME>

Amyl nitriteIsmo, Monoket, ImdurIsordil, Sorbitrate, DilatrateNitrostat, NitroQuickNitrolingualNitrogardNitrong, Nitrocine, Nitroglyn, Nitro-BidMinitran, Nitro-Dur, Transderm-Nitro,

Deponit, Nitrodisc, Nitro-DermNitro-Bid, Nltrol

Lanoxin, Lanoxicaps

NorvascPlendilDynaCirc CRCardene SRAdalat, Procardia XLNimotopSular

ApresolineLoniten

SECTION IV / APPENDICES

Verapamil Immediate ReleaseVerapamli Long ActingVerapamil-Coer

256

Nitroglycerin, topical

Nitrates and Nitroglycerin

Amyl nitriteIsosorbide mononitrateIsosorbide dinitrateNitroglycerin, sublingualNitroglycerin, translingualNitroglycerin, transmucosalNitroglycerin, sustained releaseNitroglycerin, transdermal

TABLE A-1. continued

GENERIC NAME

C~/cium Channel Blockers (Nondihydropyridines)

Diltiazem Extended Release Cardizem CD, Cardizem LA, DilacorXR, Tiazac

Calan, IsoptinCalan SR, Isoptin SR,Covera HS, Verelan PM

Calcium Channel Blockers (Dihydropyridines)

AmlodipineFelodipineIsradipineNicardipine Sustained ReleaseNifedipine Long-ActingNimodipineNisoldipine

Direct Peripheral Vasodilators

HydralazineMinoxidil

Cardiac Glycosides

Digoxin

Angiotensin-Converting Enzyme (ACE) Inhibitors

Benazepril LotensinCaptopril CapotenCilazapril InhibaceEnalapril VasotecFosinoprli MonoprilLisinopril Zestril, PrinivilMoexipril UnivascPerindopril AceonQuinapril AccuprilRamipril AltaceTrandolapril Mavik

Antilipemic Agents

Antiarrhythmic Agents

GENERIC NAME

259

BRAND NAME'

LipitorLescolMevacorPravacholZocorCrestorAdvicor

Niaspan, Nicobid, Sio-Niacin

ZetaVytorin

PlavixPersantineTrentalTiclidPletalCoumadin

AeroBidAzmacortBeclovent, QvarFloventAdvair Diskus

Pulmicort

SereventAlupentBrethineMaxairProventil, VentolinAdvair

Theo-Dur, Uniphyl

Respiratory Agents

HMG-CoA Reductase InhibitorsAtorvastatinFluvastatinLovastatinPravastatinSimvastatinRosuvastatinLovastatin + Niacin

TABLE A-1. continued

Nicotinic AcidNiacin

GENERIC NAME

Cholesterol Absorption InhibitorEzetimibeEzetimibe + Simvasatin

Blood Modifiers (Anticoagulant or Antiplatelet)ClopidogrelDipyridamolePentoxifyllineTiclopidineCilostazolWarfarin

Steroidal Antiinflammatory AgentsFlunisolideTriamcinoloneBeclomethasoneFluticasoneFluticasone and salmeterol

(132 receptor agonist)Budesonide

Bronchodilators

Anticholinergics (Acetylcholine Receptor Antagonist)Ipratropium Atrovent

Anticholinergics with Sympathomimetics (f3,-Receptor Agonists)Ipratropium and Albuterol Combivent

APPENDIX A / COMMON MEDICATIONS

continued

Sympathomimetics (f3,-Receptor Agonists)SalmeterolMetaproterenolTerbutalinePirbuterolAlbuterol

Salmeterol and Fluticasone (steroid)

Xanthine DerivativesTheophyline

BRAND NAME'

Dyazide, MaxzideModuretic

TambocorRythmol

see page 255

Xylocaine, XylocardMexitilDilantinTonocard

see page 256

Cordarone, PaceroneBretylolBetapaceTikosyn

NorpaceEthmozinePronestyl, Procan SRQuinora, Quinidex, Quinaglute,

Quinalan, Cardioquin

continued

Questran, Cholybar, PrevaliteWelcholColestid

AtromidLopidTricor, Lofibra

SECTION IV / APPENDICES258

Diuretic Combined With DiureticTriamterene + hydrochlorothiazideAmiloride + hydrochlorothiazide

TABLE A-1. continued

Class IIA

DisopyramideMoricizineProcainamideQuinidine

Class IIB

LidocaineMexiletinePhenytoinTocainide

ICFlecainidePropafenone

Class /I

I3-Blockers

Class 11/

AmiodaroneBretyliumSotalolDofetilide

Bile Acid SequestrantsCholestyramineColesevelamColestipol

Fibric Acid DerivativesClofibrateGemfibrozilFenofibrate

Class IVCalcium channel blockers

261

t

~oc co 0

""D ".;::;Q)~>:-=o ~

~.D

o.-+:E

APPENDIX A I COMMON MEDICATIONS

t

+­..- .~

2::.E• Q)

<>::-0I .~

---7---7

"Dcm

2::.•---7

\:luw

tmQ)

-'=m Q)

c >'.;:0

01 V1C fu- Q)

m 01

:; ,~ cfu- fu- 01 0

0 c uc-'= c m f'.6'l.~ '01 +-'

~ s C :J '~

m 0V1 -'= V1,., f' C f' +-' C...

~ '!! '~'~

.~ ..-'v +-' V1 +-' LL

'" V1 m V1 C m:r:Co C 0- +-' O-~'" c Q)u Q) c Q) .~

C

11I .~

t'.;:0 ~

'"m 0- t :J'v 0- 0-

C~Qi c a c

t~xw ~---7 ~

'"c:o

';::;

'"v:011I::i:

>-'(3ellC.ell

Uell.~tJ..ell)(

L.U~

Cell

­C'en­tJell=L.U

Nci:L.U....c:c::!:

Eell..ellC~..elltJe­tJell

Well.c-a.i..::lenenell..

0..~CC

c:ca.i­ell

a::1:ellell

:::ccCencC.=elltJ:cell

:E

Long-Acting

Humulin ULantus Injection

Micronase

Xenical

Meridia

ActosAvandia

DiaBeta, Glynase,GlucotrolDiamicronAmarylTolinaseOrinaseDiabinese

StarlixPrandin, Gluconorm

IntalTiladeXolair

BRAND NAME·

Intermediate- andrapid-acting combination

Humalog MixHumalog 50/50Humalog 70130Novolin 70/30

Obesity Management

Antidiabetic Agents

Intermediate-acting

Humulin LHumulin NlIetin II LentelIetin II NPHNovolin LNivalin N

SECTION IV I APPENDICES

Lipase Inhibitors

Orlistat

""Represent selected brands; these are not necessarily all inclusIVe.

Appetite Suppressants

Sibutramine

Thiazolidinediones (Increase insulin sensitivity)

PioglitazoneRosiglitazone

Meglitinides (Stimulate pancreatic islet {3 cells)

NateglinideRepaglinide

Sulfonylureas (Stimulate pancreatic islet {3 cells)

GlyburideGlipizideGliclazideGlimepirideTolazamideTolbutamideChlorpropamide

Rapid-acting

HumalogHumulin RNovolin RlIetin II R

Insulins

Glucosidase Inhibitors (Inhibit intestinal glucose absorption)

Miglitol Glyset

Biguanides (Decrease hepatic glucose production and intestinal glucose absorption)

Metformin Glucophage, Riomet

Metformin and Glyburide Glucovance

Mast Cell StabilizersCromolyn InhaledNedocromilOmalizumab

GENERIC NAME

Leukotriene Antagonists and Formation InhibitorsZafirlukast AccolateMontelukast SingulairZileuton Zyflo

260

TABLE A-1. continued

TABLE A-2. continued

Medications

V. Diuretics

VI. Vasodilators,nonadrenergic

ACE inhibitorsand AngiotensinII receptor blockers

a-Adrenergic blockersAntiadrenergic agents

without selectiveblockade

Heart Rate

H (R and E)

i or H (R and E)

H (R and E)

H (R and E).1 or H (R and E)

Blood Pressure

H or .1 (R and E)

.1 (R and E)

.1 (R and E)

.1 (R and E)

.1 (R and E)

ECG

H or PVCs (R)May cause PVCs and

" fa Ise-positive"test results ifhypokalemia occurs

May cause PVCs ifhypomagnesemiaoccurs (E)

i or H HR (R and E)

H (R and E)

H (R and E).1 or H HR (R and E)

Exercise Capacity

H, except possibly in patients with CHF

H, except i or H in patients with CHF

H, except i or H in patients with CHF

H

H

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All antiarrhythmic agents may cause new or worsened arrhythmias (proarrhythmic effect)VII. Antiarrhythmic agentsClass I

QuinidineDisopyramide

i or H (R and E) .1 or H (R)H(E)

iorHHR(R) HMay prolong QRS

and QT intervals (R)Quinidine may result

in "false-negative"test results (E)

continued

Procainamide H (R and E) H (R and E) May prolong QRS Hand QT intervals (R)

May result in "false-positive" testresults (E)

Phenytoin }Tocainide H (R and E) H (R and E) H (R and E) HMexiletineMoricizine H (R and E) H (R and E) May prolong QRS H

and QT intervals (R)H(E)

Propafenone .1 (R) H (R and E) .1 HR (R) H.1orH(E) .1 or H HR (E)

Class /I

i3-Blockers (see I.)Class 1/1

Amiodarone .1 (R and E) H (R and E) .1 HR (R) HSotalolH(E)

Class IVCalcium channel

blockers (see 111.)

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TABLE A-2. continued

Medications

VIII. Bronchodilators

Anticholinergic agentsXanthine derivatives

Sympathomimetic agentsCromolyn sodiumSteroidal Anti-inflamatory

Agents

IX. Antilipemic agents

X. Psychotropic medicationsMinor tranquilizersAntidepressants

Major tranquilizers

Heart Rate Blood Pressure ECG

H (R and E) H (R and E) H (R and E)

i or H (R and E) Hi or H HRMay produce PVCs

(R and E)

i or H (R and E) i, H, or 1. (R and E) i or H HR (R and E)

H (R and E) H (R and E) H (R and E)

H (R and E) H (R and E) H (R and E)

Clofibrate may provoke arrhythmias, angina in patients with prior

myocardial infarctionNicotinic acid may 1. BPAll other hyperlipidemic agents have no effect on HR, BP, and ECG

May 1. HR and BP by controlling anxiety; no other effectsi or H (R and E) 1. or H (R and E) Variable (R)

May result in "false-positive" testresults (E)

i or H (R and E) 1. or H (R and E) Variable (R)May result in "false-

positive" or "false­negative" testresults (E)

Exercise Capacity

Bronchodilators i exercise capacity inpatients limited by bronchospasm

H

H

H

H

continued

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XI. Nicotine

H (R and E)

i or H (R and E)

H (R and E)

i (R and E)

May result in T wavechanges andarrhythmias(R and E)

i or H HR

May provoke ischemia,arrhythmias(R and E)

H, except 1. or H inpatients with angina

XII. Antihistamines

XIII. Cold medications withsympathomimeticagents

XIV. Thyroid medications

Only levothyroxine

XV. Alcohol

H (R and E)

Effects similar tothose describedin sympathomimeticagents, althoughmagnitude ofeffects is usuallysmaller

i (R and E)

H (R and E)

H (R and E)

i (R and E)

Chronic use mayhave role in i BP(R and E)

H (R and E)

i HRMay provoke

arrhythmiasi ischemia (R and E)

May provokearrhythmias(R and E)

H

H

H, unless angina worsened

H

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APPENDIX

BEmergency Management

267

The following key points are essential components of all emergency medical plans:

• All personnel involved with exercise testing and supervision should be trainedin basic cardiopulmonary resuscitation (CPR) and preferably advanced car­diac life support (ACLS).

• There should be at least one, and preferably two trained ACLS personnel anda physician immediately available at all times when maximal sign- or symp­tom-limited exercise testing is performed.

• Telephone numbers for emergency assistance should be posted clearly on alltelephones. Emergency communication devices must be readily available andworking properly.

• Emergency plans should be established and posted. Regular rehearsal of emer­gency plans and scenalios should be conducted and documented.

• Regular drills should be conducted at least qualterly for all personnel.o A specific person or persons should be assigned to the regular mainte­

nance of the emergency equipment and regular surveillance of all phar­macologic substances.

o Records should be kept documenting function of emergency equipmentsuch as defiblillator, m,ygen supply, and suction. In addition, expiration datesfor pharmacologic agents and other suppOltive supplies (e.g., intravenousequipment and intravenous fluids) should be kept.

o Hospital emergency departments (or code teams) and other sources ofsupport such as paramedics (if exercise testing is performed outside of ahospital setting) should be advised as to the exercise testing laboratOlylocation as well as the usual ti mes of operation.

If a problem occurs during exercise testing, the nearest available physician orother licensed and trained ACLS provider (paramedic or code team) should besummoned immediately. The physician should decide whether to call for evac­uation to the nearest hospital if testing is not carried ant in the hospital. If aphysician is not available and any question exists as to the status of the patient,then emergency transportation to the closest hospital should be summonedimmediately.

EqUipment and drugs that should be available in any area where maximalexercise testing is performed are listed in Table B-1. Only those personnel

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266

Equipment

continued

Drugs (IV Form Unless Otherwise Indicated)

269APPENDIX B / EMERGENCY MANAGEMENT

o ACE inhibitors (see Appendix A for list)o Glycoprotein lib/Ilia receptor inhibitorso Fibrinolytic agents

- Tissue plasminogen activator (tPA): Alteplase- Streptokinase- Reteplase: Retavase

- Anisoylated plasminogen activator complex (APSAC): Eminase- TNKase: Tenecteplase

• Pharmacologic agents used to treat bradycardiaso Atropineo Dopamineo Epinephrineo Isoproterenol

• Pharmacologic agents used to treat unstable and stable tachycardiasMost commonly used:

o Adenosine

o I3-Adrenergic blockers (esmolol, atenolol, metoprolol)o CalCium channel blockers (diltiazem, verapamil)o Digoxino Procainamideo Amiodaroneo Lidocaineo Ibutilideo Magnesium sulfate

Less commonly used:o Flecainideo Propafenone

o Sotalol (not approved for use in United States)

TABLE B-1. continued

Drugs (IV Form Unless Otherwise Indicated)

*Drugs in parentheses are used most frequently for taChycardias Within a class of agents

The reader is encouraged to review ACLS algorithms, where the pharmacologic agents descnbed In this table areused In the context of the ABCDs (Airway, opening and maintaining the airway; Breathing, prOViding pOSltlve-pres­

sure.ventilations, CirculatIon, chest compressions; Defibrrllatlon, transcutaneous eledrical paCing or synchronizedcardloverslon). '

SECTION IV / APPENDICES

TABLE B-1. Emergency Equipment and Drugs

• Portable, battery-operated defibrillator-monitor with hardcopy printout or memory, car­dioversion capability, direct-current capability in case of battery failure (equipment musthave battery low-light indicator). Defibrillator should be able to perform hard wire mon­itoring in case of exercise testing monitor failure. An automated external defibrillator(AED) is an acceptable alternative to a manual defibrillator in most settings.

• Sphygmomanometer, including aneroid cuff and stethoscope• Airway supplies, including oral, nasopharyngeal, and/or intubation equipment (only in

situations where licensed and trained personnel are available for use)• Oxygen, available by nasal cannula and mask• AMBU bag with pressure release valve• Suction equipment• Intravenous fluids and stand• Intravenous access equipment in varying sizes including butterfly intravenous supplies• Syringes and needles in multiple sizes• Tourniquets• Adhesive tape, alcohol wipes, gauze pads• Emergency documentation forms (incidenVaccident form or code charting form)

268

• American Heart Association ACLS, 2001'• Pharmacologic agents used to treat ventricular fibrillation/pulseless ventricular

Tachycardiao Epinephrineo Vasopressin

• Antiarrhythmicso Amiodaroneo Lidocaineo Magnesiumo Procainamide

• Pharmacologic agents used to treat pulseless electrical activity and asystoleo Epinephrineo Atropine

• Pharmacologic agents used to treat acute coronary syndromes: acute ischemiachest paino Oxygen (mask or nasal cannula)o Aspirin (oral)o Nitroglycerin (oral or IV)o Morphine (if pain not relieved with nitroglycerin)

- MONA (morphine, oxygen, nitroglycerin, aspirin) greets all patientso I3-Adrenergic blockers (see Appendix A for list)o Heparin

Automated External Defibrillators

271APPENDIX B / EMERGENCY MANAGEMENT

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SECTION IV / APPENDICES

Early defibrillation continues to be the critical element for successful resusci­tation of a life-threatening cardiac arrest. There is growing use and supportfor automated external defibrillators (AEDs) in medical and nonmedicalsettings (e.g., airports, during flights, casinos). Recent guidelines from theAmerican Heart Association! indicate that for a witnessed cardiac arrest, imme­diate bystander CPR and early use of an AED can achieve outcomes equivalentto those achieved with the full ACLS armamentarium. Special conditions that

may change how you use the AED are:

• Do not use AED on child less than 8 years of age• Do not use on victim in standing water• Do not place AED electrode directly over implanted cardioverter defibrilla-

tor (ICD)• Do not place AED electrode over transdermal medication patch (nicotine,

nitroglycerin)

For more detailed explanations on the expanding role of AEDs and manage­ment of various cardiovascular emergencies, the reader is encouraged to obtainthe American Heart Association's 2000 Handbook of Emergency CardiovascularCare (ECC) and/or Advanced Cardiovascular Life Support textbook.

Tables B-2 through B-4 provide sample plans for nonemergency situations(see Table B-2) and emergency situations (see Tables B-3 and B-4). These plansare provided only as examples, and specific plans must be tailored to individualprogram needs and local standards.

authorized by law to use certain equipment (e.g., defibrillators, syringes, nee­dles) and dispense drugs can lawfully do so. It is mandatory that such person­nel be immediately available during maximal exercise testing of persons with

known coronmy artery disease.

270

TABLE B-2. continued

Level: BasicSecond Rescuer

1. Assist first rescuer, drive victim to ERor physician's office, if necessary

IntermediateSecond Rescuer

Same as Basic Level No.Add:2. Bring blood pressure cuff and ECG monitor

to site3. Assist with taking and monitoring vital signs

HighSecond Rescuer

Same as Intermediate Level Nos. 1 to 3

N-.,JN

Vlmn-l<5z<:--:t>"1)"1)mZonmVl

Abbreviations: ECG, electrocardiogram: ER, emergency room; IV, intravenous

TABLE B-3. Plan for Potentially Life-Threatening Situations

level: Basic

At a field, pool, or park without emergencyequipment

level: BasicFirst Rescuer

1. Establish responsivenessa. Responsive:

Instruct victim to sitActivate EMSDirect second rescuer to call EMSStay with victim until EMS team arrivesNote time of incidentApply pressure to any bleedingNote if victim takes any medication

(i.e., nitroglycerin)Take pulse

Intermediate

At a gymnasium or outside facility with basicequipment plus manual defibrillator(or AED) and possibly a small "start-up"kit with drugs

IntermediateFirst Rescuer

Same as Basic Level Nos. 1 and 2Add:3. Apply monitor to victim and record

rhythm (or apply AED). Monitorcontinuously

4. Take vital signs every 1 to 5 minutes5. Document vital signs and rhythm.

Note time, and victim signs andsymptoms

High

Hospital or hospital adjunct with all the equipmentof intermediate level plus a "code cart" containingemergency drugs and equipment for oxygen,intravenous drug administration, intubation,drawing arterial blood gas samples, andsuctioning

Victim may be inpatient or outpatient

HighFirst Rescuer

Same as Intermediate Level Nos. 1 to 5Also may adapt/add:1. Call nurse on ward2. Call nurse if physician

is off ward3. Notify primary physician

as soon as possible

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TABLE B-3. continued

b. Unresponsive:Activate EMSPlace victim supineOpen airwayCheck respiration. If absent, follow

directions in Table B-4Maintain open airwayCheck pulse. If absent follow directions

in Table B-4Direct second rescuer to call EMSStay with victim; continue to monitorrespiration and pulse

2. Other considerationsa. If bleeding, compress area to

decrease/stop bleedingb. Suspected neck fracture: open airway

with a jaw-thrust maneuver; do nothyperextend neck

c. If seizing: prevent injury by removingharmful objects; place something underhead if possible

d. Turn victim on side,once seizure activitystops, to help drain secretions

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TABLE B-3. continued

Level: BasicSecond Rescuer

1. Call EMS2. Wait to direct emergency team to scene3. Return to scene to assist

LEVEL: BASICTHIRD RESCUER

1. Direct emergency team to scene or2. Assist first rescuer

ECG, electrocardiogram; EMS, emergency medical services.

IntermediateSecond Rescuer

Same as Basic Level Nos. 1 to 3Add:4. Bring all emergency equipment and

a. Place victim on monitorb. Run ECG rhythm strips

(or apply AEDLc. Take vital signs

INTERMEDIATETHIRD RESCUER

Same as Basic Level

HighSecond Rescuer

Same as IntermediateLevel Nos. 1 to 4

HIGHTHIRD RESCUER

Same as Basic Level

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TABLE B-4. Plan for Life-Threatening Situations

level: Basic

At a field, pool, or park without emergencyequipment

level: BasicFirst Rescuer

1. Position victim (pull from pool ifnecessary) and place supine,determine unresponsiveness

2. Call for help (911 or local EMSnumber)

3. Open airway; look, listen, and feelfor the air

4. Give two ventilations if no respirations5. Check pulse (carotid artery)6. Administer 15:2 compression/ventilation

if no pulse7. Continue ventilation if no respiration

TABLE B-4. continued

level: BasicSecond Rescuer

1. Locate nearest phone and call EMS2. Return to scene and help with two­

person CPR, or

3. Remain at designated area anddirect emergency team to location

level: BasicThird Rescuer

1. Assist with two-person CPR or2. Help direct emergency team to site3. Help clear area

EMS, emergency medical services

Intermediate

At a gymnasium or outside facility with basicequipment plus manual defibrillator(or AED) and possibly a small "start-up"kit with drugs

IntermediateFirst Rescuer

Step Nos. 1 to 7 for Basic Level

IntermediateSecond Rescuer

Step Basic Level Nos. 1 to 3Add:

4. Return to scene, bringing defibrillator:take "quick look" at rhythm

Document rhythm (do not defibrillateunless certified to do so and this activityis part of your clinical privileges for thefacility in which the work is beingcompleted) (or apply AED)

5. Place monitor leads on patient andmonitor rhythm during CPR

6. Bring emergency drug kit if availablea. Open oxygen equipment and use

AMBU bag with oxygen at 10 Umin(i.e., 100%)2 (if trained to do so)

b. Open drug kit and prepareintravenous line and drugadministration (must only be doneby trained, licensed professionals)

c. Keep equipment at scene for use byemergency personnel

IntermediateThird Rescuer

Same as Basic Level

High

Hospital or hospital adjunct with all the equipmentof intermediate level plus a "code cart" containingemergency drugs and equipment for intravenousdrug administration, intubation, oxygenation,drawing arterial blood gas samples, and suctioning

Victim may be inpatient or outpatient

HighFirst Rescuer

Step Nos. 1 to 7 for Basic Level

HighSecond Rescuer

Step Intermediate Level Nos. 1 to 6

HighThird Rescuer

Same as Basic Level

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279

TABLE C-1. Precordial (Chest Lead) Electrode Placement

TABLE C-2. Electrocardiogram Interpretation Steps

APPENDIX

C•••••

4th intercostal space just to the right of the sternal border4th intercostal space just to the left of the sternal borderAt the midpoint of a straight line between V2 and V4

On the midclavicular line in the 5th intercostal spaceOn the anterior axillary line and horizontal to V4

On the midaxillary line and horizontal to V4 and Vs

Electrode PlacementLead

1. Check for correct calibration (1 mV = 10 mm) and paper speed (25 mmlsec)2. Calculate the heart rate and determine the heart rhythm3. Measure intervals (PR, QRS, QT)4. Determine the mean QRS axis and mean T wave axis in the limb leads5. Look for morphologic abnormalities of the P wave, QRS complex, ST segments,

T waves and U waves (e.g., chamber enlargement, conduction delays, infarction,repolarization changes)

6. Interpret the present electrocardiogram (ECG)7. Compare the present ECG with previous available ECGs8. Conclusion, clinical correlation, and recommendations

The tables in this Appendix provide a quick reference source for electrocardio­gram (ECG) recording and interpretation. Each of these tables should be used aspart of the overall clinical picture when making diagnostic decisions about an

individual.

Electrocardiogram(ECG) Interpretation1. ACLS Provider Manual. Greem;lIe, TX: American Healt Association, 2001. . .

B . L' c S ·t co' He·tith Colre Providers Greem·ille TX: American Heart AssocIatIOn, 2001.2. aSlC lIe UppOI II I (( . ,

278 SECTION IV I APPENDICES

REFERENCES

TABLE C-3. Resting 12-Lead Electrocardiogram: Normal Limits

Parameter

Heart rate

PR interval

QR5 duration

QT interval

QR5 axis

Normal Limits

60-100 beats·min- 1

0.12-0.20 sec

UptoO.l0sec

Rate dependentNormal QT = K",/RR, where K = 0.37

for men and children and0.40 for women

- 30 to + 11 0 degrees

Abnormal If

<60>100

<0.12 sec>0.20 sec

If 2':0.11 sec

QTc long

QTc short

<-30 degrees

>+110 degree

Indeterminate

possible Interpretation(s)*

BradycardiaTachycardia

Preexcitation (i.e., WPW, LGL)First-degree AV block

Conduction abnormality (i.e., incomplete orcomplete bundle branch block, WPW,aberrant conduction)

Drug effects, electrolyte abnormalities,

ischemiaDigitalis effect, hypercalcemia

Left axis deviation (ie., chamber enlargement,

hemiblock, infarction)Right axis deviation (i.e, RVH, pulmonary

disease, infarction)All limb leads transitional

(continued)

Ncoo

\,/\mCl(5z<:-:l>-0-0mZo;=;m\,/\

*If supported by other electrocardiograms (ECGs) and related clinical criteria.

Abbreviations: bpm. beats per minute; WPW, Wolff-Parkinson-White syndrome; LGL. Lown-Ganong-Levine syndrome; OTc. OT corrected for heart rate; COPD. chronic obstructive pulmonary disease.

TABLE C-3. continued

Parameter

Taxis

5T segments

Q waves

Transition zone

Normal Limits

Generally same direction as QR5 axis

Generally at isoelectric line(PR segment) or within 1 mm.The 5T may be elevated up to3 mm in leads V,-V4 .

<0.04 sec and <25% of R waveamplitude (exceptions lead IIIand V,)

Usually between Vr V4

Abnormal If

The T axis (vector) is typicallydeviated away from the area of"mischief" (i.e., ischemia, bundlebranch block, hypertrophy)

Elevation of 5T segment

Depression of 5T segment

>0.04 sec and/or >25% of R waveamplitude except leadIII (the lead of exceptions)and V,

Before V2

After V4

Possible Interpretation(s)*

Chamber enlargement, ischemia, drug effects,electrolyte disturbances

Injury, ischemia, pericarditis, electrolyteabnormality, normal variant

Injury, ischemia, electrolyte abnormality,drug effects, normal variant.

Infarction or pseudoinfarction (as fromchamber enlargement, conductionabnormalities, WPW, chronic obstructivepulmonary disease, cardiomyopathy)

Counterclockwise rotationClockwise rotation

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283

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APPENDIX C I ELECTROCARDIOGRAM (ECG) INTERPRETATION

AnteroseptalLocalized anteriorAnterolateralExtensive anteriorHigh lateralInferiorTrue posterior (RlS>l)Right ventricular

SECTION IV I APPENDICES

*Based on abnormal Q waves except for true posterior myocardial infarction, which is reflected by abnormal R

waves.

V1-V3

Vr V4

V4-V6 , I, aVLV,-V6

I, aVLII, III, aVFV,-Vl

VI, V3R, V4R

Typical ECG Leads

TABLE C-5. Localization of Transmurallnfarcts*

'Adapted from Simonson E, Cady LD, Woodbury M. The normal QT interval. Am Heart J 1962;63:747, by permis­sion of CV Mosby. Reproduced from Chou TC Electrocardi09raphy in Clinical Practice. Philadelphia: WB Saunders,

1996:16.t A good rule of thumb for the QT interval is that at normal heart rates between 60 and 100 bpm, the T wave

should be completely finished being inscribed before you get half way between the previous and subsequent Rwaves. In other words, if you bisect the RR interval, the T wave should end before you get to that bisecting line.

Abbreviations: l, lower limit in seconds; U, upper limit in seconds.

TABLE C-4. Normal OT Interval as a Function of Heart Rate*t

Age (Y)

18-29 30-39 4~9 50-60

Heart Rate L U L U L U L U

115-84 0.30 037 030 037 0.31 037 031 0.37

83-72 0.32 0.39 033 039 033 040 033 040

71-63 0.34 041 035 041 035 041 035 042

62-56 036 042 036 043 037 043 0.37 043

55-45 0.39 045 039 045 039 046 0.39 046

282

TABLE C-7. Atrioventricular Block

Interpretation

1 degree Atrioventricular (AV) block

2 degree AV block: Mobitz I(Wenckebach)

2 degree AV block: Mobitz II

3 degree AV block

P WaveRelationshipto QRS

1:1

>1:1

>1:1

None

PR Interval

>0.20 sec

Progressively lengthens until aP-wave fails to conduct

Constant but with suddendropping of QRS

Variable but P-P interval constant

R-R Interval

Regular or follows P-P interval

Progressively shortens; pause less than twoother cycles

Regular except for pause, which usuallyequals two other cycles

Usually regular (escape rhythm)

N

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TABLE C-8. Atrioventricular Dissociation*

*What IS meant by "AV dissociation") When the atria and ventricles beat independently, their contractions are "dissociated" and AV diSSOCIation exists, Thus. Pwaves and QRS complexes In the ECGare unrelated AV dissociation may be complete or incomplete, tranSient or permanent. The causes of AV dissoCIation are "block" and "Interference," and both may be present In the same ECG."Block" IS assoCiated With a pathologiC state of refractonness, preventing the primary pacemaker's Impulse from reaching the lower chamber. An example of this IS sinus rhythm With complete AV block."Interference" results from slOWing of the primary pacemaker or acceleration of a subsidiary pacemaker. The lower chamber's impulse "interferes" with conduction by producing physiologic refractori­ness, and AV diSSOCIation results. An example of this is sinus rhythm with AV junctional or ventricular tachycardia and no retrograde conduction into the atria. A clear distinction must be made betweenblock and Interference. This table descnbes the four types of AV dissoCiation.

Type of Atrioventricular(AV) Dissociation

AV dissociation resulting fromcomplete AV block

AV dissociation by defaultcausing interference

AV dissociation byusurpation

Combination

Electrophysiology

AV block

Slowing of the primary ordominant pacemakerwith escape of a subsidiarypacemaker

Acceleration of a subsidiarypacemaker usurpingcontrol of the ventricles

AV block and interference

Example

Sinus rhythm with completeAV block

Sinus bradycardia withjunctional escape rhythm

Sinus rhythm with eitherAV junctional orventricular tachycardia

Atrial fibrillation withaccelerated AV junctionalpacemaker and blockbelow this pacemaker

Significance

Pathologic

Physiologic

Physiologic

Pathologic

Comment

Unrelated P wave and QRScomplexes. PP interval isshorter than RR interval

Unrelated P wave and QRScomplexes. PP intervalis longer than RR interval.

Unrelated P wave and QRScomplexes. PP interval islonger than RR interval

Unrelated P wave and QRScomplexes

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286

MeasUling \102 requires equipment that is expensive and sophisticated and trainedprofeSSional staff that can pelform the test as well as intelpret the data; it does notlend itself to large numbers of subjects or patients. Therefore, measUling \102 isimpractical in most nonlaboratOJ')' or fitness situations. When it is not possible orfeasible to measure \102, reasonable estimates of the \102 dming exercise can bemade from regression equations delived from measured \102 dming steady-stateexercise on ergometric devices and while walking and mnning. Moreover, for exer­cise prescIiption pUlposes, these equations may be used to determine the reqUiredexercise intensity associated \\rith a desired level of energy expenditure.

For the greatest accuracy, several cautionmy notes about the use of these"metabolic equations" are in order:

• The measured \102 at a given work rate is highly reprodUcible for a givenindividual; that is, the \102 at the same exercise intensity for the sameindividual is velY similar evelY time he or she exercises. However, the inter­subject variability (vmiability between different subjects) in measured \102

may have a standard error of estimate (SEE) as high as 7%. l--;J Subsequently,the equations work well if tracking the same subject over time but are lessaccurate for comparing \102 among different individuals and should be usedv.rith caution.

• These equations were derived during steady-state submaximal aerobic exer­cise; therefore, they are only appropIiate for predicting \102 during steady­state submaximal aerobic exercise. The \10 2 is overestimated duringnon-steady-state exercise conditions, when the contlibution from anaerobicmetabolism is large.

• Although the accuracy of these equations is unaffected by most environmen­tal influences (heat and cold), variables that change the mechanical effiCiency(e.g., gait abnormalities, v.rind, snow, sand) result in a loss of accuracy.

Net V02 = Gross V02 - resting V02

Estimation of Energy Expenditure: Metabolic Calculations

APPENDIX D / METABOLIC CALCULATIONS 287

f1he relative rate of \102 (relative to body mass) is typically expressed bythe units, milliliters per kilograms of body mass per minute (mL·kg-l·min- I

) .

The relative rate is used when compaling the \102 of.individuals who vmy inbody mass, and is calculated by di\riding the absolute V02 (mL'min-I) by theindividual's body weight (kg).

V02 (mL·min- 1) 7 kg body mass = mL·kg- 1·min- 1

In some instances, one may eX1Jress \102 relative to kg of fat-free mass, tosquare meters of surface area, or to other indices of body size.

• The gross rate of oxygen uptake is the total \102 including the resting ox')'genrequirements, expressed as either L'min- I or mL·kg-1·min- I

• The net rate of ox')'gen uptake is the \102 associated \vith only the amountof exercise being performed exclusive of resting oxygen uptake, expressed aseither L·min- l or mL·kg-1·min- I

• The net V02 is calculated by subtracting the resting \102 from the gross \102.

Metabolic Calculations••••

APPENDIX

D

The energy requirements of physical activity are calculated by measuring or esti­mating the oxygen requirements of the amount of exercise or activity being per­formed, commonly called the m."ygen consumption (\102). \102 provides usefulinformation for exercise professionals, such as the cliterion measure of car­diorespiratory fitness (\102maJ. Under steady-state conditions, \102 provides ameasure of the energy cost of exercise (kcal) and in combination with \1C02 canprovide information about the fuels for exercise.

The actual measurement of \102 typically is performed in exercise laboratories orclinical settings using a procedure called open-circuit spirometry. DUling open­circuit spirometry the subject or patient uses a mouthpiece and nose clip (ormask), which directs the expired air to an integrated metabolic system and com­puter interface that measures the volume and percentage of O2 and CO2 of theexpired air. Subsequently, oxygen consumption (\102 ) and carbon dioxide output(\[C02) are calculated. In this notation for \102:

• the V stands for volume• the O2 for m."ygen• the dot above the V denotes a rate, that is, the volume of ox)'gen per unit of

time, typically per minute

Vmious expressions of \102 are used depending on the pUlpose for its meas­urement:

• The absolute rate of \102 is typically expressed by the unit liters per minute(I·min- I

). In this form, \102 can be converted to the overall rate of energyexpenditure (kcal):• The consumption of 1 L of O2 results in the liberation of approximately 5

kcal (i.e., 20.9 kJ; 1 kcal = 4.2 kj) of energy (i.e., 1 L \102 = 5 kcal 'min -I).• The energy expenditure associated v.rith a given level of \102 varies slight­

ly \vith the respiratOly quotient (RQ). When the RQ, which is the ratio of\1C02!\102, is 0.70, fats are the pIimmy fuel source for energy metabolismand the kcal equivalent of a lL \102 is approximately 4.69. This increasesto 5.05 kcal' L-I \'02 when RQ is 1.0 and the plimary fuel source for ener­gy metabolism is carbohydrates. "'hen HQ is not k'l1own, the value of 5.0kcal' L-I \102 is used.

Measurement of V02

Walking Equation

DERIVATION OF METABOLIC EQUATIONS

289

TABLE 0-1. Metabolic Equations for Gross V02 in Metric Units*

(speed = m·min-1. 1 m h 268 '-1 f ', p = . m·mln ractlonal grade is in decimal form,5% grade is 0.05)

APPENDIX D I METABOLIC CALCULATIONS

Walking

V02 (mL·kg- 1 ·min- 1) = (O.l·S) + (l.8·S·G) + 3.5 mL·kg- 1 ·min- 1

V02 (mL·kg- 1·min- 1) = [0.2 mL·kg- 1 ·meter- 1 ·5 (m·min- 1)]

+ [0.9 mL·kg- 1 ·meter- 1 ·5 (m·min- 1)·G] + 3.5 mL·kg- 1 ·min- 1

Leg Cycling

V02 (mL·kg- 1 ·min- 1) = 1.8 (work rate)/(BM) + 3.5 mL·kg- 1 ·min- 1

+ 3.5 mL·kg- 1 ·min- 1

V0 2 (mL·kg- 1 ·min- 1) = [0.1 mL·kg- 1 ·meter- 1 ·S (m·min- 1)]

+ [1.8 mL·kg- 1 ·meter- 1 ·S (m·min- 1)·G) + 3.5 mL·kg- 1 ·min- 1

Running

V02 (mL·kg- 1 ·min- 1) = (0.2·5) + (O.9·5·G) + 3.5 mL·kg- 1 ·min- 1

• \102 (n~.~.kg-l.min-l) = 0.1 (speed) + 1.8 (speed) (fractional grade) + 3.5mL·kg ·min-1

V02 (mL·kg- 1 ·min- 1) = (1.8 mL·kg- 1 ·min- 1)

X (work rate in kg·m·min- 1) (body mass in kg)

+ 3.5 mL·kg- 1 ·min- 1 + 3.5 mL·kg- 1 ·min- 1

Arm Cycling

V02 (mL·kg- 1 ·min- 1) = 3 (work rate)/(BM) + 3.5 mL·kg- 1·min- 1

V02 (mL·kg- 1 ·min- 1) = (3 mL·kg- 1 ·meter- 1)

x (work rate in kg·m·min- 1) (body mass in kg) + 3,5 mL·kg- 1 ·min- 1

Stepping

V02 (mL·kg- 1 ·min- 1) = (O.2·f) + (1.33·1.8·H·f) + 3.5 mL·kg- 1 ·min- 1

V02 (mL·kg- 1·min- 1) = 0.2 (steps·min- 1)

+ (1.33 mL·kg- 1 ·meter- 1) (1.8 mL·kg- l ·meter- 1)

x (step height in meters) (steps·min- 1) + 3.5 mL·kg- 1 ·min- 1

V02 is gross oxygen consumption in mL·kg- 1 ·min- 1; 5 is speed in m·min- 1; BM is

body mass (kg); G IS the percent grade expressed as a fraction; work rate(kg·m·mll1- 1

); f is stepping frequency in minutes; H is step height in meters.

SECTION IV I APPENDICES

• Horizontal Component (Walking): During walking, apprOXimately 0.1 mL O2

is needed for transporting each kg of body mass a horizontal distance of

1 meter (m). (O.lmL·kg-l·min- I):,

• Horizontal Component (Running): The oxygen demand of running the samedistance (1m) is twice as great (0.2 mL·kg- ' ·min- ' )fi.7 Bunning on a levelsurbee is more costly than walking because of the greater veltical displace­ment that occurs between each step and the greater need to overcome ineltia

to maintain the greater speed.• Veltical Component (Walking): The m,ygen demand of raising one's body mass

against gravity at sea level for walking on the treadmill or ground is approx.i­mately 1.8 mL per kg of body mass for each meter (m) of veltical distance(1.8 mL·kg-1·min-1).&--lo

• Veltical Component (Bunning): DUling running on a treadmill or over ground,the m;ygen cost of vertical ascent is half that of walking or 0.9

mL.kg- ' .min- I .7

.II

• Besting \102 = 3..5 mL·kg-l·min- ' = ] MET (metabolic equivalent)

Walking and Running

Constants

Despite these caveats, the proper and judiCiOUS use of metabolic calculations

prOVides valuable inf"ormation to the exercise professional.

Table D-l presents the metabolic equations f"or the gross or total o);ygen costof walking, running, leg ergomctry, arm ergometly, and stepping. For eachprediction equation, there are some essential known phYSiologic constants, suchas how much m,ygen is required to move the body hOlizontally (walking on theflat) and veltically (walking up a grade or hill) or the oxygen costs of pedaling at

no resistance.

• Conversion: 1 mph = 26.8 m·min-I

• Most accurate f"or speeds of.50 to ]00 m·min- 1 (\.9-3.7 mph)

• The use of" the prediction equations presupposes that ergometers are cali­brated properly and used appropliately (e.g., no rail holding during treadmill

exercise).• The equations are most accurate at the stated speeds and power outputs.

There is a range of" walking speeds for which neither the walking nor the run­ning equations are applicable. These speeds (3.7-.5.0 mph) are in the range of"the transition from a walking to running motion. The degree of transitionvaries depending on the individual's size, leg length, stlide length, and normalwalking pace; therefore, interindividual variability in \102 is very wide within

this speed range.'1

288

Constants

Leg and Arm Ergometry

Running Equation

• Most accurate for speeds> 134 m-min-I (.5.0 mph) but appropriate for speedsas low as 80 m-min- I (3 mph) if the individual is truly jogging or running.

• V02

(mL-kg-I-min-l) = 0.2 (speed) + 0.9 (speed) (fractional grade) + 3.5

mL-kg-J-min- 1

291

Resting+rate)/(BM)(work3

APPENDIX D / METABOLIC CALCULATIONS

• Most accurate for 110 ttl 150 dweI' au pu s 1etween an 750 kg-m-min- I

(25 and 125 W)• V02 (mL'kg I-min-I)

(3.5 mL-kg-1-min- l )

Leg Cycling Equation

• Most accurate for power outputs between 300 and 1,200 kg-m-min- I (50' d~~ ~

• V02 (~~L-k(:-min-l) = 1.8 (work rate)/(BM) + Resting \102 (3.5mL-kg -mm ) + Unloaded cycling (3.5 mL-kg-I'min- l)

(work rate = kg-m-min- 1; BM = body mass [kg])

(work rate = kg-m-min- 1; 8M = body mass [kg])

• Conversion: 1 inch = 0.0254 meters (m).• Most accurate for stepping rates between 12 and 30 steps-min- 1 and step

l~eights 0.04 to 0.40 m (1.6 to 15.7 in.)• V02 (mL- kg- ' -min I) = 0.2 (stepping rate) + 1.33-1.8 (step height) (step­

pmg rate) + 3.5 mL-kg-I'min I

(Stepping rate = steps'min- I; step height = meters)

Stepping Ergometry

Constants

Arm Cycling Equation

Practical Use of the Metabolic Calculations

Step~ing is performed traditionally in a four-part process of lifting one leg onto abox, hxed bench, or step; pushing with this leg to raise the body; placing the otherleg on tl~e box; and stepping do:vn with the first and then second leg in a repeti­tIve fashlOn. The oxy?en cost of stepping has horizontal and vertical componentsbecause one moves forward and backward horizontally, as well as up and down.

• Horizontal Component: The oxygen demand of the horizontal movement isapproximately 0.2 mL O2 per four-cycle step (stepping up and down) per kgof body mass (0.2 mL- kg I).

• Vertical Component: The O2 demand of vertical ascent is 1.8mL-kg-l-min- l

, and an additional one-third of this (1.33) must be added toaccount for the O2 cost of stepping down, the deceleration against gravity6

Stepping Equation

Tables D-2 thru D-6 were .. I . I· t d f" I' .. C<I cu a e 10111 t le equations as a practIcal referencefor the gross V02 for the respective types of steady-state exercise. The \700 ineach of the Tables are presented in METs. METs express oxygen uptake rela;iveto restmg values An ox g t· k I' 8 MET I- .;y en up a e 0 < s means t lat the m;ygen require-

SECTION IV / APPENDICES

r = the pedaling frequency (revolutions per minute).

• In the scientific literature, power is most commonly expressed in watts [\V] asopposed to kg-m-min- I \Vatts = kg-m-min- I divided hy 6 [or more accu-

rately 6.12.The total oxygen demand of leg ergometry includes: 1) unloaded cycling (i.e.,

the movement of the legs), 2) the external load (amount of resistance), and 3) the

resting oxygen uptake_

• At 50 to 60 rpm, the ox)"gen cost of unloaded cycling is approximately 3.5

mL-kg-I-min- 1 above rest. 12-14• The cost of cycling against the external load (resistance) is approximately 1.8

mL-kg-l-min- 1perkg-m-min- 1H

However, the arms arc less efficient than the legs dUling cycling, most likelybecause of the recruitment of accessory muscles needed to stabilize the torso.

• Therefore, the m;ygen cost against the external load during arm ergometry isgreater than that of leg ergometIy, approximately 3 mL- kg-I-min -I perkg' m-min -1.15-1,

speed = m-min 1; 1 mph = 26.8 m-min 1

fractional grade is in decimal form, 5% grade is 0.05

For speeds between 100 m- min -1 (3.7 mph) and 134 m-min -I (5.0 mph) obser­vations of the individuals gait pattern determine which equation (walh'ing or run­ning) may be most accurate. Use the walking equation if the individual assumes awalking patte111. Use the running equation if thc individual has to assume a running

gait.

Power is ex-pressed in kg- m-min -I for the leg and arm ergometer equations. To

determine the power output during leg or arm ergometry:

• Power (kg-m-min- I) = R (kg)-D (m)-f(revolutions per minute)

R = resistance setting in kg;D = distance in meters (m) the flywheel travels for each pedal revolution

• 6 m for Monark leg ergometers• 3 m for Tunturi and BodyGuard ergometers• 2.4 m for Monark arm crgometers

290

TABLE 0-5. Approximate Energy Requirements in METs During ArmErgometry

Power Output (kg'm'min ' and W)80dy Wt.

150 300 450 600 750 900 (kg'm'min ')kg Ib 25 50 75 100 125 150 (W)

50 110 3.6 6.1 8.7 11.3 13.9 16.460 132 3.1 5.3 7.4 9.6 11.7 13.970 154 2.8 4.7 6.5 83 10.2 12080 176 2.6 4.2 5.8 7.4 90 10.690 198 2.4 3.9 5.3 6.7 8.1 9.6

100 220 23 3.6 4.9 6.1 7.4 8.7

APPENDIX D I METABOLIC CALCULATIONS 293

ment of the task is cight timcs that of rest. Metabolic equivalents (METS) are cal­culated as METs = V02 (mL·kg- l·min- I )/3.5].

For purposcs of prescribing exercise, another utility of the metabolic equa­tions is to estimate a target work rate that will elicit a desired level of oxygenuptake or energy expenditure. The equations are solved for the unknown variableon the workload side of the equation. In the case of treadmill exercise, whenthere are two unknown variables (i.e., speed and fractional grade), it is best toselect an appropriate speed based on the ability and comfort of the client, andthen solve for thc fractional grade.

If knowledge of the caloric cost of exercise is desired, the V02 should first beexpressed in net terms (gross V02 minus resting V02 ). Once the net V02 is deter­mined, convert the value to caloric expenditllre per minute using either of thefollowing methods.

Method #]:

1. Convert V02 (mL·kg-J·min- 1 or METs) into the absolute unit ofL'min- 1

2. If starting from mL· kg-I. min -1:

a. Multiply the mL·kg-l·min- 1 by the kg body mass and divide by 1,000b. mL·kg-l·min -1 kg body mass/I,OOO (i.e., 1,000 mL per Liter).

292 SECTION IV I APPENDICES

TABLE 0-2. Approximate Energy Requirements in METs for Horizontaland Grade Walking

mph 1.7 2.0 2.5 3.0 3.4 3.75

%Grade m'min-' 45.6 53.6 67.0 80.4 91.2 100.5

0 2.3 2.5 2.9 3.3 3.6 3.92.5 2.9 3.2 3.8 4.3 4.8 5.25.0 3.5 3.9 4.6 5.4 5.9 6.57.5 4.1 4.6 5.5 6.4 7.1 7.8

10.0 4.6 5.3 6.3 7.4 8.3 9.112.5 5.2 6.0 7.2 8.5 9.5 10.415.0 5.8 6.6 8.1 9.5 10.6 11.717.5 6.4 7.3 8.9 10.5 11.8 12.920.0 7.0 8.0 9.8 11.6 13.0 14.222.5 7.6 8.7 10.6 12.6 14.2 15.525.0 8.2 9.4 11.5 13.6 15.3 16.8

TABLE 0-3. Approximate Energy Requirements in METs for Horizontaland Grade Jogging/Running

mph 5 6 7 7.5 8 9 10

% Grade m'min- 1 134 161 188 201 214 241 268

0 8.6 10.2 11 .7 12.5 13.3 14.8 16.32.5 9.5 112 12.9 13.8 14.7 16.3 18.05.0 10.3 12.3 14.1 15.1 16.1 17.9 19.77.5 11 .2 13.3 15.3 16.4 17.4 19.4

10.0 12.0 14.3 16.5 17.7 18.812.5 12.9 15.4 17.7 19.015.0 13.8 16.4 18.9

TABLE 0-4. Approximate Energy Requirements in METs During Leg TABLE 0-6. Approximate Energy Requirements in METs DuringCycle Ergometry Stair Stepping

Power Output (kg'm'min- 1 and W) Step Height Stepping Rate per Minute80dy Wt.300 450 600 750 900 1,050 1,200 (kg'm'min- 1) in m 20 22 24 26 28 30kg Ib 50 75 100 125 150 175 200 (W)

4 0.102 3.5 38 4.0 43 4.5 4.850 110 5.1 6.6 8.2 9.7 11.3 12.8 14.3 6 0152 42 4.6 4.9 5.2 5.5 5.860 132 4.6 5.9 7.1 8.4 9.7 11.0 12.3 8 0203 49 5.3 5.7 6.1 6.5 6.970 154 4.2 5.3 6.4 7.5 8.6 9.7 10.8 10 0254 5.6 6.1 6.5 7.0 7.5 7980 176 3.9 4.9 5.9 6.8 78 8.8 9.7 12 0.305 6.3 6.8 7.4 79 8.4 9.090 198 3.7 4.6 5.4 6.3 7.1 8.0 8.9 14 0.356 7.0 7.6 82 88 9.4 10.0100 220 3.5 4.3 5.1 5.9 6.6 7.4 8.2 16 0.406 7.7 8.4 90 9.7 10.4 11.118 0.457 8.4 9.1 9.9 10.6 11.4 12.1

295APPENDIX D / METABOLIC CALCULATIONS

3.5 kg = resistance setting

1,259 (kg'm'min- 1) = (resistance setting) 360

27.7 mL'kg- 1 'min- 1 = 1.8 (work rate) / 81.8 kg

34.7 mL·kg- 1 ·min- 1 = 70 + 1.8 (work rate) / 81.8 kg

34.7 = 0.1 (93.8 m'min- 1) + 1.8 (938 m'min- 1

) (fractional grade) + 3.5

31.2 = 0.1 (938 m'min- 1) + 1.8 (93.8 m'min- I ) (fractional grade)

Q: If he is comfortable pedaling at 60 rpm on a Monark cycle, whatresistance setting would be required?

A: Work rate (kg'm'min- 1) = (resistance setting) (distance) (pedal cadence)

1,259 (kg'm'min- 1) = (resistance setting) (6) (60)

31.2 = 9.38 + 168.8 (fractional grade)

1.259 kg'm'min- 1 = work rate

Q: What is the target work rate (kg'm'min- I) on the Monark bike')

A: First determine his body mass: 180 Ib/2.2 = 81.8 kgThen, use the leg cycling equation and solve for the unknown work rate.

V02 (mL'kg- 1'min- t ) = 7.0 mL'kg- 1 'min- 1 + 1.8 (work rate) / (body mass)

V02 (mL'kg- 1 'min- 1) = 0.1 (speed) + 1.8 (speed) (fractional grade)

+ 3.5 mL'kg- 1 'min- 1

21.8 = 168.8 (fractional grade)

0.129 = fractional grade = 12.9% grade

2266 = 18 (work rate)

Target V02 = 33.6 mL'kg- 1 'min- 1

The remainder ofthe questions will use 34. 7 mL'kg-1'mil1-

1 as the target V02

(i.e., 70% ofhis V02R)

Q: If he is walking at 3.5 mph, how steep should the treadmill grade beto elicit a \102 of34.7 mL'kg-I'min- ' ') Remember: 3.5 mp/l X26.8 = 93.8 m'lIIin- 1

A: Use the walking equation and solve for the unknown fractional grade.

/

SECTION IV / APPENDICES

If using a straight percentage ofV02 "'(lX as the target V02:

Target V02 (mL'kg- I 'min- 1) = (exercise intensity) x (V02011ax)

Target V02 (mL'kg- I 'min- 1) = (0.70) (44.5 mL'kg- 1 'min- l)

+ 3.5 mL'kg- 1 'min- t

A 30-year-old man has a resting hemi rate of 60 bpm, a maximal heart rate of 190bpm, weighs 180 lb, and has a \102011,,, of 48 mL· kg-I'min -I He \\~shes to beginan exercise program including treadmill walking and leg cycling on a Monarkergometer. Using feedback fi'Olll the subject, you estimate that a comfortable walk­ing speed for him is 3.5 mph. Based on his physical acti~ty history and aerobiccapacity, you select 70% \102m"x as his initial training intensity. Answer the follow­

ing questions:Q: What is his target \102 using his \102R and a straight percentage of

\102011",')A: First calculate the \102011"., reserve (\102.m,R)

V02011ax = 48 mL'kg- 1 'min- 1

V02 R = 44.5 mL'kg- 1 'min- 1

Then calculate the Target \102 (mL'kg-I'min- l)

Target V02 (mL'kg- 1 'min- 1) = (exercise intensity as a decimal)

x (V02 R) + V0 2fe51

CASE STUDY EXAMPLE

294

3. If starting from METs:a. Multiply the MET value by 3.5 to obtain mL·kg-l·min- 1 and then com-

plete step 2a.4. Convert \102 (L'min- I) to caloric expenditnre (kcahnin- l

) by multiplying by5 (i.e., approximately .5 kcal per L O2 during steady-state exercise)

Method #2:1. Convert the \'02 in METs directly to caloric expenditure using the equation

below from Chapter 7.a. Kcahnin -I = (METs X 3.5 X body weight in kg)/200

Target HR = 151 beats'min- 1

V02 in L'min- 1 = (312) (818) /1,000 = 2.55 L'min 1

Target HR = 91 + 60

297APPENDIX D / METABOLIC CALCULATIONS

ANSWERS

1. 39.2 mL·kg-'·min- 1

2. 7.9 kg (or kp)3. About 20 weeks4. 12.5 mL·kg-1·min- J

5. 131b6. 22.1mL·kg- i ·min- '7. 10.9 METs

ESTIMATING V02MAX

The metabolic equations presented in Table D-1 were derived during steady-stateexercise and are not applicable for estimating non-steady-state conditions, such aspeak or maximal levels of exercise. Using equations derived during steady-stateexercise overestimates the V02 during non-steady-state conditions and should notbe used. Other prediction equations have been deJived for use dming peak or max­imal exercise. The available equations are either generalized equations that can beused across gender, age, and for different protocols, or they are protocol specificand are a function of the time of exercise completed for that specific protocol.ModifYing the protocol invalidates the equation.

One such commonly used equation is based on the Bruce protocol:l.lB

V02max (mL'kg- 1'min- 1) = 14.8 - 1.379 (time in min) +

0.451 (time2) - 0.012 (time3)

SEE = 3.35 mL'kg- 1 'min- 1

Ramp treadmill protocols are discussed in Chapter 5. V02,m, can be predict­ed using the following equation that adjusts for the use of a ramping treadmillprotocol: 19

V02max (mL'kg- 1'min- 1) = 0.12x + 3.67

SEE = 4.4 mL'kg- 1'min- 1

(x is the predicted V02 calculated for the peak speecl!grade using the ACSMwalking equation)

Another validated equation for use \\rith a Ramp Blllce Treadmill Protocol is:2o

V02max (mL'kg- 1'min-') = 3.9 (time in min) -7.0

SEE = 3.4 mL'kg- 1 'min- 1

All of the aforementioned treadmill prediction equations assume that thepatient does not use handrail support. However, for patients who may be unsteadyor have difficulty walking on a motorized treadmill, non-handrail-supported exer­cise may be impossible or result in early test termination because of anxiety on theI?art of the patient. For such instances, there is a validated equation for predictingV02m"x dUJing handrail suppOlied treadmill exercise using the Bruce protocol:21

V02max (mL'kg- 1'min- 1) = 2.282 (time in min) + 8.545

SEE = 4.92 mL'kg- 1 'min- 1

SECTION IV / APPENDICES

Target HR = (070) (190-60) + 60

Net caloric expenditure in kcal'min 1 = 2.55 L'min 1 x 5 = 12.8 kcal'min- 1

Target HR = (0.70) (130) + 60

Q: What will be his net caloric expenditure dUling 30 minutes of exercise')A: :\let VOz = 34.7 mL·kg-l·min 1 - 3.5 mL·kg I·min-I =

31.2 mL·kg I·min- I

V02 in L'min 1 = (V02 in mL·kg-1·min- 1) (body mass) /1,000

Q: What is an appropriate target heart rate according to the heart ratereserve method?

A: Target HR = (exercise intensity as a decimal) (HRn"" - HR,.",,) +HR"est

PRACTICE METABOLIC CALCULATIONS (WITH ANSWERS)

Net caloric expenditure for 30 minutes = 128 kcal·min 1 x 30 min = 384 kcal

296

I. A man weighing 176 Ib nills at a pace of 9 minutes per mile outdoors, on levelground. What is his estimated gross VOz?

2. To match this exercise intensity (from #] above) on a Tunturi cyclc ergome­ter, what setting (kg) would you use at a pedaling rate of 60 rpm'?

3. If this same man exercised at this intensity five times per week for 30 minuteseach session, how long would it take him to lose 12 Ib (assuming all calOliesexpended in this exercise are in excess of food intake)') Hint: Use the net VOzto calculate the exercise energy expenditure.

4. A 198-lb cardiac patient \\rishes to use an arm ergometer for part of his reha­bilitation program. He works at a power output of 300 kg'm'min- I for ]5minutes, then at 450 kg·m·min I for 15 minutes. \oVhat is his average net VOz(in mL·kg-l·min- l

) over this session'?5. If an indi\ridual reduces his or her dictary intakc by 1,750 kcahvk- l

, howmuch wcight (in Ib) would he or she lose in 6 months (26 weeks)'?

6. If an 18-year-old girl steps up and down on a 12-inch step at a rate 01'20 steps(complete up and dO\\~l cycles) per minute, what would her gross \10z be (inmL.kg-"min l),?

7. A 71-year-old man weighing 180 Ib walks on a motor-driven treadmill at 3.5mph and a 1.5% grade. What is his gross MET level'?

FIELD TEST EQUATIONS

(V" = final power output completed in watts; kg = body mass; years = age)

TABLE 0-7. Common Field Test Equations to Estimate V02max*

299APPENDIX D / METABOLIC CALCULATIONS

6. Balke B. A simplified field test lor 'L"essm~nl nf pl1\·sie·t1 fltlw" C' .J A' I' tI BRepOlt, Okl,t1,oma City, 196.3:6:3-66. .'.. II "Iom~, Ie, ~s~arch Institnlt'

7. Margaria R, Cerrel,elli 1', Agh~mo P. Energy cost of running. j Appl Physiol 1963;18:367-370.8. Balke B, Ware R\I. An exp~rlln~ntal sludv of "pll\'sieal fitlless" of 'Ii' l' '. .. I US

Forces ~Ied j J959;10:67.';-688. ' - .., I ()Ice p~lsoone. Armed

9. Nagle 1', Balke B, Baptista G, et al. Compatihilitv of proaressi"e tw,dmill bic' litbascd on o,s)'gen uptake r~sponses. M~d Sci Sport; 1971;.3~149~154.· , \c ~ an, s ep lesls

10. ~~~2~'j7-1~~:8B. Naughton .II'. Gradational st~p tesls for ass~ssing \\ork capacity. JAppl ph)'siol

11. Bassett DB jr, Giese ~ID N'l"l~ Fj et·1 A . I" .• ." < b ' cl. t'1O )1(: reqLllrelllcnh of O\'ervround \'f:'I"SliS treadmill

fUllmng. Med $<:1 SPOIis Exert:: 19H.5:17:477--481. b

12. Lang PB, Latin R\I', Berg KE, ~t al. The aeeurac)' of the ACS\I c\de ~r"ometl ,~( uatiSports Ex~re 1992;24:272-276. . " ) 1 on. ~I~d Sei

13. Latin HW B~r" KE The 'WClll"IC\' I' tl ACS~I 1' ~. • < <,Ole !' allt a new c.\de ergollletrv equation for \Olll)

women. ~Ied Sel Sports Eserc 199-1;26:642-646. '. g

14. Lond~rcc BR, ~Iofntt-G~rst~nher"~rj p. df ,11 jA I 0. ',..... ~ ,cl l( t , et a. .\)gcn consumption of cycle eraOllle!"IS nonltn,.uly r~Jat('d to work rate and p~dal rate. Med Sci Sports Exere 1997'29:77.5-780 b •

15. Franklm BA Esercise I"st' t .. ' . I , .. " . . mg, l.lJnmg '111( arm ergomelr)'. Sports \Ied 19S.5;2: 100-JJ9

16. ~e~'l'gard ~'. I, reyschuss U, Strallch..·11 T. Circulatory adaptation to ann and leg (:"xen:ise in 'supine anJSlttlllg po"tlOn. j Appl Physiol 1966;2 I :37-46.

17. Stenherg j Astr'rnd PO Ekhi B t· I HI''.'. . ( . ,-' 0111 ,e <I. elllO( ynalllll' response to work with difkrent Illuscle

groups, S1ttrng and SUPll1~. j Appl Ph)'siol 1967;22:61-70.

18. Foster C. jackson AS, Pollock M L. ('t al. Gen('rajiz~d e'luations lor I'r~dicting Jim('tional ca )acit .f,om treadlllil' perronnan('e. A", H""rt j 1984; 107: I229-123~. I )

19. M)'ers j, Buehanan 1\, S"'ith D, et a1. Individualized ra"'p tr~admill. ObSelY'lIions 01' " . tcol. Ch~sl 1992; I01:2.36S-2-11S. • . '" nc\\ 1'10 0-

20. Kc.1Il1insky I,A, \ ~'Ilal(:y J\I J I. Evaluation of a llew standardized ramI' lJrotol'ol: I 3plotocol. j Cardll1puJ", R~hahiJ 1998;18:-138--144. I 1~ I SUlEruce Ramp

21. ~IcConnell TB Chrk BA p., ,. 't' I' . I• ' . .' <, .' 1(( Ie Ion 0 ma.\lIna o.\)'gen consumption Juring handrail su J JOlted

tre"dmilleselc"e. j Canilopullll Behahi' 19117;7:;324-:331. 11

22. SEtorer T\V. Da~is JA, Caiozzo \'J. ACl'uratp prediction of \'0211l,L\ in t.'\'de erl1ometr\', .\led Sci SIJO,'ts'x,'rc 1990:22,,0.J--712. ' ". .

23. Kli:W GJ\I. Porcari JP. ,HiJ1terlllt'istt"r H, et al. Estimatioll of \f02111

,L\ from a one-Ill ill' track walk (fen-del, ag~, and hod)' weight. ~I~d Sci Sports Ex~r(' 19117; IB:253-2.59 ' "

24. Dolgen~r FA. llenseh- LD. \Iarch .1.1, ~t al. \'alidatiou of th" Bock1~orl Fitn~ss Walking Test in . 1_leg(' lIIalt's and f~",al~s. Ill's Q Ex~re Sport 1994;6.5: 152-1.58. ,co

SECTION IV / APPENDICES298

Males: V02max (mL·min- 1) = 10.51 (W) + 635 (kg) - 1049 (years) + 5193

SEE = 212 mL'min- 1

For predicting V02um, during cycle ergometlY using 15 W per min incre­ments;22

(\\1 = final power output completed in watts; kg = body mass; years = age)

Females: V02max (mL'min- 1) = 9.39 (W) + 7.7 (kg) - 5.88 (years) + 136.7

SEE = 147 mL'min- 1

*See references 23 and 24: From Kline GM, Porcari JP, Hintermeister R, et al. Estimation of V02max from a one­mile track walk, gender. age. and body weight. Med Sci Sports Exerc 1987; 19:253-259; Dolgener FA. Hensely LD.March JJ. et al. Validation of the Rockport Fitness Walking Test in college males and females. Res Q Exerc Sport1994;65:152-158.

Rockport Walking Test (1-Mile Walk)

V02max (mL·kg- 1 ·min- 1) = 132.853 - 0.1692 (body mass in kg) - 0.3877 (age in

years) + 6315 (gender) - 3.2649 (time in minutes) ~ 0 1565 (HR);

(SEE = 5.0 mL·kg- 1 ·min- 1)

(gender = 0 for female, 1 for male; heart rate (HR) is taken at end of walk)

1.5-Mile Run Test

V02max (mL·kg- 1·min- 1) = 3.5 + 483/ (time in minutes)

Field tests are an efficient and economically feasible option for predictingV02",,,, when large numbers of individuals are being tested or the use of stan­dard ergomctlY is not possible. These tests involve walking or running overlevel terrain to either cover a fixed distance (e.g., 1 or 1.5 miles) as qUickly aspossible or cover the greatest distance possible in a fixed period of time (e.g.,12 or 15 minutes). Field equations may incorporate other independent vari­ables, such as age, gender, or body weight for enhanced predictive accuracy.Commonly used field test equations for the I-mile walk and 1.5-mile run aregiven in Table D-7.

REFERENCES

I. Bruce HA, Kusumi 17, Hoslller D. Maximal oxygen intake and 1100lH>graphic asseSSlnent of fUIH.:tioll-

al aerohic iinpairlllt.-'nt in cardiovascular disease. Aill Heart J 1973;85:546-562.

2. My~rs J, ~ladha"'111 B. Exercise tesling wilh gas ~xehang~ analysis. Cardiol Clin 2001;l9:4;3:J-445.3. Shephard Bj. Tesls nf nl<tsimnm osyg~n uplak~. A eritieal re,·i~w. Sporls ~Ied 19114;l:99-J 24.

4. Workman jM, Armstrong B\\'. Oxygen eosl of Irea,hnill w,liking. J Appl physiol 1963; 18:798-803.

5. Dill DB. Oxyg~n eost of hmiLOntal and grad~ walking and running on th~ tr~admili. J Appi Physiol1965;20: 19-22.

300

301

100806040

-----------wet~

Relative humidity ('Yo)

APPENDIX E / ENVIRONMENTAL CONSIDERATIONS

OF °C110

40Ql... 100::3-III 35...QlCoE 90Ql

30-.0::3.0 80>- 25...C

7020

60

0 20

--dry

FIGURE E-1. Approximate risk of heatstroke or heat exhaustion during competitive dis­tance running. Reprinted with permission from Armstrong LE, Epstein Y, Greenleaf JE,et al. American College of Sports Medicine position stand. Heat and cold illnesses dur­ing distance running. Med Sci Sports Exerc 1996;28:i-x.

The first use ofWBGT occurred in the 1950s at militmy bases. Subsequently,other organizations promulgated similar 'VGBT guidelines 1--3 that have success­fully reduced the incidence of heat illness during hot weather physical activity.4However, the 'VBGT index has limitations. For example, when relative humidi­ty is high (>70%), the WBGT tends to underestimate the risk of heat illness 4

Further, '''''BGT does not account for factors such as clothing insulation, exerciseintensity, age, fitness, acclimatization, and illness that modify the physiologicstrain imposed by a given environment.

The exertional heat illnesses (i.e., heatstroke, heat exhaustion, heat cramps,and heat syncope) are described in an ACS.'v1 position stand that focuses on com­petitive distance running. I For noncompetitive exercise, fitness profeSSionals andclinicians can use industrial standards, established by the National Institute forOccupational Safety and Health (NIOSH),2 as a convenient starting point.NIOSH standards denne WBGT levels at which the risk of heat injury isII1creased, but exercise can be performed if preventive steps are taken. These~teps include limiting the maximum duration of continuous exercise and requir­mg rest breaks between exercise periods. Table E-l prO\~des recommended exer­cise-rest intervals derived from NIOSH standards for moderate and vigorousexercise based on WBGT measurements.

EnvironmentalConsiderations

APPENDIX

E

The human body constantly responds to changes in the surrounding environmentto maintain health and performance. For example, heat, cold, and high altitudecomprise the greatest concerns for people engaged in recreational, fitness, orcompetitive activities (and the clinicians and trainers advising them). These envi­ronmental conditions exacerbate the physiologic strain of exercise.

Muscular contractions generate heat that must be released to the environment; ifnot, the temperature of internal organs increases, eventually reaching dangerouslevels. High ambient temperature and humidity impede heat dissipation.UnfOltunately, no single standard defines safe upper limits for temperature andhumidity during exercise. However, the American College of Sports Medicine(ACSM) has published guidelines regarding competitive exercise in heat1 Forexample, Figure E-l illustrates categories of risk for heat illness, based on airtemperature and humidity. Other guidelines, for industrial and military popula­tions, also may be applied to exercise environments.2

,.3 These guidelines can helpto prevent dangerous elevations in body temperature during exercise and miti­gate the deleterious effects of dehydration.

In a hot environment, body core temperature is affected by air temperature,humidity, air movement (i.e., wind speed), and solar radiation from the sun. Thewet-bulb globe temperature (WBGT) integrates the effects of all these factorsinto a single value, with the goals of quantifying heat stress and preventing heatillness. The WBGT index combines dry-bulb air temperature (Tb); natural wet­bulb temperature (Twb), which is measured by placing a wet wick over a ther­mometer bulb eX}Josed to natural air movement; and globe temperature (Tg), thetemperature measured inside a 15-cm diameter copper globe painted flat black.The WBGT is determined vvith specialized instruments that are commerciallyavailable.

Outdoors, WBGT is calculated as follows:

WBGT = 0.7 Twb + 0.2 T9 + 01 Tb

Indoors, WBGT is calculated using this formula:

WBGT = 0.7 Twb + 0.3 T9

Heat and Humidity

HEAT ACCLIMATIZATION

TABLE E-1. Guidelines for Safe Exercise Duration: Rest Periods forHealthy Unacclimatized Persons*

303APPENDIX E 1 ENVIRONMENTAL CONSIDERATIONS

DEHYDRATION

INCREASED RISK OF HEAT ILLNESS

Maintaining proper hydration is a key to preventing heat illness and optimizingperformance. Profuse sweating can lead to serious dehydration unless adequatefluid is consumed. Even mild dehydration i:npairs temperature regulation andcompromises performance during exercise:' The scientific literature indicatesthat endurance performance begins to decline at approximately 3% body weightloss and strength/power performance begins to decline at about 5% body weightloss.7 Exercise program organizers and leaders should ensure that replacementfluids are available and easily accessible. Program participants should be remind­ed to drink before, during, and after physical activity.5 However, athletes whoexercise for more than 3 hours continuously ought to realize that drinking toomuch flUId can lead to a serious medical condition known as hyponatremia,because of an excessive dilution of body fluids. Their goal ought to be to optimi;:,e,not maximi;:,e, fluid consumption.

In most people, especially those older than 60 years, drinking alleviates thirstsensations well before sufficient fluid is consumed to replace sweat losses.Generalized drinking r~commendations are difficult to make. However, a simplesuggestIOn mvolves dnnkmg two cups of fluid 2 hours before exercise, anddrinking during exercise at a rate that matches sweat lossess Active individualscan weigh themselves before and after each exercise session to determine theamount of water that must be replaced, at a rate of 16 oz of fluid for each poundof weight lost.

. Fluids should be chilled (59°F-72°F) and palatable to encourage consump­tIon. For the vast majority of workout sessions, water is the replacement drinkof choice. Unless the exercise bout lasts more than 50 to 60 minutes, there islittle advantage in supplementing carbohydrates6 Electrolyte losses (e.g., sodi­um, potassium, calcium) usually are small during brief exercise sessions (20- to40-minute duration) and persons consuming a normal diet easily replenish elec­trolytes when their next meal is eaten. Those who eat a low-salt diet should visittheir physician to discuss the effects of exercise on their salt balance.

Disease and the effects of some drugs may increase the 11sk of heat illness. Forexample, hypertension, cardiovascular disease, diabetes-associated neuropathies,and ~gmg may impair cardiovas:ular, skin blood flow, or sweating responses andImpair temperature regulation. I Drug therapies for these and other disorders(e.g., diuretics, f3-blockers, a-agonists, vasodilators) as well as licit recreation'~1d ~ . ,

rugs (e.g., alcohol), can alter blood flow and cardiovascular responses to heatstress, exacerbate dehydration, and interfere with the body's ability to dissipateheat. A prior history of heat illness or difficulty acclimatizing to heat also mayfc;;e~ast future problems. Ob~sity also impairs h~at dissipation, exacerbatingP ySlOloglC strain dunng exerCIse-heat stress, andmcreases the risk of heat iIl­ness

8Clinicians and exercise profeSSionals should consider these limitations

when recommending exercise programs for hot weather.FItness facilities and organizations that offer exercise programs must fonnu­

late a standardIzed heat stress management plan for hot or humid weather. A

Vigorous Exercise

Work/Rest Periods(min·h-')

45/1530/3020/4010/50No work should be performedNo work should be performed

Work/Rest Periods(min·h-')

Moderate Exercise

No limitation40/2030/3020/4010/50No work should be performed

SECTION IV 1APPENDICES302

70.0-72.973.0-76.9770-79980.0-81.9820-83984.0-86.0

Other strategies to alleviate heat stress include:

• \Vear clothing that allows heat loss and sweat evaporation.• Reschedule exercise for a cooler time of day.• Relocate exercise to a shady, breezy site or indoors with fans and air

conditioning.• Reduce exercise intensity and add rest breaks to maintain the same target

heart rate as normally prescribed.

'See reference 2: Adapted from National Institute for Occupational Safety and Health. Cnteria for a recommended

standard. Occupational exposure to hot environments. 1986. DHHS NIOSH Pub!. No. 86-113.

Notes: Times indicate recommended maximum duratIon of Intermittent exercise, followed by a rest period for cool­Ing. before beginning another exercise bout. Resl means minimal physical activity (slt1lng or standing) in a shaded

area If possible.

This process involves a series of physiologic adaptations that decrease the risk ofheat illness and improve exercise performance in the heat. Following heatacclimatization, the heart rate, body temperature, rating of perceived exertion,and physiologic strain decrease for a given exercise intensity. Also, sweating rateincreases and the sweat salt (i.e., sodium and chloride) concentration decreases.Thus, a person's water requirement increases but the salt requirement decreases.The best method of inducing heat acclimatization is to exercise in the heat, pro­gressively increasing the duration and/or intensity of exercise for 10 to 14 days.

Individuals whose exercise prescription specifies a target heart rate (THR)should maintain the same exercise heart rate in the heat. This approach reducesthe risk of heat illness while allO\ving acclimatization to develop. For example, inhot or humid weather, a reduced speed or resistance achieves the THR, eventhough the work of the heart (myocardial oxygen uptake) remains unchanged. Asacclimatization occurs, progressively higher exercise intensity is tolerated andrequired to elicit the THR. The first exercise session in the heat may last as littleas 10 to 15 minutes for safety reasons, but exercise duration can be increasedgradually to its usual length. Most healthy people become fully acclimatized tothe heat in 10 to 14 days, although illness or alcoholldrug abuse may slow thisprocess.

Cold, Wind, and Rain

305APPENDIX E / ENVIRONMENTAL CONSIDERATIONS

Body heat production during moderate or strenuous exercise is sufficientlyhigh to prevent hypothermia in air temperatures as low as -25°F. Once exercisestops and metabolic heat production declines, either wet clothing must bereplaced or the indi\idual must return indoors to maintain core body tempera­ture. The insulation value of wet clothing is compromised, and wetting of the skinfacilitates heat loss. During water immersion, conductive and convective heattransfer can be 70-fOld greater than in air of the same temperature,4 dependingon the water depth and amount of body surface immersed. Thus, even whenwater temperatures are relatively mild (e.g., 75°F-80°F), long-distance swim­mers, triathletes, and fishermen or hunters who wade in streams can lose consid­erable amounts of body heat and become hypothermic. Those who exercise inwindproof clothing are at less risk of frostbite than the \\ind chill tables suggest.Indeed, proper clothing can reduce the risk of frostbite markedly. Active indi­\iduals should avoid restrictivc garments because tight clothing restricts bloodflow to the skin, which in turn increases the risk of frostbite.

Both fatigue and hypothermia negatively affect human performance in thefollo\\ing ways. 12 First, prolonged exercise leads to substrate (i.e., muscle glyco­gen) depletion that compromises further exercise and reduces the rate of heatproduction. Second, fatigue that does not deplete muscle glycogen still mayimpair constriction of skin blood vessels, allowing increased heat loss. Third,chronic fatigue that lasts many weeks may delay the onset of shiveIing at rest,until body temperature falls into a hypothermic state. FOUlth, when chronicunderfeeding results in significant loss of subcutaneous adipose tissue, body insu­lation may be compromised and the risk of hypothermia may increase. 12

Health and fitness professionals also should consider the possible conse­quences of inhaling cold air during exercise. Fortunately, these effects are usuallynegligible. Upper airway temperatures, which remain unchanged during exerciseunder temperate conditions, fall substantially when extremely cold air(1°F-25°F) is breathed during strenuous exercise. In contrast, the temperatureof the lower respiratory tract and the body's core are unaffected13 Pulmonaryfunction during exercise is unaffected by breathing cold air, in healthy athletes l4

and nonathletes. J5 In allergy-prone athletes, breathing cold air during heavyexercise may cause bronchospasm. Interestingly, this bronchospasm is triggeredby facial cooling rather than cooling of respiratory passages. 16 Chronic inhalationof cold air also can increase respiratOly passage secretions and decrease mucocil­iary clearance; the resulting airway congestion may impair pulmonmy mechanicsduring exercise. 17

Older adults and persons who have cardiovascular and circulatolY disordersmay need to use greater caution. Cold e>q)osure, even when mild, stimulates thesympathetic nervous system and elevates total peripheral resistance, arterial pres­sure, rnyocardial contractility, and cardiac work at rest and during exercise. 1b Thislikely explains why patients with coromuy arteJy disease experience angina pec­toris and ST-segment depression at low exercise intensities in cold weather18

Particular caution should be ad\ised for chopping wood and snow shoveling,l9,20which require significant npper body use, because these tasks exacerbate bloodpressure responses greatly.18 Fatalities resulting from coronmy artely diseaseincrease in winter, but the extent that this reflects the effects of cold exposure onuntrained older adults remains unclear1 &

SECTION IV / APPENDICES

TABLE E-2, The Wind Chillindex*

Wind Speed Air Temperature (OF)

(mph) 40 30 20 10 0 -10 -20 -30 40

0 40 30 20 10 0 -10

10 34 21 9 -4 -16 -28

20 30 17 4 -9 -22 -35

30 28 15 1 -12 -26 -39

40 27 13 -1 -15 -29 -43

50 26 12 -3 -17 -31 -45

60 25 10 -4 -19 -33 -48

"'See reference 11 From National Oceanic and Atmosphenc Administration, 2003. Revised Wind chili chart.

Color key:o = Little risk of frostbite

= FrostbIte occurs Within 30 minutes= Frostbite occurs Within 10 minutes= FrostbIte occurs WithIn 5 minutes

Although many people avoid cold e>q)OSllre by exercising indoors during winter,those who choose to exercise outdoors usually are not at great risk becallSe exerciseaenerates heat. Health and fitness profeSSionals are often asked, "Is it too cold to~xercise?" Indeed, two cold illnesses are caused hv excessive boclv heat loss dUlingprolonged e>q10sure to cold, hypothermia (core body temperature below 95°F[normal is 98.6°F]) and frostbite (freezing of skin and body tissues). Both cold airand \\ind favor body heat loss4 The \\ind chill index (WCI), which purports tointegrate the potenti'al stress <uising from both factors, has achieved popular accept­ance9 and is presented in Table E-2. The reader should note that the color of eachrectangle tells you the amount of time required for frostbite to occurin exposedskin (i.e., unshaded, little lisk; light gray, 30 minutes; dark pmk, 10 mmutes; red,5 minutes). Thus, if weather conditions are \'el;' se\'ere, frostbite may occur in 5minutes or less. Although the \VCI provides useful guidance concerning the con­dnct or cancellation of outdoor activities, it has inhcrent limitations. 10 For example,\\ind chill tables provide no meaningful estimate of the risk of hypothermia. Also,the \VCI estimates the lisk of tissue freezing for sedentary persons only.

comprehensive heat stress management plan should establish procedures for the

following:

• Screening and surveillance of at-risk participants• Environmental assessment using the \\'BGT index• WBGT criteria for modifying or canceling cxercise• Heat accli matization of participants• Prmidina easv acccss to fluids• Increasil~g <I\~'areness of the signs and symptoms of heatstroke, hcat exhaus-

tion, heat cramps, and heat syncope• Integrating heat illness into emergency procedures

304

307

Symptoms

APPENDIX E / ENVIRONMENTAL CONSIDERATIONS

Severe headache, fatigue, irritability, nausealoss of appetite, indigestion, flatulence '

High-altitude pulmonary edema (HAPE) constipation, vomiting, sleep disturban~eVery rapid breathing and heart rate

breathlessness, cough producing 'pinkfrothy sputum, blue-colored skin becauseof low blood oxygen content

Staggering gait, loss of upper body coordi­nation, severe weakness, ashen skincolor: confusion, drowsiness, mentalImpairment, loss of consciousness, coma

High-altitude cerebral edema (HAC E)

Acute mountain sickness (AMS)

TABLE E-3. Three High-Altitude Illnesses

Condition

pulmonaJy edema, increase thc likelihood that the ill 1 . 'J]] 1to a lower altitude constitutes the d fT' tess \V1 Ceve op. Descent

The ~ J] .. ' e 1111 Ive tleatl11ent for these three illnesseso OWlJ1g SIX recommcndations22 r d 1 . . .

altitude illnesses: e uce t 1e Ilsk of expeliencing high-

See reference 24: From Hackett PH. Roach RC.St. LOUIS: Mosby, 1995:1-37. High-altitude medicine. In: Auerbach PS. ed. Wilderness Medicine.

• Ascend slowly• Conduct a climb in stages. If mo\'ina to 10 000 C .' ..

of ascent to 1 000 C t db' leet 01 higher, bmlt your rate, ,lee per ay.

• Climb with an experienced g:lide or team.• Avoid dehydration over ' t' dl 1• <. • • ,eXCI lOn, an 1ypot 1ennia.• Kit a high-carbohydrate diet to reduce the symptoms of AMS.

Ask )<1 phySICian to prescribc medications (e.g., acetazolamide dexametha-sone as a preventIve measure. '

d. IHigh-altitude exposure increases cardiac output cardiac work and1a oxygen recJu' - t ] " , myocar-· I . ~ nemen s, anc necessitates an increase in coron'uy blood 11

Ie atlve to sea level exercise IH Th _. . ' owischemic ST-' . . . ese tesponses can mduce angina ancIJorH . segment depl ess\on, at lower exercise intensities than at se' 1 1 \8

ypeltenslve patIents mav eJl.'pelience a dis ro or'. .. a eve.sU,r~ at high altitude, durit;g both rest and e~erEset:~;~I~t~I:~~~~~~: ~l~.od.PI/~S~sea eveJ resIdents ascend to high altitude use of the S'lme THR" . a

Yt s ,I tel

sea level e' ... J" \. C ' , as pI escll Jcd forxel clse I mlts carc lac stnin bec'lUse it . .cise intensitv H .' J I '] , neceSSttates a reduction in exer-

,). owevel, \V1t 1 t 1e ce\'eJop 1 t f· l' d . .longer tban a 3-d'l visi . . 11en 0 a t1tU e acclimatization (e.g.,effect of aJtitl d ,y ,. t to hIgh altItude), tachycardia abates conSiderably. This

I e acc llnatlzatlOn may req '. , d l'prescIibed TI-IR r _ . .. . uue a ownwarc adjustment in the101 some mdl\1duals.

I. Armstrong LE, Epst~in Y, Gr~enleaf JE et al Am>·'·· '. .Heat and eold illnesses d' I', . .' (1lCan Colleg(> of Sports ~ledieine positioll sland.2. C"t ,', f . . tlnng CJstance runnlllg. ~Ied Sci Sports Exerc 1996·:).")·" .

~n ellcl 01 a recommended standard. 0('<:11 ) .. f . I . _:>. . '- .1~X.Publ. No, 86-113. Washin Ion D '. '.' [1101'." e·'1)oslll( to hot ell\·lronments. ])1/1/5 ;\10511

g , C. 1':,ltlOnal In511111te for Oecup"lional Safety and Ilealth, 1986.

REFERENCES

HIGH ALTITUDE ILLNESSES

In mountainous areas, the wind, snow, and rain fre(luently contribute to coldstress, whereas strenuous activity, heavy clothing, and increased solar radiationcan contribute to heat stress. However, hypoxia (i.e., low oxygen content ofinspired air) is the unique physiologic stressor encountered at high altitudes.Because the fractional concentration of m,"ygen in the atmosphere (F 1

02) remainsconstant at 0.2093, the decreasing barometric pressure with increasing altitudc isassociated with a decreasing pressure of oxygen in the inspired air (P\02). Evenin pressurized cabins, commercial airline passengers are exposed to barometric

pressures that arc equivalent to altitudes of 5,000 to 8,000 fcet.\Vhen low-altitude residents ascend to high altitude, they notice an increased

pulmonary ventilation, particularly during exercise2

\ This accounts for thecommon sensation of breathlessness at high altitude. Although highly variablebetween individuals, this response becomes more pronounced after several daysof residence at high altitude. Despitc increased ventilation, arterial oxygenation(i.e., P,,02, and S,,02) usually falls when low-altitude residents ascend to 5,000feet above sea level or higher. 21 The resulting dccrease in blood oxygen contentnecessitates an increased cardiac ontpnt, which is achieved by tachycardia.Furthermore, \/02""" is lower at higb altitude than at sea level. Thus, theincreased cardiovascular strain of exercise, combined with the reduced \T02m'L'at higb altitude, compromise work capacity and endurance. These impairmentsusually become noticeable at an elevation of about 5,000 feet (or lower for somevery fit athletes) and worsen with increasing elevation. After 5 to 10 days ofacclimatization at higb altitude, cardiovascular adjustments lessen the physio­logic strain of exercise, enabling some improvement in endurance and workcapacity. This adaptation is not equivalent to full recovery to sea level perform-

ance, however.Air temperature decreases lOF per elevation increase of 300 feet and body

water losses may be misjudged by climbers because tbe air temperature is coolon bigh peaks. Further, the possibility of acute dehydration increases because ofinadequate drinking, increased urine production and increased water loss duringbreathing. A chronic body weigbt loss of 1 to 3 pounds per week is common atextreme altitude and results from factors such as loss of appetite and increasedenergy expenditure.22 These facts empbasize the importance of wholesome nutri-

tion in maintaining \igor and performance.

When unacclimatized persons ascend rapidly to ele\'alions abo\'e 8,000 feet,many experience high-altitude illnesses (Table £-3) and reduced exercise capac­ity2:1 The most common of thesc is acute mountain sickness (AMS), whichis characterized by severe headache, nausea, gastrointestinal disturbances, andinsomnia. In susceptible people these symptoms arise after 6 to 12 hours ataltitude and usually abate after 3 to 7 days of residence. Less common, but muchmore serious and even life threatening, are high-altitude pulmonary edema(HAPE) and high-altitude cerebral edema (UACE). Exercise at altitude usuallyexacerbates the symptoms of tbese illnesses and may, at least in the case of

High-Altitude Exposure

306 SECTION IV / APPENDICES

wI' "ton DC- Department of thePI'e\'eI1tl'on, treatment and control of heat injury. as 11l1M ' .

3. TB Med 507.

Arn1\'. 1980. d I I' . applications to sports physiology. Med4. Gon~lez RR. Biophysics of heat exchange an cot ung.

Exerc NutI' Health 1995;4:290-30.5. , I .',. College of Sports Medicine positionLE Coyle EF et a. Amellc"n

5 Com'ertino \'A, Armstrong < " '. E' " 1996·98·i-vii. . d 11 'd' I·· ent Med SCI SPOltS xelc ,-' . .

stand. ExerCise an U1 lep acem ., I t I . g exercise 'lI1d recoyelV from exerCIse. In:I C\l d Fluid rep acemen cunn,.' ,.

6. Armstrong LE, ~Iares 1 .', e s. E' .' . d SpOlt. Boca Raton, FL: CRC Press,Buskirk ER, Puhl SM, eds. Body Fluid Balance: XelClse an

1996:259-282. . . d d 'n" exercise in healthy older adults. Exerc Sport Sci7. Kennev \VL. ThermoregulatIOn at rest d.B un 0

Rev 1\;97;25:41-76 fl,e.,t disorders. Mil Med 1996;161:739-742.. CH Ob 'ty 'lnd the occurrence 0 , P' .8. Chung NK, PII1 . eSI , I' I' g in subfreezing temperatures. 10C

9. Siple PA, Passel CR. Measur:~"entsof dry atmosp lenc coo m

Am Philosoph Soc 1945;89:111-199. f'" freezing. J Appl PhysioI1996;81:2666--2673.10 Danilesson U. Wind dull and thensk 0 tIss

uet. 9003 Revised \vind chill chart.

. . I At sphenc Adnul1lstr" lOn, - . ld C11. National Oceal1lc anc 1110 .' d f:' . d thermoregulation in the co. omp

19_. Y AJ c-lStellani ]\\'. ExeltlOn-lI1duce ,'hgue an

oung , ' \ .' 19001'128'769-776.Biochem Physiol A Mol IntegI' P 'YSIO ~ C' ld ... ' \ .1. fon 'md esophageal temperature in exer-

D ·u EC J' Roberts DE, et al. 0 all 1111<1" I ,13. Jaeger jJ, e, I,.. xerc 1980;12:365-369. . .

cising humans. \Ied SCI SPOltS E . . I . db 'onchospasm at low temperature 10 ehte14. Helenius IJ, Tikkanen HO, Haahtela T. Exerctse-lIle uce I

runners. Thorax 1990;51:628-629. t.. . Orl1l'U subJ'ects following exercise at cold11 LJ R et TT Pulmonary unchon 10 n ,

15. Chal)man KR, A en . om . . \ 0 PI . '01 1990.60.998--232.E . J A I pi 'SIO ccup l)SI . ._-

ambient temperatures. UI pp 1) lb' . tl' g of cold air induces bronchocon-H F . I oling but not nasa Ie,1 un ,

16 Koskela H, Tukiainen . acm co . . E' I' .. J 1995·8·2088-2093.. I f d healthy subjects. UI ,espll . , . M 1stIiction' a studv in ast 1111a Ie an , ld' It Avi,:tt Sp'lce Environ l ec

17. Ciesbre~ht CG. The respiratory system in a co enVlfonmel. ( (

1995;66:890-902. . d d I \ I . Pollock ML, Schmidt DH, eds. Heart Disease and18. Pandolf KB, Young AJ. Alhtu e an co~: n: 1995'309-396

. CI . 'gn IL' Human Kmetlcs, . . - . I l' JAMARehabilitatIOn. lamp,u , '. T • 1 c- .d·. demands of heavy snow s lOve mg.

19. Franklin HA, Hogan P, BOl1zhell1l K, et a. at lac

1995;273:880--882. .1 I g' '1 trigger [or acute myocardial infarc-I · K Gordon S et al. Snow 5 'love m .,

20. Franklin BA, Bonz lem1 , ' -- 85"-858d

d . th Am J Cardiol 1996; 1t: .') . . T S ktion and sud en coronmy e,l. '.'_.' hi h terrestrial altitude. In: Pandolf KB, aw a

21. Young AJ, Young PM. Human acdlln,ltIzatlOn to ~ .' I gy 'lI1d Environmental Medicine atMN Gonzalez RH, eds. Human Perlonnance lYS~O 0 '

, I di I'" Benchmark 1988:491-543.Terrestrial Extremes. n anapO IS. ..' CI. 'li"n IL' Human Kinetics, 2000.

t· . . E trerne EnVIronments. 'l<lmp< M' . k MN22. Armstrong LE. Per ormmg 111 x I It. It'tude IIr Pandolf KB, Saw a I I ,

T H k PB Medical problems re atee 0 a I . . . I23. Malkonian M K, oc' .. I .. 1 ,. d Environmental Medicine at Terrestna

Gonzalez RR, eels. Human Performance P 1)'S10 og) "n

I· I' Benchmark 1988:.545-563. di' StExtremes. Inc lanapo IS: ' . . A.I ..1 PS eel Wilderness Me cme. .24. Hackett PH, Hoach HC. High-altitude mediCll1e. In: uel )<lC 1 , .

Louis: Mosby, 1995:1-37.

ACSM Certifications and The Public

This appendix details information about American College of Sports I\[euicine(ACSM) Certification and Registry Programs, as well as a complete listing ofthe currcnt knowleuge, skills, anu abilities (KSAs) that comprise the foundationsof these celtification anu registry examinations. The mission of the ACSI\[Committee on Certification and RegistlY Boarus is to develop and prOVide highquality, accessible and affordable credentials and continuing education pro­grams for health and exercise profeSSionals who are responsible for preventiveand rehabilitative programs that influence the health and wcll-bcing of allindividuals.

APPENDIX

F•••••

American College ofSports MedicineCertifications

The first of the ACSM clinical celtifkations was initiated nearly 30 years ago inconjunction with publication of the first edition of the Guidelines for ExerciseTesting and Prescription. That era was marked by rapid ue\'elopment of exerciseprograms for patients with stable coronalY cutely disease (CAD). ACSM soughta means to disseminate accurate information on this health care initiative throughexpression of consensus from its members in basic science, clinical practice, andeducation. Thus, these early clinical certifications were viewed as an aid to theestablishment of safe and scientifically based exercise services within the frame­work of cardiac rehabilitation.

Over the past 30 years, exercise has gained Widespread favor as an impOltantcomponent in programs of rehabilitative care or heaJth maintenance for anex-panding list of chronic diseases and disabling conditions. The growth of publicinterest in the role of exercise in health promotion has been equally impressivc.In addition, federal government poliCY makers have revisited questions of med­ical efficacy and financing for exercise selvices in rehabilitative care of selectedpatients. Over the past several years, recommendations from the U.S. PublicHeaJth Service and the U.S. Surgeon General have acknowledged the central rolefor regular phYSical activity in the prevention of disease anu promotion ofheaJth.

The development of the health/fitness certifications in the 1980s reflectedACSM's intent to increase the availability of qualified profeSSionals to providescientificaHy sound advice and supervision regarding appropliate physicaJ activi­ties for health maintenance in the apparently heaJthy adult population. Since1975, more than 30,000 celtificates have been awarded. \\'ith this consistent

SECTiON IV I APPENDICES308

309

ACSM Certification ProgramsThe ACSM certified Personal Trainer'" is a fitness professional involved indeveloping and implementing an individualized approach to exercise leader­ship in healthy populations andlor those individuals with medical clearance toexercise. Using a variety of teaching techniques, the Personal Trainer is profi­cient in leading and demonstrating safe and effective methods of exercise byapplying the fundamental principles of exercise science. The ACSM certifiedPersonal Trainer'" is familiar with forms of exercise used to improve, maintain,

growth, ACSM has taken steps to ensure that its competency-based celtificationswill continue to be regarded as the premier program in the exercise field. Forexample, since 2002 ACSM has provided guidelines to assist colleges and univer­sities with establishing standardized curricula that are focused on the knowledge,skills, and abilities (KSAs) requisite in the examinations for the ACSMHealthlFitness Instructor®, ACSM Exercise Specialist® and ACSM RegisteredClinical Exercise Physiologist@

Additionally, the ACSM University Connection Endorsement Program isdesigned to recognize institutions with educational programs that meet all of theKSAs specified by the ACSM Committee on Certification and Registry Boards(CCRB). Other examples include publishing a periodical addressing professionalpractice issues targeted to those who are celtified, ACSM's Certified News, andoversight of continuing education requirements for maintenance of celtifica­tion is another. Continuing education credits can be accrued through ACSM­sponsored educational programs such as ACSM workshops (Health/FitnessInstructor® and Exercise SpeciaIist®), regional chapter and annual meetings, andother educational programs approved by the ACSM Professional EducationCommittee. These enhancements are intended to SUppOlt the continued profes­sional growth of those who have made a commitment to service in this rapidlygrowing health and fitness field.

Recently, ACSM, as a founder member of the multi-organizationalCommittee on Accreditation for the Exercise Sciences (CoAES), assisted '""iththe development of Standards and Guidelines for educational programs seekingaccreditation under the auspices of the Commission on Accreditation of AlliedHealth Education Programs (CAAHEP). Additional information on outcomes­based, programmatic accreditation can be obtained by visiting www.caahep.org,and specific information regarding the standards and guidelines can be obtainedby visiting www.coaes.org. Because the standards and guidelines refer to theKSAs that follow, reference to specific KSAs as they relate to given sets of stan­dards and guidelines \vill be noted when appropriate.

ACSM also acknowledges the e'\''Pectation from successful candidates that thepublic \vill be informed of the high standards, values, and professionalism implic­it in meeting these celtification requirements. The College has formally organ­ized its volunteer committee structure and national office staff to give addedemphasis to informing the public, professionals, and government agencies aboutissues of critical importance to ACSM. Informing these constituencies about themeaning and value of ACSM certification is one important pliOlity that \vill begiven attention in this initiative.

311APPENDIX F I AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS

The celtification programs of ACSM are subject to continuous review and revi­sion. Content development is entrusted to a diverse committee of professionalvolunteers WIth expeltise in exercise science, medicine, and program manage­ment. E'\''Peltis.e in design and procedures for competency assessment is also rep­resented on tl1lS commIttee. Administration of celtification is the responsibility ofthe ACSM NatIOnal Center. Inquiries concerning celtifications, applicationreqUIrements, fees, and examination test sites and dates may be made to

ACSM Celtification Resource Center1-800-486-5643Website: www.lww.com/acsmcrcE-mail: certification@acsm.org

How to Obtain Information and Application Materials

andlor optimize health-related components of physical fitness and perform­ance. The ACSM certified Personal Trainer'" is proficient in writing appropri­ate exercise recommendations, leading and demonstrating safe and effectivemethods of exercise, and motivating individuals to begin and to continue withtheir healthy behaviors.

The ACSM Health/Fitness Instructor® (HFI) is a professional qualified toassess, design, and implement individual and group exercise and fitness pro­grams for low risk individuals and individuals \vith controlled disease. The HFIis skilled in evaluating health behaviors and risk factors, conducting fitnessassessments, writing appropriate exercise prescriptions, and motivating individ­uals to modIfy negative health habits and maintain positive lifestyle behaviors forhealth promotion.. The ACSM Exercise Specialist® (ES) is a is a healthcare professional certi­

fIed by ACSM to deliver a variety of exercise assessment, training, rehabilita­tion, risk factor identification and lifestyle management selvices to individuals\vith or at risk for cardiovascular, pulmonaJy, and metabolic disease(s). Theseselvices are typica,lIy delivered in cardiovascular/pulmonalY rehabilitation pro­grams, phySICIans offJces or medical fitness centers. The ACSM ExerciseSpecialist® is. also competent to provide exercise-related consulting forresearch, publIc health, and other clinical and non-clinical selvices and pro­grams.

The ACSM Registered Clinical Exercise Physiologist® (RCEP) is an alliedhealth professional who works with persons with chronic diseases and conditionsin w~1ich exercise has been shown to be beneficial. The RCEP performs health,ph~s~cal a:tl\!Jty, and fitness assessments, and prescribes exercise and physicalactI\!Jty ~nm~U1Jy in hospitals or other health provider settings.

. CeltlfICatlOn at a given level requires the candidate to have a knowledge andskills base commensurate with that specific level of certification. In addition, theHFI level of celtification incorporates the KSAs associated with the ACSM cer­tified Personal Trainer™ certification, and the ES level of certification incorpo­rates the KSAs associated \vith the HFI certification, as illustrated in Figure F-l.In addItIon, each level of ceItification has minimum requirements for experience,level of educatIon, or other celtifications.

SECTION IV I APPENDICES310

312 SECTION IV / APPENDICESAPPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 313

FIGURE F-1: continued

continues

Recommended Competencies

Demonstrate competence in theKSAs required of the ACSMRegistered Clinical ExercisePhysiologist® Exercise Specialist®and Health/Fitness Instructor® aslisted in the current edition ofACSM's Guidelines for ExerciseTesting and Prescription.

The RCEP is an allied healthprofessional who uses exerciseand physical activity to assess andtreat patients at risk of or withchronic diseases or conditionswhere exercise has been shown

*Demonstrate competence in theKSAs required of the ACSMExercise Specialist®,Health/Fitness Instructor®, as list­ed in the current edition ofACSM's Guidelines for ExerciseTesting and Prescription.

* Ability to demonstrate extensiveknowledge of functional anato­my, exercise physiology, patho­physiology, electrocardiography,human behavior/psychology,gerontology, graded exercisetesting for healthy and diseasedpopulations, exercise supervi­sion/leadership, patient counsel­ing, and emergency proceduresrelated to exercise testing andtraining situations.

* A Bachelor's Degree inan allied health fieldfrom a regionallyaccredited college ofuniversity (one is eligi­ble to sit for the examif the candidate is inthe last term of theirdegree program); AND

*Minimum of 600 hoursof practical experiencein a clinical exerciseprogram (e.g.cardiac/pulmonaryrehabilitation pro­grams, exercise testing,exercise prescription,electrocardiography,patient education andcounseling, diseasemanagement of car­diac, pulmonary, andmetabolic diseases, andemergency manage­ment); AND

*Current certification as aBasic Life SupportProvider or CPR for theProfessional Rescuer(available through theAmerican HeartAssociation or theAmerican Red Cross).

Requirements

* Master's Degree in exer­cise science, exercisephysiology or kinesiolo­gy from a regionallyaccredited college oruniversity

* Current certification asa Basic Life SupportProvider or CPR for theProfessional Rescuer(available through theAmerican HeartAssociation or theAmerican Red Cross).

Level

ACSM ExerciseSpecialist®

ACSM RegisteredClinical ExercisePhysiologist®

*Demonstrate competence inthe KSAs required of theACSM Health/FitnessInstructor® as listed in the cur­rent edition of the ACSM'sGuidelines for Exercise Testing

and Prescription*Work-related experience within

the health and fitness field* Adequate knowledge of, and

skill in, risk factor and healthstatus identification, fitnessappraisal, and exercise pre­scription

* Demonstrate ability to incorpo­rate suitable and innovativeactivities that will improve anindividual's functional capacity

*Demonstrate the ability toeffectively educate and/orcounsel individuals regardinglifestyle modification

*Knowledge of exercise scienceincluding kinesiology, func­tional anatomy, exercise physi­ology, nutrition, programadministration, psychology,and injury prevention

*Demonstrate competence inthe KSAs required of theACSM certified PersonalTrainer™ as listed in the cur­rent edition of the ACSM'sGuidelines for Exercise Testingand Prescription

*Adequate knowledge of andskill in risk factor and healthstatus identification, fitnessappraisal and exercise pre­

scription*Demonstrate ability to incorpo­

rate suitable and innovativeactivities that will improve anindividual's functional capacity

Demonstrate the ability to effec­tively educate and/or commu­nicate with individuals regard­ing lifestyle modification

Recommended Competencies

* An Associate's Degreeor a Bachelor's degreein a health-related fieldfrom a regionallyaccredited college/uni­versity (one is eligibleto sit for the exam ifthe candidate is in thelast term of theirdegree program), AND

* Possess current AdultCPR certification thathas a practical skillsexamination compo­nent (such as theAmerican HeartAssociation or theAmerican Red Cross).

* 18 years of age or older*high school diploma or

equivalent (GED)*Possess current Adult

CPR certification thathas a practical skillsexamination compo­nent (such as theAmerican HeartAssociation or theAmerican Red Cross).

Requirements

ACSM Health/FitnessInstructor@

ACSM certifiedPersonal Trainer'"

Level

FIGURE F-1:

314 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 315

FIGURE F-l: continued

Level Requirements Scope of Practice

tions arc based. Each may prove to be beneficial as a review of specific topicsand as a general outline of many of the integral concepts to be mastered by thoseseeking certification.

Knowledge. Skills, and Abilities (KSAsl Underlining ACSM Certifications

CLASSIFICATION/NUMBERING SYSTEM FOR KNOWLEDGE,SKILLS, AND ABILITIES (KSAS)

The system fill' classifYing and numhering KSAs has been changed. It is designedto be easier to use for cettification candidates, where all the KSAs for a given cer­tification/credential are listed in their entirety across a given Practice area aneVorContent f\latter area for each level of celtification. \\'ithin each certification's/credential's KSA set, the numbeJing of individual KSAs uses a three-pm1:number as follows:

First number-denotes Practice Area (1.x.x)Second number~denotesContent Area (x. Lx)Third number-denotes the sequential number of each KSA (x.x.I), \\~thin eachContent Area

The Practice Areas (the first number) are numhered as follows:1.x.x General Population/Core2.x.x Cardiovascular3.x.x Pulmonarv4.x.x Metabolic5.x.x Orthopedic/M useuloskeletal6.x.x Neuromuscular7.x.x Immunologic

The Content Matter Areas (the second number) are numbered as follows:x.1.x Exercise Physiology and related Exercise Sciencex.2.x Pathophysiology and Risk Factorsx.3.x Health Appraisal, Fitness and Clinical Exercise Testingx.4.x Electrocardiography and Diagnostic Techniquesx.5.x Patient Management and Medicationsx.6.x Medical and Surgical f\lanagementx.7.x Exercise Prescription and Programmingx.8.x Nutrition and Weight Managementx.9.x Human Behavior and Counselingx.lO.x Safety, Injury Prevention, and Emergency Proceduresx.ll.x Program Administration, Quality Assurance, and Outcome Assessmentx.12.x Clinical and Medical Considerations (ACSf\1 certified Personal

Trainer™ only)

EXAMPLES by Level of Certification/Credential:

ACSM celtified Personal Trainers~1 KSAs:

1.1.10 Knowledge to describe the normal acute responses to cardiovascularexercise.

In this example, the practice area is General Population/Core; the contentmatter area is Exercise Physiology and Related Exercise Science; and this KSAis the tenth KSA within this content matter area.

to provide therapeutic and/orfunctional benefit. Patients forwhom RCEP services are appropri­ate may include, but are not limit­ed to, persons with cardiovascu­lar, pulmonary, metabolic, cancer­ous, immunologic, inflammatory,orthopedic, musculoskeletal, neu­romuscular, gynecological, andobstetrical diseases and condi­tions. The RC EP provides scient if­ic, evidence-based primary andsecondary preventive and rehabili­tative exercise and physical activi­ty services to populations rangingfrom children to older adults. TheRCEP performs exercise screening,exercise testing, exercise prescrip­tion, exercise and physical activitycounseling, exercise supervision,exercise and health education/promotion, and evaluation ofexercise and physical activity out­come measures. The RCEP worksindividually and as part of aninterdisciplinary team in clinical,community, and public health set­tings. The practice and supervi­sion of the RC EP is guided bypublished professional guidelines,standards, and applicable stateand federal regulations. The prac­tice of clinical exercise physiologyis restricted to patients who arereferred by and are under thecare of a licensed physician.

*Minimum of 600 clinicalhours are required withhours in each of theclinical practice areas,which may be complet­ed as part of a formaldegree program inexercise physiology.

cardiovascular-200;pulmonary-l00 ,metabolic-120;orthopediclmusculoskeletal-l00; neuromuscu­lar-40; immunological/hematological-40;

These hours may beobtained with patientswith co-morbid condi­tions. For example,time spent workingwith a patient who hasCoronary Heart Diseaseand Parkinson'sDisease may be count­ed in two practiceareas IF you were pro­viding exercise evalua­tion or programmingspecific to each of theconditions.

Minimal competencies for each certification level are outlined below.Celtifieation examinations are constructed based upon these KSAs. Two com­panion ACSM publications, ACSM's Resource Manual for Guidelines forExercise Testing and Prescription, fifth edition, and ACSM's CertificationRez;ieu; Book, second edition, may also be used to gain further insight pertainingto the topics identified here. However, neither the Guidelines for ExerciseTesting and Prescription nor either of the ahove mentioned Resource Manualsprovides all of the information upon which the ACSM Celtiflcation exam ina-

ACSM HealthlFitness Instructor® KSAs:

1.3.8 Skill in accurately measuring heart rate, blood pressure, and obtainingrating ofperceived exertion (RPE) at rest and during exercise accordingto established guidelines.

In this example, the practice area is General Population/Core; the content mat­ter area is Health AppraisaL Fitness and Clinical Exercise Testing; and this KSAis the eighth KSA within this content matter area.

ACSM Exercise Specialist® KSAso:

1. 7.17 Design strength and flexibility programs for individuals with car­diovascular, pulmonary and/or metabolic diseases, elderly, andchildren.

In this example, the practice area is General Population/Core; the content mat­ter area is Exercise Prescliption and Programming; and this KSA is the seven­teenth KSA within this content matter area. Furthermore, because this specificKSA appears in bold, it covers multiple practice areas and content areas.

°A special note about ACSM Exercise Specialist® KSAs:

Like the other celufications presented thus far, the ACSM Exercise Specialist®KSAs are categOlized by content area. However, some ES KSAs cover multiplepractices areas within each area of content. For example, a number of themdescribe a specific topic with respect to both exercise testing and training, whichare two distinct content areas. Rather than wlite out each separately (whichwould have greatly expanded the KSA list length) they have been listed under aSingle content area. When reviewing these KSAs, please note that KSAs in boldtext cover multiple content areas. Each ES KSA begins 'vvith a '1' as the practicearea. However, where appropliate, some KSAs mention specific patient popu­lations (i.e., practice area). If a specific practice area is not mentioned within agiven KSA, then it applies equally to each of the general population, cardiovas­cular, pulmonary and metabolic practice areas. Note that "metabolic patients"are defined as those with at least one of the folloWing: overweight or obese,diabetes (type I or II), metabolic syndrome. Each KSA desclibes either a Singleor multiple knowledge (K), skill (S), or ability (A), or a combination of K, S orA, that an individual should have mastely of to be considered a competentACSM Exercise Specialist@ Finally, as stated previously, the ACSM ExerciseSpecialist® candidate is also responsible for the mastely of both the ACSMHealthlFitness Instmctor® and the ACSM celtified Personal Trainer™ KSAs.

ACSM Registered Clinical Exercise Physiologist KSAs:

7.6.1 "List the drug classifications commonly used in the treatment ofpatients with a National Institutes of Health (NIT-I) disease, name com­mon genelic and brand names drugs within each class, and explain thepurposes, indications, major side effects, and the effects, if any, on theexercising individual."

The practice area is Immunologic; the content matter area is Medical andSurgical Management; and this KSA is the second KSA \vithin this contentmatter area.

ACSM certified Personal TrainerSM Knowledge, Skills, and Abilities (KSAs):

317

EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

Knowledge of the basic structures of bone, skeletal muscle, and connectivetissues.Knowledge of the basic anatomy of the cardiovascular system andrespiratory system.Knowledge of the definition of the following terms: inferior, superior, medial,lateral, supination, pronation, flexion, extension, adduction, abduction, hyper­extension, rotation, circumduction, agonist antagonist, and stabilizer.Knowledge of the plane in which each muscle action occurs.Knowledge of the interrelationships among center of gravity, base ofsupport, balance, stability, and proper spinal alignment.Knowledge of the following curvatures of the spine: lordosis, scoliosis, andkyphosis.Knowledge to describe the myotatic stretch reflex.Knowledge of the biomechanical principles for the performance of thefollowing activities: walking, jogging, running, swimming, cycling, weightlifting, and carrying or moving objectsAbility to define aerobic and anaerobic metabolism.Knowledge to describe the normal acute responses to cardiovascular exercise.Knowledge to describe the normal acute responses to resistance training.Knowledge of the normal chronic physiological adaptations associated withcardiovascular exercise.Knowledge of the normal chronic physiological adaptations associated withresistance training.Knowledge of the physiological principles related to warm-up and cool­down.Knowledge of the common theories of muscle fatigue and delayed onsetmuscle soreness (DOMS).Knowledge of the physiological adaptations that occur at rest and duringsubmaximal and maximal exercise following chronic aerobic and anaerobicexercise training.Knowledge of the physiological principles involved in promoting gains inmuscular strength and endurance.Knowledge of blood pressure responses associated with acute exercise,including changes in body position.Knowledge of how the principle of specificity relates to the components offitness.Knowledge of the concept of detraining or reversibility of conditioning andits implications in fitness programs.Knowledge of the physical and psychological signs of overtraining and toprovide recommendations for these problems.Knowledge of the following terms: progressive resistance, isotonic/isometric,concentric, eccentric, atrophy, hypertrophy, sets, repetitions, plyometrics,Valsalva maneuver.Ability to identify the major bones and muscles. Major muscles include, butare not limited to, the following: trapezius, pectoralis major, latissimus dorsi,biceps, triceps, rectus abdominis, internal and external obliques, erectorspinae, gluteus maximus, quadriceps, hamstrings, adductors, abductors, andgastrocnemius.

APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS

11.41.1.5

1.1.1

1.1.2

1.1.3

1.1.6

1.1.71.1.8

1.113

1.1.911.101.1111.1.12

1.1.14

1.1.15

1.1.18

1.1.17

11.16

1.1.19

1.1.21

1.1.20

1.122

1.1.23

SECTION IV / APPENDICES316

319

Knowledge of selecting appropriate testing and training modalities accordingto the age and functional capaCity of the individual.Knowledgeof the recommended intensity, duration, frequency, and type ofphySical activity necessary for development of cardiorespiratory fitness in anapparently healthy population.Knowledge. to describe, and the ability to demonstrate (such as techniqueand breathing), exercises designed to enhance muscular strength and/orendurance of specific major muscle groups.Knowledge of the principles of overload, specificity, and progression andhow they relate to exercise programming.Knowledge of the components incorporated into an exercise session and theproper sequence (i.e., preexercise evaluation, warm-up, aerobic stimulusphase, cool-down, musculilr strength and/or endurance, and flexibility).Knowledge of special precautions and modifications of exercise program­ming for participation at altitude, different ambient temperatures, humidity,and enVIronmental pollution.Knowledge of the importance and ability to record exercise sessions andperforming periodic evaluations to assess changes in fitness status.Knowledge of the advantages and disadvantages of implementation ofInterval, continuous, and circuit training programs.Knowledge of the concept of "Activities of Daily Living" (ADLs) and itsImportance In the overall health of the individual.Knowledge of Progressive Adaptation in resistance training and it's implica­tions on program deSign and periodizationUnderstanding of personal training client's "personal space" and how itplays Into a trainer's interaction with their client.Skill to teach and demonstrate the components of an exercise session (i.e.,warm-up, aerobiC stimulus phase, cool-down, muscular strength/enduranceflexibility). 'Skill to teach and demonstrate appropriate modifications in specific exercisesfor the following groups: older adults, pregnant and postnatal women,obese persons, and persons with low back pain.Skill to teach and demonstrate appropriate exercises for improving range ofmotion of all major joints.Skill in the use of various methods for establishing and monitoring levels ofexerCise Intensity, Including heart rate, RPE, and METs.Knowledge of and ability to apply methods used to monitor exercise intensi­ty, including heart rate and rating of perceived exertion.Ability to describe modifications in exercise prescriptions for individuals withfunctional disabilities and musculoskeletal injuriesAbility to differentiate between the amount of physical activity required forhealth benefits and the amount of exercise required for fitness development.Ability to determine training heart rates using two methods: percent of age­predicted maximum heart rate and heart rate reserve (Karvonen).Ability to Identify proper and improper technique in the use of resistiveequipment such as stability balls, weights, bands, resistance bars and waterexercise equipment. 'Ability to identify proper and improper technique in the use of cardiovascularconditioning equipment (e.g., stairclimbers, stationary cycles, treadmills, ellip­tical trainers).Ability to teach a progression of exercises for all major muscle groups toImprove muscular strength and endurance.

APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS

1.7.11

1.7.8

1.7.9

1.7.7

1.7.17

1.7.16

1.7.10

1.7.12

1.7.14

1.7.22

1.7.18

1.7.15

1.7.21

1.7.13

1.7.19

1.728

1.7.24

1.7.27

1.7.25

1.7.20

1.7.26

1.7.23

Knowledge of the benefits and risks associated with exercise training in pre­

pubescent and postpubescent youth.Knowledge of the benefits and precautions associated with resistance and

endurance training in older adults.Knowledge of specific leadership techniques appropriate for working with

participants of all ages.Knowledge of how to modify cardiovascular and resistance exercises based

on age and physical condition.Knowledge of and ability to describe the unique adaptations to exercisetraining with regard to strength, functional capacity, and motor skills.Knowledge of common orthopedic and cardiovascular considerations forolder participants and the ability to describe modifications in exercise pre­

scription that are indicated.

Knowledge of and ability to discuss the physiological basis of the majorcomponents of physical fitness: flexibility, cardiovascular fitness, muscular

strength, muscular endurance, and body composition.Knowledge of the importance of a health/medical history.Knowledge of the value of a medical clearance prior to exercise participation.

Knowledge of the categories of participants who should receive medicalclearance prior to administration of an exercise test or participation in an

exercise program.Knowledge of relative and absolute contraindications to exercise testing or

participation.Knowledge of the limitations of informed consent and medical clearance

prior to exercise testing.Knowledge of the advantages/disadvantages and limitations of the variousbody composition techniques including, but not limited to: air displacement,plethysmography, hydrostatic weighing, Bod Pod, bioelectrical impedence.Skill in accurately measuring heart rate, and obtaining rating of perceivedexertion (RPE) at rest and during exercise according to established guidelines.Ability to locate common sites for measurement of skinfold thicknesses andcircumferences (for determination of body composition and waist-hip ratio).Ability to obtain a basic health history and risk appraisal and to stratify risk

in accordance with ACSM Guidelines.Ability to explain and obtain informed consent.Ability to instruct participants in the use of equipment and test proceduresKnowledge of the purpose and implementation of pre-activity fitness testing,

including assessments of cardiovascular fitness, muscular strength, muscular

endurance, and flexibility, and body composition.Ability to identify appropriate criteria for terminating a fitness evaluation anddemonstrate proper procedures to be followed after discontinuing such a test.

EXERCISE PRESCRIPTION AND PROGRAMMING

SECTION IV / APPENDICES

Ability to identify the major bones. Major bones include, but are not limitedto the clavicle, scapula, strernum, humerus, carpals, ulna, radius, femur,

fibia, tibia, and tarsalsAbility to identify the joints of the body.Knowledge of the primary action and joint range of motion for each major

muscle group.Ability to locate the anatomic landmarks for palpation of peripheral pulses.

HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

1.3.14

1.7.4

1.7.3

1.3.111.3.121313

1.3.10

1.7.1

1.3.9

1.7.2

1.7.5

1.7.6

1.3.8

1.3.7

1.3.6

1.3.5

1.3.21.3.31.3.4

1.31

1.1.27

1.1251.126

1.124

318

APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS320

1.7.291.730

1.7.31

1.7.32

1.7.33

1.7.34

1.7.35

1.7.36

1.8.1

1.8.2

1.8.31.84

1.8.5

1.8.6

1.8.71.8.81.8.9

1.8.10

1.8.11

1.8.12

1.8.13

1.8.14

1.9.1

1.9.2

SECTION IV / APPENDICES

Ability to modify exercises based on age and physical condition.Ability to explain and implement exercise prescription guidelines for appar­ently healthy clients or those who have medical clearance to exerciseAbility to adapt frequency, intensity, duration, mode, progression, level ofsupervision, and monitoring techniques in exercise programs for apparently

healthy clients or those who have medical clearance to exerCise .Ability to design resistive exercise programs to increase or maintain muscular

strength and/or endurance. .Ability to periodize a resistance training program for continued muscular

strength development . . ..Ability to evaluate, prescribe, and demonstrate appropriate fleXibility

exercises for all major muscle groups.Ability to design training programs using interval, continuous, and circuit

training programs. ..Ability to describe the advantages and disadvantages of various commerCialexercise equipment in developing cardiorespiratory fitness, muscular

strength, and muscular endurance.

NUTRITION AND WEIGHT MANAGEMENT

Knowledge of the role of carbohydrates, fats, and proteins as fuels for aero­

bic and anaerobic metabolism.Knowledge to define the following terms: obesity, overweight, percent fat,Body Mass Index, lean body mass, anorexia nervosa, bulimia nervosa, and

body fat distributionKnowledge of the relationship between body composition and health.Knowledge of the effects of diet plus exercise, diet alone, and exerCise alone

as methods for modifying body composition.Knowledge of the importance of an adequate daily energy intake for healthy

weight management. .Knowledge of the importance of maintaining normal hydratIOn before, dur-

ing, and after exercise.Knowledge of the USDA Food Pyramid.Knowledge of the female athlete triad .Knowledge of the myths and consequences associated with inappropriateweight loss methods (e.g, saunas, vibrating belts, body wraps, electriC simu­

lators, sweat suits, fad diets).Knowledge of the number of kilocalories in one gram of carbohydrate, fat,

protein, and alcohol.Knowledge of the number of kilocalories equivalent to losing 1 pound of

body fat. ..Knowledge of the guidelines for caloric intake for an individual deSIring to

lose or gain weight. .Knowledge of common nutritional ergogenic aids, the purported mechanismof action, and any risk and/or benefits (e.g., carbohydrates, protein/aminoacids, vitamins, minerals, sodium bicarbonate, creatine, bee pollen, etc.)Ability to describe the health implications of variation in body fat distribution

patterns and the significance of the waist to hip ratio.

HUMAN BEHAVIOR AND COUNSELING

Knowledge of at least five behavioral strategies to enhance exercise andhealth behavior change (e.g., reinforcement, goal setting, social support).

Knowledge of the stages of motivational readiness.

1.9.31.94

1.9.5

1.9.6

1.1 0.1

1.10.2

1.1 0.3

1.1 0.4

1.10.5

1.10.6

1.10.7

1.10.8

1.10.9

1.10.10

1.10.11

1.10.12

1.10.13

1.10.14

1.10.15

1.10.16

321

Knowledge of the 3 stages of learning: Cognitive, Associative, AutonomousKnowledge of specific techniques to enhance motivation (e.g., posters,recognition, bulletin boards, games, competitions). Define extrinsic andintrinsic reinforcement and give examples of each.Knowledge of the different types of learners (Auditory, Visual, Kinesthetic)and how to apply teaching and training techniques to optimize a client'straining sessionKnowledge of the types of feedback and ability to use communication skillsto optimize a client's training session.

SAFETY, INJURY PREVENTION, AND EMERGENCY PROCEDURES

Knowledge of and skill in obtaining basic life support and cardiopulmonaryresuscitation certification.Knowledge of appropriate emergency procedures (i.e., telephone proce­dures, written emergency procedures, personnel responsibilities) in a healthand fitness setting.Knowledge of basic first aid procedures for exercise-related injuries, such asbleeding, strains/sprains, fractures, and exercise intolerance (dizziness, syn­cope, heat injury).Knowledge of basic precautions taken in an exercise setting to ensure partic­ipant safety.Knowledge of the physical and physiological signs and symptoms of over­training.Knowledge of the effects of temperature, humidity, altitude, and pollutionon the physiological response to exercise.Knowledge of the following terms: shin splints, sprain, strain, tennis elbow,bursitis, stress fracture, tendonitis, patello-femoral pain syndrome, low backpain, plantar fasciitis, and rotator cuff tendonitis.Knowledge of hypothetical concerns and potential risks that may be associ­ated with the use of exercises such as straight leg sit-ups, double leg raises,full squats, hurdlers stretch, yoga plough, forceful back hyperextension, andstanding bent-over toe touch.Knowledge of safety plans, emergency procedures, and first aid techniquesneeded during fitness evaluations, exercise testing, and exercise training.Knowledge of the cPT's responsibilities, limitations, and the legal implicationsof carrying out emergency procedures.Knowledge of potential musculoskeletal injuries (e.g., contusions, sprains,strains, fractures), cardiovascular/pulmonary complications (e.g., tachycardia,bradycardia, hypotension/hypertension, tachypnea) and metabolic abnormali­ties (e.g., fainting/syncope, hypoglycemia/hyperglycemia, hypothermia/hyper­thermia).Knowledge of the initial management and first aid techniques associatedwith open wounds, musculoskeletal injuries, cardiovascular/pulmonary com­plications, and metabolic disorders.Knowledge of the components of an equipment maintenance/repair pro­gram and how it may be used to evaluate the condition of exercise equip­ment to reduce the potential risk of injury.Knowledge of the legal implications of documented safety procedures, theuse of incident documents, and ongoing safety training.Skill in demonstrating appropriate emergency procedures during exercisetesting and/or training.

Ability to idenify the components that contribute to the maintenance of asafe environment.

APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 323

GENERAL POPULATION/CORE:

EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

Knowledge of the basic structures of bone, skeletal muscle, and connectivetissues. '

Knowledge of the basic anatomy of the cardiovascular system and respiratorysystem.

Knowledge of the definition of the following terms: inferior, superior, medi­al, lateral, supination, pronation, flexion, extension, adduction, abduction,hyperextension, rotation, circumduction, agonist, antagonist, and stabilizer.Knowledge of the plane in which each muscle action occurs.Knowledge of the interrelationships among center of gravity, base ofsupport, balance, stability, and proper spinal alignment.Knowledge of the following curvatures of the spine: lordosis, scoliosis, andkyphosis

Knowledge to describe the myotatic stretch reflex.Knowledge of fundamental biomechanical principles that underlie perform­ance of the following activities: walking, jogging, running, swimming,cycling, weight lifting, and carrying or moving objectsAbility to define aerobic and anaerobic metabolism.Knowledge of the role of aerobic and anaerobic energy systems in theperformance of various activities.

Knowledge of the following terms: ischemia, angina pectoris, tachycardia,bradycardia, arrhythmia, myocardial infarction, cardiac output, strokevolume, lactic acid, oxygen consumption, hyperventilation, systolic bloodpressure, diastolic blood pressure, and anaerobic threshold.Knowledge to describe normal cardiorespiratory responses to static anddynamic exercise in terms of heart rate, blood pressure, and oxygenconsu mption.

Knowledge of how heart rate, blood pressure, and oxygen consumptionresponses change with adaptation to chronic exercise training.Knowledge of the physiological adaptations associated with strength training.Knowledge of the physiological principles related to warm-up andcool-down.

Knowledge of the common theories of muscle fatigue and delayed onsetmuscle soreness (DOMS).

Knowledge of the physiological adaptations that occur at rest and duringsubmaximal and maximal exercise following chronic aerobic and anaerobicexercise training.

Knowledge of the differences in cardiorespiratory response to acute gradedexercise between conditioned and unconditioned individuals.Knowledge of the structure of the skeletal muscle fiber and the basic mecha­nism of contraction.

1.1.2

1 1.3

ACSM Health/Fitness Instructor® Knowledge, Skills, and Abilities (KSAs):

1.1.41.1.5

1.1.1

1.1.6

1.12.10 Knowledge of common drugs from each of the following classes of med­ications and describe their effects on exercise: antianginals; antihyperten­sives; antiarrhythmics; bronchodilators; hypoglycemics; psychotropics; andvasodilators.

1.12.11 Knowledge of the effects of the following substances on exercise: antihista­mines, tranquilizers, alcohol, diet pills, cold tablets, caffeine, and nicotine.

1.1.71.1.8

1.1.91.1.10

1.1.11

1.112

1.1 13

1.1 1411.15

1.11'6

1.1.17

11.18

1.1.19

PROGRAM ADMINISTRATION, QUALITY ASSURANCE, AND OUTCOME

ASSESSMENT

322 SECTION IV / APPENDICES

1.10.17 Ability to assist or "spot" a client in a safe and effective manner duringresistance exercise

1.11.1 Knowledge of the cPT's role in administration and program managementwithin a health/fitness facility.

1.11.2 Knowledge of and the ability to use the documentation required when aclient shows abnormal signs or symptoms during an exercise session andshould be referred to a physician.

1.11.3 Knowledge of professional liability and most common types of negligenceseen in training environments

1.11.4 Understand the practical and legal ramifications of the employee vs. inde­pendent contractor classifications as they relate to personal trainers

1.11.5 Knowledge of appropriate professional conduct, practice standards, andethics in relationships dealing with clients, employers, and other alliedhealth/medical/fitness professionals.

1.11.6 Knowledge of the types of exercise programs available in the communityand how these programs are appropriate for various populations.

1.11.7 knowledge of and ability to implement effective, professional business prac­tices and ethical promotion of personal training services

CLINICAL AND MEDICAL CONSIDERATIONS

1.12.1 Knowledge of cardiovascular, respiratory, metabolic, and musculoskeletal riskfactors that may require further evaluation by medical or allied health profes­sionals before participation in physical activity.

1 12.2 Knowledge of risk factors that may be favorably modified by physical activityhabits.

1.12.3 Knowledge of the risk factor concept of Coronary Artery Disease (CAD) andthe influence of heredity and lifestyle on the development of CAD.

1.12.4 Knowledge of how lifestyle factors, including nutrition, physical activity, andheredity, influence blood lipid and lipoprotein (i.e., cholesterol: high-densitylipoprotein and low-density lipoprotein) profiles.

1.12.5 Knowledge of cardiovascular risk factors or conditions that may requireconsultation with medical personnel before testing or training, includinginappropriate changes of resting or exercise heart rate and blood pressure,new onset discomfort in chest, neck, shoulder, or arm, changes in thepattern of discomfort during rest or exercise, fainting or dizzy spells, andclaudication.

1.12.6 Knowledge of respiratory risk factors or conditions that may require consul­tation with medical personnel before testing or training, including asthma,exercise-induced bronchospasm, extreme breathlessness at rest or duringexercise, bronchitis, and emphysema.

1.12.7 Knowledge of metabolic risk factors or conditions that may require consulta­tion with medical personnel before testing or training, including body weightmore than 20% above optimal, BMI> 30, thyroid disease, diabetes or glu­cose intolerance, and hypoglycemia.

1.12.8 Knowledge of musculoskeletal risk factors or conditions that may requireconsultation with medical personnel before testing or training, includingacute or chronic back pain, osteoarthritis, rheumatoid arthritis, osteoporosis,tendonitis, and low back pain.

1.12.9 Knowledge of the basic principles of electrical conduction of the heart, it'sphases of contraction, and it's implications.

Ability to identify the joints of the body

Knowledge of the primary action and joint range of motion for each majormuscle group.

Ability to locate the anatomic landmarks for palpation of peripheral pulses

PATHOPHYSIOLOGY AND RISK FACTORS

Knowledge of the physiological and metabolic responses to exerciseassociated with chronic disease (heart disease, hypertension, diabetesmellitus, and pulmonary disease).

Knowledge of cardiovascular, respiratory, metabolic, and musculoskeletal riskfactors that may require further evaluation by medical or allied health profes­sionals before participation in physical activity.

Knowledge of risk factors that may be favorably modified by physical activityhabits

Knowledge to define the following terms: total cholesterol (Te), high-densitylipoprotein cholesterol (HDL-C), TClHDL-C ratio, low-density lipoprotein cho­lesterol (LDL-C), triglycerides, hypertension, and atherosclerosis.Knowledge of plasma cholesterol levels for adults as recommended by theNational Cholesterol Education Program.

Knowledge of the risk factor concept of CAD and the influence of heredityand lifestyle on the development of CAD.

Knowledge of the atherosclerotic process, the factors involved in its genesisand progression, and the potential role of exercise in treatment.Knowledge of how lifestyle factors, including nutrition, physical activity, andheredity, influence lipid and lipoprotein profiles.

HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

Knowledge of and ability to discuss the physiological basis of the majorcomponents of physical fitness: flexibility, cardiovascular fitness, muscularstrength, muscular endurance, and body composition.Knowledge of the importance of a health/medical history.Knowledge of the value of a medical clearance prior to exerciseparticipation.

Knowledge of the categories of participants who should receive medicalclearance prior to administration of an exercise test or participation in anexercise program.

Knowledge of relative and absolute contra indications to exercise testing orparticipation.

Knowledge of the limitations of informed consent and medical clearanceprior to exercise testing.

Knowledge of the advantages/disadvantages and limitations of the variousbody composition techniques including air displacement, plethysmography,hydrostatic weighing, skinfolds and bioelectrical impedence.Skill in accurately measuring heart rate, blood pressure, and obtaining ratingof perceived exertion (RPE) at rest and during exercise according to estab­lished guidelines.

Skill in measuring skinfold sites, skeletal diameters, and girth measurementsused for estimating body composition

Skill in techniques for calibration of a cycle ergometer and a motor-driventreadmill.

Ability to locate the brachial artery and correctly place the cuff and stetho­Scope in position for blood pressure measurement.

1.1 .43

1.1 .411.1 .42

1.2.1

12.2

1.2.3

1.2.4

1.25

1.2.6

1.2.7

1.28

APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDJUNI: LI:K r IrlLA r IUI~~

1.3.1

1.3.213.3

1.3.4

1.3.5

1.3.6

1.3.7

1.3.8

1.3.9

1.310

1.3.11

Knowledge of the characteristics of fast and slow twitch fibers.Knowledge of the sliding filament theory of muscle contraction.Knowledge of twitch, summation, and tetanus with respect to muscle

contraction. . ...Knowledge of the physiological principles involved In promoting gains Inmuscular strength and endurance. ...Knowledge of muscle fatigue as it relates to mode, Intensity, duration, andthe accumulative effects of exercise.Knowledge of the basic properties of cardiac muscle and the normalpathways of conduction in the heart. .Knowledge of the response of the following variables to acute static anddynamic exercise: heart rate, stroke volume, cardiac output, pulmonaryventilation, tidal volume, respiratory rate, and arteriovenous oxygendifference. .Knowledge of blood pressure responses associated with acute exerCise,including changes in body position. ... .Knowledge of and ability to describe the Implications of ventilatory threshold(anaerobic threshold) as it relates to exercise training and cardiorespiratoryassessment. .Knowledge of and ability to describe the physiological adaptations of therespiratory system that occur at rest and during submaxlmal and maximalexercise following chronic aerobic and anaerobic training. .. .Knowledge of how each of the following differs from the normal condition.dyspnea, hypoxia, and hypoventilation. . ..Knowledge of how the principle of speCifiCity relates to the components of

fitness. f d··· dKnowledge of the concept of detraining or reversibility 0 con ItIonlng anits implications in fitness programs. .. . .Knowledge of the physical and psychological signs of overtraining and toprovide recommendations for these problems. . .Knowledge of and ability to describe the changes that occur In maturationfrom childhood to adulthood for the follOWing: skeletal muscle: bone struc­ture, reaction time, coordination, heat and cold tolerance, maximal oxygenconsumption, strength, flexibility, body compOSition, resting and maximalheart rate, and resting and maximal blood pressure.Knowledge of the effect of the aging process on the musculoskeletal andcardiovascular structure and function at rest, dUring exerCise, and dUring

recovery. . . . .~r .Knowledge of the following terms: progressive reSistance, Isotonlvlsometrlc,concentric, eccentric, atrophy, hypertrophy, sets, repetitions, plyometrlcs,Valsalva maneuver.Knowledge of and skill to demonstrate exercises designed to enhance mus­cular strength and/or endurance of specific major muscle groups.Knowledge of and skill to demonstrate exercises for enhanCing muscu-loskeletal flexibility. .Ability to identify the majOr bones and muscles. Major muscles Include, butare not limited to, the following: trapezius, pectoraliS major, latiSSimus dorSI,biceps, triceps, rectus abdominis, internal and external obliques, erectorspinae, gluteus maximus, quadriceps, hamstrings, adductors, abductors, and

gastrocnemius. .. . .Ability to identify the major bones. Major bones Include, but are not limitedto the clavicle, scapula, strernum, humerus, carpals, ulna, radiUS, femur,fibia, tibia, and tarsals.

SECTION IV / APPENDICES

1.1.25

324

1.1.24

1.1.201.1.211.1.22

1.1.23

1.1.26

1.1.28

11.29

1.1.27

1.1.31

1.1.30

1.1.34

1.1.32

1.1.33

1.1.36

1.1.35

1.1.39

1.1.38

1.1.37

1.1.40

APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS326

1.3.12

1.3.13

1.3.141.3.15

1.3.161.3.17

1.3.18

1.3.19

1.3.20

1.3.21

1.3.22

1.3.23

14.1

142

1.5.1

1.5.2

1.7.1

1.7.2

1.7.3

SECTION IV / APPENDICES

Ability to locate common sites for measurement of skinfold thicknessesand circumferences (for determination of body composition and waist-hipratio).Ability to obtain a health history and risk appraisal that includes past andcurrent medical history, family history of cardiac disease, orthopedic limita­tions, prescribed medications, activity patterns, nutritional habits, stress andanxiety levels, and smoking and alcohol use.Ability to obtain informed consent.Ability to explain the purpose and procedures for monitoring clients prior to,during, and after cardiorespiratory fitness testing.Ability to instruct participants in the use of equipment and test procedures.Ability to describe the purpose of testing, determine an appropriate submaxi­mal or maximal protocol, and perform an assessment of cardiovascular fit­ness on the cycle ergometer or the treadmill.Ability to describe the purpose of testing, determine appropriate protocols,and perform assessments of muscular strength, muscular endurance, andflexibility.Ability to perform various techniques of assessing body composition,includ­ing the use of skinfold calipers.Ability to analyze and interpret information obtained from the cardiorespira­tory fitness test and the muscular strength and endurance, flexibility, andbody composition assessments for apparently healthy individuals and thosewith stable disease.Ability to identify appropriate criteria for terminating a fitness evaluation anddemonstrate proper procedures to be followed after discontinuing such a test.Ability to modify protocols and procedures for cardiorespiratory fitness testsin children, adolescents, and older adults.Ability to identify individuals for whom physician supervision isrecommended during maximal and submaximal exercise testing.

ElECTROCARDIOGRAPHY AND DIAGNOSTIC TECHNIQUES

Knowledge of how each of the following differs from the normal condition:premature atrial contractions and premature ventricular contractions.Ability to locate the appropriate sites for the limb and chest leads for resting,standard, and exercise (Mason Likar) electrocardiograms (ECGs), as well ascommonly used bipolar systems (e.g., CM-5).

PATIENT MANAGEMENT AND MEDICATIONS

Knowledge of common drugs from each of the following classes of medica­tions and describe the principal action and the effects on exercise testingand prescription: antianginals; antihypertensives; antiarrhythmics; bron­chodilators; hypoglycemics; psychotropics; and vasodilators.Knowledge of the effects of the following substances on exercise response:antihistamines, tranquilizers, alcohol, diet pills, cold tablets, caffeine, andnicotine.

EXERCISE PRESCRIPTION AND PROGRAMMING

Knowledge of the relationship between the number of repetitions, intensity,number of sets, and rest with regard to strength training.Knowledge of the benefits and risks associated with exercise training inprepubescent and postpubescent youth.Knowledge of the benefits and precautions associated with resistance andendurance training in older adults.

1.7.4

1.7.5

1.7.6

1.7.7

1.7.8

1.7.9

1.7.10

1.7.11

1.7.12

1.7.13

1.714

1.7.15

1.7.16

1.7.17

1718

1.7.19

1.720

1.721

1.7.22

1.7.23

17.24

1.7.25

1.7.26

327

Knowledge of specific leadership techniques appropriate for working withparticipants of all ages.

Knowledge of how to modify cardiovascular and resistance exercises basedon age and physical condition.

Knowledge of the differences in the development of an exercise prescriptionfor children, adolescents, and older participants.Knowledge of and ability to describe the unique adaptations to exercisetraining in children, adolescents, and older participants with regard tostrength, functional capacity, and motor skills.Knowledge of common orthopedic and cardiovascular considerations forolder participants and the ability to describe modifications in exerciseprescription that are indicated.Knowledge of selecting appropriate testing and training modalities accordingto the age and functional capacity of the individual.Knowledge of the recommended intensity, duration, frequency, and type ofphysical activity necessary for development of cardiorespiratory fitness in anapparently healthy populationKnowledge of and the ability to describe exercises designed to enhancemuscular strength and/or endurance of specific major muscle groups.Knowledge of the principles of overload, specificity, and progression andhow they relate to exercise programming.Knowledge of the various types of interval, continuous, and circuit trainingprograms.

Knowledge of approximate METs for various sport, recreational, and worktasks.

Knowledge of the components incorporated into an exercise session and theproper sequence (i.e., preexercise evaluation, warm-up, aerobic stimulusphase, cool-down, muscular strength and/or endurance, and flexibility).Knowledge of special precautions and modifications of exercise program­ming for participation at altitude, different ambient temperatures, humidity,and environmental pollution.Knowledge of the importance of recording exercise sessions and performingperiodic evaluations to assess changes in fitness status.Knowledge of the advantages and disadvantages of implementation ofinterval, continuous, and circuit training programs.Knowledge of the types of exercise programs available in the communityand how these programs are appropriate for various populationsKnowledge of the concept of "Activities of Daily Living" (ADLs) and itsimportance in the overall health of the individual.Skill to teach and demonstrate the components of an exercise session(i.e., warm-up, aerobic stimulus phase, cool-down, muscularstrength/endurance, flexibility).Skill to teach and demonstrate appropriate modifications in specific exercisesfor the following groups: older adults, pregnant and postnatal women,obese persons, and persons with low back pain.Skill to teach and demonstrate appropriate exercises for improving range ofmotion of all major joints.Skill in the use of various methods for establishing and monitoring levels ofexercise intensity, including heart rate, RPE, and METs.Ability to identify and apply methods used to monitor exercise intensity,including heart rate and rating of perceived exertion.Ability to describe modifications in exercise prescriptions for individuals withfunctional disabilities and musculoskeletal injuries

APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS328

1.7.27

1.7.28

1.7.29

1.7.30

1.7.31

1.7.321733

17341.7.35

1.7.36

1.7.37

1738

1739

1.7.40

1.7.41

1.7.42

1743

1.7.44

1.7.45

1.7.46

18.1

1.8.2

SECTION IV / APPENDICES

Ability to differentiate between the amount of physical activity required forhealth benefits and the amount of exercise required for fitness development.Ability to determine training heart rates using two methods: percent of age­predicted maximum heart rate and heart rate reserve (Karvonen).Ability to identify proper and improper technique in the use of resistiveequipment such as stability balls, weights, bands, resistance bars, and waterexercise equipment.Ability to identify proper and improper technique in the use of cardiovascularconditioning equipment (e.g., stairclimbers, stationary cycles, treadmills, ellip­tical trainers).Ability to teach a progression of exercises for all major muscle groups toimprove muscular strength and endurance.Ability to communicate effectively with exercise participants.Ability to design, implement, and evaluate individualized and group exerciseprograms based on health history and physical fitness assessments.Ability to modify exercises based on age and physical condition.Knowledge and ability to determine energy cost, V02 , METs, and targetheart rates and apply the information to an exercise prescription.Ability to convert weights from pounds (Ib) to kilograms (kg) and speed frommiles per hour (mph) to meters per minute (m/min- 1

).

Ability to convert METs to V02 expressed as mLlkg- 1/min- 1, L/min- 1, and/ormL/kg FFW- 1/min- 1 .

Ability to determine the energy cost in METs and kilocalories for given exer­cise intensities in stepping exercise, cycle ergometry, and during horizontaland graded walking and running.Ability to prescribe exercise intensity based on V02 data for different modesof exercise, including graded and horizontal running and walking, cycling,and stepping exerciseAbility to explain and implement exercise prescription guidelines forapparently healthy clients, increased risk clients, and clients with controlleddisease.Ability to adapt frequency, intensity, duration, mode, progression, level ofsupervision, and monitoring techniques in exercise programs for patientswith controlled chronic disease (e.g., heart disease, diabetes mellitus, obesi­ty, hypertension), musculoskeletal problems, pregnancy and/or postpartum,and exercise-induced asthma.Ability to design resistive exercise programs to increase or maintain muscularstrength and/or endurance.Ability to evaluate flexibility and prescribe appropriate flexibility exercises forall major muscle groupsAbility to design training programs using interval, continuous, and circuittraining programs.Ability to describe the advantages and disadvantages of various commercialexercise equipment in developing cardiorespiratory fitness, muscularstrength, and muscular endurance.Ability to modify exercise programs based on age, physical condition, andcurrent health status.

NUTRITION AND WEIGHT MANAGEMENT

Knowledge of the role of carbohydrates, fats, and proteins as fuels for aero­bic and anaerobic metabolism.Knowledge to define the following terms: obesity, overweight, percent fat,lean body mass, anorexia nervosa, bulimia, and body fat distribution.

1.8.31.8.4

1.8.5

1.8.6

187

18.81.8.91.8.10

1.8.11

1.8.12

1.8.13

1.8.14

1.8.15

1.8.16

1.8.17

1.9.1

1.9.2

19.3

1.9.4

1.951.9.6

1.9.7

1.9.8

329

Knowledge of the relationship between body composition and health.Knowledge of the effects of diet plus exercise, diet alone, and exercise aloneas methods for modifying body composition.Knowledge of the importance of an adequate daily energy intake for healthyweight management.

Knowledge of the difference between fat-soluble and water-solublevitamins.

Knowledge of the importance of maintaining normal hydration before, dur­ing, and after exercise.Knowledge of the USDA Food Pyramid.Knowledge of the importance of calcium and iron in women's healthKnowledge of the myths and consequences associated with inappropriateweight loss methods (e.g., saunas, vibrating belts, body wraps, electric simu­lators, sweat suits, fad diets).Knowledge of the number of kilocalories in one gram of carbohydrate, fat,protein, and alcohol.

Knowledge of the number of kilocalories equivalent to losing 1 pound ofbody fat.

Knowledge of the guidelines for caloric intake for an individual desiring tolose or gain weight.

Knowledge of common nutritional ergogenic aids, the purported mecha­nism of action, and any risk and/or benefits (e.g., carbohydrates,protein/amino acids, vitamins, minerals, sodium bicarbonate, creatine, beepollen)

Knowledge of nutritional factors related to the female athlete triadsyndrome (I.e., eating disorders, menstrual cycle abnormalities, andosteoporosis)

Knowledge of the NIH Consensus statement regarding health risks ofobesity, Nutrition for Physical Fitness Position Paper of the American DieteticAssociation, and the ACSM Position Stand on proper and improper weightloss programs.

Ability to describe the health implications of variation in body fat distributionpatterns and the significance of the waist to hip ratio

HUMAN BEHAVIOR AND COUNSELING

Knowledge of at least five behavioral strategies to enhance exercise andhealth behavior change (e.g., reinforcement, goal setting, social support).Knowledge of the five important elements that should be included in eachcounseling session.Knowledge of specific techniques to enhance motivation (e.g., posters,recognition, bulletin boards, games, competitions). Define extrinsic andintrinsic reinforcement and give examples of each.Knowledge of extrinsic and intrinsic reinforcement and give examples of

.each.

Knowledge of the stages of motivational readiness.Knowledge of three counseling approaches that may assist less motivatedclients to increase their physical activity.KnOWledge of symptoms of anxiety and depression that may necessitatereferral to a medical or mental health professional.KnOWledge of the potential symptoms and causal factors of test anxiety (i.e.,performance, appraisal threat during exercise testing) and how it may affectphysiological responses to testing.

PROGRAM ADMINISTRATION. QUALITY ASSURANCE. AND OUTCOME

ASSESSMENT

1.11.1 Knowledge of the health/fitness instructor's role in administration and pro­gram management within a health/fitness facility.

1.11.2 Knowledge of and the ability to use the documentation required when aclient shows signs or symptoms during an exercise session and should be

referred to a physician.

331

Ability to administer fitness-related programs within established budgetaryguidelines.Ability to develop marketing materials for the purpose of promoting fitness­related programs.Ability to create and maintain records pertaining to participant exerciseadherence, retention, and goal setting.Ability to develop and administer educational programs (e.g .. lectures. work­shops) and educational materials.

CARDIOVASCULAR: PATHOPHYSIOLOGY AND RISK FAGORS

Knowledge of how to manage of a fitness department (e.g., working withina budget, training exercise leaders, scheduling, running staff meetings).Knowledge of the Importance of tracking and evaluating member retention.

Knowledge of respiratory risk factors or conditions that may require consul­tation with medical personnel before testing or training, including asthma,exerCISe-induced bronchospasm. extreme breathlessness at rest or duringexercise, bronchitis, and emphysema.

Knowledge of cardiovascular risk factors or conditions that may requireconsultation with medical personnel before testing or training, includingInappropnate changes of resting or exercise heart rate and blood pressure,new onset discomfort in chest, neck. shoulder, or arm. changes in thepattern of discomfort during rest or exercise. fainting or dizzy spells. andclaudication.Knowledge of the causes of myocardial ischemia and infarction.Knowledge the pathophysiology of hypertension, obesity. hyperlipidemia.diabetes. chronic obstructive pulmonary diseases, arthritis. osteoporosis,chronic diseases, and immunosuppressive disease.Knowledge the effects of the above diseases and conditions on cardiorespi­ratory and metabolic function at rest and during exercise

PULMONARY: PATHOPHYSIOLOGY AND RISK FAGORS

METABOLIC: PATHOPHYSIOLOGY AND RISK FACTORS

Knowledge of metabolic risk factors or conditions that may require consulta­tion with medical personnel before testing or training. including body weightmore than 20% above optimal, 8MI> 30, thyroid disease. diabetes or glu­cose Intolerance, and hypoglycemia.

ORTHOPEDIc/MUSCULOSKELETAL: PATHOPHYSIOLOGY AND RISK FAGORS

APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS

1.11.3

1.11.41.11.51.11.6

1.11.7

1.11.8

1.11.9

2.2.1

2.2.22.2.3

2.2.4

3.2.1

5.2.1

4.2.1

Knowledge of musculoskeletal risk factors or conditions that may requireconsultation with medical personnel before testing or training, includingacute or chronic back pain. osteoarthritis. rheumatoid arthritis. osteoporosis.tendonitis. and low back pain.

NOTE: The KSAs listed above for the ACSM HealthlFitness Instructor'" are the same KSAs for educationalprog~ams seeking undergraduate (bachelor's degree) academic accreditation through the CoAES.SpeCifICally. these programs are typically Exercise Science. Kinesiology, andlor Physical Education depart­ments With profeSSional development tracks for those students interested in careers in the fitness indus­try_ For more information. please visit www.coaes.org.

SECTION IV / APPENDICES

Knowledge of and skill in obtaining basic life support and cardiopulmonary

resuscitation certification.Knowledge of appropriate emergency procedures (i.e. telephone proce-dures. written emergency procedures. personnel responsibilities) in a health

and fitness setting.Knowledge of basic first aid procedures for exercise-related injuries. such asbleeding, strains/sprains, fractures, and exercise intolerance (dizziness,

syncope, heat injury).Knowledge of basic precautions taken in an exercise setting to ensure

participant safety.Knowledge of the physical and physiological signs and symptoms of

overtraining.Knowledge of the effects of temperature, humidity, altitude, and pollution

on the physiological response to exercise.Knowledge of the following terms: shin splints, sprain, strain, tennis elbow.bursitis, stress fracture. tendonitis. patellar femoral pain syndrome, low back

pain. plantar fasciitis. and rotator cuff tendonitis.Knowledge of hypothetical concerns and potential risks that may be associ­ated with the use of exercises such as straight leg sit-ups. double leg raises,full squats, hurdlers stretch, yoga plough, forceful back hyperextension, and

standing bent-over toe touchKnowledge of safety plans, emergency procedures. and first aid techniquesneeded during fitness evaluations. exercise testing, and exercise training.Knowledge of the health/fitness instructor's responsibilities, limitations, andthe legal implications of carrying out emergency proceduresKnowledge of potential musculoskeletal injuries (e.g .. contusions, sprains,strains. fractures), cardiovascular/pulmonary complications (e.g., tachycardia,bradycardia. hypotension/hypertension. tachypnea) and metabolic abnormali­ties (e.g .. fainting/syncope. hypoglycemia/hyperglycemia, hypothermia/

hyperthermia)Knowledge of the initial management and first aid techniques associatedwith open wounds, musculoskeletal injuries, cardiovascular/pulmonary

complications, and metabolic disordersKnowledge of the components of an equipment maintenance/repairprogram and how it may be used to evaluate the condition of exerciseequipment to reduce the potential risk of injury.Knowledge of the legal implications of documented safety procedures, theuse of incident documents, and ongoing safety training.Skill to demonstrate exercises used for people with low back pain.Skill in demonstrating appropriate emergency procedures during exercise

testing and/or training.Ability to identify the components that contribute to the maintenance of a

safe environment.

SAFETY. INJURY PREVENTION. AND EMERGENCY PROCEDURES

1.10.17

1.10151.10.16

1.10.14

1.10.13

1.1012

1.10.11

1.10.10

1.1 0.9

1.108

1.10.7

1.10.6

1.10.5

1.10.4

1.103

1.102

1.10.1

330

ACSM Exercise Specialist® Knowledge, Skills, and Abilities (KSAs):

333

Describe common procedures and apply knowledge of results fromradionuclide imaging (e.g., thallium, technetium, sestamibi, singlephoton emission computed tomography (SPEeT».Knowledge of exercise testing procedures for various clinicalpopulations including those individuals with cardiovascular,pulmonary, and metabolic diseases in terms of exercise modality,protocol, physiological measurements, and expected outcomes.Describe anatomical landmarks as they relate to exercise testing andprogramming.

Locate and palpate anatomic landmarks of radial, brachial, carotid, femoral,popliteal, and tibialis arteries.

Select an appropriate test protocol according to the age and functionalcapacity of the individual.

Identify individuals for whom physician supervision is recommended duringmaximal and submaximal exercise testing.Conduct pre-exercise test procedures.

Describe basic equipment and facility requirements for exercise testing.Instruct the test participant in the use of the RPE scale and other appropriatesubjective rating scales, such as the dyspnea and angina scales.Obtain informed consent and describe its purpose.

Describe the importance of accurate and calibrated testing equipment(e.g., treadmill, ergometers, electrocardiograph, and sphygmomanometers).Measure physiological and subjective responses (e.g., symptoms, ECG, bloodpressure, heart rate, RPE and other scales, oxygen saturation, and oxygenconsumption) at appropriate intervals during the test.

Describe the effects of age, weight, level of fitness, and health status on theselection of an exercise test protocol.

Ability to measure oxygen consumption during an exercise test.Ability to provide testing procedures and protocol for children and theelderly with or without various clinical conditions.Obtain and interpret medical history and physical examination find­ings as they relate to health appraisal and exercise testing.Accurately record and interpret right and left arm pre-exercise bloodpressures in the supine and upright positions.Describe and analyze the importance of the absolute and relativecontraindications of an exercise test.Select and perform appropriate procedures and protocols for theexercise test, including modes of exercise, starting levels, incrementsof work, ramping versus incremental protocols, length of stages, andfrequency of data collection.Describe and conduct immediate postexercise procedures and variousapproaches to cool-down.Record, organize, perform, and interpret necessary calculations oftest data.Describe the differences in the physiological responses to variousmodes of ergometry (e.g., treadmill, cycle and arm ergometers) asthey relate to exercise testing and training.

HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS

in response to exercise testing and training in healthy and diseasestates.

1.2.11 Describe the cardiorespiratory and metabolic responses in myocardialdysfunction and ischemia at rest and during exercise.

1.3.1

1.3.6

1.3.2

1.3.3

1.34

1.3.5

1.3.71.3.81.3.9

1.3.101.3.11

1.3.12

1.3.13

1.3.141.3.15

1.3.16

1.3.17

1.3.18

1.3.19

1.3.20

1.3.21

1.3.22

SECTION IV / APPENDICES

EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

Summarize the atherosclerotic process, including current hypotheses regard­ing onset and rate of progression and/or regression.Compare and contrast the differences between typical, atypical, andvasospastic angina.Describe the pathophysiology of the healing myocardium and the potentialcomplications after acute myocardial infarction (MI) (extension, expansion,rupture)Describe silent ischemia and its implications for exercise testing and training.Examine the role of diet on cardiovascular risk factors such as hyper­tension, blood lipids and body weight.Describe the lipoprotein classifications and define their relationshipto atherosclerosis or other diseases.Describe the cardiorespiratory and metabolic responses that accom­pany or result from pulmonary diseases at rest and during exercise.Describe the influence of exercise on cardiovascular risk factors.Describe the normal and abnormal cardiorespiratory responses at restand exercise.Identify the mechanisms by which functional capacity and cardiovas- / .cular, pulmonary, metabolic, and neuromuscular adaptations occur

Describe coronary anatomy.Describe the physiological effects of bed rest and discuss the appropri­ate physical activities that might be used to counteract these changes.Identify the cardiorespiratory responses associated with postural changes.Describe activities that are primarily aerobic and anaerobic.Identify the metabolic equivalent (MET) requirements of variousoccupational. household, sporVexercise, and leisure time activities.Knowledge of the unique hemodynamic responses of arm versus leg exerciseand of static versus dynamic exercise.Define the determinants of myocardial oxygen consumption and the effectsof exercise training on those determinants.Determine maximal oxygen (02) consumption and describe the methodologyfor measuring it.Plot the normal resting and exercise values associated with increasingexercise intensity (and how they may differ for diseased populations) forthe following: heart rate, stroke volume, cardiac output, double product,arteriovenous O2 difference, O2 consumption, systolic and diastolic bloodpressure, minute ventilation, tidal volume, breathing frequency, VdNt,

'MV02, and VE/VC02

Discuss the effects of isometric exercise in individuals with cardiovas­cular, pulmonary, and/or metabolic diseases or with low functionalcapacity,Knowledge of acute and chronic adaptations to exercise for appar­ently healthy individuals (low risk) and for those with cardiovascular,pulmonary, and metabolic diseases.Describe the effects of variation in environmental factors (e.g. tem­perature, humidity, altitude) for normal individuals and those withcardiovascular, pulmonary, and metabolic diseases.

PATHOPHYSIOLOGY AND RISK FACTORS

332

1.1.6

1.1.7

1.1.31.1.411.5

1 1.9

1.2.1

1.1.11.1.2

11.8

1.2.3

1.2.2

1.1.10

1.1.11

1.1.12

1.2.10

1.2.6

1.2.7

1.2.41.2.5

1.2.81.2.9

334 SECTION IV / APPENDICES APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 335

Describe percutaneous coronary and peripheral interventions (e.g., PTCA,stent) as an alternative to medical management or bypass surgery.Describe indications and limitations for medical management andinterventional techniques in different subsets of individuals with CADand PAD.

Locate the appropriate sites for the limb and chest leads for resting,standard, and exercise (Mason Likar) electrocardiograms (ECGs), as well ascommonly used bipolar systems (e.g., CM-5).Obtain and interpret a pre-exercise standard and modified (Mason­Likar) 12-lead ECG on a participant in the supine and upright position.Ability to minimize ECG artifactDescribe the diagnostic and prognostic implications of the exercise test ECGand hemodynamic responses.Identify ECG changes that typically occur due to hyperventilation, electrolyteabnormalities, and drug therapy.Identify the causes of false positive and false negative exercise ECGresponses and methods for optimizing sensitivity and specificity.Identify and describe the significance of ECG abnormalities in design­ing the exercise prescription 'and in making activity recommendations.Explain indications and procedures for combining exercise testingwith radionuclide or echocardiographic imaging.

PATIENT MANAGEMENT AND MEDICATIONS

List indications for use of streptokinase, tissue plasminogen activase, andother thrombolytic agents.Describe mechanisms and actions of medications that may affectexercise testing and prescription.Recognize medications associated in the clinical setting, their indications forcare, and their effects at rest and during exercise (e.g., antianglnals, antihy­pertensives, antiarrythmics, bronchodilators, hypoglycemics, psychotropics,vasodilators, anticoagulant and antiplatelet drugs, and lipid-lowering agents).

MEDICAL AND SURGICAL MANAGEMENT

Describe basic joint movements, muscle actions, and points of insertions as itrelates to exercise programming.Compare and contrast benefits and risks of exercise for individualswith CAD risk factors and for individuals with cardiovascular, pul­monary, and/or metabolic diseases.Design appropriate exercise prescription in environmental extremesfor normal individuals and those with cardiovascular, pulmonary, andmetabolic diseases.Design, implement and supervise individualized exercise prescriptionsfor people with chronic disease and disabling conditions.Design a supervised exercise program beginning at hospital dischargeand continuing for up to six months for the following conditions: MI;angina: LVAD; congestive heart failure; PCI; CABG; medical manage­ment of CAD; chronic pulmonary disease; weight management; dia­betes; and cardiac transplants.Knowledge of the concept of "Activities of Daily Living" (ADLs) andits importance in the overall rehabilitation of the individual.

EXERCISE PRESCRIPTION AND PROGRAMMING

1.4.13

1.4.17

1.4.151.4.16

1.4.18

1.5.3

1.4.14

1.5.1

1.4.20

1.4.19

1.6.1

1.5.2

1.7.1

1.7.2

1.6.2

1.7.4

1.7.6

1.7.3

1.7.5

ELECTROCARDIOGRAPHY AND DIAGNOSTIC TECHNIQUES

Describe normal and abnormal chronotropic and inotropic responsesto exercise testing and training.Describe and apply Baye's theorem as it relates to pretest likelihoodof CAD and the predictive value of positive or negative diagnosticexercise ECG results.Compare and contrast obstructive and restrictive lung diseases andtheir effect on exercise testing and training.Identify orthopedic limitations (e.g., gout, foot drop, specific jointproblems) as they relate to modifications of exercise testing andprogramming.Identify neuromuscular disorders (e.g., Parkinson's disease, multiplesclerosis) as they relate to modifications of exercise testing andprogramming.Describe the aerobic and anaerobic metabolic demands of exercisetesting and training in individuals with cardiovascular, pulmonary,and/or metabolic diseases undergoing exercise testing or training.Identify the variables measured during cardiopulmonary exercisetesting (e.g., heart rate, blood pressure, rate of perceived exertion,ventilation, oxygen consumption, ventilatory threshold, pulmonarycirculation) and their potential relationship to cardiovascular, pul­monary, and metabolic disease.Discuss the appropriate use of static and dynamic exercise for individ­uals with cardiovascular, pulmonary, and metabolic disease.

Summarize the purpose of coronary angiography.Describe myocardial ischemia and identify ischemic indicators of variouscardiovascular diagnostic tests.Describe the differences between Q-wave and non-Q-wave infarction.Identify the ECG patterns at rest and responses to exercise in patients withpacemakers and ICDs.Identify resting and exercise ECG changes associated with the follow­ing abnormalities:bundle branch blocks and bifascicular blocks; atri­oventricular blocks; sinus bradycardia and tachycardia; sinus arrest;supraventricular premature contractions and tachycardia; ventricularpremature contractions (including frequency, form, couplets, salvos,tachycardia); atrial flutter and fibrillation; ventricular fibrillation;myocardial ischemia, injury, and infarction.Define the ECG criteria for initiating and/or terminating exercise test­ing or training.Identify ECG changes that correspond to ischemia in various myocar­dial regions.Describe potential causes of various cardiac arrhythmias.Identify potentially hazardous arrhythmias or conduction defectsobserved on the ECG at rest, during exercise, and recovery.Describe the diagnostic and prognostic significance of ischemic ECGresponses and arrhythmias at rest, during exercise, or recovery.Identify resting and exercise ECG changes associated with cardiovas­cular disease, hypertensive heart disease, cardiac chamber enlarge­ment, pericarditis, pulmonary disease, and metabolic disorders.Administer and interpret basic resting spirometric tests and measuresincluding FEV1.0, FVC, and MVV.

1.3.24

1.3.23

1.3.25

1.3.26

1.3.27

1.4.11.4.2

1.3.28

1.3.29

1431.4.4

1.3.30

1.4.6

1.4.5

1.4.81.4.9

1.4.7

1.4.11

1.4.12

1.4.10

APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS

336

1.7.7

1.7.81.7.91.710

1.7.111.712

1.7.13

1.7.14

1.7.15

1.7.16

1.7.17

1.7.18

1.7.19

1.7.20

1.7.21

SECTION IV / APPENDICES

Prescribe exercise using nontraditional modalities (e.g., bench step­ping, elastic bands, isodynamic exercise, water aerobics) for individu­als with cardiovascular, pulmonary, or metabolic diseases.Discuss equipment adaptations necessary for different age groups.Identify individuals who require exercise testing prior to exercise training.Organize GXT and clinical data and counsel patients regarding issues such as

ADL, return to work and physical activity.Describe relative and absolute contraindications to exercise training.Identify characteristics that correlate or predict poor compliance to exercise

programs, and strategies to increase exercise adherence.Describe the importance of warm-up and cool-down sessions with spe­cific reference to angina and ischemic ECG changes, and for overal

patient safety.Identify and explain the mechanisms by which exercise may con­tribute to preventing or rehabilitating individuals with cardiovascu­lar, pulmonary, and metabolic diseases.Describe common gait abnormalities as they relate to exercise testing

and programming.Describe the principle of specificity of training as it relates to themode of exercise testing and training.Design a strength and flexibility programs for individuals with cardio­vascular, pulmonary and/or metabolic diseases, elderly, and children.Determine appropriate testing and training modalities according tothe age and functional capacity of the individual.Describe the indications and methods for ECG monitoring during

exercise testing and training.Describe the importance of and appropriate methods for resistance

training in older individuals.Ability to modify exercise testing and training to the limitations of

peripheral arterial disease (PAD).

NUTRITION AND WEIGHT MANAGEMENT

1.9.4

1.9.5

1.9.6

1.9.7

1.10.1

1.10.2

1.10.3

1.10.4

1.10.5

1.10.6

337

Identify the psychological stages involved with the acceptance of death anddying and ability to recognize when it is necessary for a psychological consultor referral to a professional resource.Recognize observable signs and symptoms of anxiety or depressive symp­toms and the need for a psychiatric referral.DeScribe the psychological issues to be confronted by the patient and byfamily members of patients who have cardiovascular disease and/or whohave had an acute Ml or cardiac surgery.Identify the psychological issues associated with an acute cardiac event ver­sus those associated with chronic cardiac conditions.

SAFETY, INJURY PREVENTION. AND EMERGENCY PROCEDURES

Respond ap~ropriately to emergency situations (e.g. cardiac arrest,hypoglecemla and hypergly~emia; bronchospasm; sudden onset~ypotension; ~erious cardiac arrhythmias; implantable cardiac defib­nll~tor (I~D) dl~charge; transient ischemic attack (TIA) or stroke; MI)whlc~ might anse before, during, and after administration of anexercise test and/or exercise session.List ~edicati~ns that should be available for emergency situations inexercise testmg and training sessionsDescribe the emergency equipment and personnel that should bepr~s~nt in a~ exercise testing laboratory and rehabilitative exercisetrammg settmg.Des~ribe the appropriate procedures for maintaining emergencyeqUipment and supplies.Describe the effects of cardiovascular, pulmonary, and metabolic dis­e~ses on ~er~or~~nce and safety during exercise testing and training.~IS~ stratify mdlvlduals with cardiovascular, pulmonary. and metabol­IC dl~e~se~, using appropriate materials and understanding the prog­nostic mdlcators for high-risk individuals.

PROGRAM ADMINISTRATION. QUALITY ASSURANCE, AND OUTCOMEASSESSMENT

Discuss the role of outcome measures in chronic disease managementprograms such as cardiovascular and pulmonary rehabilitationprograms.Identify and discuss various outcome measurements that could be used in acardiac or pulmonary rehabilitation program.Identify and discuss specific outcome collection instruments that could be usedto collect outcome data in a cardiac or pulmonary rehabilitation program.

Describe the acute responses to aerobic and resistance exercise training onthe function of the cardiovascular, respiratory, musculoskeletal, neuromuscu­lar, metabolic, endocrine, and immune systems.Describe the chronic effects of aerobic, resistance, and flexibility exercisetraining on the structure and function of the cardiovascular, respiratory,musculoskeletal, neuromuscular, metabolic, endocrine, and immune systems.

GENERAL POPULATION/CORE:EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

1.11.2

1113

1.1.2

1.11.1

1.1.1

ACSM Registered Clinical Exercise Physiologist Knowledge, Skills, andAbilities (KSAs):

KSA#List and apply five behavioral strategies as they apply to lifestylemodifications, such as exercise, diet, stress, and medication

management.Describe signs and symptoms of maladjustment and/or failure to cope duringan illness crisis and/or personal adjustment crisis (e.g., job loss) that mightprompt a psychological consult or referral to other professional services.Describe the general principles of crisis management and factors influencing /

coping and learning in illness states

Describe and discuss dietary considerations for cardiovascular andpulmonary diseases, chronic heart failure, and diabetes that are rec­ommended to minimize disease progression and optimize disease

management.Compare and contrast dietary practices used for weight reduction andaddress the benefits, risks, and scientific support for each practice.Examples of dietary practices are high protein/low carbohydrate diets,Mediterranean diet, and low fat diets such as the American Heart

Association recommended diet.Calculate the effect of caloric intake and energy expenditure on weight

management.

HUMAN BEHAVIOR AND COUNSELING

1.9.1

1.8.2

1.8.1

1.9.2

1.9.3

1.8.3

338 SECTION IV / APPENDICES APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 339

1.1.3

1.1.4

11.5

1 1.6

11.7

1.1.8

1.1.9

11.10

1.3.1

1.3.2

1.3.3

1.3.4

1.3.51.3.6

1.3.7

List typical values in sedentary and trained persons for oxygen uptake, heartrate, mean arterial pressure, systolic and diastolic blood pressure, cardiacoutput, stroke volume, minute ventilation, respiratory rate, and tidal volumeat rest and during submaximal and maximal exercise.Describe the physiological determinants of V02, MV02, and mean arterialpressure and explain how these determinants may be altered with aerobicand resistance exercise training.Explain how environmental factors may affect the physiological responses toexercise, including ambient temperature, humidity, air quality (e.g., CO,ozone, air pollution) and altitude, and describe appropriate alterations inexercise recommendations due to environmental conditions and patienthealth status.Explain the health benefits of a physically active lifestyle, the hazards ofsedentary behavior and summarize key recommendations of US nationalreports of physical activity (e.g. US Surgeon General, Institute of Medicine,ACSM, AHA)Explain the physiological adaptations to exercise training that may resultin improvement in or maintenance of health, including metabolic (i.e.,Metabolic syndrome, glucose and lipid metabolism), cardiovascular (ie., ath­erosclerosis), musculoskeletal (i.e. bone density), neuromuscular, pulmonary(i.e. lung function), and immune system (i.e. colds, acute illness) health.Explain the mechanisms underlying the physiological adaptations to aerobicand resistance exercise training including those resulting in changes in ormaintenance of maximal and submaximal oxygen consumption, lactate andventilatory (anaerobic) threshold, myocardial oxygen consumption, heart rate,blood pressure, ventilation (including ventilatory (anaerobic) threshold), mus­cle structure, bioenergetics (e.g., substrate utilization), and immune function.Explain the physiological effects of physical inactivity, including bed rest, andmethods that may counteract these effects.Recognize and respond to abnormal signs and symptoms during exercise.

GENERAL POPULATION/CORE:HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

Conduct pre-test procedures including explaining test procedures to thepatient and obtaining informed consent, obtaining a focused medical historyand results of prior tests and physical exam, disease-specific risk factorassessment (i.e., CVD, Metabolic, Pulmonary diseases), presenting conciseinformation to other health care providers and third party payers.Conduct a brief physical examination including evaluation of peripheraledema, measuring blood pressure, peripheral pulses, respiratory rate, andausculating heart and lung sounds.Calibrate lab equipment used frequently in the practice of clinical exercisephysiology (e.g. motorized/computerized treadmill, mechanical cycle ergome­ter and arm ergometer, electrocardiograph, spirometer, respiratory gas ana­lyzer (Metabolic cart)).Administer exercise tests consistent with US nationally accepted standardsfor testing (Ie., ACSM, AHA).Identify contra indications to an exercise sessionAppropriately select and administer functional tests to measure patient out­comes and functional status including the 6 minute walk, Get Up and Go,Berg Balance Scale, Physical Performance Test.Evaluate patient outcomes from serial outcome data collected before, duringand after exercise interventions.

1.3.8

1.3.9

1.3.10

1.3.11

1.3.12

1.3.131.3.14

1.3.15

1.3.16

1.3.17

1.3.18

1.3.19

1.3.20

1.7.1

17.2

1.7.3

1.7.4

1.7.5

17.6

Interpret the variables that may be assessed during clinical exercise testingincluding maximal oxygen consumption, resting Metabolic rate, ventilatoryvolumes and capacities, respiratory exchange ratio, ratings of perceived exer­tion and discomfort (chest pain, dyspnea, claudication), ECG, heart rate,blood pressure, rate pressure product, ventilatory (anaerobic) threshold, oxy­gen saturation, breathing reserve, muscular strength, and muscularendurance and other common measures employed for diagnosis and prog­nosis of disease.

Determine atrial and ventricular rate from rhythm strip and 12-lead ECG andexplain the clinical significance of abnormal atrial or ventricular rate (e.g ..tachycardia, bradycardia).

Identify ECG changes associated with drug therapy, electrolyte abnormalities,subendocardial and transmural ischemia, myocardial injury, and infarctionand explain the clinical significance of each.

Identify SA, AV, and bundle branch blocks from a rhythm strip & 12-leadECG, and explain the clinical significance of each.Identify sinus, atrial, functional, and ventricular dysrhythmias from a rhythmstrip & 12-lead ECG, and explain the clinical significance of each.Identify contra indications to exercise testing.

Determine an individual's pre-test and post-test probability of CHD, identifyfactors associated with test complications, and apply appropriate precautionsto reduce risks to the patient.

Extract and interpret clinical information needed for safe exercise manage­ment of individuals with chronic diseaseIdentify probable disease-specific endpoints for testing in a patient withchronic disease or disability.

Select and employ appropriate techniques for preparation and measurementof ECG, heart rate, blood pressure, oxygen saturation, RPE, symptoms (e.g.,angina, dyspnea, claudication), expired gases, and other measures as neededbefore, during and following exercise, pharmacologic, echocardiography,and radionuclide tests

Select and administer appropriate exercise tests to evaluate functional capac­ity, strength, and flexibility in patients with chronic disease.Discuss strengths and limitations of various methods of measures and indicesof body composition.

Appropriately select, apply, and interpret body composition tests and indices.

GENERAL POPULATION/CORE: EXERCISE PRESCRIPTION AND PROGRAMMING

Adapt Exercise Prescriptions for patients with comorbid conditions and dis­ease complications.

Design and supervise comprehensive exercise programs for outpatients withchronic disease

Determine the appropriate level of supervision and monitoring recommend­ed for individuals with known disease based on chronic disease risk stratifica­tion (e.g., cardiovascular, metabolic, musculoskeletal, etc), and current healthstatus.

Develop and supervise an appropriate Exercise Prescription (e.g., aerobic,strength and flexibility training) for individuals with co-morbid disease.Implement appropriate precautions prior to, during, and following exercise inpatients with chronic disease according to health status, medical treatment,environmental conditions, and other relevant factors.Instruct individuals with chronic disease in techniques for performing physicalactivities safely and effectively in an unsupervised exercise setting.

340 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 341

1.77

1.9.1

1.9.2

1.9.3

1.94

1.9.5

1.9.6

1.9.7

1.10.1

1.10.2

1.10.3

1.10.41.10.5

111.1

1.11.2

1.113

1.11.4

1 11.5

1.11.6

Modify the Exercise Prescription or discontinue exercise based upon patientsymptoms, current health status, musculoskeletal limitations, and enVIron­

mental considerations

GENERAL POPULATION/CORE: HUMAN BEHAVIOR AND COUNSELING

Summarize contemporary theories of health behavior change including socialcognitive theory, theory of reasoned action, theory of planned behaVior,Transtheoretical model, health belief model and apply techniques to pro­

mote healthy behaviors including physical activity.Describe characteristics associated with poor adherence to exercise pro-

grams ..Describe the psychological issues associated with acute and chronic illness suchas depression, social isolation, hostility, aggression, and suicidal ideation. .Counsel patients with chronic diseases and conditions on tOPiCS such as dis­ease processes, treatments, diagnostic techniques, and lifestyle management.Select and apply behavioral techniques such as goal setting, relapse preven­tion, and social support, which enhance adoption of and adherence to

healthy behaviors including exercise. . .Explain factors that may increase anxiety prior to or during exerCISe testing

and describe methods to reduce anxiety.Recognize signs and symptoms of failure to cope during personal crises such

as Job loss, bereavement, and illness

GENERAL POPULATIONICORE:SAFETY, INJURY PREVENTION, AND EMERGENCY PROCEDURES

List routine emergency equipment, drugs, and supplies present in an exercise

testing laboratory and therapeutic exercise session area. ..Provide immediate responses to emergencies (I.e., first responder) Includingbasic cardiac life support, AED, joint immobilization, activation of EMS.Verify operating status of emergency equipment including defibrillator, laryn-

goscope, oxygen, etc. .Explain Universal Precautions procedures and apply as appropriate.Develop and implement a plan for responding to emergencies.

GENERAL POPULATION/CORE: PROGRAM ADMINISTRATION,QUALITY ASSURANCE AND OUTCOME ASSESSMENT

Describe appropriate staffing for exercise programs and exercise testing labo­ratories based on factors such as patient health status, facilities, and pro-

gram goals. .List necessary equipment and supplies for exercise programs and exercise

testing laboratories.Select, document and report treatment outcomes uSing patient-relevantresults of tests (e.g., exercise tests, physical work simulations, biomarkers,and other laboratory tests) and surveys (e.g., physical functioning and

health-related quality of life)Explain legal issues pertinent to health care delivery by licensed and non- .licensed health care professionals providing rehabilitative services and exercisetesting (e.g., torts, contracts, informed consent, negligence, malpractice,liability, standards of care) and legal risk management techniquesIdentify patients requiring referral to a physician or allied health services suchas physical therapy, dietary counseling, stress management, weight manage­

ment, psychosocial and social servicesDevelop a plan for patient discharge from therapeutic exercise program,

including community referrals.

2.1.1

2.12

2.13

2.2.1

2.2.2

2.2.3

2.3.1

2.3.22.3.3

2.3.4

2.6.2

2.6.3

2.6.4

2.6.5

2.6.6

2.7.1

27.2

27.3

CARDIOVASCULAR: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

Describe the indications for, physiologic responses to, and potential compli­cations of pharmacological and pacing stress testing in individuals with car­diovascular diseases.Describe the potential benefits and hazards of aerobic, resistance, and flexi­bility exercise in individuals with cardiovascular diseases.Explain how cardiovascular diseases may affect the physiological responsesto exercise training on the ischemic cascade and the components of the Fickequation.

CARDIOVASCULAR: PATHOPHYSIOLOGY AND RISK FACTORS

Explain current hypotheses regarding the pathophysiology of atherosclerosis,including the etiology and rate of progression of disease.Describe the epidemiology, pathophysiology, risk factors, and key clinicalfindings of cardiovascular diseasesExplain the ischemic cascade and its effect on myocardial function.

CARDIOVASCULAR:HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

Describe common techniques used to diagnose cardiovascular disease,including echocardiography, radionuclide imaging, angiography, pharmaco­logic testing, and biomarkers (e.g., Troponin, CK, etc) and explain the indica­tions, limitations, risks and normal and abnormal results for each.Explain how cardiovascular disease may affect physical examination findings.List the key clinical findings during a physical exam of a patient with cardio­vascular diseases.Recognize and respond to abnormal signs and symptoms in individuals withcardiovascular diseases such as pain, peripheral edema, dyspnea, fatigue.

CARDIOVASCULAR: MEDICAL AND SURGICAL MANAGEMENT

Explain the common medical and surgical treatments of cardiovascular dis­eases including pharmacologic therapy, revascularization procedures, lCD,pacemakers, and transplant.Summarize key recommendations current U.S. clinical practice guidelines forthe prevention, treatment and management of cardiovascular diseases (e.g.,AHA, ACe, NHLBI)List the drug classifications commonly used in the treatment of individualswith cardiovascular diseases, name common generic and brand names drugswithin each class, and explain the purposes, indications, major side effects,and the effects, if any, on the exercising individual.Explain how treatments for cardiovascular disease, including preventive care,may affect the rate of progression of disease.Apply current US national guidelines for primary and secondary preventionof heart disease (e.g., lipoproteins, obesity, pharmacologic, behavioral) toidentify and manage cardiovascular risk.

CARDIOVASCULAR: EXERCISE PRESCRIPTION AND PROGRAMMING

Develop an appropriate Exercise Prescription (e.g., aerobic, strength and flex­ibility training) for individuals with cardiovascular disease.Design & adapt Exercise Prescriptions for individuals with cardiovasculardisease to accomodate physical disabilities and complications due tocardiovascular diseasesDesign and supervise comprehensive outpatient exercise programs forindividuals with cardiovascular disorders.

METABOLIC: MEDICAL AND SURGICAL MANAGEMENT

METABOLIC: PATHOPHYSIOLOGY AND RISK FACTORS

Describe common techniques used to diagnose Metabolic diseases includingbiomarkers, glucose tolerance testing, GFR, and explain the indications, limi­tations, risks and normal and abnormal results for each.List the key clinical findings during a physical exam of a patient withMetabolic disease(s).Explain appropriate techniques for monitoring blood glucose before, during,and after an exercise session.Recognize and respond to abnormal signs and symptoms in individuals withMetabolic diseases such as hypo/ hyperglycemia, peripheral neuropathies,fluid overload, loss of appetite, low hematocrit, and hypotension, andorthopedic problems

Describe the epidemiology, pathophysiology, risk factors, and key clinicalfindings of Metabolic diseases (e.g. Renal Failure, Diabetes, Hyperlipidemia,Obesity, Frailty)Explain current hypotheses regarding the pathophysiology of Metabolic dis­eases, including the etiology and rate of progression of disease.Describe the potential benefits and hazards of aerobic, resistance, and flexi­bility exercise in individuals with Metabolic diseases.Explain how Metabolic diseases may affect the physiologic responses to aer­obic, resistance, and flexibility exercise.Describe the probable effects of dialysis treatment on exercise performance,functional capacity, and safety, and explain methods for preventing adverseeffectsDescribe the probable effects of hypo/hyperglycemia on exercise perform­ance, functional capacity, and safety, and explain methods for preventingadverse effect

METABOLIC: HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

Summarize key recommendations of current U.S. clinical practice guidelines(e.g. ADA, NIH, NHLBI) for the prevention, treatment and management ofMetabolic diseases (e.g. Renal Failure, Diabetes, Hyperlipidemia, Obesity,Frailty)Explain the common medical and surgical treatments of Metabolic diseasesincluding pharmacologic therapy, surgery, and transplant.List the drug classifications commonly used in the treatment of patients withMetabolic disease, name common generic and brand names drugs withineach class, and explain the purposes, indications, major side effects, and theeffects, if any, on the exercising individual.Explain how treatments for Metabolic diseases, including preventive care,may affect the rate of progression of disease.Apply current U.S. national guidelines for prevention of Metabolic diseasesto identify and manage disease complications and reduce cardiovascular risk(ie ADA)Apply current U.S. national guidelines for primary prevention of heart disease(e.g., lipoproteins, obesity, pharmacologic, behavioral) to identify and man­age cardiovascular risk.

Develop an appropriate Exercise Prescription (e.g., aerobic, strength,flexibility training) for individuals with Metabolic disease.

METABOLIC: EXERCISE PRESCRIPTION AND PROGRAMMING

4.3.2

4.2.1

4.2.5

4.2.6

431

4.2.2

4.2.3

4.2.4

APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 343

4.3.3

4.3.4

4.6.3

4.6.2

4.6.6

4.6.5

4.6.4

4.6.7

4.7.1

Explain how Pulmonary disease may affect physical examination findingsList the key clinical findings during a physical exam of a patient With

Pulmonary disease .Have knowledge of lung volumes and capacities (e.g., tidal volume, residualvolume, inspiratory volume, expiratory volume, total lung capaCity, vital .capacity, functional residual capacity, peak flow rate) and how they may dif­fer between normals and patients with Pulmonary disease.Recognize and respond to abnormal signs and symptoms in individuals withPulmonary diseases such as wheezing, cough, sputum, edema, dyspnea,

fatigue.

PULMONARY: MEDICAL AND SURGICAL MANAGEMENT

Develop an appropriate Exercise Prescription (e.g., aerobic, strength, flexibili-ty training) for individuals with chronic Pulmonary diseases .Design & adapt Exercise Prescriptions for individuals with chroniC Pulmonarydiseases to accommodate physical disabilities and complications due to

Pulmonary diseases . .Design and supervise comprehensive outpatient exercise programs for Indi-

viduals with chronic Pulmonary disease.Instruct an individual with Pulmonary diseases in proper breathing tech­niques and exercises and methods for performing physical activities safelyand effectively in an unsupervised exercise setting.

Describe the epidemiology, pathophysiology, risk factors, and key clinical

findings of Pulmonary diseases . ..List the drug classifications commonly used in the treatment of IndiVidualswith Pulmonary diseases and disabilities, name common generic and brandnames drugs within each class, and explain the purposes, indications, majorside effects, and the effects, if any, on the exercising individual.Explain how treatments for Pulmonary disease, including preventive care,

may affect the rate of progression of disease. .List the risk factors for Pulmonary disease and explain methods of reducing

risk.

PULMONARY: EXERCISE PRESCRIPTION AND PROGRAMMING

Describe the epidemiology, pathophysiology, risk factors, and key clinical

findings of Pulmonary diseases .Explain the common medical and surgical treatments of Pulmonary diseasesincluding pharmacologic therapy, surgery, and transplant.

PULMONARY: HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

Describe the potential benefits and hazards of aerobic, resistance, and flexi-

bility exercise in individuals with Pulmonary diseases. .Explain how Pulmonary diseases may affect the phySiOlogic responses to aer-

obic, resistance, and flexibility exercise.Explain how scheduling of exercise relative to meals can affect dyspnea.Explain how Pulmonary diseases may affect range of motion, muscular

strength and endurance.

PULMONARY: PATHOPHYSIOLOGY AND RISK FACTORS

Instruct an individual with cardiovascular diseases and disabilities in tech­niques for performing physical activities safely and effectively in an unsuper­

vised exercise setting.

PULMONARY: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

3.7.2

3.6.4

3.7.3

3.6.3

3.6.1

3.7.1

3.74

3.6.2

3.3.4

3.3.3

3.3.13.3.2

3.2.2

3.2.1

3133.1.4

312

3.1.1

2.7.4

342 SECTION IV / APPENDICES

344 SECTION IV / APPENDICES APPENDIX F / AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 345

4.7.2

4.7.3

4.7.4

5.1.1

5.1.2

5.1.3

5.1.4

5.2.1

5.3.1

5.6.1

5.6.2

5.7.1

5.7.2

Design, adapt. and supervise an Exercise Prescription for patients withcomplications due to Metabolic diseases (e.g., amputations, retinopathy,autonomic neuropathies, vision impairment, hypotension, hypertension and

during hemodialysis treatments)Design and supervise comprehensive outpatient exercise programs for indi-

viduals with Metabolic diseases.Instruct individuals with Metabolic diseases in techniques for performingphysical activities safely and effectively in an unsupervised exercise setting.

ORTHOPEDIc/MUSCULOSKELETAL:EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

Describe the potential benefits and hazards of aerobic, resistance, and flexi­bility exercise in individuals with musculoskeletal diseases and disabilities(e.g., low back pain, arthritis, osteoporosis/fibromyalgia, and

tendinitis/impingement syndrome, amputation).Explain how musculoskeletal diseases may affect the physiologic responses

to aerobic, resistance, and flexibility exercise.Describe the appropriate use of rest, spinal extension-flexion exercises vs.lumbar stabilization, and the appropriate dose of avoidance of physical activ­

ity in patients with back pain.Explain how musculoskeletal diseases and disabilities may affect functionalcapacity, range of motion, balance, agility, muscular strength and endurance.

ORTHOPEDIc/MUSCULOSKELETAL: PATHOPHYSIOLOGY AND RISK FACTORS

Describe the epidemiology, pathophysiology, risk factors, and key clinical find­ings of orthopedic/musculoskeletal diseases & disabilities (e.g., low back pain,arthritis, osteoporosis, tendonitis/impingement syndrome, and amputation)

ORTHOPEDIc/MUSCULOSKELETAL: HEALTH APPRAISAL, FITNESS AND

CLINICAL EXERCISE TESTING

Recognize and respond to abnormal signs and symptoms in individuals Withmusculoskeletal diseases and disabilities such as pain, muscle weakness

ORTHOPEDIC/MUSCULOSKELETAL: MEDICAL AND SURGICAL MANAGEMENT

List the drug classifications commonly used in the treatment of patientswith musculoskeletal diseases and disabilities, name common generic andbrand names drugs within each class, and explain the purposes, indica­tions, major side effects, and the effects, if any, on the exerciSing

individualExplain how treatments for musculoskeletal disease, including preventive

care, may affect the rate of progression of disease.

ORTHOPEDIc/MUSCULOSKELETAL: EXERCISE PRESCRIPTION

AND PROGRAMMING

Explain exercise training concepts specific to industrial or occupational reha­bilitation, which includes work hardening, work conditioning, work fitness,

and job coaching.Design, adapt, and supervise an Exercise Prescription (aerobic, strength, andflexibility training) to accommodate patients with complications due to mus­culoskeletal diseases & disabilities (e.g., low back pain, arthritis, osteoporosis,

tendonitis/impingement syndrome and amputation)

5.7.3 Instruct an individual with musculoskeletal diseases and disabilities in tech­niques for performing physical activities safely and effectively in an unsuper­vised exercise setti ng.

NEUROMUSCULAR: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

6.1.1 Describe the potential benefits and hazards of aerobic, resistance, and flexi­bility exercise in individuals with Neuromuscular diseases & disabilities (e.g.,Multiple Sclerosis, Muscular Dystrophy, Parkinson's Disease, Polio and PostPolio Syndrome, Stroke and Head Injury, Cerebral Palsy, Amyotrophic LateralSclerosis, Peripheral Neuropathy, Spinal cord injury, Epilepsy)

6.12 Explain how Neuromuscular diseases may affect the physiologic responses toaerobic. reSistance, and flexibility exercise.

6.1.3 Describe the effects of nonmotor complications, such as fatigue, on exerciseperformance in patients with Neuromuscular diseases and disabilities

6.1.4 Explain how Neuromuscular diseases and disabilities may affect range ofmotion, balance, agility, muscular strength and endurance.

NEUROMUSCULAR: HEALTH APPRAISAL, FITNESS AND CLINICALEXERCISE TESTING

6.3.1 Recognize and respond to abnormal signs and symptoms in individuals withNeuromuscular diseases and disabilities such as muscle weakness, cognitivedeficit, fatigue.

NEUROMUSCULAR: EXERCISE PRESCRIPTION AND PROGRAMMING

6.7.1 Adapt the Exercise Prescription based on the functional limits and benefits ofassistive devices (e.g. wheelchairs, crutches, and canes)

6.7.2 Develop an appropriate Exercise Prescription (e.g. aerobic, strength, flexibilitytraining) for individuals with Neuromuscular diseases and disabilities includ­ing those treated with surgery.

6.7.3 Design, Adapt, and Supervise aerobic, strength training and flexibility exer­cise routines to accommodate patients with complications due toNeuromuscular diseases and disabilities (e.g., Multiple Sclerosis, MuscularDystrophy, Parkinson's Disease, Polio and Post Polio Syndrome, Stroke andHead Injury, Cerebral Palsy, Amyotrophic Lateral Sclerosis, PeripheralNeuropathy, Spinal cord injury, Epilepsy)

6.7.4 Instruct an individual with Neuromuscular diseases and disabilities in tech­niques for performing physical activities safely and effectively in an unsuper­vised exercise setting.

IMMUNOLOGIC: EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

7.1.1 Describe the immediate and long-term influence of medical therapies for NIHon Cardiopulmonary and musculoskeletal responses to exercise training.

7.1.2 Describe the potential benefits and hazards of aerobic, resistance, and flexi-.' bility exercise in individuals with NIH disease (e.g. cancer, anemia, bleeding

disorders, AIDS, organ transplant, Chronic Fatigue Syndrome)7.1.3 Explain how NIH diseases may affect the physiologic responses to aerobic,

resistance, and flexibility exercise.7.1.4 Explain how cancer therapy (e.g., surgery, radiation, and chemotherapy) may

affect functional capacity, range of motion, and the physiological responses

to exercise.7.1.5 Apply current US. national guidelines for primary and secondary prevention

of NIH disease (e.g. ACS, NIH)

APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS346

7.21

7.3.1

7.6.1

7.6.2

7.6.3

7.71

7.72

7.7.3

7.7A

SECTION IV / APPENDICES

IMMUNOLOGIC: PATHOPHYSIOLOGY AND RISK FACTORS

Describe the epidemiology, pathophysiology, risk factors, and key clinicalfindings of NIH diseases (e.g. cancer, anemia, bleeding disorders, AIDS,organ transplant, Chronic Fatigue Syndrome)

IMMUNOLOGIC: HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

Recognize and respond to abnormal signs and symptoms in individuals with

NIH diseases such as fatigue, dyspnea, tachycardia.

IMMUNOLOGIC: MEDICAL AND SURGICAL MANAGEMENT

List the drug classifications commonly used in the treatment of patients withNIH disease, name common generic and brand names drugs within eachclass, and explain the purposes, indications, major side effects, and the

effects, if any, on the exercising individual.Summarize key recommendations of current u.S. clinical practice guidelines(e.g. ACS, NIH) for the prevention, treatment and management of NIH dis­eases (e.g. cancer, anemia, bleeding disorders, AIDS, organ transplant,

Chronic Fatigue Syndrome)Explain the common medical and surgical treatments of NIH diseases includ-

ing pharmacologic therapy, and surgery.

IMMUNOLOGIC: EXERCISE PRESCRIPTION AND PROGRAMMING

Develop an appropriate Exercise Prescription (e.g. aerobic, strength, flexibilitytraining) for individuals with NIH disorders (e.g. cancer, anemia, bleeding dis­orders, AIDS, organ transplant, Chronic Fatigue Syndrome)Design, adapt, and supervise the Exercise Prescription to accommodatepatients with physical disabilities and complications due to NIH diseasesDesign and supervise comprehensive outpatient exercise programs for indi­viduals with immunologic/hematological disorders (e.g. cancer, anemia,bleeding disorders, AIDS, organ transplant, Chronic Fatigue Syndrome)Instruct an individual with immunologic/hematological diseases and disabili­ties in techniques for performing physical activities safely and effectively in

an unsupervised exercise setting.

1.12

1.13

121

1.2.21.2.3

1.2.4

1.3.1

1.3.2

1.3.3

1.3.4

1.51

347

Ability to describe the relationship between biomechanical efficiency, oxygencost of activity (economy), and performance of physical activity.Knowledge of the muscular, cardiorespiratory, and metabolic responses todecreased exercise intensity.

GENERAL POPULATION/CORE: PATHOPHYSIOLOGY AND RISK FACTORS

Ability to define atherosclerosis, the factors causing it, and the interventionsthat may potentially delay or reverse the atherosclerotic process.Ability to describe the causes of myocardial ischemia and infarction.Ability to describe the pathophysiology of hypertension, obesity, hyperlipi­demia, diabetes, chronic obstructive pulmonary diseases, arthritis, osteoporo­sis, chronic diseases, and immunosuppressive disease.Ability to describe the effects of the above diseases and conditions oncardiorespiratory and metabolic function at rest and during exercise.

GENERAL POPULATION/CORE:HEALTH APPRAISAL, FITNESS AND CLINICAL EXERCISE TESTING

Knowledge of the selection of an appropriate behavioral goal and thesuggested method to evaluate goal achievement for each stage of change.Knowledge of the use and value of the results of the fitness evaluation andexerCise test for various populations.Ability to design and implement a fitness testing/health appraisal programthat includes, but is not limited to, staffing needs, physician interaction, doc­umentation, equipment, marketing, and program evaluation.Ability to recruit, train, and evaluate appropriate staff personnel for perform­ing exercise tests, fitness evaluations, and health appraisals.

GENERAL POPULATIONICORE: MEDICAL AND SURGICAL MANAGEMENT

Ability to identify and describe the principal action, mechanisms of action,and major side effects from each of the following classes of medications:Antianginals, Antihypertensives, Antiarrhythmics, Bronchodilators,Hypoglycemics, Psychotropics, and Vasodilators.

NOTE: The KSAs listed above for the ACSM Registered Clinical Exercise Specialist'" are the same KSAs foreducational programs in Clinical Exercise Physiology seeking graduate (master's degree) academic

accreditation through the CoAES. For more information, please visit www.coaes.org.

Additional KSAs required (in addition to the ACSM Health/FitnessInstructor® KSAs) for programs seeking academic accreditation in AppliedExercise PhysiologyThe KSAs that follow, IN ADDITION TO the ACSM Health/Fitness Instrudor®

KSAs above, represent the KSAs for educational programs in Applied Exercise

Physiology seeking graduate (master's degree) academic accreditation through

the CoAES. For more information, please visit wwvl.coaes.org.

GENERAL POPULATION/CORE:KSA # EXERCISE PHYSIOLOGY AND RELATED EXERCISE SCIENCE

1.1.1 Ability to describe modifications in exercise prescription for individuals withfunctional disabilities and musculoskeletal injuries.

GENERAL POPULATION/CORE: HUMAN BEHAVIOR AND COUNSELING

1.9.1 Knowledge of and ability to apply basic cognitive-behavioral interventionsuch as shaping, goal setting, motivation, cueing, problem solving, reinforce­ment strategies, and self-monitoring.

1.9.2 Knowledge of the selection of an appropriate behavioral goal and the sug­gested method to evaluate goal achievement for each stage of change.

GENERAL POPULATIONICORE:SAFETY, INJURY PREVENTION, AND EMERGENCY PROCEDURES

1.10.1 Ability to identify the process to train the exercise staff in cardiopulmonaryresuscitation.

1.10.2 Ability to design and evaluate emergency procedures for a preventive exer­cise program and an exercise testing facility.

1.10.3 Ability to train staff in safety procedures, risk reduction strategies, and injurycare techniques.

1.10A Knowledge of the legal implications of documented safety procedures, theuse of incident documents, and ongoing safety training.

348 SECTION IV / APPENDICES APPENDIX F/ AMERICAN COLLEGE OF SPORTS MEDICINE CERTIFICATIONS 349

11111.11.2

111.3

1.11.4

1.11.5

111.6

111.7

1 11.8

1.11.9111.10

111.11

1.11121.1113

1.1114

111.15

111.161.11.17

111.181.11.19111.20

111.21111.22

1.11.23

1.11.24

111.25

111.26

GENERAL POPULATION/CORE: PROGRAM ADMINISTRATION, QUALITYASSURANCE AND OUTCOME ASSESSMENT

Ability to manage personnel effectively.Ability to describe a management plan for the development of staff,continuing education, marketing and promotion, documentation, billing,facility management, and financial planning.Ability to describe the decision-making process related to budgets, marketanalysis, program evaluation, facility management, staff allocation, andcommunity development.Ability to describe the development, evaluation, and revision of policies andprocedures for programming and facility management.Ability to describe how the computer can assist in data analysis, spread­sheet report development, and daily tracking of customer utilization.Ability to define and describe the total quality management (TQM) andcontinuous quality improvement (CQI) approaches to management.Ability to interpret applied research in the areas of exercise testing, exerciseprogramming, and educational programs to maintain a comprehensive andcurrent state-of-the-art program.Ability to develop a risk factor screening program, including procedures,staff training, feedback, and follow-up.Knowledge of administration, management and supervision of personnel.Ability to describe effective interviewing, hiring, and employee terminationprocedures.Ability to describe and diagram an organizational chart and show therelationships between a health/fitness director, owner, medical advisor,and staff.Knowledge of and ability to describe various staff training techniques.Knowledge of and ability to describe performance reviews and their roll inevaluating staff.Knowledge of the legal obligations and problems involved in personnelmanagement.Knowledge of compensation, including wages, bonuses, incentive pro­grams, and benefits.Knowledge of methods for implementing a sales commission system.Ability to describe the significance of a benefits program for staff anddemonstrate an understanding in researching and selecting benefits.Ability to write and implement thorough and legal Job descriptionsKnowledge of personnel time management techniques.Knowledge of administration, management, and development of a budgetand of the financial aspects of a fitness center.Knowledge of the principles of financial management.Knowledge of basic accounting principles such as accounts payable,accounts receivable, accrual, cash flow, assets, liabilities, and return oninvestment.Ability to identify the various forms of a business enterprise such as soleproprietorship, partnership, corporation, and S-corporation.Knowledge of the procedures involved with developing, evaluating, revis­ing, and updating capital and operating budgets.Ability to manage expenses with the objective of maintaining a positivecash flow.Ability to understand and analyze financial statements, including incomestatements, balance sheets, cash flows, budgets, and pro forma projections.

111.27111.281.11.291.11.30

111.311.11.321.1133

111.34

1.11.35111.36

111.37111.38

111.39111.40

1.11.41

1.11.42

1.11.43

111.44

111.45

1.11461.11.471.11.48111.49

111.50

111.;;1

111.52

111.53

111.54

Knowledge of program-related break-even and cost/benefit analysis.Knowledge of the importance of short-term and long-term planning.Knowledge of the principles of marketing and sales.Ability to identify the steps in the development, implementation, and eval­uation of a marketing plan

Knowledge of the components of a needs assessment/market analysis.Knowledge of various sales techniques for prospective members.Knowledge of techniques for advertising, marketing, promotion, and publicrelations.

Ability to describe the principles of developing and evaluating product andservices, and establishing pricing.

Knowledge of the principles of day-to-day operation of a fitness center.Knowledge of the principles of pricing and purchasing equipment and sup­plies.Knowledge of facility layout and design.Ability to establish and evaluate an equipment preventive maintenance andrepair program.

Ability to describe a plan for implementing a housekeeping program.Ability to identify and explain the operating policies for preventive exerciseprograms, including data analysis and reporting, confidentiality of records,relationships with health care providers, accident and injury reporting, andcontinuing education of participants.Knowledge of the legal concepts of tort, negligence, liability, indemnifica­tion, standards of care, health regulations, consent, contract, confidentiali­ty, malpractice, and the legal concerns regarding emergency proceduresand informed consent.

Ability to implement capital improvements with minimal disruption of clientor business needs.

Ability to coordinate the operations of various departments, including, butnot limited to, the front desk, fitness, rehabilitation, maintenance andrepair, day care, housekeeping, pool, and management.Knowledge of management and principles of member service and commu­nication.

Skills in effective techniques for communicating with staff, management,members, health care providers, potential customers, and vendors.Knowledge of and ability to provide strong customer service.Ability to develop and implement customer surveys.Knowledge of the strategies for management conflict.Knowledge of the principles of health promotion and ability to administerhealth promotion programs.Knowledge of health promotion programs (e.g., nutrition and weight man­agement, smoking cessation, stress management, back care, body mechan­ics, and substance abuse).Knowledge of the specific and appropriate content and methods for creat­ing a health promotion program.Knowledge of and ability to access resources for various programs anddelivery systems.Knowledge of the concepts of cost-effectiveness and cost-benefit as theyrelate to the evaluation of health promotion programming.Ability to describe the means and amounts by which health promotion pro­grams might increase productivity, reduce employee loss time, reducehealth care costs, and improve profitability in the workplace.

Page numbers in italics denote figures; those followed by t denote tables; those followed by b denoteboxes.

Index

AAACVPR (American Association of

Cardiovascular and PulmonaI)'Rehabilitation), prepal1icipation risk stratill·cation for cardiac patients, 19-22,31,31b-32b

Absolute intensitv, defined, 4Acwlate, (see Zafirlukast)Accupril, (see QUinapril)Accuretic, (see Quinapril, and

hydrochlorothiazide)ACE inhibitors, (see Angiotensin converting

enzyme (ACE) inhibitors)Acebutolol, 255t, 26ltAceon, (see Perindopril)ACSM (American College of Sports Medicine)

Certification Resource Center, contactinformation, 3J.l

certifications of, 309-349 (see also ACS~1

certification)Committee on Certification and Registry

Boards, 310goals of, for health related physical /Itness,

133-l34mission of, 5-7prepal1icipation health screening guidelines

of, 19-31risk strati/lcation categories of, 28-29, 28t

ACSM cel1i/lcation, 309-310as Exercise Specialist, 311, 313

KSA (knowledge, skills, abilities) requi­sites f"r, 332-337

as Health/Fitncss Instructor, 311., 312KSA (knowledge, skills, abilities) requi­

sites for, 323-33l, 346-349information antI application materials for,

311KSA (knowledge, skills, ahilities) recjuisites

for, 314--316as Personal Trainer, 310~311, 312

KSA (knowledge, skills, ahilities) requi.sites for, 317-323

as Registered Clinical Exercise Physiologist,311,313--31-1

KSA (knowledge, skills, ahilities) requi­sites for, 337-346

ACSM Certi/lcation Resource Center, contactinformation, 311

ACSM University Connection EndorsementProgram, 310 '

Activities of daily living (ADLs), 154Activit)" Pyramid, 133, 13-1, l67

Actos, (see Pioglitazone)Acute mountain sickness, 307tAdherence to exercise program, 165-167

recommendations for, 167bAdult Treatment Panel III (ATP III), choles-

terol dassi/lcation of, 45-46Advair, (see Salmeterol, and f1uticasone)Ad",ur Diskus, (see Fluticasone, and salmeterol)Ach-icor, (see Lo"astatin, and niacin)AED (automated external defibrillator), 270Aerobic /Itness, clinical signi/lcance of, 1I8bAerobic po\\'er, (see ~Iaximal oxygen uptake)AeroBid, (see Flunisolide)Aging, (see Elderly people)AHA (American Ileal1 Association), risk stratifi­

cation criteria for cardiac patients, 33b-35bAHNACSM, preparticipation screening and

risk strati/lcation, 19-36, 33b-35bAIlNACS~1 HealthlFitness FaCility

Prepartidpation Scrf>ening Questionnaire,22,26

Albuterol, 259t, 264t, 265tAlcohol, cardiorespiratory effects of, 265tAklactone, (see Spironolactone)Aldalat, (see Niledipine, long-acting)Aldomet, (see Methyldopa)Akloril, (see Methyldopa, and hydrochloroth­

iazide)Alpha adrenergic hlockers

cardiorespiratOly efTects of, 262tgeneric and hrand names of, 255t

Altace, (see Ramipril)Alternath'e stretch, 160AJupent, (see Metaproterenol)Am"'yl, (see Glimepiride)Amiloride, 257t, 262t

and hydrochlorothiazide, 258tAmiodarone, 258t, 263tAmlodipine, 256t, 26ltAmyl nitrite, 256t, 26ltAngina

scales of assessment, 107symptoms and clinical significance of, USh

Angiotensin converting enzyme (ACE)inhibitors

"ith calcium channel blockers, generic andbrand nameS of, 257t

cardiorespiratOlY effects of, 262twith diuretics, generic and brand names of,

257tgeneric and brand namcs of, 2.56t

Angiotensin II receptor antagonistscardiorespirato,), effects of, 262t

351

353INDEX

mast cell stabilizers, 264tnicotine, 265tnitrates, 2611pentoxifylline, 266tperipheral dilators, 266tpsychotropiC agents, 264tsteroidal antiinflammatOly agents, 264tsympathomimetic agents, 264t, 26.5tthyroid medications, 265tvasodilators, 262txanthine derivatives, 264t

CardiorespiratOlY exercise prescription, 76-78,139-154

for children, 244-24.5duration of exercise in, 146--148for elderly people, 248-249energy expenditure goals in, 148-149grouping activities in, 140bintensity of exercise in, 141-146modes of exercise in, 139-141progression of training in, 149-1.51specillcity of training in, 1.51-153stimulus phase of, summary of, 1.53-154

CardiorespiratOlY fitness, 66improvement in, by physical activity, 8b-9bmaximal oxygen uptake in, 66--67submaximal exercise testing of, nb

Cardiovascular disease, (see also CoronalYartery disease)

major signs or symptoms of, 24t-25t, 28screening for, J9-36

Cardizem CD, (see Diltiazem, extended release)Cardizem LA, (see Diltiazem, extended release)Cardura, (see Doxazosin)Carvedilol, 255t, 2611Catapres, (see Clonidine)Catapres TfS patch, (see Clonidine)Central alpha agonists, and centrally acting

drugsand diuretics, generic and brand names of,

255tgeneric and brand names of, 2.55t

Certification, (see ACSM certification)Children, 241-245

and adult prescription models, 242-243cardiorespiratory training in, 244-245clinical exercise testing 01',237-240electrocardiographic changes in, 240endurance of, 239exercise menu for, 243exercise prescription for, 241-24.5exercise testing of, 240-241fitness testing of, 237lifestyle activity encouragement in, 243physiologic responses of, 239-240resistance training for, 245sedentary, and activity encouragement,

243-244unique physiologic responses of, 238t

Chlorothiazide, 2.57t, 262tChlorpropamide, 260t, 266tCholesterol absorption inhibitor, generic and

brand names of, 2.59tCholesterol testing, and management, 4.5--46Cholestyramine, 2.58t, 264tCholybar, (see Cholestyramine)

c

Bumetanide, 257t, 262tBumex, (see Bumetanide)

CAAJ-J EP (COInrnission on Accreditation ofAllied Health Education Programs), 310

Caffeine, cardiorespiratory effects of, 266tCailliet's protective hamstring stretch, 88Calan, (see Verapamil, immediate release)Calan SB, (see Verapamil, long acting)Calcium channel blockers, 258t

cardiorespiratory effects of, 2Ciltgeneric and brand names of, 2.56t

Calculations, (see Metabolic calculations)Candesartan, 257t

and hydrochlorothiazide, 2.57tCapoten, (see Captopril)Capozide, (see Captopril, and hydrochloroth­

iazide)Captopril, 2.56t, 262t

and hydrochlorothiazide, 2.57tCarbon dioxide output (VC02), 286Carboxyhemoglobin, 108Cardene SB, (see Nicardipine, sustained

release)Cardiac e\'ents, exercise related, 11-1.5, 14t, 1.5t

in adults, 12in carcliac rehabilitation, 13in exercise testing, 12-13in individuals with sickle cell trait, 12preventing, 13-1.5in young individuals, 11, 111

Cardiac glycosides, generic and brand names of,2.5Cit

Cardiac rehabilitationcardiac events in, 13, 1.5preparticipation risk screening in, 31,

3Jb-35bCardioquin, (see Quinidine)CardiorespiratolY effects, of medications,

2Ci1l-2Ci6talcohol, 26.5talpha adrenergic blockers, 262tangiotensin converting enzyme (ACE)

inhibitors, 262tangiotensin Il receptor antagonists, 262tanorexiants, 266tantiarrhythmic agents, 262t-263tanticholinergic agents, 264tanticoagulants, 266tantigout medications, 266tantihistamines, 26.5t.lmtilipemic agents, 2Mtantiplatelet agents, 2Ci6tbeta blockers, 26ltblood modillers, 266tbronchoclilators, 264tcaffeine, 266tcalcium channel blockers, 26ltdiet pills, 266tdigit<llis, 2611diuretics, 262thypoglycemic agents, 266tinsulins, 266t

Beh,wior ch'\1Igc ..'moti\'ation amI readiness for, 163-16.5,165,

166bpractical reco1l11llf'ndations for, \67h

Bpnazepril, Z56t, 2()2tand amlodipine, 257tand Imlrod,lorotbi,v.idc, 2,57t

Bench 1)f~SS test. YMCA, 1>5, 1>7tBcnicar, (see Olniesadan)Beta-2 receptor agonists, generic and hrand

llawes of, 259tBeta blllckers, 251>t

cardiorespiratory effects or, 261t .and diuretics, generic and hrand names uf.

2.55tgeneric and hrand nallles of, 2,5.:5t

Betapacc, (see Sotalol)Bct<~,olol 2,5,5t,26JtBJA (bio~ledric impedance analysis), Ci5,Bi<1uanidps, generic and hrand names of, 200tBjk-' add seqllestrants, generic and hrand namcs

or, 251>tBisllprolol, 2,5,5t, 26lt

'md lwdrochlorothiazide, 255t

Blo:adre,{, (see Timolol)Blood gases, in dinical respiratOl)' testing, 108

Blood mmlillerscardiorespiratory effects of, .26~tOelH:'ric and hrand names of, 2;)9t

Bluobd pressure, and assesslllent, 4:3-44, 76-.77

adult, classification and m~HlagP1l1entof, 44t

in children, 2:39dnring exercise testing, 10:3-105, 119

clinical significance uf. 118hpotential f'rror sources. in, 1~5h .in pre-exprcise evaluatIon, 4.3-~4, 4.3h

Bloud profilf' analyses, in pre-exerclse evalua­

tion, 46--47normal adult variahles in, 47t

Body composition, 57 '__ .anthropometric mcasurement ~I: u ,~~3df'llsitolnetric Inpasurement 01, 64-6;)or men, norms of, 60tnorms of, 66, 66t, 67tother nwasllrewellts 01", 65or WOrHPIl, norms or, 67t

Bod\' density, conversion to hody composition,

64-6,5 "population specific, 6,5t '__

Bod\' ht distribution, patterns 01, ,)1>-;>9Body mass index (13"-'1.1), 51>

discase risk classificatiol\ based on, SRtpredicted hody fat percentage based on, ,59t

BOlle integrity, 3Brand ll~llnes, of lnedications, 2.55t-260tBrethine, (see Tcrbutaline)Bretvlium,2.58tBretylol, (see Bret\'linm)Ilrc\'ihloc, (see £"nlllol)Bf()11Chodilators

cardiorespiratory efrpcts of, 264t .generic and hrand names of, 2.59t-260t

Bruce treadmill protocol, 99endurance til1iC by gendpr ~\Ilcl age un, 240tf()r tt-'sting chil(lren, 2:3B

Bndesllnide, 259t, 264t

INDEX

AnU"iotellsin II (COI/tilll/cd) .'-"with diuretics, g(-'>lleric and brand 1l,1l1lCS of,

2,57tgeneric and brand ,~allles of" ,2.S7.t '. '

Anorexianls. cardiorespiratory cf{~>clS of, 2661Anthropometric lllc<!Sllrelllcnl, of hody compo­

sition ..57-6:3Antiarrhytlll11ic <.lgf'lIts .. . :) ,:) ».

cardiorcspirator\' effeds 01, _6~t-_63tgeneric and bra;l(} namE'S of, 25Ht

Anticholinergic agents. .cardiorcspiralun" el1cets of, 264ttTcllcric and Im.l;lJ names of, 259t~'illl SVlllpatllo1nitnetics, generic iliid hral1d

nat;lCS of, 259t

Antico<.lgu1alltS. .. . Q .•

cardiorespIratory eHeds oC ,_66tgeneric and brand nalll~>s of, 2.5~~ . .

Antidepressants. c<lrdioreSplratory effects of,

264t ITAnligout llledications, cardiurespiratol)' e pets

or-. 266t " 'Al1tillistalnines, cardiorespirator!' efleets ()l,

Z6,5tAntilipemic agents " '.

cardiorespiratory elleds of, ,264t _generic and brand names of, 2.58t-2u9t

Antiplatelt-'l ag~nts ",';")'cardiorespiratury effects of, ,_G6tgeneric and hrand nal1le~ 01, 259t

Appt-'tite suppressants, genenc and hrand

names of, 260tAprcsoline, (see Ilydralazine)Arlll cycling, and ergometry, 70, 99, 102

energy rt:'qllirelllent~for, 2~3t '-'metabolic f'qnatiun for gross oxygen lIptakt

in, 21>9t, 290-291Arrlwthmi,-ls, exercise associated, J17b, 122,

J31>-J39Arthritis, exercise prescdption in, 205-207 .Astrand-l\hYllling cycle ergometer, Sllhl11i:l,XIlnal

testinO' un, 70, 72-74Astrand~1hynlingnOlllogram, modific(l, 7.3Atacand, (see Camlcsartan)Alacand !lCT, (sec Candesartan, and

hydrochlorothiazide)Atenolol, 255t, 261 t

ami chlorthialidOlw, 2.5,5tAtorvastatill,2.59tATP [] I (AdnIt Treatment Panel [] I), choles-

terol classification of, 4,5-46Atromid, (see Clofibrate)Atrm'cnt, (see Ipratropium) _Automated cxternal defibrillator (A£D), 2,0A\'alide, (see lrhesartan, and hydrochloroth-

iazidc)A\'andia, (see Bosiglitazone)Avapro, (see Irbcsaltan)A'l.1l1acort, (see TriamcinolOlw)

Balke-Warp protocol, 99Beclomethasonc, 2,59t, 264tBeclovent. (see Beclolllethasone)

B

352

355INDEX

EBC1' (dectron beam computed tomography),in clinical e,ercise testing, Ill-I 12

ECe, (s('(' Electrocardiography)Echocardiograph:, in clinical exercise testing,

110Edecrin, (Sl'(, Ethaclynic acid)Eiderii' people, 1-16 '

cardiorespiratory e:xercise for, 248-249c\ercist" prescription for, 247exercise tl'sting 01',146-147flexibilih' excrcise and range of motion

in, 2.50r('sistance trainin~ for, 149-250

Electrocardiogram (ECC) inte'1,retation, 279Electrocardiograpll)"

in clinical e\ereise tl'sting, 105, llO-11lprecllOr,~al (chest lead) placement, 179t

resting 12-lead, normal limits and waveforminlel1"'etation in, lS0t-28lt

waveform inte'l1retation in, 119-122,279,1791

atrioventricillar hlock, 2S4tat rim'cntricular dissociation, 285tnormal limits and wave/orllls, 280t-281.tnormal QT interval as function of heart

ra!l'.lS2tS1' segment depression, 1l7h, 121-112S1' sel(llIent displacement, 1.10-112,

116hS1' sl'gment ele\'ation, 117b, 11 IST segment normalization (absence of

change), 111sllpnwcntricular versus ventricular

ectopic heats, lS3ttranSlnllraJ infarct localiz,ation, 282t

Ellpstad protocol, fl9Emergency medical plan, 267, 270, 276t-278t

automated external del'ibrillators in, 170e<.juipment and drugs required in,

16S1-2691key componcnts of', 270potential. 173t-175t

Enalapril, 15(;t, 161tand ldodipine, 157tand hydrochlorothiazide, 257t

Endurance exercise, (see Cardjorespiratorv("xercise prescription) -

lOnerI(" halance, 6Energ)' expenditure goals, in carchorespirato,)'

ewrcise, 14S-149Energy requirements, of physical acti\"ity.

lS6-199, (se(' II/SO ~lctaholiccalcnlations)Environmental considerat-ions, :300

cold exposure ,LS, 304~10-5heat e,poso re as, 30(h10-lhigh altitude in. :306-:307ref('rences on, :307-30S

Dyslipidemia, exercise prescription in, 211-212Dyspnea, scales for assessing, 107Dysrhythmias, cardiac, exercise associated.

117b, 121, 138-139

E

in exercise testing. 12-1:3in indidduals with sicklf' cell trait. L2prel'enting, 1:1-15ill youne; individuals, 11

Dehydration, a\'oiding, in heat, ,30:3Dellladex, (s('(' 1'orsl'lllide)Densitollll'trl', 64-6.5Dl'poniL (s('~ 1\itrogil'cerin, transderlll,J)DE>V\ (dual en('rg" x-ral' ahs0'l,tiollletn'l, 65DiaBeta, (s('(' Cll'buridc)Diahetl's mellit,;s. 107-10S

exercise prescription in, 20"5-210f'\ercise testing in. 20';hyperglycemia and hypoglycC'lllia in, signs

of,109tspecial considerations in, 110-11 I

Diabinese, (s('(' Chlo'l,ropamilk')Diagnostic exercise testing, 9:3-9.5, 124--12H,

(s('e II/SO Clinical exercise testing)Diamicron. (s('(' Cliclazidl')Diastolic hlood prl'ssure. 119

clinical sil(nifkance of, IlSbDiet pills, cardiorespiratory cf'f'eets of, 1661Digitalis. cardiorespiratOlY effects 01',161 tDigoxin,1,56tDilacor, XH, (s('(' Dilliazem, extended release)Dilantin, (se(' Phenl'toin)Dilatrate, (s('(' 1sos~rhidc dinitrale)Diltiazl'm, extendcd releaxe, 1.561, 1611Diovan, (see Valsartan)Diol'an HC1', (se(' \'alsartan, and

Il\'drochlorothiazidl')Dij;yridallloll', 2.59tDirect method, of' ohtaining target heart

range, 144Disopyramidl', 158t. 162tDiupres, (s('e Hesel1'ine, and chlorothiazide)Diuretics

and ACE inhihitors, generic and hrandnanl('S of, 257t

and angiotensin II recf'ptor antagonists.generic and brand names of, 2057t

and beta hlockers. generic and brand namesof,1,55t

cardiorespiratolY erreds or, 261tand central alpha a~onists, generic and

hrand names of. 2.55tcombined, 25S1generic and hrand names of, 2.57t-258tloop, 257tpotassium sparing, 257t

Dinril, (s('(' Chlorothiazide)Dohlltamille, in clinical exercise testing, I I J

Dofl'lilide, 2,5StDose response relationship. physical activity and

hl'alth,7-10el'idence of, lOt

Doxazosin, 2.5.5t, 262lDrugs, (spl' ~Iedications; specific genf'ric naillf')Dukf' nomogram, 127-128Duration, of cardiorespiratory exercise. 1--1-6-148Dyazide, (8('(' Tri<lmterene, ilnd Il\'drochloroth-

iazide) ,

D\'naCirc CH, (S('I' Isradipine)D~Tenillm, (.':we Triamtcrene)

/

Data interpretation. (.~'('e Clinical excrcise test­ing; Elt'ctro<:ardiograpll:; E\ercis(' testing;I (part rate n:~pollse)

Death, ",ercis" related, 11-15in adults, 11ill cardia<: rellahiJitation, 1:3

Committee on Accreditation for tilt' E:\er<:iseSciences (CoAES), 310

acadeJllic accreuitatjoll hv, f()rHealth/Fitness Instructor in AppliedExercise PIl\'siolol('. 34fi-,149

Conditioning pllas~, 1:38 'C011ditiolling stage, or cardiol"espirator:'

e.\ercise, 1.50Content malter, of KSAs, 315-:316COIltraindications. to pre-exercisc {-'valuatioJ],

49,50tCool dm,", ewrcises. t:3S- J:39Conlarone, (Sl'(> Amiodarorle)Corcl(, (s('1' Can'edilol)Corl(ard, (s('e I'\adolol)Coronary artel.... dise<L"~t'

per~l'llt nu"nnal e.\en::ise capacit) in lIlenwith, nomograms of, 96-97

preparticipation health screeninl( in, 19-:36,9:3-94. 11.5--119 (see also Clinical e,ereisetesting; Pre-exercise e\'aluation)

ACSM ,J~orithlll IlJr, 19, 20t-2lt, 22ACS~I risk stratification categories ill,

11l-29.2SIadd.itional asseSSlllt-'nts in, 29-30medical clearance in, 22-29recomlllendations in, 30--31risk l,'clor thresholds in, 1:3trisk stratif'ication in, 22-29

for cardiac patipnts, 31-:35supervision rec.:ornmendations in, :30-31

pretest likelihnod of, 94tproglj()stic signifkanc(' of l)('ak exercise

capacity in, 98risk f,'dms 1<>1', lS, :31~1,5

reduction of, by physical actil'it),. Sb-9hCorzide, (Sl'(, Nadolol, and hendroflulllPthi-

azide)Coumadin, (sr(' \\'arf~lrin)

COl'era liS, (see "erapamil)Cozaar, (see Losartan)Crestor, (see RoslI\'astatin)Crolllollll inhaled. 1601Crunch't,·st, &41>

fitness categories in. SCitCurl-up test, ~-lb

fitness C<-ltegories in, 8mCycle erl(ollleter, 69, (se(' (dso Arill cyclinl(; LeI(

cvclinl()'arlll: 102clinical testing with, 98-99mechanicallv braked, 69sllhlll<lxilllaJ" testillg with. 70, 72-74testing children Oil. 2:38, 239t

Cycle ergometry protocol, Y.\leA, ,4

D

INDEX354

CiiazapriJ, 156t, 161tCilostazol, 159tCirClIlllfert'J)ce siles

(1)1(1 m(',l\llrelllent procedures. 5R-.59,60h-6lb

starltlardized descriptioll of, and llleaSIJ re­ment, 60h-61h

Claudication. scales for assessing. 107Clinical exercise testing, 9:3

applications nf, 93-96of children, 1:37-145compared with imaging ~tress tesb. 126cOlllpptenc) in, col(niti\'e skills, J09h (s('('

a/so ACSM certilkation)diagnost ic.: \'ahw of. 124-l28of e1derh people, N6-250imaging llIodalities ill, J.10-112indications for, 9:3-96interpretinl( results of, 115-116, 117h-llSh

blood pressure response in, IJ 9elct:trocardiograph wavefortlls in,

I J9-112gas exchange and \"(-'Iltilatory responses

in, 12J..-124heart rate response ill, 1.16-11.8Ijnliting signs or symptoms ill, 12:3

measurements during, 103-108hlood g'L"", lOSelectrocardiographic 1l1onitoring, 10.5gas exchange and \'cntilahJI)' responses,

107-10&he,ut rate and blood pressure', 10:3-105sul)jectivt' ratings and symptoms,

10(;-107mndes of, 9(1-99monitoring intclyals during, n..·L'Omlllt'ndcd,

104t['ostexereis" period in, lOS-I 09prognostic applications of, 126-12.'->prolocols of, 99-102

and associated metabolic costs, 100-101references on, 111-114for retnrn to work, 102-103as screening tool f()r coronary ~lIier)'

disease, 11.5-129supervision of, 109h, 111tennination of, indications for. J06h, JOSupper body, 102

Clol'ibrate, 2,sSt, 264tClonidine, 25,5tClopidogrd, 1,59tCoAES (Colll1llittee on Accreditation for tilt-'

Exercise Sciences), 310academic accreditation 1)\", for

Ilealth/Fitness Instruc'tor in AppliedExercise Physiolo!(j', :34&-349

Cold, as en\'ironnlcnt,ll f~lctor, ,304--30.5Cold air, effeds of inhalation of, 305Cold illnesses, :304-30,5CoIexe\'e1am, 1,5St, 16-1tC:olestid, (s('(' Colestipol)Colestipol, 15St, 16-11Comhivt'llt, (see Ipratrupilllll, and alhuterol)Commission all Accn:ditation 01' Alljed Ilealih

Edncation Programs (CAA II EP), 310

357INDEX

Cas partial pressures, 101;C(,l1lfl"rozil. 25&1. 264t~~'I)(->'ric name's. of medications, 2.5.5t-260tClrth lllf'aSUrelllellts. and measurement

pro('edures. .58-59, 60h~ IbCliclaziek,. 260t, 266tClimepiride, 260t, 266tClipizide. '260t, 266tClllconorl1l, (see HepaglinidejGillcophage. (see ~Ictformin)Glilcosidas(' inhibitors. generic and brand

1""11('S oC 260tC:'ucotrol, (sec Glipizide)~Iuco\'ance, (see Metformin, and glvburide)C.Iv"unde. 260t, 266t "Clvnase. (see Cldlllrid,,)Clvs('t. (sec ~Iigiitol)

Craded e'",rcise tcsting (GXT), 102-103C:~lllpar(~d with imaging stress tests, 126diagnostic \-aluf' of. 12..f--128lidse n('gatiw results in, causes of, 1.2.5hlIlterpr('ting r<,sults 01: 116-124, 117h-lJ8b

blood pressure r('sponsc in, 119electrocardiograph waveforms in,

J 1fl-122gas exchange and ventilatory responses

in. J2:3-124I,('alt rate respnnse in, 116-lJ8

Jin~itillg signs or symptoms in, 123ref('renc<'s for. 12S-129sensitivity of. J24-12.5

Cuanf~lcille, 2.5.5t

H11 f) L cholest('rol, classification of 45tJ!c'alth and fltlless (''"<tillation, con;prehenSive

1;9-90 '

H('altfl/Fitness Inslructor. ACSM certified 311KSA (knowl('dge. skills, abilities) requi~ites

for, 32.3--:1:11adeLtional, /01' Applied Exercise

Physiology accreeLtation, 346-.349cardio\'ascular pathophysiology and risk

faclors. 3.31electrocardiography and diagnostic

techniCjU('S, 326('\ercise physiology and related exercise

science, 32:1--325exercise prescription and programming.

:326-321; ,

he'alt" appraisal, fitness. and clinicale'x('rcise testing, 325-326

human ':chavior and counseling, 329l1letabohe pathophysiology and risk

lactors, 331 .1I1ltrition and wcight management-,32~329

orthopedic/muscilloskeletal pathopll)'si­ologv and nsk lactors. :3:J 1

pathophysiology and risk faclors, :12.5patient management and

medications. .'326

PJ()gldl1l <ldllllJ)lstration {judlltv

,lssulance. <lI1d OIltcome <lssessment.3.30<3.31

interprding resnlls of'. 11.5-1 16, 1IIb-IISbhlood pressurp response in. j 190Iectlo(;<udlogl<lph w<l\efOlIllS III

J 19-122ga~ ('\change and ventilatory r0sponses

Ill, L2:3-124heart rate r0sponse in, I 16-1 IHlimiting signs or symptoms in, ]2.3referenees for. 12S-12fl

m<'lx.imal v('rsus submaxjmal, 67~(ih

modes of, 6'>-761Il1lscllL~r strength and pndllranc(' in, 79-..').5order of tests in, .56

pre-exer<.:ise f'\'aluation in. :39-.54 (sef' alsoPr('-e.\ercise e\"aluation)

prepalticipation health screening in. Ifl~3.5(see also Prep,nticipation be,Jtb screening)

pllTlclples and gUIdelines in. 5&-.57plllmomlJy function ill. 47-t~)PUl1)oses of..55ref('rpnccs 011, 5-1, 90-92risk of'careLac elenl in, 12-13, 14ttermination-of-testing criteria in, 78, 7hhupper bod\', 102

Ezetimibe. 259t

FFat free lIl'l>S (FFM), 64Fal mass (F~I), 64Felodipine, 2.56t. '261tFenoflbrate, 2.5St. 264tPihric acid derivati\'(~s, generic and brand

name's of, 25HtField test(s), 6&. 69-70Field lest e'iualions, 2fll;, 291;tPitiless

cardiorespiratory (sec Cardiorespirator\'fitness) .

ph.l'sical, 3 (see also Physical fitness)physiologic, 3-4

Flccainide,2.5&tFbibility, S5~S6

<,xercise prescription for. 1.5S-160in elderly people, 2.50

and range of motioll of self'cted joints. H7tFlovent, (see F1uticasone) .Flunisolide, 2.59t, 264tFluticasone, 259t, 264t

and salmeterol. 2.59tFlu\'astatin.259tForeed expiratory I'olume (FEV). 41;Force,d \'ital capacit\· (F\'C), 4SFonnat, ex~rcis(' session, I :36-l:37Fosinopril:2.56t. 262tFrequency, of cardiorespiratory ('xel"(.:ise

147-141; ",

Functional capacit\' testing, 9.5-96F'llwsemide, 2057t, 262t

GGas exchange

~n clinical rcspiratOJ)' t('sting. l07-IUI-{JI1 graded ex('rcise I<,sting, 12:3-124

references for, 168-173resistance training in, 154-158specificity of, 135, 151-153stimulus or conditioning phase of, 138supervision of, 161-162, J63twarm up exercises in, 137-138

Exercise program, (see Exercise prescription)Exercise session format, 136-137Exercise Specialist, ACSM certified, 311

KSA (knowledge, skills, abilities) requisitesfor, 332--337

electrocardiography and diagnostictechniques, 334-335

exercise physiology and related exercisescience, 332

exercise prescription and programming,335-336

health appraisal, fitness, and clinicalexercise testing, 333-334

human behavior and counseling, 336medical and surgical management, 335nutrition and weight management, 336pathophysiology and risk factors,

332-333patient management and

medications, 335prograrn administration, quality

assurance, and outcomeassessment, 337

safety, injuty prevention, andemergency procedures, 337

requirements and competencies of, 313Exercise testing, 39, 41-42

after myocardial infarction, 94-95blood pressure assessment in, 43-44,

43b,44tblood profile analyses in, 46-47body composition in, 57-66 (see also Body

composition)cardiorespiratOlY, 66-80 (see also

Cardiorespiratory fitness)inte'1JCeting results of, 79~0test sequence and measures in, 76-78

of children, 240-241clinical, 93-114 (see also Clinical exercise

testing)references on, 112-114

comprehensive, 89-90contraindications to, 49, .50tin coronary artery disease evaluation,

93-94, 115-129 (see also Clinicalexercise testing; Prepalticipation healthscreening)

diagnostic, 93-95 (see also Clinical exercisetesting)

diagnostic value of, J24-128of elderly people, 246-247ell\~ronment for, 56-57lIexibility in, 85~9functional, 95-96graded, 102-J03 (see also Graded exercise

testing)he,Jth related, 55-92informed consent in, 49, 51, 52-53instructions for participants in, 51,

53-54,56

INDEX356

Eplerenone, 257t, 262tEprosartan, 257t

and hydrochlorothiazide, 257t. Equations, (see \letabolic calculations)

Equipment, emergency medical, 268tErgometer, cycle, 69

arm, 102clinical testing with, 98-99submaximal testing on, 70, 72-74testing children on, 238, 239t

Esmolol, 2.55t, 26ltEthacl)""ic acid, 257t, 262tEthmozine, (see Moricizine)Exercise, (see also Physical activity)

ACSM public health recommendations for,5-7, 133-134

benefits of regular, 7-10and cardiorespiratOlY fitness, 66-67defined, 3and immune response, 221-223lisk associated with, 10-15

Exercise capacity, in normal healthy men,96--97

Exercise intensity, cardiorespiratOlY, 141-142by heart rate, 143-146by oAygen uptake, 142-143rating of perceived exertion in, 146

Exercise prescription, 135-136adherence to, 165-167behavioral changes in, motivating, 163-165cardiorespiratOlY, 76-78, 139-154for children, 241-245in clinical conditions, 205

mthritis, 205-207diabetes mellitus, 207-211dyslipidemia,211-212hypertension, 213-215immune response, 221-223metabolic s)Oldrome, 219-220obesity, 216-219osteoporosis, 223-225peripheral altelial disease, 22.5-227pregnancy, 229-232pulmonary elisease, 227-229references for, 232-236upper respiratOly tract infection,

221-222components of, 135cool dOM' exercises in, 138-139design of, 135for elderly people, 247energy expenditure goals in, 148-149for lIexibility, 158-160format of exercise session in, 136-137general

guidelines for, 163tsummar\, of, 162t

health relat~d, 133-134individualized, 136maintenance of training elTect in, 160-161motivation in, 163-165objecth'es of, 136principles of, 134-135progression of exercise in, 149-151rate of progression in, 149-151and recreational activities, 138

359INDEX

~laintenance, of training effect, 160-161Mamtenance stage, of cardiorespiratOlY exer­

cise, 151~Iast cell stabilizers

cardiorespiratory effects of, 264tgeneric anc! brand names of, 260t

~[avik, (see Trandolapril)Maxair, (see Pirbuterol)~[aximal aerobic capacity, 5~[aximal ox)'gen uptake (V02max), 66--67,

(see also Ox)'gen uptake)in cardiorespiratOlY exercise prescription

142-143 'estimating, 297-298field testing equations for, 298, 298tpercentile values for, 79t

Maximal "oluntal)' ventilation (MVV), 49

M

Lean bo?)' mass, in resistance training, 155Leg cyclmg, and ergomctry, 70, 72-74

energy requirements for, 292tmetabolic equation for gross oxygen uptake

m, 289t, 290-291Lescol, (see Fluvastatin)Leukotriene antagonists

cardiorespiratory effects of, 265tand inhibitors, generic and brand names of

260t 'Levatol, (see Penbutolol)Lexxel, (see Enalapril, and felodipine)Lidocaine, 258tLifestyle physical activit\", 165-167

for children, 243 'exercise prescription and motivatinO'

163-165 "',Limiting signs or symptoms, in graded exercise

testing, 123Lipase inhibitors, gene,;c and brand names of

260t 'Lip~d and lipoprotein assessment, in pre-exer­

cIse evaluation, 45-46, (see o/soDyslipidemia)

Lipitor, (see Atorvastatin)Lisinopril, 256t, 262t

ancl hydrochlorothiazide, 257tLithium, carcliorespiratory effects of, 2601tLafibra, (see Fenofibrate)Laniten, (see Minoxidil)Lopid, (see Gemfibrozil)Lapressor HCT, (see Mctoprolol, and

hydrochlorothiazide)Lapressor SH, (see letoprolol)Lasa,tan, 257t

and hydrochlorothiazide, 257tLotensin, (see Benazepril)Latensin HCT, (see Benazepril, and

hydrochlorothiazide)Latrel, (see Benazepril, and amlodipine)Lovastatin, 259tLovastatin, and niacin, 259tLazol, (see Inclapamide)Lungs, (see Pulmonary disease; Pulmonary

function)

L

[ndapamide, 257t, 262tIndcral, (see Propranolol)Inderide, (see Propranolol LA, and

hydrochlorothiazide)Informed consent, in pre-exercise evaluation

49, 5l, 52--53 'Inhibace, (see Cilazapril)Inspra, (see Eplerenone)Instructions for participants. in pre-exercise

evaluation, 51, 53-54Insulins

cardiorespirato.)' effects of, 266tgeneric and brand names or, 260t

[ntal, (see CrOmOI)11 inhaled)Intensity, of cardiorespiratOlY exercise, 141-142

by heart rate, 143-146by oxygen uptake, 142-143rating of perceived exertion in, 146

lpratropium, 259t, 264tand albuterol, 259t

lrbesartan, 257tand hydrochlorothiazide, 257t

Ismo, (see Isosorbide mononitrate)Isokinetic muscular strength testing, 82-83Jsoptm, (see Verapamil, immediate release)Isoptm SH, (see Verapamil, long acting)Isord,l, (see Isosorbide dinitrate)lsosorbide dinitrate, 256t, 261tIsosorbide mononitrate, 256t, 26ltIsradipine, 256t, 26lt

Karvonen method, of obtaining target heart

range, 144-146Kerlone, (see Betaxolol)KSA (knowledge, skills, abilities) requisitesACS~[, 310 '

claSSification/numbering systern for,315-316

for Exercise Specialist certification,332-337

for HealthlFitness Instructor certification323-331,346-349 '

for Personal Trainer certification, 317-323for Registered Clinical Exercise Specialist

337-346 '

K

Labetalol, 255t, 26ltLaboratory tests, b,' risk level, in pre-exercise

evaluation, 42bLanoxicaps, (see Digoxin)Lanoxin, (see Digoxin)Lantus Injection, 260tLasix, (see Furosemide)LDL cholesterol, classification of, 45t

Jogging, horizontal and grade, energyreqlllrements for, 292t

Iletin lJ Lente, 260tIletin 11 NPH, 260tHetin [IB, 260tImaging modalities, in clinical exercise testing,

110-112lmdur, (see Isosorbide mononitrate)I rnrnune response

and exercise, 222-223in upper respiratory tract infection,

221-222Improvement stage, of cardiorespiratol)'

exercise, 150

Hemt rate (HH)in cardiorespiratOl)' exercise, 143-146during clinical exercise testing, 103-105clinical significance of, 117bdetermination or. 76and normal QT inte.val, 282t

Ilemt nlte (HH) rese.ve method, of obtainingtarget heart range, 144-146

Heart rate response, 68interpreting, in exercise testing, 116--118

HeatacclimatiZ<ltion to, 302dehydration in, 303and humidity, ellects of, on physical

activity, 300-302risk of illness due to, 303-304safe exercise duration in, guidelines for,

302tHeat illnesses, 301-302

increased risk of, 303-3001High altitude illnesses, 306--307, 307tHigh risk stretch, 160H~lG-CoA reductase inhibitors, gene,;c and

brand names of, 259tHumalog, 260tHumalog 50/50, 260tHumalog 70/30, 260tHumalog Mix, 260tHumulin L, 260tHumulin N, 260tHumulin R, 260tHumulin U, 260tHydralazine, 256t, 262tHydrochlorothiazide, 257t, 262tHydrodensitometry,64HydroDilll;l, (see Hydrochlorothiazide)Hydropres, (see Heserpine, and hydrochloroth-

iazide)Hyperglycemia and hypoglycemia, signs of, 209tHypertension, 213

exercise prescription in, 215exercise testing in, 214-215lifestyle modillcations in managing, 214tspecial considerations in, 215

Hypoglycemic agentscarcliorespiratOlY eflects of, 266tgene,;c and brand names of, 260t

Hypothermia, 305H)trin, (see Terazosin)Hyzaar, (see Lasmtan, and hydrochlorothiazide)

INDEX

Ilealth/Fitness Instructor (col1til1ued)pulmonm} pathophysiology and risk

factors, 331safety, injut)' preYention, and emer­

gency procedures, 330requirements and competencies of, 312

Health promotion, and disease pre,'ention, 4Health related exercise presc';ption, 133-134

adherence to, 165-167cardiorespirato.)' training in, J39-154components of, 135cool down exercises in, 138-139design of, 13.5energy expenditure goals in, 148-149flexibility exercises in, 1,58-160format of exercise session in, J36--137inclividualized, 136maintenance of training effect in, 160-161motivation in, 163-165objectives of, 136principles of, 134-135progression of exercise in, 149-151rate of progression in, 149-151and recreational activities, 138references for, l68-173resistance training in, 154-158specificity 01',151-153stimulus or conclitioning phase of, 138supervision of, 161-162, 163twarm up exercises in, 137-138

Health related exercise testing, 55-92body composition in, 57--ti6 (see also Body

composition)cardiorespirato.y, 66--80 (see olso

CardiorespiratOlY fitness)interpreting results of, 79-80

carruorespiratOl)' test sequence andmeasures in, 76--78

comprehensive, 89-90environn1ent for, 56-57flexibility in, 85-89instructions in, 56maximal versus submaximal, 67-68modes of, 68-76muscular strength and endurance in, 79-85order of tests in, 56p,;nciples and guidelines in, 56--57purposes of, 55references for, 90-92test termination criteria in, 78. 78b

Health related physical IItness, goals of,l33-134

Health screening, preparticipation, 19, 22,(see also Pre-exercise evaluation)

ACSM algorithm for, 19, 20t-2lt, 22ACSM guidelines for, 20t-2ltACSM .;sk stratification categories in,

28-29,28tadditional assessments in, 29-30exercise testing recommendation in, 30--31medical clearance in, 22-29risk stratification in, 22-29

for cardiac patients, 31-35supervision recommendations in, 30-31testing supervision recommendations in,

30-31

358

~la.'\iI1lUlll "OIUlllaIY contraclion (~IVC). HI\I'lszide. (sec Tria,;,terene. and hnlrochloroth­

iazidc')~Iechallic:all~' hraked <':~'cle er~olllet('rs. 6H~ledical clearance, in preparticipatioll llcalth

SlT('Clling, 22-29~ledical history <.:0l11p01lents, in pre-exercise

<.'Yaluation, -lOh~ledi<.:al situation plans

cl1wrgc!1cy.276t-278t1l01H.'lllergcl1cy, 271t-272tpotential elll('rgenc~... 27:3t-27.5l

~I<.'dications

eardiorespiratUlY e!Teds of. 26! t-266talcoho!. 2651alpha adrener~ie blockers. 262tangiotensin conn-rting cnz~ll1(, (ACE)

inhibitors. 262tangiotensin II receptor antagonists,

262t<lllorl''\iants. 2G6tantiarrlwthmic agents. 262t-26:3tanticholinergic agents, 264tanticoaguhults, 266tantigollt medicatiuns, 266tantihistamines, 26.5tantilipemic agents. 26..Hantiplatelet agellts. 266tbeta blockers. 26Jtblood modifiers, 266tbroncbocUiators, 26-ltcaneine, 266tealcium channel bloekers, 2611diet pills, 266tdigitalis, 26Jldiuretics, 262th~popJ:Temicagents, 266tinsulins, 266tm'l~t cell stabilizers. 26-ltnicotine, 26.5tnitrates,2.6Itpentosiklline.266tperipheral dilators, 266tpsychot ropic agents. 2()...ftsteroidal antiinflalilinator:' agents. 26-Hsympathomimetie agents. 264t, 265ttll\Toid medications. 265t,',;sodilators, 2621xanthine derh'ati\es. 264t

emergene\', 268t-269tgeneric and hrandnames or, 2.5.51-260t

aldosterone receptor bloekers. 257talpha adrcnergie blockers, 255talpha and heta bloekers, 255tangiotensin conn>lting ellz:'mc (ACl::)

inhibitors,2.56tangiotensin con\'crting enzyme (ACE)

inhibitors with calciulIl channelblockers, 257t

angiotensin conn~ltingenzyme (ACE)inhibitors with diuretics. 257t

angiotensin II receptor <llitagonists.257t

(lIl~iot(-'nsin II receptor anta.gOllists withdillretics. 2,57t

361INDEX

Obesity, 216-217exercise prescription in, 217-218exercise preventing onset of, 7exercise testing in, 217recommended weight loss programs in,

218-219special considerations in, 218

Olmesartan, 257tOmalizumab, 260tI-repetition maximum (I-RM), 81-82Open circuit spirometl)', 67, 286-287Oretic, (see Hydrocblorothiazide)Orinase, (sec Tolbutamide)Odistat, 260t, 266tOsteoporosis, 223-224

exercise testing and prescription in,224-225

special considerations in, 225Overload, progressive, 134-135, 157Ox'ygen uplake (\'02), 66-67

in ann cycling, and ergometl)', 289t,290-291

in eardiorespiratol)' exercise prescription,142-14:3

and espression in METs, 291-296gross, metabolic equations [or, 288-291,

289tin leg cycling, and ergomet,)', 289t,

290-291measuring, 286-287

in energy eX1Jencliture, 287-288percentile values for, 79tin stepping, 289t, 291in walking and running, 28 -290

o

Nitro-Derm, (see Nitroglycerin, transdermal):-Jitro-Dur, (see Nitroglycerin, transdermal);\itrocine, (see ;'\itrogh:cerin, sustained release):--litrodisc, (sec :-litroglycelin, transdermal)I'\itrogard, (see :-Jitroglycerin, transmucosal)I'\itroglyeerin, 256t, 261t

cardiorespiratOl)' cffects of, 261tgeneric and brand names of, 256tsublingual, 256tsustained release, 256ttransdermal, 256ttranslingual, 256ttransmucosal, 256t

:--iitroglyn, (see ;'\itroglycerin, sustained release):\itrolingual, (see :\itroglycerin, translingual)Nitrong, (see Nitroglycerin, sustained release)NitroQuick, (see :--Jitroglycerin, sublingual):\itrostat, (see I\itroglycerin, sublingual):\i"alin ~, 260t:\ormodyne, (sec Labetalo!)N0111ace, (see Disopyramide)NOlvasc, (see Amlodipine):--Io\'olin 70/30. 260tI'\o,'olin L, 260t~O\'Olin R, 260t1\uclear imaging, in c:linical exercise testing,

1l0-1l1

N

Micardis HCT, (see Telmisartan, andhydrochlorothiazide)

~licronase, (see Gkburide)~licrozide, (.lee H,:drochlorothiazide)~lidamor, (see Amiloride)Miglitol, 260t, 266tMinipress, (see Prazosin)~linitran, (see :\itrogkcerin, transderma!)~linizide, (see Prazosin)~Iinosidil, 2.56t, 262tModurctic, (see Amiloride, and hydrochloroth­

iazide)~loe,ipril, 256t, 262t

and hydrochlorothiazide, 257t~Ionoket, (see Jsosorbide mononitrate)Monopril, (see Fosinopril)Montelukast, 260tMorbidity and mOltalit)' decrease, b,' phvsicirJ

ac!i,'it,·, b-9b ' ,

~Ioricizi;,e, 258t, 263tM0I1Jhoiogic Iltness, :3Motor driven treadmills, 68-69Multiple set resistance training, 157-158~Iuscle function tests, 8~1~luscular endurance, 80, 83, 85

test procedures for, 84bMuscular strength, 80

in healtb related physical Iltness testing,81-83

of legs, 83tupper body, 82t

MVC (maximum volunta,)' contraction), 8J~lVV (maximal "oluntal)' ventilation), 49,

123-124~lykron, (see ~Ietolazone)

Myocardial inf~lI'ction, exercise testing after,94-95

~lyocarcLal tissue damage, serum enzymes indi­cating,51t

:\adolol, 25.5t, 2611and bendroHumethiazide, 255t

:-Jateglinide, 260t, 266tNaughton protocol, 99:-JCEP (:--Iational Cholesterol Education

Program), 45:-Jedocromil, 260tI'\et oxygen uptake, 287Niacin,2.59tNiaspan, (see :--Jial'in)Nieardipine, sustained releasc, 256t, 26ltNicoQid, (sec ;,\iacin)Nicotinic acid

cardiorespiratOl)' cffects of, 26,5tgencric and brand names of, 259t

I'\ifedipine, long-acting, 256t, 261tNimodipine (:\imotop), 2.56t, 2611Nisoldipine, 256t, 26JlNitrates

cardiorespiratOl)' effects of, 26J tgeneric and brand names of, 256t

Nitro-Bid, (see I'\itroglycerin. sustained release)

antiarrhytll111ic a~ents. 2.58tantidiahetic agel1ts. 260tantilipemic agents, :23)t-25~t

appetite suppressants. 260tbeta bloekers, 2.55tbeta bloekers and dilll'l'lics. 2.55thlood nlodi!\inl( agents. 259tbronchodilators. 259t-260tealcillm ehannel bloekers. 2561cardiac gl:Tosides, 256tcelltral alpha agollists and centrally

actine; drugs. 255tcentral i.Jpha agonists and diuretics. 25.5tdiureties, 2571-25~tinslllins. 260tlellkotriene antagonists and inhibitors.

260tlipase inhibitors. 260tloop diorelies, 257tmast cell stabilizers. 260tnitrates and nit roglyccrin. 2,56tohesit\' managing agents, 260tperiplieral dilators, 256tpotassium sparing dillre-tics. 25ftrespir,ltory age'nts, 2,59tsteroidal antiinflammatory agents, 259tthiazide diuretics, 257t

~Ieglitinides.generic and brand names or. 260t\Ie,ic!ia, (sec Sibutramine)~letabolie ealculations, 286

in ease studies, 294-296and eon\'t'rsion to Nt l':'1's. 4. 5. 291, 29:3in energy expenditurc cstimation. 287-2R8

leg and ann er~ometry. 2fi9t. 290-291stepping, 289t, 291walkin" and rnnnin", 288-290, 289t

in Illcl"\imal oxygcJl uptake estimation.297-298

m..yge ll uptake measurements in. 2~6-2b8

pr;'el ical use of. 291-296practice, with answers, 296-297rcfc:renc:es on, 298-299and target work rates. 2~3-29-t\'02 measurements in, 2S6-28R

~Ietabolic diseasemajor signs or symptoms of, 24t-2.5t. 28screcning 1'01', 19-36

\letaholie eCl'li"a!ents (~I ETs), 4, 5.291,29:3gross oX:'gell consumption and expression

in, 291-296Metaholie Iltness, :3~Ietaholic syndrome, exercise prescription ill.

219-220~Ietaproterenol,259t, 26-lt~Ietronnin, 260t, 266t

and glyhlll'ide, 260t~Iethy!dopa. 25,5t

and Il\'drochlurothiazide, 25.5t~Ietohv.cll',e, 257t. 262t~ Ietoprolo!. 2.55t, 26 It

and h\'drocldornlhiazidc. 255t~Ie\'acor. '(.,:we Lovastatin)~Ie,ilelille, 258t, 26:31\Iesiti!. (sec \Iexiletine)~Iicardis. (sec Tellnisartan)

INDEX360

362 INDEX

pP,lCerone, (sec Amiodarone)PAH-Q (Ph,sical Acti\ity I\~adin~ss

Qucstionnaire). 22, 27Pellhlltnlol, 2.5.5t. 261tPentoxi!\·lIine. 2.59t. 266tPercei\"ed E''\cltion. (see Hatine; of pen.:eiw'u

exertion)Percent or I i HlllilX, in obtainin~ target heart

range. 144Perindopril. 2.56t. 262tPe,ipheral artery diseas~. 22.5

exercise testing and prescription in. 22.5special considerations in, 22.5-2.26

Peripheral dilatorscarclior0spiratory effccts of, 266tgenel;c and hrand 11 ..1111l'S of. 256t

Persantine, (scc Dipyridamole)Personal Trainer, ACSM certified, :310~311

KSA (knowledge, skills, abilities) requisites

for, 317~323dinieal and lIledieal considerations.

322-:323exercise physiolog)' and related exercise

science, :317--3\8exercise prescription and pro~ralilllling.

3\ 8--320health appraisal, fitn..ss, and clinical

exercise testing, 318human behavior and counseling.

320-32\Iluldtion and weight management. 320program aclministmtion, quality assur­

ance, and outcome assessll''l('nt, 322­safety, inj\ll)' prevention, and emer­

gency procedures, 321-322requircments and competencies of. .312

Pharmacologic stress testing, IIIPhenytoin, 2.58t, 26.3tPhysteal activity, (SCI' also Physical fitness)

ACS~l pllblic health recommendations

for, .5-7benefits ami risks of, .3-18defined, 3enerh')' requirements of, 286-299 (set also

Metabolic calculations)el1\"ironlnental considerations in, 300-.308

(s(!(' also Emirollmcntal considerations)health and, dose response relationship and,

7-LOe\'idellce of, lOt

intensih" ofc1assiilcalion of. 4tterms describing, +-.5

lifestvle,16.5-\67moti~lation ill, 163-lfi.5recommendations for, 6-7regular, benefits of, 7-10risk associat0d with, 10-15

Physical Activity and lIelllth (U. S. SlIrgeonCeneral), conclusions or, 6

Ph"sical acthih' intensity, dassillcation of, 4......5. 4tPI{"sical Acti,i'h' Headi;less Questionnaire

(PAR-Q), 22: 2,

PI\)'siC<l\ exanlinalion components, in pre­e\:ercise ('\'alnation. 4th

PIl\'sical fitness. (sre also Physical adi\ih'), dellnec\.:3 . .

eY,-11llatio1l of, cOillprchensi\e, h9-90exercise prescription for. 1;):3-1,14

aelherenee to, L6.5-167cardiorespiratory training in. t39-1.5-!

components of. 1:3.5cool down e\:erc..'ises in, 138..... 139

design or. J3.5ener~y expenditure goals in, 148..... 149Ilesibilil\' exercises ill, 15~ 160format (~f exercise session in, 136-1:3/

indi\'idllalized, 136lllaintf'nance of training effect in,

160-\6\moti\'<ltion in. t6:3-1 (i.5object i\'C's of, 1.36principles of. 1:3+.-L3.5progression of e);C'n.:ise in, 149-151rate ol'progression in, 149-151and recreational aethities, 13')references for, 16'3--173resistance training in, J5..J.-15Bspecilkityof. 1.5\-\.53stimullls or conditioning phase of. 1:38supelYision of, 161-162, 163twarm lip e,=ercises in. l:3/-1:3R

('\:ercise testing for, 55.....92body composition in, .57-66 (se(' also

Bod:' cOlnpositiOl\)cardiorespiratOly, 66-80 (s('(' also

Cardiorespiratory fitness)cardiorespiratory test seqllence and

measures in, 76-78comprehensh'e, R9.....90f"11\ironnll'l1t fur. 5fr..57Ilesibilil\' io, ~5-<~9

instrllcti'ons in, 56lll,-L\:imal \'C'1'SllS suhm<l,=imal, 67-6R1110dcs or. 68-76muscular strength and endllrance in.

79-&5order of tests in, 56principles and guidelines in. 56-.57

purposes of, .5.5refc'renc..s lor, 9()-~)2

test termination critelia in, ih, 7Hh!(oals of, 133--134

Physical fitncss program, (.\:"('C Physical fitness,exercise prescription ("or)

PIl\'sieal fitlless testing. (se(' PIl\'sical fitness,exercise testing for) .

PIl\'siologic IItness. 3--4Pi Ildolol, 2.5.5t. 26 I tPioglitazone, 260t, 266tPirll1lterol, 2.59t, 264t, 26.5tPhl\ix, (see c:Jopidogrel)Plcndil, (s('(' Felodipine)Pletal, (SI'(' Cilostazol)plethysmography, 64Pnkthiazide, 2.571, 262tPo~te'\ercis(' period, in clinical c\:crcisc testin~,

IO~-I09

Practice ar~a, 01' KSAs, .31.5--316Prandin, (scc Repaglinide)Pravachol, (see Pr",'astatin)Pra\'astatin, 259tPrazosin, 2.55t, 262tPredictive value, of gradcd exercise testing

124b, 12.5-126 '

Pre)-e\:~rci.s~ eV~llation, 39, 41-42, (see alsoI repartlclpahon health screening)

blood pressure assessment in 43-444.3b,44t "

hlood profile analvs0s in 46-47contraindications ~to, 49, '50tinformed cons('nt in. 49, S1. .52-.5.3instructions for participants in, 51, 5.'3----.54laboratory tests in, I", risk Ie"el. 42hlipid and lipoprotein' ass(-'ssment in, 4.5-4Jimedical history compOllcnts in, 40hphysical ('\:a~llin<ltioJl components in, ...J.1bpulmonary function in, 47--t9references for, 54

Pregnanc\', 229-2:31COlltr:\illClications fur ('\:ercise (hiring, 2:30he\:er~is(' testing and prescription in, 2~11

speoal consid('rations in, 2:31-:232termination of exercise in, conditions for.

232hPreparticipation health screcning, 19, (see also

Pre-e:\prcisc e\'aJllation) ,ACS~I algorithm for. 19. 20t-21t 2ryACS~I risk stratification cat('gori~s i~l

28-29,28t 'addition,-~I assessments in, 29-:30c\:elTisc testing recommendation in, :30-=31llIcdical clearance in, 22-29risk stratification in, 22-29

fnr cardiac patil'nts, :31-:3.5sllpcn:ision r('commendations in, 30-3l

Pretest instructions. SfiPre\·alitc. (we' Cholest\Tamioe)Prinivi\. (sec Lisinoprii)Prinzide, (Sl'(' Lisinopril, ilnd hydrochlnroth-

iazide)ProcainamidC'. 2,58l. 26:3tProcan SR, (ser Proeainamide)Proeardia XL, (SN' I\ifedipine. long-actin")Pro~ralll, physical l'itIlCSS, (s('(' Exercise' P';('-

scriptiOlI)Progression, of cardiorespiraton ('\:ercisc,

149-1,51 'Progrf'SSi\l~ O\'erload, 1:3..f.--l:3.5 1.57PrOllcstyl, (,lON' Procainamide) ,Propafi.'none, 2.58t. 263tPropranolol. 2.5.51, 2Ci \ tPropr'41Olol LA, and h"lrochlorothiazide. 2.5.5tProprioccpli\'e n('tlroll~lISCIIJarfacilitation

(PNF). 1.5~)

Provl'ntil. (.I"'C Albnterol)Public health. and ACS~I recommendations for

ph;'sical acti\"jh'. .5--7Pulmic'ort, (see B"udesonide)Pulmon<lI)' disease, 227

('\:eITis(' prescription in, 228-22~(',\('Tcise testill~ in, 227-22Hmajor sihrrls or symptoms of, 24t-25L 2h

INDEX 363

screening for, J9--36special considerations ill, 229

Pulmonary functionin obstructi\'e lung disease, 48tin pre-€'\:ercise evaluation, 47-49in restrictive lung disease, 48t

Push-up test, 84bIItness categories in, 8.5t

QQuestran, (sec CholestlTamine)Quetelet index.58 .Quinaglute, (s;~ Quinidioe)Quinalan, (st'e Quinidine)Quinap"il, 2.56t, 262t

and hyelrochlorothiazidC'. 2.57tQuinidex, (se(' Quinidine)QuinidinC', 2,5';t. 262tQlIinora, (,{",(>t' Quinidine)Qvar, (see Bec1oll1e1hasolle)

RRain, as e!wirollrnental [actor, .30..1-30.5Hamipril. 2.56l. 262tRamp tC'sts, 99Range- ~f motion, f''\eITises f(Jr, L.5,)-160, 250Hate of progression, of cardiorespiratory

exercise, J49-1.5\ . 'Hating of perC'C'i\'ed 0xertion (HPE). 76--78106--1~1~ .

in cardiorespiratory e'\f"rcise, 146categories of, and category-mtio scales, 7itil~ resistance training, 156

Readmess to change modC'\. stages in. 166bRecreational adidty, in llf'alth related E"'=t.'rcise

prescription, 138Regist~red Clinical Exercise Physiologist,

ACSM certified, .3\1KSA (knl~vledgc', skills, abilities) r"'1"isites

for, 33h346c\:ercise ph~'siology and related exercise

scicnC'e. 3:37~338cardiovascular :340immunologic, 345ncuromuscular, 3--l.5OIthop0dic/musC'ulosk0letal .344pulmollal,', :341-:342 '

(-'\:ercise prescription andprogramming, :3,'39

carcum·ascular. :141immunologic. :346metaholic, :34:3-:344nellromuscular, :345() rthopedic/mllSculoskeletal.

:144-:345pulmonary..3~12

health apprai;a\. fitness, and c1iniC'alcxercise {I'sting, .3:38-:3:39

cardim'<lsclllar, 341imml1Jlologic..3..16metabolic. 34:3

Triamterene, 2571, 262tand hydrochlorothiazide, 258t

Tricor, (see FenoHbrate)Trunk Oexion test, 86, 88

percentiles for, 89t, 90tprocedures for, 88b

w

u

"'aist circlllllft'rence, 58-59diseas" risk c1assiHcation and, 6J tIlleasurement procedures for. ,58--59

60b-61b 'new criteria for, 61 t

Waist-to-hip ratio..59Walking

horizontal and grade, energy requirementsfor, 292t ' '

metabolic equation for gross oxvgen uptakein, 288-289, 21\9t .

\Varfarin, 259t, 266t\\'arm lip exercises, 1.'37-1:3H\\'eight loss, (''Xereise promoting. 7\Vf'ightloss programs, recommended, 218-219Welchol, (see Colesevelam)Wet bulb globe temperature (\VBCT), 300-301\\rind, as ('Tl\"iron11lental factor, .304-..305

Wind chill indcx, .304t

INDEX 365

v

Underwater weighinU' 6--tUniphd, (sec TI;eopl~'lline)Unirelic, (.w'e Moexipril, and hydrochloroth­

iazide)nivasc, (see ~Ioexipril)

Upper bod) exercise testing, ]02Upper respiratOly tract infection, exercise

prescription in, 22J-222

\'alsartan, 257tand hydrochlorothiazidl', 2.57t

\'aserl'tic, (sl'e EnalapriL and Iwdrochloroth-iazid,') .

Vasodilatorscardior"spiratOlv "ffeets of. 2621in clinical exen..is(' testing, 1LI

Vasotec, (sel' Enalapril)VCC)2 (carbon dioxide output ), 286V(.>ntilatory responses

~n c1ink'al respiratory testing, l07-JO~III graded exercise testing, 1.2,3- 1.24

\'entolin, (see Alhuterol)VentJicular cksrlnthmias, 122

clinical si'gndjcance of, 1l7bVerapamil, 2.561. 2611

immediate release, 2.56tlong acting, 2.56t

V"relan PM, (sl'e Verapamil)Veteran"s Administration score, 127-128Visken, (see Pinrlolol)\r02, (see Oxygen uptake)V02nliu, (see M"'l;ximal m.'ygen uptakC')

Surgeon Genera!"s Report (SGR), on physicalactivity and healtb, 6,133-134

Sympathomimetic agentscardiorespiratoty efTects of, 264t, 265tgeneric and brand names of, 259t

Systolic blood pressure, 119clinical significance of, 118b

TTall1bocor, (see Flecainide)Target heart range, 144-146

rnetabolic calculations in. 293-2H4Tarka, (see Trandolapril, and \'erapamil)Telmisaltan, 25ft

and hydrochlorotbiazide, 257tTenex, (see Guanfatine);enoretic, (see Atl'nolol, and eblorthialidone)fenormlll, (see Atenolol)Terazosin, 2551. 262tTerbulaJine, 2,59t, 264t, 26.5tTest environlllC'nt 56Test order, 56 'Te\'etan, (see Eprosartan)Teveten IICT. (see Eprosartan, and

hydrochlorothiazide)Thl'o-Dur, (see Theophdline)Theophylline, 2.591, 26.ltThiazolidinediones, generic and hrand names

01',2601Th:Toid medications, cardiorespirator\' effects

of, 265t '~iazae, (see Diltiazem, l'xtended rclease)llclld, (see Ticlopidine)Ticlopidine, 25,HTikosyn, (see Dofl'tilide)Tilade, (sec Nl'docromil)Timolide, (see Timolol, and

hydrochlorothiazide)Ti molol. 255t, 2611

and hydrochlorotbiazide, 2.5.5tTOBEC (total body electrical condnctivity), 65Tocainide, 2.58t, 263tTolazalllide, 2601, 266tTolbutamide, 260t, 266tTolinase, (see Tolazamide)Tonocard, (sec Tocainide)Toprol XL, (sec ~Ietoprolol)

Torsemide, 257t, 262tTraining. (see also Exercise pn:scription)

principll's of, 1.34-13.5specificity of, ],51-15:3

Training effect. maintenance of, 160-16 1Trandate, (see Lahetalo!)Tnlndolapril, 256t, 262t

and verapamil, 2,57tTranquilizers, cardiorespirato,y effccts of. 26.ltTransclenn-Nitro, (sec i\itrogl~'('erin,

transdennal)Treadmill, motor drivl'n. 68-69Treadmill testing

clinical, 96-98protocols of, IOJsubmaximal,74

Trental, (see Penloxifvlline)Tnamcinolone, 259t, '264t

Self-administered questionnaires, 19Self-administered surveys, 22Selr motivation assessment scale, 164Sensitivity, of graded exercise testing, 124-12.5,

124bSerevent, (see Salmeterol)Serpasil, (see Reserpine)Sibutramine, 260t, 266tSickle cell trait, and exercise related death, 12

Sinwastatin, 259tSingulair, (see ~Iontelukast)

Sit-and-reach test, 86, 88procedures for, 88bY~lCA, 88, 90t

Skinfold equations, generalized, 61, 63, 63bSkinfold measurement(s), 59-63

standardized sites for, 62bSlo-Niacin, (see Niacin)Sorbitrate, (see Isosorbide dinitrate)Sotalol, 255t, 258t, 2611, 263tSpeciHcity

of cardiorespiratOlY exercise, 151-153of graded exercise testing, 124b, 125principle of, 135

SPECT (single photon emission computedtomography), 110-111

Spirometly,47-49open circuit, 67, 286-287

Spironolactone, 257t, 262tST segment depression, 121-122

clinical significance of, 117bST segment displacement, interpreting, 120,

120-122in absence of coronary altery disease, 126b

ST segment elevation, 121clinical signiHcance of, 117b

ST segment normalization (absence of

change), 122Starlix, (see Nateglinide)Step testing, or exercise (stair stepping), 69

energy requirements for, 293tmetabolic equation for gross oxygen uptake

in, 289t, 291submaximal,74-76

Steroidal antiinflammatOly agentscardiorespiratOlY effects of, 264tgenelic and brand names of, 259t

Stimulus phase, of cardiorespinltoryexercise, 138

summal)' of, 153-154Strength-endurance continuum, 156Stretching exercises, and techniques, 159-160Subjective ratings, and syrnptoms, in exercise

testing, 106-107Submaximal exercise testing, 67--68, 70-76

of cardiorespiratol)' Htness, 71b, 102heart rate responses in, 7.5

Sudden death. in young illlli\iduals, 11Subr, (see Nisoklipine)Sulfonylureas, generic and brand names of, 260t

Supervisionof clinical exercise testing, 109b, 112of health related exercise prescription,

161-162, 163tof preparticipation he,Jth screening, 30-31

Supraventricular dysrhythmias, 122c1inic,J signiHcance of, 117b

INDEX

Registered Clinical Exercise Physiologist(continued)

neuromuscular, 345orthopedic/musculoskeletal, 344pulmonaty, 342

human behavior and counseling,

339-340medical and surgical management

cardiovascular, 341immunologic, 346metabolic, 3.l3orthopedic/musculoskeletal, 344pulmona')', 342

pathophysiology and lisk factorscardiovascular, 341immunologic, 346metabolic, 342-343orthopedic/musculoskeletal, 344pulmonary, 342

program administration, quality assur­ance, and outcorne assessment, 340

safety, injUly prevention, and emer­

gency procedures, 340requirements and competencies of, 313-314

Relative intensity, deHned, 4Relative metabolic rate, in resistance training,

155Renese, (see Pol)~hiazide)

Repaglinide, 260t, 266tReserpine, 255t

and chlorothiazide, 255tand hydrochlorothiazide, 255t

Resistance training, 154-158for children, 245for elderly people, 249-250guidelines in developing, 158multiple set, 157-158muscle fiber recruitment in, 156strength development in, 157strength endurance continuum in, 156

RespiratOly agents, generic and brand names of,

259tRespiratory exchange ratio (RER), 108Return-to-work exercise testing, 102-103Hiomet, (see Metformin)Hisk, associated with exercise and physical activ-

ity, 10-15Risk stratiHcation, preparticipation, 22-31

for cardiac patients, 31-35Rockport One Mile Fitness Walking Test,

69-70Rosiglitazone, 260t, 266tRosuvastatin, 259tRPE, (see Rating of perceived exertion)

Runninghorizont,J and grade, energy requirements

for, 292tmetabolic equation for gross ox')'gen uptake

in, 289t, 290Rythmol, (see Propafenone)

5Salmeterol, 259t, 264t, 265t

and Outicasone, 259tSeclral, (see Acebutolol)

364

yY~\CA bench press test, 85, 87tY~\CA cycle ergometI} protocol, 74Y~'ICA sit-and-reach test, 88, 90t

Xanthine de!i\'ath·escardiorespiratOl~' erreds of, 26-ltgeneric and brand names of, 259t

Xenical, (see Orlistat)Xolair, (see Omalizumab)Xdocaine, (see Lidocaine)X~'locard, (see Lidocaine)

Zafirlukast, 260tZarOXOI)l1, (see Metolazone)Zebeta, (see Bisoprolol)Zero to peak method, or obtaining target heart

range, 144Zestoretic, (see Lisinopril, and hydrochloroth-

iazide)Zestril, (see Lisinopril)Zeta, (see Ezetimibe)Ziac, (see Bisoprolol, and hydrochlorothiazide)

Zileuton, 260tZocor, (see Simvastatin)Zyllo, (see Zileuton)

z

INDEX

x

366

9 780781 745062