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Principles Of Exercise
Prescription
Dave Zanghi M.S., MBA, ATC/L, CSCS, FAACVPR
Figure 1.1 Role of physical activity and
exercise in disease prevention and
rehabilitation.
 General
Mode
Principles :
of exercise
Intensity of exercise
Duration of exercise
Frequency of exercise
Rate of progression
 The
general parameters of exercise
prescription hold true for
individuals who are healthy as well
as those patients who have disease
pathology. However, there must be
some special considerations for
those that have disease.
Some Acute & Chronic
Disease Pathologies Of
Concern
Cardiac Disease - MI’s, CAD, IHD
Vascular Disease - PVD, HTN, Stroke
Arteriosclerosis, Atherosclerosis
Cancer
Metabolic Disease - Diabetes, NeuroEndocrine Disorders
Patient’s With Pathology
 Exercise
is not prescribed for
these individuals until the patient
has undergone a graded exercise
stress test (GXT) under the
direction of their physician.
Graded Exercise Tests
 Low
Level Graded Exercise Test
 Regular Graded Exercise Test
Some examples ……...
Low Level Exercise Stress Test
Stage Speed Grade
I 1.7 mph 0 %
II 1.7 mph 5 %
III 1.7 mph 10 %
IV 2.5 mph 12 %
Dur. METS
3 min 2.3
3 min 3.5
3 min 4.6
3 min 6.8
 The
low level GXT is given to
patient’s with significant cardiac
damage and who have an
exercise capacity lower than 8
METs
Bruce Protocol GXT
Stage
I
II
III
IV
V
VI
Speed Grade
1.7 mph 10 %
2.5 mph 12 %
3.4 mph 14 %
4.2 mph 16 %
5.0 mph 18 %
5.5 mph 20 %
Dur.
3 min
3 min
3 min
3 min
3 min
3 min
Modified Bruce Protocol GXT
Stage
I
II
III
IV
V
VI
VII
Speed Grade
1.7 mph 0 %
1.7 mph 5 %
1.7 mph 10 %
2.5 mph 12 %
3.4 mph 14 %
4.2 mph 16 %
5.0 mph 18 %
Dur.
3 min
3 min
3 min
3 min
3 min
3 min
3 min
Question ?
 Are
the same aerobic activities
appropriate for both the cardiac
patient and the healthy individual ?
Answer
No
!! Cardiac patients have some
special concerns such as :
Intensity of the exercise
Static and dynamic balance
Syncope and falling
Degree of cardiovascular pathology
 Medications
The Exercise Prescription
Mode of Exercise
 Any
activity :
that
uses large muscle groups
that is rhthymic
that is sustained below the
patient’s anaerobic threshold for
20-60 minutes
Exercise Mode - Aerobic
biking
light
rowing
rebounding
ballroom dance
walking
water aerobics
nordic
track
slow jogging
slow jarming
skating
slow wogging
MET Equivalents
 Archery
: 4 METs
 Canoeing & Rowing : 6-8 METs
 Cycling : 5 - 8 METS
 Ballroom Dancing : 5 - 9 METs
 Fishing : 4 - 6 METs
 Golf : 4 - 7 METs
 Hiking
& Walking : 4 - 8 METs
 Judo & Tae Kwon Do : 10 - 16 METs
 Raquetball : 8 - 14 METs
 Rope Jumping : 9 - 12 METs
 Rebounding : 6 - 10 METs
 Shuffleboard : 3 - 4 METs
 Ping
Pong : 3 - 6 METs
 Tennis : 4 - 12 METs
 Swimming : 4 - 12 METs
 Sailing : 4 - 9 METs
 Running 12 min/mile : 9 Mets
 Running 10 min/mile : 11 METs
 Running 8 min/mile : 13 - 15 METs
 The
various modes of exercise
must be specifically tailored to the
patient’s physical needs such as :
aerobic
work capacity
physical condition & disease state
availability of equipment
patient’s interest & family support
Intensity Of Exercise
 Exercise
intensity is calculated
from the results of the GXT
Some examples …...
The GXT Report Should Have
Resting heart rate
Maximum ex. heart rate
Resting blood pressure
Maximum ex. blood pressure
Maximum METs achieved
How Do I Use
The GXT Data ?
Use
the Modified Karvonen’s
Formula to set the training
exercise heart rate or the training
exercise blood pressure for the
population with pathology.
The Karvonen Formula
Karvonen’s Formula to determine
target exercise heart rate was:
(HRmax - HRrest) x (.6 - .8) + HRrest
This formula needs to be modified for use in
diseased populations.
The target exercise heart rate should
look like this for special populations:
(HRmax - HRrest) X [.6 - .8 + Max METs/100] + HRrest
The bracketed portion of the formula containing the Max
METs value is called the Activity Fraction.
Advantages Of This Modified
Karvonen’s Formula
Advantage
# 1 : The modified
Karvonen’s Formula has a low
starting activity fraction to
accommodate exercising patients
with cardiac disease.
Advantage
# 2 : The adjusted
target heart rate for the patient
with disease is calculated on the
heart rate, blood pressure and
Max METs achieved during the
symptom limited GXT .
What Is A Symptom
Limited GXT ?
A symptom limited GXT is a stress
test in which the physician recorded
the onset of symptoms (angina, ST
segment depression) at the specific
heart rate, blood pressure and stage
of the GXT.
 What
value is a symptom limited
GXT to the Exercise Specialist ?
It
provides a maximum exercise HR
and BP at which significant signs
and symptoms of ischemia begin to
appear.

All exercise prescriptions are written using
the modified Karvonen’s Formula to insure
that the patient’s exercise training intensity is
significantly lower than the maximum
symptom limited exercise HR & BP values
avoiding the onset of myocardial ischemia.
However………...
Seldom does the prescription ever
have all of the ideal data !!
So ……...
How do I write the exercise
prescription with only part of the
GXT information ?
Duration of Exercise
Duration
of exercise should
ideally be between 30 - 60
minutes
If
the patient is unable to
perform 30 minutes of steady
state exercise, break the time into
7-8 minute stages.
Research
has shown that
multiple small bouts of exercise
added together have the same
training effect as a single bout of
exercise of the same total
duration.
Frequency Of Exercise
 Frequency
begins with 3days/week
and progresses to 5-7days/week.
 How
often a person exercises/week
depends on their pathology and its
severity.
Examples…...
A
Type I Insulin-Dependent Diabetic
should exercise 7 days per week for
glucose regulation.
A
Type II Non-Insulin-Dependent
Diabetic should exercise 4-5 days per
week for weight control.
Rate Of Progression….The
Art Of Exercise Prescription
 Rate
of progression is impacted
by many factors :
type
of pathology
severity of pathology
aerobic work capacity
Some Thoughts …….
Increase
duration to 45 - 60 min
Next, increase frequency
Lastly, increase intensity
 Once,
you are up to 45 - 60 minutes
per exercise session, increase
frequency from 3 times/week to 4
times/week.
 Then back off to 30 min/session to
allow the patient to adjust to an
increase in the frequency of exercise.
 When
the patient’s exercising 45 - 60
minutes/session for 5 times/week, it is
time to increase the intensity.
 Once you increase intensity, the
duration and frequency may need to
be adjusted to let the patient
accommodate to the new intensity.
Warm Up & Cool Down
 All
patients with pathology as well as
the healthy individual should have a
4-6 minute warm up period and a 6-10
minute cool down period.
Longer Cool Down Periods
 It
is smart to have the patient cool
down for 6-10 minutes after a
steady-state exercise bout.
 Many cardiac events occur after
cessation of exercise.
Monitoring The Patient
 There
are a number of ways to
monitor the patient during exercise.
Anginal Scale
Borg Scale
Dyspnea Scale
Blood Pressure
Heart Rate
Anginal Scale
 1+
 2+
 3+
 4+
Light, barely noticeable
Moderately bothersome
Severe, very uncomfortable
Most severe pain ever
experienced - must stop !!!
Stopping Points With Angina
 When
a person is exercising and they
complain of 2+ or 3+ angina, you
must stop the exercise (ACSM).
 It
would be better to stop at 2+
angina rather than allow the patient
to get to level 3 angina.
Anginal Equivalents
 Umbilical
pain
 Jaw or tooth pain
 Tingling/numbness in fingers/hands
 Shoulder pain
 Low back pain
 Chest pressure
Borg’s Ratings Of
Perceived Exertion (RPE)
7 = Very, Very Light
9 = Very Light
11 = Fairly Light
13 = Somewhat Hard
15 = Hard
17 = Very Hard
Dyspnea Scale
1+ Light Breathlessness
2+ Moderate Breathlessness
3+ Severe Breathlessness
4+ Most Severe Breathlessness Ever
Experienced
Blood Pressure
Stop
If
Exercise If BP Is >260/115
BP Is >200/115 At Rest, Don’t
Exercise - Refer The Patient To
Their Physician
 Sometimes
the diastolic pressure rises
8 - 10 mm Hg pressure during
exercise. If it rises more than this,
consider referring the patient to their
physician. In most cases, diastolic
pressure remains the same or falls
during exercise from its pre-exercise
rest value.
Heart Rate
 Initially,
for a couple of weeks,
HR should remain within the
calculated target training zone
determined from the HR values
of the symptom limited GXT. It
can be advanced in blocks of 5-6
beats as the patient tolerates this
increase in intensity.