E XERCISE P RESCRIPTION I N P ATIENTS W ITH C ARDIOVASCULAR D ISEASE L EANDRO C. B ONGOSIA, MD,...
-
Upload
mary-carter -
Category
Documents
-
view
213 -
download
0
Transcript of E XERCISE P RESCRIPTION I N P ATIENTS W ITH C ARDIOVASCULAR D ISEASE L EANDRO C. B ONGOSIA, MD,...
EXERCISE PRESCRIPTION IN PATIENTS WITH
CARDIOVASCULAR DISEASE
LEANDRO C. BONGOSIA, MD, FPCP, FPCC, FACC
Definition of terms
Physical Activity – any bodily movement produced by contraction of the skeletal muscle that results in energy expenditure
Exercise – planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness
Definition of terms
Physical Fitness – an attained set of attributes that relate to the ability to perform physical activity. This includes cardiorespiratory endurance, muscle power, balance, flexibility and body composition.
Singh, J Gerontology 2002
Dionne, Elsevier 2003
Why the need to exercise?• Regular exercise performed at low to moderate intensity is
associated with improvements in risk factors.
• Improvement in functional class and increased feeling of independence leading to a higher quality of life
• Improvements in physical function have been seen after short term exercises of 3 to 4 months with interventions that include both aerobic and resistance.
Mazzeo, J Sports Med 2001
Hessert, J of Fam Med 2005Dionne, Elsevier 2003
Pre-training
Post-training
Work rate
Rate
-pre
ssur
e pr
oduc
tExercise training and myocardial oxygen consumption
Ades PA, et al. Circulation 2006;113:2706-2712
Exercise prescription
• The exercise prescription is ideally based on the results of a maximal incremental exercise test.
• However, because of the muscular specificity of exercise testing and training, the mode of the exercise test should be tailored.
Purpose of Exercise Prescription
• To provide a safe and effective program
• To define individual patient guidelines by describing frequency, intensity , duration and mode of exercise
Theoretical relation between health and fitness benefits and the amount or intensity of exercise:
Health
Fitness
Quantity of exercise
Bene
fits
Guidelines for Exercise Prescription
• ACSM and CDC recommends 30 minutes of moderate intensity physical activity on most days of the week.
• Priority should be given to exercises that enhance everyday movements and an individual’s ability to function independently.
Mazzeo, J Sports Med 2001
Hessert, J of Fam Med 2005
The Process of Developing an Exercise Prescription
Assessment
Interpretation
PrescriptionMode
Frequency
Duration Intensity
Precautions
Progression
Components of Exercise Prescription:
A. ModeB. IntensityC. DurationD. FrequencyE. Progression
Components of Exercise Prescription
A. Mode
• Endurance exercise - uses large muscle groups over prolonged periods on activities that are rhythmic and aerobic in nature
• Should avoid high impact activities particularly early on in the exercise program
Components of Exercise Prescription
Mode(cont.)Resistance Training:- Does little to increase VO2 max
- Effective method for muscle strength and endurance- Prevents and manages a variety of chronic medical
conditions- Enhance independence in elderly patients- Attenuates rate - pressure product when lifting any given load
Components of Exercise Prescription
B. Intensity
For Cardiac Patients: 40% - 60% VO2max
“Above a minimal level required to induce a training effect but below the metabolic rate that evokes abnormal signs or symptoms”
Components of Exercise Prescription
B. Intensity (cont.)
1. Establishing a training/target HR2. Using MET method3. Rate of Perceived Exertion
Training/Target HR Method
Percent (%) maximal HR Calculates a fixed % of measured or estimated
heart rate (220-age)
Examples: 1. HRmax = 120/min60 % of 120 = 72/min
2. HRmax (estimated)Age = 60 yrs.220 – 60 =16060% of 160 = 96
Training / Target HR Method
Heart Rate Reserve (Karvonen)HRR = HRmax - HR restKarvonen Method = defines a HRR, multiplied by %
desired and adjusting for the resting HR= (HRmax - HR rest) 40-80% + HR rest
Example: HRmax = 150HR rest = 70HRR=150-70 = 80
If target is 60%, 80 x 0.6 = 48
HRR = 48 + 70 = 118
Components of Exercise Prescription
B. Intensity(cont.) MET Method
- prescribes intensity by workload or activities associated with MET values
Rate of Perceived Exertion - particularly useful in patients where HR
response is blunted ( beta blocker tx or cardiac transplant), AF, pacemakers with fixed rate.
Components of Exercise Prescription
C. Duration 20 to 60 minutes of continuous or intermittent (minimum of 10-min bouts) aerobic activity accumulated throughout the day
ACSM
Components of Exercise Prescription
D. Frequency3 – 5 days/week
3 days/week ---- 60% – 80% HRR
ACSM
Components of Exercise Prescription
E. Progression General Principle: Increase in exercise every 1 to 3
weeks achieving 20 to 30 minutes of continuous exercise before prescribing additional increase in intensity.
Five interacting elements of exercise prescription
Warm up - important for older adults prone to musculoskeletal injuries and cardiac events - light movements simulating the actual exercise activities.
Five interacting elements of exercise prescription
Exercise Intensity - low to moderate intensity initially to improve emerging risk factors. - later on moderate intensity exercises should be emphasized.
MODERATE INTENSITY IS DEFINED AS FOLLOWS:
55 to 70% of HR max (220 – age) 40 to 60% of HRR 40 to 60% of 208 – (0.7 x age) Rate of Perceived Exertion at 12 to 13
Caloric Cost of Exercise (METS x 3.5 x body weight in Kg/200=kcal/min
Example: Mr A. weighing 85 kg exercising at 8 mets on treadmill. How much calories shall he expend for 30 min?
8 x 3.5 x 85/200 = 11.9 or 12 kcal/min x 30
Caloric cost per 30 min of exercise = 360 kcal
Balady GJ, Cardiology Clinics, Vol 19, No.3 Aug 2001
Five interacting elements of exercise prescription
Duration - this should be increased first prior to increasing intensity - 30 minutes per day
Frequency - most or all days of the week - if vigorous exercise is done, should be done only 3x a week.
Five interacting elements of exercise prescription
Type / Mode - based on the fitness level - exercises which can be incorporated into everyday life instead of a structured activity - enjoyable and minimal potential for injury - results to better compliance
Mazzeo, J Sports Med 2001
Why the need to include resistance training?
Sedentary individuals lose 20 to 40% of muscle mass over the course of adult life. Muscle mass cannot usually be maintained into old age even with regular aerobic activities. Appropriate progressive resistance training of 3 to 6 months was shown to increase muscle strength by 40 to 150% and mass by 1 to 3 kg.
Singh, J Gerontology 2002
Restrictions of Resistance Training
• Unstable angina• Uncontrolled HPN ( BP > 160/100)• Uncontrolled arrhythmias• Recent CHF• Severe Valvular Heart disease or hypertrophic
cardiomyopathy
Restrictions of Resistance Training
• Poor left ventricular function• Inadequate functional capacity, less than
or equal to 5 METS (not an absolute contraindication)
Division of an exercise program
1. Warm up2. Pre-stretching3. Dexterity4. Resistance / wt.
bearing5. Endurance6. Balance7. Cool Down
5 to 10 minutes 5 to 10 minutes
10 minutes 15 minutes
20 to 30 minutes 5 to 10 minutes 5 to 10 minutes
Hessert, J of Fam Med 2005
Summary of Exercise Prescription among Patients with CVD
CVD Intensity Comments
Angina or equivalent
Shuler G, et al. Circulation 1992;86:1-11
40 - 50% of HRR with necessary adjustment to keepupper HRR limit tono more than 10 beats below ischemic threshold
Consider prophylacticNTG 15 min before anticipated exertionif symptoms limitroutine ADL’s orability to exercise
Summary of Exercise Prescription among Patients with CVD
CVD Intensity CommentsMyocardial 40 – 85% of HRR Infarction
PCI
CABG or 40-85% of HRR Valve surgery
Shuler G, et al. Circulation 1992;86:1-11
Achieve 1,500-2,000 kcalof energy expenditurethru activity each week
Restrict upper bodymovement until sternumis healed (6 - 12 weeks)
Summary of Exercise Prescription among Patients with CVD
CVD Intensity CommentsHeart failure 40(50)-70% of HRR If needed, initially guide
exercise intensity at 60%of HRR and adjust durationto 3 bouts of 10 min eachprogressing to 30 - 40 min.As patient progresses,maintain upper rate below ventilatory threshold
Summary of Exercise Prescription among Patients with CVD
CVD Intensity CommentsPacemaker, ICD, CRT
Shuler G, et al. Circulation 1992;86:1-11
10% belowactivation threshold
Avoid activities that stretchthe arms. After 8 weeksnonballistic activities maybe resumed and ballistic activities may be resumedafter 12 weeks
Summary of Exercise Prescription among Patients with CVD
CVD Intensity Comments
CAD 40-85% of HRR
Shuler G, et al. Circulation 1992;86:1-11
To affect mortality, frequency, duration and intensity of training should sum to yield a weekly energy expenditure of > 1,500 kcal/week
Summary of Exercise Prescription among Patients with CVD
Hypertension - If BP is uncontrolled, avoid weight lifting - Borderline HPN under medications: may
use light weights and avoid Valsalva - 3 sets of 8 to 15 repetitions using major
muscle groups 3 to 4x a week - Those on dialysis should have light
weights to promote the anabolic effects
Guidelines for Exercise Rx for Cardiac Patients (ACSM)
Mode: Select rhythmical aerobic activities that can be maintained continuously involving large muscle
muscle groups
Intensity: Prescribe between 40 - 85% VO2max
Duration: Schedule 20 to 60 minutes of continuous or intermittent activity
Frequency: Schedule exercise 3 to 5 days a week
Progression: Progress every 1 to 3 weeks as tolerated withincrease in duration first
Summary and Conclusion: