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Art of Clinical Exercise Programming
For individuals who are unaccustomed to physical activity or who have never
exercised as a part of their lifestyle, adopting an exercise program can be a
challenge. Individuals newly diagnosed with a chronic condition are often
advised to begin a program, but side effects of many conditions or the
treatments (or both) can cause fatigue, weakness, depression, pain, shortness
of breath, or other discomfort, and may present significant challenges to getting
started and sustaining a program. Thus, There are essential steps that should be
integrated into the process of exercise programming in individuals with chronic
conditions:
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Step 1: Assess Current Health Status
Step 2: Assess Current Level of Physical Activity
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Step 3: Identify Exertional Symptoms That Limit Physical Activity
Step 4: Evaluate Physical Function and Performance
Step 5: Selecting Physical Performance Assessments
Step 6: Considerations for Formal Exercise Tolerance Testing
Step 7: Considerations for Program Referral
Step 8: Develop a Strategy for Monitoring Progress
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Step 1: Assess Current Health Status
It is important to understand how the patient is coping with the disease,
especially in terms of participation in life activities and physical activity. The
individual’s history of physical activity and the extent to which the disease or
treatment or both have affected participation in regular exercise, leisure-time
activities, activities of daily living (ADLs), and instrumental activities of daily
living (IADLs) will help determine starting levels and goals.
This assessment should also identify current and past barriers to participating in
physical activity, as well as the understanding of the benefits of physical activity
or exercise in general and how they relate it to their condition. The following
should be identified:
• Any absolute and relative contraindications to exercise due to the
condition (see next slide for example)
• Any clinical or patient concerns related to the safety of participating
• What clinical aspects of the condition might be improved with physical
activity
• What motivates and sparks the patient’s interest in starting and
sustaining participation
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ACSM’s absolute and relative contraindications to exercise (FYI)
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Absolute
Relative
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1) recent significant change in ECG
2) unstable angina
3) uncontrolled cardiac dysrhythmias
(compromise)
4) severe aortic stenosis
5) uncontrolled heart failure
6) acute pulmonary embolus
7) acute myocarditis
8) suspected/known dissecting
aneurysm
9) acute systemic infection
Left main coronary stenosis
Moderate stenotic valvular heart disease
Electrolyte abnormalities
Severe arterial hypertension
Tachydysrhythmia or bradydysrhythmia
Hypertrophic cardiomyopathy
Neuromotor, musculoskeletal, or rheumatoid
disorders that are exacerbated by exercise
High degree atrioventricular block
Ventricular aneurysm
Uncontrolled metabolic disease
Chronic infectious disease
Mental or physical impairment leading to
inability to exercise adequately
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Step 2: Assess Current Level of Physical Activity
Assessing the patient’s current level of physical activity can range from simple
questions to more formalized questionnaires.
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During the pre-participation evaluation it’s better to start with a more openended and broader question.
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One key insight that will be helpful is how the patient defines exercise. The
follow-up questions should become more focused, dealing with the frequency
and duration of the activities and any symptoms the client has experienced.
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Example: Have the patient describe their activities over the course of a
typical day or week.
Always ask additional questions to fully understand the patient’s limitations.
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Step 3: Identify Exertional Symptoms That Limit Physical Activity
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The practitioner should try to assess any symptoms that limit physical activity. It is
helpful if the limiting symptom is both assigned an objective value and described
qualitatively, as in these examples:
• I can walk for 10 minutes before I have to stop because my legs cramp up.
• I can only fold laundry for 5 minutes before I get short of breath and my
shoulders start to hurt.
It is important to get an idea of how long the limiting symptoms last after the
patient stops to recover. This recovery time is another important measure of
physical function that may have implications in diagnosis, in prognosis, and in
developing the exercise prescription.
In some cases one would avoid activities that cause certain symptoms, but
in other cases one might actually promote exercises that provoke symptoms, all
depending on the nature and cause of symptoms.
For instance, in a patient who has a myopathy, one might avoid activities that lead
to cramps; but in a patient who has intermittent claudication, part of the intent of
the exercise is to cause a level of muscle pain that is tolerable but just shy of
causing cramps
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Step 3: Identify Exertional Symptoms That Limit Physical Activity
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Again, in some cases one would avoid activities that cause certain symptoms, but
in other cases one might actually promote exercises that provoke symptoms, all
depending on the nature and cause of symptoms.
Additional Examples:
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Symptoms that may be related to general deconditioning and weakness may
indicate the need to start with a focus on strengthening with very gradual
progression to aerobic training to ensure successful adaptation.
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Joint discomfort and stiffness that are associated with exercise may indicate
the need for specific physical therapy interventions to enhance range of
motion, reduce joint pain, or both.
Exertional symptoms are an indication that :
• a supervised program would be the best approach, so
• the exercise specialist can provide exercises to mitigate the symptoms,
and so
• the exercise specialist can guide the patient to the most appropriate
mode of exercise.
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Step 4: Evaluate Physical Function and Performance
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The pre-participation evaluation by the physician or midlevel practitioner should, at
a minimum, characterize the patient into one of four basic categories:
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Mildly impaired to normal
Moderately impaired, low functioning
Severely impaired, very low functioning
Needs aid, debilitated
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The comparisons in relation to external work are shown in Table 3.1 (next slide) ;
note especially the impact on ADLs.
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Patients who have chronic conditions but have mild to no impairment in physical
functioning should generally have their exercise prescription and programming in
accordance with the ACSM Guidelines.
Patients who have chronic conditions but have moderate impairment in physical
functioning or worse should generally be referred to an exercise specialist for more
in-depth evaluation of physical functioning.
The vast majority of patients with chronic conditions, especially the cardiometabolic
conditions, do not have gross neurological signs, and many have little or no
impairment in physical functioning.
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Step 5: Selecting Physical Performance Assessments
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Physical functioning measures have primarily been developed for use in
geriatrics; these consist of standardized tasks that test physical performance
limitations for specific movements such as walking, getting up from a chair, and
other tasks encountered in daily life. The many advantages to using these
measures include the following:
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Ease of use in the clinic (no special equipment)
Reproducibility of protocol
Efficient use of clinic time
High cost-effectiveness (no costs for special equipment)
Low preparation, aftereffects, and time or cost burdens for the patient
A major advantage of these measures is that many of them are widely used
and have well-established norms (including some condition-specific
populations). These tests are highly predictive of disability, nursing home
admission, and health care utilization in older individuals.
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Assessment of ADL and IADL limitations should be performed for individuals who are
older and those who are severely compromised by their disease (regardless of age).
Assess limitations in ADLs when working with patients who have significant physical
deconditioning or multiple comorbidities.
ADLs
Activities of daily living (ADLs) are
basic self-care tasks, akin to the
kinds of skills that people usually
learn in early childhood. They
include feeding, toileting, selecting
proper attire, grooming, maintaining
continence, putting on clothes,
Bathing, walking and transferring
(such as moving from bed to
wheelchair).
IADLs
Instrumental activities of daily living (IADLs)
are the complex skills needed to successfully
live independently. These skills are usually
learned during the teenage years and include
the following:
Managing finances
Handling transportation (driving or navigating
public transit)
Shopping
Preparing meals
Using the telephone and other communication
devices
Managing medications
Housework and basic home maintenance
Art of Clinical Exercise Programming
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Commonly Used Tests of Physical Functioning
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This section (pp. 37-41, text) is FYI only. You are encouraged to read through the
descriptions of the various physical performance tests . You will not be
examined on the information in this section of the chapter.
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Select Video Demonstrations of Commonly Used Tests
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Six-Minute Walk Test
Gait Speed Test
Chair-to-Stand Tests
Arm Curl Test
Art of Clinical Exercise Programming
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Step 6: Considerations for Formal Exercise Tolerance Testing
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Although results from diagnostic exercise testing can be used for exercise
prescription and to track improvements in fitness from exercise training, the
primary purposes of clinical exercise testing include:
• Diagnostic assessment of symptoms of ischemic heart disease
• Assessment of abnormal symptoms associated with exertion such as lightheadedness or dizziness, irregular heart rhythm or racing pulse, excessive
shortness of breath
• Assessment of blood pressure management
If diagnostic exercise testing is to be used in patients who have a severe burden
in physical functioning, one should to use a low-level graded treadmill test
(LLGXT)or ramp protocol by one of the following methods:
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Balke or Modified Naughton Treadmill Test
Low-level constant-increment protocol
Continuous low-level ramping protocol
Branching low-level protocol
It is important to reinforce the reasons why Bruce and Modified Bruce protocols are not helpful in
most patients with chronic conditions. The relatively large increments in work rates in these tests
usually lead to the rapid onset of fatigue, because the jump between stages is too big to resolve
low levels of exercise tolerance and overwhelms the individual’s capability.
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Art of Clinical Exercise Programming
In situations where the treadmill testing is not likely to be of high predictive value
or the test risks a delay in starting a low-level program that the patient really
should begin as soon as possible, the care team should consider using a functional
exercise trial.
In an extended trial, the initial sessions start at a low level; the responses to a given
session are assessed by the exercise specialist; and gradual increases in intensity
or duration are attempted and again are assessed with each successive session.
Thus an appropriate individualized progression and program can be developed
without formalized exercise testing. These sessions can be monitored using ECG,
blood pressure, and symptoms, and thereby provide even better information
on the individual responses and related symptoms than is obtained in a formalized
exercise test.
This is an ideal situation for providing positive feedback and coaching, as well as
education that will be reinforced by muscle memory. It is one thing to sit down in
an office and explain the ratings of perceived exertion (RPE) scale; it is a totally
different thing to have the client experience those ratings.
Art of Clinical Exercise Programming
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Step 7: Considerations for Program Referral
The level of program supervision falls on a continuum ranging from continuous
hemodynamic monitoring in a clinical setting to occasional phone follow-up by the
health care team to assess independent participation.
Factors that determine referral to a formal program should be:
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Specific limitations in physical functioning
Clinical condition and safety of exercise (requiring ECG or other monitoring)
Patient preference (usually out of insecurity with independent exercise)
Location that encourages attendance
Patient’s understanding of symptoms
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Physical therapy is indicated for specific impairments or deficits in range of
motion, strength, or mobility.
Occupational therapy is indicated to assist with specific impairments in basic selfcare and ADLs
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Art of Clinical Exercise Programming
Step 7: Considerations for Program Referral
Since the goal is to educate, motivate, and facilitate incorporation of regular
physical activity or exercise training (or both) into the lifestyle, for most
individuals the program should avoid creating a dependence on clinical
supervision of exercise.
Thus, depending on the clinical condition and safety considerations, supervision
should be gradually reduced over time, usually over a few weeks to a few
months (depending on the patient’s specific conditions).
Assessment of participation in physical activity or exercise training should be a
part of the routine medical care assessment, and deficits in participation or
identified problems associated with participation should result in a
reassessment by the exercise specialist on the team.
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Step 8: Develop a Strategy for Monitoring Progress
Sustaining participation in a regular program of exercise is a challenge, and many
strategies for enhancing adherence can be used depending on individual
preferences, style, and needs.
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Monitoring (frequency should be individually determined)
Strategies for monitoring participation range from regular phone follow-up to
diaries to online websites that can be set up for the individual and the team
members to monitor.
When participation drops off, the participant should be contacted to identify the
reason for reduced participation. Participation can drop off with changes in
clinical status or new onset of depression; any of these should be referred for
evaluation.
Any reporting form (i.e., diary, phone interview, phone reporting) should include those
clinical data on exercise responses and the clinical status (symptoms) of the patient.
Symptoms that could be monitored include rating of perceived exertion, anginatype symptoms, levels of dyspnea, claudication or cramping, muscle fatigue, and
overall fatigue associated with exercise.
Changes in symptoms experienced during or after a routine bout of exercise
should be evaluated by the medical care team for assessment of a change in
clinical status.
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Step 8: Develop a Strategy for Monitoring Progress
It is critical to educate participants on how to monitor their own responses to
exercise.
This includes hemodynamic responses (specifically heart rate and heart rhythm),
exertion ratings, and symptoms. The following are abnormal responses that every
patient needs to know:
• Excessive shortness of breath
• Such that a conversation could not be carried out (the talk test)
• That does not normalize with reducing intensity or stopping exercise
• Excessive heart rate
• When the heart rate is higher than prescribed or than what is usual for a
given level of exercise
• When there is the feeling that the heart is racing
• When the heart rate remains >100 beats/min (tachycardic) 30 min after
stopping the exercise
Muscle or joint pain that prevents continuation of the exercise despite reduction in
intensity or that persists after stopping exercise. Also, nausea , headache, dizziness,
or light-headedness , and chest pain.
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Step 8: Develop a Strategy for Monitoring Progress
Patients also need to know when they should not exercise, should reduce
intensity or duration, and should stop an exercise session, and when to call the
health care team or go to the emergency room.
They must also be aware of conditions and situations in which exercise must be
deferred until they are reevaluated and “cleared” for exercise by the health care
team.
In follow-up visits, it is important to assess for changes in activity since the last
visit, as a decline may be associated with new-onset symptoms (e.g., a new episode
of low back pain), a change in clinical status (e.g., gradual development of anemia), or
recent changes in medications.
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