acsms guidelines for ex testing prescription

8/3/2019 ACSMs Guidelines for Ex Testing Prescription

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SENIOR EDITORMitchell H. Whaley, PhD, FACSMProfessor and ChairSchool of Physical Education, Sport and ExerCIse SCienceBall State UniversityMunCie, IndianaASSOCIATE EDITOR-CLINICALPeter H. Brubaker, PhD, FACSMAssoCIate Professor and Executive DirectorHealthy Exercise and Lifestyle ProgramsDepartment of Health and Exercise SCienceWake Forest UniverSityWinston-Salem, North Carolina AMERICAN COLLEGE

OF SPORTS MEDICINE

SEVENTH EDITION

J lipPI COTTWIWAMS & WILKoI S A Wollers Kluwer ompanyPhiladelphia. Baltimore ew York. LondonBuenos i'll'''' . Hong Kong' Sydney Tokyo

ACSM'sGUIDELINES FOR

EXERCISE TESTINGAND PRESCRIPTION

I-Min Lee, MD, FACSMTimothy McConnell, PhD, FACSMJonathan N. Myers, PhD, FACSMFrank X. Pizza, PhD, FACSMThomas W Rowland, MD,Kerry Stewart, EdD, FACSMCSMPaul D. Thompson, MD, F ~ S MJanet P. Wallace, PhD, FA

AUTHORSLawrence Armstrong, PhD, FACSMGary J. Balady, MDMichael J. Berry, PhD, FACSMShala E. Davis, PhD, FACSMBrenda M. Davy, PhD, RD, LCKevin P. Davy, PhD, FACSMBarry A. Franklin, PhD, FACSMNeil F. Gordon, MD, PhD, MPH, FACSM

ASSOCIATE EDITOR-FITNESSRobert M. Dna, PhD, FACSMProfessor and DirectorHuman Performance LaboratoryDepartment of Health, Physical Education, andHuman Performance SCiencesAdelphi UniversityGarden City, New York


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xii CONTRIBUTORS

Contentsonathan N. Myers. PhD. FACSMClinical Assistant Professor ofXI!'dicineDepartnwnt of CardiologyStanford lj ni\ ,-rsit)Palo \Ito \. \ Ilealth Care SystemPalo \110. California .Francis X. Piua. PhDProfessorDcp,niment of KinesiologyThe Unhcrsit." of ToledoTolt'do, Ohio

Kerry Stewart. EdD. FACSMI\.>sodalc Professor of ~ I e d i c i n eDi\ision of CardiologyDirector. Johns Jlopkins IlcartHealthJohns Ilopldns Ba\Vif'w Xledical;ent('rBaltimore, ~ l < l l y l a n dPaul D. Thompson. MD. FACSMDirector. Preventiv!' CardiologyIIali tcm] lJospitalHartford, Connecticut

Section I

PrefaceNota BeneContributorsAbbreViations

Health A J l I I ~ i ~ a l B ~ l A s ~ e s s m e n t . and Safety of Exercise

VIIxxixix

Benefits and Risks Associated With Physical Activity 3Physical Activity and Fitness Terminology 3Public Health Perspective for Current Recommendations 5Divergent Physical Activity Recommendations 6Benefits of Regular PhySical Activity and/or ExerCise 7Dose-Response Relationship 7Risks Associated With ExerCise 10Sudden Death Among Young Individuals 11Exercise Events in Those With Sickle Cell Trait 12Exercise-Related Cardiac Events in Adults 12

Risks of Cardiac Events During Exercise Testing 12Risks of Cardiac Events During Cardiac Rehabilitation 13Prevention of ExerCIse-Related Cardiac Events 13191921282930

393943454647

xiii

Preparticipation Health Screening and Risk StratificationPreparticipation Screening AlgOrithm

Risk Stratification and Medical ClearanceAdditional Preparticipation AssessmentsExercise Testing and Testing SupervisionRecommendatIons

Risk Stratification for Cardiac Patients

Pre-Exercise EvaluationsMedical History. PhySical Examination, and Laboratory TestsBlood PressureLIpids and LipoproteinsBlood Profile AnalysesPulmonary Function

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Section II Exercise Testing

Janet P. Wallace. PhD. FACSMProfc'ssor and Dircctor of AdultFitnrssDepmtnwnl of KinesiologyIntliana Unhrrsit.\Bloomington, Indiana

Thomas W. Rowland. MD. FACSMl'rof('ssor, Department of Pf'diatricsTufts Unhersit) School of XledicineBoston. IvhLssachus!'tlsDirector, Pediatric CardiologyBa\ State t-Iedica.l CenterSplingl1eld, Massachnsetts


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xiv CONTENTS

4

5

(ontralndlCatlons to Exercise TestingInformed Consent

PartiCipant InstructionsHealthRelated Physical Fitness Testing and InterpretationPurposes of Health-Related Fitness TestingBasic PnnClples and GUldehnesPretest InstructionsTest Order

Test EnvironmentBody CompoSitionAnthropometric MethodsDensitometryOther TechnrquesBody Composition NormsCardloresprratory FitnessThe Concept of MaXimal Oxygen UptakeMaximal versus Submaximal Exercise TestingModes of TestingCardioresprratory Test Sequence and Measures

Test Termination CriteriaInterpretation of ResultsMuscular Strength and Muscular EnduranceMuscular StrengthMuscular EnduranceFlexibilityA ComprehenSive Health Fitness EvaluationClinical Exercise Testing

494951555556565656575764656666666768767879808183858993


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CONTENTS xv

Exercise Testing With Imaging Modalities 110Exercise Echocardiography 110Exercise Nuclear Imaging 110Pharmacologic Stress Testing 111Electron Beam Computed Tomography 111Supervision of Exercise Testing 112

Section III Exercise Prescription

115115116116119119123123124124125125126126

133134135136

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

Interpretation of Responses to Graded ExerCIse 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 Prescnption

Art ExerCIse

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7


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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 1658 Exercise Prescription Modifications for Cardiac Patients 174

Inpatient 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 189Eligibility and Exclusion Criteria for

Resistance Training 189Time Course for Resistance Training 190Resistance Training Prescription for Cardiac Patients 190

Exercise Training for Return to Work 191Special Cardiac Patient Populations 191Myocardial Ischemia 191Congestive Heart Failure 193


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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

Immunolo9Y 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 227


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xviii CONTENTS

Section IV AppendicesABCoEF

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

255267279286300309351

f


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AbbreviationsAACVPR American Association of CAD coronary artery dIsease

Cardiovascular and CDC Centers for DiseasePulmonary Rehabilitation Control and Prevention

ABI anklelbrachial systolic CHF congestive heart failurepressure Index CHO carbohydrate

ACE anglotenslnconvertlng CI cardiac Indexenzyme COPD chronic obstructive

ACGIH American Conference of pulmonary diseaseGovernmental Industrial CPAP continuous positiveHygienIsts airway pressure

ACOG American College of CPR cardiopulmonaryObstetricians and resuscitationGynecologists CPK creatine phosphokinase

ACP American College of CRQ Chronic RespiratoryPhysicians Questionnaire

ACSM American College of DBP diastolIC blood pressureSports Medlcme DOMS delayed onset muscleADl actIVities of daily lIVIng soreness

AHA American Heart ECG eledrocardlogramAssociation (electrocardiographic)

AICD automatic implantable EF ejection fractioncardioverter defibnllator EIB exercise-induced

AIHA Amencan Industrial bronchoconstnctlonHygiene Association EIH exerCIse-induced

AMA American Medical hypotension


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ABBREVIATIONS xxi

SVT supraventricular VMT ventilatory muscletachycardia traIningTHR target heart rate 1iO, volume of oxygenTlC totalluog capacity consumed per mmuteTN true negatJve \Q2m.1J; maximal oxygen uptakeTP true POSltrve V02PNk peak oxygen uptakeTPR total penpheral IiO,R oxygen uptake reserveresistance %IiO,R percentage of oxygenTV tIdal volume uptake reserveVC vital capacIty VT ventilatory threshold~ O volume of carbon WBGT wet-bulb globedioxIde per minute temperatureIi, expired ventIlatIon perWHR walst-ta-hip ratrominute W-P-W Wolff-Parkinson-WhiteVEmaJt maximal exerCIse YMCA Young Men's Christianventilation AssociationYo inspired ventilation per YWCA Young Women'sminute Christian Association


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xx ABBREVIATIONS

GXT graded exercise test Pa0 2 partial pressure ofHAPE high-altitude pulmonary artenal oxygen

edema PAC premature atrialHDL high-density lipoprotein contractionHFD Healthlfltness Dlredor4D PAR-Q PhYSICal ActiVItyHFI HealthIFrtness Readiness Questionnaire

InstructorSM PD Program DlrectorSMHR heart rate P E maXimal expIratoryH R m a ~ maximal heart rate pressureHRR heart rate reserve Pima>: maXimal InspiratoryHR res, restrng heart rate pressureIC InSpiratory capacity PNF proprioceptive neuro-ICD Implantable cardioverter muscular facilitation

defibrillator Po, partial pressure ofIDDM Insulin-dependent oxygendiabetes mellitus PTCA percutaneous translumi

KSAs knowledge, skills, and nal coronary angloplastyabilities PVC premature ventncular

LAD left aXIs deviation contractionLBBB leh bundle-branch block PVD peripheral vascularLDH lactate dehydrogenase diseaseLDL low-density lipoproteIn RER respiratory exchangeL-G-L Lown-Ganong-Levme ratioLLN lower limit of normal RAD nght aXIs deviationLV left ventricle (left RAL recommended alert limit

ventncular) RBBB nght bundle-branchMCHC mean corpuscular hemo- blockglobin concentratIon rep repetition

MET metabolic equivalent RIMT resistive Inspiratory


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Health AppraisaLRisk Assessment, andSafety of ExerciseChapter 1 Benefits and Risks Associated With

SECTIONI


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Benefits and RisksAssociated WithPhysical Activity

CHAPTER1Tllis "hapler prO\ide"l operational df'lIllitioll'l for tt.'nninology used throughoutthE' hook related to ph.\'sical adh'i ly and fitEless, and tllf'1l provides a rev iew of:1) the (;111"1"


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The Iin].,ing of adjectiv>s to ph\'sioloc ranges (>.g., light "20'7,-;39'X- \'01His based on participalion in activities ran!(ing from 20 10 (j() minntes. whie" rt'presents the recommended session dllration \\ithin mosl e,ereise pre,cription,.

Adapted from UMed Stales Department of Health and Human Serv CPS Physlcal de IVlty and healt . Areport of theSurgeon General, 1996. Amencan College of SportS MediCine Pos,tlon Stand n e f l " C o m m ~ n d e d QiJdOllty nndqualityof exerCIse for developing and rnantollnlng card ofPspiralory and museu .If fitness. dna !Iexlbll ty In h altny adults Moo SCI Spons Exerc 1998.30975-991. Howley ET Type of lJre VPfSUo;OCCUpational physICal aetMty Med SCI Sports Exere 2001,33S364-S369A b b r e v t a h O r . ~ METs. metabolic equrvalent UOlts (l MET ... 35 mLkg I mln I), VO.R, oxygen uptao::e r e s e r v ~ . HRRheart rateresl'rve

Table 1-1. Classification of Physical Activity IntensityRelative Intensity Absolute Intensity Ranges (METs) AcrossFitness levels

Intensity I iO,R (%) Maximal 12MET 10 MET BMET 6 METHRR (%) HR (%) VOzm8ll VO lmax VOzm ... VOZmall

Very l ight d all attempt to halanc.:e re'Lsihility and t'flk-ae\ ill d('wlopinl( pllhlic Iwalth reconlnwndations 1,)1' ph)sical aeti\ it). Br'callse ,\ nll'l'iealiS "re hi,gl :1.1' sed"lItlu) (t heJ!:)!.JI)"stiIiJatt's illdicating Ihat almost -Hl'k of" adlilts do not ('lI!(age in all: leisurt'tilll(' p""ical a c l i s i ~ ),n, per lIading st'dE'litary illdis idnals to bt'eolile ph"icall:aetis'" is Ulon' likely 10 b,' sllcee"flll wlll'n Ih> largel I r ~ \ ( ' 1 of pillsit'al activit\ is

SECTION II HEALTH APPRAISAL. RISK ASSESSMENT. AND SAFETY OF EXERCISE

Both h!?alth-related and physiologic IItness 1l1!?


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DIVERGENT PHYSICAL AGIVITY RECOMMENDATIONS

\n important ('Olllponl'nt of tht' C11TTt.'nl r('('omlll(nd,lti()n.. l - 111.11 h.L\ 1101Ix>en ('Inplla-"i/l"t! \ l l m ( " i t ' l I t l ~ is tl\(' d()r \ \onk ' i ( ) I I l ( ' ;J(1i\"ih is 1lt'(tC'r Ihan 1I01\(', .\IId lH(m'1(1i\il) lip to a point i" ht'tter th.m less, \ l t h ~ t 1 g h til(' oplill1.tl do\{" of p h ical a d,llil arc.' tilr 11'\s dt'ar f('g.mling IIU' Illllllllloll dc)\(' of p h ~ \ , c a lO C 1 h ~ t ) that is f("(l'lirt."(1. as \\('11 as\\ h.ll fllrtlll'r ri\1.. rc.'t!1I(1iun'i ( ) ( ' ( ' l l f \\i,1 h ' 1 ~ 1 ~ ! i t i O l l , Jamounts (duration .Ul


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

Decreased minute ventIlation at a given absolute submaXlmallntensltyDecreased myocardIal oxygen COSt for a gIVen absolute sUbmaXlrTldlIntensftyDecreased heart fate and blood pressure at a grven submaxltnalIntensityIncreased capillary density In skeletal muscleIncreased exerose threshold for the accumulation of lactate In thebloodIncreased exerose threshold for the onset of dlsed>e signs or symptoms(eg . angina pectons. ISChemIC ST-segment depresSIon, claudiCatIOn)

Reduction in coronary artery disease risk factorsReduced resting systohddidS10hc pr(>SsuresIncreased serum hlgh-denslty lipoprotein cholesterol and decreasedserum tnglycendesReduced total body fat, reduced Intraabdomlnal fatReduced InsulIn needs, Improved glucose tolerance Reduced blood platelet adheSIVeness and aggregation

Decreased morbidity and mortalityPnmary prevention (i,e", Interventions to prevent the InItIal occurrence)Higher aolVlty and/or fnness levels are aSSOCIated with lower deathrates from coronary artery disease Higher activity and/or fitness levels are assocIated wrth lower

Incidence rates for combined cardiovascular diseases, coronaryartery disease, stroke, type 2 diabetes, osteoporotic fraoures,cancer of t he c olon and breast, and gallbladder diseaseSecondary preventIon (I.e., Interventions aher a cardiac event [toprevent another) Based on meta-analyses (pooled data across studies), cardiovascularand all-eause mortality are reduced rn postmyocardlallnfarolonpatients who partlopate In cardiac rehabilitation exerCIse traIning,espeCially as a component of multlfactonal nsk faoor reduolonRandomized controlled trrals of cardIac rehablhtauon exerCISetraining Involving postmyocardlallnfarolon patients do not supporta reduolon In the rate of nonfatal relnfaralon ..

p h y ~ j ( ~ . 1 J alth) weight ~ J . i l l (:ompared \\ith theilmount neede 12 summariZf'S the ..wailable dahl on the inverse doserespellS(' rt'ialiollship Ix,tw(,(,11 phy"i


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Risks Associated With Exercise

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

Illlhitlllll pltysical a ' Ii"it} reduces th . ill 'idl?n 'p or ath ' l ' ( l ~ Iewti' 'ardio\'il.\clliard i s e i L ~ e , (\"liJwft>ss. \ ~ g O I ' O I i S physical ' ~ ( ' r t i o l l also i K ' l I t p l ~ and trallsi 'ntl}illcr 'ases th ' risk or sliddell t'iut!iac dl'ath II >; alld a '1lle IllI'( 'i1rdial infilr e.e" 1995;27641 47ITh,,,,,also h.d coronary .nomalres, one had WolflP rklnsonWhlle syndromeIInciudes anomalOYs left coronary .rllry (LCAl irom "9ht . ,nus 01 V.lsalva (N = 4J, , n ,amu'alleltame"o,descending (LAD) (N = 4), .nomalou, LCA Irorn pulmor ry artery IN 2). a"",n.fom light coron.ry artery (RCA)lrom lelt s,"us IN - 2). hypopla5l1< RCA (N =1), ,.nd 0'1 1,odge of Ie LCA (N =1) f hr s ubJ et lS W.lh coron.ry.no,n hes alsohad hypenroph" ca 'dlomyop thy md Jr . Idbuldled wllh th.t 9rouP

Category ofEvidence

B

CCB

CCCC

Evidence fo r InverseDose-ResponseRelationshipYesYesNotInsufficient da aInsufficient da aYesYesiYesInsuffiCient dataYesNot

SECTION II HEALTH APPRAISAL. RISK ASSESSMENT, AND SAFETY OF EXERCISE0

Variable

All-cause mortalityCardiovascular and coronary heart diseaseBlood pressure and hypertensionBlood lipids and Iipopro emsCoagulation and hemostatiC factorsOverweight, obeSity. and fat distributionType 2 diabetes mellitusColon cancerLow back pain, osteoar hn IS, and osteoporOSISQuality of life and Independent living Inolder personsDepression and anxiety. From Kesameml YK. Danforth E Jr, Jen5en MD. et dl Doseresponse tS!Jues {oncernlng phYSICal activity and healUan v l d e n c < ' ~ d ,ympowm. M ~ SC, SpOrtS Exe"2001.33S351 358INo Ind,c l es a l ack0 eVIdence fo, a -dose ',esponse- fo, Ihe , 'atlon,h,p belween Ih he.i1h oulcomedndphY',cal w'ly, 'I does nOI Ind,r..te the bsenceof lovo,able ",Iatlonshlp110 . r s dose-r.-pome fo, primary p",venhon, bUI not fo, Imp,owmf>nt '" blood 9lucO'" conl'ol In patient< w,lhdiabetesC.'090ry deftmtlO"sC.tegory A EVld nce '. lrom ndpo,nt


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EXERCISERELATED CARDIAC EVENTS IN ADULTS

RISKS OF CARDIAC EVENTS DURING EXERCISE TESTING

EXERCISE EVENTS IN THOSE WITH SICKLE CELL TRAIT13HAPTER 1 I BENEFITS AND RISKS ASSOCIATED WITH PHYSICALACTIVITY

PREVENTION OF EXERCISE-RELATED CARDIAC EVENTS

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,. SECTION II HEALTH APPRAISAL. RISK ASSESSMENT, AND SAFETY OF EXERCISE CHAPTER 1 I BENEFITS AND RISKS ASSOCIATED WITH PHYSICAL ACTIVITY 15Table 1-5. Number of Panicipants for One Cardiac Event in CardiacRehabilitation Programs

REFERENCESJ. Caspersen q.I'O\wll "'E. Chrhleu ...MI (:\1 l ' h \ ' i l ~ l l . l I . , t i l i l \ , \,\,'1"\.1"'. 'lIltl ph\,k .1Ow,,''' c1l"fnll'

lIOIIS ,Iud cli,!iIK.1iuM It.r 11t'.llth.nl.'II ...1 ( { ~ . I n - h I 'uhli\ I k , ~ l h Ik p 19'>5. lOll 1:!r.--1312.. Pn\k!tnt's Counl.'iIIHI I'h\'\It;,d 1-11111"" D,fillilitlll\ " ' ~ I h h . tlhw,-' ,lIul phI ,i' ,II ....-11\ ih HI''\t.ln-h

D I ~ c s l . 2000.3 U"i"'il Stalt" 1)t.'P.lr!llwul nf 1 I I ' , ~ t 1 . :.,mlllulII,ll' ~ I .... il'''' 1'!J\,i,;d .11.11\11\ .ullllu.dllJ .. ({'pur! of

11ll' ! ' u ~ , ' O n (:{'1It'm1. ItI'-J61',lt\' IIR. Pnlll M. ntur S'\..l'l. til 1 ) l l " K ~ t 1 "d i \ lh .mil puhlitlll,lhh " r t ' ( ~ l 1 l l 1 m 1 l I 1 . l l l o " fnllnlhl'Ct.nler


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21/21

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19

acsms guidelines for ex testing prescription

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