Exam # 1February 15

Exam 1 will consist of: 55 multiple choice, matching and fill-in-the-blank type questions (2 points each) and 10 short answer questions (4 points each)

In addition to this power point you will also be questions pertaining to proper patient positioning, protocols and evaluation of results as outlined in

“Recommendations for Blood Pressure Measurement in Humans and Experimental Animals” article

Medical Documentation

• SOAP notes– Not used widely in exercise prescription– Used primarily in the medical and health care fields– What does it stand for?– If working with specific populations in specific facility may be

required to use this form of documentation (i.e. Cardiac Rehab Facility)

• Most reputable facilities require at LEAST some medical history questions prior to beginning a work-out program within the facility

• American College of Sports Medicine (ACSM)suggests certain documentation be completed prior to exercise

Medical History Form

• Longer version of the health screening form• A great place to start!• Can be filled out by the individual themselves

or exercise professional can ask the questions– Use judgment– If your facilities form has sensitive material on it,

let them fill it out– If working with an elderly client ask if they would

like assistance

Health Screening Form

• Shorter version of the medical history form

• Still effective at measuring an overall profile of an individual

• NOT to be used with high risk population or for something with a prescription from a doctor for exercise– More extensive form is needed

Informed Consent

• Seven items that should be included on all informed consent documents:1. Purpose and explanation of the test2. Clients risks and discomforts3. Responsibilities of the client4. Benefits to be expected 5. Inquiries 6. Use of medical records7. Freedom of consent

Physicians Release Form

• Not needed with all clients– Individuals who fall into the “healthy population”

category may not need physician clearance– The reason that we need these evaluations is to

find out

• When would you attempt to obtain physician release form?

Risk Stratification

• ACSM has three risk categories that place people at differing levels of risk:– Low Risk: Asymptomatic men and women who

have < 1 CVD (cardiovascular disease) risk factor– Moderate Risk: Asymptomatic men and women

who have > 2 risk factors– High Risk: Individuals who have known

cardiovascular, pulmonary, or metabolic disease or one or more signs and symptoms from the following: See next slide

Major S/S or Symptoms Suggestive of CV, Pulmonary, or Metabolic Disease• Pain in the neck, jaw,

arms, or other areas that may result in ischemia

• Shortness of breath at rest or with mild exertion

• Dizziness or syncope• Orthopnea or paroxysmal

nocturnal dyspnea: shortness of breath in recumbent position or when asleep

• Ankle edema• Palpitations or tachycardia• Intermittent claudication:

pain in muscle areas with inadequate blood supply (usually from atherosclerosis)

• Known heart murmur• Unusual fatigue or

shortness of breath with usual activities

Fitness Assessment Form

• More to come on this later – When we complete exercise testing

• Essentially a recording form that allows professional to record items such as VO2 max, 1RM, musculoskeletal flexibility assessments made, etc.

• Some facilities like to list guidelines for enhancing those listed assessments – i.e. To increase muscular fitness you should have a mode,

frequency, intensity, duration and a number of repetitions specific to your client that would enhance the items measured….a lot more to come later!

Exercise Prescription Interview Form

• All forms and questions are different • Attempt to ask questions in the simplest manner

possible– i.e. Not all people understand what “mode” of exercise is, use

“type” of exercise instead• Needs to be filled out together with professional and

client• If you are going to ask the questions, be prepared to be

able to produce the materials should they want them– i.e. don’t ask if they would like a consult from a nutritionist, if

you do not have that ability, etc.

Fitness Goals and Exercise Prescription Form

• Write the population you are working with someplace on the form, even if there is not a place for it– I.e. if you are working with a weight loss client, indicate

that• Keep fitness goals limited to start out with• Rate their commitment, importance and confidence

on a “likert scale”– Likert scale: Rate the importance for you of your goal for

weight loss 1 2 3 4 5

Fitness Contract

• Not a binding contract, but let them know that they will be held accountable for the plan you have set forth for them

• Most people will sign without an issue• Be cautious and answer any questions they

might have when you get to this part• Remember that they signed an informed

consent form, which holds the legal rights• This is more of a commitment form

Defining Activity

• Physical activity: defined as any bodily movement produced by the contraction of skeletal muscles that results in a substantial increase in energy expenditure

• Exercise: type of physical activity that planned, structured, and repetitive done to improve or maintain one or more components of physical fitness

Defining Activity

• Physical fitness: set of attributes or characteristics that people have or achieve that relates to the ability to perform physical activity– Usually broken down into health-related or skill

related components

Physical Fitness Components

Health-related Skill-Related • Cardiovascular endurance

• Body composition

• Muscular strength

• Muscular endurance

• Flexibility

• Agility

• Power

• Coordination

• Balance

• Reaction time

• Speed

Exercise Intensity Measures

• VO2max: maximal oxygen consumption

• VO2R: oxygen consumption reserve

• HRR: heart rate reserve

• HRmax: maximal heart rate

• METs: metabolic equivalents

2007 AHA and ACSM Update

• Overview: – All healthy individuals 18-65 need moderate-

intensity aerobic physical activity for a minimum of 30 minutes five days a week or vigorous activity for a minimum of 20 minutes three days per week• Combinations of this can be used

– Every adult should perform activities that maintain or increase muscular strength and endurance a minimum of two days each week

Benefits of ExerciseArea Benefit

Cardiovascular/Respiratory Function •Increased maximal oxygen uptake•Decreased heart rate and blood pressure at a given submaximal intensity•Increased capillary density in skeletal muscles•Increased exercise threshold for the accumulation of lactate in the blood

CAD Risk Factors •Reduced resting systolic/diastolic pressures•Reduced total body fat, reduced intra-abdominal fat•Reduced insulin needs

Decreased Morbidity/Mortality •Primary prevention (prevent initial occurrence)•Secondary prevention (intervention after cardiac event)

Goal Setting

• Most important: include the client in the decision making– Although you may know a lot about the individual

(i.e. blood pressure, EKG readings, etc.) if you tell them what their goals are they are much less apt to follow them

• Always maintain a positive attitude and be open-minded when clients are interested or disinterested in goals you think are important

Goal Setting

• Suggest appropriate and attainable goals and follow these four guidelines:

1. Goals should be attainable but challenging2. Set long term and short term goals3. Goals should be highly specific and practical4. Clients should enlist social support to help

them reach their goals

Goals

• Help clients to break down long-term goals into short-term manageable goals

• Clients need goals associated with adopting new life behaviors, not just goals associated with exercise prescription

• Helping the client to develop social networks that will help them to stay on track is very helpful

Aerobic Demands of Exercise

• Certain demands are placed on the body anytime an individual participated in physical activity– Demands increase or decrease depending on intensity,

duration and physical fitness level of the individual• Exercise can:– Aerobic activity can increase the metabolic demands

placed on the heart and increase sympathetic nervous activity increasing likeliness a heart attack could happen in people with pre-existing coronary heart disease

Anaerobic Demands of Exercise

• Anaerobic activity can also have detrimental effects seen even in healthy populations:– Valsalva maneuver: possibly provoking coronary

ischemia in heart patients– Extreme amounts of eccentric activity can release lethal

amount of potassium into the bloodstream and cause the heart to stop

– Rhabdomyolysis: break down of skeletal muscles causing the release of myoglobin into the blood stream, eventually causes kidney failure and death (DOMS)

Left Ventricular Hypertrophy

• Also called “Athlete’s Heart”

• Most common cause of sudden death in athletics

• Thickening of the cardiac muscle as a result of training/stress, to the point that strength/size of heart can impede blood flow

• Different from Hypertrophic Cardiomyopathy (HCM)

Absolute-Risk (Children-Young Adults) (ACSM)

• High school and college athletes:– Men: 1 in 133,000– Women: 1 in 769,000

• Out of 136 total deaths that have been reported:– 100 were caused from congenital and hereditary

abnormalities leading to the heart malfunctioning including:• HCM• Coronary artery abnormalities • Aortic stenosis (?)

Absolute-Risk (Adults) (ACSM)

• Higher prevalence of cardiovascular disease in this portion of the population

• During vigorous physical activity-estimated at 1 per year for every 15,000-18,000 people

• Increased risk of sudden cardiac death and acute myocardial infarction (MI) with vigorous exercise in this population

• Active adults have between ¼ to ½ the risk of developing CVD if they are physically active as recommended by the ACSM

Recommendations for Prevention

1. Healthcare professionals knowing the conditions associated with risk so that clients can be evaluated appropriately

2. High school and college athletes undergo pre-participation screening by qualified professionals

3. Athletes or individuals with known cardiac conditions be evaluated for competition using published guidelines

4. Active individuals should modify their activity based on: exercise capacity, habitual activity, and environment

Overview of Process

• Individuals are placed in one of the three categories (low, moderate, high) based on the following:– Presence or absence of known cardiovascular,

pulmonary, and/or metabolic disease– Presence or absence of signs or symptoms

suggestive of CVD, pulmonary and/or metabolic disease

– Presence or absence of CVD risk factors

Risk Factor Explanation/Qualification

Family History Parents, brothers, or sisters having heart attack, bypass surgery, angioplasty, or sudden cardiac death (male under 55, female under 65) (If yes=risk factor)

Smoking Client smoked in the last 6 months (If yes=risk factor)

Blood Pressure ≥140/90=risk factor, takes BP meds=risk factor (1 total)

Cholesterol LDL >130 and/or HDL <40=risk factor; HDL >60= (neg.) risk factor; total cholesterol >200=risk factor

Fasting Glucose ≥100=risk factor

Height and Weight BMI ≥30=risk factor; waist girth >40 (for men)=risk factor, >34.6 (for women)=risk factor

Exercise 30 mins. Of moderate physical activity on most days of week, no? (risk factor)

Symptoms (“Yes” places person at High Risk)

• Pain or discomfort in your chest or surrounding areas?

• Do you feel faint or dizzy under normal circumstances?

• Do you find it difficult to breathe when lying down or sleeping?

• Do your ankles ever become swollen under normal circumstances?

• Do you have hear palpitations or rapid heart beat?

• Do you ever experience painful burning or cramping in the muscles in your legs?

• Has a physician ever said that you have a heart murmur?

• Do you feel unusually fatigues or find it difficult to breathe with usual activities?

Other QuestionsQuestion/Category Risk

Men ≥45 and Women ≥55 Moderate risk

Heart disease, PAD, cerebrovascular disease, COPD, asthma, interstitial lung disease, cystic fibrosis, diabetes mellitus, thyroid disorder, renal disease, or liver disease

Yes to any=High risk

Bone or joint problems that may exacerbated exercise?

Yes=exercise testing may need to be delayed or modified

Do you have a cold, flu or any other infection

Yes=exercise testing must be delayed

Are you pregnant? Yes=exercise testing postponed or modified

Any other problem that may make it difficult for you to exercise?

Yes= JUDGEMENT

Low Risk

• Young (45 or younger for men, 55 or younger for women) with no more than one coronary disease risk factor and without symptoms or known disease

• Risk of acute CV event is low and an exercise program may be pursued safely without medical exam or clearance

• Can offer low risk clients a submaximal or maximal exercise test without physician supervision

Moderate Risk

• Older (45 or older for men, 55 or older for women) or with two or more coronary disease risk factors

• Advisable to have a medical examination and exercise test before participation in vigorous exercise

• Can do submaximal testing or enter a moderate exercise program

• Do not test these individuals in a fitness facility without a doctor

High Risk

• With one or more symptoms or known cardiopulmonary, cardiovascular, metabolic, or pulmonary disease

• Should not be tested without a physician present• Should not begin an exercise program without

medical evaluation/clearance• Risk of acute MI for this population is very high

• “Ticking time-bomb….”

Recommendations for Exercise Testing and Participation

• Once risk category has been established the following can be decided upon:– Necessity for medical exam/clearance– Changing the FITT (frequency, intensity, time, and

type--more to come later) framework of an existing exercise program

– Necessity for an exercise test – Necessity for physician supervision for a maximal or

submaximal test