ACSM guidelines.pdf
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This document provides an overview of the 9th edition of ACSM's Guidelines for Exercise Testing and Prescription. It lists the senior editor, Linda S. Pescatello, and associate editors Ross Arena, Deborah Riebe, and Paul D. Thompson. It also provides a brief history of the Guidelines and those who have served as editors for previous editions. Key changes in the 9th edition include simplifying pre-participation health screening to promote physical activity and integrating the most recent guidelines from ACSM and other organizations to make it the most current primary resource.
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Ninth Edition
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Library of Congress Cataloging-in-Publication Data
ACSM’s guidelines for exercise testing and prescription / American College of Sports Medicine ; senior editor,
Linda S. Pescatello ; associate editors, Ross Arena, Deborah Riebe, Paul D. Thompson. — 9th ed.
p. ; cm.
Guidelines for exercise testing and prescription
Includes bibliographical references and index.
ISBN 978-1-60913-605-5
I. Pescatello, Linda S. II. American College of Sports Medicine. III. Title: Guidelines for exercise testing and
prescription.
[DNLM: 1. Physical Exertion—Guideline. 2. Exercise Test—standards—Guideline. 3. Exercise Therapy—
standards—Guideline. WE 103]
615.8'2—dc23
2012038784
DISCLAIMER
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or for any consequences from application of the information in this book and make no warranty, expressed
or implied, with respect to the currency, completeness, or accuracy of the contents of the publication.
Application of this information in a particular situation remains the professional responsibility of the
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![CHAPTER 1 Benefits and Risks Associated with Physical Activity 9
BENEFITS OF REGULAR PHYSICAL ACTIVITY AND/OR EXERCISE
Evidence to support the inverse relationship between physical activity and pre-
mature mortality, CVD/CAD, hypertension, stroke, osteoporosis, Type 2 diabetes
mellitus, metabolic syndrome, obesity, colon cancer, breast cancer, depression,
functional health, falls, and cognitive function continues to accumulate (42).
For many of these diseases and health conditions, there is also strong evidence
of a dose-response relationship (see Table 1.3). This evidence has resulted from
laboratory-based studies as well as large-scale, population-based, observational
studies (16,18,23,26,30,55,62).
Since the last edition of the Guidelines, additional evidence has strengthened
support for these relationships. As stated in the recent ACSM-AHA updated
recommendation on physical activity and health (23), “since the 1995 recom-
mendation, several large scale observational epidemiologic studies, enrolling
thousands to tens of thousands of individuals, have clearly documented a dose-
response relationship between physical activity and risk of cardiovascular disease
and premature mortality in men and women, and in ethnically diverse par-
ticipants” (29,31,38,45,51,66). The 2008 Physical Activity Guidelines Advisory
Committee also arrived at similar conclusions (42). It is also important to note
aerobic capacity (i.e., cardiorespiratory fitness [CRF]) has an inverse relation-
ship with risk of premature death from all causes and specifically from CVD,
and higher levels of CRF are associated with higher levels of habitual physical
activity, which in turn are associated with many health benefits (6,7,28,47,61).
Box 1.4 summarizes the benefits of regular physical activity and/or exercise.
Recently, the ACSM and AHA have released statements on “Physical Activity
and Public Health in Older Adults” (3,37). In general, these recommendations
are similar to the updated guidelines for adults (18,23), but the recommended
intensity of aerobic activity is related to the older adult’s CRF level. In addition,
age-specific recommendations are made concerning the importance of flexibility,
neuromotor, and muscle strengthening activities.
In addition, the 2008 federal physical activity guidelines made similar
age-specific recommendations targeted at adults (18–64 yr) and older adults
(ⱖ65 yr) as well as children and adolescents (6–17 yr) (http://www.health.gov/
PAguidelines) (56).
RISKS ASSOCIATED WITH EXERCISE
In general, exercise does not provoke cardiovascular events in healthy indi-
viduals with normal cardiovascular systems. The risk of sudden cardiac arrest or
myocardial infarction (MI) is very low in apparently healthy individuals perform-
ing moderate intensity, physical activity (60,63). However, there is an acute and
transient increase in the risk of sudden cardiac death and/or MI in individuals
performing vigorous intensity exercise with either diagnosed or occult CVD
(20,35,48,52,60,65). Therefore, the risk of these events during exercise increases](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-35-320.jpg)
![18 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
42. Physical Activity Guidelines Advisory Committee Report, 2008. To the Secretary of Health and Human
Services [Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008 [cited
2010 Aug 11]. 683 p. Available from: http://www.health.gov/paguidelines/committeereport.aspx;
http://www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf
43. The President’s Council on Physical Fitness and Sports. Definitions—Health, Fitness, and Physical
Activity [Internet]. Washington (DC): President’s Council on Physical Fitness and Sports; 2000
[cited 2012 Jan 7]. 11 p. Available from: http://purl.access.gpo.gov/GPO/LPS21074
44. Rochmis P, Blackburn H. Exercise tests. A survey of procedures, safety, and litigation experience in
approximately 170,000 tests. JAMA. 1971;217(8):1061–6.
45. Rockhill B, Willett WC, Manson JE, et al. Physical activity and mortality: a prospective study among
women. Am J Public Health. 2001;91(4):578–83.
46. Saris WH, Blair SN, van Baak MA, et al. How much physical activity is enough to prevent unhealthy
weight gain? Outcome of the IASO 1st Stock Conference and consensus statement. Obes Rev.
2003;4(2):101–14.
47. Sesso HD, Paffenbarger RS,Jr, Lee IM. Physical activity and coronary heart disease in men: The
Harvard Alumni Health Study. Circulation. 2000;102(9):975–80.
48. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigor-
ous exercise. N Engl J Med. 1984;311(14):874–7.
49. Stuart RJ,Jr, Ellestad MH. National survey of exercise stress testing facilities. Chest. 1980;77(1):94–7.
50. Swain DP, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise
Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2014.
51. Tanasescu M, Leitzmann MF
, Rimm EB, Willett WC, Stampfer MJ, Hu FB. Exercise type and inten-
sity in relation to coronary heart disease in men. JAMA. 2002;288(16):1994–2000.
52. Thompson PD, Funk EJ, Carleton RA, Sturner WQ. Incidence of death during jogging in Rhode
Island from 1975 through 1980. JAMA. 1982;247(18):2535–8.
53. Thompson PD, Stern MP, Williams P
, Duncan K, Haskell WL, Wood PD. Death during jogging or
running. A study of 18 cases. JAMA. 1979;242(12):1265–7.
54. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines
for Americans, 2010. 7th ed. Washington (DC): U.S. Government Printing Office; 2010. 112 p.
55. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon
General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, CDC,
National Center for Chronic Disease Prevention and Health Promotion; 1996. 278 p.
56. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans
[Internet]. Rockville (MD): Office of Disease Prevention & Health Promotion, U.S. Department of
Health and Human Services; 2008 [cited 2012 Jan 7]. 76 p. Available from: http://www.health.gov/
paguidelines
57. Van Camp SP
, Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic sports death in high
school and college athletes. Med Sci Sports Exerc. 1995;27(5):641–7.
58. Van Camp SP, Peterson RA. Cardiovascular complications of outpatient cardiac rehabilitation pro-
grams. JAMA. 1986;256(9):1160–3.
59. Vongvanich P, Paul-Labrador MJ, Merz CN. Safety of medically supervised exercise in a cardiac
rehabilitation center. Am J Cardiol. 1996;77(15):1383–5.
60. Vuori I. The cardiovascular risks of physical activity. Acta Med Scand Suppl. 1986;711:205–14.
61. Wang CY, Haskell WL, Farrell SW, et al. Cardiorespiratory fitness levels among US adults 20-49
years of age: findings from the 1999-2004 National Health and Nutrition Examination Survey. Am J
Epidemiol. 2010;171(4):426–35.
62. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac rehabilitation as secondary prevention. Agency
for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel
Quick Ref Guide Clin. 1995;(17):1–23.
63. Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women.
JAMA. 2006;295(12):1399–403.
64. Williams PT. Physical fitness and activity as separate heart disease risk factors: a meta–analysis. Med
Sci Sports Exerc. 2001;33(5):754–61.
65. Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F
, Schroder R. Physical exertion as a trigger of
acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl
J Med. 1993;329(23):1684–90.
66. Yu S, Yarnell JW, Sweetnam PM, Murray L, Caerphilly study. What level of physical activity protects
against premature cardiovascular death? The Caerphilly study. Heart. 2003;89(5):502–6.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-44-320.jpg)
![34 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
Physicians responsible for supervising exercise testing should meet or
exceed the minimal competencies for supervision and interpretation of results
as established by the AHA (25). In all situations in which exercise testing is
performed, site personnel should at least be certified at a level of basic life
support (cardiopulmonary resuscitation [CPR]) and have automated external
defibrillator (AED) training. Preferably, one or more staff members should
also be certified in first aid and advanced cardiac life support (ACLS) (15). All
exercise testing facilities with or without physician supervision (a) should also
have a written medical emergency response plan with procedures and contact
numbers; (b) should practice this plan at least quarterly; and (c) be equipped
with a defibrillator or an AED depending on staffing competencies (20).
RISK STRATIFICATION FOR PATIENTS WITH
CARDIOVASCULAR DISEASE
Patients with CVD may be further stratified regarding safety during exercise
using published guidelines (2). Risk stratification criteria from the AACVPR are
presented in Box 2.4 (2).
American Association of Cardiovascular and Pulmonary
Rehabilitation (AACVPR) Risk Stratification Criteria for Patients
with Cardiovascular Disease
BOX 2.4
w
w
with C
C
C
Car
ar
rd
dio
o
ov
va
as
sc
cula
a
ar Di
Dise
seas
a e
LOWEST RISK
Characteristics of patients at lowest risk for exercise participation (all
characteristics listed must be present for patients to remain at lowest risk)
• Absence of complex ventricular dysrhythmias during exercise testing and
recovery
• Absence of angina or other significant symptoms (e.g., unusual shortness
of breath, light-headedness, or dizziness, during exercise testing and
recovery)
• Presence of normal hemodynamics during exercise testing and recovery
(i.e., appropriate increases and decreases in heart rate and systolic blood
pressure with increasing workloads and recovery)
• Functional capacity 7 metabolic equivalents (METs)
Nonexercise Testing Findings
• Resting ejection fraction 50%
• Uncomplicated myocardial infarction or revascularization procedure
• Absence of complicated ventricular dysrhythmias at rest
• Absence of congestive heart failure
• Absence of signs or symptoms of postevent/postprocedure ischemia
• Absence of clinical depression](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-60-320.jpg)
![CHAPTER 2 Preparticipation Health Screening 35
MODERATE RISK
Characteristics of patients at moderate risk for exercise participation (any
one or combination of these findings places a patient at moderate risk)
• Presence of angina or other significant symptoms (e.g., unusual shortness
of breath, light-headedness, or dizziness occurring only at high levels of
exertion [7 METs])
• Mild to moderate level of silent ischemia during exercise testing or
recovery (ST-segment depression 2 mm from baseline)
• Functional capacity 5 METs
Nonexercise Testing Findings
• Rest ejection fraction 40% to 49%
HIGHEST RISK
Characteristics of patients at high risk for exercise participation (any one
or combination of these findings places a patient at high risk)
• Presence of complex ventricular dysrhythmias during exercise testing or
recovery
• Presence of angina or other significant symptoms (e.g., unusual shortness
of breath, light-headedness, or dizziness at low levels of exertion
[5 METs] or during recovery)
• High level of silent ischemia (ST-segment depression 2 mm from
baseline) during exercise testing or recovery
• Presence of abnormal hemodynamics with exercise testing
(i.e., chronotropic incompetence or flat or decreasing systolic BP with
increasing workloads) or recovery (i.e., severe postexercise hypotension)
Nonexercise Testing Findings
• Rest ejection fraction 40%
• History of cardiac arrest or sudden death
• Complex dysrhythmias at rest
• Complicated myocardial infarction or revascularization procedure
• Presence of congestive heart failure
• Presence of signs or symptoms of postevent/postprocedure ischemia
• Presence of clinical depression
Reprinted from (32), with permission from Elsevier.
American Association of Cardiovascular and Pulmonary
Rehabilitation (AACVPR) Risk Stratification Criteria for Patients
with Cardiovascular Disease (Continued)
BOX 2.4](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-61-320.jpg)
![CHAPTER 2 Preparticipation Health Screening 37
REFERENCES
1. 2008 Physical Activity Guidelines for Americans [Internet]. Rockville (MD): Office of Disease
Prevention Health Promotion, U.S. Department of Health and Human Services; 2008 [cited 2010
Sep 22]. 76 p. Available from: http://www.health.gov/paguidelines
2. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac
Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign (IL): Human Kinetics;
2004. 280 p.
3. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Pulmonary
Rehabilitation Programs. 3rd ed. Champaign (IL): Human Kinetics; 2004. 188 p.
4. American College of Sports Medicine Position Stand, American Heart Association. Recommendations
for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Med Sci
Sports Exerc. 1998;30(6):1009–18.
5. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care.
2007;30 Suppl 1:S42–7.
6. Brawner CA, Vanzant MA, Ehrman JK, et al. Guiding exercise using the talk test among patients
with coronary artery disease. J Cardiopulm Rehabil. 2006;26(2):72–5; quiz 76–7.
7. Buchner DM. Physical activity to prevent or reverse disability in sedentary older adults. Am J Prev
Med. 2003;25(3 Suppl 2):214–5.
8. Canada’s Physical Activity Guide to Healthy Active Living [Internet]. Ontario (Canada): Public Health
Agency of Canada; [cited 2007 Jun 15]. Available from: http://www.phac-aspc.gc.ca/pau-uap/paguide/
index.html
9. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA.
2003;289(19):2560–72.
10. Executive summary of the clinical guidelines on the identification, evaluation, and treatment of
overweight and obesity in adults. Arch Intern Med. 1998;158(17):1855–67.
11. Fletcher GF
, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a
statement for healthcare professionals from the American Heart Association. Circulation. 2001;
104(14):1694–740.
12. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing:
summary article. A report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am
Coll Cardiol. 2002;40(8):1531–40.
13. Giri S, Thompson PD, Kiernan FJ, et al. Clinical and angiographic characteristics of exertion-related
acute myocardial infarction. JAMA. 1999;282(18):1731–6.
14. Gordon SMBS. Health appraisal in the non-medical setting. In: Durstine JL, editor. ACSM’s Resource
Manual for Guidelines for Exercise Testing and Prescription. 2nd ed. Philadelphia: Williams
Wilkins; 1993. p. 219–28.
15. Kern KB, Halperin HR, Field J. New guidelines for cardiopulmonary resuscitation and emergency
cardiac care: changes in the management of cardiac arrest. JAMA. 2001;285(10):1267–9.
16. Lahav D, Leshno M, Brezis M. Is an exercise tolerance test indicated before beginning regular exer-
cise? A decision analysis. J Gen Intern Med. 2009;24(8):934–8.
17. Maron BJ, Araujo CG, Thompson PD, et al. Recommendations for preparticipation screening and
the assessment of cardiovascular disease in masters athletes: an advisory for healthcare profession-
als from the working groups of the World Heart Federation, the International Federation of Sports
Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and
Prevention. Circulation. 2001;103(2):327–34.
ACSM ExeRxcise is Medicine:
http://exerciseismedicine.org
2008 Physical Activity Guidelines for Americans (1):
http://www.health.gov/PAguidelines
Online Resources](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-63-320.jpg)
![38 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
18. Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive
athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiol-
ogy) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American
Heart Association. Circulation. 1996;94(4):850–6.
19. Mittleman MA, Maclure M, Tofler GH, et al. Triggering of acute myocardial infarction by heavy
physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial
Infarction Onset Study Investigators. N Engl J Med. 1993;329(23):1677–83.
20. Myers J, Arena R, Franklin B, et al. Recommendations for clinical exercise laboratories: a scientific
statement from the American Heart Association. Circulation. 2009;119(24):3144–61.
21. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation.
2002;106(25):3143–421.
22. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the
Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA.
1995;273(5):402–7.
23. Persinger R, Foster C, Gibson M, Fater DC, Porcari JP
. Consistency of the talk test for exercise
prescription. Med Sci Sports Exerc. 2004;36(9):1632–6.
24. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S.
Department of Health and Human Services; 2008 [cited 2011 Jan 6]. 683 p. Available from: http://
www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf
25. Rodgers GP, Ayanian JZ, Balady G, et al. American College of Cardiology/American Heart
Association clinical competence statement on stress testing. A report of the American College
of Cardiology/American Heart Association/American College of Physicians-American Society of
Internal Medicine Task Force on Clinical Competence. Circulation. 2000;102(14):1726–38.
26. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart Disease and Stroke Statistics—2012 Update: a report
from the American Heart Association. Circulation. 2012;125(1):e2–220.
27. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigor-
ous exercise. N Engl J Med. 1984;311(14):874–7.
28. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treat-
ment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology
(Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical
Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107(24):3109–16.
29. Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing
the risks into perspective: a scientific statement from the American Heart Association Council on
Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation.
2007;115(17):2358–68.
30. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon
General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, CDC,
National Center for Chronic Disease Prevention and Health Promotion; 1996. 278 p.
31. U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation state-
ment. Ann Intern Med. 2004;140(7):569–72.
32. Williams MA. Exercise testing in cardiac rehabilitation. Exercise prescription and beyond. Cardiol
Clin. 2001;19(3):415–31.
33. Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F
, Schroder R. Physical exertion as a trigger of
acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl
J Med. 1993;329(23):1684–90.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-64-320.jpg)
![48 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
and A1, and the total cholesterol-to-HDL cholesterol ratio are designated by
ATP III as emerging lipid risk factors. Thrombogenic and hemostatic factors,
inflammatory markers (e.g., high sensitivity C-reactive protein), impaired fasting
glucose, and homocysteine are designated by ATP III as emerging nonlipid risk
factors. Nevertheless, recent studies suggest that homocysteine-lowering therapy
does not result in a reduction in CVD risk.
The guiding principle of ATP III and subsequent updates by the NHLBI,
AHA, and ACC is that the intensity of LDL-lowering therapy should be adjusted
to the individual’s absolute risk for CVD (6,8,12,13,24,27). The ATP III treat-
ment guidelines and subsequent updates by the NHLBI, AHA, and ACC are
summarized in ACSM’s Resource Manual for Guidelines for Exercise Testing and
Prescription, Seventh Edition (26).
TABLE 3.3. Metabolic Syndrome Criteria: NCEP/ATP III, IDF, and WHO
Criteria NCEP/ATP III (8) IDF (14) WHO (1)a
Body Weight Waist circumferencea,c
Requiredb
Waist-to-hip ratio and/or
BMI of ⬎30 kg ⭈ m⫺2
Men ⬎102 cm (⬎40 in) ⱖ94 cm (ⱖ37 in) ⬎0.9 ratio
Women ⬎88 cm (⬎35 in) ⱖ80 cm (ⱖ31.5 in) ⬎0.85 ratio
Insulin
Resistance/
Glucose
ⱖ110 mg ⭈ dL⫺1d
ⱖ110 mg ⭈ dL⫺1
or
previously diagnosed
Type 2 diabetes
Requirede
Dyslipidemia Specific treatment or
HDL Men: ⬍40 mg ⭈ dL⫺1
Women: ⬍50 mg ⭈ dL⫺1
Men: ⬍40 mg ⭈ dL⫺1
Women: ⬍50 mg ⭈ dL⫺1f
Men: ⬍35 mg ⭈ dL⫺1
Women: ⬍39 mg ⭈ dL⫺1f
Triglycerides ⱖ150 mg ⭈ dL⫺1
ⱖ150 mg ⭈ dL⫺1
ⱖ150 mg ⭈ dL⫺1
Elevated
Blood
Pressure
ⱖ130 or ⱖ85 mm Hg ⱖ130 or ⱖ85 mm Hg or
treatment of previously
diagnosed hypertension
Antihypertensive medica-
tion and/or a BP of ⱖ140
or ⱖ90 mm Hg
Other N/A N/A Urinary albumin excretion
rate ⱖ20 g ⭈ min⫺1
or
albumin:creatinine ratio
ⱖ30 mg ⭈ g⫺1
a
Overweight and obesity are associated with insulin resistance and the metabolic syndrome (Msyn). However,
the presence of abdominal obesity is more highly correlated with these metabolic risk factors than is elevated
BMI. Therefore, the simple measure of waist circumference is recommended to identify the body weight
component of the Msyn.
b
Defined as waist circumference ⱖ94 cm (ⱖ37 in) for Europid men and ⱖ80 cm (ⱖ31.2 in) for Europid women,
with ethnicity-specific values for other groups.
c
Some men develop multiple metabolic risk factors when the waist circumference is only marginally increased
(94–102 cm [37–39 in]). Such patients may have a strong genetic contribution to insulin resistance. They should
benefit from changes in life habits, similarly to men with categorical increases in waist circumference.
d
The American Diabetes Association has established a cut point of ⱖ100 mg ⭈ dL⫺1
, above which individuals
have either prediabetes (impaired fasting glucose) or diabetes mellitus (2). This cut point should be applicable
for identifying the lower boundary to define an elevated glucose as one criterion for metabolic syndrome.
e
A required criteria of one of the following: Type 2 diabetes mellitus, impaired fasting glucose, impaired glucose
tolerance, or for those with normal fasting glucose levels (⬍110 mg ⭈ dL⫺1
), glucose uptake below the lowest
quartile for background populations under investigation under hyperinsulinemic and euglycemic conditions.
f
These values have been updated from those originally presented to ensure consistence with ATP III cut points.
NOTE: To convert glucose from mg ⭈ dL⫺1
to mmol ⭈ L⫺1
, multiply by 0.0555. To convert HDL from mg ⭈ dL⫺1
to
mmol ⭈ L⫺1
, multiply by 0.0259. To convert triglycerides from mg ⭈ dL⫺1
to mmol ⭈ L⫺1
, multiply by 0.0113.
ATP III, Adult Treatment Panel III; BMI, body mass index; BP
, blood pressure; HDL, high-density lipoprotein
cholesterol; IDF
, International Diabetes Federation; NCEP
, National Cholesterol Education Program; WHO, World
Health Organization.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-74-320.jpg)
![CHAPTER 3 Preexercise Evaluation 49
BLOOD PROFILE ANALYSES
Multiple analyses of blood profiles are commonly evaluated in clinical exercise
programs. Such profiles may provide useful information about an individual’s
overall health status and ability to exercise and may help to explain certain ECG
abnormalities. Because of varied methods of assaying blood samples, some cau-
tion is advised when comparing blood chemistries from different laboratories.
Table 3.4 gives normal ranges for selected blood chemistries, derived from a va-
riety of sources. For many patients with CVD, medications for dyslipidemia and
hypertension are common. Many of these medications act in the liver to lower
blood cholesterol and in the kidneys to lower BP (see Appendix A). One should
pay particular attention to liver function tests such as alanine transaminase
(ALT), aspartate transaminase (AST), and bilirubin as well as to renal (kidney)
function tests such as creatinine, glomerular filtration rate, blood urea nitrogen
(BUN), and BUN/creatinine ratio in patients on such medications. Indication of
volume depletion and potassium abnormalities can be seen in the sodium and
potassium measurements.
PULMONARY FUNCTION
Pulmonary function testing with spirometry is recommended for all smokers
⬎45 yr and in any individual presenting with dyspnea (i.e., shortness of breath),
chronic cough, wheezing, or excessive mucus production (9). Spirometry is a
simple and noninvasive test that can be performed easily. Indications for spi-
rometry are listed in Table 3.5. When performing spirometry, standards for the
performance of the test should be followed (16).
Although many measurements can be made from a spirometric test, the most
commonly used include the forced vital capacity (FVC), forced expiratory vol-
ume in one second (FEV1.0
), FEV1.0
/FVC ratio, and peak expiratory flow (PEF).
Results from these measurements can help to identify the presence of restrictive
or obstructive respiratory abnormalities, sometimes before symptoms or signs
of disease are present. The FEV1.0
/FVC is diminished with obstructive airway
diseases (e.g., asthma, chronic bronchitis, emphysema, chronic obstructive pul-
monary disease [COPD]) but remains normal with restrictive disorders (e.g.,
kyphoscoliosis, neuromuscular disease, pulmonary fibrosis, other interstitial
lung diseases).
The Global Initiative for Chronic Obstructive Lung Disease classifies the
presence and severity of COPD as seen in Table 3.5 (22). The term COPD can be
used when chronic bronchitis, emphysema, or both are present, and spirometry
documents an obstructive defect. A different approach for classifying the sever-
ity of obstructive and restrictive defects is that of the American Thoracic Society
(ATS) and European Respiratory Society (ERS) Task Force on Standardization of
Lung Function Testing as presented in Table 3.5 (20). This ATS/ERS Task Force
prefers to use the largest available vital capacity (VC), whether it is obtained on](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-75-320.jpg)
![CHAPTER 3 Preexercise Evaluation 53
Emergency departments may perform a symptom-limited exercise test on pa-
tients who present with chest pain (i.e., 8–12 h after initial evaluation) and meet
the indications outlined in Table 3.6 (3,25). This practice (a) appears to be safe
in appropriately screened patients; (b) may improve diagnostic accuracy; and
(c) may reduce cost of care. Generally, these patients include those who are no
ABSOLUTE
• A recent significant change in the resting electrocardiogram (ECG)
suggesting significant ischemia, recent myocardial infarction (within 2 d), or
other acute cardiac event
• Unstable angina
• Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic
compromise
• Symptomatic severe aortic stenosis
• Uncontrolled symptomatic heart failure
• Acute pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis
• Suspected or known dissecting aneurysm
• Acute systemic infection, accompanied by fever, body aches, or swollen
lymph glands
RELATIVEa
• Left main coronary stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia)
• Severe arterial hypertension (i.e., systolic blood pressure [SBP] of ⬎200
mm Hg and/or a diastolic BP [DBP] of ⬎110 mm Hg) at rest
• Tachydysrhythmia or bradydysrhythmia
• Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
• Neuromotor, musculoskeletal, or rheumatoid disorders that are exacerbated
by exercise
• High-degree atrioventricular block
• Ventricular aneurysm
• Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or
myxedema)
• Chronic infectious disease (e.g., HIV)
• Mental or physical impairment leading to inability to exercise adequately
a
Relative contraindications can be superseded if benefits outweigh the risks of exercise. In some
instances, these individuals can be exercised with caution and/or using low-level endpoints, especially if
they are asymptomatic at rest.
Modified from (11) cited 2007 June 15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12356646
Contraindications to Exercise Testing
BOX 3.5](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-79-320.jpg)
![58 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
REFERENCES
1. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its com-
plications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO
consultation. Diabet Med. 1998;15(7):539–53.
2. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care.
2007;30 Suppl 1:S42–7.
3. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency
department with chest pain: a scientific statement from the American Heart Association. Circulation.
2010;122(17):1756–76.
4. Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a
scientific statement from the American Heart Association. Hypertension. 2006;47(2):296–308.
5. Arena R, Myers J, Williams MA, et al. Assessment of functional capacity in clinical and research settings:
a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation,
and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing.
Circulation. 2007;116(3):329–43.
6. Arena R, Pinkstaff S, Wheeler E, Peberdy MA, Guazzi M, Myers J. Neuromuscular electrical stimula-
tion and inspiratory muscle training as potential adjunctive rehabilitation options for patients with
heart failure. J Cardiopulm Rehabil Prev. 2010;30(4):209–23.
7. Bickley LS, Bates B. Bates’ Pocket Guide to Physical Examination and History Taking. Baltimore (MD):
Lippincott Williams Wilkins; 2008. 416 p.
8. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults.
Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP)
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult
Treatment Panel III). JAMA. 2001;285(19):2486–97.
9. Ferguson GT, Enright PL, Buist AS, et al. Office spirometry for lung health assessment in adults: a con-
sensus statement from the National Lung Health Education Program. Chest. 2000;117(4):1146–61.
10. Gibbons RJ, Abrams J, Chatterjee K, et al. Committee on the management of patients with chronic
stable angina. ACC/AHA 2002 guideline update for the management of patients with chronic
stable angina—summary article: a report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines (Committee on the Management of Patients with
Chronic Stable Angina). Circulation. 2003;107(1):149–58.
11. Gibbons RJ, Balady GJ, Bricker JT, et al. Committee to Update the 1997 Exercise Testing Guidelines.
ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American
College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee
to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531–40.
12. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National
Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol. 2004;
44(3):720–32.
13. Hendel RC, Berman DS, Di Carli MF
, et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009
appropriate use criteria for cardiac radionuclide imaging: a report of the American College of
Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear
Cardiology, the American College of Radiology, the American Heart Association, the American
Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society
for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation.
2009;119(22):e561–87.
14. The IDF Consensus Worldwide Definition of the Metabolic Syndrome [Internet]. Brussels (Belgium):
International Diabetes Federation; 2006 [cited 2008 Jul 23]. 24 p. Available from: http://www.idf
.org/webdata/docs/IDF_Meta_def_final.pdf
15. Kantola I, Vesalainen R, Kangassalo K, Kariluoto A. Bell or diaphragm in the measurement of blood
pressure? J Hypertens. 2005;23(3):499–503.
16. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005;
26(2):319–38.
17. Miller MR, Quanjer PH, Swanney MP
, Ruppel G, Enright PL. Interpreting lung function data using
80 percent of predicted and fixed thresholds misclassifies over 20% of patients. Chest. 2010.
18. Myers J, Arena R, Franklin B, et al. Recommendations for clinical exercise laboratories: a scientific
statement from the American Heart Association. Circulation. 2009;119(24):3144–61.
19. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society state-
ment on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12):1390–413.
20. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J.
2005;26(5):948–68.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-84-320.jpg)
![CHAPTER 3 Preexercise Evaluation 59
21. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in
humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for
professionals from the Subcommittee of Professional and Public Education of the American Heart
Association Council on High Blood Pressure Research. Hypertension. 2005;45(1):142–61.
22. Rabe KF
, Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention
of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med.
2007;176(6):532–55.
23. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
of High Blood Pressure (JNC7) [Internet]. Bethesda, (MD): National High Blood Pressure Education
Program; 2004 [cited 2012 Jan 7]. 104 p. Available from: http://www.nhlbi.nih.gov/guidelines/
hypertension
24. Smith SC,Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with
coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart,
Lung, and Blood Institute. Circulation. 2006;113(19):2363–72.
25. Stein RA, Chaitman BR, Balady GJ, et al. Safety and utility of exercise testing in emergency room
chest pain centers: an advisory from the Committee on Exercise, Rehabilitation, and Prevention,
Council on Clinical Cardiology, American Heart Association. Circulation. 2000;102(12):1463–7.
26. Swain DP, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise
Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams Wilkins; 2014.
27. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [Internet].
Bethesda (MD): National Cholesterol Education Program; 2004 [cited Mar 19]. 284 p. Available
from: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm
28. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans
[Internet]. Rockville (MD): Office of Disease Prevention Health Promotion, U.S. Department of
Health and Human Services; 2008 [cited 2012 Jan 7]. 76 p. Available from: http://www.health.gov/
paguidelines](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-85-320.jpg)
![60
Benefits and Risks Associated with
Physical Activity
CHAPTER
1
Health-Related Physical Fitness Testing
and Interpretation
CHAPTER
4
Evidence as outlined in Chapter 1 now clearly supports the numerous health
benefits that result from regular participation in physical activity and structured
exercise programs including enhancement of aerobic capacity (i.e., cardio-
respiratory fitness [CRF]). The health-related components of physical fitness
have a strong relationship with overall health, are characterized by an ability
to perform activities of daily living with vigor, and are associated with a lower
prevalence of chronic disease and health conditions and their risk factors (29).
Measures of health-related physical fitness and CRF are closely allied with
disease prevention and health promotion and can be modified through regular
participation in physical activity and structured exercise programs. A funda-
mental goal of primary and secondary prevention and rehabilitative programs
should be the promotion of health; therefore, exercise programs should focus
on enhancement of the health-related components of physical fitness including
CRF
. Accordingly, the focus of this chapter is on the health-related components
of physical fitness rather than the skill-related components for the general
population (46).
PURPOSES OF HEALTH-RELATED PHYSICAL FITNESS TESTING
Measurement of physical fitness is a common and appropriate practice in preven-
tive and rehabilitative exercise programs. The purposes of health/fitness testing
in such exercise programs include the following:
• Educating participants about their present health/fitness status relative to
health-related standards and age and sex matched norms.
• Providing data that are helpful in development of individualized exercise
prescriptions (Ex Rx
) to address all health/fitness components.
• Collecting baseline and follow-up data that allow evaluation of progress by
exercise program participants.
• Motivating participants by establishing reasonable and attainable health/
fitness goals (see Chapter 11).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-86-320.jpg)
![62 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
are to be evaluated. Resting measurements such as heart rate (HR), blood pressure
(BP), height, weight, and body composition should be obtained first. Research has
not established an optimal testing order for multiple health-related components
of fitness (i.e., cardiorespiratory [CR] endurance, muscular fitness, body compo-
sition, and flexibility), but sufficient time should be allowed for HR and BP to
return to baseline between tests conducted serially. Because certain medications,
such as -blockers which lower HR, will affect some physical fitness test results,
use of these medications should be noted (see Appendix A).
TEST ENVIRONMENT
The environment is important for test validity and reliability. Test anxiety, emo-
tional problems, room temperature, and ventilation should be controlled as
much as possible. To minimize subject anxiety, the test procedures should be
explained adequately, and the test environment should be quiet and private. The
room should be equipped with a comfortable seat and/or examination table to be
used for resting BP and HR and/or electrocardiographic (ECG) recordings. The
demeanor of personnel should be one of relaxed confidence to put the subject
at ease. Testing procedures should not be rushed, and all procedures must be
explained clearly prior to initiating the process.
BODY COMPOSITION
It is well established that excess body fat, particularly when located centrally
around the abdomen, is associated with hypertension, metabolic syndrome,
Type 2 diabetes mellitus, stroke, cardiovascular disease (CVD), and dyslipidemia
(95). Approximately two-thirds of American adults are classified as overweight
(body mass index [BMI] 25 kg ⭈ m2
), and about 33% of these are classified
as obese (BMI 30 kg ⭈ m2
). Although the prevalence of obesity has steadily
risen over the last three decades, recent data indicate a plateau in obesity trends,
particularly in women (23,38). Perhaps more troubling are the statistics relat-
ing to children that indicate (a) approximately 32% of children aged 2–19 yr
are overweight or obese; and (b) over the past three decades, the percentage of
children aged 6–11 yr who are considered obese has increased from approxi-
mately 4% to more than 17% (95). Moreover, 2006 data indicate race and sex
differences in overweight/obesity, with Black and Hispanic women continuing
to have the highest prevalence (95). The troubling data on overweight/obesity
prevalence among the adult and pediatric populations and its health implications
have precipitated an increased awareness in the value of identifying and treating
individuals with excess body weight (26,33,64,105).
Basic body composition can be expressed as the relative percentage of body
mass that is fat and fat-free tissue using a two-compartment model. Body
composition can be estimated with laboratory and field techniques that vary
in terms of complexity, cost, and accuracy (34,65). Different assessment tech-
niques are briefly reviewed in this section, but details associated with obtaining](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-88-320.jpg)
![CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 69
MEN
• Seven-Site Formula (chest, midaxillary, triceps, subscapular, abdomen,
suprailiac, thigh)
Body density ⫽ 1.112 ⫺ 0.00043499 (sum of seven skinfolds)
⫹ 0.00000055 (sum of seven skinfolds)2
⫺ 0.00028826 (age) [SEE 0.008 or ⬃3.5% fat]
• Three-Site Formula (chest, abdomen, thigh)
Body density ⫽ 1.10938 ⫺ 0.0008267 (sum of three skinfolds)
⫹ 0.0000016 (sum of three skinfolds)2
⫺ 0.0002574 (age)
[SEE 0.008 or ⬃3.4% fat]
• Three-Site Formula (chest, triceps, subscapular)
Body density ⫽ 1.1125025 ⫺ 0.0013125 (sum of three skinfolds)
⫹ 0.0000055 (sum of three skinfolds)2
⫺ 0.000244 (age)
[SEE 0.008 or ⬃3.6% fat]
WOMEN
• Seven-Site Formula (chest, midaxillary, triceps, subscapular, abdomen,
suprailiac, thigh)
Body density ⫽ 1.097 ⫺ 0.00046971 (sum of seven skinfolds)
⫹ 0.00000056 (sum of seven skinfolds)2
⫺ 0.00012828
(age) [SEE 0.008 or ⬃3.8% fat]
• Three-Site Formula (triceps, suprailiac, thigh)
Body density ⫽ 1.099421 ⫺ 0.0009929 (sum of three skinfolds)
⫹ 0.0000023 (sum of three skinfolds)2
⫺ 0.0001392 (age)
[SEE 0.009 or ⬃3.9% fat]
• Three-Site Formula (triceps, suprailiac, abdominal)
Body density ⫽ 1.089733 ⫺ 0.0009245 (sum of three skinfolds)
⫹ 0.0000025 (sum of three skinfolds)2
⫺ 0.0000979 (age)
[SEE 0.009 or ⬃3.9% fat]
SEE, standard error of estimate.
Adapted from (55,87).
Generalized Skinfold Equations
BOX 4.3
DENSITOMETRY
Body composition can be estimated from a measurement of whole-body density
using the ratio of body mass to body volume. Densitometry has been used as a
reference or criterion standard for assessing body composition for many years.
The limiting factor in the measurement of body density is the accuracy of the](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-95-320.jpg)
![74 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
(or through a nonlatex mask) while pulmonary ventilation and expired fractions
of oxygen (O2
) and carbon dioxide (CO2
) are measured. Modern automated
systems provide ease of use and a detailed printout of test results that save time
and effort (27). However, system calibration is still essential to obtain accurate
results (76). Administration of the test and interpretation of results should be
reserved for professional personnel with a thorough understanding of exercise
science. Because of costs associated with the equipment, space, and personnel
needed to carry out these tests, direct measurement of V̇O2max
generally is
reserved for research or clinical settings.
When direct measurement of V̇O2max
is not feasible, a variety of submaximal
and maximal exercise tests can be used to estimate V̇O2max
. These tests have been
validated by examining (a) the correlation between directly measured V̇O2max
and the V̇O2max
estimated from physiologic responses to submaximal exercise
(e.g., HR at a specified power output); or (b) the correlation between directly mea-
sured V̇O2max
and test performance (e.g., time to run 1 or 1.5 mi [1.6 or 2.4 km]),
or time to volitional fatigue using a standard graded exercise test protocol.
It should be noted that there is the potential for a significant overestimation of
TABLE 4.6. Fitness Categories for Body Composition (% Body Fat)
for Women by Age
Age (year)
% 20–29 30–39 40–49 50–59 60–69 70–79
99
Very leana
11.4 11.2 12.1 13.9 13.9 11.7
95 14.0 13.9 15.2 16.9 17
.7 16.4
90
Excellent
15.1 15.5 16.8 19.1 20.2 18.3
85 16.1 16.5 18.3 20.8 22.0 21.2
80 16.8 17
.5 19.5 22.3 23.3 22.5
75
Good
17
.6 18.3 20.6 23.6 24.6 23.7
70 18.4 19.2 21.7 24.8 25.7 24.8
65 19.0 20.1 22.7 25.8 26.7 25.7
60 19.8 21.0 23.7 26.7 27
.5 26.6
55
Fair
20.6 22.0 24.6 27
.6 28.3 27
.6
50 21.5 22.8 25.5 28.4 29.2 28.2
45 22.2 23.7 26.4 29.3 30.1 28.9
40 23.4 24.8 27
.5 30.1 30.8 30.5
35
Poor
24.2 25.8 28.4 30.8 31.5 31.0
30 25.5 26.9 29.5 31.8 32.6 31.9
25 26.7 28.1 30.7 32.9 33.3 32.9
20 28.2 29.6 31.9 33.9 34.4 34.0
15
Very poor
30.5 31.5 33.4 35.0 35.6 35.3
10 33.5 33.6 35.1 36.1 36.6 36.4
5 36.6 36.2 37
.1 37
.6 38.2 38.1
1 38.6 39.0 39.1 39.8 40.3 40.2
n ⫽ 1,250 4,130 5,902 4,118 1,450 295
Total n ⫽ 17
,145
a
Very lean, no less than 10%–13% body fat is recommended for women.
Adapted with permission from Physical Fitness Assessments and Norms for Adults and Law Enforcement. The
Cooper Institute, Dallas, Texas. 2009. For more information: www.cooperinstitute.org](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-100-320.jpg)
![76 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
• The subject is not on medications, using high quantities of caffeine, under
large amounts of stress, ill, or in a high temperature environment, all of which
may alter HR.
MODES OF TESTING
Commonly used modes for exercise testing include treadmills, cycle ergometers,
steps, and field tests. The mode of exercise testing used is dependent on the
setting, equipment available, and training of personnel. Medical supervision is
recommended for high-risk individuals as detailed in Chapter 2 regardless of
mode (see Figure 2.4 and Table 2.3).
There are advantages and disadvantages of each exercise testing mode:
• Field tests consist of walking or running in a predetermined time or distance
(i.e., 12-min and 1.5-mi [2.4 km] walk/run tests, and the 1-mi and 6-min
walk test). The advantages of field tests are they are easy to administer to large
numbers of individuals at one time and little equipment (e.g., a stopwatch) is
needed. The disadvantages are some tests can be maximal for some individu-
als, particularly in individuals with low aerobic fitness, and potentially be
unmonitored for BP and HR. An individual’s level of motivation and pacing
ability also can have a profound impact on test results. These all-out run tests
may be inappropriate for sedentary individuals or individuals at increased
risk for cardiovascular and/or musculoskeletal complications. Nevertheless,
V̇O2max
can be estimated from the test results.
• Motor-driven treadmills can be used for submaximal and maximal testing
and are often employed for diagnostic testing in the United States (5). They
provide a familiar form of exercise and, if the correct protocol is chosen (i.e.,
aggressive vs. conservative adjustments in workload), can accommodate the
least physically fit to the fittest individuals across the continuum of walking to
running speeds. Nevertheless, a practice session might be necessary in some
cases to permit habituation and reduce anxiety. On the other hand, treadmills
usually are expensive, not easily transportable, and potentially make some
measurements (e.g., BP
, ECG) more difficult, particularly while an individual
is running. Treadmills must be calibrated to ensure the accuracy of the test
(76). In addition, holding on to the support rail(s) should be discouraged to
ensure accuracy of metabolic work output, particularly when V̇O2
is estimated
as opposed to directly measured. Extensive handrail use often leads to signifi-
cant overestimation of V̇O2
compared to actual values.
• Mechanically braked cycle ergometers are also a viable test modality for
submaximal and maximal testing and are frequently used for diagnostic
testing, particularly in European laboratories (76). Advantages of this exercise
mode include lower equipment expense, transportability, and greater ease
in obtaining BP and ECG (if appropriate) measurements. Cycle ergometers
also provide a non–weight-bearing test modality in which work rates are
easily adjusted in small increments. The main disadvantage is cycling is a less
familiar mode of exercise to individuals in the United States, often resulting](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-102-320.jpg)
![78 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
those surpassing this threshold (16). Several multivariate equations are avail-
able to predict V̇O2 peak
from the 6-min walk; however, the following equation
requires minimal clinical information (16):
• V̇O2peak
⫽ V̇O2
mL ⭈ kg⫺1
⭈ min⫺1
⫽ (0.02 ⫻ distance [m]) ⫺ (0.191 ⫻
age [yr]) ⫺ (0.07 ⫻ weight [kg]) ⫹ (0.09 ⫻ height [cm]) ⫹ (0.26 ⫻ RPP
[⫻ 10⫺3
]) ⫹ 2.45
Where m ⫽ distance in meters; yr ⫽ year; kg ⫽ kilogram; cm ⫽ centimeter;
RPP ⫽ rate pressure product (HR ⫻ systolic BP [SBP] in mm Hg)
• For the aforementioned equation: R2
⫽ 0.65 and SEE ⫽ 2.68 (R2
⫽ coefficient
of determination; SEE ⫽ standard error of estimate)
Submaximal Exercise Tests
Single-stage and multistage submaximal exercise tests are available to estimate
V̇O2max
from simple HR measurements. Accurate measurement of HR is critical
for valid testing. Although HR obtained by palpation is commonly used, the
accuracy of this method depends on the experience and technique of the evalu-
ator. It is recommended that an ECG, HR monitor, or a stethoscope be used to
determine HR. The use of a relatively inexpensive HR monitor can reduce a sig-
nificant source of error in the test. The submaximal HR response is easily altered
by a number of environmental (e.g., heat, humidity, see Chapter 8), dietary (e.g.,
caffeine, time since last meal), and behavioral (e.g., anxiety, smoking, previous
physical activity) factors. These variables must be controlled to have a valid
estimate that can be used as a reference point in an individual’s fitness program.
In addition, the test mode (e.g., cycle, treadmill, step) should be consistent with
the primary exercise modality used by the participant to address specificity of
training issues. Standardized procedures for submaximal testing are presented in
Box 4.4. Although there are no specific submaximal protocols for treadmill test-
ing, several stages from any of the treadmill protocols found in Chapter 5 can be
used to assess submaximal exercise responses. Preexercise test instructions are
presented in Chapter 3.
Cycle ErgometerTests
The Astrand-Ryhming cycle ergometer test is a single-stage test lasting 6 min
(7). For the population studied, these researchers observed at 50% V̇O2max
, the
average HR was 128 and 138 beats ⭈ min⫺1
for men and women, respectively. If a
woman was working at a V̇O2
of 1.5 L ⭈ min⫺1
and her HR was 138 beats ⭈ min⫺1
,
then her V̇O2max
was estimated to be 3.0 L ⭈ min⫺1
. The suggested work rate is
based on sex and an individual’s fitness status as follows:
men, unconditioned: 300 or 600 kg ⭈ m ⭈ min⫺1
(50 or 100 W)
men, conditioned: 600 or 900 kg ⭈ m ⭈ min⫺1
(100 or 150 W)
women, unconditioned: 300 or 450 kg ⭈ m ⭈ min⫺1
(50 or 75 W)
women, conditioned: 450 or 600 kg ⭈ m ⭈ min⫺1
(75 or 100 W)](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-104-320.jpg)
![CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 79
1. Obtain resting HR and BP immediately prior to exercise in the exercise
posture.
2. The client should be familiarized with the ergometer. If using a cycle
ergometer, properly position the client on the ergometer (i.e., upright
posture, ⬃25-degree bend in the knee at maximal leg extension, and
hands in proper position on handlebars) (81–83).
3. The exercise test should begin with a 2–3 min warm-up to acquaint the
client with the cycle ergometer and prepare him or her for the exercise
intensity in the first stage of the test.
4. A specific protocol should consist of 2- or 3-min stages with appropriate
increments in work rate.
5. HR should be monitored at least two times during each stage, near
the end of the second and third minutes of each stage. If HR is
⬎110 beats ⭈ min⫺1
, steady state HR (i.e., two HRs within 5 beats ⭈ min⫺1
)
should be reached before the workload is increased.
6. BP should be monitored in the last minute of each stage and repeated
(verified) in the event of a hypotensive or hypertensive response.
7
. RPE (using either the Borg category or category-ratio scale [see Table 4.7])
and additional rating scales should be monitored near the end of the last
minute of each stage.
8. Client’s appearance and symptoms should be monitored and recorded
regularly.
9. The test should be terminated when the subject reaches 70% heart rate
reserve (85% of age-predicted HRmax
), fails to conform to the exercise
test protocol, experiences adverse signs or symptoms, requests to stop,
or experiences an emergency situation.
10. An appropriate cool-down/recovery period should be initiated consisting
of either
a. continued exercise at a work rate equivalent to that of the first stage
of the exercise test protocol or lower or
b. a passive cool-down if the subject experiences signs of discomfort or
an emergency situation occurs
11. All physiologic observations (e.g., HR, BP
, signs and symptoms) should be
continued for at least 5 min of recovery unless abnormal responses occur,
which would warrant a longer posttest surveillance period. Continue low-
level exercise until HR and BP stabilize, but not necessarily until they
reach preexercise levels.
BP
, blood pressure; HR, heart rate; HRmax
, maximal heart rate; RPE, rating of perceived exertion.
General Procedures for Submaximal Testing of
Cardiorespiratory Fitness
BOX 4.4](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-105-320.jpg)
![CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 95
RATIONALE
Physical fitness tests of muscular strength and muscular endurance before com-
mencing exercise training or as part of a health/fitness screening evaluation can
provide valuable information on a client’s baseline physical fitness level. For
example, muscular fitness test results can be compared to established standards
and can be helpful in identifying weaknesses in certain muscle groups or muscle
imbalances that could be targeted in exercise training programs. The information
obtained during baseline muscular fitness assessments can also serve as a basis
for designing individualized exercise training programs. An equally useful appli-
cation of physical fitness testing is to show a client’s progressive improvements
over time as a result of the training program, and thus provide feedback that is
often beneficial in promoting long-term exercise adherence.
PRINCIPLES
Muscle function tests are very specific to the muscle group tested, the type of
muscle action, velocity of muscle movement, type of equipment, and joint range
of motion (ROM). Results of any one test are specific to the procedures used, and
no single test exists for evaluating total body muscular endurance or strength.
Individuals should participate in familiarization/practice sessions with test equip-
ment and adhere to a specific protocol including a predetermined repetition dura-
tion and ROM in order to obtain a reliable score that can be used to track true
physiologic adaptations over time. Moreover, warm-up consisting of 5–10 min of
light intensity, aerobic exercise (i.e., treadmill or cycle ergometer), static stretch-
ing, and several light intensity repetitions of the specific testing exercise should
precede muscular fitness testing. These warm-up activities increase muscle tem-
perature and localized blood flow and promotes appropriate cardiovascular re-
sponses to exercise. A summary of standardized conditions include the following:
• Strict posture.
• Consistent repetition duration (movement speed).
• Full ROM.
• Use of spotters (when necessary).
• Equipment familiarization.
• Warm-up.
Change in muscular fitness over time can be based on the absolute value of
the external load or resistance (e.g., newtons, kilograms [kg], or pounds [lb]),
but when comparisons are made between individuals, the values should be
expressed as relative values (per kilogram of body weight [kg ⭈ kg⫺1
]). In both
cases, caution must be used in the interpretation of the scores because the norms
may not include a representative sample of the individual being measured, a
standardized protocol may be absent, or the exact test being used (e.g., free
weight vs. machine weight) may differ. In addition, the biomechanics for a given
resistance exercise may differ significantly when using equipment from different
manufactures, further impacting generalizability.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-121-320.jpg)
![102 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
TABLE 4.14. Fitness Categories for the YMCA Bench Press Test (Total Lifts)
by Age and Sex
Age (year)
Category 18–25 26–35 36–45 46–55 56–65 ⬎65
Sex M W M W M W M W M W M W
Excellent
64 66 61 62 55 57 47 50 41 42 36 30
44 42 41 40 36 33 28 29 24 24 20 18
Good
41 38 37 34 32 30 25 24 21 21 16 16
34 30 30 29 26 26 21 20 17 17 12 12
Above average
33 28 29 28 25 24 20 18 14 14 10 10
29 25 26 24 22 21 16 14 12 12 9 8
Average
28 22 24 22 21 20 14 13 11 10 8 7
24 20 21 18 18 16 12 10 9 8 7 5
Below average
22 18 20 17 17 14 11 9 8 6 6 4
20 16 17 14 14 12 9 7 5 5 4 3
Poor
17 13 16 13 12 10 8 6 4 4 3 2
13 9 12 9 9 6 5 2 2 2 2 0
Very poor ⬍10 6 9 6 6 4 2 1 1 1 1 0
M, men; W, women.
Reprinted with permission from (111). © 2000 by YMCA of the USA, Chicago. All rights reserved.
Coronary Prone Clients
Moderate intensity resistance training performed 2–3 d ⭈ wk⫺1
is effective for im-
proving muscular fitness, preventing and managing a variety of chronic medical
conditions, modifying CVD risk factors, and enhancing psychosocial well-being
for individuals with and without CVD. Consequently, authoritative professional
health organizations including the ACSM and AHA support the inclusion of re-
sistance training as an adjunct to aerobic exercise in their current recommenda-
tions and guidelines on exercise for individuals with CVD (see Chapter 9) (110).
The absence of anginal symptoms, ischemic ST-segment changes on the ECG,
abnormal hemodynamics, and complex ventricular dysrhythmias suggests mod-
erate intensity (e.g., performance of 10–15 repetitions) resistance testing and
training can be performed safely by patients with CVD deemed “low risk” (e.g.,
individuals without resting or exercise-induced evidence of myocardial ischemia,
severe left ventricular dysfunction, or complex ventricular dysrhythmias, and
with normal or near normal CRF [see Chapter 2]). Moreover, despite concerns
that resistance exercise elicits abnormal cardiovascular “pressor responses” in
patients with CVD and/or controlled hypertension, studies have found strength
testing and resistance training in these patients elicit HR and BP responses that
appear to fall within clinically acceptable limits (110). Resistance training in
moderate-to-high risk patients with CVD may be deemed appropriate follow-
ing a thorough clinical assessment by an experienced health care professional.
Furthermore, moderate-to-high risk patients with CVD who do participate in a
resistance training program should be closely monitored (110). Absolute and rela-
tive contraindications to resistance testing and training are provided in Box 4.7.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-128-320.jpg)
![CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 109
• Each component of the assessment can be performed through several ap-
proaches to accommodate availability of equipment, the facility, training of
personnel, and health/fitness status of the individual undergoing testing.
• Adherence to the recommendations for the health/fitness assessments pro-
vided in Chapter 4 allows for an individualized and safe approach.
• When available, results from each component of the health/fitness assessment
should be compared to normative data provided in Chapter 4.
ACSM Exercise is Medicine:
http://exerciseismedicine.org
American Heart Association:
http://www.americanheart.org
Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and
Obesity in Adults: The Evidence Report:
http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm
The Cooper Institute:
http://www.cooperinstitute.org
National Heart, Lung, and Blood Institute Health Information for Professionals:
http://www.nhlbi.nih.gov/health/indexpro.htm
2008 Physical Activity Guidelines for Americans (1):
http://www.health.gov/PAguidelines
Online Resources
REFERENCES
1. 2008 Physical Activity Guidelines for Americans [Internet]. Rockville (MD): Office of Disease
Prevention Health Promotion, U.S. Department of Health and Human Services. 2008 [cited 2012
Jan 7]. 76 p. Available from: http://www.health.gov/paguidelines
2. Abidov A, Rozanski A, Hachamovitch R, et al. Prognostic significance of dyspnea in patients referred
for cardiac stress testing. N Engl J Med. 2005;353(18):1889–98.
3. American College of Sports Medicine Position Stand, American Heart Association. Recommendations
for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Med Sci
Sports Exerc. 1998;30(6):1009–18.
4. Arena R, Lavie CJ. The obesity paradox and outcome in heart failure: is excess bodyweight truly
protective? Future Cardiol. 2010;6(1):1–6.
5. Arena R, Myers J, Williams MA, et al. Assessment of functional capacity in clinical and research
settings: a scientific statement from the American Heart Association Committee on Exercise, Reha-
bilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular
Nursing. Circulation. 2007;116(3):329–43.
6. Astrand PO. Aerobic work capacity in men and women with special reference to age. Acta Physiol
Scand. 1960;49(Supplement 169):45–60.
7. Astrand PO, Ryhming I. A nomogram for calculation of aerobic capacity (physical fitness) from
pulse rate during sub-maximal work. J Appl Physiol. 1954;7(2):218–21.
8. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS state-
ment: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111–7.
9. Behm DG, Faigenbaum AD, Falk B, Klentrou P. Canadian Society for Exercise Physiology position
paper: resistance training in children and adolescents. Appl Physiol Nutr Metab. 2008;33(3):547–61.
10. Blair SN, Kohl HW,3rd, Barlow CE, Paffenbarger RS,Jr, Gibbons LW, Macera CA. Changes in
physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA.
1995;273(14):1093–8.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-135-320.jpg)
![110 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
11. Blair SN, Kohl HW,3rd, Paffenbarger RS,Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and
all-cause mortality. A prospective study of healthy men and women. JAMA. 1989;262(17):2395–401.
12. Bodegard J, Erikssen G, Bjornholt JV, Gjesdal K, Liestol K, Erikssen J. Reasons for terminating an
exercise test provide independent prognostic information: 2014 apparently healthy men followed
for 26 years. Eur Heart J. 2005;26(14):1394–401.
13. Borg G. Borg’s Perceived Exertion and Pain Scales. Champaign (IL): Human Kinetics; 1998. 104 p.
14. Bray GA. Don’t throw the baby out with the bath water. Am J Clin Nutr. 2004;79(3):347–9.
15. Brozek J, Grande F
, Anderson JT, Keys A. Densitometric analysis of body composition: revision of
some quantitative assumptions. Ann N Y Acad Sci. 1963;110:113–40.
16. Cahalin LP
, Mathier MA, Semigran MJ, Dec GW, DiSalvo TG. The six-minute walk test predicts peak
oxygen uptake and survival in patients with advanced heart failure. Chest. 1996;110(2):325–32.
17. Cailliet R. Low Back Pain Syndrome. 4th ed. Philadelphia (PA): F
.A. Davis; 1988. 341 p.
18. Callaway CW, Chumlea WC, Bouchard C, Himes JH, Lohman TG, Martin AD. Circumferences.
In: Lohman TG, Roche AF
, Martorell R, editors. Anthropometric Standardization Reference Manual.
Champaign: Human Kinetics; 1988. p. 39–80.
19. Canadian Society for Exercise Physiology. The Canadian Physical Activity, Fitness Lifestyle
Approach (CPAFLA): CSEP—Health Fitness Program’s Health-Related Appraisal and Counselling
Strategy. 3rd ed. Ottawa (Ontario): Canadian Society for Exercise Physiology; 2003. 300 p.
20. Canoy D. Distribution of body fat and risk of coronary heart disease in men and women. Curr Opin
Cardiol. 2008;23(6):591–8.
21. Casanova C, Cote C, Marin JM, et al. Distance and oxygen desaturation during the 6-min walk test
as predictors of long-term mortality in patients with COPD. Chest. 2008;134(4):746–52.
22. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine position stand:
prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012–29.
23. Ciampricotti R, Deckers JW, Taverne R, el Gamal M, Relik-van Wely L, Pool J. Characteristics of
conditioned and sedentary men with acute coronary syndromes. Am J Cardiol. 1994;73(4):219–22.
24. Clarkson HM. Musculoskeletal Assessment: Joint Range of Motion and Manual Muscle Strength. 2nd ed.
Baltimore (MD): Lippincott Williams Wilkins; 2000. 432 p.
25. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults:
The Evidence Report [Internet]. Bethesda (MD): National Institutes of Health, National Heart, Lung,
and Blood Institute. 1998 [cited 2011 Apr 27]. 266 p. Available from: http://www.nhlbi.nih.gov/
guidelines/obesity/ob_gdlns.htm
26. Daniels SR, Jacobson MS, McCrindle BW, Eckel RH, Sanner BM. American Heart Association
Childhood Obesity Research Summit Report. Circulation. 2009;119(15):e489–517.
27. Davis JA. Direct determination of aerobic power. In: Maud PJ, editor. Physiological Assessment of
Human Fitness. Champaign: Human Kinetics; 1995. p. 9–17.
28. de Koning L, Merchant AT, Pogue J, Anand SS. Waist circumference and waist-to-hip ratio as pre-
dictors of cardiovascular events: meta-regression analysis of prospective studies. Eur Heart J. 2007;
28(7):850–6.
29. Definitions—Health, Fitness, and Physical Activity [Internet]. Washington (DC): President’s Council
on Physical Fitness and Sports. 2000 [cited 2012 Jan 7]. 11 p. Available from: http://purl.access.gpo.
gov/GPO/LPS21074
30. Dehghan M, Merchant AT. Is bioelectrical impedance accurate for use in large epidemiological stud-
ies? Nutr J. 2008;7:26.
31. Dempster P
, Aitkens S. A new air displacement method for the determination of human body com-
position. Med Sci Sports Exerc. 1995;27(12):1692–7.
32. Diener MH, Golding LA, Diener D. Validity and reliability of a one-minute half sit-up test of
abdominal strength and endurance. Sports Med Training Rehab. 1995;6:105–19.
33. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports Medicine Position Stand.
Appropriate physical activity intervention strategies for weight loss and prevention of weight regain
for adults. Med Sci Sports Exerc. 2009;41(2):459–71.
34. Duren DL, Sherwood RJ, Czerwinski SA, et al. Body composition methods: comparisons and inter-
pretation. J Diabetes Sci Technol. 2008;2(6):1139–46.
35. Executive summary of the clinical guidelines on the identification, evaluation, and treatment of
overweight and obesity in adults. Arch Intern Med. 1998;158(17):1855–67.
36. Faigenbaum AD, Kraemer WJ, Blimkie CJ, et al. Youth resistance training: updated position state-
ment paper from the national strength and conditioning association. J Strength Cond Res. 2009;23
(5 Suppl):S60–79.
37. Faulkner RA, Sprigings EJ, McQuarrie A, Bell RD. A partial curl-up protocol for adults based on an
analysis of two procedures. Can J Sport Sci. 1989;14(3):135–41.
38. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults,
1999–2008. JAMA. 2010;303(3):235–41.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-136-320.jpg)
![CHAPTER 5 Clinical Exercise Testing 115
It is widely believed the diagnostic GXT has the greatest use in patients with
an intermediate pretest probability of angiographically significant CVD. The
reason for this belief is the dramatic impact the exercise response has on posttest
probability of disease. This concept is illustrated in Figure 5.1. From this graph,
it is clear that a positive GXT (i.e., ST-segment depression suggestive of CVD)
improves the probability of angiographically significant CVD to the greatest level
in the subject with intermediate pretest likelihood (i.e., third bar from left; prob-
ability increases from ⬃10% pretest to ⬎60% posttest).
The same exercise testing procedures and concepts are also used when more
advanced diagnostic techniques are employed such as nuclear perfusion scan-
ning. Asymptomatic individuals generally represent those with a low likelihood
(i.e., ⬍10%) of significant CVD. Therefore, diagnostic GXT in asymptomatic
individuals generally is not indicated but may be useful to ensure a normal physi-
ologic response (i.e., hemodynamics, ECG, and symptomatology) when multiple
CVD risk factors are present (25) (see Table 2.2), indicating at least a moderate
risk of experiencing a serious cardiovascular event within 5 yr (72). Among
asymptomatic men, ST-segment depression, failure to reach 85% of the predicted
maximal heart rate (HRmax
), and a diminished exercise capacity during peak or
symptom-limited treadmill testing provide additional prognostic information in
age and Framingham risk score adjusted models, particularly among those in
the highest risk group (10 yr predicted coronary risk ⱖ20%) (13). A diagnostic
GXT may be indicated in selected individuals that are about to start a vigorous
intensity, exercise program (see Chapter 2), or those involved in occupations in
which acute cardiovascular events may affect public safety.
In general, patients with a high probability of disease (e.g., typical angina,
prior coronary revascularization, myocardial infarction [MI]) are tested to assess
residual myocardial ischemia, threatening ventricular arrhythmias, and progno-
sis rather than for diagnostic purposes. Exercise electrocardiography for diag-
nostic purposes is less accurate in women largely because of a greater number
of false positive responses. Although differences in test accuracy between men
TABLE 5.1. Pretest Likelihood of Atherosclerotic Cardiovascular Disease (CVD)a
Age Sex
Typical/Definite
Angina Pectoris
Atypical/Probable
Angina Pectoris
Nonanginal
Chest Pain
Asymptomatic
30 to 39 yr Men Intermediate Intermediate Low Very low
Women Intermediate Very low Very low Very low
40 to 49 yr Men High Intermediate Intermediate Low
Women Intermediate Low Very low Very low
50 to 59 yr Men High Intermediate Intermediate Low
Women Intermediate Intermediate Low Very low
60 to 69 yr Men High Intermediate Intermediate Low
Women High Intermediate Intermediate Low
a
No data exist for patients who are ⬍30 or ⬎69 yr, but it can be assumed that prevalence of CVD increases
with age. In a few cases, patients with ages at the extremes of the decades listed may have probabilities
slightly outside the high or low range. High indicates ⬎90%; intermediate, 10% to 90%; low, ⬍10%; and very
low, ⬍5%.
Reprinted with permission from (25).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-141-320.jpg)
![CHAPTER 5 Clinical Exercise Testing 117
broad spectrum of patients. For example, immediate exercise testing of selected
low-risk patients (i.e., no hemodynamic abnormalities and arrhythmias, near
normal/normal ECG, and negative initial biomarkers for cardiac injury) pre-
senting to the emergency department with signs/symptoms of acute coronary
syndrome is becoming increasingly recognized as a valuable tool in making
decisions regarding which patients require additional diagnostic studies before
hospital discharge (4,5,43,46,71). The use of exercise testing in this capacity has
been found to be safe and reduces both length of hospital stay and cost. Patients
initially screened to be at low risk subsequently demonstrate a preserved exercise
capacity (i.e., ⱖ7 metabolic equivalents [METs]) and no hemodynamic/ECG
abnormalities during testing have a low likelihood of acute coronary syndrome
and subsequent events (4). In patients with chronic conditions such as CHF and
pulmonary hypertension, exercise testing may also prove valuable in guiding
treatment decisions as several variables obtained from this assessment respond
favorably to numerous pharmacologic and surgical interventions (6,8,27).
EXERCISE TESTING FOR DISEASE SEVERITY AND PROGNOSIS
Exercise testing is useful for the evaluation of disease severity among individuals
with known or suspected CVD. The magnitude of ischemia caused by a coronary
lesion generally is (a) directly proportional to the degree of ST-segment depres-
sion, the number of ECG leads involved, and the duration of ST-segment depres-
sion in recovery; and (b) inversely proportional to the ST slope, the rate pressure
product (RPP) (i.e., heart rate [HR] ⫻ systolic blood pressure [SBP]) at which the
ST-segment depression occurs, and the HRmax
, SBP
, and METs achieved.
The exercise testing response is likewise an important gauge of disease severity
in patients with chronic conditions such as CHF
, pulmonary hypertension, and
chronic obstructive pulmonary disease (COPD) (9). A progressively diminished
aerobic capacity is universally reflective of increasing disease severity in these
chronic conditions. Data exclusively obtained from ventilatory expired gas analy-
sis and reflective of abnormalities in ventilation perfusion matching (i.e., minute
ventilation/carbon dioxide production [V̇E/V̇CO2
] slope, and partial pressure of
end-tidal carbon dioxide [PETCO2
]) also provide insight into disease severity, espe-
cially among patients with CHF
, pulmonary hypertension, and COPD. The prognos-
tic value of exercise testing appears to be consistent in all individuals regardless of
their health status when there is a progressively diminishing aerobic capacity that is
a warning of worsening prognosis (9). In addition, several other HR, hemodynamic,
and ventilatory expired gas variables obtained from exercise testing provide robust
prognostic information in certain populations such as heart failure. Several numeric
indices of prognosis have been proposed and are discussed in Chapter 6 (11,47).
EXERCISE TESTING AFTER MYOCARDIAL INFARCTION
Exercise testing after MI can be performed before or soon after hospital discharge
for prognostic assessment, Ex Rx
, and evaluation of medical therapy or inter-
ventions including coronary revascularization (25). Submaximal exercise tests](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-143-320.jpg)
![142
Benefits and Risks Associated with
Physical Activity
CHAPTER
1
This chapter addresses the interpretation and clinical significance of exercise test
results with specific reference to hemodynamic, electrocardiographic (ECG), and
ventilatory expired gas responses. The diagnostic and prognostic value of the
exercise test will be discussed along with screening for atherosclerotic cardiovas-
cular disease (CVD).
EXERCISE TESTING AS A SCREENING TOOL FOR
CORONARY ARTERY DISEASE
The probability of a patient having CVD cannot be estimated accurately from the
exercise test result and diagnostic characteristics of the test alone. It also depends on
the likelihood of having disease before the test is administered. Bayes’ theorem states
that the posttest probability of having a disease is determined by the disease probabil-
ity before the test and the probability that the test will provide a true result (50). The
probability of a patient having a disease before the test is most importantly related to
the presence of symptoms (particularly chest pain characteristics), in addition to the
patient’s age, sex, and the presence of major CVD risk factors (see Table 2.2).
Exercise testing in individuals with known CVD (i.e., prior myocardial in-
farction [MI], angiographically documented coronary stenoses, and/or prior
coronary revascularization) is warranted if there is a reemergence of symptoms
postintervention (18). The description of symptoms can be most helpful among
individuals in whom the diagnosis is in question. Typical or definite angina
(i.e., substernal chest discomfort that may radiate to the back, jaw, or arms, and
symptoms provoked by exertion or emotional stress and relieved by rest and/
or nitroglycerin) makes the pretest probability so high that the test result does
not dramatically change the likelihood of underlying CVD. Atypical angina
(i.e., chest discomfort that lacks one of the mentioned characteristics of typical
angina) generally indicates an intermediate pretest likelihood of CVD in men
⬎30 yr and women ⬎50 yr (see Table 5.1 and Figure 5.1). In fact, the use of
exercise testing to assist in the diagnosis of CVD may be most beneficial in those
individuals with an intermediate pretest probability (see Chapter 5).
The use of exercise testing in screening asymptomatic individuals, particu-
larly among individuals without diabetes mellitus or major CVD risk factors,
CHAPTER
Interpretation of Clinical
Exercise Test Results
6](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-168-320.jpg)
![CHAPTER 6 Interpretation of Clinical Exercise Test Results 143
is diagnostically problematic in view of the low to very low pretest likelihood
of CVD (see Table 5.1). An American Heart Association Scientific Statement on
exercise testing in asymptomatic adults concluded that there is currently insuf-
ficient evidence to support exercise testing as a routine screening modality for
atherosclerotic CVD in asymptomatic individuals (35). Given the limited ability of
exercise testing to indentify atherosclerotic CVD and predict risk of adverse events
during exercise, this assessment is not indicated prior to initiation of an exercise
program in asymptomatic individuals (see Chapter 2). Even so, the use of exercise
testing in asymptomatic individuals may be useful to health/fitness and clinical
exercise professionals given its ability to (a) reflect general health; (b) identify nor-
mal and abnormal physiologic responses to physical exertion; (c) provide infor-
mation to more precisely design the exercise prescription (Ex Rx
); and (d) provide
prognostic insight, especially among those with multiple CVD risk factors (35).
INTERPRETATION OF RESPONSES TO GRADED EXERCISE TESTING
Before interpreting clinical exercise test data, it is important to consider the pur-
pose of the test (e.g., diagnostic, prognostic, therapeutic applications, Ex Rx
) and
the individual clinical characteristics that may influence the exercise test or its
interpretation (e.g., age, sex). Medical conditions influencing test interpretation in-
clude orthopedic limitations, pulmonary disease, obesity, neurologic disorders, and
deconditioning. Medication effects (see Appendix A) and resting ECG abnormalities
(see Appendix C) also must be considered, especially resting ST-segment changes
secondary to conduction defects, left ventricular hypertrophy (LVH), and other
factors that may contribute to spurious ST-segment depression.
Although total body and myocardial oxygen consumption (MV̇O2
) are di-
rectly related, the relationship between these variables can be altered by exercise
training, medications, and disease. For example, exercise-induced myocardial
ischemia may cause left ventricular dysfunction, exercise intolerance, and a
hypotensive blood pressure (BP) response (see Box 5.2). The severity of symp-
tomatic ischemia is inversely related to exercise capacity; however, left ventricu-
lar ejection fraction does not correlate well with exercise tolerance (39,45).
Responses to exercise tests are useful in evaluating the need for and effective-
ness of various types of therapeutic interventions. The following variables are
important to quantify accurately when assessing the diagnostic, prognostic, and
therapeutic applications of the test. Each is described in the following sections
and summarized in Box 6.1:
• Hemodynamics: assessed by the heart rate (HR) and systolic BP (SBP)/
diastolic BP (DBP) responses.
• ECG waveforms: particularly ST-segment displacement and supraventricular
and ventricular dysrhythmias.
• Limiting clinical signs or symptoms.
• Ventilatory gas exchange responses (e.g., V̇O2
, minute ventilation [V̇E],
carbon dioxide production [V̇CO2
]).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-169-320.jpg)
![144 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
Electrocardiographic, Cardiorespiratory, and Hemodynamic
Responses to Exercise Testing and Their Clinical Significance
BOX 6.1
Variable Clinical Significance
ST-segment
depression (ST ↓)
An abnormal ECG response is defined as ⱖ1 mm of horizontal
or downsloping ST ↓ 60–80 ms beyond the J point, suggesting
myocardial ischemia.
ST-segment
elevation (ST ↑)
ST ↑ in leads displaying a previous Q wave MI almost always
reflects an aneurysm or wall motion abnormality. In the absence
of significant Q waves, exercise-induced ST ↑ often is associated
with a fixed high-grade coronary stenosis.
Supraventricular
dysrhythmias
Isolated atrial ectopic beats or short runs of SVT commonly
occur during exercise testing and do not appear to have any
diagnostic or prognostic significance for CVD.
Ventricular
dysrhythmias
The suppression of resting ventricular dysrhythmias during
exercise does not exclude the presence of underlying CVD;
conversely, PVCs that increase in frequency, complexity, or both
do not necessarily signify underlying ischemic heart disease.
Complex ventricular ectopy, including paired or multiform PVCs,
and runs of ventricular tachycardia (ⱖ3 successive beats) are
likely to be associated with significant CVD and/or a poor prog-
nosis if they occur in conjunction with signs and/or symptoms of
myocardial ischemia in patients with a history of sudden cardiac
death, cardiomyopathy, or valvular heart disease. Frequent ven-
tricular ectopy during recovery has been found to be a better
predictor of mortality than ventricular ectopy that occurs only
during exercise.
Heart rate (HR) The normal HR response to progressive exercise is a relatively
linear increase, corresponding to 10 ⫾ 2 beats ⭈ MET⫺1
for
physically inactive subjects. Chronotropic incompetence may be
signified by the following:
1. A peak exercise HR that is ⬎2 SD (艐20 beats ⭈ min⫺1
) below
the age-predicted HRmax
or an inability to achieve ⱖ85% of
the age-predicted HRmax
for subjects who are limited by voli-
tional fatigue and are not taking -blockers
2. A chronotropic index (CI) ⬍0.8 (35); where CI is calculated
as the percentage of heart rate reserve to percent metabolic
reserve achieved at any test stage
Heart rate recovery An abnormal (slowed) HR recovery is associated with a poor
prognosis. HR recovery has frequently been defined as a de-
crease ⱕ12 beats ⭈ min⫺1
at 1 min (walking in recovery), or ⱕ22
beats ⭈ min⫺1
at 2 min (supine position in recovery).
Systolic blood
pressure (SBP)
The normal response to exercise is a progressive increase in
SBP
, typically 10 ⫾ 2 mm Hg ⭈ MET⫺1
with a possible plateau at
peak exercise. Exercise testing should be discontinued with SBP
values of ⬎250 mm Hg. Exertional hypotension (SBP that fails
to rise or falls [⬎10 mm Hg]) may signify myocardial ischemia
and/or LV dysfunction. Maximal exercise SBP of ⬍140 mm Hg
suggests a poor prognosis.
Diastolic blood
pressure (DBP)
The normal response to exercise is no change or a decrease
in DBP
. A DBP of ⬎115 mm Hg is considered an endpoint for
exercise testing.
(continued)](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-170-320.jpg)
![146 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
an age-predicted HRmax
⬎80% (i.e., chronotropic incompetence), using the equa-
tion {[HRpeak
⫺ HRrest
]/[(220 ⫺ age) ⫺ HRrest
]}, is also an indicator of increased
risk for adverse events (35). A delayed decrease in HR early in recovery after a
symptom-limited maximal exercise test (i.e., ⱕ12 beats ⭈ min⫺1
decrease after
the first minute in recovery) is also a powerful independent predictor of overall
mortality and should therefore be included in the exercise test assessment (35).
Achievement of age-predicted HRmax
should not be used as an absolute test
endpoint or as an indication that effort has been maximal because of its high
intersubject variability. The clinical indications for stopping an exercise test
are presented in Box 5.2. Good judgment on the part of the supervising health/
fitness, clinical exercise, or health care professional remains the most important
criterion for terminating an exercise test.
BLOOD PRESSURE RESPONSE
The normal BP response to dynamic upright exercise consists of a progressive in-
crease in SBP
, no change or a slight decrease in DBP, and a widening of the pulse
pressure (see Box 6.1). The following are key points concerning interpretation of
the BP response to progressive dynamic exercise:
• A drop in SBP (ⱖ10 mm Hg decrease in SBP with an increase in workload), or
failure of SBP to increase with increased workload, is considered an abnormal
test response. Exercise-induced decreases in SBP (i.e., exertional hypotension)
may occur in patients with CVD, valvular heart disease, cardiomyopathies,
aortic outflow obstruction, and serious dysrhythmias. Occasionally, patients
without clinically significant heart disease demonstrate exertional hypoten-
sion caused by antihypertensive therapy, prolonged strenuous exercise, and/
or vasovagal responses. However, exertional hypotension correlates with
myocardial ischemia, left ventricular dysfunction, and an increased risk of
subsequent cardiac events (17). In some cases, this response is improved after
coronary artery bypass graft surgery (CABG). An SBP ⬎250 mm Hg and/or
a DBP ⬎115 mm Hg continue to be used as termination criteria for exercise
testing. Moreover, an excessive BP response to exercise is predictive of future
hypertension and CVD (55).
• The normal postexercise response is a progressive decline in SBP
. During passive
recovery in an upright posture, SBP may decrease abruptly because of periph-
eral pooling (and usually normalizes upon resuming the supine position). SBP
remains below pretest resting values for several hours after the test, an expected
physiologic response termed postexercise hypotension, which occurs in most
individuals (51). A failure to decrease or a rise in SBP over the first several min-
utes of recovery may indicate increased mortality risk (26). DBP also remains
below pretest resting values during the postexercise period in most individuals.
• In patients on vasodilators, calcium channel blockers, angiotensin-converting
enzyme inhibitors, and ␣- and -adrenergic blockers, the BP response to
exercise is variably attenuated and cannot be accurately predicted in the
absence of clinical test data (see Appendix A).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-172-320.jpg)
![CHAPTER 6 Interpretation of Clinical Exercise Test Results 149
• Exercise-induced ST-segment elevation on an otherwise normal ECG (except
in augmented voltage right [aVR] or chest leads V1 and V2) generally indi-
cates significant myocardial ischemia and localizes the ischemia to a specific
area of myocardium (48). This response may also be associated with ventricu-
lar arrhythmias and myocardial injury.
ST-Segment Depression
• ST-segment depression (i.e., depression of the J point and the slope at 80 ms
past the J point) is the most common manifestation of exercise-induced myo-
cardial ischemia.
• Horizontal or downsloping ST-segment depression is more indicative of myo-
cardial ischemia than is upsloping depression.
• The standard criterion for a positive test is ⱖ1.0 mm (0.1 mV) of horizontal
or downsloping ST-segment at the J point extending for 60–80 ms.
• Slowly upsloping ST-segment depression should be considered a borderline
response, and added emphasis should be placed on other clinical and exercise
variables.
• ST-segment depression does not localize ischemia to a specific area of
myocardium.
• The more leads with (apparent) ischemic ST-segment shifts, the more severe
the disease.
• Significant ST-segment depression occurring only in recovery likely repre-
sents a true positive response and should be considered an important diag-
nostic finding (34).
• Adjustment of the ST-segment relative to the HR may provide additional
diagnostic information. The ST/HR index is the ratio of the maximal ST-
segment change (V) to the maximal change in HR from rest to peak exercise
(beats ⭈ min⫺1
). An ST/HR index of ⬎1.6 V ⭈ beats⫺1
⭈ min⫺1
is defined as
abnormal. The ST/HR slope reflects the maximal slope relating the amount
of the ST-segment depression (V) to HR (beats ⭈ min⫺1
) during exercise. An
ST/HR slope of ⱖ2.4 V ⭈ beats⫺1
⭈ min⫺1
is defined as abnormal (29,30).
ST-Segment Normalization or Absence of Change
• Ischemia may be manifested by normalization of resting ST-segments. ECG
abnormalities at rest including T-wave inversion and ST-segment depression
may return to normal during anginal symptoms and during exercise in some
patients (36).
Dysrhythmias
Exercise-associated dysrhythmias occur in healthy individuals as well as pa-
tients with CVD. Increased sympathetic drive and changes in extracellular and
intracellular electrolytes, pH, and oxygen tension contribute to disturbances in](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-175-320.jpg)
![152 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
dard GXT procedures is typically referred to as cardiopulmonary exercise testing
(CPX) (8). These responses can be used to assess client/patient effort during
an exercise test, particularly when a reduction in maximal exercise capacity
is suspected. Submaximal efforts from the client/patient on a maximal GXT
can interfere with the interpretation of the test results and subsequent patient
management. Moreover, the use of CPX may be advantageous when serial test-
ing is needed for either research or clinical purposes to ensure consistent effort
among assessments (6). Maximal oxygen uptake (V̇O2max
) or peak oxygen uptake
(V̇O2peak
) provides important information about cardiorespiratory fitness and is
a powerful marker of prognosis. Population-specific nomograms (see Figure 5.2)
and/or population norms (see Table 4.9) may be used to compare V̇O2peak
with
the expected value according to age, sex, and physical fitness status (28,47).
Additionally, the assessment of ventilatory efficiency (i.e., V̇E/V̇CO2
slope and
partial pressure of end-tidal carbon dioxide [PETCO2
]) provides robust prognos-
tic and/or diagnostic information in patients with congestive heart failure (CHF)
and pulmonary hypertension (4,5).
Ventilatory expired gas responses often are used in clinical settings as an
estimation of the point at which lactate accumulation in the blood occurs,
sometimes referred to as the lactate or anaerobic threshold. Assessment of this
physiologic phenomenon through ventilatory expired gas is typically referred
to as ventilatory threshold (VT). Several different methods using ventilatory
expired gas responses exist for the estimation of this point. These include the
ventilatory equivalents and V-slope method (6). Whichever approach is used, it
should be remembered VT provides only an estimation, and the concept of an-
aerobic threshold during exercise is controversial (45). Because exercise beyond
the lactate threshold is associated with metabolic acidosis, hyperventilation,
and a reduced capacity to perform work, its estimation is a useful physiologic
measurement when evaluating interventions in patients with heart and pulmo-
nary disease as well as studying the limits of performance in apparently healthy
individuals. However, it should be noted that secondary to abnormal ventilatory
responses observed in a significant proportion of patients with CHF (i.e., exercise
oscillatory ventilation), determination of VT may not be possible (13).
In addition to estimating when blood lactate values begin to increase, maxi-
mal minute ventilation (V̇Emax
) can be used in conjunction with the maximal
voluntary ventilation (MVV) to assist in determining if there is a ventilatory
limitation to maximal exercise. A comparison between V̇Emax
and MVV can be
used when evaluating responses to a CPX. MVV can be directly measured by
a 12–15 s deep and rapid breathing maneuver or estimated from the equation:
forced expiratory volume in 1 s [(FEV1.0
) ⫻ 40] (8). MVV is preferred to [FEV1.0
⫻ 40] to ensure a precise quantification of ventilatory capacity. The relationship
between V̇Emax
and MVV, typically referred to as the ventilatory reserve, tradi-
tionally is defined as the percentage of the MVV achieved at maximal exercise
(i.e., the V̇Emax
/MVV ratio). In most normal healthy individuals, the V̇Emax
/MVV
ratio is ⱕ0.80 (6). Values surpassing this threshold are indicative of a reduced
ventilatory reserve and a possible pulmonary limitation to exercise.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-178-320.jpg)
![CHAPTER 6 Interpretation of Clinical Exercise Test Results 153
Pulse oximetry should also be assessed when CPX is used to assess possible
pulmonary limitations to exercise. A decrease in pulse oximeter saturation ⬎5%
during exercise also indicates a pulmonary limitation. Lastly, most currently
available ventilatory expired gas systems also possess capabilities for pulmo-
nary function testing. Obstructive or restrictive patterns on baseline pulmonary
function testing provide insight into the mechanism of limitations to exercise.
Moreover, a ⱖ15% decrease in FEV1.0
and/or peak expiratory flow following CPX
compared to baseline values is indicative of exercise-induced bronchospasm (6).
DIAGNOSTIC VALUE OF EXERCISE TESTING
The diagnostic value of conventional exercise testing for the detection of CVD is
influenced by the principles of conditional probability (see Box 6.2). The factors
that determine the predictive outcomes of exercise testing (and other diagnostic
tests) are the sensitivity and specificity of the test procedure and prevalence of
CVD in the population tested (50). Sensitivity and specificity determine how
effective the test is in making correct diagnoses in individuals with and without
disease, respectively. Disease prevalence is an important determinant of the pre-
dictive value of the test. Moreover, non-ECG criteria (e.g., duration of exercise
or maximal metabolic equivalent [MET] level, hemodynamic responses, symp-
toms of angina or dyspnea) should be considered in the overall interpretation of
exercise test results.
SENSITIVITY
Sensitivity refers to the percentage of patients tested with known CVD who dem-
onstrate significant ST-segment (i.e., positive) changes. Exercise ECG sensitivity
sensitivity ⫽ TP/(TP ⫹ FN) ⫽ the percentage of patients with CVD who have a
positive test
specificity ⫽ TN/(TN ⫹ FP) ⫽ the percentage of patients without CVD who
have a negative test
predictive value (positive test) ⫽ TP/(TP ⫹ FP) ⫽ the percentage of patients
with a positive test result who have CVD
predictive value (negative test) ⫽ TN/(TN ⫹ FN) ⫽ the percentage of patients
with a negative test who do not have CVD
CVD, cardiovascular disease; FN, false negative (negative exercise test and CVD);
FP
, false positive (positive exercise test and no CVD); TN, true negative (negative exercise test and no
CVD); TP
, true positive (positive exercise test and CVD).
Sensitivity, Specificity, and Predictive Value of Diagnostic
Graded Exercise Testing
BOX 6.2](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-179-320.jpg)
![154 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
for the detection of CVD usually is based on subsequent angiographically
determined coronary artery stenosis of ⱖ70% in at least one vessel. A true posi-
tive (TP) exercise test reveals horizontal or downsloping ST-segment depression
of ⱖ1.0 mm and correctly identifies a patient with CVD. False negative (FN)
test results show no or nondiagnostic ECG changes and fail to identify patients
with underlying CVD.
Common factors that contribute to FN exercise tests are summarized in
Box 6.3. Test sensitivity is decreased by inadequate myocardial stress, medica-
tions that attenuate cardiac demands to exercise or reduce myocardial ischemia
(e.g., -blockers, nitrates, calcium channel blocking agents), and insufficient
ECG lead monitoring. Preexisting ECG changes such as LVH, left bundle-
branch block (LBBB), or the preexcitation syndrome (Wolff-Parkinson-White
syndrome [W-P-W]) limit the ability to interpret exercise-induced ST-segment
changes as ischemic ECG responses. The exercise test is most accurate for de-
tecting CVD by applying validated multivariate scores (i.e., pretest risk mark-
ers in addition to ST-segment changes and other exercise test responses) (7).
SPECIFICITY
The specificity of exercise tests refers to the percentage of patients without CVD
who demonstrate nonsignificant (i.e., negative) ST-segment changes. A true neg-
ative test correctly identifies an individual without CVD. Many conditions may
cause abnormal exercise ECG responses in the absence of significant obstructive
CVD (see Box 6.4).
Reported values for the specificity and sensitivity of exercise ECG testing
vary because of differences in patient selection, test protocols, ECG criteria for a
positive test, and the angiographic definition of CVD. In studies that controlled
for these variables, the pooled results show a sensitivity of 68% and specificity of
77% (22). Sensitivity, however, is somewhat lower, and specificity is higher when
workup bias (i.e., only assessing individuals with a higher likelihood for a given
disease) is removed (19,42).
• Failure to reach an ischemic threshold
• Monitoring an insufficient number of leads to detect ECG changes
• Failure to recognize non-ECG signs and symptoms that may be associated
with underlying CVD (e.g., exertional hypotension)
• Angiographically significant CVD compensated by collateral circulation
• Musculoskeletal limitations to exercise preceding cardiac abnormalities
• Technical or observer error
CVD, cardiovascular disease; ECG, electrocardiographic.
Causes of False Negative Test Results
BOX 6.3](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-180-320.jpg)
![CHAPTER 7 General Principles of Exercise Prescription 167
INTENSITY OF EXERCISE
There is a positive dose response of health/fitness benefits that results from in-
creasing exercise intensity (20). The overload principle of training states exercise
below a minimum intensity, or threshold, will not challenge the body sufficiently
to result in changes in physiologic parameters, including increased maximal
oxygen consumption (V̇O2max
) (20). However, more recent findings demonstrate
the minimum threshold of intensity for benefit seems to vary depending on an
individual’s CRF level and other factors such as age, health status, physiologic
differences, genetics, habitual physical activity, and social and psychological fac-
tors (20,46,47). Therefore, it may be difficult to precisely define an exact thresh-
old to improve CRF (20,46). For example, individuals with an exercise capacity
of 11–14 metabolic equivalents (METs) seemingly require an exercise intensity of
at least 45% oxygen uptake reserve (V̇O2
R) to increase V̇O2max
, but no threshold
is apparent in individuals with a baseline fitness of ⬍11 METs (20,46). Highly
trained athletes may need to exercise at “near maximal” (i.e., 95%–100% V̇O2max
)
training intensities to improve V̇O2max
, whereas 70%–80% V̇O2max
may provide a
sufficient stimulus in moderately trained athletes (20,46).
Interval training involves varying the exercise intensity at fixed intervals dur-
ing a single exercise bout. The duration and intensity of the intervals can be
varied depending on the goals of the training session and physical fitness level
of the client or patient. Interval training can increase the total volume and/or av-
erage exercise intensity performed during an exercise session. Improvements in
CRF and cardiometabolic biomarkers with short-term (ⱕ3 mo) interval training
are similar to or greater than with single intensity exercise in healthy adults and
individuals with metabolic, cardiovascular, or pulmonary disease (20). The use
of interval training in adults appears beneficial, but the long-term effects and the
safety of interval training remain to be evaluated.
AEROBIC EXERCISE INTENSITY
RECOMMENDATION
Moderate (e.g., 40%–⬍60% heart rate reserve [HRR] or V̇O2
R) to vigor-
ous (e.g., 60%–⬍90% HRR or V̇O2
R) intensity aerobic exercise is recom-
mended for most adults, and light (e.g., 30%–⬍40% HRR or V̇O2
R) to
moderate intensity aerobic exercise can be beneficial in individuals who
are deconditioned. Interval training may be an effective way to increase
the total volume and/or average exercise intensity performed during an
exercise session and may be beneficial for adults.
combination of 3–5 d ⭈ wk⫺1
of moderate and vigorous intensity exercise
is recommended for most adults to achieve and maintain health/fitness
benefits.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-193-320.jpg)
![168 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
Methods of Estimating Intensity of Exercise
Several effective methods for prescribing exercise intensity result in improve-
ments in CRF that can be recommended for individualized Ex Rx
(20). Table 7.1
shows the approximate classification of exercise intensity commonly used in
practice. One method of determining exercise intensity is not necessarily equiva-
lent to the intensity derived using another method, because no studies have com-
pared all of the methods of measurement of exercise intensity simultaneously. In
addition, the relationships among measures of actual energy expenditure (EE)
and the absolute (i.e., V̇O2
and METs) and relative methods to prescribe exercise
intensity (i.e., %HRR, %HRmax
[maximal heart rate], and %V̇O2max
) can vary con-
siderably depending on exercise test protocol, exercise mode, exercise intensity,
and characteristics of the client or patient (i.e., resting HR, physical fitness level,
age, and body composition) as well as other factors (20).
The HRR or V̇O2
R methods may be preferable for Ex Rx
because exercise
intensity can be underestimated or overestimated when using the HR
(i.e., %HRmax
) or V̇O2
(i.e., %V̇O2max
) methods (20,44). However, the advantage
of the HRR or V̇O2
R methods is not universally accepted (20,44). Furthermore,
the accuracy of any of these methods may be influenced by the method of mea-
surement or estimation used (20).
The formula “220 ⫺ age” is commonly used to predict HRmax
(19). This for-
mula is simple to use, but it can underestimate or overestimate measured HRmax
(21,23,48,58). Specialized regression equations for estimating HRmax
may be su-
perior to the equation of 220 ⫺ age, at least in some individuals (21,26,48,58).
Although these equations are promising, they cannot yet be recommended for
universal application, although they may be applied to populations similar to
those in which they were derived (20). Table 7.2 shows some of the more com-
monly used equations to estimate HRmax
. For greater accuracy in determining
exercise intensity for the Ex Rx
, using the directly measured HRmax
is preferred
to estimated methods; but when not feasible, estimation of exercise intensity is
acceptable.
Measured or estimated measures of absolute exercise intensity include
caloric expenditure (kcal ⭈ min⫺1
), absolute oxygen uptake (mL ⭈ min⫺1
or
L ⭈ min⫺1
), and METs. These absolute measures can result in misclassification
TABLE 7.2. Commonly Used Equations for Estimating Maximal Heart Rate
Author Equation Population
Fox (19) HRmax
⫽ 220 ⫺ age. Small group of men and women
Astrand (9) HRmax
⫽ 216.6 ⫺ (0.84 ⫻ age) Men and women ages 4⫺34 yr
Tanaka (48) HRmax
⫽ 208 ⫺ (0.7 ⫻ age) Healthy men and women
Gellish (21) HRmax
⫽ 207 ⫺ (0.7 ⫻ age) Men and women participants in an adult
fitness program with broad range of age
and fitness levels
Gulati (23) HRmax
⫽ 206 ⫺ (0.88 ⫻ age) Asymptomatic middle-aged women
referred for stress testing
HRmax
, maximum heart rate.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-194-320.jpg)
![CHAPTER 7 General Principles of Exercise Prescription 169
of exercise intensity (e.g., moderate and vigorous intensity) because they do
not take into consideration individual factors such as body weight, sex, and
fitness level (1,2,27). Measurement error, and consequently misclassification,
is greater when using estimated rather than directly measured absolute EE and
under free living compared to laboratory conditions (1,2,27). For example,
an older individual working at 6 METs may be exercising at a vigorous-to-
maximal intensity, whereas a younger individual working at the same absolute
intensity will be exercising moderately (27). Therefore, for individual Ex Rx
, a
relative measure of intensity (i.e., the energy cost of the activity relative to the
individual’s maximal capacity such as % V̇O2
[i.e., V̇O2
mL ⭈ kg⫺1
⭈ min⫺1
],
HRR, and V̇O2
R) is more appropriate, especially for older and deconditioned
individuals (27,32).
A summary of methods for calculating exercise intensity using HR, V̇O2
,
and METs are presented in Box 7.2. Intensity of exercise training is usually
determined as a range so the calculation using the formulae presented in Box
7.2 need to be repeated twice (i.e., once for the lower limit of the desired in-
tensity range and once for the upper limit of the desired intensity range). The
prescribed exercise intensity range for an individual should be determined by
taking various factors into consideration, including age, habitual physical ac-
tivity level, physical fitness level, and health status. Examples illustrating the
use of several methods for prescribing exercise intensity are found in Figure
7.1. The reader is directed to other ACSM publications (e.g., [20,45] for fur-
ther explanation and examples using these additional methods of prescribing
exercise intensity).
• HRR method: Target HR (THR) ⫽ [(HRmax/peak
a
⫺ HRrest
) ⫻ % intensity
desired] ⫹ HRrest
• V̇O2
R method: Target V̇O2
Rc
⫽ [(V̇O2max/peak
b
⫺ V̇O2rest
) ⫻ % intensity
desired] ⫹ V̇O2rest
• HR method: Target HR ⫽ HRmax/peak
a
⫻ % intensity desired
• V̇O2
method: Target V̇O2
c
⫽ V̇O2max/peak
b
⫻ % intensity desired
• MET method: Target METc
⫽ [(V̇O2max/peak
b
)/3.5 mL ⭈ kg⫺1
⭈ min⫺1
] ⫻
% intensity desired
a
HRmax/peak
is the highest value obtained during maximal/peak exercise or it can be estimated by
220 ⫺ age or some other prediction equation (see Table 7
.2).
b
V̇O2max/peak
is the highest value obtained during maximal/peak exercise or it can be estimated from a
submaximal exercise test. Please see The Concept of Maximal Oxygen Uptake in Chapter 4 for the
distinction between V̇O2max
and V̇O2peak
.
c
Activities at the target V̇O2
and MET can be determined using a compendium of physical activity (1, 2) or
metabolic calculations (22) (Table 7
.3).
HRmax/peak
, maximal or peak heart rate; HRrest
, resting heart rate; HRR, heart rate reserve; V̇O2
R, oxygen
uptake reserve.
Summary of Methods for Prescribing Exercise Intensity Using Heart
Rate (HR), Oxygen Uptake (V̇O2
), and Metabolic Equivalents (METs)
BOX 7.2](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-195-320.jpg)
![170 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
Heart Rate Reserve (HRR) Method
Available test data:
HRrest
: 70 beats ⭈ min⫺1
HRmax
: 180 beats ⭈ min⫺1
Desired exercise intensity range: 50%–60%
Formula: Target Heart Rate (THR) ⫽ [(HRmax
⫺ HRrest
) ⫻ % intensity] ⫹ HRrest
1) Calculation of HRR:
HRR ⫽ (HRmax
⫺ HRrest
)
HRR ⫽ (180 beats ⭈ min⫺1
⫺ 70 beats ⭈ min⫺1
) ⫽ 110 beats ⭈ min⫺1
2) Determination of exercise intensity as %HRR:
Convert desired %HRR into a decimal by dividing by 100
%HRR ⫽ desired intensity ⫻ HRR
%HRR ⫽ 0.5 ⫻ 110 beats ⭈ min⫺1
⫽ 55 beats ⭈ min⫺1
%HRR ⫽ 0.6 ⫻ 110 beats ⭈ min⫺1
⫽ 66 beats ⭈ min⫺1
3) Determine THR range:
THR ⫽ (%HRR) ⫹ HRrest
To determine lower limit of THR range:
THR ⫽ 55 beats ⭈ min⫺1
⫹ 70 beats ⭈ min⫺1
⫽ 125 beats ⭈ min⫺1
To determine upper limit of THR range:
THR ⫽ 66 beats ⭈ min⫺1
⫹ 70 beats ⭈ min⫺1
⫽ 136 beats ⭈ min⫺1
THR range: 125 beats ⭈ min⫺1
to 136 beats ⭈ min⫺1
V̇O2
Reserve (V̇O2
R) Method
Available test data:
V̇O2max
: 30 mL ⭈ kg⫺1
⭈ min⫺1
V̇O2rest
: 3.5 mL ⭈ kg⫺1
⭈ min⫺1
Desired exercise intensity range: 50%–60%
Formula: Target V̇O2
⫽ [(V̇O2max
⫺ V̇O2rest
) ⫻ % intensity] ⫹ V̇O2rest
1) Calculation of V̇O2
R:
V̇O2
R ⫽ V̇O2max
⫺ V̇O2rest
V̇O2
R ⫽ 30 mL ⭈ kg⫺1
⭈ min⫺1
⫺ 3.5 mL ⭈ kg⫺1
⭈ min⫺1
V̇O2
R ⫽ 26.5 mL ⭈ kg⫺1
⭈ min⫺1
2) Determination of exercise intensity as %V̇O2
R:
Convert desired intensity (%V̇O2
R) into a decimal by dividing by 100
%V̇O2
R ⫽ desired intensity ⫻ %V̇O2
R
Calculate %V̇O2
R:
%V̇O2
R ⫽ 0.5 ⫻ 26.5 mL ⭈ kg⫺1
⭈ min⫺1
⫽ 13.3 mL ⭈ kg⫺1
⭈ min⫺1
%V̇O2
R ⫽ 0.6 ⫻ 26.5 mL ⭈ kg⫺1
⭈ min⫺1
⫽ 15.9 mL ⭈ kg⫺1
⭈ min⫺1
3) Determine target V̇O2
R range:
(%V̇O2
R) ⫹ V̇O2rest
To determine the lower target V̇O2
range:
Target V̇O2
⫽ 13.3 mL ⭈ kg⫺1
⭈ min⫺1
⫹ 3.5 mL ⭈ kg⫺1
⭈ min⫺1
⫽
16.8 mL ⭈ kg⫺1
⭈ min⫺1
To determine upper target V̇O2
range:
Target V̇O2
⫽ 15.9 mL ⭈ kg⫺1
⭈ min⫺1
⫹ 3.5 mL ⭈ kg1
⭈ min⫺1
⫽
19.4 mL ⭈ kg⫺1
⭈ min⫺1
Target V̇O2
range: 16.8 mL ⭈ kg⫺1
⭈ min⫺1
to 19.4 mL ⭈ kg⫺1
⭈ min⫺1
■ FIGURE 7.1. Examples of the application of various methods for prescribing exercise
intensity. HRmax,
, maximal heart rate; HRrest
, resting heart rate; MET, metabolic equivalent;
V̇O2
, volume of oxygen consumed per unit of time; V̇O2max
, maximal volume of oxygen
consumed per unit of time. Adapted from (49).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-196-320.jpg)
![CHAPTER 7 General Principles of Exercise Prescription 173
Using metabolic calculations (22) (Table 7
.3) to determine target work rate (kg ⭈ m ⭈ min⫺1
)
on a Monarch leg cycle ergometer
Available data:
A woman 42 yr of age
Weight: 190 lb (86.4 kg)
Height: 70 in (177
.8 cm)
Desired V̇O2
: 18 kg ⭈ m ⭈ min⫺1
Formula: V̇O2
⫽ 7
.0 ⫹ (1.8 ⫻ work rate)/body mass
1. Calculate work rate on cycle ergometer:
V̇O2
⫽ 7
.0 ⫹ (1.8 ⫻ work rate)/body mass)
18 mL ⭈ kg⫺1
⭈ min⫺1
⫽ 7
.0 ⫹ (1.8 ⫻ work rate)/86.4 kg
11 ⫽ (1.8 ⫻ work rate)/86.4
950.4 ⫽ 1.8 ⫻ work rate
528 ⫽ work rate
Work rate ⫽ 528 kg ⭈ m ⭈ min⫺1
⫽ 86.6 W
■ Figure 7.1. (Continued)
TABLE 7.3. Metabolic Calculations for the Estimation of Energy Expenditure
(V̇O2max
[mL ⭈ kg⫺1
⭈ min⫺1
]) During Common Physical Activities
Sum of Resting ⫹ Horizontal ⫹ Vertical/Resistance
Components
Activity
Resting
Component
Horizontal
Component
Vertical Component/
Resistance
Component
Limitations
Walking 3.5 0.1 ⫻ speeda
1.8 ⫻ speeda
⫻
gradeb
Most accurate for
speeds of 1.9–3.7 mi ⭈
h⫺1
(50–100 m ⭈ min⫺1
)
Running 3.5 0.2 ⫻ speed a
0.9 ⫻ speed a
⫻
gradeb
Most accurate for
speeds ⬎5 mi ⭈ h⫺1
(134 m ⭈ min⫺1
)
Stepping 3.5 0.2 ⫻ steps ⭈
min⫺1
1.33 ⫻ (1.8 ⫻ step
heightc
⫻ steps ⭈
min⫺1
)
Most accurate for
stepping rates of
12–30 steps ⭈ min⫺1
Leg cycling 3.5 3.5 (1.8 ⫻ work rated
)/
body masse
Most accurate for
work rates of 300–
1,200 kg ⭈ m ⭈ min⫺1
(50–200 W)
Arm cycling 3.5 (3 ⫻ work rated
)/
body masse
Most accurate for
work rates between
150–750 kg ⭈ m ⭈
min⫺1
(25–125 W)
a
Speed in m ⭈ min⫺1
.
b
Grade is percent grade expressed in decimal format (e.g., 10% ⫽ 0.10).
c
Step height in m.
Multiply by the following conversion factors:
lb to kg: 0.454; in to cm: 2.54; ft to m: 0.3048; mi to km: 1.609; mi ⭈ h⫺1
to m ⭈ min⫺1
: 26.8; kg ⭈ m ⭈ min⫺1
to
W: 0.164; W to kg ⭈ m ⭈ min⫺1
: 6.12; V̇O2max
L ⭈ min⫺1
to kcal ⭈ min⫺1
: 4.9; V̇O2
MET to mL ⭈ kg⫺1
⭈ min⫺1
: 3.5.
d
Work rate in kilogram meters per minute (kg ⭈ m ⭈ min⫺1
) is calculated as resistance (kg) ⫻ distance per
revolution of flywheel ⫻ pedal frequency per minute. Note: Distance per revolution is 6 m for Monark leg
ergometer, 3 m for the Tunturi and BodyGuard ergometers, and 2.4 m for Monark arm ergometer.
e
Body mass in kg
V̇O2max
, maximal volume of oxygen consumed per unit of time.
Adapted from (8).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-199-320.jpg)
![176 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
EXERCISE VOLUME (QUANTITY)
Exercise volume is the product of Frequency, Intensity, and Time (duration) or
FIT of exercise. Evidence supports the important role of exercise volume in real-
izing health/fitness outcomes, particularly with respect to body composition and
weight management. Thus, exercise volume may be used to estimate the gross
EE of an individual’s Ex Rx
. MET-min ⭈ wk⫺1
and kcal ⭈ wk⫺1
can be used to esti-
mate exercise volume in a standardized manner. Box 7.3 shows the definition and
calculations for METs, MET-min, and kcal ⭈ min⫺1
for a wide array of physical
activities. These variables can also be estimated using previously published tables
(1, 2). MET-min and kcal ⭈ min⫺1
can then be used to calculate MET-min ⭈ wk⫺1
and kcal ⭈ wk⫺1
that is accumulated as part of an exercise program to evaluate
whether the exercise volume is within the ranges described later in this chapter
that will likely result in health/fitness benefits.
The results of epidemiological studies and randomized clinical trials have
shown there is a dose-response association between the volume of exercise
and health/fitness outcomes (i.e., with greater amounts of physical activity, the
Metabolic Equivalents (METs): An index of EE. “[A MET is the ratio of the
rate of energy expended during an activity to the rate of energy expended at
rest. . . . (One) MET is the rate of EE while sitting at rest . . . by convention,
[1 MET is equal to] an oxygen uptake of 3.5 [mL ⭈ kg⫺1
⭈ min⫺1
]” (38).
MET-min: An index of EE that quantifies the total amount of physical activity
performed in a standardized manner across individuals and types of activities
(38). Calculated as the product of the number of METs associated with one
or more physical activities and the number of minutes the activities were
performed (i.e., METs ⫻ min); usually standardized per week or per day as a
measure of exercise volume.
Kilocalorie (kcal): The energy needed to increase the temperature of 1 kg of
water by 1° C. To convert METs to kcal ⭈ min⫺1
, it is necessary to know an
individual’s body weight, kcal ⭈ min⫺1
⫽ [( METs ⫻ 3.5 mL ⭈ kg⫺1
⭈ min⫺1
⫻
body wt in kg) ⫼ 1000)] ⫻ 5. Usually standardized as kilocalorie per week or
per day as a measure of exercise volume.
Example:
Jogging ( at ⬃7 METs) for 30 min on 3 d ⭈ wk⫺1
for a 70 kg male:
7 METs ⫻ 30 min ⫻ 3 times per week ⫽ 630 MET-min · wk⫺1
[(7 METs ⫻ 3.5 mL ⭈ kg⫺1
⭈ min⫺1
⫻ 70 kg) ⫼ 1000)] ⫻ 5 ⫽ 8.575 kcal· min⫺1
8.575 kcal ⭈ min⫺1
⫻ 30 min ⫻ 3 times per week ⫽ 771.75 kcal · wk⫺1
Adapted from (20).
Calculation of METs, MET-Min⫺1
, and Kcal ⭈ Min⫺1
BOX 7.3](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-202-320.jpg)
![CHAPTER 7 General Principles of Exercise Prescription 177
health/fitness benefits also increase) (16,20,52). It is not clear whether or not
there is a minimum or maximum amount of exercise that is needed to attain
health/fitness benefits. However, a total EE of ⱖ500–1,000 MET-min ⭈ wk⫺1
is
consistently associated with lower rates of CVD and premature mortality. Thus,
ⱖ500–1,000 MET-min ⭈ wk⫺1
is a reasonable target volume for an exercise pro-
gram for most adults (20,52). This volume is approximately equal to (a) 1,000
kcal ⭈ wk⫺1
of moderate intensity, physical activity (or about 150 min wk⫺1
);
(b) an exercise intensity of 3–5.9 METs (for individuals weighing ⬃68–91 kg
[⬃150–200 lb]); and (c) 10 MET-h ⭈ wk⫺1
(20,52). It should be noted that lower
volumes of exercise (i.e., 4 kcal ⭈ kg⫺1
⭈ wk⫺1
or 330 kcal ⭈ wk⫺1
) can result in
health/fitness benefits in some individuals, especially in individuals who are de-
conditioned (16,20,52). Even lower volumes of exercise may also have benefit,
but evidence is lacking to make definitive recommendations (20).
Pedometers are effective tools for promoting physical activity and can be
used to approximate exercise volume in steps per day (50). The goal of 10,000
steps ⭈ d⫺1
is often cited, but it appears that achieving a pedometer step count of
at least 5,400–7,900 steps ⭈ d⫺1
can meet recommended exercise targets (20,50).
To achieve step counts of 5,400–7,900 steps ⭈ d⫺1
, one can estimate total exercise
volume by considering the following: (a) walking 100 steps ⭈ min⫺1
provides a very
rough approximation of moderate intensity exercise; (b) walking 1 mile ⭈ d⫺1
yields
about 2,000 steps ⭈ d⫺1
; and (c) walking at a moderate intensity for 30 min ⭈ d⫺1
yields about 3,000–4,000 steps ⭈ d⫺1
(10,20,28,50). For weight management,
higher step counts may be necessary, and a population-based study estimated men
may require 11,000–12,000 steps ⭈ d⫺1
, and women 8,000–12,000 steps ⭈ d⫺1
,
respectively, to maintain a normal weight (20,50). Because of the substantial errors
of prediction when using pedometer step counts, using steps ⭈ min⫺1
combined with
currently recommended time/durations of exercise (e.g., 100 steps ⭈ min⫺1
for 30
min ⭈ session⫺1
and 150 min ⭈ wk⫺1
) is judicious (20).
TYPE (MODE)
Rhythmic, aerobic type exercises involving large muscle groups are recom-
mended for improving CRF (20). The modes of physical activity that result in
improvement and maintenance of CRF are found in Table 7.4. The principle of
AEROBIC EXERCISE VOLUME
RECOMMENDATION
A target volume of ⱖ500–1,000 MET-min ⭈ wk⫺1
is recommended for most
adults. This volume is approximately equal to 1,000 kcal ⭈ wk⫺1
of moderate
intensity, physical activity, ⬃150 min ⭈ wk⫺1
of moderate intensity exercise,
or pedometer counts of ⱖ5,400–7,900 steps ⭈ d⫺1
. Because of the substan-
tial errors in prediction when using pedometer step counts, use steps ⭈ d⫺1
combined with currently recommended time/durations of exercise. Lower ex-
ercise volumes can have health/fitness benefits for deconditioned individu-
als, and greater volumes may be needed for weight management.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-203-320.jpg)
![CHAPTER 7 General Principles of Exercise Prescription 193
33. Noble BJ, Borg GA, Jacobs I, Ceci R, Kaiser P
. A category-ratio perceived exertion scale: relationship
to blood and muscle lactates and heart rate. Med Sci Sports Exerc. 1983;15(6):523–8.
34. Owen N, Healy GN, Matthews CE, Dunstan DW. Too much sitting: the population health science
of sedentary behavior. Exerc Sport Sci Rev. 2010;38(3):105–13.
35. Persinger R, Foster C, Gibson M, Fater DC, Porcari JP
. Consistency of the talk test for exercise
prescription. Med Sci Sports Exerc. 2004;36(9):1632–6.
36. Pescatello LS, Franklin BA, Fagard R, et al. American College of Sports Medicine position stand.
Exercise and hypertension. Med Sci Sports Exerc. 2004;36(3):533–53.
37. Peterson MD, Rhea MR, Alvar BA. Applications of the dose-response for muscular strength develop-
ment: a review of meta-analytic efficacy and reliability for designing training prescription. J Strength
Cond Res. 2005;19(4):950–8.
38. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S.
Department of Health and Human Services; 2008. 78 p. [cited 2011 Jan 6]. Available from: http://
www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf
39. Rees SS, Murphy AJ, Watsford ML, McLachlan KA, Coutts AJ. Effects of proprioceptive neuromus-
cular facilitation stretching on stiffness and force-producing characteristics of the ankle in active
women. J Strength Cond Res. 2007;21(2):572–7.
40. Robertson RJ, Goss FL, Dube J, et al. Validation of the adult OMNI scale of perceived exertion for
cycle ergometer exercise. Med Sci Sports Exerc. 2004;36(1):102–8.
41. Robertson RJ, Goss FL, Rutkowski J, et al. Concurrent validation of the OMNI perceived exertion
scale for resistance exercise. Med Sci Sports Exerc. 2003;35(2):333–41.
42. Sharman MJ, Cresswell AG, Riek S. Proprioceptive neuromuscular facilitation stretching: mecha-
nisms and clinical implications. Sports Med. 2006;36(11):929–39.
43. Slemenda C, Heilman DK, Brandt KD, et al. Reduced quadriceps strength relative to body weight:
a risk factor for knee osteoarthritis in women? Arthritis Rheum. 1998;41(11):1951–9.
44. Swain DP
. Energy cost calculations for exercise prescription: an update. Sports Med. 2000;30(1):17–22.
45. Swain DP, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise
Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams Wilkins; 2014.
46. Swain DP, Franklin BA. VO(2) reserve and the minimal intensity for improving cardiorespiratory
fitness. Med Sci Sports Exerc. 2002;34(1):152–7.
47. Swain DP, Leutholtz BC. Heart rate reserve is equivalent to %VO2 reserve, not to %VO2max. Med
Sci Sports Exerc. 1997;29(3):410–4.
48. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol.
2001;37(1):153–6.
49. Thompson WR, Gordon NF
, Pescatello LS, American College of Sports Medicine. ACSM’s Guidelines for
Exercise Testing and Prescription. 8th ed. Baltimore (MD): Lippincott Williams Wilkins; 2010. 400 p.
50. Tudor-Locke C, Hatano Y, Pangrazi RP, Kang M. Revisiting “how many steps are enough?” Med Sci
Sports Exerc. 2008;40(7 Suppl):S537–43.
51. U.S. Department of Agriculture. Report of the Dietary Guidelines Advisory Committee on the Dietary
Guidelines for Americans, 2010 [Internet]. Washington (DC): U.S. Goverment Printing Office; 2010.
453 p. [cited 2011 Jan 6]. Available from: http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm
52. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans
[Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008. 78 p. [cited
2011 Jan 6]. Available from: http://www.health.gov/paguidelines/pdf/paguide.pdf
53. U.S. Department of Health and Human Services. Exercise Physical Activity: Your Everyday Guide
from the National Institute on Aging [Internet]. Bethesda (MD): National Institute on Aging, U.S.
National Institutes of Health; 2011. 126 p. [cited 2011 Apr 15]. Available from: http://www.nia.nih
.gov/HealthInformation/Publications/ExerciseGuide/
54. U.S. Department of Health and Human Services, United States Department of Agriculture, United
States Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans, 2005. 6th ed.
Washington (DC): G.P
.O; 2005. 71 p.
55. Utter AC, Robertson RJ, Green JM, Suminski RR, McAnulty SR, Nieman DC. Validation of the Adult
OMNI Scale of perceived exertion for walking/running exercise. Med Sci Sports Exerc. 2004;36(10):
1776–80.
56. Winters MV, Blake CG, Trost JS, et al. Passive versus active stretching of hip flexor muscles in sub-
jects with limited hip extension: a randomized clinical trial. Phys Ther. 2004;84(9):800–7.
57. Woolstenhulme MT, Griffiths CM, Woolstenhulme EM, Parcell AC. Ballistic stretching increases
flexibility and acute vertical jump height when combined with basketball activity. J Strength Cond
Res. 2006;20(4):799–803.
58. Zhu N, Suarez-Lopez JR, Sidney S, et al. Longitudinal examination of age-predicted symptom-
limited exercise maximum HR. Med Sci Sports Exerc. 2010;42(8):1519–27.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-219-320.jpg)
![203
CHAPTER 8 Exercise Prescription for Healthy Populations
SPECIAL CONSIDERATIONS
• Children and adolescents may safely participate in strength training ac-
tivities provided they receive proper instruction and supervision. Generally,
adult guidelines for resistance training may be applied (see Chapter 7).
Eight to 15 submaximal repetitions of an exercise should be performed to
the point of moderate fatigue with good mechanical form before the resis-
tance is increased.
• Because of immature thermoregulatory systems, youth should avoid exercise
in hot humid environments and be properly hydrated. See this chapter and
the ACSM position stands on exercising in the heat (6) and fluid replacement
(8) for additional information.
• Children and adolescents who are overweight or physically inactive may not
be able to achieve 60 min ⭈ d⫺1
of moderate-to-vigorous intensity, physical
activity. These individuals should start out with moderate intensity, physical
activity as tolerated and gradually increase the frequency and time of physical
activity to achieve the 60 min ⭈ d⫺1
goal. Vigorous intensity, physical activity
can then be gradually added at least 3 d ⭈ wk⫺1
.
• Children and adolescents with diseases or disabilities such as asthma, dia-
betes mellitus, obesity, cystic fibrosis, and cerebral palsy should have their
Ex Rx
tailored to their condition, symptoms, and physical fitness level (see
Chapter 10).
• Efforts should be made to decrease sedentary activities (i.e., television watch-
ing, surfing the Internet, and playing video games) and increase activities that
promote lifelong activity and fitness (i.e., walking and cycling).
THE BOTTOM LINE
• Most children ⬎10 yr do not meet the recommended physical activity guide-
lines. Children and adolescents should participate in a variety of age appro-
priate physical activities to develop CRF and muscular and bone strength.
Exercise supervisors and leaders should be mindful of the external tempera-
ture and hydration levels of children who exercise because of their immature
thermoregulatory systems.
U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for
Americans (2008). U.S. Department of Health and Human Services [Internet]:
http://www.health.gov/paguidelines/default/aspx
U.S. Department of Health and Human Services (2008). Physical Activity Guidelines
Advisory Committee Report, 2008. Washington (DC): USDHHS (91):
http://www.health.gov/paguidelines/committeereport.aspx
Online Resources](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-229-320.jpg)
![205
CHAPTER 8 Exercise Prescription for Healthy Populations
EXERCISE TESTING
Most older adults do not require an exercise test prior to initiating a moderate
intensity, physical activity program. For older adults with multiple risk factors
as defined in Table 2.2, an individual is considered at moderate risk for adverse
responses to exercise and is advised to undergo medical examination and
exercise testing before initiating vigorous intensity exercise (see Figure 2.4).
Exercise testing may require subtle differences in protocol, methodology, and
dosage. The following list details the special considerations for testing older
adults (107):
• The initial workload should be light (i.e., ⬍3 metabolic equivalents [METs])
and workload increments should be small (i.e., 0.5–1.0 MET) for those with
low work capacities. The Naughton treadmill protocol is a good example of
such a protocol (see Figure 5.3).
• A cycle ergometer may be preferable to a treadmill for those with poor bal-
ance, poor neuromotor coordination, impaired vision, impaired gait patterns,
weight-bearing limitations, and/or foot problems. However, local muscle
fatigue may be a factor for premature test termination when using a cycle
ergometer.
• Adding a treadmill handrail support may be required because of reduced bal-
ance, decreased muscular strength, poor neuromotor coordination, and fear.
However, handrail support for gait abnormalities will reduce the accuracy of
estimating peak MET capacity based on the exercise duration or peak work-
load achieved.
• Treadmill workload may need to be adapted according to walking ability by
increasing grade rather than speed.
• For those who have difficulty adjusting to the exercise protocol, the initial
stage may need to be extended, the test restarted, or the test repeated. In these
situations, also consider an intermittent protocol (see Chapter 5).
• Exercise-induced dysrhythmias are more frequent in older adults than in
individuals in other age groups.
• Prescribed medications are common and may influence the electrocardio-
graphic (ECG) and hemodynamic responses to exercise (see Appendix A).
• The exercise ECG has higher sensitivity (i.e., ⬃84%) and lower specificity
(i.e., ⬃70%) than in younger age groups (i.e., ⬍50% sensitivity and ⬎80%
specificity). The higher rate of false positive outcomes may be related to the
greater frequency of left ventricular hypertrophy (LVH) and the presence of
conduction disturbances among older rather than younger adults (45).
There are no specific exercise test termination criteria for older adults beyond
those presented for all adults in Chapter 5. The increased prevalence of cardio-
vascular, metabolic, and orthopedic problems among older adults increases the
likelihood of an early test termination. In addition, many older adults exceed the
age-predicted HRmax
during a maximal exercise test.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-231-320.jpg)
![209
CHAPTER 8 Exercise Prescription for Healthy Populations
Neuromotor (Balance) Exercises for Frequent Fallers or Individuals
with Mobility Limitations
There are no specific recommendations for exercises that incorporate neuromo-
tor (balance) training into an Ex Rx
. However, neuromotor exercise training,
which combines balance, agility, and proprioceptive training, is effective in
reducing and preventing falls if performed 2–3 d ⭈ wk⫺1
(7,44). General recom-
mendations include using the following: (a) progressively difficult postures that
gradually reduce the base of support (e.g., two-legged stand, semitandem stand,
tandem stand, one-legged stand); (b) dynamic movements that perturb the
center of gravity (e.g., tandem walk, circle turns); (c) stressing postural muscle
Time: For moderate intensity, physical activities, accumulate at least 30
or up to 60 (for greater benefit) min ⭈ d⫺1
in bouts of at least 10 min each
to total 150–300 min ⭈ wk⫺1
, or at least 20–30 min ⭈ d⫺1
of more vigorous
intensity, physical activities to total 75–100 min ⭈ wk⫺1
or an equivalent
combination of moderate and vigorous intensity, physical activity.
Type: Any modality that does not impose excessive orthopedic stress
— walking is the most common type of activity. Aquatic exercise and
stationary cycle exercise may be advantageous for those with limited
tolerance for weight-bearing activity.
Muscle Strengthening/Endurance Exercise
Frequency: ⱖ2 d ⭈ wk⫺1
.
Intensity: Moderate intensity (i.e., 60%–70% one repetition maximum
[1-RM]). Light intensity (i.e., 40%–50% 1-RM) for older adults beginning
a resistance training program. When 1-RM is not measured, intensity can
be prescribed between moderate (5–6) and vigorous (7–8) intensity on a
scale of 0–10 (82).
Type: Progressive weight-training program or weight-bearing calisthenics
(8–10 exercises involving the major muscle groups; ⱖ1 set of 10–15
repetitions each), stair climbing, and other strengthening activities that
use the major muscle groups.
Flexibility Exercise
Frequency: ⱖ2 d ⭈ wk⫺1
.
Intensity: Stretch to the point of feeling tightness or slight discomfort.
Time: Hold stretch for 30–60 s.
Type: Any physical activities that maintain or increase flexibility using
slow movements that terminate in sustained stretches for each major
muscle group using static stretches rather than rapid ballistic movements.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-235-320.jpg)
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CHAPTER 8 Exercise Prescription for Healthy Populations
(AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema
(HAPE). Additionally, many individuals develop a sore throat and bronchitis that
may produce disabling, severe coughing spasms at high altitudes. Susceptibility to
altitude sickness is increased in individuals with a prior history and by prolonged
physical exertion and dehydration early in the altitude exposure.
AMS is the most common form of altitude sickness. Symptoms include
headache, nausea, fatigue, decreased appetite, and poor sleep, and in severe
cases, poor balance and mild swelling in the hands, feet, or face. AMS develops
within the first 24 h of altitude exposure. Its incidence and severity increases in
direct proportion to ascent rate and altitude. The estimated incidence of AMS
in unacclimatized individuals rapidly ascending directly to moderate altitudes
is 0%–20%; to high altitudes, 20%–60%; and to very high altitudes, 50%–80%
(97). In most individuals, if ascent is stopped and physical exertion is limited,
recovery from AMS occurs over 24–48 h after symptoms have peaked.
HACE is a potentially fatal, although not common, illness that occurs in ⬍2%
of individuals ascending ⬎12,000 ft (3,658 m). HACE is an exacerbation of
unresolved, severe AMS. HACE most often occurs in individuals who have AMS
symptoms and continue to ascend.
HAPE is a potentially fatal, although not common, illness that occurs in
⬍10% of individuals ascending ⬎12,000 ft (3,658 m). Individuals making re-
peated ascents and descents ⬎12,000 ft (3,658 m) and who exercise strenuously
early in the exposure have an increased susceptibility to HAPE. The presence of
crackles and rales in the lungs may indicate increased susceptibility to develop-
ing HAPE. Blue lips and nail beds may be present with HAPE.
Prevention and Treatment of Altitude Sickness
Altitude acclimatization is the best countermeasure to all altitude sickness.
Minimizing sustained exercise/physical activity and maintaining adequate hydra-
tion and food intake will reduce susceptibility to altitude sickness and facilitate
recovery. When moderate to severe symptoms and signs of an altitude-related
sickness develop, the preferred treatment is to descend to a lower altitude.
Descents of 1,000–3,000 ft (305–914 m) with an overnight stay are effective in
prevention and recovery of all altitude sickness.
AMS may be significantly diminished or prevented with prophylactic or
therapeutic use of acetazolamide (i.e., acetazolamide [Diamox]). Headaches may
be treated with aspirin, acetaminophen, ibuprofen, indomethacin, or naproxen
(see Appendix A). Oxygen or hyperbaric chamber therapy will usually relieve
some symptoms such as headache, fatigue, and poor sleep. Prochlorperazine
(Compazine) may be used to help relieve nausea and vomiting. Dexamethasone
(Decadron, Hexadrol) may be used if other treatments are not available or
effective (53). Acetazolamide (Diamox) may be helpful (53). Treatment of indi-
viduals diagnosed with HACE or HAPE includes descent, oxygen therapy, and/
or hyperbaric bag therapy. Dexamethasone (Decadron, Hexadrol) and acetazol-
amide (Diamox) are also helpful.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-253-320.jpg)
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CHAPTER 8 Exercise Prescription for Healthy Populations
THE BOTTOM LINE
Physical performance decreases with increasing altitude ⬎3,950 ft (1,200 m),
with greater decrements associated with higher elevation, longer activity duration,
and larger muscle mass. During the first few days at high altitudes, individuals
should minimize their physical activity to reduce susceptibility to altitude illness.
After this period, individuals whose Ex Rx
specifies a THR should maintain the
same exercise HR at higher altitudes.
United States Army Institute of Environmental Medicine (USARIEM):
http://www.usariem.army.mil
Online Resources
REFERENCES
1. Abenhaim L, Rossignol M, Valat J, et al. The role of activity in the therapeutic management of back
pain. Report of the International Paris Task Force on Back Pain. Spine. 2000;25(4):1S–33S.
2. ACOG Committee Obstetric Practice. ACOG Committee opinion. Number 267, January 2002:
exercise during pregnancy and the postpartum period. Obstet Gynecol. 2002;99(1):171–3.
3. Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms—a systematic review.
Man Ther. 2004;9:134–43.
4. Airaksinen O, Brox J, Cedraschi C, et al. Chapter 4 European guidelines for the management of
chronic nonspecific low back pain. Eur Spine J. 2006;15:s192–300.
5. American College of Sports Medicine. Position stand. Exercise and physical activity for older adults.
Med Sci Sports Exerc. 1998;30(6):992–1008.
6. American College of Sports Medicine, Armstrong LE, Casa DJ, et al. American College of Sports
Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports
Exerc. 2007;39(3):556–72.
7. American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, et al. American College of
Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc.
2009;41(7):1510–30.
8. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports
Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377–90.
9. Andersson EI, Lin CC, Smeets RJ. Performance tests in people with chronic low back pain: respon-
siveness and minimal clinically important change. Spine (Phila Pa 1976). 2010;35(26):E1559–63.
10. Armstrong LE. Heat and humidity. In: Armstrong LE, editor. Performing in Extreme Environments.
Champaign: Human Kinetics; 2000. p. 15–70.
11. Artal R, O’Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exer-
cise during pregnancy and the postpartum period. Br J Sports Med. 2003;37(1):6–12; discussion 12.
12. Assessing Physical Performance in the Older Patient [Internet]. Bethesda (MD): National Institute on
Aging, U.S. National Institutes of Health; [cited 2011 Feb 4]. Available from: http://www.grc.nia.nih.
gov/branches/ledb/sppb/index.htm
13. Atlas S, Deyo R. Evaluating and managing acute low back pain in the primary care setting. J Gen
Intern Med. 2001;16(2):120–31.
14. Bar-Or O, Rowland TW. Pediatric Exercise Medicine: From Physiological Principles to Health Care
Application. Champaign (IL): Human Kinetics; 2004. 501 p.
15. Beimborn D, Morrissey M. A review of the literature related to trunk muscle performance. Spine.
1988;13(6):655–60.
16. Binkley HM, Beckett J, Casa DJ, Kleiner DM, Plummer PE. National Athletic Trainers’ Association
Position Statement: exertional heat illnesses. J Athl Train. 2002;37(3):329–43.
17. Bouwmeester W, van Enst A, van Tulder M. Quality of low back pain guidelines improved. Spine.
2009;34(23):2563–7.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-257-320.jpg)
![232 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
18. Brajkovic D, Ducharme MB. Facial cold-induced vasodilation and skin temperature during exposure
to cold wind. Eur J Appl Physiol. 2006;96(6):711–21.
19. Campbell MK, Mottola MF
. Recreational exercise and occupational activity during pregnancy and
birth weight: a case-control study. Am J Obstet Gynecol. 2001;184(3):403–8.
20. Canada’s Windchill Index: Windchill Hazards and What To Do [Internet]. Gatineau (Quebec):
Environment Canada; [cited 2011 Feb 4]. Available from: http://www.ec.gc.ca/meteo-weather/
default.asp?lang=Enn=5FBF816A-1
21. Cappaert TA, Stone JA, Castellani JW, et al. National Athletic Trainers’ Association position state-
ment: environmental cold injuries. J Athl Train. 2008;43(6):640–58.
22. Carter R,3rd, Cheuvront SN, Williams JO, et al. Epidemiology of hospitalizations and deaths from
heat illness in soldiers. Med Sci Sports Exerc. 2005;37(8):1338–44.
23. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine position stand:
prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012–29.
24. Cesari M, Kritchevsky SB, Newman AB, et al. Added value of physical performance measures in
predicting adverse health-related events: results from the health, aging and body composition study.
J Am Geriatr Soc. 2009;57(2):251–9.
25. Cheuvront SN, Carter R,3rd, Haymes EM, Sawka MN. No effect of moderate hypohydration or
hyperthermia on anaerobic exercise performance. Med Sci Sports Exerc. 2006;38(6):1093–7.
26. Cheuvront SN, Sawka MN. Hydration assessment of athletes. Gatorade Sports Sci Exch. 2005;18(2):1–5.
27. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice
guideline from the American College of Physicians and the American Pain Society. Ann Intern Med.
2007;147:478–91.
28. Continuous Scale Physical Functional Performance: Evaluation of Functional Performance in Older
Adults [Internet]. Athens (GA): University of Georgia; [cited 2011 Feb 4]. Available from: http://
www.coe.uga.edu/cs-pfp/index.html
29. Cress ME, Buchner DM, Questad KA, Esselman PC, deLateur BJ, Schwartz RS. Continuous-scale
physical functional performance in healthy older adults: a validation study. Arch Phys Med Rehabil.
1996;77(12):1243–50.
30. Danielsson U. Windchill and the risk of tissue freezing. J Appl Physiol. 1996;81(6):2666–73.
31. Davenport MH, Charlesworth S, Vanderspank D, Sopper MM, Mottola MF
. Development and valida-
tion of exercise target heart rate zones for overweight and obese pregnant women. Appl Physiol Nutr
Metab. 2008;33(5):984–9.
32. Davies GA, Wolfe LA, Mottola MF
, et al. Joint SOGC/CSEP clinical practice guideline: exercise in
pregnancy and the postpartum period. Can J Appl Physiol. 2003;28(3):330–41.
33. Demoulin C, Vanderthommen M, Duysens C, Crielaard J. Spinal muscle evaluation using the
Sorensen test: a critical appraisal of the literature. Joint Bone Spine. 2004;73(1):43–50.
34. Dempsey JC, Butler CL, Williams MA. No need for a pregnant pause: physical activity may reduce
the occurrence of gestational diabetes mellitus and preeclampsia. Exerc Sport Sci Rev. 2005;
33(3):141–9.
35. Dugan S. The role of exercise in the prevention and management of acute low back pain. Clin Occup
Environ Med. 2006;5(3):615–32.
36. Duque I, Parra J, Duvallet A. Aerobic fitness and limiting factors of maximal performance in chronic
low back pain patients. J Back Musculoskelet Rehabil. 2009;22(2):113–9.
37. Evetovich TK, Boyd JC, Drake SM, et al. Effect of moderate dehydration on torque, electromyogra-
phy, and mechanomyography. Muscle Nerve. 2002;26(2):225–31.
38. Federal Interagency Forum on Aging-Related Statistics (U.S.). Older Americans 2004: Key Indicators of
Well-Being. Washington (DC): Federal Interagency Forum on Aging-Related Statistics; 2004. 141 p.
39. Fitnessgram/Activitygram Reference Guide [Internet]. Dallas (TX): The Cooper Institute; 2008 [cited
2011 Jan 26]. 206 p. Available from: http://www.cooperinstitute.org/ourkidshealth/fitnessgram/
documents/FITNESSGRAM_ReferenceGuide.pdf
40. Franklin BA, Hogan P
, Bonzheim K, et al. Cardiac demands of heavy snow shoveling. JAMA.
1995;273(11):880–2.
41. Fulco CS, Muza SR, Beidleman BA, et al. Effect of repeated normobaric hypoxia exposures during
sleep on acute mountain sickness, exercise performance, and sleep during exposure to terrestrial
altitude. Am J Physiol Regul Integr Comp Physiol. 2011;300(2):R428–36.
42. Fulco CS, Rock PB, Cymerman A. Maximal and submaximal exercise performance at altitude. Aviat
Space Environ Med. 1998;69(8):793–801.
43. Gagge AP
, Gonzalez RR. Mechanisms of heat exchange: biophysics and physiology. In: Fregly
MJ, editor. Handbook of Physiology/Section 4, Environmental Physiology. Bethesda: American
Physiological Society; 1996. p. 45–84.
44. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand.
Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal,](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-258-320.jpg)
![233
CHAPTER 8 Exercise Prescription for Healthy Populations
and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci
Sports Exerc. 2011;43(7):1334–559.
45. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: sum-
mary article: a report of the American College of Cardiology/American Heart Association Task Force
on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation.
2002;106(14):1883–92.
46. Gill TM, DiPietro L, Krumholz HM. Role of exercise stress testing and safety monitoring for older
persons starting an exercise program. JAMA. 2000;284(3):342–9.
47. Gonzalez RR, Cheuvront SN, Montain SJ, et al. Expanded prediction equations of human sweat loss
and water needs. J Appl Physiol. 2009;107(2):379–88.
48. Gruther W, Wick F
, Paul B, et al. Diagnostic accuracy and reliability of muscle strength and endu-
rance measurements in patients with chronic low back pain. J Rehabil Med. 2009;41(8):613–9.
49. Guralnik JM, Ferrucci L, Pieper CF
, et al. Lower extremity function and subsequent disability: con-
sistency across studies, predictive models, and value of gait speed alone compared with the short
physical performance battery. J Gerontol A Biol Sci Med Sci. 2000;55(4):M221–31.
50. Guralnik JM, Leveille S, Volpato S, Marx MS, Cohen-Mansfield J. Targeting high-risk older adults
into exercise programs for disability prevention. J Aging Phys Activ. 2003;11(2):219–28.
51. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower
extremity function: association with self-reported disability and prediction of mortality and nursing
home admission. J Gerontol. 1994;49(2):M85–94.
52. Gutin B, Barbeau P
, Owens S, et al. Effects of exercise intensity on cardiovascular fitness, total body
composition, and visceral adiposity of obese adolescents. Am J Clin Nutr. 2002;75(5):818–26.
53. Hackett PH, Roach RC. High-altitude illness. N Engl J Med. 2001;345(2):107–14.
54. Hasenbring M, Hallner D, Rusu A. Fear-avoidance- and endurance-related responses to pain: devel-
opment and validation of the Avoidance-Endurance Questionnaire (AEQ). European Journal of Pain
[Internet]. 2008 [cited 2012 Jan 7]. doi:10.1016/j.ejpain.2008.11.001
55. Hayden J, van Tulder M, Tomlinson G. Systematic review: strategies for using exercise therapy to
improve outcomes in chronic low back pain. Ann Intern Med. 2005;142:776–85.
56. Hebestreit HU, Bar-Or O. Differences between children and adults for exercise testing and prescrip-
tion. In: Skinner JS, editor. Exercise Testing and Exercise Prescription for Special Cases: Theoretical
Basis and Clinical Application. 3rd ed. Baltimore: Lippincott Williams Wilkins; 2005. p. 68–84.
57. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review
of studies of general patient populations. Eur Spine J. 2003;12(2):149–65.
58. Hicks G, Fritz J, Delitto A, McGill S. Preliminary development of a clinical prediction rule for
determining which patients with low back pain will respond to a stabilization exercise program.
Arch Phys Med Rehabil. 2005;86:1753–62.
59. Hodselmans A, Dijkstra P, Geertzen J, van der Schans C. Exercise capacity in non-specific chronic
low back pain patients: a lean body mass-based Astrand bicycle test; reliability, validity and feasibil-
ity. J Occup Rehabil. 2008;18(3):282–9.
60. Impact of physical activity during pregnancy and postpartum on chronic disease risk. Med Sci Sports
Exerc. 2006;38(5):989–1006.
61. Institute of Medicine (É.U.). Panel on Dietary Reference Intakes for Electrolytes and Water. Dietary
Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington (DC): National
Academies Press; 2005. 617 p.
62. Jensen O, Schmidt-Olsen S. A new functional test in the diagnostic evaluation of neurogenic inter-
mittent claudication. Clin Rheumatol. 1989;8(3):363–7.
63. Kang HS, Gutin B, Barbeau P
, et al. Physical training improves insulin resistance syndrome markers
in obese adolescents. Med Sci Sports Exerc. 2002;34(12):1920–7.
64. Larivière C, Da Silva R, Arsenault B, Nadeau S, Plamondon A, Vadeboncoeur R. Specificity of a back
muscle exercise machine in healthy and low back pain subjects. Med Sci Sports Exerc. 2010;42(3):592–9.
65. Lee C, Simmonds M, Novy D, Jones S. Functional self-efficacy, perceived gait ability and perceived
exertion in walking performance of individuals with low back pain. Physiother Theory Pract.
2002;18(4):193–203.
66. Macdonald HM, Kontulainen SA, Khan KM, McKay HA. Is a school-based physical activity inter-
vention effective for increasing tibial bone strength in boys and girls? J Bone Miner Res. 2007;
22(3):434–46.
67. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific
low back pain: a systematic review. Phys Ther. 2009;89(1):9–25.
68. MacKelvie KJ, Petit MA, Khan KM, Beck TJ, McKay HA. Bone mass and structure are enhanced fol-
lowing a 2-year randomized controlled trial of exercise in prepubertal boys. Bone. 2004;34(4):755–64.
69. Malina RM. Weight training in youth-growth, maturation, and safety: an evidence-based review.
Clin J Sport Med. 2006;16(6):478–87.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-259-320.jpg)
![234 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
70. Mazzeo RS, Fulco CS. Physiological systems and their responses to conditions to hypoxia. In:
Tipton CM, editor. ACSM’s Advanced Exercise Physiology. Baltimore: Lippincott Williams Wilkins;
2006. p. 564–580.
71. McGill S, Karpowicz A. Exercises for spine stabilization: motion/motor patterns, stability progres-
sions, and clinical technique. Arch Phys Med Rehabil. 2009;90(1):118–26.
72. McGregor AH, Hukins DW. Lower limb involvement in spinal function and low back pain. J Back
Musculoskelet Rehabil. 2009;22(4):219–22.
73. Molnar GW, Hughes AL, Wilson O, Goldman RF
. Effect of skin wetting on finger cooling and freez-
ing. J Appl Physiol. 1973;35(2):205–7.
74. Montain SJ, Latzka WA, Sawka MN. Control of thermoregulatory sweating is altered by hydration
level and exercise intensity. J Appl Physiol. 1995;79(5):1434–9.
75. Mottola MF
. Exercise in the postpartum period: practical applications. Curr Sports Med Rep. 2002;
1(6):362–8.
76. Mottola MF
, Davenport MH, Brun CR, Inglis SD, Charlesworth S, Sopper MM. VO2peak prediction
and exercise prescription for pregnant women. Med Sci Sports Exerc. 2006;38(8):1389–95.
77. Mottola MF
, Giroux I, Gratton R, et al. Nutrition and exercise prevent excess weight gain in over-
weight pregnant women. Med Sci Sports Exerc. 2010;42(2):265–72.
78. Muza SR, Fulco C, Beidleman BA, Cymerman A. Altitude Acclimatization and Illness Management.
Washington (DC): Department of the Army Technical Bulletin: TB MED 505; 2010. 120 p.
79. Nadel ER, Fortney SM, Wenger CB. Circulatory adjustments during heat stress. In: Cerretelli
P, Whipp BJ, editors. Exercise Bioenergetics and Gas Exchange: Proceedings of the International
Symposium on Exercise Bioenergetics and Gas Exchange, Held in Milan, Italy, July 7–9, 1980, a Satellite
of the XXVIII International Congress of Physiological Sciences. Amsterdam (NY): Elsevier/North-
Holland Biomedical Press; sole distributors for the USA and Canada, Elsevier North Holland; 1980.
p. 303–313.
80. Nassis GP
, Papantakou K, Skenderi K, et al. Aerobic exercise training improves insulin sensitivity
without changes in body weight, body fat, adiponectin, and inflammatory markers in overweight
and obese girls. Metabolism. 2005;54(11):1472–9.
81. National Institute for Occupational Safety and Health, Division of Standards Development and
Technology Transfer. Working in Hot Environments. Cincinnati (OH): NIOSH; 1992. 12 p.
82. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recom-
mendation from the American College of Sports Medicine and the American Heart Association. Med
Sci Sports Exerc. 2007;39(8):1435–45.
83. Neufer PD, Young AJ, Sawka MN. Gastric emptying during exercise: effects of heat stress and hypo-
hydration. Eur J Appl Physiol Occup Physiol. 1989;58(4):433–9.
84. NWS Windchill Chart [Internet]. Silver Spring (MD): NOAA, National Weather Service; 2009 [cited
2011 Feb 4]. Available from: http://www.nws.noaa.gov/om/windchill/index.shtml
85. Obert P
, Mandigouts S, Nottin S, Vinet A, N’Guyen LD, Lecoq AM. Cardiovascular responses to
endurance training in children: effect of gender. Eur J Clin Invest. 2003;33(3):199–208.
86. Panjabi M, Lydon C, Vasavada A, Grob D, Crisco J, Dvorak J. On the understanding of clinical
instability. Spine. 1994;19(23):2642–50.
87. Paridon SM, Alpert BS, Boas SR, et al. Clinical stress testing in the pediatric age group: a statement
from the American Heart Association Council on Cardiovascular Disease in the Young, Committee
on Atherosclerosis, Hypertension, and Obesity in Youth. Circulation. 2006;113(15):1905–20.
88. PARmed-X for Pregnancy [Internet]. Ottawa (Ontario): Canadian Society for Exercise Physiology;
2002 [cited 2011 Feb 4]. 4 p. Available from: http://www.csep.ca/english/view.asp?x=698
89. Pengel L, Herbert R, Maher C, Refshauge K. Acute low back pain: systematic review of its prognosis.
BMJ. 2003;327:323.
90. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in com-
mon physical performance measures in older adults. J Am Geriatr Soc. 2006;54(5):743–9.
91. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S.
Department of Health and Human Services; 2008 [cited 2011 Jan 6]. 683 p. Available from: http://
www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf
92. Pincus T, Burton A, Vogel S, Field A. A systematic review of psychological factors as predictors of
chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27(5):E109–20.
93. Pozos RS, Danzl DF
. Human physiological responses to cold stress and hypothermia. In: Pandolf KB,
editor. Textbooks of Military Medicine: Medical Aspects of Harsh Environments. Falls Church: Office of
the Surgeon General, United States Army; 2002. p. 351–382.
94. Renkawitz T, Boluki D, Grifka J. The association of low back pain, neuromuscular imbalance, and
trunk extension strength in athletes. Spine J. 2006;6(6):673–783.
95. Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for Spinal Segmental Stabilization in
Low Back Pain. Toronto (Ontario): Churchill Livingstone; 1999.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-260-320.jpg)
![235
CHAPTER 8 Exercise Prescription for Healthy Populations
96. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign (IL): Human Kinetics; 2001. 161 p.
97. Roach R, Stepanek J, Hackett P. Acute mountain sickness and high-altitute cerebral edema. In:
Pandolf KB, Burr RE, editors. Textbooks of Military Medicine: Medical Aspects of Harsh Environments.
Falls Church: Office of the Surgeon General, United States Army; 2002. p. 760–88.
98. Sawka MN, Coyle EF
. Influence of body water and blood volume on thermoregulation and exercise
performance in the heat. Exerc Sport Sci Rev. 1999;27:167–218.
99. Sawka MN, Francesconi RP
, Young AJ, Pandolf KB. Influence of hydration level and body fluids on
exercise performance in the heat. JAMA. 1984;252(9):1165–9.
100. Sawka MN, Young AJ. Physiological systems and their responses to conditions of heat and cold. In:
Tipton CM, American College of Sports Medicine, editors. ACSM’s Advanced Exercise Physiology.
Baltimore: Lippincott Williams Wilkins; 2006. p. 535–63.
101. Sawka MN, Young AJ, Latzka WA, Neufer PD, Quigley MD, Pandolf KB. Human tolerance to heat
strain during exercise: influence of hydration. J Appl Physiol. 1992;73(1):368–75.
102. Senay LC,Jr. Relationship of evaporative rates to serum [Na⫹], [K⫹], and osmolarity in acute heat
stress. J Appl Physiol. 1968;25(2):149–52.
103. Simmonds MJ, Goubert L, Moseley GL, Verbunt JA. Moving with pain. In: Flor H, Kalso E,
Dostrovsky JO, editors. Proceedings of the 11th World Congress on Pain, Sydney, Australia, August
21–26, 2005. Seattle: IASP Press; 2006. p. 799–811.
104. Simmonds MJ, Lee CE. Physical performance tests: an expanded model of assessment and out-
come. In: Liebenson C, Czech School of Manual Medicine, editors. Rehabilitation of the Spine: A
Practitioner’s Manual. Baltimore: Lippincott, Williams Wilkins; 2006. p. 260–275.
105. Simmonds MJ, Olson S, Jones S, et al. Psychometric characteristics and clinical usefulness of
physical performance tests in patients with low back pain. Spine. 1998;23(22):2412–21.
106. Singh MA. Exercise comes of age: rationale and recommendations for a geriatric exercise prescrip-
tion. J Gerontol A Biol Sci Med Sci. 2002;57(5):M262–82.
107. Skinner JS. Aging for exercise testing and exercise prescription. In: Skinner JS, editor. Exercise
Testing and Exercise Prescription for Special Cases: Theoretical Basis and Clinical Application. 3rd ed.
Baltimore: Lippincott Williams Wilkins; 2005. p. 85–99.
108. Skytte L, May S, Petersen P. Centralization: its prognostic value in patients with referred symptoms
and sciatica. Spine. 2005;30(11):E293–9.
109. Smeets R, van Geel K, Verbunt J. Is the fear avoidance model associated with the reduced level
of aerobic fitness in patients with chronic low back pain? Arch Phys Med Rehabil. 2009;90(1):
109–17.
110. Smeets R, Wittink H, Hidding A, Knottnerus J. Do patients with chronic low back pain have a
lower level of aerobic fitness than healthy controls?: are pain, disability, fear of injury, working
status, or level of leisure time activity associated with the difference in aerobic fitness level? Spine.
2006;31(1):90–7.
111. Strong WB, Malina RM, Blimkie CJ, et al. Evidence based physical activity for school-age youth. J
Pediatr. 2005;146(6):732–7.
112. Sullivan M, Shoaf L, Riddle D. The relationship of lumbar flexion to disability in patients with low
back pain. Phys Ther. 2000;80(3):240–50.
113. Troiano RP
, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United
States measured by accelerometer. Med Sci Sports Exerc. 2008;40(1):181–8.
114. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans
[Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008 [cited 2011
Jan 6]. 76 p. Available from: http://www.health.gov/paguidelines/pdf/paguide.pdf
115. van Tulder M, Becker A, Bekkering T, et al. Chapter 3 European guidelines for the management of
acute nonspecific low back pain in primary care. Eur Spine J. 2006;15:s169–91.
116. Verbunt JA, Smeets RJ, Wittink HM. Cause or effect? Deconditioning and chronic low back pain.
Pain. 2010;149(3):428–30.
117. Wasiak R, Kim J, Pransky G. Work disability and costs caused by recurrence of low back pain:
longer and more costly than in first episodes. Spine. 2006;31(2):219–25.
118. Weight Gain During Pregnancy: Reexamining the Guideline. Report Brief [Internet]. Washington
(DC): National Academy of Sciences; 2009 [cited 2011 Jan 13]. 4 p. Available from: http://www.
iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx
119. Werneke M, Hart D, Cook D. A descriptive study of the centralization phenomenon: a prospective
analysis. Spine. 1999;24(7):676–83.
120. Wittink H, Michel T, Kulich R, et al. Aerobic fitness testing in patients with chronic low back pain:
which test is best? Spine. 2000;25(13):1704–10.
121. Wolfe LA. Pregnancy. In: Skinner JS, editor. Exercise Testing and Exercise Prescription for Special
Cases: Theoretical Basis and Clinical Application. 3rd ed. Baltimore: Lippincott Williams Wilkins;
2005. p. 377–391.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-261-320.jpg)
![CHAPTER 9 Exercise Prescription for Patients with CVD 243
When patients whose -blocker dose has been altered exercise without
a new exercise test, signs and symptoms should be monitored, and RPE
and HR responses should be recorded at previously performed workloads.
These new HRs may serve as the patient’s new exercise target HR (THR)
range. Patients on diuretic therapy may become volume depleted, have hy-
pokalemia, or demonstrate orthostatic hypotension particularly after bouts
of exercise. For these patients, the BP response to exercise, symptoms of
dizziness or light-headedness, and arrhythmias should be monitored while
providing education regarding proper hydration (3). See Appendix A for
other medications that may influence the hemodynamic response during
and after exercise.
Time: Warm-up and cool-down activities of 5–10 min, including static
stretching, ROM, and light intensity (i.e., ⬍40% V
.
O2
R, ⬍64% peak heart
rate [HRpeak
], or ⬍11 RPE) aerobic activities, should be a component of
each exercise session and precede and follow the conditioning phase.
The goal for the duration of the aerobic conditioning phase is generally
20–60 min per session. After a cardiac-related event, patients may begin
with as little as 5–10 min of aerobic conditioning with a gradual increase
in aerobic exercise time of 1–5 min per session or an increase in time per
session of 10%–20% per week.
Type: The aerobic exercise portion of the session should include rhyth-
mic, large muscle group activities with an emphasis on increased caloric
expenditure for maintenance of a healthy body weight and its many other
associated health benefits (see Chapters 1, 7, and 10). To promote whole
body physical fitness, conditioning that includes the upper and lower
extremities and multiple forms of aerobic activities and exercise equipment
should be incorporated into the exercise program. The different types of
exercise equipment may include the following:
• Arm ergometer
• Combination of upper or lower (dual action) extremity cycle ergometer
• Upright and recumbent cycle ergometer
• Recumbent stepper
• Rower
• Elliptical
• Stair climber
• Treadmill for walking
Aerobic interval training (AIT) involves alternating 3–4 min pe-
riods of exercise at high intensity (90%–95% HRpeak
) with exercise at
moderate intensity (60%–70% HRpeak
). Such training for approximately
40 min, three times per week has been shown to yield a greater improve-
ment in V
.
O2peak
in patients with heart failure (44) and greater long-term](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-269-320.jpg)
![CHAPTER 9 Exercise Prescription for Patients with CVD 251
• Dual-chambered pacemakers that have two leads; one placed in the right
atrium and one in the right ventricle.
• Cardiac resynchronization therapy pacemakers that have three leads; one in
right atrium, one in right ventricle, and one in coronary sinus or, less com-
monly, the left ventricular myocardium via an external surgical approach.
The type of pacemaker is identified by a four-letter code as indicated in the
following section:
• The first letter of the code describes the chamber paced (e.g., atria [A],
ventricle [V], dual [D]).
• The second letter of the code describes the chamber sensed.
• The third letter of the code describes the pacemaker’s response to a sensed
event.
• The fourth letter of the code describes the rate response capabilities of the
pacemaker, (e.g., inhibited [I], rate responsive [R]).
For example, a VVIR code pacemaker means (a) the ventricle is paced (V)
and sensed (V); (b) when the pacemaker senses a normal ventricular contrac-
tion, it is inhibited (I); and (c) the pulse generator is rate responsive (R).
Implantable cardiac defibrillators (ICDs) are devices that monitor heart
rhythms and deliver shocks if life-threatening rhythms are detected. ICDs are
used for high-rate ventricular tachycardia or ventricular fibrillation in patients
who are at risk for these conditions as a result of previous cardiac arrest, cardio-
myopathy, heart failure, or ineffective drug therapy for abnormal heart rhythms.
When ICDs detect a too rapid or irregular heartbeat, they may first try to pace the
heart into a normal rate and rhythm (i.e., antitachycardia pacing). If unsuccess-
ful, they can then deliver a shock that resets the heart to a more normal HR and
electrical pattern (i.e., cardioversion). Thus, ICDs aim to protect against sudden
cardiac death from ventricular tachycardia and ventricular fibrillation.
Ex Rx
considerations for those with pacemakers are as follows:
• Programmed pacemaker modes, HR limits, and ICD rhythm detection algo-
rithms should be obtained from the patient’s cardiologist prior to exercise
testing or training.
• Exercise testing should be used to evaluate HR and rhythm responses prior to
beginning an exercise program.
• When an ICD is present, the HRpeak
during the exercise test and exercise
training program should be maintained at least 10 beats ⭈ min⫺1
below the
programmed HR threshold for antitachycardia pacing and defibrillation.
• After the first 24 h following the device implantation, mild upper extremity
ROM activities can be performed and may be useful to avoid subsequent joint
complications.
• To maintain device and incision integrity, for 3–4 wk after implant, rigorous
upper extremity activities such as swimming, bowling, lifting weights,
elliptical machines, and golfing should be avoided. However, lower extremity
activities are allowable.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-277-320.jpg)
![254 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
• Equipment (Type)
• Elastic bands
• Cuff and hand weights
• Free weights
• Wall pulleys
• Machines (dependent on weight of lever arms and range of motion)
• Proper techniques
• Raise and lower weights with slow, controlled movements to full
extension.
• Maintain regular breathing pattern and avoid breath holding.
• Avoid straining.
• Avoid sustained, tight gripping, which may evoke an excessive blood
pressure (BP) response.
• A rating of perceived exertion (RPE) of 11–14 (“light” to “somewhat
hard”) on a scale of 6–20 may be used as a subjective guide to effort.
• Terminate exercise if warning signs or symptoms occur including
dizziness, arrhythmias, unusual shortness of breath, or anginal
discomfort.
• Initial load should allow 10–15 repetitions that can be lifted without
straining (⬃30%–40% one repetition maximum [1-RM] for the upper body;
⬃50%–60% for the lower body). 1-RM is the maximum load that can be
lifted one time. When determination of 1-RM is deemed inappropriately,
multiple trials using progressively higher loads can be performed until the
patient can perform no more than 10 repetitions without straining. That load
can then be used for training.
• Exercise dosage can be progressed by increasing the resistance,
increasing the number of repetitions, or decreasing the rest period
between sets or exercises.
• Increase loads by 5% increments when the patient can comfortably
achieve the upper limit of the prescribed repetition range
(e.g., 12–15 repetitions).
• Low-risk patients may progress to 8–12 repetitions with a resistance of
⬃60%–80% 1-RM.
• Because of the potential for an elevated BP response, the rate pressure
product (RPP) should not exceed that during prescribed endurance
exercise as determined from the exercise test.
• Each major muscle group (i.e., chest, shoulders, arms, abdomen, back, hips,
and legs) should be trained initially with one set; multiple set regimens may
be introduced later as tolerated.
• Sets may be of the same exercise or from different exercises affecting
the same muscle group.
Resistance Training Guidelinesa
(43)
BOX 9.8](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-280-320.jpg)
![CHAPTER 9 Exercise Prescription for Patients with CVD 255
• Perform 8–10 exercises of the major muscle groups.
• Exercise large muscle groups before small muscle groups.
• Include multijoint exercises or “compound” exercises that affect more
than one muscle group.
• Frequency: 2–3 d ⭈ wk⫺1
with at least 48 h separating training sessions
for the same muscle group. All muscle groups to be trained may be done
in the same session, that is, whole body or each session may “split” the
body into selected muscle groups so that only a few are trained in any
one session. Resistance training should be performed after the aerobic
component of the exercise session to allow for adequate warm-up.
• Progression: Increase slowly as the patient adapts to the program
(⬃2–5 lb ⭈ wk⫺1
[0.91–2.27 kg] for upper body and 5–10 lb ⭈ wk⫺1
for
lower body [0.91–4.5 kg]).
a
For additional information on resistance training, see Chapter 7.
Resistance Training Guidelinesa
(43) (Continued)
BOX 9.8
• Assessment of patient’s work demands and environment
• Nature of work
• Muscle groups used at work
• Work demands that primarily involve muscular strength and endurance
• Primary movements performed during work
• Periods of high metabolic demands vs. periods of low metabolic
demands
• Environmental factors including temperature, humidity, and altitude
• Exercise prescription
• Emphasize exercise modalities that use muscle groups involved in work
tasks.
• If possible, use exercises that mimic movement patterns used during
work tasks.
• Balance resistance vs. aerobic training relative to work tasks.
• If environmental stress occurs at work, educate the patient about
appropriate precautions including avoidance if need be, and, if possible,
expose them to similar environmental conditions while performing
activities similar to work tasks (see the American College of Sports
Medicine Position Stands [1,2,10] and Chapter 8 for additional
information on environmental precautions).
• If possible, monitor the physiologic responses to a simulated work
environment.
Exercise Prescription for Return to Work
BOX 9.9](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-281-320.jpg)
![CHAPTER 9 Exercise Prescription for Patients with CVD 257
• It is important that outpatients eventually transition from a medically su-
pervised program to an independent (i.e., self-monitored and unsupervised)
home exercise program. The optimal number of weeks of attendance at a
supervised program before entering an independent program is unknown and
is likely patient specific.
• PAD is a common disorder with increasing prevalence in older adults.
Conservative management of patients with asymptomatic PAD and patients
with intermittent claudication is recommended to modify risk factors and
improve ambulatory ability, whereas patients with more severe PAD typically
require revascularization of the lower extremities. Exercise rehabilitation is
a highly effective, conservative treatment to improve ambulation in patients
with intermittent claudication.
• Resistance training is now a standard part of the overall exercise training
program for most, if not all, patients with CVD (see Chapter 7).
• Standard stroke care during the initial 3–6 mo postevent period focuses on
basic mobility function and recovery of ADL. Exercise interventions that go
beyond the early subacute period are needed to optimize functional capacity
for the long term.
American Association for Cardiovascular and Pulmonary Rehabilitation (1):
http://www.aacvpr.org
American Heart Association (4):
http://www.americanheart.org
Clinical Exercise Physiology Association (11):
http://www.acsm-cepa.org
Society for Vascular Medicine:
http://www.svmb.org
VascularWeb:
http://www.vascularweb.org
Online Resources
REFERENCES
1. American Association for Cardiovascular and Pulmonary Rehabilitation Web site [Internet].
Chicago (IL): American Association for Cardiovascular and Pulmonary Rehabilitation; [cited 2011
Jan 6]. Available from: http://www.aacvpr.org/
2. American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac rehabilitation in the
inpatient and transitional setting. In: Guidelines for Cardiac Rehabilitation and Secondary Prevention
Programs. 4th ed. Champaign: Human Kinetics; 2004. p. 31–52.
3. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports
Medicine Position Stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377–90.
4. American Heart Association Web site [Internet]. Dallas (TX): American Heart Association; [cited
2011 Jan 6]. Available from: http://www.americanheart.org/
5. Armstrong LE, Brubaker PH, Whaley MH, Otto RM, American College of Sports Medicine. ACSM’s
Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams
Wilkins; 2005. 366 p.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-283-320.jpg)
![258 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
6. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–81.
7. Borg G. Scaling pain and related subjective somatic symptoms. In: Borg’s Perceived Exertion and Pain
Scales. Champaign: Human Kinetics; 1998. p. 63–67.
8. Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity
and improve health: a systematic review. JAMA. 2007;298(19):2296–304.
9. Bulmer AC, Coombes JS. Optimising exercise training in peripheral arterial disease. Sports Med.
2004;34(14):983–1003.
10. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine Position Stand:
prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012–29.
11. Clinical Exercise Physiology Association Web site [Internet]. Indianapolis (IN): Clinical Exercise
Physiology Association; [cited 2011 Jun 7]. Available from: http://www.acsm-cepa.org/
12. Convertino VA. Blood volume response to physical activity and inactivity. Am J Med Sci. 2007;
334(1):72–9.
13. Gardner AW, Montgomery PS, Afaq A. Exercise performance in patients with peripheral arterial
disease who have different types of exertional leg pain. J Vasc Surg. 2007;46(1):79–86.
14. Gardner AW, Montgomery PS, Flinn WR, Katzel LI. The effect of exercise intensity on the
response to exercise rehabilitation in patients with intermittent claudication. J Vasc Surg. 2005;
42(4):702–9.
15. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain.
A meta-analysis. JAMA. 1995;274(12):975–80.
16. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing:
summary article. A report of the American College of Cardiology/American Heart Association Task
Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am
Coll Cardiol. 2002;40(8):1531–40.
17. Hare DL, Ryan TM, Selig SE, Pellizzer AM, Wrigley TV, Krum H. Resistance exercise training
increases muscle strength, endurance, and blood flow in patients with chronic heart failure. Am J
Cardiol. 1999;83(12):1674–7, A7.
18. Hiatt WR, Cox L, Greenwalt M, Griffin A, Schechter C. Quality of the assessment of primary and
secondary endpoints in claudication and critical leg ischemia trials. Vasc Med. 2005;10(3):207–13.
19. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and
treatment in primary care. JAMA. 2001;286(11):1317–24.
20. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management
of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal
aortic): a collaborative report from the American Association for Vascular Surgery/Society for
Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular
Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on
Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients
with Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular
and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular
Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation.
2006;113(11):e463–654.
21. Hunt SA, American College of Cardiology, American Heart Association Task Force on Practice
Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management
of Heart Failure). ACC/AHA 2005 guideline update for the diagnosis and management of
chronic heart failure in the adult: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines
for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2005;46(6):e1–82.
22. Ivey FM, Hafer-Macko CE, Macko RF
. Exercise rehabilitation after stroke. NeuroRx. 2006;3(4):
439–50.
23. Leon AS, Franklin BA, Costa F
, et al. Cardiac rehabilitation and secondary prevention of coronary
heart disease: an American Heart Association scientific statement from the Council on Clinical
Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council
on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collabora-
tion with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation.
2005;111(3):369–76.
24. Losanoff JE, Jones JW, Richman BW. Primary closure of median sternotomy: techniques and prin-
ciples. Cardiovasc Surg. 2002;10(2):102–10.
25. Luft AR, Macko RF
, Forrester LW, et al. Treadmill exercise activates subcortical neural networks and
improves walking after stroke: a randomized controlled trial. Stroke. 2008;39(12):3341–50.
26. Macko RF
, Ivey FM, Forrester LW, et al. Treadmill exercise rehabilitation improves ambulatory
function and cardiovascular fitness in patients with chronic stroke: a randomized, controlled trial.
Stroke. 2005;36(10):2206–11.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-284-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 261
exercise is essential for managing these conditions. Specifically, exercise reduces
pain, maintains muscle strength around affected joints, reduces joint stiffness, pre-
vents functional decline, and improves mental health and quality of life (208,274).
EXERCISE TESTING
Most individuals with arthritis tolerate symptom-limited exercise testing consis-
tent with recommendations for apparently healthy adults (see Chapters 4 and 5).
The following are special considerations for individuals with arthritis:
• High intensity exercise is contraindicated when there is acute inflammation
(i.e., hot, swollen, and painful joints). If individuals are experiencing acute in-
flammation, exercise testing should be postponed until the flare has subsided.
• Although some individuals with arthritis tolerate treadmill walking, use of
cycle leg ergometry alone or combined with arm ergometry may be less painful
for some and allow better assessment of cardiorespiratory function. The mode
of exercise chosen should be the least painful for the individual being tested.
• Allow ample time for individuals to warm up at a light intensity level prior to
beginning the graded exercise test.
• Monitor pain levels during testing. There are many validated scales available
including the Borg CR10 Scale (see Figure 9.1) (27) and visual numeric scale
(see Figure 10.1) (205). Testing should be stopped if the patient indicates pain
is too severe to continue.
• Muscle strength and endurance can be measured using typical protocols
(see Chapter 4). However, pain may limit maximum muscle contraction in
affected joints.
EXERCISE PRESCRIPTION
Pain can be a major barrier to beginning and maintaining a regular exercise
program. Therefore, when prescribing exercise for individuals with arthritis, a
key guiding principle should be identifying a program that minimizes pain while
gradually progressing toward levels that provide greater health benefits (155).
In general, recommendations for Ex Rx
are consistent with those for apparently
■ FIGURE 10.1. Visual numeric pain scale. (Reprinted with permission from [205].)
No pain Severe pain
0 10
9
8
7
6
5
4
3
2
1](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-287-320.jpg)
![264 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
CANCER
Cancer is a group of nearly 200 diseases characterized by the uncontrolled
growth and spread of abnormal cells resulting from damage to deoxyribonucleic
acid (DNA) by internal factors (e.g., inherited mutations) and environmental
exposures (e.g., tobacco smoke). Most cancers are classified according to the cell
type from which they originate. Carcinomas develop from the epithelial cells of
organs and compose at least 80% of all cancers. Other cancers arise from the cells
of the blood (leukemias), immune system (lymphomas), and connective tissues
(sarcomas). The lifetime prevalence of cancer is one in two for men and one in
three for women (5). Cancer affects all ages but is most common in older adults.
About 76% of all cancers are diagnosed in individuals 55 yr (5); hence, there
is a strong likelihood that individuals diagnosed with cancer will have other
chronic diseases (e.g., cardiopulmonary disease, diabetes mellitus, osteoporosis,
arthritis).
Treatment for cancer may involve surgery, radiation, chemotherapy, hormones,
and immunotherapy. In the process of destroying cancer cells, some treatments
also damage healthy tissue. Patients may experience side effects that limit their
ability to exercise during treatment and afterward. These long-term and late
effects of cancer treatment are described elsewhere (152). Furthermore, overall
physical function is generally diminished because of losses of aerobic capacity,
muscle tissue, and ROM. Even among cancer survivors who are 5 yr or more
posttreatment, more than half report physical performance limitations including
crouching/kneeling, standing for 2 h, lifting/carrying 10 lb (4.5 kg), and walk-
ing 0.25 mi (0.4 km) (170). In the following sections, the National Coalition for
Cancer Survivorship definition of cancer survivor is used; that is, from the time of
diagnosis to the balance of life including the time period during treatment (165).
EXERCISE TESTING
A diagnosis of cancer and curative cancer treatments pose challenges for mul-
tiple body systems involved in performing exercise and/or affected by exercise.
For example, survivors of breast cancer who have had lymph nodes removed
may respond differently to inflammation and injury on the side of the body that
underwent surgery, having implications for exercise testing and Ex Rx
. Cancer
and cancer therapy have the potential to affect the health-related components
of physical fitness (i.e., cardiorespiratory fitness [CRF], muscular strength and
endurance, body composition, and flexibility) as well as neuromotor function.
Understanding how an individual has been affected by his or her cancer expe-
rience is important prior to exercise testing and designing the Ex Rx
for survivors
of cancer during and after treatment (121). Every individual with cancer can
have a unique experience and response. Because of the diversity in this patient
population, the safety guidance for preexercise evaluations of cancer survivors
focuses on general as well as cancer site–specific recommendations of the medi-
cal assessments (see Table 10.1) (221).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-290-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 267
FITT RECOMMENDATIONS FOR
INDIVIDUALS WITH CANCER
Aerobic, Resistance, and Flexibility Exercise
The appropriate FITT recommendations will vary across the cancer experi-
ence and requires individualization of the Ex Rx
.
Frequency: For those who have completed treatment, the goal for aerobic
exercise should be to increase gradually from the current physical activ-
ity level to 3–5 d ⭈ wk1
with resistance training 2–3 d ⭈ wk1
. Flexibility
activities can occur daily, even during treatment. Evidence indicates even
those currently undergoing systemic cancer treatments can increase daily
physical activity sessions over the course of 1 mo (221).
Intensity: Exercise tolerance may be highly variable during active treatment.
Survivors who have completed treatment may increase intensity slowly for all
physical activities. Heart rate (HR) may be less reliable for monitoring inten-
sity for cancer survivors currently undergoing treatment. Therefore, educating
survivors to use perceived exertion to monitor intensity may be advisable
(see Chapter 7). If tolerated without adverse effects of symptoms or side effects,
exercise intensity need not differ from healthy populations. Aerobic exercise
should be moderate (i.e., 40%–60% V̇O2
R or HRR; rating of perceived exer-
tion [RPE] of 12–13 on a scale of 6–20 [27]) to vigorous (60%–85% V̇O2
R or
HRR or RPE of 12–16 on a scale of 6–20 [27]) intensity. Moderate intensity
resistance exercise should be 60%–70% 1-RM. Flexibility intensity should be
mindful of ROM restrictions resultant to surgery and/or radiation therapy (151).
Time: Several short bouts per day rather than a single bout may be useful,
particularly during active treatment. Survivors who have completed
treatment can increase duration as tolerated for all activities. When
tolerated without exacerbation of symptoms or side effects, exercise session
duration should be no different than that for healthy populations. Aerobic
exercise should be 75 min ⭈ wk1
of vigorous intensity or 150 min ⭈ wk1
of moderate intensity activity or an equivalent combination of the two.
Resistance training should be at least 1 set of 8–12 repetitions.
Type: Aerobic exercise should be prolonged, rhythmic activities using
large muscle groups (e.g., walking, cycling, swimming). Resistance exer-
cise should be weights, resistance machines, or weight-bearing functional
tasks (e.g., sit-to-stand) targeting all major muscle groups. Flexibility ex-
ercise should be stretching or ROM exercises of all major muscle groups
also addressing specific areas of joint or muscle restriction that may have
resulted from treatment with steroids, radiation, or surgery.
Progression: Slower progression may be needed among survivors of cancer
compared to healthy adults. Awareness of the highly variable impact of ex-
ercise on symptoms in survivors of cancer undergoing treatment is needed
(222). If exercise progression leads to an increase in fatigue or other com-
mon adverse symptoms as a result of prescribed exercise, the FITT principle
of Ex Rx
should be reduced to a level that is better tolerated.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-293-320.jpg)
![280 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
using HbA1c ⬎6.5% as a diagnostic tool for diabetes, most diagnoses are still
based on elevated fasting glucose.
EXERCISE TESTING
The following are special considerations for exercise testing in individuals
with DM:
• When beginning an exercise program of light-to-moderate intensity (i.e., equiv-
alent to noticeable increases in HR and breathing such as walking), exercise
testing may not be necessary for individuals with DM or prediabetes who are
asymptomatic for cardiovascular disease (CVD) and low risk (10% risk of
cardiac event over a 10-yr period) (252) (see Tables 2.1 and 2.3).
• Individuals with DM or prediabetes with 10% risk of a cardiac event over
a 10-yr period and who want to begin a vigorous intensity exercise program
(i.e., 60% V̇O2
R that substantially increases HR and breathing) should un-
dergo a medically supervised graded exercise test (GXT) with electrographic
(ECG) monitoring (6,39).
• If positive or nonspecific ECG changes in response to exercise are noted or
nonspecific ST and T wave changes at rest are observed, follow-up testing
may be performed (227). However, consider the Detection of Ischemia in
Asymptomatic Diabetes (DIAD) trial involving 1,123 individuals with Type 2
DM and no symptoms of coronary artery disease (CAD) found screening with
adenosine-stress radionuclide myocardial perfusion imaging for myocardial
ischemia over a 4.8 yr follow-up period did not alter rates of cardiac events
(273); thus, the cost-effectiveness and diagnostic value of more intensive test-
ing remains in question.
• SilentischemiainpatientswithDMoftengoesundetected(262).Consequently,
annual CVD risk factor assessment should be conducted by a health care
provider (6).
EXERCISE PRESCRIPTION
The benefits of regular exercise in individuals with Type 2 DM and prediabetes
include improved glucose tolerance, increased insulin sensitivity, and decreased
HbA1C. In individuals with Type 1 DM and those with Type 2 DM using insulin,
regular exercise reduces insulin requirements. Important exercise benefits for
individuals with either Type 1 or Type 2 DM or prediabetes include improve-
ment in CVD risk factors (i.e., lipid profiles, blood pressure [BP], body weight,
and functional capacity) and well-being (2,6). Regular exercise participation may
also prevent or at least delay the transition to Type 2 DM for individuals with
prediabetes who are at very high risk for developing DM (132) (see Table 10.5).
The FITT principle of Ex Rx
for healthy adults generally applies to indi-
viduals with DM (see Chapter 7). Participating in an exercise program confers
benefits that are extremely important to individuals with Type 1 and Type 2 DM.
Maximizing the cardiovascular health–related benefits resulting from exercise is](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-306-320.jpg)
![282 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
SPECIAL CONSIDERATIONS
• Hypoglycemia is the most serious problem for individuals with DM who
exercise and is mainly a concern for individuals taking insulin or oral hypo-
glycemic agents that increase insulin secretion (e.g., sulfonylurea drugs) (6)
(see Appendix A). Hypoglycemia, that is, blood glucose level 70 mg ⭈ dL1
(3.89 mmol ⭈ L1
), is relative (6). Rapid drops in blood glucose may occur
with exercise and render patients symptomatic even when blood glucose
is well above 70 mg ⭈ dL1
. Conversely, rapid drops in blood glucose may
occur without generating noticeable symptoms. Common symptoms as-
sociated with hypoglycemia include shakiness, weakness, abnormal sweat-
ing, nervousness, anxiety, tingling of the mouth and fingers, and hunger.
Neuroglycopenic symptoms may include headache, visual disturbances,
mental dullness, confusion, amnesia, seizures, and coma (3). Importantly,
hypoglycemia may be delayed and can occur up to 12 h postexercise.
• Blood glucose monitoring before and for several hours following exercise,
especially when beginning or modifying the exercise program, is prudent.
• The timing of exercise should be considered in individuals taking insulin or
hypoglycemic agents. For individuals with diabetes using insulin, changing
insulin timing, reducing insulin dose, and/or increasing carbohydrate con-
sumption are effective strategies to prevent hypoglycemia both during and
after exercise.
• Physical activity combined with oral hypoglycemic agents has not been
well studied and little is known about the potential for interactions.
retinopathy, and recent treatments using laser surgery. The recommen-
dations for healthy individuals generally apply to individuals with DM
(see Chapter 7). Given that many patients may present with comorbidities,
it may be necessary to tailor the resistance Ex Rx
accordingly.
There is some evidence that a combination of aerobic and resistance
training improves blood glucose control more than either modality alone
(50). Whether the added benefits are caused by a greater overall caloric
expenditure or are specific to the combination of aerobic and resistance
training has not yet been resolved.
No more than two consecutive days of physical inactivity per week
should be allowed. A greater emphasis should eventually be placed on
vigorous intensity exercise if CRF is a primary goal. On the other hand,
greater amounts of moderate intensity exercise that result in a caloric EE
of 2,000 kcal ⭈ wk1
(⬎7 hr ⭈ wk1
), including daily exercise, may be
required if weight loss maintenance is the goal, as is the case for most in-
dividuals with Type 2 DM (54) (see this chapter and other relevant ACSM
position stands [6,54]).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-308-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 283
Sulfonylurea drugs, glucagon-like peptide 1 (GLP-1) agonists, and other
compounds that enhance insulin secretion probably do increase the risk
for hypoglycemia because the effects of insulin and muscle contraction
on blood glucose uptake are additive (86). The few data that exist on the
common biguanide (e.g., metformin) and thiazolidinedione drugs suggest
the interactions are complex and may not be predictable based on indi-
vidual effects of the drug or exercise alone (226) (see Appendix A). Extra
blood glucose monitoring is prudent when beginning a program of regular
exercise in combination with oral agents to assess whether changes in
medication dose are necessary or desirable.
• Adjust carbohydrate intake and/or medications before and after exercise
based on blood glucose levels and exercise intensity to prevent hypoglycemia
associated with exercise (230).
• For individuals with Type 1 DM using insulin pumps, insulin delivery
during exercise can be markedly reduced or the pump can be discon-
nected depending on the intensity and duration of exercise. Reducing
basal delivery rates for up to 12 h postexercise may be necessary to avoid
hypoglycemia.
• The use of continuous glucose monitoring can be very useful to detect pat-
terns in blood glucose across multiple days and evaluate both the immediate
and delayed effects of exercise (4). Adjustments to insulin dose, oral medica-
tions, and/or carbohydrate intake can be fine-tuned using the detailed infor-
mation provided by continuous glucose monitoring.
• Exercise with a partner or under supervision to reduce the risk of problems
associated with hypoglycemic events.
• Hyperglycemia with or without ketosis is a concern for individuals with
Type 1 DM who are not in glycemic control. Common symptoms associated
with hyperglycemia include polyuria, fatigue, weakness, increased thirst,
and acetone breath (3). Individuals who present with hyperglycemia, pro-
vided they feel well and have no ketone bodies present in either the blood or
urine, may exercise; but they should test blood sugar often and refrain from
vigorous intensity exercise until they see that blood glucose concentrations
are declining (10,230).
• Dehydration resulting from polyuria, a common occurrence of hyperglyce-
mia, may contribute to a compromised thermoregulatory response (259).
Thus, a patient with hyperglycemia should be treated as having an elevated
risk for heat illness requiring more frequent monitoring of signs and symp-
toms (see Chapter 8 and other relevant ACSM positions stands [7,9]).
• Individuals with DM and retinopathy are at risk for retinal detachment and
vitreous hemorrhage associated with vigorous intensity exercise. However,
risk may be minimized by avoiding activities that dramatically elevate
BP. Thus, for those with severe nonproliferative and proliferative diabetic
retinopathy, vigorous intensity aerobic and resistance exercise should be
avoided (6,230).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-309-320.jpg)
![284 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
• During exercise, autonomic neuropathy may cause chronotropic incompe-
tence (i.e., a blunted BP response), attenuated V̇O2
kinetics, and anhydrosis
(i.e., water deprivation) (6,259). In these situations, the following should be
considered:
• Monitor the signs and symptoms of hypoglycemia because of the inability
of the individual to recognize them. Also, monitor the signs and symp-
toms of silent ischemia such as unusual shortness of breath or back pain
because of the inability to perceive angina.
• Monitor BP before and after exercise to manage hypotension and hyper-
tension associated with vigorous intensity exercise (259) (see the section
on hypertension in this chapter).
• The HR and BP responses to exercise may be blunted. RPE should also be
used to assess exercise intensity (259).
• Given the likelihood thermoregulation in hot and cold environments is
impaired, additional precautions for heat and cold illness are warranted
(see Chapter 8 and other relevant ACSM positions stands [7,9,31]).
• For individuals with peripheral neuropathy, take proper care of the feet
to prevent foot ulcers (6). Special precautions should be taken to prevent
blisters on the feet. Feet should be kept dry and the use of silica gel or air
midsoles as well as polyester or blend socks should be used.
• For individuals with nephropathy (6,11), although protein excretion acutely
increases postexercise, there is no evidence vigorous intensity exercise accel-
erates the rate of progression of kidney disease. Although there are no current
exercise intensity restrictions for individuals with diabetic nephropathy, it
is prudent to encourage sustainable exercise programming that more likely
includes tolerable moderate intensity.
• Most individuals with Type 2 DM and prediabetes are overweight (see the
section on overweight and obesity in this chapter and the relevant ACSM
position stand [54]).
• Most individuals with prediabetes or either subtype of DM are at high risk
for or have CVD (see Chapter 9).
THE BOTTOM LINE
• The benefits of regular exercise in individuals with prediabetes and Type 2
DM include improved glucose tolerance and increased insulin sensitivity.
Regular exercise reduces insulin requirements in individuals with Type 1
DM. The general FITT principle of Ex Rx
generally applies to individuals
with DM. Individuals with retinopathy or recent treatments using laser sur-
gery may need to avoid resistance training. Hypoglycemia is the most seri-
ous problem for individuals with DM who exercise and is mainly a concern
for those taking insulin or oral hypoglycemic agents that increase insulin
secretion.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-310-320.jpg)
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EXERCISE TESTING
• Individuals with dyslipidemia should be screened and risk classified prior to
exercise testing (see Chapters 2 and 3).
• Use caution when testing individuals with dyslipidemia because underlying
CVD may be present.
• Standard exercise testing methods and protocols are appropriate for use with
individuals with dyslipidemia cleared for exercise testing. Special consider-
ation should be given to the presence of other chronic diseases and health
conditions (e.g., metabolic syndrome, obesity, hypertension) that may require
modifications to standard exercise testing protocols and modalities (see the
sections of this chapter and other relevant ACSM positions stands on these
chronic diseases and health conditions [54,183]).
EXERCISE PRESCRIPTION
The FITT principle of Ex Rx
for individuals with dyslipidemia without comorbities
is very similar to the Ex Rx
for healthy adults (87,102) (see Chapter 7). A major
difference in the FITT principle of Ex Rx
for individuals with dyslipidemia com-
pared to healthy adults is that healthy weight maintenance should be emphasized.
Accordingly, aerobic exercise becomes the foundation of the Ex Rx
. Resistance
and flexibility exercises are adjunct to an aerobic training program designed for
the treatment of dyslipidemia primarily because these modes of exercise do not
substantially contribute to the overall caloric expenditure goals that appear to be
beneficial for improvements in blood lipid and lipoprotein concentrations.
FITT RECOMMENDATIONS FOR INDIVIDUALS
WITH DYSLIPIDEMIA
Aerobic Exercise
The FITT principle of Ex Rx
recommended for individuals with dylipidemia:
Frequency: 5 d ⭈ wk1
to maximize caloric expenditure.
Intensity: 40%–75% V̇O2
R or HRR.
Time: 30–60 min ⭈ d1
. However, to promote or maintain weight
loss, 50–60 min ⭈ d1
or more of daily exercise is recommended (54).
Performance of intermittent exercise of at least 10 min in duration to
accumulate these duration recommendations is an effective alternative
to continuous exercise.
Type: The primary mode should be aerobic physical activities that involve
the large muscle groups. As part of a balanced exercise program, resistance
training and flexibility exercise should be incorporated. Individuals with
dyslipidemia without comorbidities may follow the resistance training and
flexibility guidelines for healthy adults (see Chapter 7).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-312-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 287
The FITT recommendations for individuals with dyslipidemia are consistent
with the recommendations for healthy weight loss maintenance of ⬎250 min ⭈
wk1
(see the sections on overweight and obesity in this chapter and the relevant
ACSM position stand [54]).
SPECIAL CONSIDERATIONS
• The FITT principle of Ex Rx
may need to be modified should the individuals
with dyslipidemia present with other chronic diseases and health conditions
such as metabolic syndrome, obesity, and hypertension (see the sections in
this chapter and other relevant ACSM position stands on these chronic dis-
eases and health conditions [54,183]).
• Individuals taking lipid-lowering medications that have the potential to cause
muscle damage (i.e., HMG-CoA reductase inhibitors or statins and fibric acid)
may experience muscle weakness and soreness termed myalgia (see Appendix A).
Physicians should be consulted if an individual experiences unusual or persis-
tent muscle soreness when exercising while taking these medications.
THE BOTTOM LINE
• Dyslipidemia is a major modifiable cause of CVD. Cholesterol-lowering ther-
apy and lifestyle behavioral modifications are important in the management
of individuals with dyslipidemia. The FITT principle of Ex Rx
for individuals
with dyslipidemia without comorbidities is similar to that of healthy adults,
although healthy weight maintenance should be emphasized.
National Heart Lung and Blood Institute:
http://www.nhlbi.nih.gov/guidelines/cholesterol/atp4/index.htm
Online Resources
FIBROMYALGIA
Fibromyalgia is a syndrome characterized by widespread chronic nonarticular
(soft tissue) musculoskeletal pain. Fibromyalgia affects approximately 2%–4% of
the population in the United States (137). Individuals with fibromyalgia do not
show signs of inflammation or neurological abnormalities and do not develop
joint deformities or joint disease. Therefore, fibromyalgia is not considered a
true form of arthritis. Fibromyalgia is primarily diagnosed in women (i.e., seven
women for every one man), and its prevalence increases with age.
Signs and symptoms of fibromyalgia include chronic diffuse pain and ten-
derness, fatigue, sleep disturbance, morning stiffness, and depression. Irritable](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-313-320.jpg)
![290 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
the FITT principle of Ex Rx
is generally consistent with the Ex Rx
for apparently
healthy adults (see Chapter 7) with the following considerations:
• Monitor an individual’s pain level and location.
• Give appropriate recovery time between exercises within a session and be-
tween days of exercise. Exercises should be alternated between different parts
of the body or different systems (e.g., musculoskeletal vs. cardiorespiratory).
• Individuals with fibromyalgia are commonly physically inactive because of
their symptoms. Prescribe exercise, especially at the beginning, at a physical
exertion level that the individual will be able to do or do without undue pain.
• Begin the exercise progression at a low enough level and progress slowly so as
to allow for physiologic adaptation without an increase in symptoms (44). In
general, this population has poor exercise adherence that is not only because
of an increase in symptoms but also because of the mixed and sometimes con-
tradictory information they receive from their various health care providers
(212). Individuals with fibromyalgia typically have several different profes-
sionals on their health care team (i.e., rheumatologist, primary care physician,
clinical exercise physiologist, nurse practitioner, and physical therapist) and
may get conflicting advice from several members (212).
• The individual’s symptoms always determine the starting point and rate of
progression for any type of exercise (27,76,211,242).
FITT RECOMMENDATIONS FOR INDIVIDUALS
WITH FIBROMYALGIA
Aerobic Exercise (29,76)
Frequency: Begin 2–3 d ⭈ wk1
and progress to 3–4 d ⭈ wk1
.
Intensity: Begin at 30% V̇O2
R or HRR and progress to 60% V̇O2
R
or HRR.
Time: Begin with 10 min increments and accumulate to a total of at least
30 min ⭈ d1
and progress to 60 min ⭈ d1
.
Type: Low impact/non–weight-bearing exercise (e.g., water exercise [147],
cycling, walking, swimming) initially to minimize pain that may be caused
by exercise.
Resistance Exercise
Resistance exercise generally includes muscular strength and endurance
to train the muscles for improved performance of functional activities.
Resistance training improves muscular strength and endurance in indi-
viduals with fibromyalgia, although the level of evidence is less than that
for aerobic exercise (129,211,213,242).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-316-320.jpg)
![298 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
SPECIAL CONSIDERATIONS
• Patients with uncontrolled severe hypertension (i.e., resting SBP 180 mm Hg
and/or DBP 110 mm Hg) should add exercise training to their treatment
plan only after first being evaluated by their physician and being prescribed
appropriate antihypertensive medication.
• For individuals with documented CVD such as ischemic heart disease, heart
failure, or stroke, vigorous intensity exercise training is best initiated in reha-
bilitation centers under medical supervision (see Chapter 9).
• Resting SBP ⬎200 mm Hg and/or DBP ⬎110 mm Hg, is a relative contrain-
dication to exercise testing. When exercising, it appears prudent to maintain
SBP ⱕ220 mm Hg and/or DBP ⱕ105 mm Hg.
• -Blockers and diuretics may adversely affect thermoregulatory function.
-Blockers may also increase the predisposition to hypoglycemia in certain
individuals (especially patients with DM who take insulin or insulin secre-
tagogues) and mask some of the manifestations of hypoglycemia (particu-
larly tachycardia). In these situations, educate patients about the signs and
symptoms of heat intolerance (7,9) and hypoglycemia, and the precautions
that should be taken to avoid these situations (see the section on DM in this
chapter and Appendix A).
• -Blockers, particularly the nonselective types, may reduce submaximal and
maximal exercise capacity primarily in patients without myocardial ischemia
(see Appendix A). Using perceived exertion to monitor exercise intensity is
especially beneficial in these individuals (see Chapters 4 and 7).
• Antihypertensive medications such as ␣-blockers, calcium channel blockers,
and vasodilators may lead to sudden excessive reductions in postexercise BP
.
Extend and carefully monitor the cool-down period in these individuals.
• Individuals with hypertension are often overweight or obese. Ex Rx
for these
individuals should focus on increasing caloric expenditure coupled with
reducing caloric intake to facilitate weight reduction (see the section on
overweight and obesity in this chapter and the relevant ACSM position stand
[54]).
programs should consist of 8–10 different exercises targeting the major
muscle groups (see Chapter 7).
Progression: The FITT principle of Ex Rx
relating to progression for
healthy adults, generally apply to those with hypertension. However,
consideration should be given to the level of BP control, recent changes
in antihypertensive drug therapy, medication-related adverse effects,
and the presence of target organ disease and/or other comorbidities, and
adjustments should be made accordingly. Progression should be gradual,
avoiding large increases in any of the FITT components of the Ex Rx
,
especially intensity for most individuals with hypertension.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-324-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 299
• A majority of older individuals will have hypertension. Older individuals ex-
perience similar exercise induced BP reductions as younger individuals (see
Chapter 8 and the relevant ACSM position stand [8]).
• The BP-lowering effects of aerobic exercise are immediate, a physiologic
response referred to as postexercise hypotension. To enhance exercise adher-
ence, educate these individuals about the acute or immediate BP-lowering
effects of exercise, although investigation is limited that education about BP
effects of acute exercise will improve adherence.
• For individuals with documented episodes of ischemia during exercise,
the exercise intensity should be set below the ischemic threshold (ⱕ10
beats ⭈ min1
).
• Avoid the Valsalva maneuver during resistance training.
THE BOTTOM LINE
• Recommendations regarding exercise testing for individuals with hyperten-
sion vary depending on their BP level and the presence of other CVD risk
factors, target organ disease, or CVD, as well as the intensity of the exercise
program. Patients with uncontrolled severe hypertension (i.e., resting SBP
180 mm Hg and/or DBP 110 mm Hg) should add exercise training to
their treatment plan only after first being evaluated by their physician and
being prescribed appropriate antihypertensive medication. Although vigor-
ous intensity aerobic exercise (i.e., 60% V̇O2
R) is not necessarily contra-
indicated in patients with hypertension, moderate intensity aerobic exercise
(i.e., 40%–60% V̇O2
R) is generally recommended in preference to vigorous
intensity aerobic exercise to optimize the benefit to risk ratio.
American College of Sports Medicine:
http://www.acsm.org to access the position stand on exercise and hypertension
American Heart Association:
http://www.american heart.org
National Heart Lung and Blood Institute:
http://www.nhlbi.nih.gov/hbp
Online Resources
INTELLECTUAL DISABILITY AND DOWN SYNDROME
Intellectual disability (ID) (older terminology referred to ID as mental retarda-
tion) is the most common developmental disorder in the Unites States with
an estimated prevalence of 3% of the total population (66). ID is defined as
(a) significant subaverage intelligence (i.e., two standard deviations below the](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-325-320.jpg)
![304 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
correctly performing complex movements should be minimized (e.g., if using
dance movements, allow each individual to just do what they can).
• Most individuals with ID have a short attention span. Plan exercise testing
and programming accordingly.
• Provide appropriate familiarization and practice before actual testing because
individuals with ID are often not able to adequately perform exercise tests or
exercise training.
• During exercise testing and training, careful supervision is required. Some
individuals with ID will eventually be able to perform exercise training in an
unsupervised setting but most will require supervised exercise sessions.
• Careful spotting and supervision is needed during the beginning phases of
resistance exercise training even when using machines.
• Because individuals with ID have limited attention span and limited exposure
to exercise, varied activities are suggested to maximize enjoyment and
adherence. Consider using music and simple games as part of the exercise
training program. Also consider encouraging participation in sports programs
such as Special Olympics.
• Individualize exercise training as much as possible. Large group-based
programs are likely to be less effective.
SPECIAL CONSIDERATIONS FOR INDIVIDUALS WITH
DOWN SYNDROME
• Individuals with DS have very low levels of aerobic capacity and muscle strength,
often at levels approximately 50% of the level expected based on age and sex.
• Individuals with DS are often obese, and severe obesity is not uncommon
(see the section on overweight and obesity in this chapter and the relevant
ACSM position stand [54]).
• Almost all individuals with DS have low HRmax
likely caused by reduced
catecholamine response to exercise (70).
• The likelihood of congenital heart disease is high in individuals with DS.
• It is not unusual for individuals with DS to have atlantoaxial instability. Thus, ac-
tivities involving hyperflexion or hyperextension of the neck are contraindicated.
• Many individuals with DS exhibit skeletal muscle hypotonia coupled with
excessive joint laxity. Increasing muscle strength, especially around major
joints (e.g., knee), is a priority. Also, caution should be used regarding in-
volvement in contact sports.
• Physical characteristics such as short stature, limbs, and digits commonly
coupled with malformations of feet and toes, and small mouth and nasal cavities
with a large protruding tongue may negatively impact exercise performance.
THE BOTTOM LINE
• Individuals with and without DS have different responses to exercise, and
individuals with DS often exhibit a greater number of special considerations
such as congenital heart disease, atlantoaxial instability, low levels of physical](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-330-320.jpg)
![310 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
The IDF secondary intervention includes pharmacotherapy for associated CVD
risk factors (49,113).
EXERCISE TESTING
• Special consideration should be given to associated CVD risk factors as
outlined in Chapters 2 and 3 on exercise testing and in this chapter for indi-
viduals with dyslipidemia, hypertension, and hyperglycemia.
• Because many individuals with the metabolic syndrome are either overweight
or obese, exercise testing considerations specific to those individuals should
be followed (see the section on overweight and obesity in this chapter and the
relevant ACSM position stand [54]).
• The potential for low exercise capacity in individuals who are overweight or
obese may necessitate a low initial workload (i.e., 2–3 metabolic equivalents
[METs]) and small increments per testing stage (0.5–1.0 MET).
• Because of the potential presence of elevated BP, strict adherence to protocols
for assessing BP before and during exercise testing should be followed (183)
(see Chapters 3 and 5).
EXERCISE PRESCRIPTION/SPECIAL CONSIDERATIONS
The FITT principle of Ex Rx
is consistent with the recommendations for healthy
adults regarding aerobic, resistance, and flexibility exercise (see Chapter 7).
Similarly, the minimal dose of physical activity to improve health/fitness
outcomes is consistent with the consensus public health recommendations
of 150 min ⭈ wk1
or 30 min of physical activity on most days of the week
(102,249). For these reasons and because of the impact of the clustering of
chronic diseases and health conditions that accompany the metabolic syndrome,
the following FITT principle of Ex Rx
and special considerations are combined
in this section:
• Individuals with the metabolic syndrome will likely present with multiple
CVD and DM risk factors (i.e., dyslipidemia, hypertension, obesity, and
hyperglycemia). Special consideration should be given to the FITT principle
of Ex Rx
recommendations based on the presence of these associated CVD
risk factors and the goals of the participant and/or health care provider (see
other sections of this chapter on the FITT principle Ex Rx
for these other
chronic diseases and health conditions as well as relevant ACSM position
stands [6,54,183]).
• To reduce risk factors associated with CVD and DM, initial exercise training
should be performed at a moderate intensity (i.e., 40%–60% V̇O2
R or HRR)
and when appropriate, progress to a more vigorous intensity (i.e., 60%
V̇O2
R or HRR), totaling a minimum of 150 min ⭈ wk1
or 30 min ⭈ d1
most
days of the week to allow for optimal health/fitness improvements.
• To reduce body weight, most individuals with the metabolic syndrome may
benefit by gradually increasing their physical activity levels to approximately](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-336-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 311
300 min ⭈ wk1
or 50–60 min on 5 d ⭈ wk1
when appropriate (54,216,251).
This amount of physical activity may be accumulated in multiple daily bouts
of at least 10 min in duration or through increases in other forms of moder-
ate intensity lifestyle physical activities. For some individuals to promote or
maintain weight loss, progression of 60–90 min ⭈ d1
may be necessary (see
the Ex Rx
recommendations for those with overweight and obesity in this
chapter and the relevant ACSM position stand [54]).
THE BOTTOM LINE
• The prevalence of the metabolic syndrome in the United States is increas-
ing. Many individuals with the metabolic syndrome are overweight or obese
and present with multiple CVD and DM risk factors. Special consideration
should be given to exercise testing and the FITT principle of Ex Rx
based
on the clustering of these chronic diseases and health conditions. The goal
of the Ex Rx
is to reduce the risk factors associated with CVD and DM and
reduce body weight.
American College of Sports Medicine:
http://www.acsm.org to access relevant position stands to the metabolic syndrome
American Heart Association:
http://www.heart.org
Online Resources
MULTIPLE SCLEROSIS
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the
central nervous system (CNS) that currently affects an estimated 2.1 million in-
dividuals worldwide (167). The onset of MS usually occurs between 20 and 50 yr
and affects women at a rate two to three times more than men. Initial symptoms
often include transient neurological deficits such as numbness or weakness and
blurred or double vision. Although the exact cause of MS is still unknown, most
researchers believe it involves an autoimmune response that is influenced by a
combination of environmental, infectious, and genetic factors. During an exac-
erbation, activated T cells cross the blood–brain barrier precipitating an autoim-
mune attack on myelin in the CNS. Following the initial inflammatory response,
damaged myelin forms scarlike plaques that can impair nerve conduction and
transmission (167). This can lead to a wide variety of symptoms; the most com-
mon of which include visual disturbances, weakness, sensory loss, fatigue, pain,
coordination deficits, bowel or bladder dysfunction, and cognitive and emotional
changes (144,225).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-337-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 313
of foot straps may be needed to prevent the foot from falling off the pedal
because of weakness and/or spasticity.
• A recumbent stepping ergometer (e.g., NuStep) that allows for the use of
upper and lower extremities may be advantageous because it distributes work
to all extremities, thus minimizing the potential influence of local muscle
fatigue on maximal aerobic testing.
• Depending on the disability and physical fitness level of the individual, use a
continuous or discontinuous protocol of 3–5 min stages increasing work rate
for each stage from 12 to 25 W.
• Heat sensitivity is common in individuals with MS so it is important to use a
fan or other cooling strategies during testing.
• Assessment of joint ROM and flexibility is important because increased tone
and spasticity can lead to contracture formation.
• Isokinetic dynamometry can be used to accurately evaluate muscle perfor-
mance. However, use of an 8–10-RM or functional testing (e.g., 30 s sit-to-stand
test) can also be used to measure muscular strength and endurance in the clini-
cal or community setting.
• Use physical performance tests as needed to assess endurance (6-min walk
test) (see Chapter 4), strength (5 repetition sit-to-stand), gait (walking
speed) (see Chapter 8), and balance (Berg Balance Scale [23], and Dynamic
Gait Index [107]).
EXERCISE PRESCRIPTION
For individuals with minimal disability (EDSS 0–2.5), the FITT principle of
Ex Rx
is generally consistent with those outlined in Chapter 7 for healthy adults.
As MS symptoms and level of disability increase, the following modifications
outlined may be required.
FITT RECOMMENDATIONS FOR INDIVIDUALS
WITH MULTIPLE SCLEROSIS
Aerobic Exercise
Frequency: 3–5 d ⭈ wk1
.
Intensity: 40%–70% V̇O2
R or HRR; RPE 11–14.
Time: Increase exercise time initially to a minimum of 10 min before
increasing intensity. Progress to 20–60 min. In individuals with excessive
fatigue, begin with lower intensity and discontinuous bouts of exercise.
Resistance Exercise
Frequency: 2 d ⭈ wk1
.
Intensity: 60%–80% 1-RM.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-339-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 317
SPECIAL CONSIDERATIONS
• It is difficult to quantify exercise intensity in terms of bone loading forces.
However, the magnitude of bone loading force generally increases in parallel with
exercise intensity quantified by conventional methods (e.g., %HRmax
or %1-RM).
• There are currently no established guidelines regarding contraindications for
exercise for individuals with osteoporosis. The general recommendation is to
prescribe moderate intensity exercise that does not cause or exacerbate pain.
Exercises that involve explosive movements or high-impact loading should be
avoided. Exercises that cause twisting, bending, or compression of the spine
should also be avoided.
• BMD of the spine may appear normal or increased after osteoporotic compression
fractures have occurred or in individuals with osteoarthritis of the spine. Hip
BMD is a more reliable indicator of risk for osteoporosis than spine BMD (141).
• For older women and men at increased risk for falls, the Ex Rx
should also
include activities that improve balance (see Chapter 8 and the relevant ACSM
position stand [8]).
1-RM, 8–12 repetitions with exercises involving each major muscle group)
to vigorous (e.g., 80%–90% 1-RM, 5–6 repetitions with exercises involving
each major muscle group) intensity in terms of bone loading forces.
Time: 30–60 min ⭈ d⫺1
of a combination of weight-bearing aerobic and
resistance activities.
Type: Weight-bearing aerobic activities (e.g., tennis, stair climbing/
descending, walking with intermittent jogging), activities that involve
jumping (e.g., volleyball, basketball), and resistance exercise (e.g., weight
lifting).
Individuals with Osteoporosis
In individuals with osteoporosis, the following FITT principle of Ex Rx
is
recommended to help prevent disease progression:
Frequency: Weight-bearing aerobic activities 3–5 d ⭈ wk⫺1
and resistance
exercise 2–3 d ⭈ wk⫺1
.
Intensity: Moderate intensity (i.e., 40%–⬍60% V̇O2
R or HRR) for weight-
bearing aerobic activities and moderate intensity (e.g., 60%–80% 1-RM,
8–12 repetitions of exercises involving each major muscle group) in terms
of bone loading forces, although some individuals may be able to tolerate
more intense exercise.
Time: 30–60 min ⭈ d⫺1
of a combination of weight-bearing aerobic and
resistance activities.
Type: Weight-bearing aerobic activities (e.g., stair climbing/descending,
walking, other activities as tolerated) and resistance exercise (e.g., weight
lifting).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-343-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 325
benefits. Evidence demonstrates exercise improves gait performance, quality of
life, reduces disease severity, and improves aerobic capacity in individuals with
PD (24,106,219). Exercise might also play a neuroprotective role in individu-
als with PD.
EXERCISE TESTING
Most individuals with PD have impaired mobility and problems with gait, bal-
ance, and functional ability, which vary from individual to individual. These
impairments are often accompanied by low levels of physical fitness (e.g., CRF
,
muscular strength and endurance, flexibility). The following are special consid-
erations in performing exercise testing for individuals with PD:
• Tests of balance, gait, general mobility, ROM, flexibility, and muscular
strength are recommended before exercise testing is performed. Results of the
tests can guide how to safely exercise test the individual with PD.
• Fall history should also be recorded. Patients with PD with more than one fall
in the previous year are likely to fall again within the next 3 mo (126).
• Manual muscle testing, arm curl tests, weight machines, dynamometers, and
chair rise tests (89) can be used for strength evaluation.
• Flexibility can be measured by using goniometry, the sit-and-reach test, and
the back scratch test (202).
• The 6-min walk test can be used to assess CRF (63).
• The Timed Get Up and Go test (146) and chair sit-to-stand test (228) can be
used to measure functional mobility. Gait observation can be done during the
10-m walk test at a comfortable walking speed (127,218).
• Balance evaluation and physical limitations of the individual should be used
in making decisions regarding testing modes for test validity and safety.
Clinical balance tests include the Functional Reach test (57), the Get Up and
Go test (146,148,149), tandem stance (180), single limb stance (233), and
pull tests (163,180,233). Static and dynamic balance evaluation of sitting
and standing should be performed prior to the exercise test for safety.
• Decisions regarding exercise testing protocols may be influenced by the
severity of PD (see Table 10.8) or physical limitations of the individual. Use
of a cycle leg ergometer alone or combined with arm ergometry may be more
suitable for individuals with severe gait and balance impairment or with a
history of falls (192) because they reduce fear of falling on a treadmill and
increase confidence during the test. However, use of leg/arm ergometers may
preclude individuals with PD from achieving a maximum cardiorespiratory
response because of early muscular fatigue before the maximal cardiorespi-
ratory levels are attained (267). Treadmill protocols can be used safely in
individuals with a mild stage of PD (Hoehn and Yahr [HY] stage 1–2) (267).
Submaximal tests may be most appropriate in advanced cases (HY stage 3)
or with severe mobility impairment.
• Individuals with very advanced PD (HY stage 4) and those unable to per-
form a GXT for various reasons, such as inability to stand without falling,](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-351-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 341
As a starting point and on the basis of proven efficacy and specificity to daily
activity patterns, Rimaud et al. (203) has recommended interval wheelchair
ergometry training at 70% HRpeak
for 30 min ⭈ session1
, 3 sessions ⭈ wk1
.
• Individuals with tetraplegia who have a very small active musculature will
also experience muscular fatigue before exhausting central cardiorespiratory
capacity. Aerobic exercise programs should start with 5–10 min bouts of mod-
erate intensity (i.e., 40%–60% V̇O2
R), alternated with 5 min active recovery
periods. As exercise tolerance improves, training can progress to 10–20 min
bouts of vigorous intensity (i.e., 60 V̇O2
R) alternated with 5 min active
recovery periods.
• Individuals with higher SCI levels, especially those with tetraplegia, may
benefit from use of lower body positive pressure by applying compres-
sive stockings, an elastic abdominal binder, or electrical stimulation to leg
muscles. Beneficial hemodynamic effects may include maintenance of BP,
lower HR, and higher stroke volume during arm work to compensate for
blood pooling below the lesion. Electrical stimulation of paralyzed lower
limb muscles can increase venous return and Q̇. These responses usually
occur only in individuals with spastic paralysis above T12 who have sub-
stantial sensory loss and respond to the stimulation with sustainable static
or dynamic contractions.
• Muscular strength training sessions from a seated position in the wheelchair
should be complemented with nonwheelchair exercise bouts to involve all
trunk stabilizing muscles. However, transfers (e.g., from wheelchair to the
exercise apparatus) should be limited because they result in a significant
hemodynamic load and increase the glenohumeral contact forces, and the
risk of repetitive strain injuries such as shoulder impingement syndrome and
rotator cuff strain/tear, especially in individuals with tetraplegia (256). Special
attention should be given to shoulder muscle imbalance and the prevention of
repetitive strain injuries. The prime movers of wheelchair propulsion should
be lengthened (i.e., muscles of the anterior shoulder and chest) and antago-
nists should be strengthened (i.e., muscles of the posterior shoulder, scapula,
and upper back [74]).
• Tenodesis (i.e., active wrist extensor driven finger flexion) allows functional
grasp in individuals with tetraplegia who do not have use of the hand mus-
cles. To retain the tenodesis effect, these individuals should never stretch the
finger flexor muscles (i.e., maximal and simultaneous extension of wrist and
fingers).
• Individuals with SCI tend to endure higher core temperatures during endur-
ance exercise than their able-bodied counterparts. Despite this enhanced
thermoregulatory drive, they generally have lower sweat rates. The following
factors reduce heat tolerance and should be avoided: lack of acclimatization,
dehydration, glycogen depletion, sleep loss, alcohol, and infectious disease.
During training and competition, the use of light clothing, ice vests, protec-
tive sunscreen cream, and mist spray are recommended (7,9).](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-367-320.jpg)
![344 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
• Begin with the FITT principle of Ex Rx
for the single disease and health
condition that confers the greatest risk and/or is the most limiting regarding
ADL, quality of life, and/or starting or maintaining an exercise program. Also
consider client and patient preference and goals.
• Alternatively, begin with the FITT that is the most conservative FITT pre-
scribed for the multiple diseases, health conditions, and/or CVD risk factors
the client and patient presents with as listed in Table 10.11.
• Know the magnitude and time course of response of the various health
outcome(s) that can be expected as a result of the FITT principle of Ex Rx
that
is prescribed in order to progress the client and patient safely and appropriately.
• Frequently monitor signs and symptoms to ensure safety and proper adapta-
tion and progression.
REFERENCES
1. Ahlborg L, Andersson C, Julin P
. Whole-body vibration training compared with resistance training:
effect on spasticity, muscle strength and motor performance in adults with cerebral palsy. J Rehabil Med.
2006;38(5):302–8.
2. Albright A, Franz M, Hornsby G, et al. American College of Sports Medicine position stand. Exercise
and type 2 diabetes. Med Sci Sports Exerc. 2000;32(7):1345–60.
3. Albright AL. Diabetes. In: Ehrman JK, editor. Clinical Exercise Physiology. Champaign: Human Kinetics;
2003. p. 191–210.
4. Allen NA, Fain JA, Braun B, Chipkin SR. Continuous glucose monitoring counseling improves
physical activity behaviors of individuals with type 2 diabetes: a randomized clinical trial. Diabetes
Res Clin Pract. 2008;80(3):371–9.
5. American Cancer Society. Cancer Facts and Figures 2010 [Internet]. Atlanta (GA): American Cancer
Society; [cited 2011 Feb 15]. Available from: http://www.cancer.org/acs/groups/content/@nho/
documents/document/acspc-024113.pdf
6. American College of Sports Medicine, American Diabetes Association. Exercise and type 2 diabetes:
American College of Sports Medicine and the American Diabetes Association: joint position statement.
Exercise and type 2 diabetes. Med Sci Sports Exerc. 2010;42(12):2282–303.
7. American College of Sports Medicine, Armstrong LE, Casa DJ, et al. American College of Sports
Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports Exerc.
2007;39(3):556–72.
8. American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, et al. American College of
Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc.
2009;41(7):1510–30.
9. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports
Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377–90.
10. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;
33 Suppl 1:S62–9.
11. American Diabetes Association. Standards of medical care in diabetes—2007. Diabetes Care. 2007;
30 Suppl 1:S4–41.
12. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012;
35 Suppl 1:S11–63.
13. American Thoracic Society, American College of Chest Physicians. ATS/ACCP Statement on cardio-
pulmonary exercise testing. Am J Respir Crit Care Med. 2003;167(2):211–77.
14. Anandacoomarasamy A, Caterson I, Sambrook P, Fransen M, March L. The impact of obesity on the
musculoskeletal system. Int J Obes (Lond). 2008;32(2):211–22.
15. Anuurad E, Semrad A, Berglund L. Human immunodeficiency virus and highly active antiretroviral
therapy-associated metabolic disorders and risk factors for cardiovascular disease. Metab Syndr Relat
Disord. 2009;7(5):401–10.
16. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement:
guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111–7.
17. Auxter D, Pyfer J, Huettig C. Principles and Methods of Adapted Physical Education and Recreation.
9th ed. Boston (MA): McGraw-Hill; 2001. 718 p.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-370-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 345
18. Baim S, Leonard MB, Bianchi ML, et al. Official positions of the International Society for Clinical
Densitometry and executive summary of the 2007 ISCD Pediatric Position Development Conference.
J Clin Densitom. 2008;11(1):6–21.
19. Bartlett DJ, Hanna SE, Avery L, Stevenson RD, Galuppi B. Correlates of decline in gross motor
capacity in adolescents with cerebral palsy in Gross Motor Function Classification System levels III
to V: an exploratory study. Dev Med Child Neurol. 2010;52(7):e155–60.
20. Baynard T, Pitetti KH, Guerra M, Unnithan VB, Fernhall B. Age-related changes in aerobic capacity
in individuals with mental retardation: a 20-yr review. Med Sci Sports Exerc. 2008;40(11):1984–9.
21. Beck BR, Snow CM. Bone health across the lifespan—exercising our options. Exerc Sport Sci Rev.
2003;31(3):117–22.
22. Benzo RP, Paramesh S, Patel SA, Slivka WA, Sciurba FC. Optimal protocol selection for cardio-
pulmonary exercise testing in severe COPD. Chest. 2007;132(5):1500–5.
23. Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary
development of an instrument. Physiother Can. 1989;41(6):304–11.
24. Bergen JL, Toole T, Elliott RG,3rd, Wallace B, Robinson K, Maitland CG. Aerobic exercise intervention
improves aerobic capacity and movement initiation in Parkinson’s disease patients. NeuroRehabilitation.
2002;17(2):161–8.
25. Bhole R, Flynn JC, Marbury TC. Quadriceps tendon ruptures in uremia. Clin Orthop Relat Res.
1985;(195):200–6.
26. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–81.
27. Borg GA. Scaling pain and related subjective somatic symptoms. In: Borg GA, editor. Borg’s Perceived
Exertion and Pain Scales. Champaign: Human Kinetics; 1998. p. 63–7.
28. Burckhardt CS, Clark SR, Bennett RM. The fibromyalgia impact questionnaire: development and
validation. J Rheumatol. 1991;18(5):728–33.
29. Busch AJ, Barber KA, Overend TJ, Peloso PM, Schachter CL. Exercise for treating fibromyalgia
syndrome. Cochrane Database Syst Rev. 2007;(4):CD003786.
30. Butler JM, Scianni A, Ada L. Effect of cardiorespiratory training on aerobic fitness and carryover to
activity in children with cerebral palsy: a systematic review. Int J Rehabil Res. 2010;33(2):97–103.
31. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine position stand:
prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012–29.
32. Centers for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis-
attributable activity limitation—United States, 2007–2009. MMWR Morb Mortal Wkly Rep. 2010;
59(39):1261–5.
33. Cerebral Palsy International Sports Recreation Association. Classification and Sports Rules
Manual. 9th ed. Nottingham, England: CPISRA; 2006.
34. Chaudhuri KR, Martinez-Martin P
, Brown RG, et al. The metric properties of a novel non-motor
symptoms scale for Parkinson’s disease: results from an international pilot study. Mov Disord.
2007;22(13):1901–11.
35. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on
prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42(6):
1206–52.
36. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults—The Evidence Report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S–209S.
37. Clyne N, Ekholm J, Jogestrand T, Lins LE, Pehrsson SK. Effects of exercise training in predialytic
uremic patients. Nephron. 1991;59(1):84–9.
38. Clyne N, Jogestrand T, Lins LE, Pehrsson SK. Factors influencing physical working capacity in renal
transplant patients. Scand J Urol Nephrol. 1989;23(2):145–50.
39. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports
Medicine and the American Diabetes Association: joint position statement executive summary.
Diabetes Care. 2010;33(12):2692–6.
40. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical
trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93(3):391–8.
41. COPD Guidelines (2004) [Internet]. New York (NY): American Thoracic Society; [cited 2011 Mar
11]. Available from: http://www.thoracic.org/clinical/copd-guidelines/index.php
42. Cowley PM, Ploutz-Snyder LL, Baynard T, et al. Physical fitness predicts functional tasks in indi-
viduals with Down syndrome. Med Sci Sports Exerc. 2010;42(2):388–93.
43. Crapo RO, Casaburi R, Coates AL, et al. Guidelines for methacholine and exercise challenge
testing-1999. This official statement of the American Thoracic Society was adopted by the ATS
Board of Directors, July 1999. Am J Respir Crit Care Med. 2000;161(1):309–29.
44. Dadabhoy D, Clauw DJ. Musculoskeletal signs and symptoms. E. The Fibromyalgia Syndrome. In:
Klippel JH, editor. Primer on the Rheumatic Diseases. 13th ed. New York: Springer; 2008. p. 87–93.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-371-320.jpg)
![346 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
45. Damiano DL. Activity, activity, activity: rethinking our physical therapy approach to cerebral palsy.
Phys Ther. 2006;86(11):1534–40.
46. Darrah J, Wessel J, Nearingburg P
, O’Connor M. Evaluation of a community fitness program for
adolescents with cerebral palsy. Ped Phys Ther. 1999;11(1):18–23.
47. de Haan A, de Ruiter CJ, van Der Woude LH, Jongen PJH. Contractile properties and fatigue of
quadriceps muscles in multiple sclerosis. Muscle Nerve. 2000;23(10):1534–41.
48. de Jong Z, Munneke M, Zwinderman AH, et al. Is a long-term high-intensity exercise program effective
and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial. Arthritis Rheum.
2003;48(9):2415–24.
49. Dela F
, Larsen JJ, Mikines KJ, Ploug T, Petersen LN, Galbo H. Insulin-stimulated muscle glucose
clearance in patients with NIDDM. Effects of one-legged physical training. Diabetes. 1995;44(9):
1010–20.
50. D’hooge R, Hellinckx T, Van Laethem C, et al. Influence of combined aerobic and resistance training
on metabolic control, cardiovascular fitness and quality of life in adolescents with type 1 diabetes:
a randomized controlled trial. Clin Rehabil. 2011;25(4):349–59.
51. Dibble LE, Addison O, Papa E. The effects of exercise on balance in persons with Parkinson’s disease:
a systematic review across the disability spectrum. J Neurol Phys Ther. 2009;33(1):14–26.
52. Diesel W, Noakes TD, Swanepoel C, Lambert M. Isokinetic muscle strength predicts maximum
exercise tolerance in renal patients on chronic hemodialysis. Am J Kidney Dis. 1990;16(2):109–14.
53. Dodd KJ, Taylor NF
, Damiano DL. A systematic review of the effectiveness of strength-training
programs for people with cerebral palsy. Arch Phys Med Rehabil. 2002;83(8):1157–64.
54. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports Medicine Position Stand.
Appropriate physical activity intervention strategies for weight loss and prevention of weight regain
for adults. Med Sci Sports Exerc. 2009;41(2):459–71.
55. Donnelly JE, Jakicic JM, Pronk NP
, et al. Is resistance exercise effective for weight management? Evid
Based Prev Med. 2004;1(1):21–9.
56. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment:
an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323–53.
57. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance.
J Gerontol. 1990;45(6):M192–7.
58. Earhart GM. Dance as therapy for individuals with Parkinson disease. Eur J Phys Rehabil Med. 2009;
45(2):231–8.
59. Ervin RB. Prevalence of metabolic syndrome among adults 20 years of age and over, by sex,
age, race and ethnicity, and body mass index: United States, 2003–2006. Natl Health Stat Report.
2009;13(13):1–7.
60. Ettinger WH,Jr, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resis-
tance exercise with a health education program in older adults with knee osteoarthritis. The Fitness
Arthritis and Seniors Trial (FAST). JAMA. 1997;277(1):25–31.
61. Evans RK, Bond DS, Wolfe LG, et al. Participation in 150 min/wk of moderate or higher intensity
physical activity yields greater weight loss after gastric bypass surgery. Surg Obes Relat Dis. 2007;
3(5):526–30.
62. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma [Internet].
Bethesda (MD): National Institutes of Health; National Heart, Lung, and Blood Institute; [cited 2011
Mar 11]. Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
63. Falvo MJ, Earhart GM. Six-minute walk distance in persons with Parkinson disease: a hierarchical
regression model. Arch Phys Med Rehabil. 2009;90(6):1004–8.
64. Falvo MJ, Schilling BK, Earhart GM. Parkinson’s disease and resistive exercise: rationale, review, and
recommendations. Mov Disord. 2008;23(1):1–11.
65. Fanelli A, Cabral AL, Neder JA, Martins MA, Carvalho CR. Exercise training on disease control and
quality of life in asthmatic children. Med Sci Sports Exerc. 2007;39(9):1474–80.
66. Fernhall B. Mental retardation. In: American College of Sports Medicine, editor. ACSM’s Exercise
Management for Persons with Chronic Diseases and Disabilities. Champaign: Human Kinetics; 1997,
p. 221–226.
67. Fernhall B. Mental retardation. In: American College of Sports Medicine, editor. ACSM’s Exercise
Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign: Human Kinetics;
2003. p. 304–310.
68. Fernhall B. Mental retardation. In: LeMura LM, Von Duvillard SP
, editors. Clinical Exercise Physiology:
Application and Physiological Principles. Baltimore: Lippincott Williams Wilkins; 2004. p. 617–27.
69. Fernhall B. The young athlete with a mental disability. In: Hebestreit H, Bar-Or O, IOC Medical
Commission, International Federation of Sports Medicine, editors. The Young Athlete. Malden:
Blackwell Pub; 2008. p. 403–12.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-372-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 347
70. Fernhall B, Baynard T, Collier SR, et al. Catecholamine response to maximal exercise in persons
with Down syndrome. Am J Cardiol. 2009;103(5):724–6.
71. Fernhall B, McCubbin JA, Pitetti KH, et al. Prediction of maximal heart rate in individuals with
mental retardation. Med Sci Sports Exerc. 2001;33(10):1655–60.
72. Fernhall B, Pitetti KH, Vukovich MD, et al. Validation of cardiovascular fitness field tests in children
with mental retardation. Am J Ment Retard. 1998;102(6):602–12.
73. Fernhall B, Tymeson G. Graded exercise testing of mentally retarded adults: a study of feasibility.
Arch Phys Med Rehabil. 1987;68(6):363–5.
74. Figoni SF
. Overuse shoulder problems after spinal cord injury: a conceptual model of risk and protective
factors. Clin Kinesiol. 2009;63(2):12–22.
75. Finckh A, Iversen M, Liang MH. The exercise prescription in rheumatoid arthritis: primum non nocere.
Arthritis Rheum. 2003;48(9):2393–5.
76. Fisher NM. Osteoarthritis, rheumatoid arthritis, and fibromyalgia. In: Myers J, Nieman DC, American
College of Sports Medicine, editors. ACSM’s Resources for Clinical Exercise Physiology: Musculoskeletal,
Neuromuscular, Neoplastic, Immunologic, and Hematologic Conditions. 2nd ed. Baltimore: Lippincott
Williams Wilkins; 2010. p. 132–43.
77. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults,
1999–2008. JAMA. 2010;303(3):235–41.
78. Follett KA, Weaver FM, Stern M, et al. Pallidal versus subthalamic deep-brain stimulation for
Parkinson’s disease. N Engl J Med. 2010;362(22):2077–91.
79. Fontaine KR, Conn L, Clauw DJ. Effects of lifestyle physical activity on perceived symptoms and
physical function in adults with fibromyalgia: results of a randomized trial. Arthritis Res Ther.
2010;12(2):R55.
80. Ford ES. Prevalence of the metabolic syndrome defined by the International Diabetes Federation
among adults in the U.S. Diabetes Care. 2005;28(11):2745–9.
81. Ford ES, Giles WH, Mokdad AH. Increasing prevalence of the metabolic syndrome among U.S. adults.
Diabetes Care. 2004;27(10):2444–9.
82. Fowler EG, Knutson LM, Demuth SK, et al. Pediatric endurance and limb strengthening (PEDALS)
for children with cerebral palsy using stationary cycling: a randomized controlled trial. Phys Ther.
2010;90(3):367–81.
83. Franks PW, Olsson T. Metabolic syndrome and early death: getting to the heart of the problem.
Hypertension. 2007;49(1):10–2.
84. Franzen E, Paquette C, Gurfinkel VS, Cordo PJ, Nutt JG, Horak FB. Reduced performance in balance,
walking and turning tasks is associated with increased neck tone in Parkinson’s disease. Exp Neurol.
2009;219(2):430–8.
85. From Cancer Patient to Survivor: Lost in Transition [Internet]. Washington (DC): National Academies
Press; [cited 2011 Mar 11]. Available from: http://www.nap.edu/catalog.php?record_id=11468#toc
86. Gao J, Ren J, Gulve EA, Holloszy JO. Additive effect of contractions and insulin on GLUT-4
translocation into the sarcolemma. J Appl Physiol. 1994;77(4):1597–601.
87. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand.
The quantity and quality of exercise for developing and maintaining cardiorespiratory, musculo-
skeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med
Sci Sports Exerc. 2011;43(7):1334–559.
88. Garber CE, Friedman JH. Effects of fatigue on physical activity and function in patients with
Parkinson’s disease. Neurology. 2003;60(7):1119–24.
89. Gill TM, Williams CS, Tinetti ME. Assessing risk for the onset of functional dependence among
older adults: the role of physical performance. J Am Geriatr Soc. 1995;43(6):603–9.
90. GINA Report, Global Strategy for Asthma Management and Prevention Report [Internet]. Global
Initiative for Asthma; [cited 2010 Dec 22]. Available from: http://www.ginasthma.org
91. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary
Disease [Internet]. Medical Communications Resources, Inc.; [cited 2012 Jan 7]. Available from:
http://www.goldcopd.com/download.asp?intId=554
92. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National
Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol. 2004;
44(3):720–32.
93. Haapaniemi TH, Kallio MA, Korpelainen JT, et al. Levodopa, bromocriptine and selegiline modify
cardiovascular responses in Parkinson’s disease. J Neurol. 2000;247(11):868–74.
94. Hackney ME, Earhart GM. Effects of dance on gait and balance in Parkinson’s disease: a comparison
of partnered and nonpartnered dance movement. Neurorehabil Neural Repair. 2010;24(4):384–92.
95. Hackney ME, Earhart GM. Effects of dance on movement control in Parkinson’s disease: a comparison
of Argentine tango and American ballroom. J Rehabil Med. 2009;41(6):475–81.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-373-320.jpg)
![348 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
96. Haisma JA, van der Woude LH, Stam HJ, Bergen MP
, Sluis TA, Bussmann JB. Physical capacity in
wheelchair-dependent persons with a spinal cord injury: a critical review of the literature. Spinal Cord.
2006;44(11):642–52.
97. Hampton T. Parkinson disease registry launched. JAMA. 2005;293(2):149.
98. Hand GA, Jaggers JR, Lyerly GW, Dudgeon WD. Physical activity for CVD prevention in patients
with HIV/AIDS. Curr Cardiovasc Risk Rep. 2009;3(4):288–95.
99. Hand GA, Lyerly GW, Dudgeon WD. Acquired immune deficiency syndrome (AIDS). In: Durstine
JL, American College of Sports Medicine, ACSM’s exercise management for persons with chronic
diseases and disabilities, editors. ACSM’s Exercise Management for Persons with Chronic Diseases and
Disabilities. 3rd ed. Champaign: Human Kinetics; 2009. p. 219–25.
100. Hand GA, Lyerly GW, Jaggers JR, Dudgeon WD. Impact of aerobic and resistance exercise on the
health of HIV-infected persons. Am J Lifestyle Med. 2009;3(6):489–99.
101. Hand GA, Phillips KD, Dudgeon WD, William LG, Durstine LJ, Burgess SE. Moderate intensity
exercise training reverses functional aerobic impairment in HIV-infected individuals. AIDS Care.
2008;20(9):1066–74.
102. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for
adults from the American College of Sports Medicine and the American Heart Association. Med Sci
Sports Exerc. 2007;39(8):1423–34.
103. Hayden MF
. Mortality among people with mental retardation living in the United States: research
review and policy application. Ment Retard. 1998;36(5):345–59.
104. Hazes JM, van den Ende CH. How vigorously should we exercise our rheumatoid arthritis patients?
Ann Rheum Dis. 1996;55(12):861–2.
105. Headley S, Germain M, Mailloux P, et al. Resistance training improves strength and functional
measures in patients with end-stage renal disease. Am J Kidney Dis. 2002;40(2):355–64.
106. Herman T, Giladi N, Gruendlinger L, Hausdorff JM. Six weeks of intensive treadmill training improves
gait and quality of life in patients with Parkinson’s disease: a pilot study. Arch Phys Med Rehabil.
2007;88(9):1154–8.
107. Herman T, Inbar-Borovsky N, Brozgol M, Giladi N, Hausdorff JM. The Dynamic Gait Index in
healthy older adults: the role of stair climbing, fear of falling and gender. Gait Posture. 2009;
29(2):237–41.
108. Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology. 1967;17(5):427–42.
109. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations.
Arthritis Rheum. 2006;54(1):226–9.
110. Hopman MT, Oeseburg B, Binkhorst RA. Cardiovascular responses in persons with paraplegia to
prolonged arm exercise and thermal stress. Med Sci Sports Exerc. 1993;25(5):577–83.
111. Horowitz MB, Littenberg B, Mahler DA. Dyspnea ratings for prescribing exercise intensity in patients
with COPD. Chest. 1996;109(5):1169–75.
112. Hurley BF
, Roth SM. Strength training in the elderly: effects on risk factors for age-related diseases.
Sports Med. 2000;30(4):249–68.
113. The IDF Concensus Worldwide Definition of the Metabolic Syndrome. 2006 [Internet]. Brussels, Belgium:
International Diabetes Federation; [cited 2008 Jul 23]. Available from: http://www.idf.org/webdata/
docs/IDF_Meta_def_final.pdf
114. Jacobi D, Ciangura C, Couet C, Oppert JM. Physical activity and weight loss following bariatric surgery.
Obes Rev. 2011;12(5):366–77
115. Jakicic JM, Clark K, Coleman E, et al. American College of Sports Medicine position stand.
Appropriate intervention strategies for weight loss and prevention of weight regain for adults. Med Sci
Sports Exerc. 2001;33(12):2145–56.
116. Jakicic JM, Winters C, Lang W, Wing RR. Effects of intermittent exercise and use of home exercise
equipment on adherence, weight loss, and fitness in overweight women: a randomized trial. JAMA.
1999;282(16):1554–60.
117. Jan MH, Lin JJ, Liau JJ, Lin YF
, Lin DH. Investigation of clinical effects of high- and low-resistance
training for patients with knee osteoarthritis: a randomized controlled trial. Phys Ther. 2008;
88(4):427–36.
118. Jankovic J, Stacy M. Medical management of levodopa-associated motor complications in patients
with Parkinson’s disease. CNS Drugs. 2007;21(8):677–92.
119. Johansen KL. Exercise and chronic kidney disease: current recommendations. Sports Med. 2005;
35(6):485–99.
120. Jones KD, Burckhardt CS, Clark SR, Bennett RM, Potempa KM. A randomized controlled trial of
muscle strengthening versus flexibility training in fibromyalgia. J Rheumatol. 2002;29(5):1041–8.
121. Jones LW, Eves ND, Peppercorn J. Pre-exercise screening and prescription guidelines for cancer
patients. Lancet Oncol. 2010;11(10):914–6.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-374-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 349
122. Kaminsky LA, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for
Exercise Testing and Prescription. 5th ed. Baltimore (MD): Lippincott Williams Wilkins; 2005. 749 p.
123. Kendrick AH, Johns DP, Leeming JP. Infection control of lung function equipment: a practical
approach. Respir Med. 2003;97(11):1163–79.
124. Kent-Braun JA, Sharma KR, Weiner MW, Miller RG. Effects of exercise on muscle activation and
metabolism in multiple sclerosis. Muscle Nerve. 1994;17(10):1162–9.
125. Kenyon LK, Sleeper MD, Tovin MM. Sport-specific fitness testing and intervention for an adolescent
with cerebral palsy: a case report. Pediatr Phys Ther. 2010;22(2):234–40.
126. Keus SH, Bloem BR, Hendriks EJ, Bredero-Cohen AB, Munneke M, Practice Recommendations
Development Group. Evidence-based analysis of physical therapy in Parkinson’s disease with
recommendations for practice and research. Mov Disord. 2007;22(4):451–60; quiz 600.
127. Keus SHJ, Hendriks HJM, Bloem BR, et al. KNGF Guidelines for physical therapy in Parkinson’s
disease. Ned Tijdschr Fysiother. 2004;114(Suppl 3):5–86.
128. King WC, Belle SH, Eid GM, et al. Physical activity levels of patients undergoing bariatric surgery
in the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis. 2008;4(6):721–8.
129. Kingsley JD, McMillan V, Figueroa A. The effects of 12 weeks of resistance exercise training on
disease severity and autonomic modulation at rest and after acute leg resistance exercise in women
with fibromyalgia. Arch Phys Med Rehabil. 2010;91(10):1551–7.
130. Klippel JH. Primer on the Rheumatic Diseases. 13th ed. New York (NY): Springer; 2008. 721 p.
131. Kloos AD, Heiss DG. Exercise for impaired balance. In: Kisner C, Colby LA, editors. Therapeutic
Exercise: Foundations and Techniques. 5th ed. Philadelphia: F
.A. Davis; 2007. p. 251–72.
132. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403.
133. Kohrt WM, Bloomfield SA, Little KD, Nelson ME, Yingling VR, American College of Sports
Medicine. American College of Sports Medicine position stand: physical activity and bone health.
Med Sci Sports Exerc. 2004;36(11):1985–96.
134. Krebs P
. Mental retardation. In: Winnick JP
, editor. Adapted Physical Education and Sport. Champaign:
Human Kinetics; 1990. p. 153–76.
135. Kurtzke JF
. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale
(EDSS). Neurology. 1983;33(11):1444.
136. Lambert CP
, Archer RL, Evans WJ. Muscle strength and fatigue during isokinetic exercise in individuals
with multiple sclerosis. Med Sci Sports Exerc. 2001;33(10):1613–9.
137. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other
rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26–35.
138. Leger L, Boucher R. An indirect continuous running multistage field test: the Universite de Montreal
track test. Can J Appl Sport Sci. 1980;5(2):77–84.
139. Levey AS, Tangri N, Stevens LA. Classification of chronic kidney disease: a step forward. Ann Intern
Med. 2011;154(1):65–7.
140. Lin K, Stewart D, Cooper S, Davis CL. Pre-transplant cardiac testing for kidney-pancreas transplant
candidates and association with cardiac outcomes. Clin Transplant. 2001;15(4):269–75.
141. Liu G, Peacock M, Eilam O, Dorulla G, Braunstein E, Johnston CC. Effect of osteoarthritis in the
lumbar spine and hip on bone mineral density and diagnosis of osteoporosis in elderly men and
women. Osteoporos Int. 1997;7(6):564–9.
142. Lockette KF
, Keyes AM. Conditioning with Physical Disabilities. Champaign (IL): Human Kinetics;
1994. 272 p.
143. Longitudinal Assessment of Bariatric Surgery [Internet]. University of Pittsburgh, Epidemiology
Data Center; [cited 2012 Jan 7]. Available from: http://www.edc.gsph.pitt.edu/labs/
144. Lublin FD, Reingold SC, National Multiple Sclerosis Society (USA) Advisory Committee on Clinical
Trials of New Agents in Multiple Sclerosis. Defining the clinical course of multiple sclerosis: results
of an international survey. Neurology. 1996;46(4):907–11.
145. Macfarlane DJ, Taylor LH, Cuddihy TF
. Very short intermittent vs continuous bouts of activity in
sedentary adults. Prev Med. 2006;43(4):332–6.
146. Mak MK, Pang MY. Balance confidence and functional mobility are independently associated with
falls in people with Parkinson’s disease. J Neurol. 2009;256(5):742–9.
147. Mannerkorpi K, Nordeman L, Ericsson A, Arndorw M, GAU Study Group. Pool exercise for
patients with fibromyalgia or chronic widespread pain: a randomized controlled trial and subgroup
analyses. J Rehabil Med. 2009;41(9):751–60.
148. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med
Rehabil. 1986;67(6):387–9.
149. Matinolli M, Korpelainen JT, Korpelainen R, Sotaniemi KA, Matinolli VM, Myllyla VV. Mobility
and balance in Parkinson’s disease: a population-based study. Eur J Neurol. 2009;16(1):105–11.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-375-320.jpg)
![350 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
150. McNeely ML, Courneya KS. Exercise programs for cancer-related fatigue: evidence and clinical
guidelines. J Natl Compr Canc Netw. 2010;8(8):945–53.
151. McNeely ML, Peddle C, Parliament M, Courneya KS. Cancer rehabilitation: recommendations
for integrating exercise programming in the clinical practice setting. Curr Cancer Ther Rev. 2006;
2(4):351–60.
152. The medical and psychological concerns of cancer survivors after treatment. In: Hewitt M,
Greenfield S, Stovall E, editors. From Cancer Patient to Survivor: Lost in Transition. Washington:
National Academies Press; 2006. p. 66–186.
153. Mendes FA, Almeida FM, Cukier A, et al. Effects of aerobic training on airway inflammation in
asthmatic patients. Med Sci Sports Exerc. 2011;43(2):197–203.
154. Mendes FA, Goncalves RC, Nunes MP, et al. Effects of aerobic training on psychosocial morbidity
and symptoms in patients with asthma: a randomized clinical trial. Chest. 2010;138(2):331–7.
155. Messier SP. Arthritic diseases and conditions. In: Kaminsky LA, editor. ACSM’s Resource Manual for
Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore: Lippincott Williams Wilkins;
2006. p. 500–13.
156. Miller TD, Squires RW, Gau GT, Ilstrup DM, Frohnert PP
, Sterioff S. Graded exercise testing and
training after renal transplantation: a preliminary study. Mayo Clin Proc. 1987;62(9):773–7.
157. Minor MA, Kay DR. Arthritis. In: American College of Sports Medicine, editor. ACSM’s Exercise
Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign: Human
Kinetics; 2003. p. 210–16.
158. Mockford M, Caulton JM. Systematic review of progressive strength training in children and
adolescents with cerebral palsy who are ambulatory. Pediatr Phys Ther. 2008;20(4):318–33.
159. Morris ME. Locomotor training in people with Parkinson disease. Phys Ther. 2006;86(10):
1426–35.
160. Morris ME. Movement disorders in people with Parkinson disease: a model for physical therapy.
Phys Ther. 2000;80(6):578–97.
161. Morris ME, Martin CL, Schenkman ML. Striding out with Parkinson disease: evidence-based
physical therapy for gait disorders. Phys Ther. 2010;90(2):280–8.
162. Mostert S, Kesselring J. Effects of a short-term exercise training program on aerobic fitness, fatigue,
health perception and activity level of subjects with multiple sclerosis. Mult Scler; 2002;8(2):161–8.
163. Munhoz RP
, Li JY, Kurtinecz M, et al. Evaluation of the pull test technique in assessing postural
instability in Parkinson’s disease. Neurology. 2004;62(1):125–7.
164. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the
National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation.
2002;106(25):3143–421.
165. National Coalition for Cancer Survivorship Web site [Internet]. Silver Spring (MD): National Coalition
for Cancer Survivorship; [cited 2011 Feb 14]. Available from: http://www.canceradvocacy.org/about/
org/history.html
166. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease:
evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1–266.
167. National Multiple Sclerosis Society Web site [Internet]. New York (NY): National Multiple Sclerosis
Society; [cited 2010 Oct 18]. Available from: http://www.nationalmssociety.org/index.aspx
168. National Multiple Sclerosis Society. Clinical Study Measures: Modified Fatigue Impact Scale (MFIS)
[Internet]. New York (NY): National Multiple Sclerosis Society; [cited 2011 Feb 6]. Available from:
http://www.nationalmssociety.org/for-professionals/researchers/clinical-study-measures/mfis/index
.aspx
169. Needle RH, Trotter RT,2nd, Singer M, et al. Rapid assessment of the HIV/AIDS crisis in racial and
ethnic minority communities: an approach for timely community interventions. Am J Public Health.
2003;93(6):970–9.
170. Ness KK, Wall MM, Oakes JM, Robison LL, Gurney JG. Physical performance limitations and
participation restrictions among cancer survivors: a population-based study. Ann Epidemiol. 2006;
16(3):197–205.
171. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement
on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12):1390–413.
172. O’Donnell DE, Laveneziana P
, Ora J, Webb KA, Lam YM, Ofir D. Evaluation of acute bronchodilator
reversibility in patients with symptoms of GOLD stage I COPD. Thorax. 2009;64(3):216–23.
173. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in
US children and adolescents, 2007–2008. JAMA. 2010;303(3):242–9.
174. Painter PL. Exercise after renal transplantation. Adv Ren Replace Ther. 1999;6:159–64.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-376-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 351
175. Painter PL. Physical functioning in end-stage renal disease patients: update 2005. Hemodial Int.
2005;9(3):218–35.
176. Painter PL, Hector L, Ray K, et al. A randomized trial of exercise training after renal transplanta-
tion. Transplantation. 2002;74(1):42–8.
177. Painter PL, Krasnoff JB. End-stage metabolic disease: renal failure and liver failure. In: Durstine
JL, editor. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. 2nd ed.
Champaign: Human Kinetics; 2003. p. 126–32.
178. Painter P, Moore GE. The impact of recombinant human erythropoietin on exercise capacity in
hemodialysis patients. Adv Ren Replace Ther. 1994;1(1):55–65.
179. Palisano RJ, Snider LM, Orlin MN. Recent advances in physical and occupational therapy for
children with cerebral palsy. Semin Pediatr Neurol. 2004;11(1):66–77.
180. Pastor MA, Day BL, Marsden CD. Vestibular induced postural responses in Parkinson’s disease.
Brain. 1993;116(Pt 5):1177–90.
181. Perkins EA, Moran JA. Aging adults with intellectual disabilities. JAMA. 2010;304(1):91–2.
182. Perri MG, Anton SD, Durning PE, et al. Adherence to exercise prescriptions: effects of prescribing
moderate versus higher levels of intensity and frequency. Health Psychol. 2002;21(5):452–8.
183. Pescatello LS, Franklin BA, Fagard R, et al. American College of Sports Medicine position stand.
Exercise and hypertension. Med Sci Sports Exerc. 2004;36(3):533–53.
184. Petajan JH, Gappmaier E, White AT, Spencer MK, Mino L, Hicks RW. Impact of aerobic training
on fitness and quality of life in multiple sclerosis. Ann Neurol. 1996;39(4):432–41.
185. Pezzoli G, Zini M. Levodopa in Parkinson’s disease: from the past to the future. Expert Opin
Pharmacother. 2010;11(4):627–35.
186. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S.
Department of Health and Human Services; [cited 2011 Jan 6]. Available from: http://www.health
.gov/paguidelines/Report/pdf/CommitteeReport.pdf
187. Pitetti K, Fernandez J, Lanciault M. Feasibility of an exercise program for adults with cerebral palsy
a pilot study. Adapt Phys Act Q. 1991; 8(4):333–41.
188. Politis M, Wu K, Molloy S, G Bain P, Chaudhuri KR, Piccini P. Parkinson’s disease symptoms:
the patient’s perspective. Mov Disord. 2010;25(11):1646–51.
189. Ponichtera-Mulcare JA, Glaser RM, Mathews T, Camaione D. Maximal aerobic exercise in persons
with MS. Clin Kinesiol. 1983;46(4):12–21.
190. Ponichtera-Mulcare JA, Mathews T, Barrett PJ, Gupta SC. Changes in aerobic fitness of patients
with multiple sclerosis during a 6-month training program. Sports Med Train Rehabil. 1997;7(3):
265–72.
191. Ponichtera-Mulcare JA, Mathews T, Glaser RM, Mathrews T, Gupta SC. Maximal aerobic exercise
of individuals with MS using three modes of ergometry. Clin Kinesiol. 1995;49:4–13.
192. Protas EJ, Stanley RK. Parkinson’s disease. In: Myers J, Herbert WG, Humphrey RH, editors. ACSM’s
Resources for Clinical Exercise Physiology: Musculoskeletal, Neuromuscular, Neoplastic, Immunologic,
and Hematologic Conditions. Baltimore: Lippincott Williams Wilkins; 2002. p. 38–47.
193. Protas EJ, Stanley RK. Parkinson’s disease. In: Myers J, Nieman DC, American College of
Sports Medicine, editors. ACSM’s Resources for Clinical Exercise Physiology: Musculoskeletal,
Neuromuscular, Neoplastic, Immunologic, and Hematologic Conditions. 2nd ed. Baltimore: Lippincott
Williams Wilkins; 2010. p. 44–57.
194. Protas EJ, Stanley RK, Jankovic J. Parkinson’s disease. In: American College of Sports Medicine,
editor. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Champaign:
Human Kinetics; 1997. p. 212–18.
195. Ram FS, Robinson SM, Black PN, Picot J. Physical training for asthma. Cochrane Database Syst Rev.
2005;(4):CD001116.
196. Ram FS, Wellington SR, Barnes NC. Inspiratory muscle training for asthma. Cochrane Database
Syst Rev. 2003;(4):CD003792.
197. Reid S, Hamer P, Alderson J, Lloyd D. Neuromuscular adaptations to eccentric strength training in
children and adolescents with cerebral palsy. Dev Med Child Neurol. 2010;52(4):358–63.
198. Rezak M. Current pharmacotherapeutic treatment options in Parkinson’s disease. Dis Mon. 2007;
53(4):214–22.
199. Rice CL, Vollmer TL, Bigland-Ritchie B. Neuromuscular responses of patients with multiple sclerosis.
Muscle Nerve. 1992;15(10):1123–32.
200. Richmond J, Hunter D, Irrgang J, et al. American Academy of Orthopaedic Surgeons clinical prac-
tice guideline on the treatment of osteoarthritis (OA) of the knee. J Bone Joint Surg Am. 2010;92(4):
990–3.
201. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-
Based Clinical Practice Guidelines. Chest. 2007;131(5 Suppl):4S–42S.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-377-320.jpg)
![352 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
202. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign (IL): Human Kinetics; 2001. 161 p.
203. Rimaud D, Calmels P, Devillard X. Training programs in spinal cord injury. Ann Readapt Med Phys.
2005;48(5):259–69.
204. Rimmer JH. Physical fitness levels of persons with cerebral palsy. Dev Med Child Neurol. 2001;
43(3):208–12.
205. Ritter PL, Gonzalez VM, Laurent DD, Lorig KR. Measurement of pain using the visual numeric
scale. J Rheumatol. 2006;33(3):574–80.
206. Robertson MC, Campbell AJ, Gardner MM, Devlin N. Preventing injuries in older people by
preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc. 2002;50(5):905–11.
207. Robertson RJ, Goss FL, Dube J, et al. Validation of the adult OMNI scale of perceived exertion for
cycle ergometer exercise. Med Sci Sports Exerc. 2004;36(1):102–8.
208. Roddy E, Zhang W, Doherty M. Aerobic walking or strengthening exercise for osteoarthritis of the
knee? A systematic review. Ann Rheum Dis. 2005;64(4):544–8.
209. Rogers A, Furler BL, Brinks S, Darrah J. A systematic review of the effectiveness of aerobic exercise
interventions for children with cerebral palsy: an AACPDM evidence report. Dev Med Child Neurol.
2008;50(11):808–14.
210. Roizen NJ, Patterson D. Down’s syndrome. Lancet. 2003;361(9365):1281–9.
211. Rooks DS. Fibromyalgia treatment update. Curr Opin Rheumatol. 2007;19(2):111–7.
212. Rooks DS. Talking to patients with fibromyalgia about physical activity and exercise. Curr Opin
Rheumatol. 2008;20(2):208–12.
213. Rooks DS, Silverman CB, Kantrowitz FG. The effects of progressive strength training and aerobic
exercise on muscle strength and cardiovascular fitness in women with fibromyalgia: a pilot study.
Arthritis Rheum. 2002;47(1):22–8.
214. Rosendorff C, Black HR, Cannon CP
, et al. Treatment of hypertension in the prevention and manage-
ment of ischemic heart disease: a scientific statement from the American Heart Association Council
for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and
Prevention. Circulation. 2007;115(21):2761–88.
215. Ryuzaki M, Konishi K, Kasuga A, et al. Spontaneous rupture of the quadriceps tendon in patients on
maintenance hemodialysis—report of three cases with clinicopathological observations. Clin Nephrol.
1989;32(3):144–8.
216. Saris WH, Blair SN, van Baak MA, et al. How much physical activity is enough to prevent unhealthy
weight gain? Outcome of the IASO 1st Stock Conference and consensus statement. Obes Rev.
2003;4(2):101–14.
217. Scandalis TA, Bosak A, Berliner JC, Helman LL, Wells MR. Resistance training and gait function in
patients with Parkinson’s disease. Am J Phys Med Rehabil. 2001;80(1):38–43; quiz 44–6.
218. Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to improve spinal flexibility and func-
tion for people with Parkinson’s disease: a randomized, controlled trial. J Am Geriatr Soc. 1998;
46(10):1207–16.
219. Schenkman M, Hall D, Kumar R, Kohrt WM. Endurance exercise training to improve economy of
movement of people with Parkinson disease: three case reports. Phys Ther. 2008;88(1):63–76.
220. Schmid A, Schmidt-Trucksass A, Huonker M, et al. Catecholamines response of high performance
wheelchair athletes at rest and during exercise with autonomic dysreflexia. Int J Sports Med.
2001;22(1):2–7.
221. Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on
exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409–26.
222. Schneider CM, Dennehy CA, Roozeboom M, Carter SD. A model program: exercise intervention
for cancer rehabilitation. Integr Cancer Ther. 2002;1(1):76–82; discussion 82.
223. Scholtes VA, Becher JG, Comuth A, Dekkers H, Van Dijk L, Dallmeijer AJ. Effectiveness of func-
tional progressive resistance exercise strength training on muscle strength and mobility in children
with cerebral palsy: a randomized controlled trial. Dev Med Child Neurol. 2010;52(6):e107–13.
224. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure [Internet]: Bethesda (MD): U.S. Department of Health and Human
Services, National High Blood Pressure Education Program; 2004 [cited 2012 Jan 7]. Available
from: http://www.ncbi.nlm.nih.gov.ezproxy.lib.uconn.edu/books/bv.fcgi?rid=hbp7.TOC
225. Shapiro R. Managing the Symptoms of Multiple Sclerosis. 4th ed. New York (NY): Demos Medical
Publishers; 2003. 192 p.
226. Sharoff CG, Hagobian TA, Malin SK, et al. Combining short-term metformin treatment and one
bout of exercise does not increase insulin action in insulin-resistant individuals. Am J Physiol
Endocrinol Metab. 2010;298(4):E815–23.
227. Sharples L, Hughes V, Crean A, et al. Cost-effectiveness of functional cardiac testing in the diagnosis
and management of coronary artery disease: a randomised controlled trial. The CECaT trial. Health
Technol Assess. 2007;11(49):iii–iv, ix–115.](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-378-320.jpg)
![CHAPTER 10 Exercise Prescription for Other Clinical Populations 353
228. Shrier I. Flexibility versus stretching. Br J Sports Med. 2001;35(5):364.
229. Sidney S, Lewis CE, Hill JO, et al. Association of total and central adiposity measures with fasting
insulin in a biracial population of young adults with normal glucose tolerance: the CARDIA study.
Obes Res. 1999;7(3):265–72.
230. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and
type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care.
2006;29(6):1433–8.
231. Silsupadol P, Shumway-Cook A, Lugade V, et al. Effects of single-task versus dual-task training on
balance performance in older adults: a double-blind, randomized controlled trial. Arch Phys Med
Rehabil. 2009;90(3):381–7.
232. Skeletal muscle dysfunction in chronic obstructive pulmonary disease. A statement of the
American Thoracic Society and European Respiratory Society. Am J Respir Crit Care Med. 1999;
159(4 Pt 2):S1–40.
233. Smithson F
, Morris ME, Iansek R. Performance on clinical tests of balance in Parkinson’s disease.
Phys Ther. 1998;78(6):577–92.
234. Stacy M. Medical treatment of Parkinson disease. Neurol Clin. 2009;27(3):605–31, v.
235. Steadward R. Musculoskeletal and neurological disabilities: implications for fitness appraisal,
programming, and counselling. Can J Appl Physiol. 1998;23(2):131–65.
236. Sterman AB, Coyle PK, Panasci DJ, Grimson R. Disseminated abnormalities of cardiovascular
autonomic functions in multiple sclerosis. Neurology. 1985;35(11):1665.
237. Stoessl AJ. Continuous dopaminergic therapy in Parkinson disease: time to stride back? Ann Neurol.
2010;68(1):3–5.
238. Stone PC, Minton O. Cancer-related fatigue. Eur J Cancer. 2008;44(8):1097–104.
239. Svien LR, Berg P
, Stephenson C. Issues in aging with cerebral palsy. Top Geriatr Rehabil. 2008;
24(1):26–40.
240. Teo-Koh SM, McCubbin JA. Relationship between peak VO2
and 1-mile walk test performance of
adolescent males with mental retardation. Pediatr Exerc Sci. 1999;11(2):144–57.
241. Thomas TR, Warner SO, Dellsperger KC, et al. Exercise and the metabolic syndrome with weight
regain. J Appl Physiol. 2010;109(1):3–10.
242. Tomas-Carus P, Gusi N, Hakkinen A, Hakkinen K, Raimundo A, Ortega-Alonso A. Improvements
of muscle strength predicted benefits in HRQOL and postural balance in women with fibromyalgia:
an 8-month randomized controlled trial. Rheumatology (Oxford). 2009;48(9):1147–51.
243. Tresierras MA, Balady GJ. Resistance training in the treatment of diabetes and obesity: mechanisms
and outcomes. J Cardiopulm Rehabil Prev. 2009;29(2):67–75.
244. Troosters T, Casaburi R, Gosselink R, Decramer M. Pulmonary rehabilitation in chronic obstructive
pulmonary disease. Am J Respir Crit Care Med. 2005;172(1):19–38.
245. Tsai AG, Williamson DF, Glick HA. Direct medical cost of overweight and obesity in the USA:
a quantitative systematic review. Obes Rev. 2011;12(1):50–61.
246. Turner S, Eastwood P, Cook A, Jenkins S. Improvements in symptoms and quality of life follow-
ing exercise training in older adults with moderate/severe persistent asthma. Respiration. 2011;
81(4):302–10.
247. Twelves D, Perkins KS, Counsell C. Systematic review of incidence studies of Parkinson’s disease.
Mov Disord. 2003;18(1):19–31.
248. Unnithan VB, Clifford C, Bar-Or O. Evaluation by exercise testing of the child with cerebral palsy.
Sports Med. 1998;26(4):239–51.
249. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans
[Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008 [cited 2011
Jan 6] 78 p. Available from: http://www.health.gov/paguidelines/pdf/paguide.pdf
250. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the
Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health
Service, Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion; 1996. 278 p. Available from: U.S. GPO, Washington.
251. U.S. Department of Health and Human Services, United States Department of Agriculture, United
States Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans, 2005. 6th ed.
Washington (DC): G.P
.O; 2005. 71 p.
252. U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation statement.
Ann Intern Med. 2004;140(7):569–72.
253. U.S. Public Health Service, Office of the Surgeon General. Bone Health and Osteoporosis: A Report of
the Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, Public Health
Service, Office of the Surgeon General; 2004. 404 p.
254. U.S. Renal Data System. USRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-
Stage Renal Disease in the United States [Internet]. Bethesda (MD): National Institutes of Health,](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-379-320.jpg)
![354 GUIDELINES FOR EXERCISE TESTING • www.acsm.org
National Institute of Diabetes and Digestive and Kidney Diseases; [cited 2012 Jun 9]. Available
from: http://www.usrds.org/atlas09.aspx
255. van den Ende CH, Hazes JM, le Cessie S, et al. Comparison of high and low intensity training
in well controlled rheumatoid arthri](https://image.slidesharecdn.com/acsmguidelines-230807164336-c3baa452/85/ACSM-guidelines-pdf-380-320.jpg)
ACSM guidelines.pdf
- 3. ACSM’S Guidelines for Exercise Testing and Prescription NINTH EDITION
- 4. ii GUIDELINES FOR EXERCISE TESTING • www.acsm.org SENIOR EDITOR Linda S. Pescatello, PhD, FACSM, FAHA, ACSM-PD, ACSM-ETT Professor Department of Kinesiology & Human Performance Laboratory Neag School of Education University of Connecticut Storrs, Connecticut ASSOCIATE EDITORS Ross Arena, PhD, PT, FACSM, FAACVPR, FAHA, ACSM-CES Director and Professor Physical Therapy Program Department of Orthopaedics & Rehabilitation University of New Mexico Health Sciences Center Albuquerque, New Mexico Deborah Riebe, PhD, FACSM, ACSM-HFS Chair and Professor Department of Kinesiology University of Rhode Island Kingston, Rhode Island Paul D.Thompson, MD, FACSM, FACC Chief of Cardiology Hartford Hospital Hartford, Connecticut
- 5. AMERICAN COLLEGE OF SPORTS MEDICINE ACSM’S Guidelines for Exercise Testing and Prescription NINTH EDITION
- 6. Acquisitions Editor: Emily Lupash Product Manager: Meredith L. Brittain Marketing Manager: Sarah Schuessler Vendor Manager: Marian Bellus Creative Director: Doug Smock Compositor: Absolute Service, Inc. ACSM Committee on Certification and Registry Boards Chair: Deborah Riebe, PhD, FACSM, ACSM-HFS ACSM Publications Committee Chair: Walter R. Thompson, PhD, FACSM, FAACVPR ACSM Group Publisher: Kerry O’Rourke Umbrella Editor: Jonathan K. Ehrman, PhD, FACSM Ninth Edition Copyright © 2014, 2010, 2006, 2001 American College of Sports Medicine 351 West Camden Street Two Commerce Square / 2001 Market Street Baltimore, MD 21201 Philadelphia, PA 19103 Printed in China All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data ACSM’s guidelines for exercise testing and prescription / American College of Sports Medicine ; senior editor, Linda S. Pescatello ; associate editors, Ross Arena, Deborah Riebe, Paul D. Thompson. — 9th ed. p. ; cm. Guidelines for exercise testing and prescription Includes bibliographical references and index. ISBN 978-1-60913-605-5 I. Pescatello, Linda S. II. American College of Sports Medicine. III. Title: Guidelines for exercise testing and prescription. [DNLM: 1. Physical Exertion—Guideline. 2. Exercise Test—standards—Guideline. 3. Exercise Therapy— standards—Guideline. WE 103] 615.8'2—dc23 2012038784 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at (800) 638-3030 or fax orders to (301) 223-2320. International customers should call (301) 223-2300. Visit Lippincott Williams & Wilkins on the Internet: http://www.lww.com. Lippincott Williams & Wilkins customer service representatives are available from 8:30 am to 6:00 pm, EST.
- 7. This book is dedicated to the hundreds of volunteer professionals who have, since 1975, contributed their valuable time and expertise to develop and update the Guidelines. Now in its ninth edition, it is the most widely circulated set of guidelines used by professionals performing exercise testing or exercise programs. Specifically, this edition is dedicated to the editors, contributing authors, and reviewers of this and previous editions, who have not only provided their collective expertise but also their valuable time to ensure the Guidelines meet the highest standards in exercise science and practice.
- 8. vi The American College of Sports Medicine (ACSM) Guidelines origins are within the ACSM Committee on Certification and Registry Boards (CCRB, formerly known as the Certification and Education Committee and the Preventive and Rehabilitative Exercise Committee). Today, the Guidelines remain under the auspices of the CCRB, and have become the primary resource for anyone conducting exercise testing or exercise programs. The Guidelines provide the foundation of content for its sup- porting companion texts produced by ACSM, which include the seventh edition of ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, fourth edition of ACSM’s Certification Review, fourth edition of ACSM’s Resources for the Personal Trainer, first edition of ACSM’s Resources for the Health Fitness Specialist, fourth edition of ACSM’s Health-Related Physical Fitness Assessment Manual, and second edition of ACSM’s Resources for Clinical Exercise Physiology: Musculoskeletal, Neuromuscular, Neoplastic, Immunologic, and Hematologic Conditions. The first edition of the Guidelines was published in 1975, with updated edi- tions published approximately every 4 to 6 years. The outstanding scientists and clinicians who have served in leadership positions as chairs and editors of the Guidelines since 1975 are: First Edition, 1975 Karl G. Stoedefalke, PhD, FACSM, Cochair John A. Faulkner, PhD, FACSM, Cochair Second Edition, 1980 Anne R. Abbott, PhD, FACSM, Chair Third Edition, 1986 Steven N. Blair, PED, FACSM, Chair Fourth Edition, 1991 Russell R. Pate, PhD, FACSM, Chair Fifth Edition, 1995 Larry W. Kenney, PhD, FACSM, Senior Editor Reed H. Humphrey, PhD, PT, FACSM, Associate Editor Clinical Cedric X. Bryant, PhD, FACSM, Associate Editor Fitness Sixth Edition, 2000 Barry A. Franklin, PhD, FACSM, Senior Editor Mitchell H. Whaley, PhD, FACSM, Associate Editor Clinical Edward T. Howley, PhD, FACSM, Associate Editor Fitness Seventh Edition, 2005 Mitchell H. Whaley, PhD, FACSM, Senior Editor Peter H. Brubaker, PhD, FACSM, Associate Editor Clinical Robert M. Otto, PhD, FACSM, Associate Editor Fitness Eighth Edition, 2009 Walter R. Thompson, PhD, FACSM, Senior Editor Neil F . Gordon, MD, PhD, FACSM, Associate Editor Linda S. Pescatello, PhD, FACSM, Associate Editor Ninth Edition, 2013 Linda S. Pescatello, PhD, FACSM, Senior Editor Ross Arena, PhD, PT, FACSM, Associate Editor Deborah Riebe, PhD, FACSM, Associate Editor Paul D. Thompson, MD, FACSM, Associate Editor
- 9. Index vii Preface This edition of ACSM’s Guidelines for Exercise Testing and Prescription will con- tinue the efforts of the editors and contributing authors of the eighth edition to make the ninth edition a true guidelines book rather than a sole and inclusive resource. For it was the original intent of the Guidelines to be user friendly, easily accessible, and a current primary resource for professionals that conduct exer- cise testing and exercise programs. To this effect, in this edition, text descrip- tions have been minimized; more tables, boxes, and figures have been included; summary boxes have been added throughout to highlight important information; and take home messages and key Web sites now conclude each chapter. The reader of this edition of ACSM’s Guidelines for Exercise Testing and Prescription will notice several new themes. First and foremost, the ninth edi- tion supports the public health message that all people should adopt a physically active lifestyle by reducing the emphasis on the need for medical evaluation (i.e., medical examination and exercise testing) as part of the preparticipation health screening process prior to initiating a progressive exercise regimen among healthy, asymptomatic persons. This edition of the Guidelines seeks to simplify the preparticipaton health screening process in order to remove unnecessary and unproven barriers to adopting a physically active lifestyle. Secondly, we have instituted an automated referencing system that is the beginning of an ACSM evidence-based library that will become available to the membership at some time in the future. We have integrated the most recent guidelines and recom- mendations available from ACSM position stands and other relevant professional organization’s scientific statements so that the Guidelines are the most current, primary resource for professionals that conduct exercise testing and exercise pro- grams in academic, corporate, health/fitness, health care, and research settings. It is important for the readership to know these new themes and the more specific innovations of the ninth edition that follow were developed with input from the ACSM membership prior to the initiation of this project via an electronic survey and in-house focus group that asked respondents and participants, respectively, for their suggestions regarding the content of the ninth edition. More specific, noteworthy innovations of the ninth edition include the following: • The introduction of the Frequency, Intensity, Time, Type — Volume, and Progression or FITT-VP principle of exercise prescription in Chapter 7. • An expanded number of special populations in Chapter 10 because more information related to exercise testing, prescription, and special consider- ations of these new populations has become available since the publication of the eighth edition. • Inclusion of Chapter 11, a new chapter on behavioral change strategies addressing the challenges of exercise adherence.
- 10. viii Preface Several of the appendices have undergone significant changes. Appendix A, Common Medications, is now authored by registered pharmacists in academic settings with clinical expertise in the pharmacology of medications likely to be used by patients and clients in exercise testing and programmatic settings. The content of Appendix B, Medical Emergency Management, is now based primarily on the fourth edition of ACSM’s Health/Fitness Facility Standards and Guidelines. The learning objectives have been removed from Appendix D, ACSM Certifications, because these are now available via the ACSM Certification link www.acsmcertification.org/exam-content-outlines. Appendix E, which lists the contributing authors to the two previous editions of the Guidelines, has been added. Any updates made in this edition of the Guidelines after their publication and prior to the publication of the next edition of the Guidelines, can be accessed from the ACSM Certification link (www.acsmcertification.org/getp9-updates). Furthermore, the reader is referred to the ACSM Access Public Information Books and Media link for a list of ACSM books (www.acsm.org/access-public- information/books-multimedia), and to the ACSM Get Certified link for a listing of ACSM certifications (www.acsmcertification.org/get-certified). ACKNOWLEDGMENTS It is in this preface that the editors of the ninth edition have the opportunity to thank the many people who helped to see this project to completion. To be consistent with the theme of the Guidelines, our thanks will remain short, to the point, and without great elaboration. We thank our families and friends for their understanding of the extensive time commitment we made to this project that encompassed over three years. We thank our publisher, and in particular Emily Lupash, senior acquisitions editor; Meredith Brittain, senior product manager; Christen Murphy and Sarah Schuessler, marketing managers; and Zachary Shapiro, editorial assistant. We thank Richard T. Cotton, ACSM National Director of Certification; Traci Sue Rush, ACSM Assistant Director of Certification Programs; Kela Webster, ACSM Certification Coordinator; Robin Ashman and Dru Romanini, ACSM Certification Department Assistants; Angela Chastain, ACSM Editorial Services Office; Kerry O’Rourke, ACSM Director of Publishing; Walter R. Thompson, ACSM Publications Committee Chair; and the extraordinarily hardworking Publications Committee. We thank the ACSM CCRB for their valuable insights into the content of this edition of the Guidelines and counsel on administrative issues related to seeing this project to completion. The ACSM CCRB tirelessly reviewed manu- script drafts to ensure the content of this edition of the Guidelines meets the highest standards in exercise science and practice. We thank Dr. David Swain, senior editor of the seventh edition of ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, for his very careful and insightful review of
- 11. ix Preface the Guidelines and collegial assistance with seeing this project to completion. We thank Dr. Jonathan Ehrman, the umbrella editor of this project, who made it his mission to ensure congruency between the ninth edition of the Guidelines and seventh edition of ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. We thank the University of Connecticut Medical Librarian, Jill Livingston, for her patience and guidance with implementing the ACSM evi- dence-based RefWorks library and teaching the editors and contributing authors how to become proficient in using RefWorks in this edition of the Guidelines. The Guidelines review process was extensive, undergoing many layers of ex- pert scrutiny to ensure the highest quality of content. We thank the external and CCRB reviewers of the ninth edition for their careful reviews. These reviewers are listed later in this front matter. We are in great debt to the contributing authors of the ninth edition of the Guidelines for volunteering their expertise and valuable time to ensure the Guidelines meet the highest standards in exercise science and practice. The ninth edition contributing authors are listed in the following section. On a more personal note, I thank my three associate editors — Dr. Ross Arena, Dr. Deborah Riebe, and Dr. Paul D. Thompson — who selflessly devoted their valuable time and expertise to the ninth edition of the Guidelines. Their strong sense of selfless commitment to the Guidelines emanated from an underly- ing belief held by the editorial team of the profound importance the Guidelines have in informing and directing the work we do in exercise science and practice. Words cannot express the extent of my gratitude to the three of you for your tireless efforts to see this project to completion. Linda S. Pescatello, PhD, FACSM Senior Editor ADDITIONAL RESOURCES ACSM’s Guidelines for Exercise Testing and Prescription, Ninth Edition includes additional resources for instructors that are available on the book’s companion Web site at http://thepoint.lww.com/ACSMGETP9e. INSTRUCTORS Approved adopting instructors will be given access to the following additional resources: • Brownstone test generator • PowerPoint presentations • Image bank • WebCT/Angel/Blackboard ready cartridge
- 12. In addition, purchasers of the text can access the searchable Full Text Online by going to the ACSM’s Guidelines for Exercise Testing and Prescription, Ninth Edition Web site at http://thepoint.lww.com/ACSMGETP9e. See the inside front cover of this text for more details, including the passcode you will need to gain access to the Web site. NOTA BENE The views and information contained in the ninth edition of ACSM’s Guidelines for Exercise Testing and Prescription are provided as guidelines as opposed to standards of practice. This distinction is an important one because specific legal connotations may be attached to standards of practice that are not attached to guidelines. This distinction is critical inasmuch as it gives the professional in exercise testing and programmatic settings the freedom to deviate from these guidelines when necessary and appropriate in the course of using independent and prudent judgment. ACSM’s Guidelines for Exercise Testing and Prescription presents a framework whereby the professional may certainly — and in some cases has the obligation to — tailor to individual client or patient needs while balancing institutional or legal requirements. x Preface
- 13. Index xi Contributing Authors to the Ninth Edition* Kelli Allen, PhD VA Medical Center Durham, North Carolina Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Mark Anderson, PT, PhD University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Gary Balady, MD Boston University School of Medicine Boston, Massachusetts Chapter 9: Exercise Prescription for Patients with Cardiovascular and Cerebrovascular Disease Michael Berry, PhD Wake Forest University Winston-Salem, North Carolina Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Bryan Blissmer, PhD University of Rhode Island Kingston, Rhode Island Chapter 11: Behavioral Theories and Strategies for Promoting Exercise Kim Bonzheim, MSA, FACSM Genesys Regional Medical Center Grand Blanc, Michigan Appendix C: Electrocardiogram Interpretation Barry Braun, PhD, FACSM University of Massachusetts Amherst, Massachusetts Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Monthaporn S. Bryant, PT, PhD Michael E. DeBakey VA Medical Center Houston, Texas Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Thomas Buckley, MPH, RPh University of Connecticut Storrs, Connecticut Appendix A: Common Medications John Castellani, PhD United States Army Research Institute of Environmental Medicine Natick, Massachusetts Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Dino Costanzo, MA, FACSM, ACSM-RCEP , ACSM-PD, ACSM-ETT The Hospital of Central Connecticut New Britain, Connecticut Appendix D: American College of Sports Medicine Certifications Michael Deschenes, PhD, FACSM The College of William and Mary Williamsburg, Virginia Chapter 7: General Principles of Exercise Prescription Joseph E. Donnelly, EdD, FACSM University of Kansas Medical Center Kansas City, Kansas Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Bo Fernhall, PhD, FACSM University of Illinois at Chicago Chicago, Illinois Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions *See Appendix E for a list of contributing authors for the previous two editions.
- 14. xii Contributing Authors to the Ninth Edition Stephen F. Figoni, PhD, FACSM VA West Los Angeles Healthcare Center Los Angeles, California Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Nadine Fisher, EdD University at Buffalo Buffalo, New York Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Charles Fulco, ScD United States Army Research Institute of Environmental Medicine Natick, Massachusetts Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Carol Ewing Garber, PhD, FACSM, ACSM-RCEP , ACSM-HFS, ACSM-PD Columbia University New York, New York Chapter 7: General Principles of Exercise Prescription Andrew Gardner, PhD University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma Chapter 9: Exercise Prescription for Patients with Cardiovascular and Cerebrovascular Disease Neil Gordon, MD, PhD, MPH, FACSM Intervent International Savannah, Georgia Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Eric Hall, PhD, FACSM Elon University Elon, North Carolina Chapter 11: Behavioral Theories and Strategies for Promoting Exercise Gregory Hand, PhD, MPH, FACSM University of South Carolina Columbia, South Carolina Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Samuel Headley, PhD, FACSM, ACSM-RCEP Springfield College Springfield, Massachusetts Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Kurt Jackson, PT, PhD University of Dayton Dayton, Ohio Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Robert Kenefick, PhD, FACSM United States Army Research Institute of Environmental Medicine Natick, Massachusetts Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Christine Kohn, PharmD University of Connecticut School of Pharmacy Storrs, Connecticut Appendix A: Common Medications Wendy Kohrt, PhD, FACSM University of Colorado—Anschutz Medical Campus Aurora, Colorado Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions I-Min Lee, MBBS, MPH, ScD Brigham and Women’s Hospital, Harvard Medical School Boston, Massachusetts Chapter 1: Benefits and Risks Associated with Physical Activity
- 15. xiii Contributing Authors to the Ninth Edition David X. Marquez, PhD, FACSM University of Illinois at Chicago Chicago, Illinois Chapter 11: Behavioral Theories and Strategies for Promoting Exercise Kyle McInnis, ScD, FACSM Merrimack College North Andover, Massachusetts Appendix B: Emergency Risk Management Miriam Morey, PhD, FACSM VA and Duke Medical Centers Durham, North Carolina Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Michelle Mottola, PhD, FACSM The University of Western Ontario London, Ontario, Canada Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Stephen Muza, PhD, FACSM United States Army Research Institute of Environmental Medicine Natick, Massachusetts Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Patricia Nixon, PhD Wake Forest University Winston-Salem, North Carolina Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Jennifer R. O’Neill, PhD, MPH, ACSM-HFS University of South Carolina, Columbia, South Carolina Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Russell Pate, PhD, FACSM University of South Carolina Columbia, South Carolina Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Richard Preuss, PhD, PT McGill University Montreal, Quebec, Canada Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Kathryn Schmitz, PhD, MPH, FACSM, ACSM-HFS University of Pennsylvania Philadelphia, Pennsylvania Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Carrie Sharoff, PhD Arizona State University Tempe, Arizona Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions Maureen Simmonds, PhD, PT University of Texas Health Science Center San Antonio, Texas Chapter 8: Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations Paul D.Thompson, MD, FACSM, FACC Hartford Hospital Hartford, Connecticut Chapter 1: Benefits and Risks Associated with Physical Activity Chapter 2: Preparticipation Health Screening Chapter 10: Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions
- 16. Index xiv Reviewers for the Ninth Edition* Robert Axtell, PhD, FACSM, ACSM-ETT Southern Connecticut State University New Haven, Connecticut *Christopher Berger, PhD, ACSM-HFS The George Washington University Washington, District of Columbia *Clinton A. Brawner, MS, ACSM-RCEP , FACSM Henry Ford Hospital Detroit, Michigan Barbara A. (Kooiker) Bushman, PhD, FACSM, ACSM-PD, ACSM-CES, ACSM-HFS, ACSM-CPT, ACSM-EIM3 Senior Editor of ACSM’s Resources for the Personal Trainer, Fourth Edition Missouri State University Springfield, Missouri *Brian J. Coyne, MEd, ACSM-RCEP Duke University Health System Morrisville, North Carolina Lance Dalleck, PhD, ACSM-RCEP University of Auckland Auckland, New Zealand *Julie J. Downing, PhD, FACSM, ACSM-HFD, ACSM-CPT Central Oregon Community College Bend, Oregon *Gregory B. Dwyer, PhD, FACSM, ACSM-PD, ACSM-RCEP , ACSM-CES, ACSM-ETT Senior Editor of ACSM’s Certification Review, Fourth Edition East Stroudsburg University East Stroudsburg, Pennsylvania Carl Foster, PhD, FACSM University of Wisconsin-La Crosse La Crosse, Wisconsin Patty Freedson, PhD, FACSM University of Massachusetts Amherst, Massachusetts Leonard A. Kaminsky, PhD, FACSM, ACSM-PD, ACSM-ETT Senior Editor of ACSM’s Health-Related Physical Fitness Assessment Manual, Fourth Edition Ball State University Muncie, Indiana Steven Keteyian, PhD, FACSM Henry Ford Hospital Detroit, Michigan Gary M. Liguori, PhD, FACSM, ACSM-CES, ACSM-HFS Senior Editor of ACSM’s Resources for the Health Fitness Specialist, First Edition North Dakota State University Fargo, North Dakota *Randi S. Lite, MA, ACSM-RCEP Simmons College Boston, Massachusetts Claudio Nigg, PhD University of Hawaii Honolulu, Hawaii *Madeline Paternostro-Bayles, PhD, FACSM, ACSM-PD, ACSM-CES Indiana University of Pennsylvania Indiana, Pennsylvania *Peter J. Ronai, MS, FACSM, ACSM-PD, ACSM-RCEP , ACSM-CES, ACSM-ETT, ACSM-HFS Sacred Heart University Milford, Connecticut Robert Sallis, MD, FACSM Kaiser Permanente Medical Center Rancho Cucamonga, California *Jeffrey T. Soukup, PhD, ACSM-CES Appalachian State University Boone, North Carolina Sean Walsh, PhD Central Connecticut State University New Britain, Connecticut David S. Zucker, MD, PhD Swedish Cancer Institute Seattle, Washington *Denotes reviewers who were also members of the ACSM Committee on Certification and Registry Boards.
- 17. Index xv Contents Section I: Health Appraisal and Risk Assessment 1 Associate Editor: Paul D. Thompson, MD, FACSM, FACC 1 Benefits and Risks Associated with Physical Activity. . . . . . . . . . . . . . . . 2 Physical Activity and Fitness Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Public Health Perspective for Current Recommendations . . . . . . . . . . . . . . . . . . . . 5 Benefits of Regular Physical Activity and/or Exercise . . . . . . . . . . . . . . . . . . . . . . . . 9 Risks Associated with Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Sudden Cardiac Death Among Young Individuals . . . . . . . . . . . . . . . . . . . . . . . . . 11 Exercise-Related Cardiac Events in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Exercise Testing and the Risk of Cardiac Events. . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Risks of Cardiac Events During Cardiac Rehabilitation . . . . . . . . . . . . . . . . . . . . . 14 Prevention of Exercise-Related Cardiac Events. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2 Preparticipation Health Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Preparticipation Health Screening. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Self-Guided Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Atherosclerotic Cardiovascular Disease Risk Factor Assessment . . . . . . . . . . . . . . 23 Recommendations for a Medical Examination Prior to Initiating Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Recommendations for Exercise Testing Prior to Initiating Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Recommendations for Supervision of Exercise Testing. . . . . . . . . . . . . . . . . . . . . . 33 Risk Stratification for Patients with Cardiovascular Disease. . . . . . . . . . . . . . . . . . 34 Section II: Exercise Testing 39 Associate Editor: Ross Arena, PhD, PT, FACSM, FAACVPR, FAHA, ACSM-CES 3 Preexercise Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Medical History, Physical Examination, and Laboratory Tests . . . . . . . . . . . . . . . . 41 Blood Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Lipids and Lipoproteins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Blood Profile Analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Pulmonary Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Contraindications to Exercise Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Informed Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Participant Instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 4 Health-Related Physical Fitness Testing and Interpretation . . . . . . . . . . . 60 Purposes of Health-Related Physical Fitness Testing . . . . . . . . . . . . . . . . . . . . . . . 60 Basic Principles and Guidelines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Pretest Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
- 18. xvi Contents Test Organization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Test Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Body Composition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Anthropometric Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Densitometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Other Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Body Composition Norms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Cardiorespiratory Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 The Concept of Maximal Oxygen Uptake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Maximal versus Submaximal Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . 75 Modes of Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Cardiorespiratory Test Sequence and Measures. . . . . . . . . . . . . . . . . . . . . . . . . 85 Test Termination Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 Interpretation of Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Muscular Strength and Muscular Endurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Rationale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Principles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 Muscular Strength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Muscular Endurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Special Considerations in Muscular Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Flexibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 A Comprehensive Health Fitness Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 5 Clinical Exercise Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Indications and Purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Diagnostic Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 Exercise Testing for Disease Severity and Prognosis . . . . . . . . . . . . . . . . . . . . 117 Exercise Testing After Myocardial Infarction. . . . . . . . . . . . . . . . . . . . . . . . . . 117 Functional Exercise Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Exercise Test Modalities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Exercise Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Upper Body Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Testing for Return to Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Measurements During Exercise Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Heart Rate and Blood Pressure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Electrocardiographic Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Subjective Ratings and Symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130 Gas Exchange and Ventilatory Responses . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Arterial Blood Gas Assessment During Exercise . . . . . . . . . . . . . . . . . . . . . . . 133 Indications for Exercise Test Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Postexercise Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 Imaging Modalities Used in Conjunction with Exercise Testing. . . . . . . . . . . . . . 134 Exercise Echocardiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Cardiac Radionuclide Imaging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 Imaging Modalities not Used in Conjunction with Exercise Testing . . . . . . . . . . 135 Pharmacologic Stress Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Computed Tomography in the Assessment of Cardiovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136 Supervision of Exercise Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
- 19. xvii Contents 6 Interpretation of Clinical Exercise Test Results. . . . . . . . . . . . . . . . . . . . 142 Exercise Testing as a Screening Tool for Coronary Artery Disease . . . . . . . . . . . . 142 Interpretation of Responses to Graded Exercise Testing . . . . . . . . . . . . . . . . . . . . 143 Heart Rate Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Blood Pressure Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Electrocardiograph Waveforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Limiting Signs and Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Ventilatory Expired Gas Responses to Exercise. . . . . . . . . . . . . . . . . . . . . . . . 151 Diagnostic Value of Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 Specificity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154 Predictive Value . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Comparison with Imaging Stress Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Prognostic Applications of the Exercise Test. . . . . . . . . . . . . . . . . . . . . . . . . . 156 Section III: Exercise Prescription 161 Associate Editor: Deborah Riebe, PhD, FACSM, ACSM-HFS 7 General Principles of Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . 162 An Introduction to the Principles of Exercise Prescription. . . . . . . . . . . . . . . . . . 162 General Considerations for Exercise Prescription. . . . . . . . . . . . . . . . . . . . . . . . . 163 Components of the Exercise Training Session. . . . . . . . . . . . . . . . . . . . . . . . . . . . 164 Aerobic (Cardiorespiratory Endurance) Exercise . . . . . . . . . . . . . . . . . . . . . . . . . 166 Frequency of Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166 Intensity of Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Exercise Time (Duration) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 Exercise Volume (Quantity) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176 Type (Mode) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177 Rate of Progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Muscular Fitness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Frequency of Resistance Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181 Types of Resistance Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182 Volume of Resistance Exercise (Sets and Repetitions) . . . . . . . . . . . . . . . . . . 182 Resistance Exercise Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Progression/Maintenance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184 Flexibility Exercise (Stretching) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Types of Flexibility Exercises. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 Volume of Flexibility Exercise (Time, Repetitions, and Frequency). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188 Neuromotor Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Exercise Program Supervision. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 8 Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations. . . . . . . . . . . . . . . . 194 Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
- 20. Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210 Low Back Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215 Environmental Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Exercise in Hot Environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216 Exercise in Cold Environments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Exercise in High Altitude Environments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226 9 Exercise Prescription for Patients with Cardiovascular and Cerebrovascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Inpatient Rehabilitation Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236 Outpatient Exercise Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241 Types of Outpatient Exercise Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Resistance Training for Cardiac Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252 Exercise Training for Return to Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253 Exercise Prescription for Patients with Cerebrovascular Disease (Stroke) . . . . . . 256 10 Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions. . . . . . . . . . . . . . . . . . . . . . . . . . 260 Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263 Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270 Cerebral Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Exercise Prescription/Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . 276 Diabetes Mellitus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Dyslipidemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 xviii Contents
- 21. xix Fibromyalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 288 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292 Human Immunodeficiency Virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Hypertension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298 Intellectual Disability and Down Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302 Special Considerations for Individuals with Intellectual Disability . . . . . . . . 303 Special Considerations for Individuals with Down Syndrome . . . . . . . . . . . . 304 Kidney Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308 Metabolic Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310 Exercise Prescription/Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . 310 Multiple Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314 Osteoporosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 Overweight and Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320 Weight Loss Program Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321 Parkinson Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 Pulmonary Diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 Asthma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 Chronic Obstructive Pulmonary Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Contents
- 22. Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336 Spinal Cord Injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Exercise Prescription/Special Considerations . . . . . . . . . . . . . . . . . . . . . . . . . 340 Individuals with Multiple Chronic Diseases and Health Conditions . . . . . . . . . . 342 Preparticipation Health Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Exercise Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342 Exercise Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 Special Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343 11 Behavioral Theories and Strategies for Promoting Exercise . . . . . . . . 355 Exercise Prescription. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 Frequency/Time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355 Intensity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356 Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356 Theoretical Foundations for Understanding Exercise Behavior . . . . . . . . . . . . . . 356 Social Cognitive Theory and Self-Efficacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . 357 Transtheoretical Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 360 Health Belief Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362 Self-Determination Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 Theory of Planned Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363 Social Ecological . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Theoretical Strategies and Approaches to Change Behavior/Increase Adherence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Building Self-Efficacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 Brief Counseling and Motivational Interviewing. . . . . . . . . . . . . . . . . . . . . . . 367 Stage of Change Tailored Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 Group Leader Interactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 Cognitive-Behavioral Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372 Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374 Association versus Disassociation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374 Affect Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Relapse Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Cultural Diversity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376 Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Individuals with Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Individuals with Chronic Diseases and Health Conditions. . . . . . . . . . . . . . . 378 Appendices A Common Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 B Emergency Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407 C Electrocardiogram Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .413 D American College of Sports Medicine Certifications. . . . . . . . . . . . . . . .419 E Contributing Authors to the Previous Two Editions . . . . . . . . . . . . . . . 438 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441 xx Contents
- 23. Index xxi Abbreviations AACVPR American Association of Cardiovascular and Pulmonary Rehabilitation ABI ankle-brachial index ACC American College of Cardiology ACCP American College of Chest Physicians ACE-I angiotensin-converting enzyme inhibitors ACLS advanced cardiac life support ACS American Cancer Society ACSM American College of Sports Medicine ADL activities of daily living ADP-R adenosine diphosphate- ribose ADT androgen deprivation therapy AED automated external defibrillator AHA American Heart Association AHFS American Hospital Formulary Service AIDS acquired immunodeficiency syndrome AIT aerobic interval training ALT alanine transaminase AMS acute mountain sickness APAP acetaminophen ARB angiotensin II receptor blocker ART antiretroviral therapy AST aspartate transaminase ATP Adult Treatment Panel ATS American Thoracic Society AV atrioventricular aVR augmented voltage right BB beta-blockers BIA bioelectrical impedance analysis BLS basic life support BMD bone mineral density BMI body mass index BMT bone marrow transplantation BP blood pressure BUN blood urea nitrogen CAAHEP Commission on Accreditation of Allied Health Education Programs CABG coronary artery bypass graft CAD coronary artery disease CCB calcium channel blocker CDC U.S. Centers for Disease Control and Prevention CEPA Clinical Exercise Physiology Association CES ACSM Certified Clinical Exercise SpecialistSM CHD coronary heart disease CHF congestive heart failure CI chronotropic index CKD chronic kidney disease CM cardiomyopathy CNS central nervous system CO2 carbon dioxide CoAES Committee on Accreditation for the Exercise Sciences COPD chronic obstructive pulmonary disease COX-I cyclooxygenase inhibitor CP cerebral palsy CP-ISRA Cerebral Palsy International Sport and Recreation Association CPR cardiopulmonary resuscitation CPT ACSM Certified Personal Trainer® CPX cardiopulmonary exercise testing CR cardiorespiratory CRF cardiorespiratory fitness CSEP Canadian Society for Exercise Physiology CT computed tomography
- 24. xxii Abbreviations CV cardiovascular CVD cardiovascular disease DASH Dietary Approaches to Stop Hypertension Db body density DBP diastolic blood pressure DBS deep brain stimulation DEXA dual energy X-ray absorptiometry DIAD Detection of Ischemia in Asymptomatic Diabetes DM Diabetes mellitus DNA deoxyribonucleic acid DS Down syndrome DVR Dynamic Variable Resistance EBCT electron beam computed tomography ECG electrocardiogram (electrocardiographic) EDSS expanded disability status scale EE energy expenditure EMG electromyographic EMS emergency medical services ERS European Respiratory Society Ex Rx exercise prescription FBG fasting blood glucose FC functional capacity FDA Food and Drug Administration FEV1.0 forced expiratory volume in one second FFBd fat-free body density FFM fat-free mass FITT Frequency, Intensity, Time, and Type FITT-VP Frequency, Intensity, Time, and Type, Volume and Progression FM fat mass FN false negative FP false positive FVC forced vital capacity GEI ACSM Certified Group Exercise InstructorSM GFR glomerular filtration rate GLP-1 glucagon-like peptide 1 GOLD Global Initiative for Chronic Obstructive Lung Disease GXT graded exercise test HACE high altitude cerebral edema HAPE high altitude pulmonary edema HbA1C glycosylated hemoglobin HBM Health Belief Model HCTZ hydrochlorothiazide HDL high-density lipoprotein cholesterol HF heart failure HFS ACSM Certified Health Fitness SpecialistSM HIPAA Health Insurance Portability and Accountability Act HIV human immunodeficiency virus HMG-CoA hydroxymethylglutaryl-CoA HR heart rate HRmax maximal heart rate (maximum heart rate) HRpeak peak heart rate HRR heart rate reserve HRrest resting heart rate HSCT hematopoietic stem cell transplantation HTN hypertension HY Hoehn and Yahr ICD implantable cardiac defibrillator ID intellectual disability IDF International Diabetes Federation IDL intermediate-density lipoprotein IFG impaired fasting glucose IGT impaired glucose tolerance ISA intrinsic sympathomimetic activity IVC obtained on inspiration IVCD intraventricular conduction delay JNC7 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JTA job task analysis
- 25. xxiii Abbreviations K/DOQI Kidney Disease Outcomes Quality Initiative LABS Longitudinal Assessment of Bariatric Surgery LBBB left bundle-branch block LBP low back pain LDL low-density lipoprotein cholesterol L-G-L Lown-Ganong-Levine syndrome LLN lower limit of normal LMWH low-molecular weight heparin LV left ventricular LVH left ventricular hypertrophy MAO-I monoamine oxidase inhibitor MET metabolic equivalent MI myocardial infarction MS multiple sclerosis Msyn metabolic syndrome MVC maximum voluntary contraction MV̇O2 myocardial oxygen consumption MVV maximal voluntary ventilation NCCA National Commission for Certifying Agencies NCEP National Cholesterol Education Program NCPAD National Center on Physical Activity and Disability NHANES National Health and Nutrition Examination Survey NHLBI National Heart, Lung, and Blood Institute non-DHP Nondihydropyridines NOTF National Obesity Task Force NPAS National Physical Activity Society NSAIDs nonsteroidal anti- inflammatory drugs O2 oxygen OGTT oral glucose tolerance test OSHA Occupational Safety and Health Administration Pa CO2 arterial partial pressure of carbon dioxide (partial pressure of carbon dioxide in arterial blood) PAC premature atrial contraction PAD peripheral artery disease PAG physical activity guideline Pa O2 arterial partial pressure of oxygen (partial pressure of oxygen in arterial blood) PARmed-X Physical Activity Readiness PAR-Q Physical Activity Readiness Questionnaire PD Parkinson disease PDE phosphodiesterase PEF peak expiratory flow PETCO2 partial pressure of end-tidal carbon dioxide PNF proprioceptive neuromuscular facilitation PPMS primary progressive multiple sclerosis PRMS progressive relapsing multiple sclerosis PTCA percutaneous transluminal coronary angioplasty PVC premature ventricular contraction Q̇ cardiac output QTc QT corrected for heart rate RCEP ACSM Registered Clinical Exercise Physiologist® RER respiratory exchange ratio RHR resting heart rate RM repetition maximum 1-RM one repetition maximum ROM range of motion RPE rating of perceived exertion RPP rate pressure product RRMS relapsing remitting multiple sclerosis RT resistance training RVH right ventricular hypertrophy SaO2 oxygen saturation in arterial blood (arterial oxygen saturation, arterial oxyhemoglobin saturation)
- 26. xxiv Abbreviations SARI serotonin antagonist reuptake inhibitor SBP systolic blood pressure SCA sudden cardiac arrest SCI spinal cord injury SCT social cognitive theory SD standard deviation SDT self-determination theory SEE standard error of estimate SET social ecological theory SFT Senior Fitness Test SGOT serum glutamic-oxaloacetic transaminase SGPT serum glutamic-pyruvic transaminase SI Système International SNRI serotonin-norepinephrine reuptake inhibitor SPECT single-photon emission computed tomography SPMS secondary progressive multiple sclerosis SpO2 estimation of arterial oxygen saturation SPPB Short Physical Performance Battery SSRI selective serotonin reuptake inhibitor SVC slow expiration SVT supraventricular tachycardia Tc technetium TCA tricyclic antidepressant TeCA tetracyclic antidepressant THR target heart rate TLC total lung capacity TN true negative TOBEC total body electrical conductivity TP true positive TPB theory of planned behavior TTM Transtheoretical Model USPSTF U.S. Preventive Services Task Force V̇CO2 carbon dioxide production V̇E minute ventilation V̇E/V̇CO2 minute ventilation/carbon dioxide production V̇E/V̇O2 ventilatory equivalent for oxygen V̇Emax maximal minute ventilation V̇O2 oxygen uptake (oxygen consumption) V̇O2max maximal volume of oxygen consumed per minute (maximum oxygen consumption, maximal oxygen uptake) V̇O2max /V̇CO2 ventilatory equivalent for carbon dioxide V̇O2peak peak oxygen uptake (peak oxygen consumption) V̇O2 R oxygen uptake reserve (oxygen consumption reserve) V̇O2 Rmax maximal oxygen uptake reserve V1 chest lead I VC vital capacity VF ventricular fibrillation VLDLs very low-density lipoproteins VT ventilatory threshold WBGT wet-bulb globe temperature WCT Wind Chill Temperature Index WHO World Health Organization WHR waist-to-hip ratio W-P-W Wolff-Parkinson-White syndrome
- 27. Health Appraisal and Risk Assessment SECTION I 1 SECTION I PAUL D. THOMPSON, MD, FACSM, FACC, Associate Editor
- 28. 2 CHAPTER 1 Benefits and Risks Associated with Physical Activity The purpose of this chapter is to provide current information on the benefits and risks of physical activity and/or exercise. For clarification purposes, key terms used throughout the Guidelines related to physical activity and fitness are defined in this chapter. Additional information specific to a disease, disability, or health condition are explained within the context of the chapter in which they are dis- cussed in the Guidelines. Physical activity continues to take on an increasingly important role in the prevention and treatment of multiple chronic diseases, health conditions, and their risk factors. Therefore, Chapter 1 focuses on the public health perspective that forms the basis for the current physical activity recommendations (3,18,23,37,56). Chapter 1 concludes with recommendations for reducing the incidence and severity of exercise-related complications for pri- mary and secondary prevention programs. PHYSICAL ACTIVITY AND FITNESS TERMINOLOGY Physical activity and exercise are often used interchangeably, but these terms are not synonymous. Physical activity is defined as any bodily movement produced by the contraction of skeletal muscles that results in a substantial increase in caloric requirements over resting energy expenditure (8,43). Exercise is a type of physical activity consisting of planned, structured, and repetitive bodily move- ment done to improve and/or maintain one or more components of physical fit- ness. Physical fitness is defined as a set of attributes or characteristics individuals have or achieve that relates to their ability to perform physical activity. These characteristics are usually separated into the health-related and skill-related components of physical fitness (see Box 1.1). In addition to defining physical activity, exercise, and physical fitness, it is important to clearly define the wide range of intensities associated with physical activity. Methods for quantifying the relative intensity of physical activity include specifying a percentage of oxygen uptake reserve (V̇O2 R), heart rate reserve (HRR), oxygen consumption (V̇O2 ), heart rate (HR), or metabolic equivalents (METs) (see Box 7.2). Each of these methods for describing the intensity of physical activity has strengths and limitations. Although determining the most appropriate method is left to the health/fitness and clinical exercise professional,
- 29. CHAPTER 1 Benefits and Risks Associated with Physical Activity 3 Chapter 7 provides the methodology and guidelines for selecting a suitable method. METs are a useful, convenient, and standarized way to describe the absolute intensity of a variety of physical activities. Light physical activity is defined as requiring ⬍3 METs, moderate as 3–⬍6 METs, and vigorous as ⱖ6 METs (42). Table 1.1 gives specific examples of activities in METs for each of the intensity ranges. A fairly complete list of physical activities and their associated estimates of energy expenditure can be found in the companion book of these Guidelines, ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (50). Maximum aerobic capacity usually declines with age (14,37). For this reason, when older and younger individuals work at the same absolute MET level, the relative exercise intensity (e.g., %V̇O2max ) will usually be different. In other words, the older individual will be working at a greater %V̇O2max than their younger counterpart (see Chapter 8). Nonetheless, physically active older adults may have aerobic capacities comparable to or greater than those of sedentary younger adults. Table 1.2 shows the approximate relationships among relative and absolute exercise intensities for various fitness levels ranging from 6 to 12 METs. HEALTH-RELATED PHYSICAL FITNESS COMPONENTS • Cardiorespiratory endurance: The ability of the circulatory and respiratory system to supply oxygen during sustained physical activity. • Body composition: The relative amounts of muscle, fat, bone, and other vital parts of the body. • Muscular strength: The ability of muscle to exert force. • Muscular endurance: The ability of muscle to continue to perform without fatigue. • Flexibility: The range of motion available at a joint. SKILL-RELATED PHYSICAL FITNESS COMPONENTS • Agility: The ability to change the position of the body in space with speed and accuracy. • Coordination: The ability to use the senses, such as sight and hearing, together with body parts in performing tasks smoothly and accurately. • Balance: The maintenance of equilibrium while stationary or moving. • Power: The ability or rate at which one can perform work. • Reaction time: The time elapsed between stimulation and the beginning of the reaction to it. • Speed: The ability to perform a movement within a short period of time. Adapted from (43,55). Available from http://www.fitness.gov/digest_mar2000.htm Health-Related and Skill-Related Components of Physical Fitness BOX 1.1
- 30. 4 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 1.1. Metabolic Equivalents (METs) Values of Common Physical Activities Classified as Light, Moderate, or Vigorous Intensity Light (⬍3 METs) Moderate (3–⬍6 METs) Vigorous (ⱖ6 METs) Walking Walking Walking, jogging, and running Walking slowly around home, store, or office ⫽ 2.0a Walking 3.0 mi ⭈ h⫺1 ⫽ 3.0a Walking at very, very brisk pace (4.5 mi ⭈ h⫺1 ) ⫽ 6.3a Household and occupation Walking at very brisk pace (4 mi ⭈ h⫺1 ) ⫽ 5.0a Walking/hiking at moderate pace and grade with no or light pack (⬍10 lb) ⫽ 7 .0 Sitting—using computer, work at desk, using light hand tools ⫽ 1.5 Household and occupation Hiking at steep grades and pack 10–42 lb ⫽ 7 .5–9.0 Standing performing light work, such as making bed, washing dishes, ironing, preparing food, or store clerk ⫽ 2.0–2.5 Cleaning, heavy — washing windows, car, clean garage ⫽ 3.0 Jogging at 5 mi ⭈ h⫺1 ⫽ 8.0a Leisure time and sports Sweeping floors or carpet, vacuuming, mopping ⫽ 3.0–3.5 Jogging at 6 mi ⭈ h⫺1 ⫽ 10.0a Arts and crafts, playing cards ⫽ 1.5 Carpentry — general ⫽ 3.6 Running at 7 mi ⭈ h⫺1 ⫽ 11.5a Billiards ⫽ 2.5 Carrying and stacking wood ⫽ 5.5 Household and occupation Boating — power ⫽ 2.5 Mowing lawn — walk power mower ⫽ 5.5 Shoveling sand, coal, etc. ⫽ 7 .0 Croquet ⫽ 2.5 Leisure time and sports Carrying heavy loads, such as bricks ⫽ 7 .5 Darts ⫽ 2.5 Badminton — recreational ⫽ 4.5 Heavy farming, such as bailing hay ⫽ 8.0 Fishing — sitting ⫽ 2.5 Basketball — shooting a round ⫽ 4.5 Shoveling, digging ditches ⫽ 8.5 Playing most musical instruments ⫽ 2.0–2.5 Leisure time and sports Bicycling on flat — light effort (10–12 mi ⭈ h⫺1 ) ⫽ 6.0 Dancing — ballroom slow ⫽ 3.0; ballroom fast ⫽ 4.5 Basketball game ⫽ 8.0 Fishing from riverbank and walking ⫽ 4.0 Bicycling on flat — moderate effort (12–14 mi ⭈ h⫺1 ) ⫽ 8 fast (14–16 mi ⭈ h⫺1 ) ⫽ 10 Golf — walking pulling clubs ⫽ 4.3 Skiing cross-country — slow (2.5 mi ⭈ h⫺1 ⫽ 7 .0; fast (5.0–7 .9 mi ⭈ h⫺1 ) ⫽ 9.0 Sailing boat, wind surfing ⫽ 3.0 Soccer — casual ⫽ 7 .0; competitive ⫽ 10.0 Swimming leisurely ⫽ 6.0b Swimming — moderate/ hard ⫽ 8–11b Table tennis ⫽ 4.0 Tennis singles ⫽ 8.0 Tennis doubles ⫽ 5.0 Volleyball — competitive at gym or beach ⫽ 8.0 Volleyball — noncompetitive ⫽ 3.0–4.0 a On flat, hard surface. b MET values can vary substantially from individual to individual during swimming as a result of different strokes and skill levels. Adapted from (1).
- 31. CHAPTER 1 Benefits and Risks Associated with Physical Activity 5 PUBLIC HEALTH PERSPECTIVE FOR CURRENT RECOMMENDATIONS Over 25 yr ago, the American College of Sports Medicine (ACSM) in conjunc- tion with the U.S. Centers for Disease Control and Prevention (CDC) (40), the U.S. Surgeon General (55), and the National Institutes of Health (41) issued landmark publications on physical activity and health. These publications called attention to the health-related benefits of regular physical activity that did not meet traditional criteria for improving fitness levels (e.g., ⬍20 min ⭈ session⫺1 of moderate rather than vigorous intensity). An important goal of these reports was to clarify for public health, health/ fitness, clinical exercise, and health care professionals the amount and intensity of physical activity needed to improve health, lower susceptibility to disease (morbidity), and decrease premature mortality (40,41,55). In addition, these re- ports documented the dose-response relationship between physical activity and health (i.e., some activity is better than none, and more activity, up to a point, is better than less). Williams (64) performed a meta-analysis of 23 sex-specific cohorts reporting varying levels of physical activity or fitness representing 1,325,004 individual-years of follow-up and showed a dose-response relation- ship between physical activity or physical fitness and the risks of coronary artery disease (CAD) and cardiovascular disease (CVD) (see Figure 1.1). It is clear that greater amounts of physical activity or increased physical fitness levels provide additional health benefits. Table 1.3 provides the strength of evidence for the dose-response relationships among physical activity and numerous health out- comes. More recently, the federal government convened an expert panel, the 2008 Physical Activity Guidelines Advisory Committee, to review the scientific evidence on physical activity and health published since the 1996 U.S. Surgeon General’s Report (42). This committee found compelling evidence on the TABLE 1.2. Classification of Physical Activity Intensity Relative Intensity Absolute Intensity Ranges (METs) Across Fitness Levels Intensity V̇O2 R(%) HRR (%) Maximal HR (%) 12 METs V̇O2max 10 METs V̇O2max 8 METs V̇O2max 6 METs V̇O2max Very light ⬍20 ⬍50 ⬍3.2 ⬍2.8 ⬍2.4 ⬍2.0 Light 20–⬍40 50–⬍64 3.2–⬍5.4 2.8–⬍4.6 2.4–⬍3.8 2.0–⬍3.1 Moderate 40–⬍60 64–⬍77 5.4–⬍7 .6 4.6–⬍6.4 3.8–⬍5.2 3.1–⬍4.1 Vigorous (hard) 60–⬍85 77–⬍94 7 .6–⬍10.3 6.4–⬍8.7 5.2–⬍7 .0 4.1–⬍5.3 Vigorous (very hard) 85–⬍100 94–⬍100 10.3–⬍12 8.7–⬍10 7 .0–⬍8 5.3–⬍6 Maximal 100 100 12 10 8 6 HR, heart rate; HRR, heart rate reserve; METs, metabolic equivalents (1 MET ⫽ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ); V̇O2max , maximal volume of oxygen consumed per minute; V̇O2 R, oxygen uptake reserve. Adapted from (18,24,55).
- 32. 6 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Physical activity Physical fitness Percentage Relative risk 1 0.8 0.6 0.4 0.2 0 25 50 75 100 ■ FIGURE 1.1. Estimated dose-response curve for the relative risk of atherosclerotic cardiovas- cular disease (CVD) by sample percentages of fitness and physical activity. Studies weighted by individual-years of experience. Used with permission from (64). TABLE 1.3. Evidence for Dose-Response Relationship between Physical Activity and Health Outcome Variable Evidence for Inverse Dose- Response Relationship Strength of Evidencea All-cause mortality Yes Strong Cardiorespiratory health Yes Strong Metabolic health Yes Moderate Energy balance: Weight maintenance Insufficient data Weak Weight loss Yes Strong Weight maintenance following weight loss Yes Moderate Abdominal obesity Yes Moderate Musculoskeletal health: Bone Yes Moderate Joint Yes Strong Muscular Yes Strong Functional health Yes Moderate Colon and breast cancers Yes Moderate Mental health: Depression and distress Yes Moderate Well-being Anxiety, cognitive health, and sleep Insufficient data Weak a Strength of the evidence was classified as follows: “Strong” — Strong, consistent across studies and populations “Moderate” — Moderate or reasonable, reasonably consistent “Weak” — Weak or limited, inconsistent across studies and populations Adapted from (42).
- 33. CHAPTER 1 Benefits and Risks Associated with Physical Activity 7 benefits of physical activity for health (described in the following section) as well as the presence of a dose-response relationship for many diseases and health conditions. Two important conclusions from the expert committee that have influenced the development of the recommendations appearing in the Guidelines are the following: • Important health benefits can be obtained by performing a moderate amount of physical activity on most, if not all, days of the week. • Additional health benefits result from greater amounts of physical activity. Individuals who maintain a regular program of physical activity that is longer in duration and/or of more vigorous intensity are likely to derive greater ben- efit than those who engage in lesser amounts. In 1995, the CDC and ACSM issued the recommendation, “every U.S. adult should accumulate 30 minutes or more of moderate physical activity on most, preferably all, days of the week” (40). The intent of this statement was to increase public awareness of the importance of the health-related benefits of moderate intensity, physical activity. Unfortunately, although there is some evidence that leisure time physical inactivity has decreased (9), sedentary be- havior remains a major public health concern. Specifically, only 46% of adults in the United States in a recent survey indicated that they met the minimum CDC-ACSM physical activity recommendation of participating in moderate intensity, physical activity for 30 min ⭈ d⫺1 on ⱖ5 d ⭈ wk⫺1 or vigorous intensity for 20 min ⭈ d⫺1 on ⱖ3 d ⭈ wk⫺1 (10). As indicated earlier, the inverse relationship between physical activity and chronic disease and premature mortality is well established. Since the release of the U.S. Surgeon General’s Report in 1996 (55), several reports have advocated physical activity levels above the minimum CDC-ACSM physical activity recommendations (14,18,36,46,54). These guidelines and recommendations primarily refer to the volume of physical activity required to prevent weight gain and/or obesity and should not be viewed as contra- dictory. In other words, physical activity that is sufficient to reduce the risk of developing chronic diseases and delaying mortality is likely insufficient to prevent or reverse weight gain and/or obesity given the typical American lifestyle. Physical activity beyond the minimum recommendations is likely needed in many individuals to manage and/or prevent weight gain and obesity. Since the original 1995 CDC-ACSM recommendation (40), several large-scale epidemiologic studies have been performed that further document the dose- response relationship between physical activity and CVD and premature mortality (29,31,39,45,51,66). As a result of an increasing awareness of the adverse health effects of sedentary behavior and because of some confusion and misinterpreta- tion of the original physical activity recommendations, the ACSM and American Heart Association (AHA) issued updated recommendations for physical activity and health in 2007 (see Box 1.2) (23).
- 34. 8 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Similar recommendations have been made in the 2008 federal physical activity guidelines (http://www.health.gov/PAguidelines) (56) based on the 2008 Physical Activity Guidelines Advisory Committee Report (42) (see Box 1.3). Regarding aero- bic physical activity, rather than recommending a specific frequency of activity per week, the committee decided the scientific evidence supported a total volume of physical activity per week for health. • All healthy adults aged 18–65 yr should participate in moderate intensity, aerobic physical activity for a minimum of 30 min on 5 d ⭈ wk⫺1 or vigorous intensity, aerobic activity for a minimum of 20 min on 3 d ⭈ wk⫺1 . • Combinations of moderate and vigorous intensity exercise can be performed to meet this recommendation. • Moderate intensity, aerobic activity can be accumulated to total the 30 min minimum by performing bouts each lasting ⱖ10 min. • Every adult should perform activities that maintain or increase muscular strength and endurance for a minimum of 2 d ⭈ wk⫺1 . • Because of the dose-response relationship between physical activity and health, individuals who wish to further improve their fitness, reduce their risk for chronic diseases and disabilities, and/or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity. ACSM, American College of Sports Medicine; AHA, American Heart Association. The ACSM-AHA Primary Physical Activity Recommendations (23) BOX 1.2 • All Americans should participate in an amount of energy expenditure equivalent to 150 min ⭈ wk⫺1 of moderate intensity, aerobic activity; 75 min ⭈ wk⫺1 of vigorous intensity, aerobic activity; or a combination of both that generates energy equivalency to either regimen for substantial health benefits. • These guidelines further specify a dose-response relationship, indicating additional health benefits are obtained with 300 min ⭈ wk⫺1 or more of moderate intensity, aerobic activity; 150 min ⭈ wk⫺1 or more of vigorous intensity, aerobic activity; or an equivalent combination of moderate and vigorous intensity, aerobic activity. The 2008 federal physical activity guidelines also recommend breaking the total amount of physical activity into regular sessions during the week (e.g., 30 min on 5 d ⭈ wk⫺1 of moderate intensity, aerobic activity) in order to reduce the risk of musculoskeletal injuries. The Primary Physical Activity Recommendations from the 2008 Physical Activity Guidelines Committee Report (56) BOX 1.3
- 35. CHAPTER 1 Benefits and Risks Associated with Physical Activity 9 BENEFITS OF REGULAR PHYSICAL ACTIVITY AND/OR EXERCISE Evidence to support the inverse relationship between physical activity and pre- mature mortality, CVD/CAD, hypertension, stroke, osteoporosis, Type 2 diabetes mellitus, metabolic syndrome, obesity, colon cancer, breast cancer, depression, functional health, falls, and cognitive function continues to accumulate (42). For many of these diseases and health conditions, there is also strong evidence of a dose-response relationship (see Table 1.3). This evidence has resulted from laboratory-based studies as well as large-scale, population-based, observational studies (16,18,23,26,30,55,62). Since the last edition of the Guidelines, additional evidence has strengthened support for these relationships. As stated in the recent ACSM-AHA updated recommendation on physical activity and health (23), “since the 1995 recom- mendation, several large scale observational epidemiologic studies, enrolling thousands to tens of thousands of individuals, have clearly documented a dose- response relationship between physical activity and risk of cardiovascular disease and premature mortality in men and women, and in ethnically diverse par- ticipants” (29,31,38,45,51,66). The 2008 Physical Activity Guidelines Advisory Committee also arrived at similar conclusions (42). It is also important to note aerobic capacity (i.e., cardiorespiratory fitness [CRF]) has an inverse relation- ship with risk of premature death from all causes and specifically from CVD, and higher levels of CRF are associated with higher levels of habitual physical activity, which in turn are associated with many health benefits (6,7,28,47,61). Box 1.4 summarizes the benefits of regular physical activity and/or exercise. Recently, the ACSM and AHA have released statements on “Physical Activity and Public Health in Older Adults” (3,37). In general, these recommendations are similar to the updated guidelines for adults (18,23), but the recommended intensity of aerobic activity is related to the older adult’s CRF level. In addition, age-specific recommendations are made concerning the importance of flexibility, neuromotor, and muscle strengthening activities. In addition, the 2008 federal physical activity guidelines made similar age-specific recommendations targeted at adults (18–64 yr) and older adults (ⱖ65 yr) as well as children and adolescents (6–17 yr) (http://www.health.gov/ PAguidelines) (56). RISKS ASSOCIATED WITH EXERCISE In general, exercise does not provoke cardiovascular events in healthy indi- viduals with normal cardiovascular systems. The risk of sudden cardiac arrest or myocardial infarction (MI) is very low in apparently healthy individuals perform- ing moderate intensity, physical activity (60,63). However, there is an acute and transient increase in the risk of sudden cardiac death and/or MI in individuals performing vigorous intensity exercise with either diagnosed or occult CVD (20,35,48,52,60,65). Therefore, the risk of these events during exercise increases
- 36. 10 GUIDELINES FOR EXERCISE TESTING • www.acsm.org IMPROVEMENT IN CARDIOVASCULAR AND RESPIRATORY FUNCTION • Increased maximal oxygen uptake resulting from both central and peripheral adaptations • Decreased minute ventilation at a given absolute submaximal intensity • Decreased myocardial oxygen cost for a given absolute submaximal intensity • Decreased heart rate and blood pressure at a given submaximal intensity • Increased capillary density in skeletal muscle • Increased exercise threshold for the accumulation of lactate in the blood • Increased exercise threshold for the onset of disease signs or symptoms (e.g., angina pectoris, ischemic ST-segment depression, claudication) REDUCTION IN CARDIOVASCULAR DISEASE RISK FACTORS • Reduced resting systolic/diastolic pressure • Increased serum high-density lipoprotein cholesterol and decreased serum triglycerides • Reduced total body fat, reduced intra-abdominal fat • Reduced insulin needs, improved glucose tolerance • Reduced blood platelet adhesiveness and aggregation • Reduced inflammation DECREASED MORBIDITY AND MORTALITY • Primary prevention (i.e., interventions to prevent the initial occurrence) • Higher activity and/or fitness levels are associated with lower death rates from coronary artery disease • Higher activity and/or fitness levels are associated with lower incidence rates for CVD, CAD, stroke, Type 2 diabetes mellitus, metabolic syndrome, osteoporotic fractures, cancer of the colon and breast, and gallbladder disease • Secondary prevention (i.e., interventions after a cardiac event to prevent another) • Based on meta-analyses (i.e., pooled data across studies), cardiovascular and all-cause mortality are reduced in patients with post-myocardial infarction (MI) who participate in cardiac rehabilitation exercise training, especially as a component of multifactorial risk factor reduction • Randomized controlled trials of cardiac rehabilitation exercise training involving patients with post-MI do not support a reduction in the rate of nonfatal reinfarction OTHER BENEFITS • Decreased anxiety and depression • Improved cognitive function Benefits of Regular Physical Activity and/or Exercise BOX 1.4
- 37. CHAPTER 1 Benefits and Risks Associated with Physical Activity 11 with the prevalence of CVD in the population. Chapter 2 includes the prepar- ticipation health screening guidelines for individuals who wish to be physically active in order to maximize the many health benefits associated with physical activity, while minimizing the risks. SUDDEN CARDIAC DEATH AMONG YOUNG INDIVIDUALS The risk of sudden cardiac death in individuals younger than 30–40 yr is very low because of the low prevalence of CVD in this population. In 2007, the AHA released a scientific statement on “Exercise and Acute Cardiovascular Events: Placing the Risks into Perspective” (2). Table 1.4 (taken from this publication) shows the cardiovascular causes of exercise-related sudden death in young athletes. It is clear from these data that the most common causes of death in young individuals are congenital and hereditary abnormalities including hypertrophic cardiomyopathy, coronary artery abnormalities, and aortic stenosis. The absolute annual risk of exercise-related death among high school and college athletes is one per 133,000 men and 769,000 women (57). It should be noted that these rates, although low, include all sports-related nontraumatic deaths. Of the 136 total identifiable causes of death, 100 were caused by CVD. A more recent estimate places the annual incidence of cardio- vascular deaths among young competitive athletes in the United States as one death per 185,000 men and 1.5 million women. (32). Some experts, however, believe the incidence of exercise-related sudden death in young sports partici- pants is as high as one per 50,000 athletes per year. (15). Experts debate on why estimates of the incidence of exercise-related sudden deaths vary among studies. These variances are likely due to differences in (a) the populations studied; (b) estimation of the number of sport participants; and (c) subject and/or incident case assignment. • Enhanced physical function and independent living in older individuals • Enhanced feelings of well-being • Enhanced performance of work, recreational, and sport activities • Reduced risk of falls and injuries from falls in older individuals • Prevention or mitigation of functional limitations in older adults • Effective therapy for many chronic diseases in older adults CAD, coronary artery disease; CVD, cardiovascular disease. Adapted from (26,37 ,55). Benefits of Regular Physical Activity and/or Exercise (Continued) BOX 1.4
- 38. 12 GUIDELINES FOR EXERCISE TESTING • www.acsm.org EXERCISE-RELATED CARDIAC EVENTS IN ADULTS The risk of sudden cardiac death or acute MI is higher in middle-aged and older adults than in younger individuals. This is due to the higher prevalence of CVD in the older population. The absolute risk of sudden cardiac death during vigorous intensity, physical activity has been estimated at one per year for every 15,000– 18,000 previously asymptomatic individuals (48,53). Although these rates are low, more recent available research has confirmed the increased rate of sudden cardiac death and acute MI among adults performing vigorous intensity exercise when compared with their younger counterparts (20,35,48,53,65). In addition, the rates of sudden cardiac death and acute MI are disproportionately higher in the most sedentary individuals when they perform unaccustomed or infrequent exercise (2). Health/fitness and clinical exercise professionals should understand that although there is an increased risk of sudden cardiac death and acute MI with vigorous intensity exercise, the physically active or fit adult has about 30%–40% lower risk of developing CVD compared to those who are inactive (56). The TABLE 1.4. Cardiovascular Causes of Exercise-Related Sudden Death in Young Athletesa Van Camp (n ⴝ 100)b (57) Maron (n ⴝ 134) (33) Corrado (n ⴝ 55)c (12) Hypertrophic CM 51 36 1 Probable hypertrophic CM 5 10 0 Coronary anomalies 18 23 9 Valvular and subvalvular aortic stenosis 8 4 0 Possible myocarditis 7 3 5 Dilated and nonspecific CM 7 3 1 Atherosclerotic CVD 3 2 10 Aortic dissection/rupture 2 5 1 Arrhythmogenic right ventricular CM 1 3 11 Myocardial scarring 0 3 0 Mitral valve prolapse 1 2 6 Other congenital abnormalities 0 1.5 0 Long QT syndrome 0 0.5 0 Wolff-Parkinson-White syndrome 1 0 1 Cardiac conduction disease 0 0 3 Cardiac sarcoidosis 0 0.5 0 Coronary artery aneurysm 1 0 0 Normal heart at necropsy 7 2 1 Pulmonary thromboembolism 0 0 1 a Ages ranged from 13 to 24 yr (57), 12 to 40 yr (33), and 12 to 35 yr (12). References (57) and (33) used the same database and include many of the same athletes. All (57), 90% (33), and 89% (12) had symptom onset during or within an hour of training or competition. b Total exceeds 100% because several athletes had multiple abnormalities. c Includes some athletes whose deaths were not associated with recent exertion. Includes aberrant artery origin and course, tunneled arteries, and other abnormalities. CM, cardiomyopathy; CVD, cardiovascular disease. Used with permission from (2).
- 39. CHAPTER 1 Benefits and Risks Associated with Physical Activity 13 exact mechanism of sudden cardiac death during vigorous intensity exercise with asymptomatic adults is not completely understood. However, evidence exists that the increased frequency of cardiac contraction and excursion of the coronary arteries produces bending and flexing of the coronary arteries may be the underlying cause. This response may cause cracking of the atherosclerotic plaque with resulting platelet aggregation and possible acute thrombosis and has been documented angiographically in individuals with exercise-induced cardiac events (5,11,21). EXERCISE TESTING AND THE RISK OF CARDIAC EVENTS As with vigorous intensity exercise, the risk of cardiac events during exercise testing varies directly with the prevalence of diagnosed or occult CVD in the study population. Several studies have documented the risks of exercise testing (4,19,25,27,34,44,49). Table 1.5 summarizes the risks of various cardiac events including acute MI, ventricular fibrillation, hospitalization, and death. These data indicate in a mixed population the risk of exercise testing is low with approximately six cardiac events per 10,000 tests. One of these studies includes data for which the exercise testing was supervised by nonphysicians (27). In addition, the majority of these studies used symptom-limited exercise tests. Therefore, it would be expected that the risk of submaximal testing in a similar population would be lower. TABLE 1.5. Cardiac Complications during Exercise Testinga Reference Year Site No. of Tests MI VF Death Hospitalization Comment Rochmis (44) 1971 73 U.S. centers 170,000 NA NA 1 3 34% of tests were symptom limited; 50% of deaths in 8 h; 50% over the next 4 d Irving (25) 1977 15 Seattle facilities 10,700 NA 4.67 0 NR McHenry (34) 1977 Hospital 12,000 0 0 0 0 Atterhog (4) 1979 20 Swedish centers 50,000 0.8 0.8 6.4 5.2 Stuart (49) 1980 1,375 U.S. centers 518,448 3.58 4.78 0.5 NR VF includes other dysrhythmias requiring treatment Gibbons (19) 1989 Cooper Clinic 71,914 0.56 0.29 0 NR Only 4% of men and 2% of women had CVD Knight (27) 1995 Geisinger Cardiology Service 28,133 1.42 1.77 0 NR 25% were inpatient tests supervised by non-MDs a Events are per 10,000 tests. CVD, cardiovascular disease; MD, medical doctor; MI, myocardial infarction; NA, not applicable; NR, not reported; VF , ventricular fibrillation.
- 40. 14 GUIDELINES FOR EXERCISE TESTING • www.acsm.org RISKS OF CARDIAC EVENTS DURING CARDIAC REHABILITATION The highest risk of cardiovascular events occurs in those individuals with diag- nosed CAD. In one survey, there was one nonfatal complication per 34,673 h and one fatal cardiovascular complication per 116,402 h of cardiac rehabilitation (22). More recent studies have found a lower rate, one cardiac arrest per 116,906 patient-hours, one MI per 219,970 patient-hours, one fatality per 752,365 patient- hours, and one major complication per 81,670 patient-hours (13,17,58,59). These studies are presented in Table 1.6 (2). Although these complication rates are low, it should be noted that patients were screened and exercised in medically supervised settings equipped to handle cardiac emergencies. The mortality rate appears to be six times higher when patients exercised in facilities without the ability to successfully manage cardiac arrest (2,13,17,58,59). Interestingly, how- ever, a review of home-based cardiac rehabilitation programs found no increase in cardiovascular complications versus formal center-based exercise programs (62). PREVENTION OF EXERCISE-RELATED CARDIAC EVENTS Because of the low incidence of cardiac events related to vigorous intensity exercise, it is very difficult to test the effectiveness of strategies to reduce the occurrence of these events. According to a recent statement by the ACSM and AHA, “Physicians should not overestimate the risks of exercise because the benefits of habitual physical activity substantially outweigh the risks.” This report also recommends sev- eral strategies to reduce these cardiac events during vigorous intensity exercise (2): • Health care professionals should know the pathologic conditions associated with exercise-related events so that physically active children and adults can be appropriately evaluated. TABLE 1.6. Summary of Contemporary Exercise-Based Cardiac Rehabilitation Program Complication Rates Investigator Year Patient Exercise Hours Cardiac Arrest Myocardial Infarction Fatal Events Major Complicationsa Van Camp (58) 1980–1984 2,351,916 1/111,996b 1/293,990 1/783,972 1/81,101 Digenio (13) 1982–1988 480,000 1/120,000c 1/160,000 1/120,000 Vongvanich (59) 1986–1995 268,503 1/89,501d 1/268,503d 0/268,503 1/67 ,126 Franklin (17) 1982–1998 292,254 1/146,127d 1/97 ,418d 0/292,254 1/58,451 Average 1/116,906 1/219,970 1/752,365 1/81,670 a Myocardial infarction and cardiac arrest. b Fatal 14%. c Fatal 75%. d Fatal 0%. Used with permission from (2).
- 41. CHAPTER 1 Benefits and Risks Associated with Physical Activity 15 • Physically active individuals should know the nature of cardiac prodromal symptoms (e.g., excessive, unusual fatigue and pain in the chest and/or upper back) and seek prompt medical care if such symptoms develop (see Table 2.1). • High school and college athletes should undergo preparticipation screening by qualified professionals. • Athletes with known cardiac conditions or a family history should be evaluated prior to competition using established guidelines. • Health care facilities should ensure their staff is trained in managing cardiac emergencies and have a specified plan and appropriate resuscitation equip- ment (see Appendix B). • Physically active individuals should modify their exercise program in response to variations in their exercise capacity, habitual activity level, and the environment (see Chapters 7 and 8). Although strategies for reducing the number of cardiovascular events during vigorous intensity exercise have not been systematically studied, it is incumbent on the health/fitness and clinical exercise professional to take reasonable pre- cautions when working with individuals who wish to become more physically active/fit and/or increase their physical activity/fitness levels. These precautions are particularly true when the exercise program will be of vigorous intensity. Although many sedentary individuals can safely begin a light-to-moderate inten- sity, physical activity program, individuals of all ages should undergo risk clas- sification to determine the need for further medical evaluation and/or clearance, need for and type of exercise testing (maximal or submaximal), and need for medical supervision during testing (see Chapter 2). Sedentary individuals or those who exercise infrequently should begin their programs at lower intensities and progress at a slower rate because a dispro- portionate number of cardiac events occur in this population. Individuals with known or suspected cardiovascular, pulmonary, metabolic, or renal disease should obtain medical clearance before beginning a vigorous intensity exercise program. Health/fitness and clinical exercise professionals who supervise vigorous intensity exercise programs should have current training in basic and/or advanced cardiac life support and emergency procedures. These emergency procedures should be reviewed and practiced at regular intervals (see Appendix B). Finally, individuals should be educated on the signs and symptoms of CVD and should be referred to a physician for further evaluation should these symptoms occur. THE BOTTOM LINE • A large body of scientific evidence supports the role of physical activity in delaying premature mortality and reducing the risks of many chronic diseases and health conditions. There is also clear evidence for a dose-response rela- tionship between physical activity and health. Thus, any amount of physical activity should be encouraged. • Ideally, an initial target should be 150 min ⭈ wk⫺1 of moderate intensity, aerobic activity; 75 min ⭈ wk⫺1 of vigorous intensity, aerobic activity; or an equivalent
- 42. 16 GUIDELINES FOR EXERCISE TESTING • www.acsm.org combination of moderate and vigorous intensity, aerobic activity. To minimize musculoskeletal injuries, physical activity bouts should be broken up during the week (e.g., 30 min of moderate intensity, aerobic activity on 5 d ⭈ wk⫺1 ). • Additional health benefits result from greater amounts of physical activity. Individuals who maintain a regular program of physical activity that is longer in duration and/or is more vigorous in intensity are likely to derive greater benefit than those who do lesser amounts. • Although the risks associated with exercise transiently increase while exercising, especially exercising at vigorous intensity, the benefits of habitual physical activity substantially outweigh the risks. In addition, the transient increase in risk is of lesser magnitude among individuals who are regularly physically active compared with those who are inactive. American College of Sports Medicine Position Stand on the Quantity and Quality of Exercise: http://www.acsm.org 2008 Physical Activity Guidelines for All Americans: http://www.health.gov/PAguidelines Online Resources REFERENCES 1. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc. 2000;32(9 Suppl):S498–504. 2. American College of Sports Medicine, American Heart Association. Exercise and acute cardiovascu- lar events: placing the risks into perspective. Med Sci Sports Exerc. 2007;39(5):886–97. 3. American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510–30. 4. Atterhog JH, Jonsson B, Samuelsson R. Exercise testing: a prospective study of complication rates. Am Heart J. 1979;98(5):572–9. 5. Black A, Black MM, Gensini G. Exertion and acute coronary artery injury. Angiology. 1975;26(11): 759–83. 6. Blair SN, Kohl HW,3rd, Barlow CE, Paffenbarger RS,Jr, Gibbons LW, Macera CA. Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA. 1995;273(14):1093–8. 7. Blair SN, Kohl HW,3rd, Paffenbarger RS,Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA. 1989;262(17):2395–401. 8. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: defini- tions and distinctions for health-related research. Public Health Rep. 1985;100(2):126–31. 9. Centers for Disease Control and Prevention. Adult participation in recommended levels of physical activity—United States, 2001 and 2003. MMWR Morb Mortal Wkly Rep. 2005;54(47):1208–12. 10. Centers for Disease Control and Prevention. Trends in leisure-time physical inactivity by age, sex, and race/ethnicity—United States, 1994–2004. MMWR Morb Mortal Wkly Rep. 2005;54(39):991–4. 11. Ciampricotti R, Deckers JW, Taverne R, el Gamal M, Relik-van Wely L, Pool J. Characteristics of conditioned and sedentary men with acute coronary syndromes. Am J Cardiol. 1994;73(4):219–22. 12. Corrado D, Basso C, Rizzoli G, Schiavon M, Thiene G. Does sports activity enhance the risk of sud- den death in adolescents and young adults? J Am Coll Cardiol. 2003;42(11):1959–63. 13. Digenio AG, Sim JG, Dowdeswell RJ, Morris R. Exercise-related cardiac arrest in cardiac rehabilita- tion. The Johannesburg experience. S Afr Med J. 1991;79(4):188–91. 14. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41(2):459–71.
- 43. CHAPTER 1 Benefits and Risks Associated with Physical Activity 17 15. Drezner JA, Chun JS, Harmon KG, Derminer L. Survival trends in the United States following exercise-related sudden cardiac arrest in the youth: 2000–2006. Heart Rhythm. 2008;5(6):794–9. 16. Feskanich D, Willett W, Colditz G. Walking and leisure-time activity and risk of hip fracture in postmenopausal women. JAMA. 2002;288(18):2300–6. 17. Franklin BA, Bonzheim K, Gordon S, Timmis GC. Safety of medically supervised outpatient cardiac rehabilitation exercise therapy: a 16-year follow-up. Chest. 1998;114(3):902–6. 18. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine Position Stand. The quantity and quality of exercise for developing and maintaining cardiorespiratory, musculosk- eletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–559. 19. Gibbons L, Blair SN, Kohl HW, Cooper K. The safety of maximal exercise testing. Circulation. 1989;80(4):846–52. 20. Giri S, Thompson PD, Kiernan FJ, et al. Clinical and angiographic characteristics of exertion-related acute myocardial infarction. JAMA. 1999;282(18):1731–6. 21. Hammoudeh AJ, Haft JI. Coronary-plaque rupture in acute coronary syndromes triggered by snow shoveling. N Engl J Med. 1996;335(26):2001. 22. Haskell WL. Cardiovascular complications during exercise training of cardiac patients. Circulation. 1978;57(5):920–4. 23. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1423–34. 24. Howley ET. Type of activity: resistance, aerobic and leisure versus occupational physical activity. Med Sci Sports Exerc. 2001;33(6 Suppl):S364,S369; discussion S419–20. 25. Irving JB, Bruce RA, DeRouen TA. Variations in and significance of systolic pressure during maximal exercise (treadmill) testing. Am J Cardiol. 1977;39(6):841–8. 26. Kesaniemi YK, Danforth E,Jr, Jensen MD, Kopelman PG, Lefebvre P, Reeder BA. Dose-response issues concerning physical activity and health: an evidence-based symposium. Med Sci Sports Exerc. 2001;33(6 Suppl):S351–8. 27. Knight JA, Laubach CA,Jr, Butcher RJ, Menapace FJ. Supervision of clinical exercise testing by exercise physiologists. Am J Cardiol. 1995;75(5):390–1. 28. Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all- cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009;301(19):2024–35. 29. Lee IM, Rexrode KM, Cook NR, Manson JE, Buring JE. Physical activity and coronary heart disease in women: is “no pain, no gain” passe? JAMA. 2001;285(11):1447–54. 30. Leitzmann MF , Rimm EB, Willett WC, et al. Recreational physical activity and the risk of cholecys- tectomy in women. N Engl J Med. 1999;341(11):777–84. 31. Manson JE, Greenland P , LaCroix AZ, et al. Walking compared with vigorous exercise for the pre- vention of cardiovascular events in women. N Engl J Med. 2002;347(10):716–25. 32. Maron BJ, Doerer JJ, Haas TS, Tierney DM, Mueller FO. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980–2006. Circulation. 2009;119(8):1085–92. 33. Maron BJ, Shirani J, Poliac LC, Mathenge R, Roberts WC, Mueller FO. Sudden death in young com- petitive athletes. Clinical, demographic, and pathological profiles. JAMA. 1996;276(3):199–204. 34. McHenry PL. Risks of graded exercise testing. Am J Cardiol. 1977;39(6):935–7. 35. Mittleman MA, Maclure M, Tofler GH, Sherwood JB, Goldberg RJ, Muller JE. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regu- lar exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med. 1993;329(23):1677–83. 36. National Research Council (U.S.). Dietary Reference Intakes for Energy, Carbohydrates, Fiber, Fat, Protein, and Amino Acids. Washington (DC): National Academies; 2003. 1331 p. 37. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recom- mendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1435–45. 38. Paffenbarger RS,Jr, Hyde RT, Wing AL, Lee IM, Jung DL, Kampert JB. The association of changes in physical-activity level and other lifestyle characteristics with mortality among men. N Engl J Med. 1993;328(8):538–45. 39. Paffenbarger RS,Jr, Lee IM. Smoking, physical activity, and active life expectancy. Clin J Sport Med. 1999;9(4):244. 40. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273(5):402–7. 41. Physical activity and cardiovascular health. NIH Consensus Development Panel on Physical Activity and Cardiovascular Health. JAMA. 1996;276(3):241–6.
- 44. 18 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 42. Physical Activity Guidelines Advisory Committee Report, 2008. To the Secretary of Health and Human Services [Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008 [cited 2010 Aug 11]. 683 p. Available from: http://www.health.gov/paguidelines/committeereport.aspx; http://www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf 43. The President’s Council on Physical Fitness and Sports. Definitions—Health, Fitness, and Physical Activity [Internet]. Washington (DC): President’s Council on Physical Fitness and Sports; 2000 [cited 2012 Jan 7]. 11 p. Available from: http://purl.access.gpo.gov/GPO/LPS21074 44. Rochmis P, Blackburn H. Exercise tests. A survey of procedures, safety, and litigation experience in approximately 170,000 tests. JAMA. 1971;217(8):1061–6. 45. Rockhill B, Willett WC, Manson JE, et al. Physical activity and mortality: a prospective study among women. Am J Public Health. 2001;91(4):578–83. 46. Saris WH, Blair SN, van Baak MA, et al. How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st Stock Conference and consensus statement. Obes Rev. 2003;4(2):101–14. 47. Sesso HD, Paffenbarger RS,Jr, Lee IM. Physical activity and coronary heart disease in men: The Harvard Alumni Health Study. Circulation. 2000;102(9):975–80. 48. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigor- ous exercise. N Engl J Med. 1984;311(14):874–7. 49. Stuart RJ,Jr, Ellestad MH. National survey of exercise stress testing facilities. Chest. 1980;77(1):94–7. 50. Swain DP, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2014. 51. Tanasescu M, Leitzmann MF , Rimm EB, Willett WC, Stampfer MJ, Hu FB. Exercise type and inten- sity in relation to coronary heart disease in men. JAMA. 2002;288(16):1994–2000. 52. Thompson PD, Funk EJ, Carleton RA, Sturner WQ. Incidence of death during jogging in Rhode Island from 1975 through 1980. JAMA. 1982;247(18):2535–8. 53. Thompson PD, Stern MP, Williams P , Duncan K, Haskell WL, Wood PD. Death during jogging or running. A study of 18 cases. JAMA. 1979;242(12):1265–7. 54. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th ed. Washington (DC): U.S. Government Printing Office; 2010. 112 p. 55. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion; 1996. 278 p. 56. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans [Internet]. Rockville (MD): Office of Disease Prevention & Health Promotion, U.S. Department of Health and Human Services; 2008 [cited 2012 Jan 7]. 76 p. Available from: http://www.health.gov/ paguidelines 57. Van Camp SP , Bloor CM, Mueller FO, Cantu RC, Olson HG. Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc. 1995;27(5):641–7. 58. Van Camp SP, Peterson RA. Cardiovascular complications of outpatient cardiac rehabilitation pro- grams. JAMA. 1986;256(9):1160–3. 59. Vongvanich P, Paul-Labrador MJ, Merz CN. Safety of medically supervised exercise in a cardiac rehabilitation center. Am J Cardiol. 1996;77(15):1383–5. 60. Vuori I. The cardiovascular risks of physical activity. Acta Med Scand Suppl. 1986;711:205–14. 61. Wang CY, Haskell WL, Farrell SW, et al. Cardiorespiratory fitness levels among US adults 20-49 years of age: findings from the 1999-2004 National Health and Nutrition Examination Survey. Am J Epidemiol. 2010;171(4):426–35. 62. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin. 1995;(17):1–23. 63. Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295(12):1399–403. 64. Williams PT. Physical fitness and activity as separate heart disease risk factors: a meta–analysis. Med Sci Sports Exerc. 2001;33(5):754–61. 65. Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F , Schroder R. Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl J Med. 1993;329(23):1684–90. 66. Yu S, Yarnell JW, Sweetnam PM, Murray L, Caerphilly study. What level of physical activity protects against premature cardiovascular death? The Caerphilly study. Heart. 2003;89(5):502–6.
- 45. 19 The previous versions of Chapter 2 have recommended cardiovascular disease (CVD) risk assessment and stratification of all individuals, and a medical examination and symptom-limited exercise testing as part of the preparticipation health screening prior to initiating vigorous intensity, physical activity in individuals at increased risk for occult CVD. Individuals at increased risk in these recommendations were men 45 and women 55 yr, those with two or more major CVD risk factors, individuals with signs and symptoms of CVD, and those with known cardiac, pulmonary, or metabolic disease. These recommendations were designed to avoid exposing physi- cally unfit individuals to the documented risks of exercise including sudden cardiac death and acute myocardial infarction (MI) as discussed in Chapter 1. Compared to previous editions of the Guidelines, the present version of Chapter 2 regarding the preparticipation health screening process: • Reduces the emphasis on the need for medical evaluation (i.e., medical exam- ination and exercise testing) as part of the preparticipation health screening process prior to initiating a progressive exercise regimen in healthy, asymp- tomatic individuals. • Uses the term risk classification to group individuals as low, moderate, or high risk based on the presence or absence of CVD risk factors, signs and symp- toms, and/or known cardiovascular, pulmonary, renal, or metabolic disease. • Emphasizes identifying those with known disease because they are at greatest risk for an exercise-related cardiac event. • Adopts the American Association of Cardiovascular and Pulmonary Rehabi- litation (AACVPR) risk stratification scheme for individuals with known CVD because it considers overall patient prognosis and potential for rehabili- tation (32) (see Chapter 9). • Supports the public health message that all individuals should adopt a physi- cally active lifestyle. This edition of the Guidelines continues to encourage atherosclerotic CVD risk factor assessment because such measurements are an important part of the prepar- ticipation health screening process and good medical care, but does seek to sim- plify the preparticipation health screening process in order to remove unnecessary and unproven barriers to adopting a physically active lifestyle (24). This edition of the Guidelines also recommends health/fitness and clinical exercise professionals Preparticipation Health Screening CHAPTER 2
- 46. 20 GUIDELINES FOR EXERCISE TESTING • www.acsm.org consult with their medical colleagues when there are questions about patients with known disease and their ability to participate in exercise programs. There are multiple considerations that have prompted these different points of emphasis in the present version of Chapter 2. The risk of a cardiovascular event is increased during vigorous intensity exercise relative to rest, but the absolute risk of a cardiac event is low in healthy individuals (see Chapter 1). Recommending a medical examination and/or stress test as part of the preparticipation health screen- ing process for all individuals at moderate to high risk prior to initiating light-to- moderate intensity exercise programs implies being physically active confers greater risk than a sedentary lifestyle (7). Yet, the cardiovascular health benefits of regular exercise far outweigh the risks of exercise for the general population (28,29). There is also an increased appreciation that exercise testing is a poor predictor of CVD events in asymptomatic individuals probably because such testing detects flow- limiting coronary lesions, whereas sudden cardiac death and acute MI are usually produced by the rapid progression of a previously nonobstructive lesion (29). Furthermore, there is lack of consensus regarding the extent of the medical evalu- ation (i.e., medical examination, stress testing) needed as part of the preparticipation health screening process prior to initiating an exercise program even if it is of vigorous intensity. The American College of Cardiology (ACC)/American Heart Association (AHA) recommend exercise testing prior to moderate or vigorous intensity exercise programs when the risk of CVD is increased but recognize these recommendations are based on conflicting evidence and divergent opinions (12). The U.S. Preventive Services Task Force (USPSTF) concluded that there is an insufficient evidence to evaluate the benefits and harm of exercise testing before initiating a physical activity program and did not make a specific recommendation regarding the need for exercise testing (31). The 2008 Physical Activity Guidelines Advisory Committee Report to the Secretary of Health and Human Services (24) states that even “symptomatic persons or those with cardiovascular disease, diabetes, or other active chronic conditions who want to begin engaging in vigorous physical activity and who have not already devel- oped a physical activity plan with their health care provider may wish to do so,” but does not mandate such medical contact. There is also evidence from decision analysis modeling routine screening that using exercise testing prior to initiating an exercise program is not warranted regardless of baseline individual risk (16). These conside- rations form the basis for the present American College of Sports Medicine (ACSM) recommendations made in Chapter 2 of this edition of the Guidelines. The present version of Chapter 2 does not recommend abandoning all medi- cal evaluation as part of the preparticipation health screening process, as implied by the Physical Activity Guidelines Advisory Committee Report (24). Such changes would be a radical departure from prior editions of the Guidelines. In addition, individuals at highest risk and those with possible CVD symptoms may benefit from an evaluation by a health care provider. The present chapter provides guidance for: • Identifying individuals with unstable symptoms of CVD who could benefit from medical evaluation and treatment (see Table 2.1).
- 47. CHAPTER 2 Preparticipation Health Screening 21 TABLE 2.1. Major Signs or Symptoms Suggestive of Cardiovascular, Pulmonary, or Metabolic Diseasea Signs or Symptoms Clarification/Significance Pain; discomfort (or other anginal equivalent) in the chest, neck, jaw, arms, or other areas that may result from ischemia One of the cardinal manifestations of cardiac disease, in particular coronary artery disease Key features favoring an ischemic origin include the following: • Character: constricting, squeezing, burning, “heaviness, ” or “heavy feeling” • Location: substernal, across midthorax, anteriorly; in one or both arms, shoulders; in neck, cheeks, teeth; in forearms, fingers in interscapular region • Provoking factors: exercise or exertion, excitement, other forms of stress, cold weather, occurrence after meals Key features against an ischemic origin include the following: • Character: dull ache; “knifelike, ” sharp, stabbing; “jabs” aggra- vated by respiration • Location: in left submammary area; in left hemithorax • Provoking factors: after completion of exercise, provoked by a specific body motion Shortness of breath at rest or with mild exertion Dyspnea (defined as an abnormally uncomfortable awareness of breathing) is one of the principal symptoms of cardiac and pulmo- nary disease. It commonly occurs during strenuous exertion in healthy, well-trained individuals and during moderate exertion in healthy, untrained individuals. However, it should be regarded as abnormal when it occurs at a level of exertion that is not expected to evoke this symptom in a given individual. Abnormal exertional dyspnea suggests the presence of cardiopulmonary disorders, in particular left ventricular dysfunction or chronic obstructive pulmo- nary disease. Dizziness or syncope Syncope (defined as a loss of consciousness) is most commonly caused by a reduced perfusion of the brain. Dizziness and, in par- ticular, syncope during exercise may result from cardiac disorders that prevent the normal rise (or an actual fall) in cardiac output. Such cardiac disorders are potentially life threatening and include severe coronary artery disease, hypertrophic cardiomyopathy, aortic stenosis, and malignant ventricular dysrhythmias. Although dizziness or syncope shortly after cessation of exercise should not be ignored, these symptoms may occur even in healthy individuals as a result of a reduction in venous return to the heart. Orthopnea or paroxysmal nocturnal dyspnea Orthopnea refers to dyspnea occurring at rest in the recumbent position that is relieved promptly by sitting upright or standing. Paroxysmal nocturnal dyspnea refers to dyspnea, beginning usually 2–5 h after the onset of sleep, which may be relieved by sitting on the side of the bed or getting out of bed. Both are symptoms of left ventricular dysfunction. Although nocturnal dyspnea may occur in individuals with chronic obstructive pulmonary disease, it differs in that it is usually relieved after the individual relieves himself or herself of secretions rather than specifically by sitting up. Ankle edema Bilateral ankle edema that is most evident at night is a character- istic sign of heart failure or bilateral chronic venous insufficiency. Unilateral edema of a limb often results from venous thrombosis or lymphatic blockage in the limb. Generalized edema (known as anasarca) occurs in individuals with the nephrotic syndrome, severe heart failure, or hepatic cirrhosis. (continued)
- 48. 22 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • Identifying those with diagnosed disease who could benefit from a medical evaluation that includes an exercise test. • Providing appropriate recommendations regarding the initiation, continua- tion, or progression of an individual’s physical activity program to minimize the potential for catastrophic cardiac events. Potential participants should be screened for the presence of risk factors for various cardiovascular, pulmonary, and metabolic diseases as well as other health conditions (e.g., pregnancy, orthopedic limitations) that require special attention (14,17,18) to (a) optimize safety during exercise testing; and (b) aid in the deve- lopment of a safe and effective exercise prescription (Ex Rx ). The purposes of the preparticipation health screening include the following: • Identification of individuals with medical contraindications that require ex- clusion from exercise programs until those conditions have been abated or controlled. • Recognition of individuals with clinically significant disease(s) or conditions who should participate in a medically supervised exercise program. TABLE 2.1. Major Signs or Symptoms Suggestive of Cardiovascular, Pulmonary, or Metabolic Diseasea (Continued) Signs or Symptoms Clarification/Significance a These signs or symptoms must be interpreted within the clinical context in which they appear because they are not all specific for cardiovascular, pulmonary, or metabolic disease. Modified from (14). Palpitations or tachycardia Palpitations (defined as an unpleasant awareness of the forceful or rapid beating of the heart) may be induced by various disorders of cardiac rhythm. These include tachycardia, bradycardia of sudden onset, ectopic beats, compensatory pauses, and accentuated stroke volume resulting from valvular regurgitation. Palpitations also often result from anxiety states and high cardiac output (or hyperkinetic) states, such as anemia, fever, thyrotoxicosis, arteriovenous fistula, and the so-called idiopathic hyperkinetic heart syndrome. Intermittent claudication Intermittent claudication refers to the pain that occurs in a muscle with an inadequate blood supply (usually as a result of atheroscle- rosis) that is stressed by exercise. The pain does not occur with standing or sitting, is reproducible from day to day, is more severe when walking upstairs or up a hill, and is often described as a cramp, which disappears within 1–2 min after stopping exercise. Coronary artery disease is more prevalent in individuals with inter- mittent claudication. Patients with diabetes are at increased risk for this condition. Known heart murmur Although some may be innocent, heart murmurs may indicate valvular or other cardiovascular disease. From an exercise safety standpoint, it is especially important to exclude hypertrophic car- diomyopathy and aortic stenosis as underlying causes because these are among the more common causes of exertion-related sudden cardiac death. Unusual fatigue or shortness of breath with usual activities Although there may be benign origins for these symptoms, they also may signal the onset of or change in the status of cardiovas- cular, pulmonary, or metabolic disease.
- 49. CHAPTER 2 Preparticipation Health Screening 23 • Detection of individuals who should undergo a medical evaluation and/or exercise testing as part of the preparticipation health screening process before initiating an exercise program or increasing the frequency and intensity of their current program. PREPARTICIPATION HEALTH SCREENING Preparticipation health screening before initiating physical activity or an exercise program is a multistage process that may include 1. Self-guided methods such as the Physical Activity Readiness Questionnaire (PAR-Q) (8) (see Figure 2.1) or the modified AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire (4) (see Figure 2.2); 2. CVD risk factor assessment and classification by qualified health/fitness, clinical exercise, or health care professionals; and 3. Medical evaluation including a physical examination and stress test by a qualified health care provider. Preparticipation health screening before initiating an exercise program should be distinguished from a periodic medical examination (24). A periodic health examination or a similar contact with a health care provider should be encour- aged as part of routine health maintenance and to detect medical conditions unrelated to exercise. SELF-GUIDED METHODS Preparticipation health screening by self-reported medical history or health risk appraisal should be done for all individuals wishing to initiate a physical activity program. These self-guided methods can be easily accomplished by using such instruments as the PAR-Q (8) (see Figure 2.1) or an adaptation of the AHA/ ACSM Health/Fitness Facility Preparticipation Screening Questionnaire (4) (see Figure 2.2). Patients with cardiac symptoms often perceive chest discom- fort rather than pain. The AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire may be more useful in these situations because it inquires about “chest discomfort” rather than “chest pain” as does the PAR-Q. ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK FACTOR ASSESSMENT ACSM risk classification as delineated in Figure 2.3 is based in part on the pres- ence or absence of the CVD risk factors listed in Table 2.2 (5,9,12,21,22,26,30,31). The completed PAR-Q or AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire should be reviewed by a qualified health/fitness, clinical exercise, or health care professional to determine if the individual meets any of the criteria for positive CVD risk factors shown in Table 2.2. If the presence or absence
- 50. 24 GUIDELINES FOR EXERCISE TESTING • www.acsm.org ■ FIGURE 2.1. Physical Activity Readiness Questionnaire (PAR-Q) form. Reprinted from (8), with permission from the Canadian Society for Exercise Physiology, http://www.csep.ca. © 2002.
- 51. CHAPTER 2 Preparticipation Health Screening 25 Assess your health status by marking all true statements History You have had: a heart attack heart surgery cardiac catheterization coronary angioplasty (PTCA) pacemaker/implantable cardiac defibrillator/rhythm disturbance heart valve disease heart failure heart transplantation congenital heart disease If you marked any of these statements in this section, consult your physician or other appropriate health care provider before engaging in exercise. You may need to use a facility with a medically qualified staff. Symptoms You experience chest discomfort with exertion You experience unreasonable breathlessness You experience dizziness, fainting, or blackouts You experience ankle swelling You experience unpleasant awareness of a forceful or rapid heart rate You take heart medications Other health issues You have diabetes You have asthma or other lung disease You have burning or cramping sensation in your lower legs when walking short distance You have musculoskeletal problems that limit your physical activity You have concerns about the safety of exercise You take prescription medications You are pregnant Cardiovascular risk factors You are a man 45 yr You are a woman 55 yr You smoke or quit smoking within the previous 6 mo Your blood pressure is 140/90 mm Hg You do not know your blood pressure You take blood pressure medication Your blood cholesterol level is 200 mg ⭈ dL1 You do not know your cholesterol level You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother) or age 65 (mother or sister) You are physically inactive (i.e., you get 30 min of physical activity on at least 3 d per week) You have a body mass index 30 kg ⭈ m2 You have prediabetes You do not know if you have prediabetes If you marked two or more of the statements in this section you should consult your physician or other appropriate health care as part of good medical care and progress gradually with your exercise program. You might benefit from using a facility with a professionally qualified exercise staffa to guide your exercise program. None of the above You should be able to exercise safely without consulting your physician or other appropriate health care provider in a self-guide program or almost any facility that meets your exercise program needs. a Professionally qualified exercise staff refers to appropriately trained individuals who possess academic training, practical and clinical knowledge, skills, and abilities commensurate with the credentials defined in Appendix D. ■ FIGURE 2.2. AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire. Individuals with multiple CVD risk factors (see Table 2.2) should be encouraged to consult with their physician prior to initiating a vigorous intensity exercise program as part of good medical care and should progress gradually with their exercise program of any exercise intensity. ACSM, American College of Sports Medicine; AHA, American Heart Association; CVD, cardiovascular disease, PTCA, percutaneous transluminal coronary angioplasty. Modified from (4).
- 52. 26 GUIDELINES FOR EXERCISE TESTING • www.acsm.org ■ FIGURE 2.3. Logic model for classification of risk. CV, cardiovascular; CVD, cardiovascular disease. Review Health/ Medical History for: Known Disease, Signs/Symptoms, CVD Risk Factors Known CV, Pulmonary, Metabolic Disease? (see Table 2.3) Number of CVD Risk Factors High Risk Moderate Risk Low Risk Cardiovascular: Cardiac, peripheral vascular, or cerebrovascular disease Pulmonary: COPD, asthma, interstitial lung disease, or cystic fibrosis renal disease Metabolic: Diabetes mellitus (Types 1 and 2) or Pain, discomfort in the chest, neck, jaw, arms, or other areas that may result from ischemia Shortness of breath at rest or with mild exertion Dizziness or syncope Orthopnea or paroxysmal nocturnal dyspnea Ankle edema Palpitations or tachycardia Intermittent claudication Known heart murmur Unusual fatigue or shortness of breath with usual activities Age Family History Current Cigarette Smoking Sedentary Lifestyle Obesity Hypertension Dyslipidemia Prediabetes Yes No Major Signs or Symptoms Suggestive of CV, Pulmonary, Metabolic Disease? Yes No of a CVD risk factor is not disclosed or is not available, that CVD risk factor should be counted as a risk factor except for prediabetes. If the prediabetes criteria are missing or unknown, prediabetes should be counted as a risk factor for those (a) 45 yr, especially for those with a body mass index (BMI) 25 kg ⭈ m2 ; and (b) 45 yr with a BMI 25 kg ⭈ m2 and additional CVD risk factors for prediabetes (e.g., family history of diabetes mellitus). The number of positive risk factors is
- 53. CHAPTER 2 Preparticipation Health Screening 27 then summed. Because of the cardioprotective effect of high-density lipoprotein cholesterol (HDL), HDL is considered a negative CVD risk factor. For individuals having HDL 60 mg ⭈ dL1 (1.55 mmol ⭈ L1 ), one positive CVD risk factor is subtracted from the sum of positive CVD risk factors. CVD risk factor assessment provides the health/fitness, clinical exercise, and health care professionals with important information for the development of a client or patient’s Ex Rx . CVD risk factor assessment in combination with the determination of the presence of various cardiovascular, pulmonary, renal, and metabolic diseases is important when making decisions about (a) the level of medical clearance; (b) the need for exercise testing; and (c) the level of super- vision for exercise testing and exercise program participation (see Figures 2.3 and 2.4). Please refer to the case studies in Box 2.1 that provide a framework for conducting CVD risk factor assessment and classification. a If the presence or absence of a CVD risk factor is not disclosed or is not available, that CVD risk factor should be counted as a risk factor except for prediabetes. If the prediabetes criteria are missing or unknown, prediabetes should be counted as a risk factor for those 45 yr, especially for those with a body mass index (BMI) 25 kg ⭈ m2 , and those 45 yr with a BMI 25 kg ⭈ m2 and additional CVD risk factors for prediabetes. The number of positive risk factors is then summed. b High HDL is considered a negative risk factor. For individuals having high HDL 60 mg ⭈ dL1 (1.55 mmol ⭈ L1 ), for these individuals one positive risk factor is subtracted from the sum of positive risk factors. V̇O2 R, oxygen uptake reserve. TABLE 2.2. Atherosclerotic Cardiovascular Disease (CVD) Risk Factors and Defining Criteria (26,31) Risk Factors Defining Criteria Age Men 45 yr; women 55 yr (12) Family history Myocardial infarction, coronary revascularization, or sudden death before 55 yr in father or other male first-degree relative or before 65 yr in mother or other female first-degree relative Cigarette smoking Current cigarette smoker or those who quit within the previous 6 mo or exposure to environmental tobacco smoke Sedentary lifestyle Not participating in at least 30 min of moderate intensity, physical activity (40%–60% V̇O2 R) on at least 3 d of the week for at least 3 mo (22,30) Obesity Body mass index 30 kg ⭈ m2 or waist girth 102 cm (40 in) for men and 88 cm (35 in) for women (10) Hypertension Systolic blood pressure 140 mm Hg and/or diastolic 90 mm Hg, confirmed by measurements on at least two separate occasions, or on antihypertensive medication (9) Dyslipidemia Low-density lipoprotein (LDL) cholesterol 130 mg ⭈ dL1 (3.37 mmol ⭈ L1 ) or high-density lipoproteinb (HDL) cholesterol 40 mg ⭈ dL1 (1.04 mmol ⭈ L1 ) or on lipid-lowering medication. If total serum cholesterol is all that is available, use 200 mg ⭈ dL1 (5.18 mmol ⭈ L1 ) (21) Prediabetesa Impaired fasting glucose (IFG) fasting plasma glucose 100 mg ⭈ dL1 (5.55 mmol ⭈ L1 ) and 125 mg ⭈ dL1 (6.94 mmol ⭈ L1 ) or impaired glucose tolerance (IGT) 2 h values in oral glucose tolerance test (OGTT) 140 mg ⭈ dL1 (7 .77 mmol ⭈ L1 ) and 199 mg ⭈ dL1 (11.04 mmol ⭈ L1 ) confirmed by measurements on at least two separate occasions (5) Negative Risk Factors Defining Criteria High-density lipoprotein (HDL) cholesterol 60 mg ⭈ dL1 (1.55 mmol ⭈ L1 )
- 54. 28 GUIDELINES FOR EXERCISE TESTING • www.acsm.org ■ FIGURE 2.4. Medical examination, exercise testing, and supervision of exercise testing preparticipation recommendations based on classification of risk. Ex Rx , exercise prescription; HR, heart rate; METs, metabolic equivalents; V̇O2 R, oxygen uptake reserve. Risk Classification Low Risk Moderate Risk Asymptomatic Asymptomatic 2 Risk Factors ≥2 Risk Factors High Risk Symptomatic, or known cardiovascular, pulmonary, renal, or metabolic disease (see Table 2.3) Medical Exam Rec Before Exercise? Medical Exam Rec Before Exercise? Medical Exam Rec Before Exercise? Exercise Test Rec Before Exercise? Exercise Test Rec Before Exercise? Exercise Test Rec Before Exercise? Mod Ex - No Vig Ex - No Mod Ex - No Vig Ex - Yes Mod Ex - Yes Vig Ex - Yes Mod Ex - No Vig Ex - No Mod Ex - No Vig Ex - No Mod Ex - Yes Vig Ex - Yes MD Supervision of E if Done? if Done? if Done? xercise Test Submax - No Max - No Submax - No Max - No Submax - Yes Max - Yes MD Supervision of Exercise Test MD Supervision of Exercise Test Mod Ex: Vig Ex: Not Rec: Rec: • Moderate intensity exercise; 40%–60% VO2R; 3–6 METs “An intensity that causes noticeable increases in HR and breathing.” • Vigorous intensity exercise; ≥60% VO2R; ≥6 METs “An intensity that causes substantial increases in HR and breathing.” Reflects the notion a medical examination, exercise test, and physician supervision of exercise testing are not recommended in the preparticipation screening; however, they may be considered when there are concerns about risk, more information is needed for the Ex Rx, and/or are requested by the patient or client. Reflects the notion a medical examination, exercise test, and physician supervision are recommended in the preparticipation health screening process.
- 55. CHAPTER 2 Preparticipation Health Screening 29 CASE STUDY I Female, age 21 yr, smokes socially on weekends (⬃10–20 cigarettes). Drinks alcohol one or two nights a week, usually on weekends. Height 63 in (160 cm), weight 124 lb (56.4 kg), BMI 22.0 kg ⭈ m2 . RHR 76 beats ⭈ min1 , resting BP 118/72 mm Hg.Total cholesterol 178 mg ⭈ dL1 (4.61 mmol ⭈ L1 ), LDL 98 mg ⭈ dL1 (2.54 mmol ⭈ L1 ), HDL 57 mg ⭈ dL1 (1.48 mmol ⭈ L1 ), FBG unknown. Currently taking oral contraceptives. Attends group exercise class two to three times a week. Reports no symptoms. Both parents living and in good health. CASE STUDY II Man, age 54 yr, nonsmoker. Height 72 in (182.9 cm), weight 168 lb (76.4 kg), BMI 22.8 kg ⭈ m2 . RHR 64 beats ⭈ min1 , resting BP 124/78 mm Hg. Total cholesterol 187 mg ⭈ dL1 (4.84 mmol ⭈ L1 ), LDL 103 mg ⭈ L1 (2.67 mmol ⭈ L1 ), HDL 52 mg ⭈ dL1 (1.35 mmol ⭈ L1 ), FBG 88 mg ⭈ dL1 (4.84 mmol ⭈ L1 ). Recreationally competitive runner, runs 4–7 d ⭈ wk1 , completes one to two marathons and numerous other road races every year. No medications other than over-the-counter ibuprofen as needed. Reports no symptoms. Father died at age 77 yr of a heart attack, mother died at age 81 yr of cancer. CASE STUDY III Man, age 44 yr, nonsmoker. Height 70 in (177 .8 cm), weight 216 lb (98.2 kg), BMI 31.0 kg ⭈ m2 . RHR 62 beats ⭈ min1 , resting BP 128/84 mm Hg. Total serum cholesterol 184 mg ⭈ dL1 (4.77 mmol ⭈ L1 ), LDL 106 mg ⭈ dL1 (2.75 mmol ⭈ L1 ), HDL 44 mg ⭈ dL1 (1.14 mmol ⭈ L1 ), FBG unknown. Walks 2–3 mi two to three times a week. Father had Type 2 diabetes and died at age 67 yr of a heart attack; mother living, no CVD. No medications; reports no symptoms. CASE STUDY IV Women, age 36 yr, nonsmoker. Height 64 in (162.6 cm), weight 108 lb (49.1 kg), BMI 18.5 kg ⭈ m2 . RHR 61 beats ⭈ min1 , resting BP 114/62 mm Hg. Total cholesterol 174 mg ⭈ dL1 (4.51 mmol ⭈ L1 ), blood glucose normal with insulin injections. Type 1 diabetes diagnosed at age 7 yr. Teaches dance aerobic classes three times a week, walks approximately 45 min four times a week. Reports no symptoms. Both parents in good health with no history of CVD. Case Studies to Conduct Cardiovascular Disease (CVD) Risk Factor Assessment and Determine Risk Classification BOX 2.1 (continued)
- 56. 30 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Case Study I Case Study II Case Study III Case Study IV Known cardiovascular, pulmonary, and/or metabolic disease? No No No Yes — diagnosed Type 1 diabetes Major signs or symptoms? No No No Yes CVD risk factors: Age? No Yes No No Family history? No No No No Current cigarette smoking? Yes No No No Sedentary lifestyle? No No No No Obesity? No No Yes — BMI 30 kg ⭈ m2 No Hypertension? No No No No Hypercholesterolemia? No No No No Prediabetes? Unknown — count as No in absence of age or obesity as risk factors No Unknown — count as Yes in presence of obesity Diagnosed Type 1 diabetes Summary No known disease, no major signs or symptoms, one CVD risk factor No known disease, no major signs or symptoms, one CVD risk factor No known disease, no major signs or symptoms, two CVD risk factors Diagnosed metabolic disease with major signs and symptoms At low, moderate, or high risk?a Low Low Moderate High a See Figure 2.4 for medical examination, exercise testing, and supervision of exercise testing preparticipation recommendations based on classification of risk. BMI, body mass index; BP , blood pressure; CVD, cardiovascular disease; FBG, fasting blood glucose; HDL, high-density lipoprotein cholesterol; LDL, low-density lipoprotein cholesterol; RHR, resting heart rate. Case Studies to Conduct Cardiovascular Disease (CVD) Risk Factor Assessment and Determine Risk Classification (Continued) BOX 2.1 All individuals wanting to initiate a physical activity program should be screened at minimum by a self-reported medical history or health risk appraisal questionnaire such as the PAR-Q (8) (see Figure 2.1) or the modified AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire (4) (see Figure 2.2) for the presence of risk factors for various cardiovascular, pulmonary, renal, and metabolic diseases as well as other conditions (e.g., pregnancy, orthopedic
- 57. CHAPTER 2 Preparticipation Health Screening 31 injury) that require special attention when developing the Ex Rx (14,17,18). The answers to the self-guided methods of the preparticipation health screening pro- cess then determine the need for and degree of follow-up by a qualified health/ fitness, clinical exercise, or health care provider before initiating physical activity or an exercise program. The ACSM recommendations regarding the need for and degree of follow-up are detailed in the following sections. RECOMMENDATIONS FOR A MEDICAL EXAMINATION PRIOR TO INITIATING PHYSICAL ACTIVITY The risk of an exercise-related event such as sudden cardiac death (27) or acute MI (13,19,27) is greatest in those individuals performing unaccustomed physical activity and is greatest during vigorous intensity, physical activity. However, the CVD risk of light-to-moderate intensity, physical activity approximates that at rest (33). Consequently, physically unfit individuals initiating a physical activity pro- gram should start with light-to-moderate intensity levels of exercise and progress gradually as their fitness improves. Moderate intensity in most studies of exercise- related CVD events is defined as activity requiring 3 to 6 metabolic equivalents (METs), but the relative intensity of any specific activity varies with the fitness and age of the subject. Moderate intensity, physical activity can also be defined as that requiring 40% to 60% oxygen uptake reserve (V̇O2 R). This physical exertion level can be estimated without exercise testing and direct measurement of maximal oxygen consumption (V̇O2max ) by instructing subjects to use a rating of perceived exertion scale (see Chapter 7) or by exercising to the point of developing moderate shortness of breath or dyspnea but still able to talk comfortably (6,23). The present ACSM recommendations (see Box 2.2) are based on the observa- tions that the absolute risk of an exercise-related CVD event is low especially for • Individuals at moderate risk with two or more CVD risk factors (see Table 2.2 and Figure 2.3) should be encouraged to consult with their physician prior to initiating a vigorous intensity exercise program as part of good medical care and should progress gradually with their exercise program of any exercise intensity (see Figure 2.4). Although medical evaluation is taking place for the initiation of vigorous intensity exercise, the majority of these individuals can begin light-to-moderate intensity exercise programs such as walking without consulting a physician. • Individuals at high risk with symptoms or diagnosed disease (see Table 2.1) should consult with their physician prior to initiating an exercise program (see Figure 2.4). CVD, cardiovascular disease. Recommendations for a Medical Examination Prior to Initiating Physical Activity BOX 2.2
- 58. 32 GUIDELINES FOR EXERCISE TESTING • www.acsm.org individuals willing to initiate light-to-moderate intensity exercise and to progress gradually. The exceptions to these observations are individuals with diagnosed disease, with unstable symptoms, or at extremely high risk for occult disease (see Table 2.1). RECOMMENDATIONS FOR EXERCISE TESTING PRIOR TO INITIATING PHYSICAL ACTIVITY See Table 2.3 for recommendations for exercise testing prior to initiating physi- cal activity. No set of guidelines for exercise testing prior to initiation of physical activity covers all situations. Local circumstances and policies vary, and specific program procedures are also properly diverse. To provide guidance on the need for a medi- cal examination and exercise test before participation in a moderate-to-vigorous intensity exercise program, ACSM suggests the recommendations presented in Figure 2.4 for determining when a medical examination and exercise test are appropriate and when physician supervision of exercise testing is recommended. Exercise testing before initiating a physical activity program is not routinely recommended except for individuals at high risk as defined earlier (see Tables 2.1 and 2.3). Nevertheless, the information gathered from an exercise test may be useful in establishing a safe and effective Ex Rx for lower risk individuals. Recommending an exercise test for lower risk individuals may be considered if the purpose of the test is to design an effective Ex Rx . The exercise testing recom- mendations found in Figure 2.4 reflect the notion that the risk of cardiovascular events increases as a direct function of exercise intensity (i.e., vigorous moder- ate light intensity exercise) and the number of CVD risk factors (see Table 2.2 TABLE 2.3. New ACSM Recommendations for Exercise Testing Prior to Exercise-Diagnosed Cardiovascular Disease Unstable or new or possible symptoms of cardiovascular disease (see Table 2.2) Diabetes mellitus and at least one of the following: Age 35 yr OR Type 2 diabetes mellitus 10-yr duration OR Type 1 diabetes mellitus 15-yr duration OR Hypercholesterolemia (total cholesterol 240 mg ⭈ L1 ) (6.62 mmol ⭈ L1 ) OR Hypertension (systolic blood pressure 140 or diastolic 90 mm Hg) OR Smoking OR Family history of CAD in first-degree relative 60 yr OR Presence of microvascular disease OR Peripheral artery disease OR Autonomic neuropathy End-stage renal disease Patients with symptomatic or diagnosed pulmonary disease including chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease, or cystic fibrosis. ACSM, American College of Sports Medicine; CAD, coronary artery disease.
- 59. CHAPTER 2 Preparticipation Health Screening 33 and Figure 2.3). Although Figure 2.4 provides both absolute (METs) and relative (%V̇O2max ) thresholds for moderate and vigorous intensity exercise, health/ fitness and clinical exercise professionals should choose the most appropriate absolute or relative intensity threshold for their setting and population when making decisions about the level of preparticipation health screening needed before initiating an exercise program. RECOMMENDATIONS FOR SUPERVISION OF EXERCISE TESTING The degree of medical supervision of exercise testing varies appropriately from physician-supervised tests to situations in which there is no physician present (11). It is important to distinguish between patients who require an exercise test before exercise participation and patients who require a physician to supervise the exercise test. Exercise tests as part of the preparticipation health screening for individuals at moderate to high risk are often maximal tests done in those without prior exercise training. Both factors probably increase the risk of a cardiac event. Furthermore, there are legal implications for the testing facility if a complication occurs during testing and the testing is not physician or professionally supervised. There is consensus that exercise testing of all patient risk groups can be su- pervised by nonphysician health care professionals if the professional is specially trained in clinical exercise testing and a physician is immediately available if needed (20). There is also general agreement that such testing in patients at low risk can be supervised by nonphysicians without a physician being immediately available. There is no consensus whether or not nonphysicians should supervise exercise testing in patients at moderate risk without a physician immediately available. Having a physician available for testing of patients at moderate risk is recommended, but whether or not a physician must be immediately available for exercise testing of patients at moderate risk will depend on local policies and circumstances, the health status of the patients, and the training and experience of the laboratory staff. See Box 2.3 for a summary of these recommendations. Exercise testing of individuals at high risk can be supervised by nonphysi- cian health care professionals if the professional is specially trained in clinical exercise testing with a physician immediately available if needed. Exercise testing of individuals at moderate risk can be supervised by nonphysician health care professionals if the professional is specially trained in clinical exercise testing, but whether or not a physician must be immediately avail- able for exercise testing is dependent on local policies and circumstances, the health status of the patients, and the training and experience of the laboratory staff. Recommendations for Supervision of Exercise Testing BOX 2.3
- 60. 34 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Physicians responsible for supervising exercise testing should meet or exceed the minimal competencies for supervision and interpretation of results as established by the AHA (25). In all situations in which exercise testing is performed, site personnel should at least be certified at a level of basic life support (cardiopulmonary resuscitation [CPR]) and have automated external defibrillator (AED) training. Preferably, one or more staff members should also be certified in first aid and advanced cardiac life support (ACLS) (15). All exercise testing facilities with or without physician supervision (a) should also have a written medical emergency response plan with procedures and contact numbers; (b) should practice this plan at least quarterly; and (c) be equipped with a defibrillator or an AED depending on staffing competencies (20). RISK STRATIFICATION FOR PATIENTS WITH CARDIOVASCULAR DISEASE Patients with CVD may be further stratified regarding safety during exercise using published guidelines (2). Risk stratification criteria from the AACVPR are presented in Box 2.4 (2). American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease BOX 2.4 w w with C C C Car ar rd dio o ov va as sc cula a ar Di Dise seas a e LOWEST RISK Characteristics of patients at lowest risk for exercise participation (all characteristics listed must be present for patients to remain at lowest risk) • Absence of complex ventricular dysrhythmias during exercise testing and recovery • Absence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness, during exercise testing and recovery) • Presence of normal hemodynamics during exercise testing and recovery (i.e., appropriate increases and decreases in heart rate and systolic blood pressure with increasing workloads and recovery) • Functional capacity 7 metabolic equivalents (METs) Nonexercise Testing Findings • Resting ejection fraction 50% • Uncomplicated myocardial infarction or revascularization procedure • Absence of complicated ventricular dysrhythmias at rest • Absence of congestive heart failure • Absence of signs or symptoms of postevent/postprocedure ischemia • Absence of clinical depression
- 61. CHAPTER 2 Preparticipation Health Screening 35 MODERATE RISK Characteristics of patients at moderate risk for exercise participation (any one or combination of these findings places a patient at moderate risk) • Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness occurring only at high levels of exertion [7 METs]) • Mild to moderate level of silent ischemia during exercise testing or recovery (ST-segment depression 2 mm from baseline) • Functional capacity 5 METs Nonexercise Testing Findings • Rest ejection fraction 40% to 49% HIGHEST RISK Characteristics of patients at high risk for exercise participation (any one or combination of these findings places a patient at high risk) • Presence of complex ventricular dysrhythmias during exercise testing or recovery • Presence of angina or other significant symptoms (e.g., unusual shortness of breath, light-headedness, or dizziness at low levels of exertion [5 METs] or during recovery) • High level of silent ischemia (ST-segment depression 2 mm from baseline) during exercise testing or recovery • Presence of abnormal hemodynamics with exercise testing (i.e., chronotropic incompetence or flat or decreasing systolic BP with increasing workloads) or recovery (i.e., severe postexercise hypotension) Nonexercise Testing Findings • Rest ejection fraction 40% • History of cardiac arrest or sudden death • Complex dysrhythmias at rest • Complicated myocardial infarction or revascularization procedure • Presence of congestive heart failure • Presence of signs or symptoms of postevent/postprocedure ischemia • Presence of clinical depression Reprinted from (32), with permission from Elsevier. American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) Risk Stratification Criteria for Patients with Cardiovascular Disease (Continued) BOX 2.4
- 62. 36 GUIDELINES FOR EXERCISE TESTING • www.acsm.org The AACVPR guidelines provide recommendations for participant and/or patient monitoring and supervision and for activity restriction. Clinical exer- cise professionals should recognize the AACVPR guidelines do not consider comorbidities (e.g., Type 2 diabetes mellitus, morbid obesity, severe pulmonary disease, debilitating neurologic, orthopedic conditions) that could result in modification of the recommendations for monitoring and supervision during exercise training. THE BOTTOM LINE The ACSM Preparticipation Health Screening Recommendations are the following: • All individuals wishing to initiate a physical activity program should be screened at minimum by a self-reported medical history or health risk ap- praisal questionnaire. The need and degree of follow-up is determined by the answers to these self-guided methods. • Individuals at moderate risk with two or more CVD risk factors (see Table 2.2 and Figures 2.3 and 2.4) should be encouraged to consult with their physician prior to initiating a vigorous intensity, physical activity program. Although medical evaluation is taking place, the majority of these individuals can begin light-to-moderate intensity exercise programs such as walking without con- sulting their physician. • Individuals at high risk with symptoms or diagnosed disease (see Table 2.1) should consult with their physician prior to initiating a physical activity pro- gram (see Figure 2.4). • Routine exercise testing is recommended only for individuals at high risk (see Table 2.3 and Figures 2.3 and 2.4) including those with diagnosed CVD, symptoms suggestive of new or changing CVD, diabetes mellitus, and additional CVD risk factors, end-stage renal disease, and specified lung disease. • Exercise testing of individuals at high risk can be supervised by nonphy- sician health care professionals if the professional is specially trained in clinical exercise testing with a physician immediately available if needed. Exercise testing of individuals at moderate risk can be supervised by nonphysician health care professionals if the professional is specially trained in clinical exercise testing, but whether or not a physician must be immediately available for exercise testing is dependent on a variety of considerations. These recommendations are made to reduce barriers to the adoption of a physically active lifestyle because (a) much of the risk associated with exercise can be mitigated by adopting a progressive exercise training regi- men; and (b) there is an overall low risk of participation in physical activity programs (24).
- 63. CHAPTER 2 Preparticipation Health Screening 37 REFERENCES 1. 2008 Physical Activity Guidelines for Americans [Internet]. Rockville (MD): Office of Disease Prevention Health Promotion, U.S. Department of Health and Human Services; 2008 [cited 2010 Sep 22]. 76 p. Available from: http://www.health.gov/paguidelines 2. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign (IL): Human Kinetics; 2004. 280 p. 3. American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Pulmonary Rehabilitation Programs. 3rd ed. Champaign (IL): Human Kinetics; 2004. 188 p. 4. American College of Sports Medicine Position Stand, American Heart Association. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Med Sci Sports Exerc. 1998;30(6):1009–18. 5. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2007;30 Suppl 1:S42–7. 6. Brawner CA, Vanzant MA, Ehrman JK, et al. Guiding exercise using the talk test among patients with coronary artery disease. J Cardiopulm Rehabil. 2006;26(2):72–5; quiz 76–7. 7. Buchner DM. Physical activity to prevent or reverse disability in sedentary older adults. Am J Prev Med. 2003;25(3 Suppl 2):214–5. 8. Canada’s Physical Activity Guide to Healthy Active Living [Internet]. Ontario (Canada): Public Health Agency of Canada; [cited 2007 Jun 15]. Available from: http://www.phac-aspc.gc.ca/pau-uap/paguide/ index.html 9. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003;289(19):2560–72. 10. Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Arch Intern Med. 1998;158(17):1855–67. 11. Fletcher GF , Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001; 104(14):1694–740. 12. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531–40. 13. Giri S, Thompson PD, Kiernan FJ, et al. Clinical and angiographic characteristics of exertion-related acute myocardial infarction. JAMA. 1999;282(18):1731–6. 14. Gordon SMBS. Health appraisal in the non-medical setting. In: Durstine JL, editor. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 2nd ed. Philadelphia: Williams Wilkins; 1993. p. 219–28. 15. Kern KB, Halperin HR, Field J. New guidelines for cardiopulmonary resuscitation and emergency cardiac care: changes in the management of cardiac arrest. JAMA. 2001;285(10):1267–9. 16. Lahav D, Leshno M, Brezis M. Is an exercise tolerance test indicated before beginning regular exer- cise? A decision analysis. J Gen Intern Med. 2009;24(8):934–8. 17. Maron BJ, Araujo CG, Thompson PD, et al. Recommendations for preparticipation screening and the assessment of cardiovascular disease in masters athletes: an advisory for healthcare profession- als from the working groups of the World Heart Federation, the International Federation of Sports Medicine, and the American Heart Association Committee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2001;103(2):327–34. ACSM ExeRxcise is Medicine: http://exerciseismedicine.org 2008 Physical Activity Guidelines for Americans (1): http://www.health.gov/PAguidelines Online Resources
- 64. 38 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 18. Maron BJ, Thompson PD, Puffer JC, et al. Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiol- ogy) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association. Circulation. 1996;94(4):850–6. 19. Mittleman MA, Maclure M, Tofler GH, et al. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med. 1993;329(23):1677–83. 20. Myers J, Arena R, Franklin B, et al. Recommendations for clinical exercise laboratories: a scientific statement from the American Heart Association. Circulation. 2009;119(24):3144–61. 21. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143–421. 22. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273(5):402–7. 23. Persinger R, Foster C, Gibson M, Fater DC, Porcari JP . Consistency of the talk test for exercise prescription. Med Sci Sports Exerc. 2004;36(9):1632–6. 24. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008 [cited 2011 Jan 6]. 683 p. Available from: http:// www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf 25. Rodgers GP, Ayanian JZ, Balady G, et al. American College of Cardiology/American Heart Association clinical competence statement on stress testing. A report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. Circulation. 2000;102(14):1726–38. 26. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart Disease and Stroke Statistics—2012 Update: a report from the American Heart Association. Circulation. 2012;125(1):e2–220. 27. Siscovick DS, Weiss NS, Fletcher RH, Lasky T. The incidence of primary cardiac arrest during vigor- ous exercise. N Engl J Med. 1984;311(14):874–7. 28. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treat- ment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation. 2003;107(24):3109–16. 29. Thompson PD, Franklin BA, Balady GJ, et al. Exercise and acute cardiovascular events placing the risks into perspective: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism and the Council on Clinical Cardiology. Circulation. 2007;115(17):2358–68. 30. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion; 1996. 278 p. 31. U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation state- ment. Ann Intern Med. 2004;140(7):569–72. 32. Williams MA. Exercise testing in cardiac rehabilitation. Exercise prescription and beyond. Cardiol Clin. 2001;19(3):415–31. 33. Willich SN, Lewis M, Lowel H, Arntz HR, Schubert F , Schroder R. Physical exertion as a trigger of acute myocardial infarction. Triggers and Mechanisms of Myocardial Infarction Study Group. N Engl J Med. 1993;329(23):1684–90.
- 65. Exercise Testing SECTION II 39 SECTION II ROSS ARENA, PHD, PT, FACSM, FAACVPR, FAHA, ACSM-CES, Associate Editor
- 66. 40 Benefits and Risks Associated with Physical Activity CHAPTER 1 This chapter contains information related to the preexercise evaluation and serves as a bridge among the preparticipation health screening concepts presented in Chapter 2, the fitness assessment in Chapter 4, and the clinical exercise testing concepts in Chapters 5 and 6. Although Chapter 3 contents (e.g., medical history, physical examination, identification of exercise contraindications, informed con- sent procedures) relate to health/fitness and clinical exercise settings, lower risk populations typically encountered in health/fitness settings will allow for a less sophisticated approach to the preexercise evaluation. Therefore, abbreviated ver- sions of the preexercise evaluation described within this chapter are appropriate for low- and moderate-risk individuals wishing to engage in light-to-moderate intensity exercise within health/fitness settings. However, high-risk individuals whether in health/fitness or clinical settings will require a more intensive medical evaluation prior to initiating an exercise program (see Chapter 2). The extent of the preexercise evaluation depends on the assessment of risk as outlined in Chapter 2 and the proposed exercise intensity of the physical activity program. For individuals at high risk (see Tables 2.1 and 2.3), a physical exami- nation and exercise test are recommended as part of the preexercise evaluation by a qualified health care professional to develop a safe and effective exercise pre- scription (Ex Rx ). For individuals at low and moderate risk wishing to perform light-to-moderate intensity exercise such as walking, a preexercise evaluation that includes an exercise test is generally not recommended (see Figures 2.3 and 2.4). Nonetheless, a preexercise evaluation that includes a physical examina- tion, an exercise test, and/or laboratory tests may be warranted for these lower risk individuals whenever the health/fitness and clinical exercise professional has concerns about an individual’s cardiovascular disease (CVD) risk, requires additional information to design an Ex Rx , or when the exercise participant has concerns about starting an exercise program of any intensity without such a medical evaluation. A comprehensive preexercise test evaluation in the clinical setting generally includes a medical history, physical examination, and laboratory tests, the results of which should be documented in the client’s or patient’s file. The goal of Chapter 3 is not to be totally inclusive or to supplant more specific considerations that may surround the exercise participant, but rather to provide a concise set of guidelines for the various components of the preexercise evaluation. Preexercise Evaluation 3 CHAPTER
- 67. CHAPTER 3 Preexercise Evaluation 41 MEDICAL HISTORY, PHYSICAL EXAMINATION, AND LABORATORY TESTS The preexercise medical history should be thorough and include past and cur- rent information. Appropriate components of the medical history are presented in Box 3.1. A preliminary physical examination should be performed by a physi- cian or other qualified health care professional before exercise testing individuals at high risk as outlined in Chapter 2. Appropriate components of the physical examination specific to subsequent exercise testing are presented in Box 3.2. An expanded discussion and alternatives can be found in ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (26). Identification and risk stratification of individuals with CVD and those at high risk of developing CVD are facilitated by review of previous test results such as coronary angiography, nuclear imaging, echocardiography, or coronary artery calcium score studies (13) (see Box 2.2). Additional testing may include ambulatory electrocardiogram (ECG) or Holter monitoring and pharmacologic stress testing to further clarify the need for and extent of intervention, assess re- sponse to treatment such as medical therapies and revascularization procedures, or determine the need for additional assessment. As outlined in Box 3.3, other laboratory tests may be warranted based on the level of risk and clinical status of the patient, especially for those with diabetes mellitus. These laboratory tests may include, but are not limited to, serum chemistries, complete blood count, serum lipids and lipoproteins, inflammatory markers, fasting plasma glucose, hemoglobin A1C, and pulmonary function. Detailed exercise testing/training guidelines for a number of chronic diseases can be found in Chapters 5, 6, 9, and 10 within the Guidelines. Although a detailed description of all the physical examination procedures listed in Box 3.2 and the recommended laboratory tests listed in Box 3.3 are beyond the scope of the Guidelines, additional basic information related to assessment of blood pressure (BP), lipids and lipoproteins, other blood chemis- tries, and pulmonary function are provided in the following section. For more detailed descriptions of these assessments, the reader is referred to the work of Bickley (7). BLOOD PRESSURE Measurement of resting BP is an integral component of the preexercise evaluation. Subsequent decisions should be based on the average of two or more properly measured, seated BP readings recorded during each of two or more office visits (21). Specific techniques for measuring BP are critical to accuracy and detec- tion of high BP and are presented in Box 3.4. In addition to high BP readings, unusually low readings should also be evaluated for clinical significance. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) provides guidelines for hypertension
- 68. 42 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Appropriate components of the medical history may include the following: • Medical diagnosis. Cardiovascular disease risk factors including hypertension, obesity, dyslipidemia, diabetes, and metabolic syndrome; cardiovascular disease including heart failure, valvular dysfunction (e.g., aortic stenosis/mitral valve disease), myocardial infarction, and other acute coronary syndromes; percutaneous coronary interventions including angioplasty and coronary stent(s), coronary artery bypass surgery, and other cardiac surgeries such as valvular surgery(s); cardiac transplantation; pacemaker and/or implantable cardioverter defibrillator; ablation procedures for dysrhythmias; peripheral vascular disease; pulmonary disease including asthma, emphysema, and bronchitis; cerebrovascular disease including stroke and transient ischemic attacks; anemia and other blood dyscrasias (e.g., lupus erythematosus); phlebitis, deep vein thrombosis, or emboli; cancer; pregnancy; osteoporosis; musculoskeletal disorders; emotional disorders; and eating disorders. • Previous physical examination findings. Murmurs, clicks, gallop rhythms, other abnormal heart sounds, and other unusual cardiac and vascular findings; abnormal pulmonary findings (e.g., wheezes, rales, crackles); plasma glucose, hemoglobin A1C, high sensitivity C-reactive protein, serum lipids and lipoproteins, or other significant laboratory abnormalities; high blood pressure; and edema. • History of symptoms. Discomfort (e.g., pressure, tingling sensation, pain, heaviness, burning, tightness, squeezing, numbness) in the chest, jaw, neck, back, or arms; light-headedness, dizziness, or fainting; temporary loss of visual acuity or speech; transient unilateral numbness or weakness; shortness of breath; rapid heartbeat or palpitations, especially if associated with physical activity, eating a large meal, emotional upset, or exposure to cold (or any combination of these activities). • Recent illness, hospitalization, new medical diagnoses, or surgical procedures. • Orthopedic problems including arthritis, joint swelling, and any condition that would make ambulation or use of certain test modalities difficult. • Medication use (including dietary/nutritional supplements) and drug allergies. • Other habits including caffeine, alcohol, tobacco, or recreational (illicit) drug use. • Exercise history. Information on readiness for change and habitual level of activity: frequency, duration or time, type, and intensity or FITT of exercise. • Work history with emphasis on current or expected physical demands, noting upper and lower extremity requirements. • Family history of cardiac, pulmonary, or metabolic disease, stroke, or sudden death. FITT, Frequency, Intensity, Time, and Type. Adapted from (7). Components of the Medical History BOX 3.1
- 69. CHAPTER 3 Preexercise Evaluation 43 detection and management (23). Table 3.1 summarizes the JNC7 recommenda- tions for the classification and management of BP for adults. The relationship between BP and risk for cardiovascular events is continuous, consistent, and independent of other risk factors. For individuals 40–70 yr, each increment of 20 mm Hg in systolic BP (SBP) or 10 mm Hg in diastolic BP (DBP) doubles the risk of CVD across the entire BP range of 115/75 to 185/115 mm Hg. According to JNC7, individuals with a SBP of 120–139 mm Hg and/or a DBP of 80–89 mm Hg have prehypertension and require health-promoting lifestyle modifications to prevent the development of hypertension (4,23). Lifestyle modification including physical activity, weight reduction, a Dietary Approaches to Stop Hypertension (DASH) eating plan (i.e., a diet rich in fruits, vegetables, low-fat dairy products with a reduced content of saturated and total fat), dietary sodium reduction (no more than 100 mmol or 2.4 g sodium ⭈ d⫺1 ), and moderation of alcohol consumption remains the cornerstone of antihyper- tensive therapy (4,23). However, JNC7 emphasizes the fact that most patients with hypertension who require drug therapy in addition to lifestyle modification Appropriate components of the physical examination may include the following: • Body weight; in many instances determination of body mass index, waist girth, and/or body composition (percent body fat) is desirable • Apical pulse rate and rhythm • Resting blood pressure: seated, supine, and standing • Auscultation of the lungs with specific attention to uniformity of breath sounds in all areas (absence of rales, wheezes, and other breathing sounds) • Palpation of the cardiac apical impulse and point of maximal impulse • Auscultation of the heart with specific attention to murmurs, gallops, clicks, and rubs • Palpation and auscultation of carotid, abdominal, and femoral arteries • Evaluation of the abdomen for bowel sounds, masses, visceromegaly, and tenderness • Palpation and inspection of lower extremities for edema and presence of arterial pulses • Absence or presence of tendon xanthoma and skin xanthelasma • Follow-up examination related to orthopedic or other medical conditions that would limit exercise testing • Tests of neurologic function including reflexes and cognition (as indicated) • Inspection of the skin, especially of the lower extremities in known patients with diabetes mellitus Adapted from (7). Components of the Preparticipation Symptom-Limited Exercise Test Physical Examination (7) BOX 3.2
- 70. 44 GUIDELINES FOR EXERCISE TESTING • www.acsm.org INDIVIDUALS AT LOW-TO-MODERATE RISK • Fasting serum total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides • Fasting plasma glucose, especially in individuals ⱖ45 yr and younger individuals who are overweight (body mass index ⱖ25 kg ⭈ m⫺2 ) and have one or more of the following risk factors for Type 2 diabetes mellitus: a first-degree relative with diabetes, member of a high-risk ethnic population (e.g., African American, Latino, Native American, Asian American, Pacific Islander), delivered a baby weighing ⬎9 lb (4.08 kg) or history of gestational diabetes, hypertension (BP ⱖ140/90 mm Hg in adults), HDL cholesterol ⬍40 mg ⭈ dL⫺1 (⬍1.04 mmol ⭈ L⫺1 ) and/or triglycerides ⱖ150 mg ⭈ dL⫺1 (ⱖ1.69 mmol ⭈ L⫺1 ), previously identified impaired glucose tolerance or impaired fasting glucose (fasting glucose ⱖ100 mg ⭈ dL⫺1 ; ⱖ5.55 mmol ⭈ L⫺1 ), habitual physical inactivity, polycystic ovary disease, and history of vascular disease • Thyroid function, as a screening evaluation especially if dyslipidemia is present INDIVIDUALS AT HIGH RISK • Preceding tests plus pertinent previous cardiovascular laboratory tests (e.g., resting 12-lead ECG, Holter monitoring, coronary angiography, radionuclide or echocardiography studies, previous exercise tests) • Carotid ultrasound and other peripheral vascular studies • Consider measures of lipoprotein(a), high sensitivity C-reactive protein, LDL particle size and number, and HDL subspecies (especially in young individuals with a strong family history of premature CVD and in those individuals without traditional CVD risk factors) • Chest radiograph, if heart failure is present or suspected • Comprehensive blood chemistry panel and complete blood count as indicated by history and physical examination (see Table 3.4) PATIENTS WITH PULMONARY DISEASE • Chest radiograph • Pulmonary function tests (see Table 3.5) • Carbon monoxide diffusing capacity • Other specialized pulmonary studies (e.g., oximetry or blood gas analysis) BP , blood pressure; CVD, cardiovascular disease; ECG, electrocardiogram; HDL, high-density lipoprotein cholesterol; LDL, low-density lipoprotein cholesterol. Recommended Laboratory Tests by Level of Risk and Clinical Assessment BOX 3.3
- 71. CHAPTER 3 Preexercise Evaluation 45 1. Patients should be seated quietly for at least 5 min in a chair with back support (rather than on an examination table) with their feet on the floor and their arms supported at heart level. Patients should refrain from smoking cigarettes or ingesting caffeine for at least 30 min preceding the measurement. 2. Measuring supine and standing values may be indicated under special circumstances. 3. Wrap cuff firmly around upper arm at heart level; align cuff with brachial artery. 4. The appropriate cuff size must be used to ensure accurate measurement. The bladder within the cuff should encircle at least 80% of the upper arm. Many adults require a large adult cuff. 5. Place stethoscope chest piece below the antecubital space over the brachial artery. Bell and diaphragm side of chest piece appear equally effective in assessing BP (15). 6. Quickly inflate cuff pressure to 20 mm Hg above first Korotkoff sound. 7 . Slowly release pressure at rate equal to 2–5 mm Hg ⭈ s⫺1 . 8. SBP is the point at which the first of two or more Korotkoff sounds is heard (phase 1), and DBP is the point before the disappearance of Korotkoff sounds (phase 5). 9. At least two measurements should be made (minimum of 1 min apart) and the average should be taken. 10. BP should be measured in both arms during the first examination. Higher pressure should be used when there is consistent interarm difference. 11. Provide to patients, verbally and in writing, their specific BP numbers and BP goals. BP , blood pressure; DBP; diastolic blood pressure; SBP , systolic blood pressure. Modified from (23). For additional, more detailed recommendations, see (21). Procedures for Assessment of Resting Blood Pressure BOX 3.4 require two or more antihypertensive medications to achieve the goal BP (i.e., ⬍140/90 mm Hg or ⬍130/80 mm Hg for patients with diabetes mellitus or chronic kidney disease) (23). LIPIDS AND LIPOPROTEINS The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III or ATP III) outlines the National Cholesterol Education Program’s (NCEP) recommendations for cholesterol testing and management (see Table 3.2) (27). ATP III and subsequent updates by the National Heart, Lung, and Blood Institute (NHLBI), American
- 72. 46 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 3.2. ATP III Classification of LDL,Total, and HDL Cholesterol (mg ⭈ dL⫺1 ) LDL Cholesterol ⬍100a Optimal 100–129 Near optimal/above optimal 130–159 Borderline high 160–189 High ⱖ190 Very high Total Cholesterol ⬍200 Desirable 200–239 Borderline high ⱖ240 High HDL Cholesterol ⬍40 Low ⱖ60 High Triglycerides ⬍150 Normal 150–199 Borderline high 200–499 High ⱖ500 Very high a According to the American Heart Association/American College of Cardiology 2006 update (endorsed by the National Heart, Lung, and Blood Institute), it is reasonable to treat LDL cholesterol to ⬍70 mg ⭈ dL⫺1 (⬍1.81 mmol ⭈ L⫺1 ) in patients with coronary and other atherosclerotic vascular disease (24). NOTE: To convert LDL, total cholesterol, and HDL from mg ⭈ dL⫺1 to mmol ⭈ L⫺1 , multiply by 0.0259. To convert triglycerides from mg ⭈ dL⫺1 to mmol ⭈ L⫺1 , multiply by 0.0113. ATP III, AdultTreatment Panel III; HDL, high-density lipoprotein cholesterol; LDL, low-density lipoprotein cholesterol. Adapted from (27). a Treatment determined by highest BP category. b Compelling indications include heart failure, postmyocardial infarction, high coronary heart disease risk, diabetes mellitus, chronic kidney disease, and recurrent stroke prevention. Treat patients with chronic kidney disease or diabetes mellitus to BP goal of ⬍130/80 mm Hg. c Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension. BP , blood pressure; DBP , diastolic blood pressure; SBP , systolic blood pressure. Adapted from (23). TABLE 3.1. Classification and Management of Blood Pressure for Adultsa Initial Drug Therapy BP Classification SBP (mm Hg) DBP (mm Hg) Lifestyle Modification Without Compelling Indication With Compelling Indications Normal ⬍120 And ⬍80 Encourage Prehypertension 120–139 Or 80–89 Yes No antihyper- tensive drug indicated Drug(s) for compel- ling indicationsb Stage 1 hypertension 140–159 Or 90–99 Yes Antihypertensive drug(s) indicated Drug(s) for compel- ling indicationsb Other antihyper- tensive drugs, as needed Stage 2 hypertension ⱖ160 Or ⱖ100 Yes Antihypertensive drug(s) indicated Two-drug combi- nation for mostc
- 73. CHAPTER 3 Preexercise Evaluation 47 Heart Association (AHA), and American College of Cardiology (ACC) identify low-density lipoprotein (LDL) cholesterol as the primary target for cholesterol- lowering therapy (12,24,27). This designation is based on a wide variety of evidence indicating elevated LDL cholesterol is a powerful risk factor for CVD, and lowering of LDL cholesterol results in a striking reduction in the incidence of CVD. Table 3.2 summarizes the ATP III classifications of LDL, total, and high- density lipoprotein (HDL) cholesterol, and triglycerides. According to ATP III, a low HDL cholesterol, defined as ⬍40 mg ⭈ dL⫺1 , is strongly and inversely associated with CVD risk. Clinical trials provide sug- gestive evidence that raising HDL cholesterol reduces CVD risk. However, the mechanism explaining the role of low serum HDL cholesterol in accelerating the CVD process remains unclear. Moreover, it remains uncertain whether raising HDL cholesterol per se, independent of other changes in lipid and/ or nonlipid risk factors, always reduces the risk for CVD. In view of this, ATP III does not identify a specific HDL cholesterol goal level to achieve with therapy. Rather, ATP III encourages nondrug and drug therapies that raise HDL cholesterol and are part of the management of other lipid and nonlipid risk factors. There is growing evidence of a strong association between elevated triglyc- erides and CVD risk. Recent studies suggest some species of triglyceride-rich lipoproteins, notably small very low-density lipoproteins (VLDLs) and inter- mediate-density lipoproteins (IDLs), promote atherosclerosis and predispose to CVD. Because VLDL and IDL appear to have atherogenic potential similar to that of LDL cholesterol, ATP III recommends non-HDL cholesterol (i.e., VLDL plus LDL cholesterol) as a secondary target of therapy for individuals with elevated triglycerides (triglycerides ⱖ200 mg ⭈ dL⫺1 ). The metabolic syndrome is characterized by a constellation of metabolic risk factors in one individual. Abdominal obesity, atherogenic dyslipidemia (i.e., elevated triglycerides, small LDL cholesterol particles, and reduced HDL cholesterol), elevated BP, insulin resistance, prothrombotic state (i.e., increased risk for thrombus formation), and proinflammatory state (i.e., elevated C-reactive protein and interleukin-6) generally are accepted as being characteristic of the metabolic syndrome. Although the primary cause is debatable, the root causes of the metabolic syndrome are overweight/obesity, physical inactivity, insulin resistance, and genetic factors. Because the metabolic syndrome has emerged as an important contributor to CVD, ATP III places emphasis on the metabolic syndrome as a risk enhancer. However, ATP III recognized that there are no well- established criteria for diagnosing the metabolic syndrome. Table 3.3 lists differ- ent professional organizations’ proposed metabolic syndrome criteria including the recommendations put forth by ATP III (27). ATP III designates hypertension, cigarette smoking, diabetes mellitus, over- weight and obesity, physical inactivity, and an atherogenic diet as modifiable nonlipid risk factors, whereas age, male gender, and family history of premature CVD are nonmodifiable nonlipid risk factors for CVD. Triglycerides, lipoprotein remnants, lipoprotein(a), small LDL particles, HDL subspecies, apolipoproteins B
- 74. 48 GUIDELINES FOR EXERCISE TESTING • www.acsm.org and A1, and the total cholesterol-to-HDL cholesterol ratio are designated by ATP III as emerging lipid risk factors. Thrombogenic and hemostatic factors, inflammatory markers (e.g., high sensitivity C-reactive protein), impaired fasting glucose, and homocysteine are designated by ATP III as emerging nonlipid risk factors. Nevertheless, recent studies suggest that homocysteine-lowering therapy does not result in a reduction in CVD risk. The guiding principle of ATP III and subsequent updates by the NHLBI, AHA, and ACC is that the intensity of LDL-lowering therapy should be adjusted to the individual’s absolute risk for CVD (6,8,12,13,24,27). The ATP III treat- ment guidelines and subsequent updates by the NHLBI, AHA, and ACC are summarized in ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (26). TABLE 3.3. Metabolic Syndrome Criteria: NCEP/ATP III, IDF, and WHO Criteria NCEP/ATP III (8) IDF (14) WHO (1)a Body Weight Waist circumferencea,c Requiredb Waist-to-hip ratio and/or BMI of ⬎30 kg ⭈ m⫺2 Men ⬎102 cm (⬎40 in) ⱖ94 cm (ⱖ37 in) ⬎0.9 ratio Women ⬎88 cm (⬎35 in) ⱖ80 cm (ⱖ31.5 in) ⬎0.85 ratio Insulin Resistance/ Glucose ⱖ110 mg ⭈ dL⫺1d ⱖ110 mg ⭈ dL⫺1 or previously diagnosed Type 2 diabetes Requirede Dyslipidemia Specific treatment or HDL Men: ⬍40 mg ⭈ dL⫺1 Women: ⬍50 mg ⭈ dL⫺1 Men: ⬍40 mg ⭈ dL⫺1 Women: ⬍50 mg ⭈ dL⫺1f Men: ⬍35 mg ⭈ dL⫺1 Women: ⬍39 mg ⭈ dL⫺1f Triglycerides ⱖ150 mg ⭈ dL⫺1 ⱖ150 mg ⭈ dL⫺1 ⱖ150 mg ⭈ dL⫺1 Elevated Blood Pressure ⱖ130 or ⱖ85 mm Hg ⱖ130 or ⱖ85 mm Hg or treatment of previously diagnosed hypertension Antihypertensive medica- tion and/or a BP of ⱖ140 or ⱖ90 mm Hg Other N/A N/A Urinary albumin excretion rate ⱖ20 g ⭈ min⫺1 or albumin:creatinine ratio ⱖ30 mg ⭈ g⫺1 a Overweight and obesity are associated with insulin resistance and the metabolic syndrome (Msyn). However, the presence of abdominal obesity is more highly correlated with these metabolic risk factors than is elevated BMI. Therefore, the simple measure of waist circumference is recommended to identify the body weight component of the Msyn. b Defined as waist circumference ⱖ94 cm (ⱖ37 in) for Europid men and ⱖ80 cm (ⱖ31.2 in) for Europid women, with ethnicity-specific values for other groups. c Some men develop multiple metabolic risk factors when the waist circumference is only marginally increased (94–102 cm [37–39 in]). Such patients may have a strong genetic contribution to insulin resistance. They should benefit from changes in life habits, similarly to men with categorical increases in waist circumference. d The American Diabetes Association has established a cut point of ⱖ100 mg ⭈ dL⫺1 , above which individuals have either prediabetes (impaired fasting glucose) or diabetes mellitus (2). This cut point should be applicable for identifying the lower boundary to define an elevated glucose as one criterion for metabolic syndrome. e A required criteria of one of the following: Type 2 diabetes mellitus, impaired fasting glucose, impaired glucose tolerance, or for those with normal fasting glucose levels (⬍110 mg ⭈ dL⫺1 ), glucose uptake below the lowest quartile for background populations under investigation under hyperinsulinemic and euglycemic conditions. f These values have been updated from those originally presented to ensure consistence with ATP III cut points. NOTE: To convert glucose from mg ⭈ dL⫺1 to mmol ⭈ L⫺1 , multiply by 0.0555. To convert HDL from mg ⭈ dL⫺1 to mmol ⭈ L⫺1 , multiply by 0.0259. To convert triglycerides from mg ⭈ dL⫺1 to mmol ⭈ L⫺1 , multiply by 0.0113. ATP III, Adult Treatment Panel III; BMI, body mass index; BP , blood pressure; HDL, high-density lipoprotein cholesterol; IDF , International Diabetes Federation; NCEP , National Cholesterol Education Program; WHO, World Health Organization.
- 75. CHAPTER 3 Preexercise Evaluation 49 BLOOD PROFILE ANALYSES Multiple analyses of blood profiles are commonly evaluated in clinical exercise programs. Such profiles may provide useful information about an individual’s overall health status and ability to exercise and may help to explain certain ECG abnormalities. Because of varied methods of assaying blood samples, some cau- tion is advised when comparing blood chemistries from different laboratories. Table 3.4 gives normal ranges for selected blood chemistries, derived from a va- riety of sources. For many patients with CVD, medications for dyslipidemia and hypertension are common. Many of these medications act in the liver to lower blood cholesterol and in the kidneys to lower BP (see Appendix A). One should pay particular attention to liver function tests such as alanine transaminase (ALT), aspartate transaminase (AST), and bilirubin as well as to renal (kidney) function tests such as creatinine, glomerular filtration rate, blood urea nitrogen (BUN), and BUN/creatinine ratio in patients on such medications. Indication of volume depletion and potassium abnormalities can be seen in the sodium and potassium measurements. PULMONARY FUNCTION Pulmonary function testing with spirometry is recommended for all smokers ⬎45 yr and in any individual presenting with dyspnea (i.e., shortness of breath), chronic cough, wheezing, or excessive mucus production (9). Spirometry is a simple and noninvasive test that can be performed easily. Indications for spi- rometry are listed in Table 3.5. When performing spirometry, standards for the performance of the test should be followed (16). Although many measurements can be made from a spirometric test, the most commonly used include the forced vital capacity (FVC), forced expiratory vol- ume in one second (FEV1.0 ), FEV1.0 /FVC ratio, and peak expiratory flow (PEF). Results from these measurements can help to identify the presence of restrictive or obstructive respiratory abnormalities, sometimes before symptoms or signs of disease are present. The FEV1.0 /FVC is diminished with obstructive airway diseases (e.g., asthma, chronic bronchitis, emphysema, chronic obstructive pul- monary disease [COPD]) but remains normal with restrictive disorders (e.g., kyphoscoliosis, neuromuscular disease, pulmonary fibrosis, other interstitial lung diseases). The Global Initiative for Chronic Obstructive Lung Disease classifies the presence and severity of COPD as seen in Table 3.5 (22). The term COPD can be used when chronic bronchitis, emphysema, or both are present, and spirometry documents an obstructive defect. A different approach for classifying the sever- ity of obstructive and restrictive defects is that of the American Thoracic Society (ATS) and European Respiratory Society (ERS) Task Force on Standardization of Lung Function Testing as presented in Table 3.5 (20). This ATS/ERS Task Force prefers to use the largest available vital capacity (VC), whether it is obtained on
- 76. 50 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 3.4. Typical Ranges of Normal Values for Selected Blood Variables in Adultsa Variable Men Neutral Women SI Conversion Factor Hemoglobin (g ⭈ dL⫺1 ) 13.5–17 .5 11.5–15.5 10 (g ⭈ L⫺1 ) Hematocrit (%) 40–52 36–48 0.01 (proportion of 1) Red cell count (⫻106 ⭈ L⫺1 ) 4.5–6.5 million 3.9–5.6 million 1 (⫻1012 ⭈ L⫺1 ) Hemoglobin (whole blood) 30–35 10 (g ⭈ L⫺1 ) Mass concentration (g ⭈ dL⫺1 ) White blood cell count (⫻103 ⭈ L⫺1 ) 4–11 thousand 1 (⫻109 ⭈ L⫺1 ) Platelet count (⫻103 ⭈ L⫺1 ) 150–450 thousand 1 (⫻109 ⭈ L⫺1 ) Fasting glucoseb (mg ⭈ dL⫺1 ) 60–99 0.0555 (mmol ⭈ L⫺1 ) Hemoglobin A1C ⱕ6% N/A Blood urea nitrogen (BUN; mg ⭈ dL⫺1 ) 4–24 0.357 (mmol ⭈ L⫺1 ) Creatinine (mg ⭈ dL⫺1 ) 0.3–1.4 88.4 (mol ⭈ L⫺1 ) BUN/creatinine ratio 7–27 Uric acid (mg ⭈ dL⫺1 ) 3.6–8.3 59.48 (mol ⭈ L⫺1 ) Sodium (mEq ⭈ dL⫺1 ) 135–150 1.0 (mmol ⭈ L⫺1 ) Potassium (mEq ⭈ dL⫺1 ) 3.5–5.5 1.0 (mmol ⭈ L⫺1 ) Chloride (mEq ⭈ dL⫺1 ) 98–110 1.0 (mmol ⭈ L⫺1 ) Osmolality (mOsm ⭈ kg⫺1 ) 278–302 1.0 (mmol ⭈ kg⫺1 ) Calcium (mg ⭈ dL⫺1 ) 8.5–10.5 0.25 (mmol ⭈ L⫺1 ) Calcium, ion (mg ⭈ dL⫺1 ) 4.0–5.0 0.25 (mmol ⭈ L⫺1 ) Phosphorus (mg ⭈ dL⫺1 ) 2.5–4.5 0.323 (mmol ⭈ L⫺1 ) Protein, total (g ⭈ dL⫺1 ) 6.0–8.5 10 (g ⭈ L⫺1 ) Albumin (g ⭈ dL⫺1 ) 3.0–5.5 10 (g ⭈ L⫺1 ) Globulin (g ⭈ dL⫺1 ) 2.0–4.0 10 (g ⭈ L⫺1 ) A/G ratio 1.0–2.2 10 Iron, total (g ⭈ dL⫺1 ) 40–190 35–180 0.179 (mol ⭈ L⫺1 ) Liver Function Tests Bilirubin (mg ⭈ dL⫺1 ) ⬍1.5 17 .1 (mol ⭈ L⫺1 ) SGOT (AST; U ⭈ L⫺1 ) 8–46 7–34 1 (U ⭈ L⫺1 ) SGPT (ALT; U ⭈ L⫺1 ) 7–46 4–35 1 (U ⭈ L⫺1 ) a Certain variables must be interpreted in relation to the normal range of the issuing laboratory. b Fasting blood glucose 100–125 mg ⭈ dL⫺1 is considered impaired fasting glucose or prediabetes. NOTE: For a complete list of Système International (SI) conversion factors, please see http://jama.ama-assn.org/ content/vol295/issue1/images/data/103/DC6/JAMA_auinst_si.dtl ALT, alanine transaminase (formerly SGPT); AST, aspartate transaminase (formerly SGOT); SGOT, serum glutamic-oxaloacetic transaminase; SGPT, serum glutamic-pyruvic transaminase.
- 77. CHAPTER 3 Preexercise Evaluation 51 TABLE 3.5. Indications for Spirometry A. Indications for Spirometry Diagnosis To evaluate symptoms, signs, or abnormal laboratory tests To measure the effect of disease on pulmonary function To screen individuals at risk of having pulmonary disease To assess preoperative risk To assess prognosis To assess health status before beginning strenuous physical activity programs Monitoring To assess therapeutic intervention To describe the course of diseases that affect lung function To monitor individuals exposed to injurious agents To monitor for adverse reactions to drugs with known pulmonary toxicity Disability/Impairment Evaluations To assess patients as part of a rehabilitation program To assess risks as part of an insurance evaluation To assess individuals for legal reasons Public Health Epidemiologic surveys Derivation of reference equations Clinical research B.The Global Initiative for Chronic Obstructive Lung Disease Spirometric Classification of COPD Severity Based on Postbronchodilator FEV1.0 Stage I Mild FEV1.0 /FVC ⬍0.70 FEV1.0 ⱖ80% of predicted Stage II Moderate FEV1.0 /FVC ⬍0.70 50% ⱕ FEV1.0 ⬍80% predicted Stage III Severe FEV1.0 /FVC ⬍0.70 30% ⱕ FEV1.0 ⬍50% predicted Stage IV Very severe FEV1.0 /FVC ⬍0.70 FEV1.0 ⬍30% predicted or FEV1.0 ⬍50% predicted plus chronic respiratory failure C.The American Thoracic Society and European Respiratory Society Classification of Severity of Any Spirometric Abnormality Based on FEV1.0 Degree of Severity FEV1.0 % Predicted Mild Less than the LLN but ⱖ70 Moderate 60–69 Moderately severe 50–59 Severe 35–49 Very severe ⬍35 COPD, chronic obstructive pulmonary disease; FEV1.0 , forced expiratory volume in one second; FVC, forced vital capacity; respiratory failure defined as arterial partial pressure of oxygen (PaO2 ) ⬍8.0 kPa (60 mm Hg) with or without arterial partial pressure of CO2 (Pa CO2 ) ⬎6.7 kPa (50 mm Hg) while breathing air at sea level; LLN, lower limit of normal. Modified from (20,22).
- 78. 52 GUIDELINES FOR EXERCISE TESTING • www.acsm.org inspiration (IVC), slow expiration (SVC), or forced expiration (FVC). An ob- structive defect is defined by a reduced FEV1.0 /FVC ratio below the fifth percen- tile of the predicted value. The use of the fifth percentile of the predicted value as the lower limit of normal does not lead to an overestimation of the presence of an obstructive defect in older individuals, which is more likely when a fixed value for FEV1.0 /FVC or a FEV1.0 /FVC of 0.7 is used as the dividing line between normal and abnormal (17). A restrictive defect is characterized by a reduction in the total lung capacity (TLC), as measured on a lung volume study, below the fifth percentile of the predicted value, and a normal FEV1.0 /VC (17). The spirometric classification of lung disease is useful in predicting health status, use of health resources, and mortality. Abnormal spirometry can also be indicative of an increased risk for lung cancer, heart attack, and stroke and can be used to identify patients in which interventions such as smoking cessation and use of pharmacologic agents would be most beneficial. Spirometric testing is also valuable in identifying patients with chronic disease (i.e., COPD and heart failure) that have diminished pulmonary function that may benefit from an in- spiratory muscle training program (6,19). The determination of the maximal voluntary ventilation (MVV) should also be obtained during routine spirometric testing (16,20). MVV can be used to estimate breathing reserve during maximal exercise. The MVV should ideally be measured rather than estimated by multiplying the FEV1.0 by a constant value as is often done in practice (20). CONTRAINDICATIONS TO EXERCISE TESTING For certain individuals, the risks of exercise testing outweigh the potential bene- fits. For these patients, it is important to carefully assess risk versus benefit when deciding whether the exercise test should be performed. Box 3.5 outlines both absolute and relative contraindications to exercise testing (10). Performing the preexercise evaluation with a careful review of prior medical history, as described earlier in Chapter 3, helps identify potential contraindications and increases the safety of the exercise test. Patients with absolute contraindications should not perform exercise tests until such conditions are stabilized or adequately treated. Patients with relative contraindications may be tested only after careful evalua- tion of the risk–benefit ratio. However, it should be emphasized that contraindi- cations might not apply in certain specific clinical situations such as soon after acute myocardial infarction, revascularization procedure, or bypass surgery or to determine the need for or benefit of drug therapy. Finally, conditions exist that preclude reliable diagnostic ECG information from exercise testing (e.g., left bundle-branch block, digitalis therapy). The exercise test may still provide useful information regarding exercise capacity, subjective symptomatology, pulmonary function, dysrhythmias, and hemodynamics. In these conditions, additional evaluative techniques such as ventilatory expired gas analysis, echocardiography, or nuclear imaging can be added to the exercise test to improve sensitivity, speci- ficity, and diagnostic capabilities.
- 79. CHAPTER 3 Preexercise Evaluation 53 Emergency departments may perform a symptom-limited exercise test on pa- tients who present with chest pain (i.e., 8–12 h after initial evaluation) and meet the indications outlined in Table 3.6 (3,25). This practice (a) appears to be safe in appropriately screened patients; (b) may improve diagnostic accuracy; and (c) may reduce cost of care. Generally, these patients include those who are no ABSOLUTE • A recent significant change in the resting electrocardiogram (ECG) suggesting significant ischemia, recent myocardial infarction (within 2 d), or other acute cardiac event • Unstable angina • Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise • Symptomatic severe aortic stenosis • Uncontrolled symptomatic heart failure • Acute pulmonary embolus or pulmonary infarction • Acute myocarditis or pericarditis • Suspected or known dissecting aneurysm • Acute systemic infection, accompanied by fever, body aches, or swollen lymph glands RELATIVEa • Left main coronary stenosis • Moderate stenotic valvular heart disease • Electrolyte abnormalities (e.g., hypokalemia or hypomagnesemia) • Severe arterial hypertension (i.e., systolic blood pressure [SBP] of ⬎200 mm Hg and/or a diastolic BP [DBP] of ⬎110 mm Hg) at rest • Tachydysrhythmia or bradydysrhythmia • Hypertrophic cardiomyopathy and other forms of outflow tract obstruction • Neuromotor, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise • High-degree atrioventricular block • Ventricular aneurysm • Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or myxedema) • Chronic infectious disease (e.g., HIV) • Mental or physical impairment leading to inability to exercise adequately a Relative contraindications can be superseded if benefits outweigh the risks of exercise. In some instances, these individuals can be exercised with caution and/or using low-level endpoints, especially if they are asymptomatic at rest. Modified from (11) cited 2007 June 15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12356646 Contraindications to Exercise Testing BOX 3.5
- 80. 54 GUIDELINES FOR EXERCISE TESTING • www.acsm.org longer symptomatic and who have unremarkable ECGs and no change in serial cardiac enzymes. Exercise testing in this setting should be performed only as part of a carefully constructed patient management protocol, what is now commonly referred to as a chest pain unit, and only after patients have been screened for high-risk features or other indicators for hospital admission (3). INFORMED CONSENT Obtaining adequate informed consent from participants before exercise testing in health/fitness or clinical settings is an important ethical and legal consideration. Although the content and extent of consent forms may vary, enough information must be present in the informed consent process to ensure that the participant knows and understands the purposes and risks associated with the test or exer- cise program in health/fitness or clinical settings. The consent form should be verbally explained and include a statement indicating the client or patient has been given an opportunity to ask questions about the procedure and has suf- ficient information to give informed consent. Note specific questions from the participant on the form along with the responses provided. The consent form must indicate the participant is free to withdraw from the procedure at any time. If the participant is a minor, a legal guardian or parent must sign the consent form. It is advisable to check with authoritative bodies (e.g., hospital risk man- agement, institutional review boards, facility legal counsel) to determine what is appropriate for an acceptable informed consent process. Also, all reasonable ef- forts must be made to protect the privacy of the patient’s health information (e.g., medical history, test results) as described in the Health Insurance Portability and Accountability Act (HIPAA) of 1996. A sample consent form for exercise testing is provided in Figure 3.1. No sample form should be adopted for a specific test TABLE 3.6. Indications and Contraindications for Exercise ECG Testing in the Emergency Department Setting Requirements before exercise ECG testing that should be considered in the emergency department setting • 2 Sets of cardiac enzymes at 4-h intervals should be normal • ECG at the time of presentation, and preexercise 12-lead ECG shows no significant change • Absence of rest ECG abnormalities that would preclude accurate assessment of the exercise ECG • From admission to the time results are available from the second set of cardiac enzymes: patient asymptomatic, lessening chest pain symptoms, or persistent atypical symptoms • Absence of ischemic chest pain at the time of exercise testing Contraindications to exercise ECG testing in the emergency department setting • New or evolving ECG abnormalities on the rest tracing • Abnormal cardiac enzymes • Inability to perform exercise • Worsening or persistent ischemic chest pain symptoms from admission to the time of exercise testing • Clinical risk profiling indicating imminent coronary angiography is likely ECG, electrocardiogram. Reprinted with permission from (25).
- 81. CHAPTER 3 Preexercise Evaluation 55 Informed Consent for an Exercise Test 1. Purpose and Explanation of the Test You will perform an exercise test on a cycle ergometer or a motor-driven treadmill. The exercise intensity will begin at a low level and will be advanced in stages depending on your fitness level. We may stop the test at any time because of signs of fatigue or changes in your heart rate, electrocardiogram, or blood pressure, or symptoms you may experience. It is important for you to realize that you may stop when you wish because of feelings of fatigue or any other discomfort. 2. Attendant Risks and Discomforts There exists the possibility of certain changes occurring during the test. These include abnormal blood pressure; fainting; irregular, fast, or slow heart rhythm; and, in rare instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by evaluation of preliminary information relating to your health and fitness and by careful observations during testing. Emergency equipment and trained personnel are available to deal with unusual situations that may arise. 3. Responsibilities of the Participant Information you possess about your health status or previous experiences of heart- related symptoms (e.g., shortness of breath with low-level activity; pain; pressure; tightness; heaviness in the chest, neck, jaw, back, and/or arms) with physical effort may affect the safety of your exercise test. Your prompt reporting of these and any other unusual feelings with effort during the exercise test itself is very important. You are responsible for fully disclosing your medical history as well as symptoms that may occur during the test. You are also expected to report all medications (including nonpre- scription) taken recently and, in particular, those taken today to the testing staff. 4. Benefits To Be Expected The results obtained from the exercise test may assist in the diagnosis of your illness, in evaluating the effect of your medications, or in evaluating what type of physical activi- ties you might do with low risk. 5. Inquiries Any questions about the procedures used in the exercise test or the results of your test are encouraged. If you have any concerns or questions, please ask us for further explanations. 6. Use of Medical Records The information that is obtained during exercise testing will be treated as privileged and confidential as described in the Health Insurance Portability and Accountability Act of 1996. It is not to be released or revealed to any individual except your referring physi- cian without your written consent. However, the information obtained may be used for statistical analysis or scientific purposes with your right to privacy retained. 7. Freedom of Consent I hereby consent to voluntarily engage in an exercise test to determine my exercise capacity and state of cardiovascular health. My permission to perform this exercise test is given voluntarily. I understand that I am free to stop the test at any point if I so desire. I have read this form, and I understand the test procedures that I will perform and the attendant risks and discomforts. Knowing these risks and discomforts, and having had an opportunity to ask questions that have been answered to my satisfaction, I consent to participate in this test. Date Signature of Patient Date Signature of Witness Date Signature of Physician or Authorized Delegate ■ FIGURE 3.1. Sample of informed consent form for a symptom-limited exercise test.
- 82. 56 GUIDELINES FOR EXERCISE TESTING • www.acsm.org or program unless approved by local legal counsel and/or the appropriate insti- tutional review board. When the exercise test is for purposes other than diagnosis or Ex Rx (i.e., for experimental purposes), this should be indicated during the consent process and reflected on the Informed Consent Form and applicable policies for the testing of human subjects must be implemented. Health care professionals and scientists should obtain approval from their institutional review board when conducting an exercise test for research purposes. Because most consent forms include the statement “emergency procedures and equipment are available,” the program must ensure available personnel are appropriately trained and authorized to carry out emergency procedures that use such equipment. Written emergency policies and procedures should be in place, and emergency drills should be practiced at least once every 3 mo or more often when there is a change in staff (18). See Appendix B for more information on emergency management. PARTICIPANT INSTRUCTIONS Explicit instructions for participants before exercise testing increase test validity and data accuracy. Whenever possible, written instructions along with a descrip- tion of the preexercise evaluation should be provided well in advance of the appointment so the client or patient can prepare adequately. When serial testing is performed, every effort should be made to ensure exercise testing procedures are consistent between/among assessments (5). The following points should be considered for inclusion in such preliminary instructions; however, specific in- structions vary with test type and purpose: • At a minimum, participants should refrain from ingesting food, alcohol, or caffeine or using tobacco products within 3 h of testing. • Participants should be rested for the assessment, avoiding significant exertion or exercise on the day of the assessment. • Clothing should permit freedom of movement and include walking or run- ning shoes. Women should bring a loose fitting, short-sleeved blouse that buttons down the front, and should avoid restrictive undergarments. • If the evaluation is on an outpatient basis, participants should be made aware that the exercise test may be fatiguing, and they may wish to have someone accompany them to the assessment to drive home afterward. • If the exercise test is for diagnostic purposes, it may be helpful for patients to discontinue prescribed cardiovascular medications, but only with physi- cian approval. Currently, prescribed antianginal agents alter the hemody- namic response to exercise and significantly reduce the sensitivity of ECG changes for ischemia. Patients taking intermediate or high dose -blocking agents may be asked to taper their medication over a 2- to 4-d period to minimize hyperadrenergic withdrawal responses (see Appendix A).
- 83. CHAPTER 3 Preexercise Evaluation 57 • If the exercise test is for functional or Ex Rx purposes, patients should continue their medication regimen on their usual schedule so that the exer- cise responses will be consistent with responses expected during exercise training. • Participants should bring a list of their medications including dosage and fre- quency of administration to the assessment and should report the last actual dose taken. As an alternative, participants may wish to bring their medica- tions with them for the exercise testing staff to record. • Drink ample fluids over the 24-h period preceding the exercise test to ensure normal hydration before testing. THE BOTTOM LINE The ACSM Exercise Testing Summary Statements are the following: • The preexercise evaluation is vital to ensuring exercise training can be safely initiated. • Regardless of whether or not an exercise test is indicated prior to starting a physical activity program, identifying known CVD risk factors (see Table 2.2) is important for patient management. • Exercise testing information can be used to counsel an individual regarding the risk for developing CVD, tayloring the lifestyle intervention program (i.e., exercise, diet, and weight loss) to potentially ameliorate CVD risk fac- tors, and when appropriate, refer to the appropriate health care professional for additional assessment. • In those individuals who require exercise testing, absolute and relative contraindications must be considered before initiating the assessment (see Box 3.5). • Individuals undergoing an exercise test should receive detailed instructions regarding the procedure and complete an informed consent document. American College of Sports Medicine Exercise is Medicine: http://exerciseismedicine.org American Heart Association: http://www.americanheart.org National Heart, Lung, and Blood Institute Health Information for Professionals: http://www.nhlbi.nih.gov/health/indexpro.htm Physical Activity Guidelines for Americans (28): http://www.health.gov/PAguidelines Online Resources
- 84. 58 GUIDELINES FOR EXERCISE TESTING • www.acsm.org REFERENCES 1. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its com- plications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med. 1998;15(7):539–53. 2. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2007;30 Suppl 1:S42–7. 3. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756–76. 4. Appel LJ, Brands MW, Daniels SR, et al. Dietary approaches to prevent and treat hypertension: a scientific statement from the American Heart Association. Hypertension. 2006;47(2):296–308. 5. Arena R, Myers J, Williams MA, et al. Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Circulation. 2007;116(3):329–43. 6. Arena R, Pinkstaff S, Wheeler E, Peberdy MA, Guazzi M, Myers J. Neuromuscular electrical stimula- tion and inspiratory muscle training as potential adjunctive rehabilitation options for patients with heart failure. J Cardiopulm Rehabil Prev. 2010;30(4):209–23. 7. Bickley LS, Bates B. Bates’ Pocket Guide to Physical Examination and History Taking. Baltimore (MD): Lippincott Williams Wilkins; 2008. 416 p. 8. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486–97. 9. Ferguson GT, Enright PL, Buist AS, et al. Office spirometry for lung health assessment in adults: a con- sensus statement from the National Lung Health Education Program. Chest. 2000;117(4):1146–61. 10. Gibbons RJ, Abrams J, Chatterjee K, et al. Committee on the management of patients with chronic stable angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients with Chronic Stable Angina). Circulation. 2003;107(1):149–58. 11. Gibbons RJ, Balady GJ, Bricker JT, et al. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531–40. 12. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol. 2004; 44(3):720–32. 13. Hendel RC, Berman DS, Di Carli MF , et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009;119(22):e561–87. 14. The IDF Consensus Worldwide Definition of the Metabolic Syndrome [Internet]. Brussels (Belgium): International Diabetes Federation; 2006 [cited 2008 Jul 23]. 24 p. Available from: http://www.idf .org/webdata/docs/IDF_Meta_def_final.pdf 15. Kantola I, Vesalainen R, Kangassalo K, Kariluoto A. Bell or diaphragm in the measurement of blood pressure? J Hypertens. 2005;23(3):499–503. 16. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005; 26(2):319–38. 17. Miller MR, Quanjer PH, Swanney MP , Ruppel G, Enright PL. Interpreting lung function data using 80 percent of predicted and fixed thresholds misclassifies over 20% of patients. Chest. 2010. 18. Myers J, Arena R, Franklin B, et al. Recommendations for clinical exercise laboratories: a scientific statement from the American Heart Association. Circulation. 2009;119(24):3144–61. 19. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society state- ment on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12):1390–413. 20. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;26(5):948–68.
- 85. CHAPTER 3 Preexercise Evaluation 59 21. Pickering TG, Hall JE, Appel LJ, et al. Recommendations for blood pressure measurement in humans and experimental animals: Part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005;45(1):142–61. 22. Rabe KF , Hurd S, Anzueto A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532–55. 23. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) [Internet]. Bethesda, (MD): National High Blood Pressure Education Program; 2004 [cited 2012 Jan 7]. 104 p. Available from: http://www.nhlbi.nih.gov/guidelines/ hypertension 24. Smith SC,Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation. 2006;113(19):2363–72. 25. Stein RA, Chaitman BR, Balady GJ, et al. Safety and utility of exercise testing in emergency room chest pain centers: an advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation. 2000;102(12):1463–7. 26. Swain DP, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams Wilkins; 2014. 27. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [Internet]. Bethesda (MD): National Cholesterol Education Program; 2004 [cited Mar 19]. 284 p. Available from: http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm 28. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans [Internet]. Rockville (MD): Office of Disease Prevention Health Promotion, U.S. Department of Health and Human Services; 2008 [cited 2012 Jan 7]. 76 p. Available from: http://www.health.gov/ paguidelines
- 86. 60 Benefits and Risks Associated with Physical Activity CHAPTER 1 Health-Related Physical Fitness Testing and Interpretation CHAPTER 4 Evidence as outlined in Chapter 1 now clearly supports the numerous health benefits that result from regular participation in physical activity and structured exercise programs including enhancement of aerobic capacity (i.e., cardio- respiratory fitness [CRF]). The health-related components of physical fitness have a strong relationship with overall health, are characterized by an ability to perform activities of daily living with vigor, and are associated with a lower prevalence of chronic disease and health conditions and their risk factors (29). Measures of health-related physical fitness and CRF are closely allied with disease prevention and health promotion and can be modified through regular participation in physical activity and structured exercise programs. A funda- mental goal of primary and secondary prevention and rehabilitative programs should be the promotion of health; therefore, exercise programs should focus on enhancement of the health-related components of physical fitness including CRF . Accordingly, the focus of this chapter is on the health-related components of physical fitness rather than the skill-related components for the general population (46). PURPOSES OF HEALTH-RELATED PHYSICAL FITNESS TESTING Measurement of physical fitness is a common and appropriate practice in preven- tive and rehabilitative exercise programs. The purposes of health/fitness testing in such exercise programs include the following: • Educating participants about their present health/fitness status relative to health-related standards and age and sex matched norms. • Providing data that are helpful in development of individualized exercise prescriptions (Ex Rx ) to address all health/fitness components. • Collecting baseline and follow-up data that allow evaluation of progress by exercise program participants. • Motivating participants by establishing reasonable and attainable health/ fitness goals (see Chapter 11).
- 87. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 61 BASIC PRINCIPLES AND GUIDELINES The information obtained from health-related physical fitness testing, in com- bination with the individual’s health and medical information, is used by the health/fitness and clinical exercise professional to enable an individual to achieve specific health/fitness goals. An ideal health-related physical fitness test is reli- able, valid, relatively inexpensive, and easy to administer. The test should yield results that are indicative of the current state of physical fitness, reflect positive changes in health status from participation in a physical activity or exercise intervention, and be directly comparable to normative data. PRETEST INSTRUCTIONS All pretest instructions should be provided and adhered to prior to arrival at the testing facility (see Chapter 3). Certain steps should be taken to ensure client safety and comfort before administering a health-related physical fitness test. A minimal recommendation is that individuals complete a self-guided questionnaire such as the Physical Activity Readiness Questionnaire (PAR-Q) (see Figure 2.1) (89) or the American Heart Association (AHA)/American College of Sports Medicine (ACSM) Health/Fitness Facility Preparticipation Screening Questionnaire (see Figure 2.2) (3,102). A listing of preliminary testing instructions for all clients can be found in Chapter 3 under “Participant Instructions.” These instructions may be modified to meet specific needs and circumstances. TEST ORGANIZATION The following should be accomplished before the client/patient arrives at the test site: • Assure all forms, score sheets, tables, graphs, and other testing documents are organized in the client’s or patient’s file and available for the test’s administration. • Calibrate all equipment (e.g., metronome, cycle ergometer, treadmill, sphyg- momanometer, skinfold calipers) at least monthly, or more frequently based on use; certain equipment such as ventilatory expired gas analysis systems should be calibrated prior to each test according to manufacturers’ specifica- tions; and document equipment calibration in a designated folder. • Organize equipment so that tests can follow in sequence without stressing the same muscle group repeatedly. • Provide an informed consent form and allow time for the individual under- going assessment to have all questions adequately addressed (see Figure 3.1). • Maintain room temperature between 68° F and 72° F (20° C and 22° C) and humidity of less than 60% with adequate airflow. When multiple tests are to be administered, the organization of the testing session can be very important, depending on what physical fitness components
- 88. 62 GUIDELINES FOR EXERCISE TESTING • www.acsm.org are to be evaluated. Resting measurements such as heart rate (HR), blood pressure (BP), height, weight, and body composition should be obtained first. Research has not established an optimal testing order for multiple health-related components of fitness (i.e., cardiorespiratory [CR] endurance, muscular fitness, body compo- sition, and flexibility), but sufficient time should be allowed for HR and BP to return to baseline between tests conducted serially. Because certain medications, such as -blockers which lower HR, will affect some physical fitness test results, use of these medications should be noted (see Appendix A). TEST ENVIRONMENT The environment is important for test validity and reliability. Test anxiety, emo- tional problems, room temperature, and ventilation should be controlled as much as possible. To minimize subject anxiety, the test procedures should be explained adequately, and the test environment should be quiet and private. The room should be equipped with a comfortable seat and/or examination table to be used for resting BP and HR and/or electrocardiographic (ECG) recordings. The demeanor of personnel should be one of relaxed confidence to put the subject at ease. Testing procedures should not be rushed, and all procedures must be explained clearly prior to initiating the process. BODY COMPOSITION It is well established that excess body fat, particularly when located centrally around the abdomen, is associated with hypertension, metabolic syndrome, Type 2 diabetes mellitus, stroke, cardiovascular disease (CVD), and dyslipidemia (95). Approximately two-thirds of American adults are classified as overweight (body mass index [BMI] 25 kg ⭈ m2 ), and about 33% of these are classified as obese (BMI 30 kg ⭈ m2 ). Although the prevalence of obesity has steadily risen over the last three decades, recent data indicate a plateau in obesity trends, particularly in women (23,38). Perhaps more troubling are the statistics relat- ing to children that indicate (a) approximately 32% of children aged 2–19 yr are overweight or obese; and (b) over the past three decades, the percentage of children aged 6–11 yr who are considered obese has increased from approxi- mately 4% to more than 17% (95). Moreover, 2006 data indicate race and sex differences in overweight/obesity, with Black and Hispanic women continuing to have the highest prevalence (95). The troubling data on overweight/obesity prevalence among the adult and pediatric populations and its health implications have precipitated an increased awareness in the value of identifying and treating individuals with excess body weight (26,33,64,105). Basic body composition can be expressed as the relative percentage of body mass that is fat and fat-free tissue using a two-compartment model. Body composition can be estimated with laboratory and field techniques that vary in terms of complexity, cost, and accuracy (34,65). Different assessment tech- niques are briefly reviewed in this section, but details associated with obtaining
- 89. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 63 measurements and calculating estimates of body fat for all of these techniques are beyond the scope of the Guidelines. For more detailed information, see ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (101) and elsewhere (48,51,60). Before collecting data for body composi- tion assessment, the technician must be trained, experienced in the techniques, and already have demonstrated reliability in his or her measurements, indepen- dent of the technique being used. Experience can be accrued under the direct supervision of a highly qualified mentor in a controlled testing environment. ANTHROPOMETRIC METHODS Body Mass Index BMI or the Quetelet index is used to assess weight relative to height and is calcu- lated by dividing body weight in kilograms by height in meters squared (kg ⭈ m⫺2 ). For most individuals, obesity-related health problems increase beyond a BMI of 25.0 kg ⭈ m⫺2 . The Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults (35) defines a BMI of 25.0–29.9 kg ⭈ m⫺2 as overweight and BMI of ⱖ30.0 kg ⭈ m⫺2 as obese. BMI fails to distinguish between body fat, muscle mass, or bone. Nevertheless, an increased risk of hypertension, sleep apnea, Type 2 diabetes mellitus, certain cancers, CVD, and mortality are associated with a BMI ⱖ30.0 kg ⭈ m⫺2 (Table 4.1) (86). Interestingly, there is compelling evidence to indicate patients diagnosed with congestive heart failure (CHF) actually have improved survival when BMI is ⱖ30.0 kg ⭈ m⫺2 , a pheno- menon known as the “obesity paradox” (79), for reasons that are not clear (4). Compared to individuals classified as obese, the link between a BMI in the over- weight range (25.0–29.9 kg ⭈ m⫺2 ) and higher mortality risk is less clear. However, a BMI of 25.0–29.9 kg ⭈ m⫺2 , similar to a BMI ⱖ30.0 kg ⭈ m⫺2 , is more convincingly linked to an increased risk for other health issues such as Type 2 diabetes mellitus, dyslipidemia, hypertension, and certain cancers (68). A BMI of ⬍18.5 kg ⭈ m⫺2 TABLE 4.1. Classification of Disease Risk Based on Body Mass Index (BMI) and Waist Circumference Disease Riska Relative to Normal Weight and Waist Circumference BMI (kg ⭈ m⫺2 ) Men, ⱕ102 cm Women, ⱕ88 cm Men, ⬎102 cm Women, ⬎88 cm Underweight ⬍18.5 — — Normal 18.5–24.9 — — Overweight 25.0–29.9 Increased High Obesity, class I 30.0–34.9 High Very high II 35.0–39.9 Very high Very high III ⱖ40.0 Extremely high Extremely high a Disease risk for Type 2 diabetes, hypertension, and cardiovascular disease. Dashes (—) indicate that no additional risk at these levels of BMI was assigned. Increased waist circumference can also be a marker for increased risk even in individuals of normal weight. Modified from (35).
- 90. 64 GUIDELINES FOR EXERCISE TESTING • www.acsm.org also increases mortality risk and is responsible for the lower portion of the J-shaped curve when plotting risk on the y-axis and BMI on the x-axis (39). The use of spe- cific BMI values to predict percent body fat and health risk can be found in Table 4.2 (41). Because of the relatively large standard error of estimating percent body fat from BMI (⫾5% fat) (34), other methods of body composition assessment should be used to estimate percent body fat during a physical fitness assessment. Circumferences The pattern of body fat distribution is recognized as an important indicator of health and prognosis (28,90). Android obesity that is characterized by more fat on the trunk (i.e., abdominal fat) increases the risk of hypertension, metabolic syndrome, Type 2 diabetes mellitus, dyslipidemia, CVD, and premature death compared with individuals who demonstrate gynoid or gynecoid obesity (i.e., fat distributed in the hip and thigh) (85). Moreover, among individuals with increased abdominal fat, higher levels in the visceral compartment confer a higher risk for development of the metabolic syndrome compared to a similar distribution of fat within the subcutaneous compartment (40). Circumference (or girth) measurements may be used to provide a general rep- resentation of body composition, and equations are available for both sexes and a range of age groups (103,104). The accuracy may be within 2.5%–4.0% of the actual body composition if the subject possesses similar characteristics to the original validation population and the girth measurements are precise. A cloth tape measure with a spring-loaded handle (e.g., Gulick tape measure) reduces skin compression and improves consistency of measurement. Duplicate measurements are recom- mended at each site and should be obtained in a rotational instead of a consecu- tive order (i.e., take measurements of all sites being assessed and then repeat the sequence). The average of the two measures is used provided they do not differ by more than 5 mm. Box 4.1 contains a description of the common measurement sites. The waist-to-hip ratio (WHR) is the circumference of the waist (above the iliac crest) divided by the circumference of the hips (see Box 4.1 for buttocks/hips TABLE 4.2. Predicted Body Fat Percentage Based on Body Mass Index (BMI) for African American and White Adultsa BMI (kg ⭈ m⫺2 ) Health Risk 20–39 yr 40–59 yr 60–79 yr Men ⬍18.5 Elevated ⬍8% ⬍11% ⬍13% 18.6–24.9 Average 8%–19% 11%–21% 13%–24% 25.0–29.9 Elevated 20%–24% 22%–27% 25%–29% ⬎30 High ⱖ25% ⱖ28% ⱖ30% Women ⬍18.5 Elevated ⬍21% ⬍23% ⬍24% 18.6–24.9 Average 21%–32% 23%–33% 24%–35% 25.0–29.9 Elevated 33%–38% 34%–39% 36%–41% ⬎30 High ⱖ39% ⱖ40% ⱖ42% a Standard error of estimate is ⫾5% for predicting percent body fat from BMI (based on a four compartment estimate of body fat percentage). Reprinted with permission from (41).
- 91. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 65 Abdomen: With the subject standing upright and relaxed, a horizontal measure taken at the height of the iliac crest, usually at the level of the umbilicus. Arm: With the subject standing erect and arms hanging freely at the sides with hands facing the thigh, a horizontal measure midway between the acromion and olecranon processes. Buttocks/Hips: With the subject standing erect and feet together, a horizontal measure is taken at the maximal circumference of buttocks. This measure is used for the hip measure in a waist/hip measure. Calf: With the subject standing erect (feet apart ⬃20 cm), a horizontal measure taken at the level of the maximum circumference between the knee and the ankle, perpendicular to the long axis. Forearm: With the subject standing, arms hanging downward but slightly away from the trunk and palms facing anteriorly, a measure is taken perpendicular to the long axis at the maximal circumference. Hips/Thigh: With the subject standing, legs slightly apart (⬃10 cm), a horizontal measure is taken at the maximal circumference of the hip/proximal thigh, just below the gluteal fold. Mid-Thigh With the subject standing and one foot on a bench so the knee is flexed at 90 degrees, a measure is taken midway between the inguinal crease and the proximal border of the patella, perpendicular to the long axis. Waist: With the subject standing, arms at the sides, feet together, and abdomen relaxed, a horizontal measure is taken at the narrowest part of the torso (above the umbilicus and below the xiphoid process). The National Obesity Task Force (NOTF) suggests obtaining a horizontal measure directly above the iliac crest as a method to enhance standardization. Unfortunately, current formulae are not predicated on the NOTF suggested site. Standardized Description of Circumference Sites and Procedures BOX 4.1
- 92. 66 GUIDELINES FOR EXERCISE TESTING • www.acsm.org measure) and has traditionally been used as a simple method for assessing body fat distribution and identifying individuals with higher and more detrimental amounts of abdominal fat (34,85). Health risk increases as WHR increases, and the standards for risk vary with age and sex. For example, health risk is very high for young men when WHR is ⬎0.95 and for young women when WHR is ⬎0.86. For individuals aged 60–69 yr, the WHR cutoff values are ⬎1.03 for men and ⬎0.90 for women for the same high-risk classification as young adults (51). The waist circumference may also be used as an indicator of health risk because abdominal obesity is the primary issue (20,28). The Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults provides a classification of disease risk based on both BMI and waist circumfe- rence as shown in Table 4.1 (35). Previous research has demonstrated that the waist circumference thresholds shown in Table 4.1 effectively identify individuals at increased health risk across the different BMI categories (56). Furthermore, a newer risk stratification scheme for adults based on waist circumference has been proposed (see Table 4.3) (14). Several methods for waist circumference measurement involving different anatomical sites are available. Evidence indi- cates that all currently available waist circumference measurement techniques Procedures • All measurements should be made with a flexible yet inelastic tape measure. • The tape should be placed on the skin surface without compressing the subcutaneous adipose tissue. • If a Gulick spring-loaded handle is used, the handle should be extended to the same marking with each trial. • Take duplicate measures at each site and retest if duplicate measurements are not within 5 mm. • Rotate through measurement sites or allow time for skin to regain normal texture. Modified from (18). Standardized Description of Circumference Sites and Procedures (Continued) BOX 4.1 TABLE 4.3. Risk Criteria for Waist Circumference in Adults Waist Circumference cm (in) Risk Category Women Men Very low ⬍70 cm (⬍28.5 in) ⬍80 cm (31.5 in) Low 70–89 (28.5–35.0) 80–99 (31.5–39.0) High 90–110 (35.5–43.0) 100–120 (39.5–47 .0) Very high ⬎110 (⬎43.5) ⬎120 (⬎47 .0) Reprinted with permission from (14).
- 93. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 67 are equally reliable and effective in identifying individuals at increased health risk (96,108). Measurement of Waist Circumference Measurement of waist circumference immediately above the iliac crest, as proposed by National Institutes of Health guidelines, may be the prefer- able circumference method to assess health risk given the ease by which this anatomical landmark is identified (25). Skinfold Measurements Body composition determined from skinfold thickness measurements correlates well (r ⫽ 0.70–0.90) with body composition determined by hydrodensitometry (48). The principle behind skinfold measurements is that the amount of subcutane- ous fat is proportional to the total amount of body fat. It is assumed that close to one-third of the total fat is located subcutaneously. The exact proportion of subcuta- neous to total fat varies with sex, age, and race (94). Therefore, regression equations used to convert sum of skinfolds to percent body fat should consider these variables for greatest accuracy. Box 4.2 presents a standardized description of skinfold sites and procedures. Refer to ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (101) for additional descriptions of skinfold sites. Skinfold assessment of body composition is very dependent on the expertise of the technician, so proper training (i.e., knowledge of anatomical landmarks) and ample practice of the technique is necessary to obtain accurate measurements. The accuracy of predicting percent body fat from skinfolds is approximately ⫾3.5%, assuming appropriate techniques and equations have been used (51). Factors that may contribute to measurement error within skinfold assessment include poor technique and/or an inexperienced evaluator, an extremely obese or extremely lean subject, and an improperly calibrated caliper (i.e., tension should be set at ⬃12 g ⭈ mm⫺2 ) (49). Various regression equations have been developed to predict body density or percent body fat from skinfold measure- ments. For example, Box 4.3 lists generalized equations that allow calculation of body density without a loss in prediction accuracy for a wide range of individuals (49,54). Other equations have been published that are sex, age, race, fat, and sport specific (50). At a minimum, simple anthropometric measurements should be included in the health assessment of all individuals. Anthropometric Measurements Although limited in the ability to provide highly precise estimates of percent body fat, anthropometric measurements (i.e., BMI, WHR, waist circumference, and skinfolds) provide valuable information on general health and risk stratification. As such, inclusion of these easily obtainable variables during a comprehensive health/fitness assessment is beneficial.
- 94. 68 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SKINFOLD SITE Abdominal Vertical fold; 2 cm to the right side of the umbilicus Triceps Vertical fold; on the posterior midline of the upper arm, halfway between the acromion and olecranon processes, with the arm held freely to the side of the body Biceps Vertical fold; on the anterior aspect of the arm over the belly of the biceps muscle, 1 cm above the level used to mark the triceps site Chest/Pectoral Diagonal fold; one-half the distance between the anterior axillary line and the nipple (men), or one-third of the distance between the anterior axillary line and the nipple (women) Medial calf Vertical fold; at the maximum circumference of the calf on the midline of its medial border Midaxillary Vertical fold; on the midaxillary line at the level of the xiphoid process of the sternum. An alternate method is a horizontal fold taken at the level of the xiphoid/sternal border in the midaxillary line Subscapular Diagonal fold (at a 45-degree angle); 1–2 cm below the inferior angle of the scapula Suprailiac Diagonal fold; in line with the natural angle of the iliac crest taken in the anterior axillary line immediately superior to the iliac crest Thigh Vertical fold; on the anterior midline of the thigh, midway between the proximal border of the patella and the inguinal crease (hip) Procedures • All measurements should be made on the right side of the body with the subject standing upright • Caliper should be placed directly on the skin surface, 1 cm away from the thumb and finger, perpendicular to the skinfold, and halfway between the crest and the base of the fold • Pinch should be maintained while reading the caliper • Wait 1–2 s (not longer) before reading caliper • Take duplicate measures at each site and retest if duplicate measurements are not within 1–2 mm • Rotate through measurement sites or allow time for skin to regain normal texture and thickness Standardized Description of Skinfold Sites and Procedures BOX 4.2
- 95. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 69 MEN • Seven-Site Formula (chest, midaxillary, triceps, subscapular, abdomen, suprailiac, thigh) Body density ⫽ 1.112 ⫺ 0.00043499 (sum of seven skinfolds) ⫹ 0.00000055 (sum of seven skinfolds)2 ⫺ 0.00028826 (age) [SEE 0.008 or ⬃3.5% fat] • Three-Site Formula (chest, abdomen, thigh) Body density ⫽ 1.10938 ⫺ 0.0008267 (sum of three skinfolds) ⫹ 0.0000016 (sum of three skinfolds)2 ⫺ 0.0002574 (age) [SEE 0.008 or ⬃3.4% fat] • Three-Site Formula (chest, triceps, subscapular) Body density ⫽ 1.1125025 ⫺ 0.0013125 (sum of three skinfolds) ⫹ 0.0000055 (sum of three skinfolds)2 ⫺ 0.000244 (age) [SEE 0.008 or ⬃3.6% fat] WOMEN • Seven-Site Formula (chest, midaxillary, triceps, subscapular, abdomen, suprailiac, thigh) Body density ⫽ 1.097 ⫺ 0.00046971 (sum of seven skinfolds) ⫹ 0.00000056 (sum of seven skinfolds)2 ⫺ 0.00012828 (age) [SEE 0.008 or ⬃3.8% fat] • Three-Site Formula (triceps, suprailiac, thigh) Body density ⫽ 1.099421 ⫺ 0.0009929 (sum of three skinfolds) ⫹ 0.0000023 (sum of three skinfolds)2 ⫺ 0.0001392 (age) [SEE 0.009 or ⬃3.9% fat] • Three-Site Formula (triceps, suprailiac, abdominal) Body density ⫽ 1.089733 ⫺ 0.0009245 (sum of three skinfolds) ⫹ 0.0000025 (sum of three skinfolds)2 ⫺ 0.0000979 (age) [SEE 0.009 or ⬃3.9% fat] SEE, standard error of estimate. Adapted from (55,87). Generalized Skinfold Equations BOX 4.3 DENSITOMETRY Body composition can be estimated from a measurement of whole-body density using the ratio of body mass to body volume. Densitometry has been used as a reference or criterion standard for assessing body composition for many years. The limiting factor in the measurement of body density is the accuracy of the
- 96. 70 GUIDELINES FOR EXERCISE TESTING • www.acsm.org body volume measurement because body mass is measured simply as body weight. Body volume can be measured by hydrodensitometry (underwater) weighing and by plethysmography. Hydrodensitometry (Underwater) Weighing This technique of measuring body composition is based on Archimedes’ prin- ciple that states when a body is immersed in water, it is buoyed by a counterforce equal to the weight of the water displaced. This loss of weight in water allows for calculation of body volume. Bone and muscle tissue are denser than water, whereas fat tissue is less dense. Therefore, an individual with more fat-free mass (FFM) for the same total body mass weighs more in water and has a higher body density and lower percentage of body fat. Although hydrostatic weighing is a standard method for measuring body volume and hence, body composition, it requires special equipment, the accurate measurement of residual volume, population-specific formulas, and significant cooperation by the subject (44). For a more detailed explanation of the technique, see ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (101). Plethysmography Body volume also can be measured by air rather than water displacement. One commercial system uses a dual-chamber plethysmograph that measures body volume by changes in pressure in a closed chamber. This technology is now well established and generally reduces the anxiety associated with the technique of hydrodensitometry (31,44,70). For a more detailed explanation of the technique, see ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (101). Conversion of Body Density to Body Composition Percent body fat can be estimated once body density has been determined. Two of the most common prediction equations used to estimate percent body fat from body density are derived from the two-component model of body composition (15,100): % fat ⫽ 457 __ Body Density ⫺ 414.2 % fat ⫽ 495 __ Body Density ⫺ 450 Each method assumes a slightly different density of fat mass (FM) and FFM. Several population-specific, two-component model conversion formulas are also available (see Table 4.4). Currently, three to six component model conversion formulas are available and are increasingly more precise in calculating percent body fat compared to two-component models (34,51).
- 97. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 71 TABLE 4.4. Population-Specific Formulas for Conversion of Body Density to Percent Body Fat Population Age Gender %BF FFBda (g ⭈ cm⫺3 ) ETHNICITY African American 9–17 Women (5.24 / Db) ⫺ 4.82 1.088 19–45 Men (4.86 / Db) ⫺ 4.39 1.106 24–79 Women (4.86 / Db) ⫺ 4.39 1.106 American Indian 18–62 Men (4.97 / Db) ⫺ 4.52 1.099 18–60 Women (4.81 / Db) ⫺ 4.34 1.108 Asian Japanese Native 18–48 Men (4.97 / Db) ⫺ 4.52 1.099 Women (4.76 / Db) ⫺ 4.28 1.111 61–78 Men (4.87 / Db) ⫺ 4.41 1.105 Women (4.95 / Db) ⫺ 4.50 1.100 Singaporean (Chinese, Indian, Malay) Men (4.94 / Db) ⫺ 4.48 1.102 Women (4.84 / Db) ⫺ 4.37 1.107 Caucasian 8–12 Men (5.27 / Db) ⫺ 4.85 1.086 Women (5.27 / Db) ⫺ 4.85 1.086 13–17 Men (5.12 / Db) ⫺ 4.69 1.092 Women (5.19 / Db) ⫺ 4.76 1.090 18–59 Men (4.95 / Db) ⫺ 4.50 1.100 Women (4.96 / Db) ⫺ 4.51 1.101 60–90 Men (4.97 / Db) ⫺ 4.52 1.099 Women (5.02 / Db) ⫺ 4.57 1.098 Hispanic Men NA NA 20–40 Women (4.87 / Db) ⫺ 4.41 1.105 ATHLETES Resistance trained 24 ⫾ 4 Men (5.21 / Db) ⫺ 4.78 1.089 35 ⫾ 6 Women (4.97 / Db) ⫺ 4.52 1.099 Endurance trained 21 ⫾ 2 Men (5.03 / Db) ⫺ 4.59 1.097 21 ⫾ 4 Women (4.95 / Db) ⫺ 4.50 1.100 All sports 18–22 Men (5.12 / Db) ⫺ 4.68 1.093 18–22 Women (4.97 / Db) ⫺ 4.52 1.099 CLINICAL POPULATIONS b Anorexia nervosa 15–44 Women (4.96 / Db) ⫺ 4.51 1.101 Cirrhosis Childs A (5.33 / Db) ⫺ 4.91 1.084 Childs B (5.48 / Db) ⫺ 5.08 1.078 Childs C (5.69 / Db) ⫺ 5.32 1.070 Obesity 17–62 Women (4.95 / Db) ⫺ 4.50 1.100 Spinal cord injury (paraplegic/quadriplegic) 18–73 Men (4.67 / Db) ⫺ 4.18 1.116 18–73 Women (4.70 / Db) ⫺ 4.22 1.114 a FFBd, fat-free body density based on average values reported in selected research articles. b There are insufficient multicomponent model data to estimate the average FFBd of the following clinical populations: coronary artery disease, heart/lung transplants, chronic obstructive pulmonary disease, cystic fibrosis, diabetes mellitus, thyroid disease, HIV/AIDS, cancer, kidney failure (dialysis), multiple sclerosis, and muscular dystrophy. %BF , percentage of body fat; Db, body density; NA, no data available for this population subgroup. Adapted with permission from (51).
- 98. 72 GUIDELINES FOR EXERCISE TESTING • www.acsm.org OTHER TECHNIQUES Additional reliable and accurate body composition assessment techniques include dual-energy X-ray absorptiometry (DEXA) and total body electrical conductivity (TOBEC), but these techniques have limited applicability in routine health/fitness testing because of cost and the need for highly trained personnel (48). Rather, bioelectrical impedance analysis (BIA) and near-infrared interactance are used as assessment techniques in routine health/fitness testing. Generally, the accuracy of BIA is similar to skinfolds, as long as stringent protocol adherence (e.g., assurance of normal hydration status) is followed, and the equations programmed into the analyzer are valid and accurate for the populations being tested (30,47). It should be noted, however, that the ability of BIA to provide an accurate assessment of percent body fat in obese individuals may be limited secondary to differences in body water distribution compared to those who are in the normal weight range (34). Near-infrared interactance requires additional research to substantiate the validity and accuracy for body composition assessment (58,73). Detailed explanations of these techniques are found in ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (101). BODY COMPOSITION NORMS There are no universally accepted norms for body composition; however, Tables 4.5 and 4.6, which are based on selected populations, provide percentile values for percent body fat in men and women, respectively. A consensus opinion for an exact percent body fat value associated with optimal health risk has yet to be defined; however, a range of 10%–22% and 20%–32% for men and women, respectively, has long been viewed as satisfactory for health (70). More recent data support this range although age and race, in addition to sex, impact what may be construed as a healthy percent body fat (41). CARDIORESPIRATORY FITNESS CRF is related to the ability to perform large muscle, dynamic, moderate-to- vigorous intensity exercise for prolonged periods of time. Performance of exer- cise at this level of physical exertion depends on the integrated physiologic and functional state of the respiratory, cardiovascular, and musculoskeletal systems. CRF is considered a health-related component of physical fitness because (a) low levels of CRF have been associated with a markedly increased risk of premature death from all causes and specifically from CVD; (b) increases in CRF are associated with a reduction in death from all causes; and (c) high levels of CRF are associated with higher levels of habitual physical activity, which in turn are associated with many health benefits (10,11,63,98,107). As such, the assessment of CRF is an important part of any primary or secondary prevention and reha- bilitative programs.
- 99. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 73 TABLE 4.5. Fitness Categories for Body Composition (% Body Fat) for Men by Age Age (year) % 20–29 30–39 40–49 50–59 60–69 70–79 99 Very leana 4.2 7 .3 9.5 11.0 11.9 13.6 95 6.4 10.3 12.9 14.8 16.2 15.5 90 Excellent 7 .9 12.4 15.0 17 .0 18.1 17 .5 85 9.1 13.7 16.4 18.3 19.2 19.0 80 10.5 14.9 17 .5 19.4 20.2 20.1 75 Good 11.5 15.9 18.5 20.2 21.0 21.0 70 12.6 16.8 19.3 21.0 21.7 21.6 65 13.8 17 .7 20.1 21.7 22.4 22.3 60 14.8 18.4 20.8 22.3 23.0 22.9 55 Fair 15.8 19.2 21.4 23.0 23.6 23.7 50 16.6 20.0 22.1 23.6 24.2 24.1 45 17 .5 20.7 22.8 24.2 24.9 24.7 40 18.6 21.6 23.5 24.9 25.6 25.3 35 Poor 19.7 22.4 24.2 25.6 26.4 25.8 30 20.7 23.2 24.9 26.3 27 .0 26.5 25 22.0 24.1 25.7 27 .1 27 .9 27 .1 20 23.3 25.1 26.6 28.1 28.8 28.4 15 Very poor 24.9 26.4 27 .8 29.2 29.8 29.4 10 26.6 27 .8 29.2 30.6 31.2 30.7 5 29.2 30.2 31.3 32.7 33.3 32.9 1 33.4 34.4 35.2 36.4 36.8 37 .2 n ⫽ 1,844 10,099 15,073 9,255 2,851 522 Total n ⫽ 39,644 a Very lean, no less than 3% body fat is recommended for men. Adapted with permission from Physical Fitness Assessments and Norms for Adults and Law Enforcement. The Cooper Institute, Dallas, Texas. 2009. For more information: www.cooperinstitute.org THE CONCEPT OF MAXIMAL OXYGEN UPTAKE Maximal oxygen uptake (V̇O2max ) is accepted as the criterion measure of CRF . This variable is typically expressed clinically in relative (mL ⭈ kg⫺1 ⭈ min⫺1 ) as opposed to absolute (mL ⭈ min⫺1 ) terms, allowing for meaningful comparisons between/among individuals with differing body weight. V̇O2max is the product of the maximal cardiac output Q̇ (L blood ⭈ min⫺1 ) and arterial-venous oxygen dif- ference (mL O2 ⭈ L blood⫺1 ). Significant variation in V̇O2max across populations and fitness levels results primarily from differences in Q̇ in individuals without pulmonary disease; therefore, V̇O2max is closely related to the functional capacity of the heart. The designation of V̇O2max implies an individual’s true physiologic limit has been reached and a plateau in V̇O2 may be observed between the final two work rates of a progressive exercise test. This plateau is rarely observed in individuals with CVD or pulmonary disease. Therefore, peak V̇O2 is commonly used to describe CRF in these and other populations with chronic diseases and health conditions (5). Open circuit spirometry is used to measure V̇O2max . In this procedure, the subject breathes through a low-resistance valve with her or his nose occluded
- 100. 74 GUIDELINES FOR EXERCISE TESTING • www.acsm.org (or through a nonlatex mask) while pulmonary ventilation and expired fractions of oxygen (O2 ) and carbon dioxide (CO2 ) are measured. Modern automated systems provide ease of use and a detailed printout of test results that save time and effort (27). However, system calibration is still essential to obtain accurate results (76). Administration of the test and interpretation of results should be reserved for professional personnel with a thorough understanding of exercise science. Because of costs associated with the equipment, space, and personnel needed to carry out these tests, direct measurement of V̇O2max generally is reserved for research or clinical settings. When direct measurement of V̇O2max is not feasible, a variety of submaximal and maximal exercise tests can be used to estimate V̇O2max . These tests have been validated by examining (a) the correlation between directly measured V̇O2max and the V̇O2max estimated from physiologic responses to submaximal exercise (e.g., HR at a specified power output); or (b) the correlation between directly mea- sured V̇O2max and test performance (e.g., time to run 1 or 1.5 mi [1.6 or 2.4 km]), or time to volitional fatigue using a standard graded exercise test protocol. It should be noted that there is the potential for a significant overestimation of TABLE 4.6. Fitness Categories for Body Composition (% Body Fat) for Women by Age Age (year) % 20–29 30–39 40–49 50–59 60–69 70–79 99 Very leana 11.4 11.2 12.1 13.9 13.9 11.7 95 14.0 13.9 15.2 16.9 17 .7 16.4 90 Excellent 15.1 15.5 16.8 19.1 20.2 18.3 85 16.1 16.5 18.3 20.8 22.0 21.2 80 16.8 17 .5 19.5 22.3 23.3 22.5 75 Good 17 .6 18.3 20.6 23.6 24.6 23.7 70 18.4 19.2 21.7 24.8 25.7 24.8 65 19.0 20.1 22.7 25.8 26.7 25.7 60 19.8 21.0 23.7 26.7 27 .5 26.6 55 Fair 20.6 22.0 24.6 27 .6 28.3 27 .6 50 21.5 22.8 25.5 28.4 29.2 28.2 45 22.2 23.7 26.4 29.3 30.1 28.9 40 23.4 24.8 27 .5 30.1 30.8 30.5 35 Poor 24.2 25.8 28.4 30.8 31.5 31.0 30 25.5 26.9 29.5 31.8 32.6 31.9 25 26.7 28.1 30.7 32.9 33.3 32.9 20 28.2 29.6 31.9 33.9 34.4 34.0 15 Very poor 30.5 31.5 33.4 35.0 35.6 35.3 10 33.5 33.6 35.1 36.1 36.6 36.4 5 36.6 36.2 37 .1 37 .6 38.2 38.1 1 38.6 39.0 39.1 39.8 40.3 40.2 n ⫽ 1,250 4,130 5,902 4,118 1,450 295 Total n ⫽ 17 ,145 a Very lean, no less than 10%–13% body fat is recommended for women. Adapted with permission from Physical Fitness Assessments and Norms for Adults and Law Enforcement. The Cooper Institute, Dallas, Texas. 2009. For more information: www.cooperinstitute.org
- 101. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 75 directly measured V̇O2max by these types of indirect measurement techniques. Overestimation is more likely to occur when (a) the exercise protocol chosen for testing is too aggressive for a given individual (i.e., Bruce treadmill protocol in patients with CHF); or (b) when treadmill testing is employed and the individual heavily relies on handrail support (5). Every effort should therefore be taken to choose the appropriate exercise protocol given an individual’s characteristics and minimize handrail use during testing on a treadmill (76). MAXIMAL VERSUS SUBMAXIMAL EXERCISE TESTING The decision to use a maximal or submaximal exercise test depends largely on the reasons for the test, risk level of the client/patient, and availability of appropriate equipment and personnel. V̇O2max can be estimated using conventional exercise test protocols by considering test duration at a given workload on an ergometer and using the prediction equations found in Chapter 7. The user should con- sider the population being tested and standard error of the associated equation. Maximal tests require participants to exercise to the point of volitional fatigue, which might entail the need for medical supervision as detailed in Chapter 2 and/ or emergency equipment (see Appendix B). However, maximal exercise testing offers increased sensitivity in the diagnosis of CVD in asymptomatic individuals and provides a better estimate of V̇O2max (see “Indications and Purposes” section in Chapter 5). In addition, the use of open circuit spirometry during maximal exercise testing may allow for the accurate assessment of anaerobic/ventilatory threshold and direct measurement of V̇O2max / V̇O2peak . Practitioners commonly rely on submaximal exercise tests to assess CRF because maximal exercise testing is not always feasible in the health/fitness setting. Submaximal exercise testing is also recommended in stable patients 4–7 d post-myocardial infarction (MI) to assess efficacy of medical therapy prior to hospital discharge among other clinical indices (43). In the health/ fitness setting, the basic aim of submaximal exercise testing is to determine the HR response to one or more submaximal work rates and use the results to predict V̇O2max . Although the primary purpose of the test has traditionally been to predict V̇O2max from the HR workload relationship, it is important to obtain additional indices of the client’s response to exercise. The practitioner should use the various submaximal measures of HR, BP, workload, rating of perceived exertion (RPE), and other subjective indices as valuable information regarding one’s functional response to exercise. This information can be used to evalu- ate submaximal exercise responses over time in a controlled environment and appropriately determine the Ex Rx . The most accurate estimate of V̇O2max is achieved from the HR response to submaximal exercise tests if all of the following assumptions are achieved: • A steady state HR is obtained for each exercise work rate. • A linear relationship exists between HR and work rate. • The difference between actual and predicted maximal HR is minimal. • Mechanical efficiency (i.e., V̇O2 at a given work rate) is the same for everyone.
- 102. 76 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • The subject is not on medications, using high quantities of caffeine, under large amounts of stress, ill, or in a high temperature environment, all of which may alter HR. MODES OF TESTING Commonly used modes for exercise testing include treadmills, cycle ergometers, steps, and field tests. The mode of exercise testing used is dependent on the setting, equipment available, and training of personnel. Medical supervision is recommended for high-risk individuals as detailed in Chapter 2 regardless of mode (see Figure 2.4 and Table 2.3). There are advantages and disadvantages of each exercise testing mode: • Field tests consist of walking or running in a predetermined time or distance (i.e., 12-min and 1.5-mi [2.4 km] walk/run tests, and the 1-mi and 6-min walk test). The advantages of field tests are they are easy to administer to large numbers of individuals at one time and little equipment (e.g., a stopwatch) is needed. The disadvantages are some tests can be maximal for some individu- als, particularly in individuals with low aerobic fitness, and potentially be unmonitored for BP and HR. An individual’s level of motivation and pacing ability also can have a profound impact on test results. These all-out run tests may be inappropriate for sedentary individuals or individuals at increased risk for cardiovascular and/or musculoskeletal complications. Nevertheless, V̇O2max can be estimated from the test results. • Motor-driven treadmills can be used for submaximal and maximal testing and are often employed for diagnostic testing in the United States (5). They provide a familiar form of exercise and, if the correct protocol is chosen (i.e., aggressive vs. conservative adjustments in workload), can accommodate the least physically fit to the fittest individuals across the continuum of walking to running speeds. Nevertheless, a practice session might be necessary in some cases to permit habituation and reduce anxiety. On the other hand, treadmills usually are expensive, not easily transportable, and potentially make some measurements (e.g., BP , ECG) more difficult, particularly while an individual is running. Treadmills must be calibrated to ensure the accuracy of the test (76). In addition, holding on to the support rail(s) should be discouraged to ensure accuracy of metabolic work output, particularly when V̇O2 is estimated as opposed to directly measured. Extensive handrail use often leads to signifi- cant overestimation of V̇O2 compared to actual values. • Mechanically braked cycle ergometers are also a viable test modality for submaximal and maximal testing and are frequently used for diagnostic testing, particularly in European laboratories (76). Advantages of this exercise mode include lower equipment expense, transportability, and greater ease in obtaining BP and ECG (if appropriate) measurements. Cycle ergometers also provide a non–weight-bearing test modality in which work rates are easily adjusted in small increments. The main disadvantage is cycling is a less familiar mode of exercise to individuals in the United States, often resulting
- 103. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 77 in limiting localized muscle fatigue and an underestimation of V̇O2 . The cycle ergometer must be calibrated, and the subject must maintain the proper pedal rate because most tests require HR to be measured at specific work rates (76). Electronic cycle ergometers can deliver the same work rate across a range of pedal rates (i.e., revolutions ⭈ min⫺1 , rpm), but calibration might require special equipment not available in some laboratories. Some electronic fitness cycles cannot be calibrated and should not be used for testing. • Step testing is an inexpensive modality for predicting CRF by measuring the HR response to stepping at a fixed rate and/or a fixed step height or by measuring postexercise recovery HR. Step tests require little or no equipment, steps are easily transportable, stepping skill requires little practice, the test usually is of short duration, and stepping is advantageous for mass testing (22,72). Postexercise (recovery) HR decreases with improved CRF , and test results are easy to explain to participants (59). Special precautions may be needed for those who have balance problems or are extremely deconditioned. Some single-stage step tests require an energy cost of 7–9 metabolic equiva- lents (METs), which may exceed the maximal capacity of the participant (6). Therefore, the protocol chosen must be appropriate for the physical fitness level of the client. In addition, inadequate compliance to the step cadence and excessive fatigue in the lead limb may diminish the value of a step test. Most tests do not monitor HR and BP while stepping because of the difficulty of measuring HR and BP. Field Tests Two of the most widely used walk/run (based on subject preference) tests for assessing CRF are the Cooper 12-min test and the 1.5-mi (2.4 km) test for time. The objective of the 12-min test is to cover the greatest distance in the allotted time period and for the 1.5-mi (2.4 km) test to run the distance in the shortest period of time. V̇O2max can be estimated from the equations in Chapter 7. The Rockport One-Mile Fitness Walking Test is another well-recognized field test for estimating CRF . In this test, an individual walks 1 mi (1.6 km) as fast as possible, preferably on a track or a level surface, and HR is obtained in the final minute. An alternative is to measure a 10 s HR immediately on completion of the 1 mi (1.6 km) walk, but this may overestimate the V̇O2max compared to when HR is measured during the walk. V̇O2max is estimated from a regression equation found in Chapter 7 based on weight, age, sex, walk time, and HR (62). In addition to independently predicting morbidity and mortality (21,97), the 6-min walk test has been used to evaluate CRF in older adults and some clini- cal patient populations (e.g., individuals with CHF or pulmonary disease). The American Thoracic Society has published guidelines on 6-min walk test proce- dures and interpretation (8). Even though the test is considered submaximal, it may result in near-maximal performance for those with low physical fitness levels or disease (57). Clients and patients completing less than 300 m (⬃984 ft) during the 6-min walk demonstrate a poorer short-term survival compared to
- 104. 78 GUIDELINES FOR EXERCISE TESTING • www.acsm.org those surpassing this threshold (16). Several multivariate equations are avail- able to predict V̇O2 peak from the 6-min walk; however, the following equation requires minimal clinical information (16): • V̇O2peak ⫽ V̇O2 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ (0.02 ⫻ distance [m]) ⫺ (0.191 ⫻ age [yr]) ⫺ (0.07 ⫻ weight [kg]) ⫹ (0.09 ⫻ height [cm]) ⫹ (0.26 ⫻ RPP [⫻ 10⫺3 ]) ⫹ 2.45 Where m ⫽ distance in meters; yr ⫽ year; kg ⫽ kilogram; cm ⫽ centimeter; RPP ⫽ rate pressure product (HR ⫻ systolic BP [SBP] in mm Hg) • For the aforementioned equation: R2 ⫽ 0.65 and SEE ⫽ 2.68 (R2 ⫽ coefficient of determination; SEE ⫽ standard error of estimate) Submaximal Exercise Tests Single-stage and multistage submaximal exercise tests are available to estimate V̇O2max from simple HR measurements. Accurate measurement of HR is critical for valid testing. Although HR obtained by palpation is commonly used, the accuracy of this method depends on the experience and technique of the evalu- ator. It is recommended that an ECG, HR monitor, or a stethoscope be used to determine HR. The use of a relatively inexpensive HR monitor can reduce a sig- nificant source of error in the test. The submaximal HR response is easily altered by a number of environmental (e.g., heat, humidity, see Chapter 8), dietary (e.g., caffeine, time since last meal), and behavioral (e.g., anxiety, smoking, previous physical activity) factors. These variables must be controlled to have a valid estimate that can be used as a reference point in an individual’s fitness program. In addition, the test mode (e.g., cycle, treadmill, step) should be consistent with the primary exercise modality used by the participant to address specificity of training issues. Standardized procedures for submaximal testing are presented in Box 4.4. Although there are no specific submaximal protocols for treadmill test- ing, several stages from any of the treadmill protocols found in Chapter 5 can be used to assess submaximal exercise responses. Preexercise test instructions are presented in Chapter 3. Cycle ErgometerTests The Astrand-Ryhming cycle ergometer test is a single-stage test lasting 6 min (7). For the population studied, these researchers observed at 50% V̇O2max , the average HR was 128 and 138 beats ⭈ min⫺1 for men and women, respectively. If a woman was working at a V̇O2 of 1.5 L ⭈ min⫺1 and her HR was 138 beats ⭈ min⫺1 , then her V̇O2max was estimated to be 3.0 L ⭈ min⫺1 . The suggested work rate is based on sex and an individual’s fitness status as follows: men, unconditioned: 300 or 600 kg ⭈ m ⭈ min⫺1 (50 or 100 W) men, conditioned: 600 or 900 kg ⭈ m ⭈ min⫺1 (100 or 150 W) women, unconditioned: 300 or 450 kg ⭈ m ⭈ min⫺1 (50 or 75 W) women, conditioned: 450 or 600 kg ⭈ m ⭈ min⫺1 (75 or 100 W)
- 105. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 79 1. Obtain resting HR and BP immediately prior to exercise in the exercise posture. 2. The client should be familiarized with the ergometer. If using a cycle ergometer, properly position the client on the ergometer (i.e., upright posture, ⬃25-degree bend in the knee at maximal leg extension, and hands in proper position on handlebars) (81–83). 3. The exercise test should begin with a 2–3 min warm-up to acquaint the client with the cycle ergometer and prepare him or her for the exercise intensity in the first stage of the test. 4. A specific protocol should consist of 2- or 3-min stages with appropriate increments in work rate. 5. HR should be monitored at least two times during each stage, near the end of the second and third minutes of each stage. If HR is ⬎110 beats ⭈ min⫺1 , steady state HR (i.e., two HRs within 5 beats ⭈ min⫺1 ) should be reached before the workload is increased. 6. BP should be monitored in the last minute of each stage and repeated (verified) in the event of a hypotensive or hypertensive response. 7 . RPE (using either the Borg category or category-ratio scale [see Table 4.7]) and additional rating scales should be monitored near the end of the last minute of each stage. 8. Client’s appearance and symptoms should be monitored and recorded regularly. 9. The test should be terminated when the subject reaches 70% heart rate reserve (85% of age-predicted HRmax ), fails to conform to the exercise test protocol, experiences adverse signs or symptoms, requests to stop, or experiences an emergency situation. 10. An appropriate cool-down/recovery period should be initiated consisting of either a. continued exercise at a work rate equivalent to that of the first stage of the exercise test protocol or lower or b. a passive cool-down if the subject experiences signs of discomfort or an emergency situation occurs 11. All physiologic observations (e.g., HR, BP , signs and symptoms) should be continued for at least 5 min of recovery unless abnormal responses occur, which would warrant a longer posttest surveillance period. Continue low- level exercise until HR and BP stabilize, but not necessarily until they reach preexercise levels. BP , blood pressure; HR, heart rate; HRmax , maximal heart rate; RPE, rating of perceived exertion. General Procedures for Submaximal Testing of Cardiorespiratory Fitness BOX 4.4
- 106. 80 GUIDELINES FOR EXERCISE TESTING • www.acsm.org The pedal rate is set at 50 rpm. The goal is to obtain HR values between 125 and 170 beats ⭈ min⫺1 , with HR measured during the fifth and sixth minute of work. The average of the two HRs is then used to estimate V̇O2max from a nomo- gram (see Figure 4.1). This value must then be adjusted for age because HRmax decreases with age by multiplying the V̇O2max value by the following correction factors (6): AGE CORRECTION FACTOR 15 1.10 25 1.00 35 0.87 40 0.83 45 0.78 50 0.75 55 0.71 60 0.68 65 0.65 In contrast to the Astrand-Ryhming cycle ergometer single-stage test, Maritz et al. (71) measured HR at a series of submaximal work rates and extrapolated the response to the subject’s age-predicted HRmax . This multistage method is a well-known assessment technique to estimate V̇O2max , and the YMCA test is a good example (111). The YMCA protocol uses two to four 3-min stages of con- tinuous exercise (see Figure 4.2). The test is designed to raise the steady state HR of the subject to between 110 beats ⭈ min⫺1 and 70% heart rate reserve (HRR) (or 85% of the age-predicted HRmax ) for at least two consecutive stages. It is im- portant to remember that two consecutive HR measurements must be obtained within this HR range to predict V̇O2max . In the YMCA protocol, each work rate is performed for at least 3 min, and HR is recorded during the final 15–30 s of the second and third minutes. The work TABLE 4.7. The Borg Rating of Perceived Exertion Scale 6 No exertion at all 7 Extremely light 8 9 Very light 10 11 Light 12 13 Somewhat hard 14 15 Hard (heavy) 16 17 Very hard 18 19 Extremely hard 20 Maximal exertion From (13). © Gunnar Borg. Reproduced with permission. The scale with correct instructions can be obtained from Borg Perception, Radisvagen 124, 16573 Hasselby, Sweden. See also the home page: http://www .borgperception.se/index.html.
- 107. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 81 1.500 1.200 1.050 900 750 450 600 300 300 450 600 750 900 170 166 162 158 154 150 146 142 138 134 130 126 122 120 124 128 5.8 5.4 5.0 4.6 4.2 3.8 3.4 3.0 2.6 2.2 1.8 1.6 0.8 0.9 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3.0 3.1 3.2 3.3 3.4 3.5 2.0 2.4 2.8 3.2 3.6 4.0 4.4 4.8 5.2 5.6 6.0 132 136 140 144 148 152 156 160 60 60 50 40 50 40 70 70 80 90 164 168 172 Pulse rate Men Women Step test 33 cm 40 cm Women Men (weight, kg) VO2max, L VO2, L Work load (kg/min) Women Men 80 90 100 ■ FIGURE 4.1. Modified Astrand-Ryhming nomogram. Used with permission from (7).
- 108. 82 GUIDELINES FOR EXERCISE TESTING • www.acsm.org rate should be maintained for an additional minute if the two HRs vary by more than 5 beats ⭈ min⫺1 . The test administrator should recognize the error associated with age-predicted HRmax and monitor the subject throughout the test to ensure the test remains submaximal. The HR measured during the last minute of each steady state stage is plotted against work rate. The line generated from the plot- ted points is then extrapolated to the age-predicted HRmax (e.g., 220 ⫺ age), and a perpendicular line is dropped to the x-axis to estimate the work rate that would have been achieved if the individual had worked to maximum (see Figure 4.3). The two lines noted as ⫾1 standard deviation (SD) in Figure 4.3 show what the estimated V̇O2max would be if the subject’s true HRmax were 168 or 192 beats ⭈ min⫺1 , rather than 180 beats ⭈ min⫺1 . Part of the error involved in estimating V̇O2max from submaximal HR responses occurs because the formula “220 ⫺ age” has an SD of ⫾12 beats ⭈ min⫺1 and can provide only an estimate of HRmax (106). In addition, errors can be attributed to inaccurate pedaling cadence (workload) and imprecise achievement of steady state HR. Table 4.8 provides normative values for estimated V̇O2max from work rate on the YMCA submax cycle ergometer test with specific reference to age and sex (111). V̇O2max can also be estimated from the work rate using the formula in Chapter 7 (see Table 7.3). This equation is valid to estimate V̇O2 at submaximal steady state workloads 2nd stage 1st stage 3rd stage 4th stage 750 kgm/min (2.5 kg)* 150 kgm/min (0.5 kg) 600 kgm/min (2.0 kg) 450 kgm/min (1.5 kg) 300 kgm/min (1.0 kg) 900 kgm/min (3.0 kg) 750 kgm/min (2.5 kg) 600 kgm/min (2.0 kg) 450 kgm/min (1.5 kg) 1050 kgm/min (3.5 kg) Directions: 1 Set the 1st work rate at 150 kgm/min (0.5 kg at 50 rpm) 2 If the HR in the third minute of the stage is: 80, set the 2nd stage at 750 kgm/min (2.5 kg at 50 rpm) 80-89, set the 2nd stage at 600 kgm/min (2.0 kg at 50 rpm) 90-100, set the 2nd stage at 450 kgm/min (1.5 kg at 50 rpm) 100, set the 2nd stage at 300 kgm/min (1.0 kg at 50 rpm) 3 Set the 3rd and 4th (if required) according to the work rates in the columns below the 2nd loads 900 kgm/min (3.0 kg) 750 kgm/min (2.5 kg) 600 kgm/min (2.0 kg) HR: 80 HR: 100 HR: 80–89 HR: 90–100 ■ FIGURE 4.2. YMCA cycle ergometry protocol. Resistance settings shown here are appropriate for an ergometer with a flywheel of 6 m ⭈ rev⫺1 (111).
- 109. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 83 (from 300 to 1,200 kg ⭈ m ⭈ min⫺1 ) (49.0 W to 196.1 W); therefore, caution must be used if extrapolating to workloads outside of this range. TreadmillTests The primary exercise modality for submaximal exercise testing traditionally has been the cycle ergometer, although treadmills are used in many settings. The same endpoint (70% HRR or 85% of age-predicted HRmax ) is used, and the stages of the test should be 3 min or longer to ensure a steady state HR response at each stage. The HR values are extrapolated to age-predicted HRmax , and V̇O2max is estimated using the formula in Chapter 7 from the highest speed and/or grade that would have been achieved if the individual had worked to maximum. Most common treadmill protocols presented in Chapter 5 can be used, but the dura- tion of each stage should be at least 3 min. -1SD 130 120 140 150 160 170 180 190 200 150 300 450 600 750 900 1050 1200 110 +1SD ■ FIGURE 4.3. Heart rate responses to three submaximal work rates for a sedentary woman 40 yr of age weighing 64 kg. V̇O2max was estimated by extrapolating the heart rate (HR) response to the age-predicted HRmax of 180 beats ⭈ min⫺1 (based on 220 ⫺ age). The work rate that would have been achieved at that HR was determined by dropping a line from that HR value to the x-axis. V̇O2max estimated using the formula in Chapter 7 and expressed in L ⭈ min⫺1 was 2.2 L ⭈ min⫺1 . The other two lines estimate what the V̇O2max would have been if the sub- ject’s true HRmax was ⫾1 standard deviation (SD) from the 180 beats ⭈ min⫺1 value.
- 110. 84 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 4.8. Fitness Categories for Estimated V̇O2max from the YMCA Submaximal Cycle Ergometer Test by Age and Sex Norms for Max V̇O2 (mL/kg) — MEN Age (year) % Ranking 18–25 26–35 36–45 46–55 56–65 Over 65 100 Excellent 100 95 90 83 65 53 95 75 66 61 55 50 42 90 65 60 55 49 43 38 85 Good 60 55 49 45 40 34 80 56 52 47 43 38 33 75 53 50 45 40 37 32 70 Above average 50 48 43 39 35 31 65 49 45 41 38 34 30 60 48 44 40 36 33 29 55 Average 45 42 38 35 32 28 50 44 40 37 33 31 27 45 43 39 36 32 30 26 40 Below average 42 38 35 31 28 25 35 39 37 33 30 27 24 30 38 34 31 29 26 23 25 Poor 36 33 30 27 25 22 20 35 32 29 26 23 21 15 32 30 27 25 22 20 10 Very poor 30 27 24 24 21 18 5 26 24 21 20 18 16 0 20 15 14 13 12 10 Norms for Max V̇O2 (mL/kg) — WOMEN Age (year) % Ranking 18–25 26–35 36–45 46–55 56–65 Over 65 100 Excellent 95 95 75 72 58 55 95 69 65 56 51 44 48 90 59 58 50 45 40 34 85 Good 56 53 46 41 36 31 80 52 51 44 39 35 30 75 50 48 42 36 33 29 70 Above average 47 45 41 35 32 28 65 45 44 38 34 31 27 60 44 43 37 32 30 26 55 Average 42 41 36 31 28 25 50 40 40 34 30 27 24 45 39 37 33 29 26 23 40 Below average 38 36 32 28 25 22 35 37 35 30 27 24 21 30 35 34 29 26 23 20 25 Poor 33 32 28 25 22 19 20 32 30 26 23 20 18 15 20 28 25 22 19 17 10 Very poor 27 25 24 20 18 16 5 24 22 20 18 15 14 0 15 14 12 11 10 10 Adapted with permission from (111). © 2000 by YMCA of the USA, Chicago. All rights reserved.
- 111. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 85 StepTests Step tests are also used to estimate V̇O2max . Astrand and Ryhming (7) used a single- step height of 33 cm (13 in) for women and 40 cm (15.7 in) for men at a rate of 22.5 steps ⭈ min⫺1 . These tests require V̇O2 of about 25.8 and 29.5 mL ⭈ kg⫺1 ⭈ min⫺1 , respectively. HR is measured as described for the cycle test, and V̇O2max is estimated from the nomogram (see Figure 4.1). In contrast, Maritz et al. (71) used a single- step height of 12 in (30.5 cm) and four step rates to systematically increase the work rate. A steady state HR is measured for each step rate, and a line formed from these HR values are extrapolated to age-predicted HRmax . The maximal work rate is determined as described for the YMCA cycle test. V̇O2max can be estimated from the formula for stepping in Chapter 7. Such step tests should be modified to suit the population being tested. The Canadian Home Fitness Test has demonstrated that such testing can be performed on a large scale and at low cost (99). Instead of estimating V̇O2max from HR responses to several submaximal work rates, a wide variety of step tests have been developed to categorize CRF based on an individual’s recovery HR following a standardized step test. The 3-Minute YMCA Step Test is a good example of such a test. This test uses a 12-in (30.5 cm) bench, with a stepping rate of 24 steps ⭈ min⫺1 (estimated V̇O2 of 25.8 mL ⭈ kg⫺1 ⭈ min⫺1 ). After stepping is completed, the subject immediately sits down and HR is counted for 1 min. Counting must start within 5 s at the end of exercise. HR values are used to obtain a qualitative rating of fitness from published normative tables (111). CARDIORESPIRATORY TEST SEQUENCE AND MEASURES A minimum of HR, BP , and subjective symptoms (i.e., RPE, dyspnea, and angina) should be measured during exercise tests. After the initial screening process, selected baseline measurements should be obtained prior to the start of the exercise test. Taking a resting ECG prior to exercise testing requires that trained personnel are available to interpret the ECG and provide medical guidance. An ECG is not considered necessary when diagnostic testing is not being done. The sequence of measures is listed in Table 5.2. HR can be determined using several techniques including radial pulse pal- pation, auscultation with a stethoscope, or the use of HR monitors. The pulse palpation technique involves “feeling” the pulse by placing the second and third fingers (i.e., index and middle fingers) most typically over the radial artery, located near the thumb side of the wrist. The pulse is typically counted for 15 s, and then multiplied by 4, to determine the HR for 1 min. For the auscultation method, the bell of the stethoscope should be placed to the left of the sternum just above the level of the nipple. The auscultation method is most accurate when the heart sounds are clearly audible, and the subject’s torso is relatively stable. HR telemetry monitors with chest electrodes or radio telemetry have proven to be accurate and reliable, provided there is no outside electrical interfer- ence (e.g., emissions from the display consoles of computerized exercise equip- ment) (66). Many electronic cycles and treadmills have embedded HR telemetry monitoring into the equipment.
- 112. 86 GUIDELINES FOR EXERCISE TESTING • www.acsm.org BP should be measured at heart level with the subject’s arm relaxed and not grasping a handrail (treadmill) or handlebar (cycle ergometer). To help ensure accurate readings, the use of an appropriate-sized BP cuff is important. The rub- ber bladder of the BP cuff should encircle at least 80% of the subject’s upper arm. If the subject’s arm is large, a normal size adult cuff will be too small, thus resul- ting in an erroneous elevated reading; whereas if the cuff is too large for the sub- ject’s arm, the resultant reading will be erroneously low. BP measurements should be taken with a recently calibrated aneroid sphygmomanometer. Systolic (SBP) and diastolic (DBP) BP measurements can be used as indicators for stopping an exercise test (see next section of Chapter 4). To obtain accurate BP measures during exercise, follow the guidelines in Chapter 3 (see Box 3.4) for resting BP; however, BP will be obtained in the exercise position. If an automated BP system is used during exercise testing, calibration checks with manual BP measurements must be routinely performed to confirm accuracy of the automated readings (76). RPE can be a valuable indicator for monitoring an individual’s exercise tole- rance. Although RPEs correlate with exercise HRs and work rates, large interin- dividual variability in RPE with healthy individuals as well as patient populations mandates caution in the universal application of RPE scales (109). Borg’s RPE scale was developed to allow the exerciser to subjectively rate her or his feelings during exercise, taking into account personal physical fitness level and general fa- tigue levels (77). Ratings can be influenced by psychological factors, mood states, environmental conditions (13), exercise modes, and age reducing its utility (93). Currently, two RPE scales are widely used: (a) the original Borg or category scale, which rates exercise intensity from 6 to 20 (see Table 4.7); and (b) the category- ratio scale of 0–10. Both RPE scales are appropriate subjective tools (13,43). During exercise testing, the RPE can be used as an indication of impending fatigue. Most apparently, healthy subjects reach their subjective limit of fatigue at an RPE of 18–19 (very, very hard) on the category Borg scale, or 9–10 (very, very strong) on the category-ratio scale; therefore, RPE can be used to monitor progress toward maximal exertion during exercise testing (75). The development of dyspnea and/or angina during exercise is also important to subjectively quantify. In particular, exercise limited by dyspnea as opposed to other subjective symptoms appears to indicate an increased risk for future adverse events (2,12). Four level scales for perceived dyspnea and angina during exercise are available through the current AHA scientific statements on recom- mendations for clinical exercise laboratories (76). TEST TERMINATION CRITERIA Graded exercise test (GXT), whether maximal or submaximal, is a safe procedure when subject screening and testing guidelines as outlined in Chapter 2 are adhered to. Occasionally, for safety reasons, the test may have to be terminated prior to the subject reaching a measured V̇O2max /V̇O2peak, volitional fatigue, or a predetermined endpoint (i.e., 50%–70% HRR or 70%–85% age-predicted HRmax ). Because of the individual variation in HRmax , the upper limit of 85% of an estimated HRmax may
- 113. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 87 result in a maximal effort for some individuals and submaximal effort in others. General indications — those that do not rely on physician involvement or ECG monitoring — for stopping an exercise test are outlined in Box 4.5. More specific termination criteria for clinical or diagnostic testing are provided in Chapter 5. INTERPRETATION OF RESULTS Table 4.9 provides normative values for V̇O2max (in mL ⭈ kg⫺1 ⭈ min⫺1 ) estimated from treadmill speed and grade with specific reference to age and sex. Research suggests a V̇O2max below the 20th percentile for age and sex, that is often indicative of a sedentary lifestyle, is associated with an increased risk of death from all causes (10). Several regression equations for estimating CRF according to age and sex are also available. These equations produce a single expected aerobic capacity value for comparison to a measured response as opposed to percentiles. Of the avail- able regression equations, research indicates prediction formulas derived from a Veterans Affairs cohort (Predicted METs ⫽ 18 ⫺ 0.15*age) and the St. James Take Heart project (Predicted METs ⫽ 14.7 ⫺ 0.13*age) may provide somewhat better prognostic information in men and women, respectively (61). Although percent predicted aerobic capacity appears to be prognostic (i.e., lower percent predicted ⫽ worse prognosis), an individual’s age has a signif- icant influence on predictive characteristics in men and women. Specifically, in younger individuals (⬃40–60 yr), percent predicted aerobic capacity may have to decrease below 60%–70% before indicating poor prognosis, after which the • Onset of angina or angina-like symptoms • Drop in SBP of ⱖ10 mm Hg with an increase in work rate or if SBP decreases below the value obtained in the same position prior to testing • Excessive rise in BP: systolic pressure ⬎250 mm Hg and/or diastolic pressure ⬎115 mm Hg • Shortness of breath, wheezing, leg cramps, or claudication • Signs of poor perfusion: light-headedness, confusion, ataxia, pallor, cyanosis, nausea, or cold and clammy skin • Failure of HR to increase with increased exercise intensity • Noticeable change in heart rhythm by palpation or auscultation • Subject requests to stop • Physical or verbal manifestations of severe fatigue • Failure of the testing equipment a Assumes that testing is nondiagnostic and is being performed without direct physician involvement or ECG monitoring. For clinical testing, Box 5.2 provides more definitive and specific termination criteria. BP , blood pressure; ECG, electrocardiogram; HR, heart rate; SBP , systolic blood pressure. General Indications for Stopping an Exercise Testa BOX 4.5
- 114. 88 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 4.9. Fitness Categories for Maximal Aerobic Power for Men and Women by Age MEN Age 20–29 Age 30–39 % Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) 99 Superior 31:30 60.5 2.00 8:29 30:00 58.3 1.94 8:49 95 28:05 55.5 1.86 9:17 27:03 54.1 1.82 9:33 90 Excellent 27:00 54.0 1.81 9:34 25:25 51.7 1.75 10:01 85 25:30 51.8 1.75 10:00 24:13 50.0 1.70 10:24 80 25:00 51.1 1.73 10:09 23:06 48.3 1.66 10:46 75 Good 23:13 48.5 1.66 10:43 22:10 47 .0 1.62 11:06 70 22:30 47 .5 1.63 10:59 21:30 46.0 1.59 11:22 65 22:00 46.8 1.61 11:10 21:00 45.3 1.57 11:33 60 21:10 45.6 1.58 11:29 20:09 44.1 1.54 11:54 55 Fair 21:40 44.8 1.56 11:41 20:00 43.9 1.53 11:58 50 20:00 43.9 1.53 11:58 19:00 42.4 1.49 12:24 45 19:08 42.6 1.50 12:20 18:07 41.2 1.46 12:50 40 18:30 41.7 1.47 12:38 17:49 40.7 1.44 12:58 35 Poor 18:00 41.0 1.45 12:53 17:00 39.5 1.41 13:24 30 17:17 39.9 1.42 13:15 16:24 38.7 1.39 13:44 25 16:38 39.0 1.40 13:36 15:46 37 .8 1.36 14:05 20 15:56 38.0 1.37 14:00 15:00 36.7 1.33 14:34 15 Very poor 15:00 36.7 1.33 14:34 14:02 35.2 1.29 15:13 10 13:37 34.7 1.28 15:30 13:00 33.8 1.25 15:57 5 11:38 31.8 1.20 17:04 11:15 31.2 1.18 17:25 1 8:00 26.5 1.05 20:58 8:00 26.5 1.05 20:58 n ⫽ 2,328 n ⫽ 12,730 Total n ⫽ 15,058
- 115. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 89 (continued) Age 40–49 Age 50–59 % Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) 99 Superior 28:30 56.1 1.87 9:10 27:00 54.0 1.81 9:34 95 26:00 52.5 1.77 9:51 23:32 49.0 1.68 10:37 90 Excellent 24:00 49.6 1.69 10:28 22:00 46.8 1.61 11:10 85 23:00 48.2 1.65 10:48 20:30 44.6 1.55 11:45 80 21:45 46.4 1.60 11:15 19:37 43.3 1.52 12:08 75 Good 20:42 44.9 1.56 11:40 18:35 41.8 1.48 12:36 70 20:01 43.9 1.53 11:58 18:00 41.0 1.45 12:53 65 19:30 43.1 1.51 12:11 17:08 39.7 1.42 13:20 60 19:00 42.4 1.49 12:24 16:39 39.0 1.40 13:35 55 Fair 18:00 41.0 1.45 12:53 16:00 38.1 1.37 13:58 50 17:22 40.1 1.43 13:12 15:18 37 .1 1.34 14:23 45 17:00 39.5 1.41 13:24 15:00 36.7 1.33 14:34 40 16:14 38.4 1.38 13:50 14:12 35.5 1.30 15:06 35 Poor 15:38 37 .6 1.36 14:11 13:43 34.8 1.28 15:26 30 15:00 36.7 1.33 14:34 13:00 33.8 1.25 15:58 25 14:30 35.9 1.31 14:53 12:21 32.8 1.23 16:28 20 13:45 34.8 1.28 15:24 11:45 32.0 1.20 16:58 15 Very poor 13:00 33.8 1.25 15:58 11:00 30.9 1.17 17:38 10 12:00 32.3 1.21 16:46 10:00 29.4 1.13 18:37 5 10:01 29.4 1.13 18:48 8:15 26.9 1.06 20:38 1 7:00 25.1 1.01 22:22 5:25 22.8 0.95 25:00 n ⫽ 18,104 n ⫽ 10,627 Total n ⫽ 28,731 MEN
- 116. 90 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Age 60–69 Age 70–79 % Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) 99 Superior 25:00 51.1 1.73 10:09 24:00 49.6 1.69 10:28 95 21:18 45.7 1.59 11:26 20:00 43.9 1.53 11:58 90 Excellent 19:10 42.7 1.50 12:20 17:00 39.5 1.41 13:24 85 18:01 41.0 1.45 12:53 16:00 38.1 1.37 13:58 80 17:01 39.6 1.41 13:23 15:00 36.7 1.33 14:34 75 Good 16:09 38.3 1.38 13:52 14:01 35.2 1.29 15:14 70 15:30 37 .4 1.35 14:16 13:05 33.9 1.26 15:54 65 15:00 36.7 1.33 14:34 12:32 33.1 1.23 16:19 60 14:15 35.6 1.30 15:04 12:03 32.4 1.21 16:43 55 Fair 13:47 34.9 1.28 15:23 11:29 31.6 1.19 17:12 50 13:02 33.8 1.25 15:56 11:00 30.9 1.17 17:38 45 12:30 33.0 1.23 16:21 10:26 30.1 1.15 18:11 40 12:00 32.3 1.21 16:46 10:00 29.4 1.13 18:38 35 Poor 11:30 31.6 1.19 17:11 9:17 28.4 1.10 19:24 30 10:57 30.8 1.17 17:41 9:00 28.0 1.09 19:43 25 10:04 29.5 1.13 18:33 8:17 26.9 1.06 20:36 20 9:30 28.7 1.11 19:10 7:24 25.7 1.03 21:47 15 Very poor 8:30 27 .3 1.07 20:19 6:40 24.6 1.00 22:52 10 7:21 25.6 1.03 21:51 5:31 23.0 0.95 24:49 5 5:57 23.6 0.97 24:03 4:00 20.8 0.89 27:58 1 3:16 19.7 0.86 29:47 2:15 18.2 0.82 32:46 n ⫽ 2,971 n ⫽ 417 Total n ⫽ 3,388 TABLE 4.9. Fitness Categories for Maximal Aerobic Power for Men and Women by Age (Continued) MEN
- 117. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 91 Age 20–29 Age 30–39 % Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) 99 Superior 27:23 54.5 1.83 9:30 25:37 52.0 1.76 9:58 95 24:00 49.6 1.69 10:28 22:26 47 .4 1.63 11:00 90 Excellent 22:00 46.8 1.61 11:10 21:00 45.3 1.57 11:33 85 21:00 45.3 1.57 11:33 20:00 43.9 1.53 11:58 80 20:01 43.9 1.53 11:58 19:00 42.4 1.49 12:24 75 Good 19:00 42.4 1.49 12:24 18:02 41.0 1.45 12:53 70 18:04 41.1 1.46 12:51 17:01 39.6 1.41 13:24 65 18:00 41.0 1.45 12:53 16:18 38.5 1.38 13:47 60 17:00 39.5 1.41 13:24 15:43 37 .7 1.36 14:08 55 Fair 16:17 38.5 1.38 13:48 15:10 36.9 1.34 14:28 50 15:50 37 .8 1.37 14:04 15:00 36.7 1.33 14:34 45 15:00 36.7 1.33 14:34 14:00 35.2 1.29 15:14 40 14:36 36.1 1.32 14:50 13:20 34.2 1.27 15:43 35 Poor 14:00 35.2 1.29 15:14 13:00 33.8 1.25 15:58 30 13:15 34.1 1.26 15:46 12:03 32.4 1.21 16:42 25 12:30 33.0 1.23 16:21 11:47 32.0 1.20 16:56 20 12:00 32.3 1.21 16:46 11:00 30.9 1.17 17:38 15 Very poor 11:01 30.9 1.17 17:38 10:00 29.4 1.13 18:37 10 10:04 29.5 1.13 18:33 9:00 28.0 1.09 19:43 5 8:43 27 .6 1.08 20:03 7:33 25.9 1.03 21:34 1 6:00 23.7 0.97 23:58 5:27 22.9 0.95 24:56 n ⫽ 1,280 n ⫽ 4,257 Total n ⫽ 5,537 WOMEN (continued)
- 118. 92 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Age 40–49 Age 50–59 % Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) 99 Superior 25:00 51.1 1.73 10:09 21:31 46.1 1.59 11:20 95 21:00 45.3 1.57 11:33 18:01 41.0 1.45 12:53 90 Excellent 19:30 43.1 1.51 12:11 16:30 38.8 1.39 13:40 85 18:02 41.0 1.45 12:53 15:16 37 .0 1.34 14:24 80 17:02 39.6 1.41 13:23 15:00 36.7 1.33 14:34 75 Good 16:22 38.6 1.39 13:45 14:02 35.2 1.29 15:13 70 16:00 38.1 1.37 13:58 13:20 34.2 1.27 15:43 65 15:01 36.7 1.33 14:34 12:40 33.3 1.24 16:13 60 14:30 35.9 1.31 14:53 12:13 32.6 1.22 16:35 55 Fair 14:01 35.2 1.29 15:13 12:00 32.3 1.21 16:46 50 13:32 34.5 1.27 15:34 11:21 31.4 1.19 17:19 45 13:00 33.8 1.25 15:58 11:00 30.9 1.17 17:38 40 12:18 32.8 1.22 16:31 10:19 29.9 1.14 18:18 35 Poor 12:00 32.3 1.21 16:46 10:00 29.4 1.13 18:37 30 11:10 31.1 1.18 17:29 9:30 28.7 1.11 19:10 25 10:32 30.2 1.15 18:05 9:00 28.0 1.09 19:43 20 10:00 29.4 1.13 18:37 8:10 26.8 1.06 20:44 15 Very poor 9:07 28.2 1.10 19:35 7:30 25.8 1.03 21:38 10 8:04 26.6 1.05 20:52 6:40 24.6 1.00 22:52 5 7:00 25.1 1.01 22:22 5:33 23.0 0.95 24:46 1 5:00 22.2 0.93 25:49 3:31 20.1 0.87 29:09 n ⫽ 5,908 n ⫽ 3,923 Total n ⫽ 9,831 TABLE 4.9. Fitness Categories for Maximal Aerobic Power for Men and Women by Age (Continued) WOMEN
- 119. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 93 Age 60–69 Age 70–79 % Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) Balke Treadmill (time) Max V̇O2 (mL/kgⲐ min) 12-Min Run (miles) 1.5-Mi Run (time) 99 Superior 19:00 42.4 1.49 12:24 19:00 42.4 1.49 12:24 95 15:46 37 .8 1.36 14:05 15:21 37 .2 1.35 14:21 90 Excellent 14:30 35.9 1.31 14:53 12:06 32.5 1.22 16:40 85 13:17 34.2 1.26 15:45 12:00 32.3 1.21 16:46 80 12:15 32.7 1.22 16:33 10:47 30.6 1.16 17:51 75 Good 12:00 32.3 1.21 16:46 10:16 29.8 1.14 18:21 70 11:09 31.1 1.18 17:30 10:01 29.4 1.13 18:37 65 11:00 30.9 1.17 17:38 10:00 29.4 1.13 18:37 60 10:10 29.7 1.14 18:27 9:06 28.1 1.10 19:36 55 Fair 10:00 29.4 1.13 18:37 9:00 28.0 1.09 19:43 50 9:35 28.8 1.12 19:04 8:44 27 .6 1.08 20:02 45 9:07 28.2 1.10 19:35 8:05 26.7 1.05 20:52 40 8:33 27 .3 1.07 20:16 7:35 25.9 1.03 21:31 35 Poor 8:04 26.6 1.05 20:52 7:07 25.3 1.02 22:07 30 7:32 25.9 1.03 21:36 6:44 24.7 1.00 22:46 25 7:01 25.1 1.01 22:21 6:23 24.2 0.99 23:20 20 6:39 24.6 1.00 22:52 5:55 23.5 0.97 24:06 15 Very poor 6:12 23.9 0.98 23:37 5:00 22.2 0.93 25:49 10 5:32 23.0 0.95 24:48 4:30 21.5 0.91 26:51 5 4:45 21.8 0.92 26:19 3:12 19.6 0.86 30:00 1 3:07 19.5 0.86 30:12 1:17 16.8 0.78 36:13 n ⫽ 1,131 n ⫽ 155 Total n ⫽ 1,286 Adapted with permission from Physical Fitness Assessments and Norms for Adults and Law Enforcement. The Cooper Institute, Dallas, Texas. 2009. For more information: www.cooperinstitute.org WOMEN
- 120. 94 GUIDELINES FOR EXERCISE TESTING • www.acsm.org increase in mortality risk becomes rather steep. In older individuals (⬎60 yr), there appears to be a more linear relationship between percent predicted aero- bic capacity and mortality risk across the range of potential values as opposed to a single threshold. In a comparison of the physical fitness status of any one individual to published norms, the accuracy of the classification is dependent on the similarities between the populations and methodology (e.g., estimated vs. measured V̇O2max , maximal vs. submaximal). Although submaximal exercise testing is not as precise as maximal exercise testing, it provides a general reflection of an individual’s physical fitness at a lower cost, potentially reduced risk for adverse events, and requires less time and effort on the part of the subject. Some of the assumptions inherent in a sub- maximal test are more easily met (e.g., steady state HR can be verified), whereas others (e.g., estimated HRmax ) introduce unknown errors into the prediction of V̇O2max . When an individual is given repeated submaximal exercise tests over a period of weeks or months and the HR response to a fixed work rate decreases over time, it is likely that the individual’s CRF has improved, independent of the accuracy of the V̇O2max prediction. Despite differences in test accuracy and methodology, virtually all evaluations can establish a baseline and be used to track relative progress. MUSCULAR STRENGTH AND MUSCULAR ENDURANCE Muscular strength and endurance are health-related fitness components that may improve or maintain the following (110): • Bone mass, which is related to osteoporosis. • Glucose tolerance, which is pertinent in both the prediabetic and diabetic state. • Musculotendinous integrity, which is related to a lower risk of injury includ- ing low back pain. • The ability to carry out the activities of daily living, which is related to per- ceived quality of life and self-efficacy among other indicators of mental health. • The FFM and resting metabolic rate, which are related to weight management. The ACSM has melded the terms muscular strength, endurance, and power into a category termed “muscular fitness” and included it as an integral portion of total health-related fitness in the position stand on the quantity and quality of exercise for developing and maintaining fitness (42). Muscular strength refers to the muscle’s ability to exert force, muscular endurance is the muscle’s ability to continue to perform successive exertions or many repetitions, and muscular power is the muscle’s ability to exert force per unit of time (i.e., rate) (29). Traditionally, tests allowing few (⬍3) repetitions of a task prior to reaching momentary mus- cular fatigue have been considered strength measures, whereas those in which numerous repetitions (⬎12) are performed prior to momentary muscular fatigue were considered measures of muscular endurance. However, the performance of a maximal repetition range (i.e., 4, 6, or 8 repetitions at a given resistance) also can be used to assess strength.
- 121. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 95 RATIONALE Physical fitness tests of muscular strength and muscular endurance before com- mencing exercise training or as part of a health/fitness screening evaluation can provide valuable information on a client’s baseline physical fitness level. For example, muscular fitness test results can be compared to established standards and can be helpful in identifying weaknesses in certain muscle groups or muscle imbalances that could be targeted in exercise training programs. The information obtained during baseline muscular fitness assessments can also serve as a basis for designing individualized exercise training programs. An equally useful appli- cation of physical fitness testing is to show a client’s progressive improvements over time as a result of the training program, and thus provide feedback that is often beneficial in promoting long-term exercise adherence. PRINCIPLES Muscle function tests are very specific to the muscle group tested, the type of muscle action, velocity of muscle movement, type of equipment, and joint range of motion (ROM). Results of any one test are specific to the procedures used, and no single test exists for evaluating total body muscular endurance or strength. Individuals should participate in familiarization/practice sessions with test equip- ment and adhere to a specific protocol including a predetermined repetition dura- tion and ROM in order to obtain a reliable score that can be used to track true physiologic adaptations over time. Moreover, warm-up consisting of 5–10 min of light intensity, aerobic exercise (i.e., treadmill or cycle ergometer), static stretch- ing, and several light intensity repetitions of the specific testing exercise should precede muscular fitness testing. These warm-up activities increase muscle tem- perature and localized blood flow and promotes appropriate cardiovascular re- sponses to exercise. A summary of standardized conditions include the following: • Strict posture. • Consistent repetition duration (movement speed). • Full ROM. • Use of spotters (when necessary). • Equipment familiarization. • Warm-up. Change in muscular fitness over time can be based on the absolute value of the external load or resistance (e.g., newtons, kilograms [kg], or pounds [lb]), but when comparisons are made between individuals, the values should be expressed as relative values (per kilogram of body weight [kg ⭈ kg⫺1 ]). In both cases, caution must be used in the interpretation of the scores because the norms may not include a representative sample of the individual being measured, a standardized protocol may be absent, or the exact test being used (e.g., free weight vs. machine weight) may differ. In addition, the biomechanics for a given resistance exercise may differ significantly when using equipment from different manufactures, further impacting generalizability.
- 122. 96 GUIDELINES FOR EXERCISE TESTING • www.acsm.org MUSCULAR STRENGTH Although muscular strength refers to the external force (properly expressed in newtons, although kilograms and pounds are commonly used as well) that can be generated by a specific muscle or muscle group, it is commonly expressed in terms of resistance met or overcome. Strength can be assessed either stati- cally (i.e., no overt muscular movement at a given joint or group of joints) or dynamically (i.e., movement of an external load or body part in which the muscle changes length). Static or isometric strength can be measured conveniently using a variety of devices including cable tensiometers and handgrip dynamometers. In certain instances, measures of static strength are specific to the muscle group and joint angle involved in testing; therefore, their utility in describing overall muscular strength may be limited. Peak force development in such tests is com- monly referred to as the maximum voluntary contraction (MVC). Traditionally, the one repetition maximum (1-RM), the greatest resistance that can be moved through the full ROM in a controlled manner with good posture, has been the standard for dynamic strength assessment. With appropriate testing familiarization, 1-RM is a reliable indicator of muscle strength (67,84). A multiple RM, such as 4- or 8-RM, can be used as a measure of muscular strength. For exam- ple, if one were training with 6- to 8-RM, the performance of a 6-RM to momentary muscular fatigue would provide an index of strength changes over time, indepen- dent of the true 1-RM. Reynolds et al. (91) have demonstrated multiple repetition tests in the 4- to 8-RM range provide a reasonably accurate estimate of 1-RM. In addition, a conservative approach to assessing maximal muscle strength should be considered in patients at high risk for or with known CVD, pulmonary, and metabolic diseases and health conditions. For these groups, assessment of 10- to 15-RM that approximates training recommendations may be prudent (110). Valid measures of general upper body strength include the 1-RM values for bench press or shoulder press. Corresponding indices of lower body strength include 1-RM values for the leg press or leg extension. Norms based on resistance lifted divided by body mass for the bench press and leg press are provided in Tables 4.10 and 4.11, respectively. The following represents the basic steps in 1-RM (or any multiple RM) testing following familiarization/practice sessions (69): 1. The subject should warm up by completing a number of submaximal repeti- tions of the specific exercise that will be used to determine the 1-RM. 2. Determine the 1-RM (or any multiple of 1-RM) within four trials with rest periods of 3–5 min between trials. 3. Select an initial weight that is within the subject’s perceived capacity (⬃50%–70% of capacity). 4. Resistance is progressively increased by 2.5–20.0 kg (5.5–44.0 lb) until the subject cannot complete the selected repetition(s); all repetitions should be performed at the same speed of movement and ROM to instill consistency between trials. 5. The final weight lifted successfully is recorded as the absolute 1-RM or multiple RM.
- 123. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 97 TABLE 4.10. Fitness Categories for Upper Body Strengtha for Men and Women by Age Bench Press Weight Ratio ⫽ weight pushed in lbs __ body weight in lbs MEN Age % ⬍20 20–29 30–39 40–49 50–59 60⫹ 99 Superior ⬎1.76 ⬎1.63 ⬎1.35 ⬎1.20 ⬎1.05 ⬎0.94 95 1.76 1.63 1.35 1.20 1.05 0.94 90 Excellent 1.46 1.48 1.24 1.10 0.97 0.89 85 1.38 1.37 1.17 1.04 0.93 0.84 80 1.34 1.32 1.12 1.00 0.90 0.82 75 Good 1.29 1.26 1.08 0.96 0.87 0.79 70 1.24 1.22 1.04 0.93 0.84 0.77 65 1.23 1.18 1.01 0.90 0.81 0.74 60 1.19 1.14 0.98 0.88 0.79 0.72 55 Fair 1.16 1.10 0.96 0.86 0.77 0.70 50 1.13 1.06 0.93 0.84 0.75 0.68 45 1.10 1.03 0.90 0.82 0.73 0.67 40 1.06 0.99 0.88 0.80 0.71 0.66 35 Poor 1.01 0.96 0.86 0.78 0.70 0.65 30 0.96 0.93 0.83 0.76 0.68 0.63 25 0.93 0.90 0.81 0.74 0.66 0.60 20 0.89 0.88 0.78 0.72 0.63 0.57 15 Very poor 0.86 0.84 0.75 0.69 0.60 0.56 10 0.81 0.80 0.71 0.65 0.57 0.53 5 0.76 0.72 0.65 0.59 0.53 0.49 1 ⬍0.76 ⬍0.72 ⬍0.65 ⬍0.59 ⬍0.53 ⬍0.49 n 60 425 1,909 2,090 1,279 343 Total n ⫽ 6,106 WOMEN 99 Superior ⬎0.88 ⬎1.01 ⬎0.82 ⬎0.77 ⬎0.68 ⬎0.72 95 0.88 1.01 0.82 0.77 0.68 0.72 90 Excellent 0.83 0.90 0.76 0.71 0.61 0.64 85 0.81 0.83 0.72 0.66 0.57 0.59 80 0.77 0.80 0.70 0.62 0.55 0.54 75 Good 0.76 0.77 0.65 0.60 0.53 0.53 70 0.74 0.74 0.63 0.57 0.52 0.51 65 0.70 0.72 0.62 0.55 0.50 0.48 60 0.65 0.70 0.60 0.54 0.48 0.47 55 Fair 0.64 0.68 0.58 0.53 0.47 0.46 50 0.63 0.65 0.57 0.52 0.46 0.45 45 0.60 0.63 0.55 0.51 0.45 0.44 40 0.58 0.59 0.53 0.50 0.44 0.43 35 Poor 0.57 0.58 0.52 0.48 0.43 0.41 30 0.56 0.56 0.51 0.47 0.42 0.40 25 0.55 0.53 0.49 0.45 0.41 0.39 20 0.53 0.51 0.47 0.43 0.39 0.38 (continued)
- 124. 98 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 4.10. Fitness Categories for Upper Body Strengtha for Men and Women by Age (Continued) Bench Press Weight Ratio ⫽ weight pushed in lbs __ body weight in lbs WOMEN Age % ⬍20 20–29 30–39 40–49 50–59 60⫹ 15 Very poor 0.52 0.50 0.45 0.42 0.38 0.36 10 0.50 0.48 0.42 0.38 0.37 0.33 5 0.41 0.44 0.39 0.35 0.31 0.26 1 ⬍0.41 ⬍0.44 ⬍0.39 ⬍0.35 ⬍0.31 ⬍0.26 n 20 191 379 333 189 42 Total n ⫽ 1,154 a One repetition maximum bench press, with bench press weight ratio ⫽ weight pushed in pounds per body weight in pounds. Adapted with permission from Physical Fitness Assessments and Norms for Adults and Law Enforcement. The Cooper Institute, Dallas, Texas. 2009. For more information: www.cooperinstitute.org TABLE 4.11. Fitness Categories for Leg Strength by Age and Sexa Age (year) Percentile 20–29 30–39 40–49 50–59 60⫹ Men 90 Well above average 2.27 2.07 1.92 1.80 1.73 80 Above average 2.13 1.93 1.82 1.71 1.62 70 2.05 1.85 1.74 1.64 1.56 60 Average 1.97 1.77 1.68 1.58 1.49 50 1.91 1.71 1.62 1.52 1.43 40 Below average 1.83 1.65 1.57 1.46 1.38 30 1.74 1.59 1.51 1.39 1.30 20 Well below average 1.63 1.52 1.44 1.32 1.25 10 1.51 1.43 1.35 1.22 1.16 Women 90 Well above average 1.82 1.61 1.48 1.37 1.32 80 Above average 1.68 1.47 1.37 1.25 1.18 70 1.58 1.39 1.29 1.17 1.13 60 Average 1.50 1.33 1.23 1.10 1.04 50 1.44 1.27 1.18 1.05 0.99 40 Below average 1.37 1.21 1.13 0.99 0.93 30 1.27 1.15 1.08 0.95 0.88 20 Well below average 1.22 1.09 1.02 0.88 0.85 10 1.14 1.00 0.94 0.78 0.72 a One repetition maximum leg press with leg press weight ratio ⫽ weight pushed per body weight. Adapted from Institute for Aerobics Research, Dallas, 1994. Study population for the data set was predominantly white and college educated. A Universal Dynamic Variable Resistance (DVR) machine was used to measure the 1-repetition maximum (RM).
- 125. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 99 Isokinetic testing involves the assessment of maximal muscle tension throughout a ROM set at a constant angular velocity (e.g., 60 angles ⭈ s⫺1 ). Equipment that allows control of the speed of joint rotation (degrees ⭈ s⫺1 ) as well as the ability to test movement around various joints (e.g., knee, hip, shoul- der, elbow) is available from commercial sources. Such devices measure peak rotational force or torque, but an important drawback is that this equipment is substantially more expensive compared to other strength testing modalities (45). MUSCULAR ENDURANCE Muscular endurance is the ability of a muscle group to execute repeated muscle actions over a period of time sufficient to cause muscular fatigue or to maintain a specific percentage of the 1-RM for a prolonged period of time. If the total number of repetitions at a given amount of resistance is measured, the result is termed absolute muscular endurance. If the number of repetitions performed at a percentage of the 1-RM (e.g., 70%) is used pretesting and posttesting, the result is termed relative muscular endurance. Simple field tests such as a curl-up (crunch) test (19,45) or the maximum number of push-ups that can be performed without rest (19) may be used to evaluate the endurance of the abdominal muscle groups and upper body muscles, respectively. Procedures for conducting the push-up and curl-up (crunch) muscular endurance tests are given in Box 4.6, and physical fitness categories are provided in Tables 4.12 and 4.13, respectively. Resistance training equipment also can be adapted to measure muscular endurance by selecting an appropriate submaximal level of resistance and mea- suring the number of repetitions or the duration of static muscle action before fatigue. For example, the YMCA bench press test involves performing standard- ized repetitions at a rate of 30 lifts or reps ⭈ min⫺1 . Men are tested using a 36.3-kg (80 lb) barbell and women using a 15.9-kg (35 lb) barbell. Subjects are scored by the number of successful repetitions completed (111). The YMCA test is an excellent example of a test that attempts to control for repetition duration and posture alignment, thus possessing high reliability. Normative data for the YMCA bench press test are presented in Table 4.14. SPECIAL CONSIDERATIONS IN MUSCULAR FITNESS Older Adults The number of older adults in the United States is expected to increase expo- nentially over the next several decades as described in Chapter 8. As individuals are living longer, it is becoming increasingly more important to find ways to extend active and independent life expectancy. Assessing muscular strength and endurance, neuromotor fitness, and other aspects of health-related physical fitness among older adults can aid in detecting physical limitations and yield important information used to design exercise programs that improve muscular fitness before serious functional limitations or injuries occur. The Senior Fitness Test (SFT) was developed in response to a need for improved health/fitness
- 126. 100 GUIDELINES FOR EXERCISE TESTING • www.acsm.org PUSH-UP 1. The push-up test is administered with men starting in the standard “down” position (hands pointing forward and under the shoulder, back straight, head up, using the toes as the pivotal point) and women in the modified “knee push-up” position (legs together, lower leg in contact with mat with ankles plantar-flexed, back straight, hands shoulder width apart, head up, using the knees as the pivotal point). 2. The client/patient must raise the body by straightening the elbows and return to the “down” position, until the chin touches the mat. The stomach should not touch the mat. 3. For both men and women, the subject’s back must be straight at all times and the subject must push up to a straight arm position. 4. The maximal number of push-ups performed consecutively without rest is counted as the score. 5. The test is stopped when the client strains forcibly or unable to maintain the appropriate technique within two repetitions. CURL-UP (CRUNCH)† 1. Two strips of masking tape are to be placed on a mat on the floor at a distance of 12 cm apart (for clients/patients ⬍45 yr) or 8 cm apart (for clients/patients ⱖ45 yr). 2. Subjects are to lie in a supine position across the tape, knees bent at 90° with feet on the floor and arms extended to their sides, such that their fingertips touch the nearest strip. This is the bottom position. To reach the top position, subjects are to flex their spines to 30°, reaching their hands forward until their fingers touch the second strip of tape. 3. A metronome is to be set at 40 beats ⭈ min⫺1 . At the first beep, the subject begins the curl-up, reaching the top position at the second beep, returning to the starting position at the third, top position at the fourth, etc. 4. Repetitions are counted each time the subject reaches the bottom position. The test is concluded either when the subject reaches 75 curl-ups, or the cadence is broken. 5. Every subject will be allowed several practice repetitions prior to the start of the test. † Alternatives include: 1) having the hands held across the chest with the head activating a counter when the trunk reaches a 30o position (32) and placing the hands on the thighs and curling up until the hands reach the knee caps (37). Elevation of the trunk to 30o is the important aspect of the movement. Reprinted with permission from (19). ©2003. Used with permission from the Canadian Society for Exercise Physiology www.csep.ca Push-up and Curl-up (Crunch) Test Procedures for Measurement of Muscular Endurance BOX 4.6
- 127. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 101 TABLE 4.13. Fitness Categories for the Partial Curl-Up by Age and Sex Age (year) Percentile 20–29 30–39 40–49 50–59 60–69 Gender M W M W M W M W M W 90 Well above average 75 70 75 55 75 55 74 48 53 50 80 Above average 56 45 69 43 75 42 60 30 33 30 70 41 37 46 34 67 33 45 23 26 24 60 Average 31 32 36 28 51 28 35 16 19 19 50 27 27 31 21 39 25 27 9 16 13 40 Below average 24 21 26 15 31 20 23 2 9 9 30 20 17 19 12 26 14 19 0 6 3 20 Well below average 13 12 13 0 21 5 13 0 0 0 10 4 5 0 0 13 0 0 0 0 0 M, men; W, women. Adapted from (37). assessment tools for older individuals (92). The test was designed to assess the key physiologic parameters (e.g., strength, endurance, agility, balance) needed to perform common everyday physical activities that are often difficult to perform in later years. One aspect of the SFT is the 30-s chair stand test. This test, and others of the SFT, meets scientific standards for reliability and validity, is simple and easy to administer in the “field” setting, and has accompanying performance norms for older men and women 60–94 yr based on a study of over 7,000 older Americans (92). This test has been shown to correlate well with other muscular fitness tests such as the 1-RM. Two specific tests included in the SFT — the 30-s chair stand and single-arm curl — can be used by the health/fitness and clini- cal exercise professionals to safely and effectively assess muscular strength and endurance in most older adults. TABLE 4.12. Fitness Categories for the Push-Up by Age and Sex Age (year) Category 20–29 30–39 40–49 50–59 60–69 Sex M W M W M W M W M W Excellent 36 30 30 27 25 24 21 21 18 17 Very good 35 29 29 26 24 23 20 20 17 16 29 21 22 20 17 15 13 11 11 12 Good 28 20 21 19 16 14 12 10 10 11 22 15 17 13 13 11 10 7 8 5 Fair 21 14 16 12 12 10 9 6 7 4 17 10 12 8 10 5 7 2 5 2 Needs improvement 16 9 11 7 9 4 6 1 4 1 M, men; W, women. Reprinted with permission from (19). ©2003. Used with permission from the Canadian Society for Exercise Physiology www.csep.ca
- 128. 102 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 4.14. Fitness Categories for the YMCA Bench Press Test (Total Lifts) by Age and Sex Age (year) Category 18–25 26–35 36–45 46–55 56–65 ⬎65 Sex M W M W M W M W M W M W Excellent 64 66 61 62 55 57 47 50 41 42 36 30 44 42 41 40 36 33 28 29 24 24 20 18 Good 41 38 37 34 32 30 25 24 21 21 16 16 34 30 30 29 26 26 21 20 17 17 12 12 Above average 33 28 29 28 25 24 20 18 14 14 10 10 29 25 26 24 22 21 16 14 12 12 9 8 Average 28 22 24 22 21 20 14 13 11 10 8 7 24 20 21 18 18 16 12 10 9 8 7 5 Below average 22 18 20 17 17 14 11 9 8 6 6 4 20 16 17 14 14 12 9 7 5 5 4 3 Poor 17 13 16 13 12 10 8 6 4 4 3 2 13 9 12 9 9 6 5 2 2 2 2 0 Very poor ⬍10 6 9 6 6 4 2 1 1 1 1 0 M, men; W, women. Reprinted with permission from (111). © 2000 by YMCA of the USA, Chicago. All rights reserved. Coronary Prone Clients Moderate intensity resistance training performed 2–3 d ⭈ wk⫺1 is effective for im- proving muscular fitness, preventing and managing a variety of chronic medical conditions, modifying CVD risk factors, and enhancing psychosocial well-being for individuals with and without CVD. Consequently, authoritative professional health organizations including the ACSM and AHA support the inclusion of re- sistance training as an adjunct to aerobic exercise in their current recommenda- tions and guidelines on exercise for individuals with CVD (see Chapter 9) (110). The absence of anginal symptoms, ischemic ST-segment changes on the ECG, abnormal hemodynamics, and complex ventricular dysrhythmias suggests mod- erate intensity (e.g., performance of 10–15 repetitions) resistance testing and training can be performed safely by patients with CVD deemed “low risk” (e.g., individuals without resting or exercise-induced evidence of myocardial ischemia, severe left ventricular dysfunction, or complex ventricular dysrhythmias, and with normal or near normal CRF [see Chapter 2]). Moreover, despite concerns that resistance exercise elicits abnormal cardiovascular “pressor responses” in patients with CVD and/or controlled hypertension, studies have found strength testing and resistance training in these patients elicit HR and BP responses that appear to fall within clinically acceptable limits (110). Resistance training in moderate-to-high risk patients with CVD may be deemed appropriate follow- ing a thorough clinical assessment by an experienced health care professional. Furthermore, moderate-to-high risk patients with CVD who do participate in a resistance training program should be closely monitored (110). Absolute and rela- tive contraindications to resistance testing and training are provided in Box 4.7.
- 129. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 103 Children and Adolescents Along with CRF , flexibility, and body composition, muscular fitness is rec- ognized as an important component of health-related fitness in children and adolescents (see Chapter 8) (9,36). The benefits of enhancing muscular strength and endurance in youth include developing proper posture, reducing the risk of injury, improving body composition, enhancing motor performance skills such as sprinting and jumping, and enhancing self-confidence and self- esteem. As a general guide, children who are ready to begin participation in sport activities (⬃7–8 yr) may also be ready to initiate a resistance training program (36). Assessing muscular strength and endurance with the push-up and ab- dominal curl-up is common practice in most physical education programs, YMCA/YWCA recreation programs, and youth sport centers. Use of resistance ABSOLUTE Unstable CHD Decompensated HF Uncontrolled arrhythmias Severe pulmonary hypertension (mean pulmonary arterial pressure ⬎55 mm Hg) Severe and symptomatic aortic stenosis Acute myocarditis, endocarditis, or pericarditis Uncontrolled hypertension (⬎180/110 mm Hg) Aortic dissection Marfan syndrome High intensity RT (80% to 100% of 1-RM) in patients with active proliferative retinopathy or moderate or worse nonproliferative diabetic retinopathy RELATIVE (SHOULD CONSULT A PHYSICIAN BEFORE PARTICIPATION) Major risk factors for CHD Diabetes at any age Uncontrolled hypertension (⬎160/100 mm Hg) Low functional capacity (⬍4 METs) Musculoskeletal limitations Individuals who have implanted pacemakers or defibrillators CHD, Coronary heart disease; HF , Heart failure; METs, Metabolic equivalents; RM, Repetition maximum; RT, Resistance training. Reprinted with permission from (110). ©2007 , American Heart Association, Inc. Absolute and Relative Contraindications to Resistance Training and Testing BOX 4.7
- 130. 104 GUIDELINES FOR EXERCISE TESTING • www.acsm.org training equipment commonly available in fitness facilities is also appropri- ate for the assessment of muscle strength and endurance. When properly administered, different muscular fitness measures can be used to assess a child’s strengths and weaknesses, develop a personalized fitness program, track progress, and motivate participants. Conversely, unsupervised or poorly administered muscular fitness assessments may not only discourage youth from participating in fitness activities, but may also result in injury. Qualified health/fitness and clinical exercise professionals should demonstrate proper performance of each skill, provide an opportunity for each child to practice a few repetitions of each skill, and offer guidance and instruction when neces- sary. In addition, it is important and usually required to obtain informed con- sent from the parent or legal guardian prior to initiating muscular testing. The informed consent includes information on potential benefits and risks, the right to withdraw at any time, and issues regarding confidentiality. General guidelines for resistance training in children and adolescents are listed in Box 4.8 (see Chapter 8). • Ensure appropriate training for individual providing training instruction and supervision • Provide a safe exercise environment • Start training session with a 5- to 10-min dynamic warm-up • Initiate training program two to three times per week on nonconsecutive days, with light resistance, and ensure exercise technique is correct • General training session guidelines: one to three sets of 6–15 repetitions with combination of upper and lower body exercise • Incorporate exercises specifically focusing on trunk • Training program should induce symmetrical and balanced muscular development • Individualized exercise progression based on goals and skill • Gradual increase (⬃5%–10%) in training resistance as gains are made • Use calisthenics and/or stretching postresistance training session • Be aware of individual needs/concerns during each session • Consider use of an individualized exercise log • Continually alter training program to maintain interest and avoid training plateaus • Ensure proper nutrition, hydration, and sleep • Instructor and parents should be supportive and encouraging to help maintain interest Adapted from (36). Guidelines for Resistance Training in Children and Adolescents BOX 4.8
- 131. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 105 FLEXIBILITY Flexibility is the ability to move a joint through its complete ROM. It is impor- tant in athletic performance (e.g., ballet, gymnastics) and in the ability to carry out activities of daily living. Consequently, maintaining flexibility of all joints facilitates movement; in contrast, when an activity moves the structures of a joint beyond its full ROM, tissue damage can occur. Flexibility depends on a number of specific variables including distensibility of the joint capsule, adequate warm-up, and muscle viscosity. In addition, compliance (i.e., tightness) of various other tissues such as ligaments and tendons affects the ROM. Just as muscular strength and endurance is specific to the muscles involved, flexibility is joint specific; therefore, no single flexibility test can be used to evaluate total body flexibility. Laboratory tests usually quantify flexibility in terms of ROM expressed in degrees. Common devices for this purpose include goniometers, electrogoniometers, the Leighton flexometer, inclinometers, and tape measures. Comprehensive instruc- tions are available for the evaluation of flexibility of most anatomic joints (24,80). Visual estimates of ROM can be useful in fitness screening but are inaccurate relative to directly measured ROM. These estimates can include neck and trunk flexibility, hip flexibility, lower extremity flexibility, shoulder flexibility, and postural assessment. A more precise measurement of joint ROM can be assessed at most anatomic joints following strict procedures (24,80) and the proper use of a goniometer. Accurate measurements require in-depth knowledge of bone, muscle, and joint anatomy as well as experience in administering the evaluation. Table 4.15 TABLE 4.15. Range of Motion of Select Single Joint Movements in Degrees Degrees Degrees Shoulder Girdle Movement Flexion 90–120 Extension 20–60 Abduction 80–100 Horizontal abduction 30–45 Horizontal adduction 90–135 Medial rotation 70–90 Lateral rotation 70–90 Elbow Movement Flexion 135–160 Supination 75–90 Pronation 75–90 Trunk Movement Flexion 120–150 Extension 20–45 Lateral flexion 10–35 Rotation 20–40 Hip Movement Flexion 90–135 Extension 10–30 Abduction 30–50 Adduction 10–30 Medial rotation 30–45 Lateral rotation 45–60 Knee Movement Flexion 130–140 Extension 5–10 Ankle Movement Dorsiflexion 15–20 Plantarflexion 30–50 Inversion 10–30 Eversion 10–20 Adapted from (78).
- 132. 106 GUIDELINES FOR EXERCISE TESTING • www.acsm.org provides normative ROM values for select anatomic joints. Additional infor- mation can be found in the ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (101). The sit-and-reach test has been used commonly to assess low back and ham- string flexibility; however, its relationship to predict the incidence of low back pain is limited (54). The sit-and-reach test is suggested to be a better measure of hamstring flexibility than low back flexibility (53). The relative importance of hamstring flexibility to activities of daily living and sports performance, there- fore, supports the inclusion of the sit-and-reach test for health-related fitness testing until a criterion measure evaluation of low back flexibility is available. Although limb and torso length disparity may impact sit-and-reach scoring, modified testing that establishes an individual zero point for each participant has not enhanced the predictive index for low back flexibility or low back pain (17,52,74). Poor lower back and hip flexibility, in conjunction with poor abdominal strength and endurance or other causative factors, may contribute to develop- ment of muscular low back pain; however, this hypothesis remains to be sub- stantiated (88). Methods for administering the sit-and-reach test are presented in Box 4.9. Normative data for two sit-and-reach tests are presented in Tables 4.16 and 4.17. Pretest: Clients/Patients should perform a short warm-up prior to this test and include some stretches (e.g., modified hurdler’s stretch). It is also recommended that the participant refrain from fast, jerky movements, which may increase the possibility of an injury. The participant’s shoes should be removed. 1. For the Canadian Trunk Forward Flexion test, the client sits without shoes and the soles of the feet flat against the flexometer (sit-and-reach box) at the 26 cm mark. Inner edges of the soles are placed within 2 cm of the measuring scale. For the YMCA sit-and-reach test, a yardstick is placed on the floor and tape is placed across it at a right angle to the 15 in mark. The client/patient sits with the yardstick between the legs, with legs extended at right angles to the taped line on the floor. Heels of the feet should touch the edge of the taped line and be about 10 to 12 in apart. (Note the zero point at the foot/box interface and use the appropriate norms.) 2. The client/patient should slowly reach forward with both hands as far as possible, holding this position approximately 2 s. Be sure that the participant keeps the hands parallel and does not lead with one hand. Fingertips can be overlapped and should be in contact with the measuring portion or yardstick of the sit-and-reach box. Trunk Flexion (Sit-and-Reach) Test Procedures BOX 4.9
- 133. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 107 TABLE 4.16. Fitness Categories for Trunk Forward Flexion Using a Sit-and- Reach Box (cm)a by Age and Sex Age (year) Category 20–29 30–39 40–49 50–59 60–69 Sex M W M W M W M W M W Excellent 40 41 38 41 35 38 35 39 33 35 Very good 39 40 37 40 34 37 34 38 32 34 34 37 33 36 29 34 28 33 25 31 Good 33 36 32 35 28 33 27 32 24 30 30 33 28 32 24 30 24 30 20 27 Fair 29 32 27 31 23 29 23 29 19 26 25 28 23 27 18 25 16 25 15 23 Needs improvement 24 27 22 26 17 24 15 24 14 22 a These norms are based on a sit-and-reach box in which the “zero” point is set at 26 cm. When using a box in which the zero point is set at 23 cm, subtract 3 cm from each value in this table. M, men; W, women. Reprinted with permission from (19). ©2003. Used with permission from the Canadian Society for Exercise Physiology www.csep.ca A COMPREHENSIVE HEALTH FITNESS EVALUATION A comprehensive health/fitness assessment includes the following: • Prescreening/risk classification. • Resting HR, BP , height, weight, BMI, and ECG (if appropriate). • Body composition. • Waist circumference. • Skinfold assessment. 3. The score is the most distant point (cm or in) reached with the fingertips. The best of two trials should be recorded. To assist with the best attempt, the client/patient should exhale and drop the head between the arms when reaching. Testers should ensure that the knees of the participant stay extended; however, the participant’s knees should not be pressed down. The client/patient should breathe normally during the test and should not hold her/his breath at any time. Norms for the Canadian test are presented in Table 4.16. Note that these norms use a sit-and- reach box in which the “zero” point is set at the 26 cm mark. If a box is used in which the zero point is set at 23 cm (e.g., Fitnessgram), subtract 3 cm from each value in this table. The norms for the YMCA test are presented in Table 4.17. Reprinted with permission from (19) and (111). Trunk Flexion (Sit-and-Reach) Test Procedures (Continued) BOX 4.9
- 134. 108 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 4.17. Fitness Categories for the YMCA Sit-and-Reach Test (in) by Age and Sex Age (year) Percentile 18–25 26–35 36–45 46–55 56–65 ⬎65 Gender M W M W M W M W M W M W 90 Well above average 22 24 21 23 21 22 19 21 17 20 17 20 80 Above average 20 22 19 21 19 21 17 20 15 19 15 18 70 19 21 17 20 17 19 15 18 13 17 13 17 60 Average 18 20 17 20 16 18 14 17 13 16 12 17 50 17 19 15 19 15 17 13 16 11 15 10 15 40 Below average 15 18 14 17 13 16 11 14 9 14 9 14 30 14 17 13 16 13 15 10 14 9 13 8 13 20 Well below average 13 16 11 15 11 14 9 12 7 11 7 11 10 11 14 9 13 7 12 6 10 5 9 4 9 M, men; W, women. Adapted with permission from (111). © 2000 by YMCA of the USA, Chicago. All rights reserved. • Cardiorespiratory fitness. • Submaximal or maximal test typically on a cycle ergometer or treadmill. • Muscular strength. • 1- to multiple-RM upper body (bench press) and lower body (leg press). • Muscular endurance. • Curl-up test. • Push-up test. • Specific motion using appropriate equipment to fatigue (i.e., bench press). • Flexibility. • Sit-and-reach test or goniometric measures of isolated anatomic joints. Additional evaluations may be administered; however, the components of a health/fitness evaluation listed earlier represent a comprehensive assessment that can be performed within 1 d. The data accrued from the evaluation should be interpreted by a competent health/fitness or clinical exercise professional and conveyed to the client/patient. This information is central to the development of a client’s/patient’s short- and long-term goals as well as forming the basis for the initial Ex Rx and subsequent evaluations to monitor progress. THE BOTTOM LINE The ACSM Health-Related Fitness Testing and Interpretation Summary Statements. • Health/fitness assessments provide a wealth of information regarding an in- dividual’s health and functional status. A comprehensive assessment includes an evaluation of body composition, CRF , muscle strength/endurance, and flexibility.
- 135. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 109 • Each component of the assessment can be performed through several ap- proaches to accommodate availability of equipment, the facility, training of personnel, and health/fitness status of the individual undergoing testing. • Adherence to the recommendations for the health/fitness assessments pro- vided in Chapter 4 allows for an individualized and safe approach. • When available, results from each component of the health/fitness assessment should be compared to normative data provided in Chapter 4. ACSM Exercise is Medicine: http://exerciseismedicine.org American Heart Association: http://www.americanheart.org Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm The Cooper Institute: http://www.cooperinstitute.org National Heart, Lung, and Blood Institute Health Information for Professionals: http://www.nhlbi.nih.gov/health/indexpro.htm 2008 Physical Activity Guidelines for Americans (1): http://www.health.gov/PAguidelines Online Resources REFERENCES 1. 2008 Physical Activity Guidelines for Americans [Internet]. Rockville (MD): Office of Disease Prevention Health Promotion, U.S. Department of Health and Human Services. 2008 [cited 2012 Jan 7]. 76 p. Available from: http://www.health.gov/paguidelines 2. Abidov A, Rozanski A, Hachamovitch R, et al. Prognostic significance of dyspnea in patients referred for cardiac stress testing. N Engl J Med. 2005;353(18):1889–98. 3. American College of Sports Medicine Position Stand, American Heart Association. Recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities. Med Sci Sports Exerc. 1998;30(6):1009–18. 4. Arena R, Lavie CJ. The obesity paradox and outcome in heart failure: is excess bodyweight truly protective? Future Cardiol. 2010;6(1):1–6. 5. Arena R, Myers J, Williams MA, et al. Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Reha- bilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Circulation. 2007;116(3):329–43. 6. Astrand PO. Aerobic work capacity in men and women with special reference to age. Acta Physiol Scand. 1960;49(Supplement 169):45–60. 7. Astrand PO, Ryhming I. A nomogram for calculation of aerobic capacity (physical fitness) from pulse rate during sub-maximal work. J Appl Physiol. 1954;7(2):218–21. 8. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS state- ment: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111–7. 9. Behm DG, Faigenbaum AD, Falk B, Klentrou P. Canadian Society for Exercise Physiology position paper: resistance training in children and adolescents. Appl Physiol Nutr Metab. 2008;33(3):547–61. 10. Blair SN, Kohl HW,3rd, Barlow CE, Paffenbarger RS,Jr, Gibbons LW, Macera CA. Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. JAMA. 1995;273(14):1093–8.
- 136. 110 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 11. Blair SN, Kohl HW,3rd, Paffenbarger RS,Jr, Clark DG, Cooper KH, Gibbons LW. Physical fitness and all-cause mortality. A prospective study of healthy men and women. JAMA. 1989;262(17):2395–401. 12. Bodegard J, Erikssen G, Bjornholt JV, Gjesdal K, Liestol K, Erikssen J. Reasons for terminating an exercise test provide independent prognostic information: 2014 apparently healthy men followed for 26 years. Eur Heart J. 2005;26(14):1394–401. 13. Borg G. Borg’s Perceived Exertion and Pain Scales. Champaign (IL): Human Kinetics; 1998. 104 p. 14. Bray GA. Don’t throw the baby out with the bath water. Am J Clin Nutr. 2004;79(3):347–9. 15. Brozek J, Grande F , Anderson JT, Keys A. Densitometric analysis of body composition: revision of some quantitative assumptions. Ann N Y Acad Sci. 1963;110:113–40. 16. Cahalin LP , Mathier MA, Semigran MJ, Dec GW, DiSalvo TG. The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure. Chest. 1996;110(2):325–32. 17. Cailliet R. Low Back Pain Syndrome. 4th ed. Philadelphia (PA): F .A. Davis; 1988. 341 p. 18. Callaway CW, Chumlea WC, Bouchard C, Himes JH, Lohman TG, Martin AD. Circumferences. In: Lohman TG, Roche AF , Martorell R, editors. Anthropometric Standardization Reference Manual. Champaign: Human Kinetics; 1988. p. 39–80. 19. Canadian Society for Exercise Physiology. The Canadian Physical Activity, Fitness Lifestyle Approach (CPAFLA): CSEP—Health Fitness Program’s Health-Related Appraisal and Counselling Strategy. 3rd ed. Ottawa (Ontario): Canadian Society for Exercise Physiology; 2003. 300 p. 20. Canoy D. Distribution of body fat and risk of coronary heart disease in men and women. Curr Opin Cardiol. 2008;23(6):591–8. 21. Casanova C, Cote C, Marin JM, et al. Distance and oxygen desaturation during the 6-min walk test as predictors of long-term mortality in patients with COPD. Chest. 2008;134(4):746–52. 22. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine position stand: prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012–29. 23. Ciampricotti R, Deckers JW, Taverne R, el Gamal M, Relik-van Wely L, Pool J. Characteristics of conditioned and sedentary men with acute coronary syndromes. Am J Cardiol. 1994;73(4):219–22. 24. Clarkson HM. Musculoskeletal Assessment: Joint Range of Motion and Manual Muscle Strength. 2nd ed. Baltimore (MD): Lippincott Williams Wilkins; 2000. 432 p. 25. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report [Internet]. Bethesda (MD): National Institutes of Health, National Heart, Lung, and Blood Institute. 1998 [cited 2011 Apr 27]. 266 p. Available from: http://www.nhlbi.nih.gov/ guidelines/obesity/ob_gdlns.htm 26. Daniels SR, Jacobson MS, McCrindle BW, Eckel RH, Sanner BM. American Heart Association Childhood Obesity Research Summit Report. Circulation. 2009;119(15):e489–517. 27. Davis JA. Direct determination of aerobic power. In: Maud PJ, editor. Physiological Assessment of Human Fitness. Champaign: Human Kinetics; 1995. p. 9–17. 28. de Koning L, Merchant AT, Pogue J, Anand SS. Waist circumference and waist-to-hip ratio as pre- dictors of cardiovascular events: meta-regression analysis of prospective studies. Eur Heart J. 2007; 28(7):850–6. 29. Definitions—Health, Fitness, and Physical Activity [Internet]. Washington (DC): President’s Council on Physical Fitness and Sports. 2000 [cited 2012 Jan 7]. 11 p. Available from: http://purl.access.gpo. gov/GPO/LPS21074 30. Dehghan M, Merchant AT. Is bioelectrical impedance accurate for use in large epidemiological stud- ies? Nutr J. 2008;7:26. 31. Dempster P , Aitkens S. A new air displacement method for the determination of human body com- position. Med Sci Sports Exerc. 1995;27(12):1692–7. 32. Diener MH, Golding LA, Diener D. Validity and reliability of a one-minute half sit-up test of abdominal strength and endurance. Sports Med Training Rehab. 1995;6:105–19. 33. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41(2):459–71. 34. Duren DL, Sherwood RJ, Czerwinski SA, et al. Body composition methods: comparisons and inter- pretation. J Diabetes Sci Technol. 2008;2(6):1139–46. 35. Executive summary of the clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. Arch Intern Med. 1998;158(17):1855–67. 36. Faigenbaum AD, Kraemer WJ, Blimkie CJ, et al. Youth resistance training: updated position state- ment paper from the national strength and conditioning association. J Strength Cond Res. 2009;23 (5 Suppl):S60–79. 37. Faulkner RA, Sprigings EJ, McQuarrie A, Bell RD. A partial curl-up protocol for adults based on an analysis of two procedures. Can J Sport Sci. 1989;14(3):135–41. 38. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303(3):235–41.
- 137. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 111 39. Flegal KM, Graubard BI, Williamson DF , Gail MH. Excess deaths associated with underweight, overweight, and obesity. JAMA. 2005;293(15):1861–7. 40. Fox CS, Massaro JM, Hoffmann U, et al. Abdominal visceral and subcutaneous adipose tissue compartments: association with metabolic risk factors in the Framingham Heart Study. Circulation. 2007;116(1):39–48. 41. Gallagher D, Heymsfield SB, Heo M, Jebb SA, Murgatroyd PR, Sakamoto Y. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr. 2000;72(3):694–701. 42. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine Position Stand. The quantity and quality of exercise for developing and maintaining cardiorespiratory, musculo- skeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–559. 43. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531–40. 44. Going BS. Densitometry. In: Roche AF , editor. Human Body Composition. Champaign: Human Kinetics; 1996. p. 3–23. 45. Graves JE, Pollock ML, Bryant CX. Assessment of muscular strength and endurance. In: Roitman JL, editor. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 4th ed. Baltimore: Lippincott Williams Wilkins; 2001. p. 376–80. 46. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1081–93. 47. Hendel HW, Gotfredsen A, Hojgaard L, Andersen T, Hilsted J. Change in fat-free mass assessed by bioelectrical impedance, total body potassium and dual energy X-ray absorptiometry during pro- longed weight loss. Scand J Clin Lab Invest. 1996;56(8):671–9. 48. Heymsfield S. Human Body Composition. 2nd ed. Champaign (IL): Human Kinetics; 2005. 523 p. 49. Heyward VH. Practical body composition assessment for children, adults, and older adults. Int J Sport Nutr. 1998;8(3):285–307. 50. Heyward VH, Stolarczyk LM. Applied Body Composition Assessment. Champaign (IL): Human Kinetics; 1996. 221 p. 51. Heyward VH, Wagner DR. Applied Body Composition Assessment. 2nd ed. Champaign (IL): Human Kinetics; 2004. 268 p. 52. Hoeger WW, Hopkins DR. A comparison of the sit and reach and the modified sit and reach in the measurement of flexibility in women. Res Q Exerc Sport. 1992;63(2):191–5. 53. Jackson AW, Baker AA. The relationship of the sit and reach test to criterion measures of hamstring and back flexibility in young females. Res Q Exerc Sport. 1986;57(3):183–6. 54. Jackson AW, Morrow JR,Jr, Brill PA, Kohl HW,3rd, Gordon NF , Blair SN. Relations of sit-up and sit- and-reach tests to low back pain in adults. J Orthop Sports Phys Ther. 1998;27(1):22–6. 55. Jackson AW, Pollock ML. Practical assessment of body composition. Phys Sportsmed. 1985;13(5):76, 80, 82–90. 56. Janssen I, Katzmarzyk PT, Ross R. Body mass index, waist circumference, and health risk: evidence in support of current National Institutes of Health guidelines. Arch Intern Med. 2002;162(18): 2074–9. 57. Jehn M, Halle M, Schuster T, et al. The 6-min walk test in heart failure: is it a max or sub-maximum exercise test? Eur J Appl Physiol. 2009;107(3):317–23. 58. Jennings CL, Micklesfield LK, Lambert MI, Lambert EV, Collins M, Goedecke JH. Comparison of body fatness measurements by near-infrared reactance and dual-energy X-ray absorptiometry in normal-weight and obese black and white women. Br J Nutr. 2010;103(7):1065–9. 59. Jette M, Campbell J, Mongeon J, Routhier R. The Canadian Home Fitness Test as a predictor for aerobic capacity. Can Med Assoc J. 1976;114(8):680–2. 60. Kaminsky LA, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore (MD): Lippincott Williams Wilkins; 2005. 749 p. 61. Kim ES, Ishwaran H, Blackstone E, Lauer MS. External prognostic validations and comparisons of age- and gender-adjusted exercise capacity predictions. J Am Coll Cardiol. 2007;50(19):1867–75. 62. Kline GM, Porcari JP, Hintermeister R. Estimation of V̇O2max from a one-mile track walk, gender, age, and body weight. Med Sci Sports Exerc. 1987;19(3):253–9. 63. Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009; 301(19):2024–35.
- 138. 112 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 64. Kumanyika SK, Obarzanek E, Stettler N, et al. Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific state- ment from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science). Circulation. 2008;118(4):428–64. 65. Lee SY, Gallagher D. Assessment methods in human body composition. Curr Opin Clin Nutr Metab Care. 2008;11(5):566–72. 66. Leger L, Thivierge M. Heart rate monitors: validity, stability, and functionality. Phys Sportsmed. 1988; 16(5):143,146,148,149,151. 67. Levinger I, Goodman C, Hare DL, Jerums G, Toia D, Selig S. The reliability of the 1RM strength test for untrained middle-aged individuals. J Sci Med Sport. 2009;12(2):310–6. 68. Lewis CE, McTigue KM, Burke LE, et al. Mortality, health outcomes, and body mass index in the overweight range: a science advisory from the American Heart Association. Circulation. 2009; 119(25):3263–71. 69. Logan P, Fornasiero D, Abernathy P. Protocols for the assessment of isoinertial strength. In: Gore CJ, editor. Physiological Tests for Elite Athletes. Champaign: Human Kinetics; 2000. p. 200–21. 70. Lohman TG. Body composition methodology in sports medicine. Phys Sportsmed. 1982;10(12):46–7. 71. Maritz JS, Morrison JF , Peter J. A practical method of estimating an individual’s maximal oxygen uptake. Ergonomics. 1961;4:97–122. 72. McConnell TR. Cardiorespiratory assessment of apparently healthy populations. In: American College of Sports Medicine, editor. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. Baltimore: Lippincott Williams Wilkins; 2009. p. 361–75. 73. McLean KP , Skinner JS. Validity of Futrex-5000 for body composition determination. Med Sci Sports Exerc. 1992;24(2):253–8. 74. Minkler S, Patterson P . The validity of the modified sit-and-reach test in college-age students. Res Q Exerc Sport. 1994;65(2):189–92. 75. Morgan W, Borg GA. Perception of effort in the prescription of physical activity. In: Nelson T, editor. Mental Health and Emotional Aspects of Sports. Chicago: American Medical Association; 1976. p. 126–9. 76. Myers J, Arena R, Franklin B, et al. Recommendations for clinical exercise laboratories: a scientific statement from the American Heart Association. Circulation. 2009;119(24):3144–61. 77. Noble BJ, Borg GA, Jacobs I, Ceci R, Kaiser P . A category-ratio perceived exertion scale: relationship to blood and muscle lactates and heart rate. Med Sci Sports Exerc. 1983;15(6):523–8. 78. Norkin CC, Levangie PK. Joint Structure Function: A Comprehensive Analysis. 2nd ed. Philadelphia (PA): Davis; 1992. 512 p. 79. Oreopoulos A, Padwal R, Kalantar-Zadeh K, Fonarow GC, Norris CM, McAlister FA. Body mass index and mortality in heart failure: a meta-analysis. Am Heart J. 2008;156(1):13–22. 80. Palmer ML, Epler ME. Fundamentals of Musculoskeletal Assessment Techniques. 2nd ed. Baltimore (MD): Lippincott Williams Wilkins; 1998. 415 p. 81. Peveler WW. Effects of saddle height on economy in cycling. J Strength Cond Res. 2008;22(4): 1355–9. 82. Peveler WW, Green JM. Effects of saddle height on economy and anaerobic power in well-trained cyclists. J Strength Cond Res. 2011;25(3):633. 83. Peveler WW, Pounders JD, Bishop PA. Effects of saddle height on anaerobic power production in cycling. J Strength Cond Res. 2007;21(4):1023–7. 84. Phillips WT, Batterham AM, Valenzuela JE, Burkett LN. Reliability of maximal strength testing in older adults. Arch Phys Med Rehabil. 2004;85(2):329–34. 85. Pi-Sunyer FX. The epidemiology of central fat distribution in relation to disease. Nutr Rev. 2004; 62(7 Pt 2):S120–6. 86. Poirier P , Giles TD, Bray GA, et al. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2006;113(6):898–918. 87. Pollack ML, Schmidt DH, Jackson AS. Measurement of cardiorespiratory fitness and body composi- tion in the clinical setting. Compr Ther. 1980;6(9):12–27. 88. Protas EJ. Flexibility and range of motion. In: Roitman JL, editor. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 4th ed. Baltimore: Lippincott Williams Wilkins; 2001. p. 381–90. 89. Public Health Agency of Canada, Canadian Society for Exercise Physiology. Physical Activity Readiness Questionnaire (PAR-Q). 2007.
- 139. CHAPTER 4 Health-Related Physical Fitness Testing and Interpretation 113 90. Reis JP , Macera CA, Araneta MR, Lindsay SP, Marshall SJ, Wingard DL. Comparison of overall obesity and body fat distribution in predicting risk of mortality. Obesity (Silver Spring). 2009; 17(6):1232–9. 91. Reynolds JM, Gordon TJ, Robergs RA. Prediction of one repetition maximum strength from mul- tiple repetition maximum testing and anthropometry. J Strength Cond Res. 2006;20(3):584–92. 92. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign (IL): Human Kinetics; 2001. 161 p. 93. Robertson RJ, Noble BJ. Perception of physical exertion: methods, mediators, and applications. Exerc Sport Sci Rev. 1997;25:407–52. 94. Roche AF . Anthropometry and ultrasound. In: Roche AF , Heymsfield S, Lohman T, editors. Human Body Composition. Champaign: Human Kinetics; 1996. p. 167–89. 95. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart Disease and Stroke Statistics—2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2–220. 96. Ross R, Berentzen T, Bradshaw AJ, et al. Does the relationship between waist circumference, morbidity and mortality depend on measurement protocol for waist circumference? Obes Rev. 2008;9(4):312–25. 97. Salzman SH. The 6-min walk test: clinical and research role, technique, coding, and reimburse- ment. Chest. 2009;135(5):1345–52. 98. Sesso HD, Paffenbarger RS,Jr, Lee IM. Physical activity and coronary heart disease in men: The Harvard Alumni Health Study. Circulation. 2000;102(9):975–80. 99. Shephard RJ, Thomas S, Weller I. The Canadian Home Fitness Test. 1991 update. Sports Med. 1991;11(6):358–66. 100. Siri WE. Body composition from fluid spaces and density: analysis of methods. Nutrition. 1961; 9(5):480,491; discussion 480,492. 101. Swain DP , American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams Wilkins; 2014. 102. Tharrett SJ, Peterson JA, American College of Sports Medicine. ACSM’s Health/Fitness Facility Standards and Guidelines. 4th ed. Champaign (IL): Human Kinetics; 2012. 256 p. 103. Tran ZV, Weltman A. Generalized equation for predicting body density of women from girth mea- surements. Med Sci Sports Exerc. 1989;21(1):101–4. 104. Tran ZV, Weltman A. Predicting body composition of men from girth measurements. Hum Biol. 1988;60(1):167–75. 105. U.S. Preventive Services Task Force, Barton M. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2010;125(2):361–7. 106. Wallace J. Principles of cardiorespiratory endurance programming. In: Kaminsky LA, editor. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore: Lippincott Williams Wilkins; 2006. p. 336–349. 107. Wang CY, Haskell WL, Farrell SW, et al. Cardiorespiratory fitness levels among US adults 20–49 years of age: findings from the 1999–2004 National Health and Nutrition Examination Survey. Am J Epidemiol. 2010;171(4):426–35. 108. Wang J, Thornton JC, Bari S, et al. Comparisons of waist circumferences measured at 4 sites. Am J Clin Nutr. 2003;77(2):379–84. 109. Whaley MH, Brubaker PH, Kaminsky LA, Miller CR. Validity of rating of perceived exertion during graded exercise testing in apparently healthy adults and cardiac patients. J Cardiopulm Rehabil. 1997;17(4):261–7. 110. Williams MA, Haskell WL, Ades PA, et al. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007;116(5):572–84. 111. YMCA of the USA, Golding LA. YMCA Fitness Testing and Assessment Manual. 4th ed. Champaign (IL): Human Kinetics; 2000.
- 140. 114 Benefits and Risks Associated with Physical Activity CHAPTER 1 Standard graded exercise tests (GXT) are used clinically to assess a patient’s ability to tolerate increasing intensities of aerobic exercise. Electrocardiographic (ECG), hemodynamic, and symptomatic responses are monitored during the GXT for manifestations of myocardial ischemia, hemodynamic/electrical instability, or other exertion-related signs or symptoms. Ventilatory expired gas analysis may also be performed during the GXT, particularly in patients with congestive heart failure (CHF), suspected/confirmed pulmonary limitations, and/or unexplained dyspnea upon exertion. INDICATIONS AND PURPOSES The exercise test may be used for diagnostic (i.e., identify abnormal physiologic responses), prognostic (i.e., identify adverse events), and therapeutic (i.e., gauge impact of a given intervention) purposes as well as for physical activity coun- seling and to design an exercise prescription (Ex Rx ) (see Chapters 7 and 9). However, the recommendations for conducting the GXT as part of the prepar- ticipation health screening for purposes of initiating or maintaining an exercise program (see Chapter 2), especially a program of vigorous intensity, may differ from those regarding the use of the GXT to gain information for clinical decision making and management that may include an exercise program. DIAGNOSTIC EXERCISE TESTING Determining appropriateness for diagnostic exercise testing to assess for angio- graphically significant cardiovascular disease (CVD) is influenced by age, sex, and symptomatolgy as outlined in Table 5.1. Asymptomatic men and women have a very low (⬍5% probability) to low (⬍10% probability) likelihood of angiographi- cally significant CVD across the third to the sixth decade of life. Conversely, the presence of definite angina pectoris increases the likelihood of angiographically significant CVD, although the probability is modulated by sex. Specifically, men with definite angina pectoris have a high (⬎90% probability) likelihood of angio- graphically significant CVD from the fourth to the sixth decade of life, whereas women have an intermediate (10%–90% probability) likelihood from the fourth to the fifth decade and high likelihood in the sixth decade onward. Clinical Exercise Testing CHAPTER 5
- 141. CHAPTER 5 Clinical Exercise Testing 115 It is widely believed the diagnostic GXT has the greatest use in patients with an intermediate pretest probability of angiographically significant CVD. The reason for this belief is the dramatic impact the exercise response has on posttest probability of disease. This concept is illustrated in Figure 5.1. From this graph, it is clear that a positive GXT (i.e., ST-segment depression suggestive of CVD) improves the probability of angiographically significant CVD to the greatest level in the subject with intermediate pretest likelihood (i.e., third bar from left; prob- ability increases from ⬃10% pretest to ⬎60% posttest). The same exercise testing procedures and concepts are also used when more advanced diagnostic techniques are employed such as nuclear perfusion scan- ning. Asymptomatic individuals generally represent those with a low likelihood (i.e., ⬍10%) of significant CVD. Therefore, diagnostic GXT in asymptomatic individuals generally is not indicated but may be useful to ensure a normal physi- ologic response (i.e., hemodynamics, ECG, and symptomatology) when multiple CVD risk factors are present (25) (see Table 2.2), indicating at least a moderate risk of experiencing a serious cardiovascular event within 5 yr (72). Among asymptomatic men, ST-segment depression, failure to reach 85% of the predicted maximal heart rate (HRmax ), and a diminished exercise capacity during peak or symptom-limited treadmill testing provide additional prognostic information in age and Framingham risk score adjusted models, particularly among those in the highest risk group (10 yr predicted coronary risk ⱖ20%) (13). A diagnostic GXT may be indicated in selected individuals that are about to start a vigorous intensity, exercise program (see Chapter 2), or those involved in occupations in which acute cardiovascular events may affect public safety. In general, patients with a high probability of disease (e.g., typical angina, prior coronary revascularization, myocardial infarction [MI]) are tested to assess residual myocardial ischemia, threatening ventricular arrhythmias, and progno- sis rather than for diagnostic purposes. Exercise electrocardiography for diag- nostic purposes is less accurate in women largely because of a greater number of false positive responses. Although differences in test accuracy between men TABLE 5.1. Pretest Likelihood of Atherosclerotic Cardiovascular Disease (CVD)a Age Sex Typical/Definite Angina Pectoris Atypical/Probable Angina Pectoris Nonanginal Chest Pain Asymptomatic 30 to 39 yr Men Intermediate Intermediate Low Very low Women Intermediate Very low Very low Very low 40 to 49 yr Men High Intermediate Intermediate Low Women Intermediate Low Very low Very low 50 to 59 yr Men High Intermediate Intermediate Low Women Intermediate Intermediate Low Very low 60 to 69 yr Men High Intermediate Intermediate Low Women High Intermediate Intermediate Low a No data exist for patients who are ⬍30 or ⬎69 yr, but it can be assumed that prevalence of CVD increases with age. In a few cases, patients with ages at the extremes of the decades listed may have probabilities slightly outside the high or low range. High indicates ⬎90%; intermediate, 10% to 90%; low, ⬍10%; and very low, ⬍5%. Reprinted with permission from (25).
- 142. 116 GUIDELINES FOR EXERCISE TESTING • www.acsm.org and women may approximate 10% on average, the standard GXT is considered the initial diagnostic evaluation of choice, regardless of sex (25). A truly positive exercise test requires a hemodynamically significant coronary lesion (e.g., ⬎75% stenosis) (3), yet nearly 90% of acute MIs occur at the site of previously nonob- structive atherosclerotic plaque(s) (36). The use of maximal or sign/symptom-limited GXT has expanded greatly to help guide decisions regarding medical management and surgical therapy in a (–) ST (+) ST 45 y/o M. Atypical Chest Pain 55 y/o M. Typical Angina 45 y/o M. Asymptomatic HBP. ↑Chol. D.M. 45 y/o M. Asymptomatic No Risk Factors 0 20 40 60 80 100 0 20 40 60 80 100 Pretest (Clinical) Probability of CAD (%) Posttest Probability of CAD (%) ■ FIGURE 5.1. Impact of positive or negative ST-segment response during GXT on the posttest probability of angiographically significant CVD in subjects with different pretest probabilities. CAD, coronary artery disease. Reprinted with permission from (63).
- 143. CHAPTER 5 Clinical Exercise Testing 117 broad spectrum of patients. For example, immediate exercise testing of selected low-risk patients (i.e., no hemodynamic abnormalities and arrhythmias, near normal/normal ECG, and negative initial biomarkers for cardiac injury) pre- senting to the emergency department with signs/symptoms of acute coronary syndrome is becoming increasingly recognized as a valuable tool in making decisions regarding which patients require additional diagnostic studies before hospital discharge (4,5,43,46,71). The use of exercise testing in this capacity has been found to be safe and reduces both length of hospital stay and cost. Patients initially screened to be at low risk subsequently demonstrate a preserved exercise capacity (i.e., ⱖ7 metabolic equivalents [METs]) and no hemodynamic/ECG abnormalities during testing have a low likelihood of acute coronary syndrome and subsequent events (4). In patients with chronic conditions such as CHF and pulmonary hypertension, exercise testing may also prove valuable in guiding treatment decisions as several variables obtained from this assessment respond favorably to numerous pharmacologic and surgical interventions (6,8,27). EXERCISE TESTING FOR DISEASE SEVERITY AND PROGNOSIS Exercise testing is useful for the evaluation of disease severity among individuals with known or suspected CVD. The magnitude of ischemia caused by a coronary lesion generally is (a) directly proportional to the degree of ST-segment depres- sion, the number of ECG leads involved, and the duration of ST-segment depres- sion in recovery; and (b) inversely proportional to the ST slope, the rate pressure product (RPP) (i.e., heart rate [HR] ⫻ systolic blood pressure [SBP]) at which the ST-segment depression occurs, and the HRmax , SBP , and METs achieved. The exercise testing response is likewise an important gauge of disease severity in patients with chronic conditions such as CHF , pulmonary hypertension, and chronic obstructive pulmonary disease (COPD) (9). A progressively diminished aerobic capacity is universally reflective of increasing disease severity in these chronic conditions. Data exclusively obtained from ventilatory expired gas analy- sis and reflective of abnormalities in ventilation perfusion matching (i.e., minute ventilation/carbon dioxide production [V̇E/V̇CO2 ] slope, and partial pressure of end-tidal carbon dioxide [PETCO2 ]) also provide insight into disease severity, espe- cially among patients with CHF , pulmonary hypertension, and COPD. The prognos- tic value of exercise testing appears to be consistent in all individuals regardless of their health status when there is a progressively diminishing aerobic capacity that is a warning of worsening prognosis (9). In addition, several other HR, hemodynamic, and ventilatory expired gas variables obtained from exercise testing provide robust prognostic information in certain populations such as heart failure. Several numeric indices of prognosis have been proposed and are discussed in Chapter 6 (11,47). EXERCISE TESTING AFTER MYOCARDIAL INFARCTION Exercise testing after MI can be performed before or soon after hospital discharge for prognostic assessment, Ex Rx , and evaluation of medical therapy or inter- ventions including coronary revascularization (25). Submaximal exercise tests
- 144. 118 GUIDELINES FOR EXERCISE TESTING • www.acsm.org are currently recommended before hospital discharge at 4–6 d after acute MI. Submaximal exercise testing provides sufficient data to assess the effectiveness of current pharmacologic management (e.g., hemodynamic response to physical exertion on antihypertensive medication) (see Appendix A) as well as activities of daily living and early ambulatory exercise therapy recommendations. Symptom- limited GXTs are considered safe and appropriate early after discharge (⬃14–21 d) for Ex Rx and physical activity counseling and further assessment of pharmacologic management efficacy (25). Patients who have not undergone coronary revascular- ization and are unable to undergo exercise testing appear to have a poor prognosis. Other indicators of adverse prognosis in the post-MI patient include ischemic ST-segment depression at a low level of exercise (particularly if accompanied by reduced left ventricular systolic function), functional capacity of ⬍5 METs, and a hypotensive SBP response to exercise (see Box 6.1). FUNCTIONAL EXERCISE TESTING Exercise testing is useful to determine functional capacity. This information can be valuable for physical activity counseling, Ex Rx , disability assessment, and to help estimate prognosis. Exercise testing may also provide valuable information as part of a return to work evaluation if the patient’s occupation requires aerobic activity. Functional capacity can be evaluated based on percentile ranking (based on apparently healthy men and women) as presented in Table 4.9. Exercise capacity also may be reported as the percentage of expected METs for age using one of several established nomograms with 100% considered normal (see Figure 5.2) (25,51). Separate nomograms are provided in Figure 5.2 for men with suspected CVD and healthy men, and for asymptomatic healthy and sedentary women. Normal standards for exercise capacity based on directly measured maximal oxygen consumption (V̇O2max ) are also available for men and women (59). When using a particular regression equation for estimating percentage of normal exercise capacity achieved, factors such as population specificity, exercise mode, and whether exercise capacity was measured directly or estimated should be con- sidered. Lastly, recent investigations have found that percent predicted aerobic capacity is prognostic in patients with CVD and CHF (7,39). Data supporting the prognostic ability of aerobic capacity in apparently healthy, high-risk individuals for the development of CVD, and known CVD cohorts are convincing (9). Kodama et al. (42) performed a meta-analysis that collectively included 33 studies totaling more than 100,000 subjects and 6,000 all-cause mortality and 4,000 cardiovascular events. They found estimated aerobic capacity from treadmill speed and grade or ergometer workload was a consistent prog- nostic marker in apparently healthy men and women. Each 1 MET increase in aerobic capacity reflected a 13% decrease in all-cause mortality and 15% decrease in cardiovascular events (42). Myers et al. (55) examined a large cohort of ⬎3,000 men with variable CVD risk factors with and without confirmed disease and found aerobic capacity was a superior predictor of mortality when compared to tobacco use, hypertension, elevated lipids, and diabetes mellitus. Subjects with CVD and
- 145. CHAPTER 5 Clinical Exercise Testing 119 an exercise capacity 4.9 METs had a relative risk of death 4.1 times greater compared to those with an exercise capacity ⱖ10.7 METs over a mean follow-up of 6.2 yr. For every 1 MET increase in exercise capacity, there was a 12% improve- ment in survival. Similarly, findings from the National Exercise and Heart Disease Project among post-MI patients demonstrated that every 1 MET increase after the 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Sedentary Active 150 150 140 140 130 130 120 120 110 110 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 Exercise Capacity (% of Normal in Referred Men) Age METs 0 ■ FIGURE 5.2. Nomograms of percent normal exercise capacity in men with suspected coronary artery disease who were referred for clinical exercise testing and in apparently healthy men and women. METs, metabolic equivalents. Reprinted with permission from (51) and (28). (continued)
- 146. 120 GUIDELINES FOR EXERCISE TESTING • www.acsm.org exercise training program conferred an approximate 10% reduction in mortality from any cause over 19 yr of follow-up, regardless of study group assignment (21). Kavanagh et al. (37,38) investigated two large cohorts of men and women with confirmed CVD who were referred to cardiac rehabilitation and found directly measured peak oxygen uptake (V̇O2peak ) during a progressive cycle ergometer test 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Sedentary Active 150 150 140 140 130 130 120 120 110 110 100 100 90 90 80 80 70 70 60 60 50 50 40 40 30 30 20 20 Exercise Capacity (% of Normal in Healthy Men) METs 0 Age ■ FIGURE 5.2. (Continued)
- 147. CHAPTER 5 Clinical Exercise Testing 121 to exhaustion at program entry was a powerful predictor of cardiovascular and all- cause mortality. The cutoff points above which there was a marked survival benefit were 13 mL kg min1 (3.7 METs) in women and 15 mL kg min1 (4.3 METs) in men. For each 1 mL kg min1 increase in aerobic capacity, there was a 9% and 10% reduction in cardiac mortality in men and women, respectively. 85 80 75 70 65 60 55 50 45 40 35 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Sedentary Active 10 10 150 140 130 120 110 100 90 80 70 60 50 40 30 20 150 140 130 120 110 100 90 80 70 60 50 40 30 20 Exercise Capacity (% of Normal in Healthy Women) METs 15 Age ■ FIGURE 5.2. (Continued)
- 148. 122 GUIDELINES FOR EXERCISE TESTING • www.acsm.org In patients diagnosed with CHF , the prognostic ability of V̇O2peak is supported by ⬃20 yr of research (8). O’Neil et al. (59) found a V̇O2peak ⬍10 mL kg min1 is indicative of a particularly poor prognosis, a threshold supported by other investigations (8). In fact, the use of V̇O2peak at this threshold is considered a key acceptable indication for heart transplant candidacy (25). Aerobic capacity is a valuable prognostic marker in patients with interstitial lung disease and pulmonary arterial hypertension as well. Two groups of inves- tigators have found V̇O2peak to be a significant predictor of mortality in patients with COPD (32,60). Similar to patients with CHF , Hiraga et al. (32) found a V̇O2peak ⬍10 mL kg min1 to be indicative of a particularly poor prognosis in a cohort with COPD. A small investigation by Miki et al. (50) indicated V̇O2peak may also be prognostic in patients with pulmonary fibrosis. Several small investigations likewise indicate V̇O2peak is prognostic in patients with pulmonary arterial hypertension (6). Moreover, Shah et al. (69) found aerobic capacity esti- mated from treadmill time was a significant predictor of mortality in a cohort of 603 patients with pulmonary arterial hypertension. Additional research is needed to solidify the prognostic use of aerobic capacity in patients with interstitial and vascular pulmonary diseases and conditions. The presurgical assessment of aerobic capacity is gaining increased recognition as an important indicator of poor outcome. Loewen et al. (45) found patients with suspected lung cancer are at significantly greater risk for surgical complications and poor outcome postprocedure if V̇O2peak falls lower than 16–15 mL kg min1 , respectively. Recent guidelines put forth by the American College of Chest Physicians (ACCP) support the use of exercise testing with ventilatory expired gas analysis to assess presurgical and postsurgical risk in patients with lung cancer (19). This guideline recommends patients with a V̇O2peak ⬍10 mL kg min1 be consid- ered at high risk for postsurgical complications and mortality, regardless of other characteristics such as pulmonary function. Additionally, patients with a V̇O2peak ⬍15 mL kg min1 in combination with a forced expiratory volume in one second (FEV1.0 ) and diffusion capacity that is ⬍40% predicted should also be considered high risk for complications and poor outcome. In older patients undergoing gastric bypass surgery, McCullough et al. (48) reported a V̇O2peak ⬍15.8 mL kg min1 signified a higher risk for postsurgical complications. Lastly, Older et al. (61) found a V̇O2 at a ventilatory threshold of ⬍11.0 mL kg min1 was a significant predictor of cardiopulmonary mortality in patients undergoing intraabdominal surgery. Given the growing body of evidence, it appears presurgical assessment of aerobic capacity to quantify risk for postsurgical complications may be advantageous. EXERCISE TEST MODALITIES The treadmill is the most common exercise testing mode used in the United States. Treadmills in clinical exercise laboratories should be electronically driven, allow for a wide range of speed (1–8 mph or 1.61–12.8 km h1 ) and grade (0%– 20%), and be able to support a body weight of at least 350 lb (159.1 kg). The treadmill should have handrails for balance and stability; but given the negative
- 149. CHAPTER 5 Clinical Exercise Testing 123 impact tight gripping of the handrails can have on both the accuracy of estimated exercise capacity (i.e., estimated V̇O2peak with handrail gripping is greater than measured V̇O2peak ) and the quality of the ECG recording, handrail use should be discouraged or minimized to the lowest level possible when maintaining balance is a concern. An emergency stop button should be readily visible and available to both the subject undergoing testing and supervising staff (52). Cycle ergometers are the most common exercise testing modes used in many European countries. Cycle ergometry is less expensive and requires less space than treadmill testing and is a viable alternative to treadmill testing in individuals with obesity and those who have orthopedic, peripheral vascular, and/or neuro- logic limitations. The cycle ergometer must include handlebars and an adjust- able seat, allowing for the knee to be flexed ⬃25 degrees of full extension in a given subject (64–66). Incremental work rates on an electronically braked cycle ergometer are more sensitive than mechanically braked ergometers because the work rate can be maintained over a wide range of pedal rates. Because there is less movement of the patient’s arms and thorax during cycling, it is easier to obtain better quality ECG recordings and blood pressure (BP) measurements. However, stationary cycling is an unfamiliar method of exercise for many and is highly de- pendent on patient motivation. Thus, the test may end prematurely (i.e., because of localized leg fatigue) before a cardiopulmonary endpoint has been achieved. Lower values for V̇O2max /V̇O2peak during cycle ergometer testing (vs. treadmill test- ing) can range from 5% to 25%, depending on the participant’s habitual activity, physical conditioning, leg strength, and familiarity with cycling (30,54,67). Arm ergometry is an alternative method of exercise testing for patients who cannot perform leg exercise. Because a smaller muscle mass is used during arm ergometry, V̇O2max /V̇O2peak during arm exercise is generally 20%–30% lower than that obtained during treadmill testing (24). Although this test has diagnostic use (14), it has been largely replaced by the nonexercise pharmacologic stress techniques that are described later in this chapter. Arm ergometer tests can be used for physical activity counseling and Ex Rx for certain disabled populations (e.g., spinal cord injury) and individuals who perform primarily dynamic upper body work during occupational or leisure time activities. Routine calibration procedures should be followed for all exercise testing modes (i.e., treadmill, lower extremity, and upper extremity ergometry). Specific calibration procedures are usually provided by the manufacturer. A description of general calibration procedures for the treadmill and cycle and arm ergometers are available from Myers et al. (52). EXERCISE PROTOCOLS The protocol employed during an exercise test should consider the purpose of the evaluation, the specific outcomes desired, and the characteristics of the indi- vidual being tested (e.g., age, symptomatology). Some of the most common ex- ercise protocols and the predicted V̇O2 for each stage are illustrated in Figure 5.3. The Bruce treadmill test remains one of the most commonly used protocols,
- 150. 124 GUIDELINES FOR EXERCISE TESTING • www.acsm.org ■ FIGURE 5.3. Common exercise protocols and associated metabolic costs of each stage. FUNCTIONAL CLASS CLINICAL STATUS BICYCLE ERGOMETER METS BRUCE 3 MIN STAGES MPH / %AGR RAMP O2 COST ml/kg/min NORMAL AND I II III IV HEALTHY, DEPENDENT ON AGE, ACTIVITY SEDENTARY HEALTHY LIMITED SYMPTOMATIC 73.5 70 66.5 63 59.5 56.0 52.5 49.0 45.5 42.0 38.5 35.0 31.5 28.0 24.5 21.0 17.5 14.0 10.5 7.0 3.5 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 FOR 70 KG BODY WEIGHT Kpm/min (WATTS) 1500 (246) 1350 (221) 1200 (197) 1050 (172) 900 (148) 750 (123) 600 (98) 450 (74) 300 (49) 150 (24) 5.5 20 5.0 18 3.4 14 2.5 12 1.7 10 4.2 16 PER 30 SEC MPH / %GR 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 3.0 2.5 2.0 1.5 1.0 0.5 25.0 24.0 23.0 22.0 21.0 20.0 19.0 18.0 17.0 16.0 15.0 14.0 13.0 12.0 11.0 10.0 9.0 8.0 7.0 6.0 5.0 4.0 3.0 2.0 1.0 0 0 0 0 0 0
- 151. CHAPTER 5 Clinical Exercise Testing 125 USAFSAM ACIP BRUCE RAMP BALKE- WARE SLOW USAFSAM MODIFIED BALKE MOD. NAUGHTON (CHF) TREADMILL PROTOCOLS METS PER MIN MPH / %GR 5.8 20 5.6 19 5.3 18 3.3 15 2 25 2 20 2 15 2 10 2 5 2 0 3.3 10 3.3 5 3.3 0 2.0 0 3.3 25 3.0 25 3.0 25 3.0 22.5 3.0 20 3.0 17.5 3.0 15 3.0 12.5 3.0 10 3.0 7.5 2.0 10.5 2.0 7.0 2.0 3.5 1.5 0 1.0 0 3.4 24.0 3.1 24.0 3.0 21.0 3.0 17.5 3.0 14.0 3.0 10.5 3.0 3.0 2.5 2.0 3.0 7.0 2.0 0.0 3.0 22.5 3.0 20 3.0 17.5 3.0 15 3.0 12.5 3.0 10 3.0 7.5 3.0 5 3.0 2.5 3.0 0 2.0 0 3.3 20 5.0 18 4.8 17 4.5 16 4.2 16 4.1 15 3.8 14 3.4 14 3.1 13 2.8 12 2.5 12 2.3 11 2.1 10 1.7 10 1.3 5 1.0 0 %GRADE AT 3.3 MPH 1 MIN STAGES 26 25 24 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 MPH / %GR MPH / %GR MPH / %GR MPH / %GR MPH / %GR 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1
- 152. 126 GUIDELINES FOR EXERCISE TESTING • www.acsm.org particularly in cardiac stress testing centers (56). However, the Bruce protocol employs relatively large incremental workload adjustments (i.e., 2–3 METs per stage) every 3 min. Consequently, changes in physiologic responses tend to be less uniform, and exercise capacity may be markedly overestimated when it is predicted from exercise time or workload, which is particularly true with hand- rail use. Recent evidence indicates ischemic thresholds are observed at similar RPP when comparing the Bruce protocol to a more conservative treadmill protocol (57). However, it does appear the RPP corresponding to an ischemic threshold is significantly different for a given patient with CVD when performing an exercise test on a treadmill compared to a cycle ergometer (57,58). Specifically, the RPP corresponding to an ischemic threshold and maximal ST-segment depression is significantly lower during cycle ergometry compared to treadmill testing. In general, protocols with larger incremental workload adjustments such as the Bruce or Ellestad are better suited for screening younger and/or physically active individuals; whereas protocols with smaller increments such as the Naughton or Balke-Ware (i.e., 1 MET per stage) are preferable for older or deconditioned individuals and patients with chronic diseases. If serial testing is performed, the mode of testing and exercise protocol should be consistent across all assessments. Ramping protocols, which increase work rate in a constant and continuous manner, are an alternative approach to incremental exercise testing that has gained in popularity (10). Individualized (53) and standardized ramp tests, such as the Ball State University/Bruce ramp (35), have been used to improve patient tolerance and test quality. The former test individualizes the rate of increase in intensity based on the subject. The latter standardized ramp test matches work rates to equivalent periods on the Bruce protocol while increasing the work rates in ramp fashion. Advantages of ramp protocols include the following (54): • Avoidance of large and unequal increments in workload. • Uniform increase in hemodynamic and physiologic responses. • More accurate estimates of exercise capacity and ventilatory threshold. • Individualized test protocol (ramp rate). • Targeted test duration (applies only to individualized ramp protocols). Whichever exercise protocol is chosen, it should be individualized so that the treadmill speed and increments in grade are based on the subject’s perceived func- tional capacity. Ideally, increments in work rate should be chosen so that the total test time ranges between 8 and 12 min (10), assuming the endpoint is volitional fatigue. For example, increments of 10–15 W min1 (61–92 kg m min1 ) can be used on the cycle ergometer for older individuals, deconditioned individuals, and patients with CVD or pulmonary disease. Increases in treadmill grade of 1%–3% min1 with constant belt speeds of 1.5–2.5 mph (2.4–4.0 kph) can also be used for such populations. Submaximal testing is strongly recommended by the American Heart Association (AHA) in post-MI patients prior to discharge (about 4–6 d postevent)
- 153. CHAPTER 5 Clinical Exercise Testing 127 for (a) prognostic assessment; (b) physical activity counseling and Ex Rx ; and (c) evaluation of medical therapy (25). Moreover, submaximal exercise testing may be preferred in health/fitness settings, particularly during the assessment of indi- viduals deemed to be at greater risk of cardiovascular events. These tests are gen- erally terminated at a predetermined level such as an HR of 120 beats · min1 , 70% of heart rate reserve (HRR), 85% of age predicted HRmax , or 5 METs, but these termination criteria may vary based on the patient and clinical judgment (10). Established treadmill or ergometry exercise testing protocols that are more conservative in nature (i.e., ramp) are typically appropriate for submaximal testing. UPPER BODY EXERCISE TESTING An arm cycle ergometer can be purchased as such or modified from an existing stationary cycle ergometer by replacing the pedals with handles and mounting the unit on a table at shoulder height. Similar to leg cycle ergometers, these can be either mechanically or electrically braked. This mode of testing is appropriate in individuals unable to exercise on a treadmill or lower extremity ergometer (i.e., patients with vascular, orthopedic, and neurologic comorbidities). Peak METs obtained during arm ergometry appear to be predictive of adverse events in patients unable to perform treadmill testing (34). Work rates are adjusted by altering the cranking rates and/or resistance against the flywheel. Work rate increments of 5–10 W (30.6–61.2 kg m min1 ) every 2–3 min at a cadence of 60–75 revolutions min1 (rpm) are common recommendations (52). Arm ergometry is best performed in the seated position with the fulcrum of the handle adjusted to shoulder height. SBP taken by the standard cuff method immediately after arm crank ergometry are likely to underestimate “true” SBP responses (33). Brachial SBP during arm ergometry can also be approximated using a Doppler stethoscope at the dorsalis pedis artery. TESTING FOR RETURN TO WORK The decision to return to work after a cardiac event is a complex one with ⬃25% of these patients failing to resume work (29). National and cultural customs, local economic conditions, numerous nonmedical variables, employer stereo- types, and worker attitudes may govern failure to return to work. To counteract these deterrents, job modifications should be explored and implemented to facilitate the resumption of gainful employment. Work assessment and counseling are useful in optimizing return to work de- cisions. Early discussion of work-related issues with patients, preferably before hospital discharge, may help establish reasonable return to work expectations. Discussion with the patient could include a job history analysis to (a) ascertain job aerobic requirements and potential cardiac demands; (b) establish tentative time lines for work evaluation and return to work; (c) individualize rehabilita- tion according to job demands; and (d) determine special work-related needs
- 154. 128 GUIDELINES FOR EXERCISE TESTING • www.acsm.org or job contacts (70). The appropriate time to return to work varies with type of cardiac event or intervention, associated complications, and prognosis. The GXT provides valuable information regarding a patient’s ability to safely return to work (25) because (a) the patient’s responses can help assess prog- nosis; and (b) measured or estimated MET capacity can be compared to the estimated aerobic requirements of the patient’s job to assess expected relative work energy demands (2). For most patients, physical demands are considered appropriate if the 8 h energy expenditure work requirement averages 50% peak METs achieved on the GXT and peak job demands (e.g., 5–45 min) are within guidelines prescribed for a home exercise program (e.g., 80% METpeak ). Most contemporary job tasks require only very light to light aerobic requirements (i.e., 3 METs) (70). A GXT is commonly the only functional assessment required to determine return to work status. However, some patients may benefit from further func- tional testing if job demands differ substantially from those evaluated with the GXT, especially patients with (a) borderline physical work capacity in relation- ship to the anticipated job demands; (b) concomitant left ventricular dysfunc- tion; and/or (c) concerns about resuming a physically demanding occupation. Job tasks that may evoke disproportionate myocardial demands compared to a GXT include those requiring static muscular contraction work combined with temperature stress and intermittent heavy work (70). Tests simulating the task(s) in question can be administered when insufficient information is available to determine a patient’s ability to resume work within a reasonable degree of safety. For patients at risk for serious arrhythmias or silent or symptomatic myocardial ischemia on the job, ambulatory ECG monitoring may be considered in conjunction with simple, inexpensive tests that can be set up to evaluate types of work not evaluated with a GXT (70). For example, a weight carrying test that simulates occupational tasks can be used to evaluate tolerance for light-to-heavy static work combined with light dynamic work. MEASUREMENTS DURING EXERCISE TESTING Common variables assessed during clinical exercise testing include BP , ECG changes, subjective ratings, and signs and symptoms. Ventilatory expired gas analysis responses may be included in the exercise test, particularly in certain groups such as patients with CHF and individuals being assessed for unex- plained exertional dyspnea. Lastly, arterial blood gas analysis can also be per- formed during an advanced exercise test assessment. HEART RATE AND BLOOD PRESSURE HR and BP should be measured before, during, and after the GXT. Table 5.2 indicates the recommended frequency and sequence of these measures. A stan- dardized procedure should be adopted for each laboratory so that baseline mea- sures can be assessed more accurately when repeat testing is performed.
- 155. CHAPTER 5 Clinical Exercise Testing 129 Several devices have been developed to automate BP measurements during exercise and demonstrate reasonable accuracy (52). These devices also typically allow for auditory confirmation of the automated BP measurement, which may improve confidence in the value obtained. When an automated system is used, calibration and maintenance should be followed according to manufacturer specifications, and calibration checks should periodically be performed by comparing automated to manual BP recordings. Despite advances in automated BP measurements during exercise, manual assessment (standard cuff method) is still commonplace. Boxes 3.4 and 5.1 contain methods for BP assessment at rest and potential sources of error during exercise, respectively. Abnormal hy- pertensive and hypotensive responses to the GXT are also possible absolute and relative indications for test termination (see Box 5.2) (23). TABLE 5.2. Recommended Monitoring Intervals Associated with Exercise Testing Variable Before Exercise Test During Exercise Test After Exercise Test ECG Monitored continu- ously; recorded supine position and posture of exercise Monitored contin- uously; recorded during the last 15 s of each stage (interval protocol) or the last 15 s of each 2 min period (ramp protocols) Monitored continu- ously; recorded imme- diately postexercise, during the last 15 s of first minute of recov- ery, and then every 2 min thereafter HRa Monitored continu- ously; recorded supine position and posture of exercise Monitored continu- ously; recorded during the last 5 s of each minute Monitored continu- ously; recorded during the last 5 s of each minute BPa,b Measured and recorded in supine position and posture of exercise Measured and recorded during the last 45 s of each stage (interval protocol) or the last 45 s of each 2 min period (ramp protocols) Measured and recor- ded immediately postexercise and then every 2 min thereafter Signs and symptoms Monitored continuously; recorded as observed Monitored con- tinuously; recorded as observed Monitored con- tinuously; recorded as observed RPE Explain scale Recorded during the last 15 s of each exer- cise stage or every 2 min with ramping protocol Obtain peak exercise value then not measured in recovery Gas exchange Baseline reading to ensure proper operational status Measured continuously Generally not needed in recovery a In addition, BP and HR should be assessed and recorded whenever adverse symptoms or abnormal ECG changes occur. b An unchanged or decreasing systolic blood pressure with increasing workloads should be retaken (i.e., verified immediately). BP , blood pressure; ECG, electrocardiogram; HR, heart rate; RPE, rating of perceived exertion. Adapted and used by permission from (16).
- 156. 130 GUIDELINES FOR EXERCISE TESTING • www.acsm.org ELECTROCARDIOGRAPHIC MONITORING A high quality ECG is of paramount importance for an appropriately conducted GXT (see Appendix C). Proper skin preparation lowers the resistance at the skin electrode interface, and thereby improves the signal to noise ratio. The general areas for electrode placement should be shaved, if necessary, and cleansed with an alcohol saturated gauze pad. The superficial layer of skin should then be re- moved using light abrasion with fine grain emery paper or gauze and electrodes placed according to standardized anatomic landmarks (23). Although 12 leads are simultaneously recorded and readily available for assessment, three leads — representing the inferior, anterior, and lateral cardiac distribution — are typically monitored in real time, with 12-lead ECGs printed at the end of each stage and at maximal exercise. The limb electrodes are affixed to the torso for the GXT (23). Because torso leads may give a slightly different ECG configuration when compared with the standard 12-lead resting ECG, use of torso leads should be noted on the ECG. Signal processing techniques have made it possible to average ECG wave- forms and attenuate or eliminate electrical interference or artifact. Although this technology continues to evolve, computer driven ECG interpretation should be considered a compliment rather than a replacement to manual interpretation. Moreover, all reports automatically derived from computer interpretation should be over read by a clinician appropriately trained in ECG interpretation (40). SUBJECTIVE RATINGS AND SYMPTOMS The measurement of perceptual responses during exercise testing can provide useful clinical information. Somatic ratings of perceived exertion (RPE) (see Chapters 4, 7, and 10) and/or specific symptoms (e.g., degree of chest pain, • Inaccurate sphygmomanometer • Improper cuff size • Auditory acuity of technician • Rate of inflation or deflation of cuff pressure • Experience of technician • Reaction time of technician • Faulty equipment • Improper stethoscope placement or pressure • Background noise • Allowing patient to hold treadmill handrails or flex elbow • Certain physiologic abnormalities (e.g., damaged brachial artery, subclavian steal syndrome, arteriovenous fistula) Potential Sources of Error in Blood Pressure Assessment BOX 5.1
- 157. CHAPTER 5 Clinical Exercise Testing 131 burning, discomfort, dyspnea, light-headedness, leg discomfort/pain) should be assessed routinely during clinical exercise tests. Patients are asked to pro- vide subjective estimates during the last 15 s of each exercise stage (or every 2 min during ramp protocols) either verbally or manually. For example, the individual can provide a number verbally or point to a number if a mouthpiece or face mask precludes oral communication. The exercise technician should restate the number to confirm the correct rating. Either the 6–20 category scale (see Chapter 4) or the 0–10 category-ratio scale may be used to assess RPE dur- ing exercise testing (15). Before the start of the exercise test, the patient should be given clear and concise instructions for use of the selected scale. ABSOLUTE INDICATIONS • Drop in systolic BP of ⱖ10 mm Hg with an increase in work rate, or if systolic BP decreases below the value obtained in the same position prior to testing when accompanied by other evidence of ischemia • Moderately severe angina (defined as 3 on standard scale) • Increasing nervous system symptoms (e.g., ataxia, dizziness, or near syncope) • Signs of poor perfusion (cyanosis or pallor) • Technical difficulties monitoring the ECG or SBP • Subject’s desire to stop • Sustained ventricular tachycardia • ST elevation (⫹1.0 mm) in leads without diagnostic Q waves (other than V1 or aVR) RELATIVE INDICATIONS • Drop in systolic BP of ⱖ10 mm Hg with an increase in work rate, or if systolic BP below the value obtained in the same position prior to testing • ST or QRS changes such as excessive ST depression (⬎2 mm horizontal or downsloping ST-segment depression) or marked axis shift • Arrhythmias other than sustained ventricular tachycardia, including multifocal PVCs, triplets of PVCs, supraventricular tachycardia, heart block, or bradyarrhythmias • Fatigue, shortness of breath, wheezing, leg cramps, or claudication • Development of bundle-branch block or intraventricular conduction delay that cannot be distinguished from ventricular tachycardia • Increasing chest pain • Hypertensive response (SBP of ⬎250 mm Hg and/or a DBP of ⬎115 mm Hg). aVR, augmented voltage right; BP , blood pressure; DBP , diastolic blood pressure; ECG, electrocardiogram; PVC, premature ventricular contraction; SBP , systolic blood pressure; V1 , chest lead I. Reprinted with permission from (25). Indications for Terminating Exercise Testing BOX 5.2
- 158. 132 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Use of alternative rating scales that are specific to subjective symptoms are recommended if subjects become symptomatic during exercise testing. Frequently used scales for assessing the patients’ level of angina, claudication, and/or dyspnea can be found in Figure 5.4. In general, ratings of ⱖ3 on the an- gina scale or a degree of chest discomfort that would cause the patient to stop normal daily activities are reasons to terminate the exercise test (see Box 5.2). Interestingly, patients with CVD reporting dyspnea as a primary factor limiting exercise may have a worse prognosis compared to those reporting alternate sub- jective symptoms (i.e., exercise limited by leg fatigue or angina) (1,18). GAS EXCHANGE AND VENTILATORY RESPONSES Currently, the combination of standard GXT procedures and ventilatory expired gas analysis (i.e., cardiopulmonary exercise testing) is the clinical standard for patients with CHF being assessed for transplantation candidacy and individuals with unexplained exertional dyspnea (25). The analysis of ventilatory expired gas overcomes the potential inaccuracies associated with estimating V̇O2 from work rate (i.e., treadmill speed and grade). The direct measurement of V̇O2 is more reliable and reproducible than estimated values from treadmill or cycle ergometer work rates. V̇O2peak is the most accurate measurement of functional capacity and is a useful index of overall cardiopulmonary health (12). 1 Mild, barely noticeable 2 Moderate, bothersome 3 Moderately severe, very uncomfortable 4 Most severe or intense pain ever experienced 4 Excruciating and unbearable pain 4 Most severe or intense dyspnea ever experienced 1 Light, barely noticable 1 Definite discomfort or pain, but only at initial or modest levels (established, but minimal) 2 Moderate discomfort or pain from which the patient’s attention can be diverted (e.g., by conversation) 3 Intense pain (short of grade 4) from which the patient’s attention cannot be diverted 2 Moderate, bothersome 3 Moderately severe, very uncomfortable Angina Scale Claudication Scale Dyspnea Scale ■ FIGURE 5.4. Frequently used scales for assessing the patient’s level of angina (top), claudica- tion (middle), and dyspnea (bottom).
- 159. CHAPTER 5 Clinical Exercise Testing 133 The measurement of V̇O2 , V̇CO2 , and the subsequent calculation of the re- spiratory exchange ratio (RER) can also be used to assess the level of physical exertion during the GXT with greater precision than that obtained from age-pre- dicted HRmax . The assessment of V̇E also should be made whenever gas exchange responses are obtained. In fact, the combined assessment of V̇E and V̇CO2 , com- monly expressed as the V̇E/V̇CO2 slope and termed ventilatory efficiency, provides robust prognostic information in patients with CHF (12). Because heart and lung diseases frequently lead to ventilatory and/or gas exchange abnormalities during exercise, an integrated analysis of these measures can be useful for differential diagnosis (12). Most currently available ventilatory expired gas analysis systems are also able to perform pulmonary function testing, which is advantageous when performing this type of differential diagnosis. Lastly, collection of gas ex- change and ventilatory responses are increasingly being used in clinical trials to objectively assess the response to specific interventions (10). ARTERIAL BLOOD GAS ASSESSMENT DURING EXERCISE In patients who present with unexplained exertional dyspnea, pulmonary disease should be considered as a potential underlying cause. It is important to quantify gas partial pressures in these patients because oxygen desaturation may occur during exertion. Although measurement of the partial pressure of oxygen in arte- rial blood (Pa O2 ) and partial pressure of carbon dioxide in arterial blood (Pa CO2 ) have been the standard in the past, the availability of pulse oximetry and the estimation of arterial oxygen saturation (SpO2 ) has replaced the need to routinely draw arterial blood in most patients. In patients with pulmonary disease, mea- surements of oxygen saturation in arterial blood (SaO2 ) correlate reasonably well with SpO2 ( 2%–3% accuracy rates), provided SpO2 remains ⬎85%. A decrease of ⬎5% in SpO2 during exercise testing is considered an abnormal response sug- gestive of exercise induced hypoxemia. Invasive assessment of arterial blood gases is still required if a precise measurement is clinically warranted (12). INDICATIONS FOR EXERCISE TEST TERMINATION The absolute and relative indications for termination of an exercise test are listed in Box 5.2. Absolute indications are unambiguous, whereas relative indications may be superseded by clinical judgment. POSTEXERCISE PERIOD Regardless of the postexercise procedures (i.e., active vs. passive recovery), mon- itoring should continue for at least 6 min after exercise or until ECG changes return to baseline and significant signs and symptoms resolve (23). ST-segment changes that occur only during the postexercise period are currently recognized to be an important diagnostic part of the test (68). HR and BP should also return to near baseline levels before discontinuation of monitoring. In addition, the
- 160. 134 GUIDELINES FOR EXERCISE TESTING • www.acsm.org HR recovery from exercise is an important prognostic marker that should be recorded (see Chapter 6) (25,44). IMAGING MODALITIES USED IN CONJUNCTION WITH EXERCISE TESTING Cardiac imaging modalities are being increasingly used in conjunction with GXT to more accurately diagnose myocardial ischemia and assess myocardial function during physical exertion. Commonly used imaging procedures are described in the following sections. EXERCISE ECHOCARDIOGRAPHY Exercise echocardiography is an established assessment procedure for patients with suspected myocardial ischemia. Myocardial contractility normally in- creases with exercise. However, ischemia results in decreased myocardial con- tractility via hypokinetic (i.e., decreased), dyskinetic (i.e., impaired), or akinetic (i.e., absent) wall motion in the affected segments. Exercise echocardiography is highly indicated in patients with suspected myocardial ischemia with an inter- mediate pretest probability for CVD and/or an uninterpretable ECG. Exercise echocardiography is also valuable in the assessment of viable/ischemic myocardium in patients with known CVD that are being considered for a revascu- larization procedure. Patients with known or suspected CVD and a normal exer- cise echocardiography response appear to have a low risk for adverse events (49). In patients with valvular disease, exercise echocardiography is highly indicated for the assessment of (a) equivocal aortic stenosis; (b) evidence of low cardiac output; (c) symptomatic patients with mild mitral stenosis; and (d) asymptomatic severe aortic insufficiency or mitral regurgitation where left ventricular size and function are not meeting surgical criteria. In patients with suspected pulmonary hypertension, exercise echocardiography with tissue Doppler imaging may also be advantageous, although the evidence in support of this approach is less robust. A recently published report on the appropriateness of stress echocardiography provides a comprehensive list of indications for this procedure (22). CARDIAC RADIONUCLIDE IMAGING Nuclear imaging is now commonly used in conjunction with standard GXT pro- cedures in order to improve the diagnostic accuracy in patients with suspected CVD. There are several different imaging protocols using technetium (Tc)-99m or thallous (thallium) chloride-201. Comparison of the rest and stress images permits the identification of fixed and reversible perfusion abnormalities as well as their differentiation. Tc-99m permits higher dosing with less radiation exposure than thallium and results in improved images that are sharper and have less artifact and attenuation. Consequently, Tc is the preferred imaging agent when performing tomographic
- 161. CHAPTER 5 Clinical Exercise Testing 135 images of the heart using single-photon emission computed tomography (SPECT). SPECT images are obtained with a gamma camera that rotates 180 degrees around the patient stopping at preset angles to record the image. Cardiac images then are displayed in slices from three different axes to allow visualization of the heart in three dimensions. Thus, multiple myocardial segments can be viewed individu- ally without the overlap of segments that occurs with planar imaging. Perfusion defects that are present during exercise but not seen at rest suggest myocardial ischemia. Perfusion defects that are present during exercise and persist at rest suggest previous MI or scar. The extent and distribution of ischemic myocardium can be identified in this manner. Exercise nuclear SPECT imaging has a sensitivity (i.e., percentage of individuals with positive test who have a given disease) of 87% and specificity (i.e., percentage of individuals with negative test who do not have a given disease) of 73% for detecting CVD with ⱖ50% coronary stenosis (41). Cardiac radionuclide imaging is highly indicated for patients with an intermediate pretest (see Table 5.1) probability for CVD and/or uninterpretable ECG as well as in those patients with a high pretest probability irrespective of ECG interpretability. This procedure is also highly valuable in the assessment of viable/ischemic myocardium in patients with ischemic cardiomyopathy and severe left ventricular dysfunction who are being considered for a revasculariza- tion procedure. Patients with known or suspected CVD and a normal cardiac radionuclide imaging study appear to have a low risk for adverse events (49). Conversely, patients with a perfusion defect are at higher risk for adverse events regardless of angiography findings (20). A recently published report on the ap- propriate criteria for cardiac radionuclide imaging provides a comprehensive list of indications for this procedure (31). IMAGING MODALITIES NOT USED IN CONJUNCTION WITH EXERCISE TESTING PHARMACOLOGIC STRESS TESTING Patients unable to undergo a GXT for reasons such as severe deconditioning, peripheral vascular disease, orthopedic disabilities, neurologic disease, and/or concomitant illness may be evaluated by pharmacologic stress testing. The two most commonly used pharmacologic tests are dobutamine stress echocardiogra- phy and dipyridamole or adenosine stress nuclear scintigraphy. Some protocols include light intensity exercise in combination with pharmacologic infusion. Dobutamine elicits wall motion abnormalities by increasing HR, and there- fore myocardial oxygen demand. Dobutamine is infused intravenously with the dose increased gradually until the maximal dose or an endpoint is achieved. Endpoints may include new or worsening wall motion abnormalities, an adequate HR response, serious arrhythmias, angina, significant ST depression, intolerable side effects, and a significant increase or decrease in BP . Atropine may be given if an adequate HR is not achieved or other endpoints have not been reached at peak dobutamine dose. HR, BP , ECG, and echocardiographic images
- 162. 136 GUIDELINES FOR EXERCISE TESTING • www.acsm.org are obtained throughout the infusion of atropine. Echocardiographic images are obtained similar to exercise echocardiography. A new or worsening wall motion abnormality constitutes a positive test for ischemia. Vasodilators such as dipyridamole and adenosine are commonly used to assess coronary perfusion in conjunction with a nuclear imaging agent. Dipyridamole and adenosine cause maximal coronary vasodilation in normal epicardial arteries, but not in stenotic segments. As a result, a coronary steal phenomenon occurs with a relatively increased flow to normal arteries and a relatively decreased flow to stenotic arteries. Nuclear perfusion imaging under resting conditions is then compared with imaging obtained after coronary vasodilation. Interpretation is similar to that for exercise nuclear testing. Severe side effects are uncommon, but both dipyridamole and adenosine may induce marked bronchospasm, particularly in patients with asthma or reactive airway disease. Thus, administration of these agents is contraindicated in such patients (41). The bronchospasm can be treated with theophylline, although this is rarely needed with adenosine because the half- life is very short. Caffeine and other methylxanthines can block the vasodilator effects of dipyridamole and adenosine, and thus reduce the sensitivity of the test. Therefore, it is recommended that these substances be avoided for at least 24 h before the stress test. The diagnostic accuracy of pharmacologic nuclear stress testing is similar to that of exercise nuclear stress testing (41). COMPUTED TOMOGRAPHY IN THE ASSESSMENT OF CARDIOVASCULAR DISEASE Advances in cardiac computed tomography (CT) offer additional methods for the clinical assessment of CVD. Although there are several types of cardiac CT, electron beam computed tomography (EBCT) has been available since 1987 and provides the most robust scientific data. EBCT is a highly sensitive method for the detection of coronary artery calcified plaque (17). However, it is important to understand the presence of calcified plaque does not in itself indicate the presence of a flow obstructing coronary lesion; con- versely, the absence of coronary calcium does not itself indicate the absence of atherosclerotic plaque. A coronary calcium score of zero makes the presence of atherosclerotic plaque including vulnerable plaque highly unlikely. Moreover, a score of zero is associated with a low annual risk (0.1%) of a cardiovascular event over the next 2–5 yr, whereas a high calcium score (⬎100) is associated with a high annual risk (⬎2%). Calcium scores correlate poorly with stenosis severity, although a score ⬎400 is frequently associated with perfusion ischemia from obstructive CVD. Measurement of coronary artery calcium appears to im- prove risk prediction in individuals with an intermediate Framingham risk score (i.e., those with 10%–20% 10 yr likelihood of a cardiovascular event). Thus, in clinically selected intermediate risk patients (see Table 5.1), it may be reasonable to use EBCT to further refine risk prediction. However, the measurement of coro- nary artery calcium is not recommended in individuals with a low (i.e., ⬍10% 10 yr likelihood of a cardiovascular event) or high (i.e., ⬎20% 10 yr likelihood of
- 163. CHAPTER 5 Clinical Exercise Testing 137 a cardiovascular event) Framingham risk score. A recently published consensus statement on coronary artery calcium scoring provides a comprehensive discus- sion on the appropriate indications for this procedure (26). SUPERVISION OF EXERCISE TESTING Although clinical exercise tests are generally considered to be safe, the potential for adverse events does exist. The risk of complications requiring hospital ad- mission, acute MI, and sudden cardiac death occurring during or immediately postexercise is 0.20%, 0.04%, and 0.01%, respectively (52). Accordingly, individuals who supervise exercise tests must have the necessary cognitive and technical skills to safely administer an exercise test. The American College of Cardiology (ACC), AHA, and ACCP, with broad involvement from other pro- fessional organizations involved with exercise testing including the American College of Sports Medicine (ACSM), have outlined the cognitive skills needed to competently supervise exercise tests (68). These skills are presented in Box 5.3. • Knowledge of appropriate indications for exercise testing • Knowledge of alternative physiologic cardiovascular tests • Knowledge of appropriate contraindications, risks, and risk assessment of testing • Knowledge to promptly recognize and treat complications of exercise testing • Competence in cardiopulmonary resuscitation and successful completion of an American Heart Association-sponsored course in advance cardiovascular life support and renewal on a regular basis • Knowledge of various exercise protocols and indications for each • Knowledge of basic cardiovascular and exercise physiology including hemodynamic response to exercise • Knowledge of cardiac arrhythmia and the ability to recognize and treat serious arrhythmias (see Appendix C) • Knowledge of cardiovascular drugs and how they can affect exercise performance, hemodynamics, and the electrocardiogram (see Appendix A) • Knowledge of the effects of age and disease on hemodynamic and the electrocardiographic response to exercise • Knowledge of principles and details of exercise testing including proper lead placement and skin preparation • Knowledge of endpoints of exercise testing and indications to terminate exercise testing Adapted from (68). Cognitive Skills Required to Competently Supervise Exercise Tests BOX 5.3
- 164. 138 GUIDELINES FOR EXERCISE TESTING • www.acsm.org In most cases, clinical exercise tests can be supervised by properly trained health care professionals such as exercise physiologists, nurses, and physi- cian assistants who are working under the supervision of a physician (i.e., the physician must be in the immediate vicinity and available for emergencies for exercise testing of individuals at high risk) (see Chapter 2 and Appendix B) (68). Several studies have demonstrated that the incidence of cardiovascular com- plications during GXT is similar with experienced and appropriately trained nonphysician personnel supervising the test and physicians in the immediate vicinity compared to those conducted with direct physician supervision (52). In situations in which the patient is deemed to be at increased risk for an ad- verse event during the GXT, the physician should be immediately available to manage potential emergency situations. Such cases include, but are not limited to, patients undergoing symptom-limited testing following recent acute events (i.e., acute coronary syndrome or MI), severe left ventricular dysfunction, severe valvular stenosis (e.g., aortic stenosis), or known complex arrhythmias (68) (see Chapter 2). THE BOTTOM LINE The ACSM Clinical Exercise Testing Key Points are as follows: • Although a clinical exercise test may not be indicated for most individuals about to begin an exercise program (see Chapter 2), the high value of informa- tion obtained from this procedure is not debatable. • Aerobic capacity may be one of the single best prognostic markers in all indi- viduals regardless of health status. • Standard clinical exercise testing is well accepted for the assessment of indi- viduals with signs and/or symptoms suggestive of CVD. • The use of cardiopulmonary exercise testing, which combines standard clinical exercise testing with simultaneous ventilatory expired gas analysis, is common practice in patients with CHF as well as those with unexplained exertional dyspnea. • The recent recognition that appropriately trained nonphysician personnel can safely perform a clinical exercise test may result in the expanded use of this valuable procedure in various clinical settings. Scientific Statements and Guidelines from the Amercian Heart Association (10,12,23,25,44,52): http://my.americanheart.org/professional/StatementsGuidelines/Statements-Guidelines_ UCM_316885_SubHomePage.jsp Online Resources
- 165. CHAPTER 5 Clinical Exercise Testing 139 REFERENCES 1. Abidov A, Rozanski A, Hachamovitch R, et al. Prognostic significance of dyspnea in patients referred for cardiac stress testing. N Engl J Med. 2005;353(18):1889–98. 2. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activ- ity codes and MET intensities. Med Sci Sports Exerc. 2000;32(9 Suppl):S498–504. 3. American Thoracic Society, American College of Chest Physicians. ATS/ACCP Statement on cardio- pulmonary exercise testing. Am J Respir Crit Care Med. 2003;167(2):211–77. 4. Amsterdam EA, Kirk JD, Bluemke DA, et al. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122(17):1756–76. 5. Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain. J Am Coll Cardiol. 2002;40(2):251–6. 6. Arena R, Lavie CJ, Milani RV , Myers J, Guazzi M. Cardiopulmonary exercise testing in patients with pul- monary arterial hypertension: an evidence-based review. J Heart Lung Transplant. 2010;29(2):159–73. 7. Arena R, Myers J, Abella J, et al. Determining the preferred percent-predicted equation for peak oxygen consumption in patients with heart failure. Circ Heart Fail. 2009;2(2):113–20. 8. Arena R, Myers J, Guazzi M. The clinical and research applications of aerobic capacity and ventila- tory efficiency in heart failure: an evidence-based review. Heart Fail Rev. 2008;13(2):245–69. 9. Arena R, Myers J, Guazzi M. The future of aerobic exercise testing in clinical practice: is it the ultimate vital sign? Future Cardiol. 2010;6(3):325–42. 10. Arena R, Myers J, Williams MA, et al. Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Circulation. 2007;116(3):329–43. 11. Ashley E, Myers J, Froelicher V. Exercise testing scores as an example of better decisions through science. Med Sci Sports Exerc. 2002;34(8):1391–8. 12. Balady GJ, Arena R, Sietsema K, et al. Clinician’s guide to cardiopulmonary exercise testing in adults. A scientific statement from the American Heart Association. Circulation. 2010;122(2):191–225. 13. Balady GJ, Larson MG, Vasan RS, Leip EP, O’Donnell CJ, Levy D. Usefulness of exercise test- ing in the prediction of coronary disease risk among asymptomatic persons as a function of the Framingham risk score. Circulation. 2004;110(14):1920–5. 14. Balady GJ, Weiner DA, McCabe CH, Ryan TJ. Value of arm exercise testing in detecting coronary artery disease. Am J Cardiol. 1985;55(1):37–9. 15. Borg G. Borg’s Perceived Exertion and Pain Scales. Champaign (IL): Human Kinetics; 1998. 104 p. 16. Brubaker PH, Kaminsky LA, Whaley MH. Coronary Artery Disease: Essentials of Prevention and Rehabilitation Programs. Champaign (IL): Human Kinetics; 2002. 364 p. 17. Budoff MJ, Achenbach S, Blumenthal RS, et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation. 2006;114(16):1761–91. 18. Chase P , Arena R, Myers J, et al. Prognostic usefulness of dyspnea versus fatigue as reason for exer- cise test termination in patients with heart failure. Am J Cardiol. 2008;102(7):879–82. 19. Colice GL, Shafazand S, Griffin JP , Keenan R, Bolliger CT, American College of Chest Physicians. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest. 2007;132(3 Suppl):161S–77S. 20. Delcour KS, Khaja A, Chockalingam A, Kuppuswamy S, Dresser T. Outcomes in patients with abnor- mal myocardial perfusion imaging and normal coronary angiogram. Angiology. 2009;60(3):318–21. 21. Dorn J, Naughton J, Imamura D, Trevisan M. Results of a multicenter randomized clinical trial of exercise and long-term survival in myocardial infarction patients: the National Exercise and Heart Disease Project (NEHDP). Circulation. 1999;100(17):1764–9. 22. Douglas PS, Khandheria B, Stainback RF , et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. Circulation. 2008;117(11):1478–97. 23. Fletcher GF , Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001;104(14):1694–740. 24. Franklin BA. Exercise testing, training and arm ergometry. Sports Med. 1985;2(2):100–19.
- 166. 140 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 25. Gibbons RJ, Balady GJ, Bricker JT, et al. Committee to Update the 1997 Exercise Testing Guidelines. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531–40. 26. Greenland P , Bonow RO, Brundage BH, et al. ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assess- ment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography). Circulation. 2007;115(3):402–26. 27. Guazzi M, Arena R. The impact of pharmacotherapy on the cardiopulmonary exercise test response in patients with heart failure: a mini review. Curr Vasc Pharmacol. 2009;7(4):557–69. 28. Gulati M, Black HR, Shaw LJ, et al. The prognostic value of a nomogram for exercise capacity in women. N Engl J Med. 2005;353(5):468–75. 29. Hallberg V, Palomaki A, Kataja M, et al. Return to work after coronary artery bypass surgery. A 10-year follow-up study. Scand Cardiovasc J. 2009;43(5):277–84. 30. Hambrecht RP, Schuler GC, Muth T, et al. Greater diagnostic sensitivity of treadmill versus cycle exercise testing of asymptomatic men with coronary artery disease. Am J Cardiol. 1992;70(2):141–6. 31. Hendel RC, Berman DS, Di Carli MF , et al. ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation. 2009;119(22):e561–87. 32. Hiraga T, Maekura R, Okuda Y, et al. Prognostic predictors for survival in patients with COPD using cardiopulmonary exercise testing. Clin Physiol Funct Imaging. 2003;23(6):324–31. 33. Hollingsworth V, Bendick P , Franklin B, Gordon S, Timmis GC. Validity of arm ergometer blood pressures immediately after exercise. Am J Cardiol. 1990;65(20):1358–60. 34. Ilias NA, Xian H, Inman C, Martin WH,3rd. Arm exercise testing predicts clinical outcome. Am Heart J. 2009;157(1):69–76. 35. Kaminsky LA, Whaley MH. Evaluation of a new standardized ramp protocol: the BSU/Bruce Ramp protocol. J Cardiopulm Rehabil. 1998;18(6):438–44. 36. Katritsis DG, Pantos J, Efstathopoulos E. Hemodynamic factors and atheromatic plaque rupture in the coronary arteries: from vulnerable plaque to vulnerable coronary segment. Coron Artery Dis. 2007;18(3):229–37. 37. Kavanagh T, Mertens DJ, Hamm LF , et al. Peak oxygen intake and cardiac mortality in women referred for cardiac rehabilitation. J Am Coll Cardiol. 2003;42(12):2139–43. 38. Kavanagh T, Mertens DJ, Hamm LF , et al. Prediction of long-term prognosis in 12 169 men referred for cardiac rehabilitation. Circulation. 2002;106(6):666–71. 39. Kim ES, Ishwaran H, Blackstone E, Lauer MS. External prognostic validations and comparisons of age- and gender-adjusted exercise capacity predictions. J Am Coll Cardiol. 2007;50(19):1867–75. 40. Kligfield P, Gettes LS, Bailey JJ, et al. Recommendations for the standardization and interpretation of the electrocardiogram: part I: the electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society: endorsed by the International Society for Computerized Electrocardiology. Circulation. 2007;115(10):1306–24. 41. Klocke FJ, Baird MG, Lorell BH, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation. 2003;108(11):1404–18. 42. Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all- cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009;301(19):2024–35. 43. Kogan A, Shapira R, Lewis BS, Tamir A, Rennert G. The use of exercise stress testing for the manage- ment of low-risk patients with chest pain. Am J Emerg Med. 2009;27(7):889–92. 44. Lauer M, Froelicher ES, Williams M, et al. Exercise testing in asymptomatic adults: a statement for professionals from the American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2005;112(5):771–6. 45. Loewen GM, Watson D, Kohman L, et al. Preoperative exercise Vo2 measurement for lung resection candidates: results of Cancer and Leukemia Group B Protocol 9238. J Thorac Oncol. 2007;2(7):619–25. 46. Madsen T, Mallin M, Bledsoe J, et al. Utility of the emergency department observation unit in ensuring stress testing in low-risk chest pain patients. Crit Pathw Cardiol. 2009;8(3):122–4.
- 167. CHAPTER 5 Clinical Exercise Testing 141 47. Mark DB, Shaw L, Harrell FE Jr, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med. 1991;325(12):849–53. 48. McCullough PA, Gallagher MJ, Dejong AT, et al. Cardiorespiratory fitness and short-term complica- tions after bariatric surgery. Chest. 2006;130(2):517–25. 49. Metz LD, Beattie M, Hom R, Redberg RF , Grady D, Fleischmann KE. The prognostic value of normal exercise myocardial perfusion imaging and exercise echocardiography: a meta-analysis. J Am Coll Cardiol. 2007;49(2):227–37. 50. Miki K, Maekura R, Hiraga T, et al. Impairments and prognostic factors for survival in patients with idiopathic pulmonary fibrosis. Respir Med. 2003;97(5):482–90. 51. Morris CK, Myers J, Froelicher VF , Kawaguchi T, Ueshima K, Hideg A. Nomogram based on metabolic equivalents and age for assessing aerobic exercise capacity in men. J Am Coll Cardiol. 1993;22(1):175–82. 52. Myers J, Arena R, Franklin B, et al. Recommendations for clinical exercise laboratories: a scientific statement from the American Heart Association. Circulation. 2009;119(24):3144–61. 53. Myers J, Buchanan N, Smith D, et al. Individualized ramp treadmill. Observations on a new proto- col. Chest. 1992;101(5 Suppl):236S–41S. 54. Myers J, Buchanan N, Walsh D, et al. Comparison of the ramp versus standard exercise protocols. J Am Coll Cardiol. 1991;17(6):1334–42. 55. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002;346(11):793–801. 56. Myers J, Voodi L, Umann T, Froelicher VF . A survey of exercise testing: methods, utilization, inter- pretation, and safety in the VAHCS. J Cardiopulm Rehabil. 2000;20(4):251–8. 57. Noel M, Jobin J, Marcoux A, Poirier P , Dagenais G, Bogaty P . Comparison of myocardial ische- mia on the ergocycle versus the treadmill in patients with coronary heart disease. Am J Cardiol. 2010;105(5):633–9. 58. Noel M, Jobin J, Poirier P, Dagenais GR, Bogaty P. Different thresholds of myocardial ischemia in ramp and standard bruce protocol exercise tests in patients with positive exercise stress tests and angiographically demonstrated coronary arterial narrowing. Am J Cardiol. 2007;99(7):921–4. 59. Normal values. In: Wasserman K, Hansen JE, Sue DY, Stringer W, Whipp BJ, editors. Principles of Exercise Testing and Interpretation: Including Pathophysiology and Clinical Applications. 4th ed. Baltimore: Lippincott Williams Wilkins; 2005. p. 160–182. 60. Oga T, Nishimura K, Tsukino M, Sato S, Hajiro T. Analysis of the factors related to mortality in chronic obstructive pulmonary disease: role of exercise capacity and health status. Am J Respir Crit Care Med. 2003;167(4):544–9. 61. Older P, Hall A, Hader R. Cardiopulmonary exercise testing as a screening test for perioperative management of major surgery in the elderly. Chest. 1999;116(2):355–62. 62. O’Neill JO, Young JB, Pothier CE, Lauer MS. Peak oxygen consumption as a predictor of death in patients with heart failure receiving beta-blockers. Circulation. 2005;111(18):2313–8. 63. Patterson RE, Horowitz SF . Importance of epidemiology and biostatistics in deciding clinical strate- gies for using diagnostic tests: a simplified approach using examples from coronary artery disease. J Am Coll Cardiol. 1989;13(7):1653–65. 64. Peveler WW. Effects of saddle height on economy in cycling. J Strength Cond Res. 2008;22(4):1355–9. 65. Peveler WW, Green JM. Effects of saddle height on economy and anaerobic power in well-trained cyclists. J Strength Cond Res. 2011;25(3):633. 66. Peveler WW, Pounders JD, Bishop PA. Effects of saddle height on anaerobic power production in cycling. J Strength Cond Res. 2007;21(4):1023–7. 67. Pollock ML. Exercise in Health and Disease: Evaluation and Prescription for Prevention and Rehabilitation. 2nd ed. Philadelphia (PA): W.B. Saunders; 1990. 741 p. 68. Rodgers GP, Ayanian JZ, Balady G, et al. American College of Cardiology/American Heart Association Clinical Competence Statement on Stress Testing. A Report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on Clinical Competence. Circulation. 2000;102(14):1726–38. 69. Shah SJ, Thenappan T, Rich S, Sur J, Archer SL, Gomberg-Maitland M. Value of exercise tread- mill testing in the risk stratification of patients with pulmonary hypertension. Circ Heart Fail. 2009;2(4):278–86. 70. Sheldahl LM, Wilke NA, Tristani FE. Evaluation and training for resumption of occupational and leisure-time physical activities in patients after a major cardiac event. Med Exerc Nutr Health. 1995;4:273–89. 71. Stein RA, Chaitman BR, Balady GJ, et al. Safety and utility of exercise testing in emergency room chest pain centers: An advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation. 2000;102(12):1463–7. 72. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 1998;97(18):1837–47.
- 168. 142 Benefits and Risks Associated with Physical Activity CHAPTER 1 This chapter addresses the interpretation and clinical significance of exercise test results with specific reference to hemodynamic, electrocardiographic (ECG), and ventilatory expired gas responses. The diagnostic and prognostic value of the exercise test will be discussed along with screening for atherosclerotic cardiovas- cular disease (CVD). EXERCISE TESTING AS A SCREENING TOOL FOR CORONARY ARTERY DISEASE The probability of a patient having CVD cannot be estimated accurately from the exercise test result and diagnostic characteristics of the test alone. It also depends on the likelihood of having disease before the test is administered. Bayes’ theorem states that the posttest probability of having a disease is determined by the disease probabil- ity before the test and the probability that the test will provide a true result (50). The probability of a patient having a disease before the test is most importantly related to the presence of symptoms (particularly chest pain characteristics), in addition to the patient’s age, sex, and the presence of major CVD risk factors (see Table 2.2). Exercise testing in individuals with known CVD (i.e., prior myocardial in- farction [MI], angiographically documented coronary stenoses, and/or prior coronary revascularization) is warranted if there is a reemergence of symptoms postintervention (18). The description of symptoms can be most helpful among individuals in whom the diagnosis is in question. Typical or definite angina (i.e., substernal chest discomfort that may radiate to the back, jaw, or arms, and symptoms provoked by exertion or emotional stress and relieved by rest and/ or nitroglycerin) makes the pretest probability so high that the test result does not dramatically change the likelihood of underlying CVD. Atypical angina (i.e., chest discomfort that lacks one of the mentioned characteristics of typical angina) generally indicates an intermediate pretest likelihood of CVD in men ⬎30 yr and women ⬎50 yr (see Table 5.1 and Figure 5.1). In fact, the use of exercise testing to assist in the diagnosis of CVD may be most beneficial in those individuals with an intermediate pretest probability (see Chapter 5). The use of exercise testing in screening asymptomatic individuals, particu- larly among individuals without diabetes mellitus or major CVD risk factors, CHAPTER Interpretation of Clinical Exercise Test Results 6
- 169. CHAPTER 6 Interpretation of Clinical Exercise Test Results 143 is diagnostically problematic in view of the low to very low pretest likelihood of CVD (see Table 5.1). An American Heart Association Scientific Statement on exercise testing in asymptomatic adults concluded that there is currently insuf- ficient evidence to support exercise testing as a routine screening modality for atherosclerotic CVD in asymptomatic individuals (35). Given the limited ability of exercise testing to indentify atherosclerotic CVD and predict risk of adverse events during exercise, this assessment is not indicated prior to initiation of an exercise program in asymptomatic individuals (see Chapter 2). Even so, the use of exercise testing in asymptomatic individuals may be useful to health/fitness and clinical exercise professionals given its ability to (a) reflect general health; (b) identify nor- mal and abnormal physiologic responses to physical exertion; (c) provide infor- mation to more precisely design the exercise prescription (Ex Rx ); and (d) provide prognostic insight, especially among those with multiple CVD risk factors (35). INTERPRETATION OF RESPONSES TO GRADED EXERCISE TESTING Before interpreting clinical exercise test data, it is important to consider the pur- pose of the test (e.g., diagnostic, prognostic, therapeutic applications, Ex Rx ) and the individual clinical characteristics that may influence the exercise test or its interpretation (e.g., age, sex). Medical conditions influencing test interpretation in- clude orthopedic limitations, pulmonary disease, obesity, neurologic disorders, and deconditioning. Medication effects (see Appendix A) and resting ECG abnormalities (see Appendix C) also must be considered, especially resting ST-segment changes secondary to conduction defects, left ventricular hypertrophy (LVH), and other factors that may contribute to spurious ST-segment depression. Although total body and myocardial oxygen consumption (MV̇O2 ) are di- rectly related, the relationship between these variables can be altered by exercise training, medications, and disease. For example, exercise-induced myocardial ischemia may cause left ventricular dysfunction, exercise intolerance, and a hypotensive blood pressure (BP) response (see Box 5.2). The severity of symp- tomatic ischemia is inversely related to exercise capacity; however, left ventricu- lar ejection fraction does not correlate well with exercise tolerance (39,45). Responses to exercise tests are useful in evaluating the need for and effective- ness of various types of therapeutic interventions. The following variables are important to quantify accurately when assessing the diagnostic, prognostic, and therapeutic applications of the test. Each is described in the following sections and summarized in Box 6.1: • Hemodynamics: assessed by the heart rate (HR) and systolic BP (SBP)/ diastolic BP (DBP) responses. • ECG waveforms: particularly ST-segment displacement and supraventricular and ventricular dysrhythmias. • Limiting clinical signs or symptoms. • Ventilatory gas exchange responses (e.g., V̇O2 , minute ventilation [V̇E], carbon dioxide production [V̇CO2 ]).
- 170. 144 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Electrocardiographic, Cardiorespiratory, and Hemodynamic Responses to Exercise Testing and Their Clinical Significance BOX 6.1 Variable Clinical Significance ST-segment depression (ST ↓) An abnormal ECG response is defined as ⱖ1 mm of horizontal or downsloping ST ↓ 60–80 ms beyond the J point, suggesting myocardial ischemia. ST-segment elevation (ST ↑) ST ↑ in leads displaying a previous Q wave MI almost always reflects an aneurysm or wall motion abnormality. In the absence of significant Q waves, exercise-induced ST ↑ often is associated with a fixed high-grade coronary stenosis. Supraventricular dysrhythmias Isolated atrial ectopic beats or short runs of SVT commonly occur during exercise testing and do not appear to have any diagnostic or prognostic significance for CVD. Ventricular dysrhythmias The suppression of resting ventricular dysrhythmias during exercise does not exclude the presence of underlying CVD; conversely, PVCs that increase in frequency, complexity, or both do not necessarily signify underlying ischemic heart disease. Complex ventricular ectopy, including paired or multiform PVCs, and runs of ventricular tachycardia (ⱖ3 successive beats) are likely to be associated with significant CVD and/or a poor prog- nosis if they occur in conjunction with signs and/or symptoms of myocardial ischemia in patients with a history of sudden cardiac death, cardiomyopathy, or valvular heart disease. Frequent ven- tricular ectopy during recovery has been found to be a better predictor of mortality than ventricular ectopy that occurs only during exercise. Heart rate (HR) The normal HR response to progressive exercise is a relatively linear increase, corresponding to 10 ⫾ 2 beats ⭈ MET⫺1 for physically inactive subjects. Chronotropic incompetence may be signified by the following: 1. A peak exercise HR that is ⬎2 SD (艐20 beats ⭈ min⫺1 ) below the age-predicted HRmax or an inability to achieve ⱖ85% of the age-predicted HRmax for subjects who are limited by voli- tional fatigue and are not taking -blockers 2. A chronotropic index (CI) ⬍0.8 (35); where CI is calculated as the percentage of heart rate reserve to percent metabolic reserve achieved at any test stage Heart rate recovery An abnormal (slowed) HR recovery is associated with a poor prognosis. HR recovery has frequently been defined as a de- crease ⱕ12 beats ⭈ min⫺1 at 1 min (walking in recovery), or ⱕ22 beats ⭈ min⫺1 at 2 min (supine position in recovery). Systolic blood pressure (SBP) The normal response to exercise is a progressive increase in SBP , typically 10 ⫾ 2 mm Hg ⭈ MET⫺1 with a possible plateau at peak exercise. Exercise testing should be discontinued with SBP values of ⬎250 mm Hg. Exertional hypotension (SBP that fails to rise or falls [⬎10 mm Hg]) may signify myocardial ischemia and/or LV dysfunction. Maximal exercise SBP of ⬍140 mm Hg suggests a poor prognosis. Diastolic blood pressure (DBP) The normal response to exercise is no change or a decrease in DBP . A DBP of ⬎115 mm Hg is considered an endpoint for exercise testing. (continued)
- 171. CHAPTER 6 Interpretation of Clinical Exercise Test Results 145 HEART RATE RESPONSE Maximal heart rate (HRmax ) may be predicted from age using any of several published equations (21,23,56) (see Chapter 7). For the most used equation (220 ⫺ age), the relationship between age and HRmax for a large sample of subjects is well established; however, interindividual variability is high (⫾12 beats ⭈ min⫺1 ). As a result, there is a potential for considerable error in the use of methods that extrapolate submaximal test data to an age-predicted HRmax . It has yet to be demonstrated alternate equations that claim higher accuracy and less variability provide clinically superior information compared to use of the 220 ⫺ age equation (52). Using the 220 ⫺ age equation, failure to achieve an age-predicted HRmax ⱖ85% in the presence of maximal effort (i.e., chronotropic incompetence) is an ominous prognostic marker. In addition, failure to achieve Electrocardiographic, Cardiorespiratory, and Hemodynamic Responses to Exercise Testing and Their Clinical Significance (Continued) BOX 6.1 Variable Clinical Significance Anginal symptoms Can be graded on a scale of 1–4, corresponding to perceptible but mild, moderate, moderately severe, and severe, respectively. A rating of 3 (moderately severe) generally should be used as an endpoint for exercise testing. Cardiorespiratory fitness Average values of V̇O2max /V̇O2peak expressed as METs, expected in healthy sedentary men and women, can be predicted from one of several regression equations (28). Also, see Table 4.9 for age-specific V̇O2max norms. Recent meta- analysis suggests each 1 MET increase in aerobic capacity equates to 13% and 15% decrease in all-cause mortality and cardiovascular events, respectively (32). Ventilatory efficiency Normal V̇E/V̇CO2 slope value ⬍30. Elevated value is strongly prognostic in patients with heart failure and potentially patients with pulmonary hypertension. Values of ⬃45 or more are indica- tive of particularly poor prognosis in patients with heart failure. Elevated values are clearly indicative of worsening ventilation perfusion abnormalities in heart failure and pulmonary hyper- tension populations and thus provide an accurate depiction of disease severity (8). Partial pressure of end-tidal carbon dioxide (PETCO2 ) PETCO2 is normally 36–42 mm Hg at rest; increases 3–8 mm Hg during exercise at mild-to-moderate workloads and decreases at maximal exercise. Abnormally low values at rest and during exercise reflective of worsening ventilation perfusion abnormali- ties and in heart failure and pulmonary hypertension populations, and thus provide an accurate depiction of disease severity and indicate poor prognosis. Also appears to reflect cardiac function in patients with heart failure (4,8). CVD, cardiovascular disease; ECG, electrocardiographic; LV, left ventricular; MET, metabolic equivalent; MI, myocardial infarction; PVC, premature ventricular contraction; SD, standard deviation; SVT, supraventricular tachycardia; V̇E, minute ventilation; V̇CO2 , carbon dioxide production; V̇O2max , maximal oxygen uptake; V̇O2peak , peak oxygen uptake.
- 172. 146 GUIDELINES FOR EXERCISE TESTING • www.acsm.org an age-predicted HRmax ⬎80% (i.e., chronotropic incompetence), using the equa- tion {[HRpeak ⫺ HRrest ]/[(220 ⫺ age) ⫺ HRrest ]}, is also an indicator of increased risk for adverse events (35). A delayed decrease in HR early in recovery after a symptom-limited maximal exercise test (i.e., ⱕ12 beats ⭈ min⫺1 decrease after the first minute in recovery) is also a powerful independent predictor of overall mortality and should therefore be included in the exercise test assessment (35). Achievement of age-predicted HRmax should not be used as an absolute test endpoint or as an indication that effort has been maximal because of its high intersubject variability. The clinical indications for stopping an exercise test are presented in Box 5.2. Good judgment on the part of the supervising health/ fitness, clinical exercise, or health care professional remains the most important criterion for terminating an exercise test. BLOOD PRESSURE RESPONSE The normal BP response to dynamic upright exercise consists of a progressive in- crease in SBP , no change or a slight decrease in DBP, and a widening of the pulse pressure (see Box 6.1). The following are key points concerning interpretation of the BP response to progressive dynamic exercise: • A drop in SBP (ⱖ10 mm Hg decrease in SBP with an increase in workload), or failure of SBP to increase with increased workload, is considered an abnormal test response. Exercise-induced decreases in SBP (i.e., exertional hypotension) may occur in patients with CVD, valvular heart disease, cardiomyopathies, aortic outflow obstruction, and serious dysrhythmias. Occasionally, patients without clinically significant heart disease demonstrate exertional hypoten- sion caused by antihypertensive therapy, prolonged strenuous exercise, and/ or vasovagal responses. However, exertional hypotension correlates with myocardial ischemia, left ventricular dysfunction, and an increased risk of subsequent cardiac events (17). In some cases, this response is improved after coronary artery bypass graft surgery (CABG). An SBP ⬎250 mm Hg and/or a DBP ⬎115 mm Hg continue to be used as termination criteria for exercise testing. Moreover, an excessive BP response to exercise is predictive of future hypertension and CVD (55). • The normal postexercise response is a progressive decline in SBP . During passive recovery in an upright posture, SBP may decrease abruptly because of periph- eral pooling (and usually normalizes upon resuming the supine position). SBP remains below pretest resting values for several hours after the test, an expected physiologic response termed postexercise hypotension, which occurs in most individuals (51). A failure to decrease or a rise in SBP over the first several min- utes of recovery may indicate increased mortality risk (26). DBP also remains below pretest resting values during the postexercise period in most individuals. • In patients on vasodilators, calcium channel blockers, angiotensin-converting enzyme inhibitors, and ␣- and -adrenergic blockers, the BP response to exercise is variably attenuated and cannot be accurately predicted in the absence of clinical test data (see Appendix A).
- 173. CHAPTER 6 Interpretation of Clinical Exercise Test Results 147 • Although HRmax is comparable for men and women, men generally have higher SBPs (⬃20 ⫾5 mm Hg) during maximal treadmill testing. However, the sex difference is no longer apparent after 70 yr. The rate pressure product (RPP), or double product (SBP mm Hg ⫻ HR beats ⭈ min⫺1 ), is an indica- tor of myocardial oxygen demand. Maximal double product values during exercise testing are typically between 25,000 (10th percentile) and 40,000 (90th percentile) (17). Signs and symptoms of ischemia generally occur at a reproducible double product. ELECTROCARDIOGRAPH WAVEFORMS Appendix C provides information to aid in the interpretation of resting and exercise ECGs. Moreover, a detailed review of ECG analysis is provided in the ACSM Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh Edition (54). It should be noted an athlete’s resting ECG may present with several benign normal variants including respiratory sinus arrhythmia, sinus bradycar- dia, incomplete right bundle-branch block, early repolarization, and increased voltage in the precordial leads (24). Additional information is provided here with respect to common exercise-induced changes in ECG variables. The normal ECG response to exercise includes the following: • Minor and insignificant changes in P wave morphology. • Superimposition of the P and T waves of successive beats. • Increases in septal Q wave amplitude. • Slight decreases in R wave amplitude. • Increases in T wave amplitude (although wide variability exists among clients/patients). • Minimal shortening of the QRS duration. • Depression of the J point. • Rate-related shortening of the QT interval. However, some changes in ECG wave morphology may be indicative of underlying pathology. For example, although QRS duration tends to decrease slightly with exercise (and increasing HR) in healthy individuals, it may increase in patients with either angina or left ventricular dysfunction. Exercise-induced P wave changes are rarely seen and are of questionable significance. Many fac- tors affect R wave amplitude; consequently, such changes during exercise have no independent predictive power (44). ST-Segment Displacement ST-segment changes are widely accepted criteria for myocardial ischemia and injury. The interpretation of ST-segments may be affected by the resting ECG configuration (e.g., bundle-branch blocks, LVH) and pharmacologic agents (e.g., digitalis therapy). There may be J point depression and tall, peaked T waves at high exercise intensities and during recovery in healthy individuals (49).
- 174. 148 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Depression of the J point that leads to marked ST-segment upsloping is caused by competition between normal repolarization and delayed terminal depolarization forces rather than by ischemia (41). Exercise-induced myocardial ischemia may be manifested by different types of ST-segment changes on the ECG as shown in Figure 6.1. ST-Segment Elevation • ST-segment elevation (early repolarization) may be seen in the normal resting ECG in various patterns. Recent data suggest that an early repolarization pat- tern in the inferior leads may indicate an increased risk of cardiac mortality in middle-aged individuals (53,57). Benign early repolarization can be common in the ECG of athletes and is typically localized to the chest leads V2–V5 (24). Early repolarization exclusively observed in the anterolateral left pre- cordial leads is not thought to be associated with increased risk for sustained ventricular arrhythmias, whereas global early repolarization (i.e., limb and precordial leads) appears to indicate a higher risk (3). Increasing HR usually causes these elevated ST-segments to return to the isoelectric line. • Exercise-induced ST-segment elevation in leads with Q waves consistent with a prior MI may be indicative of wall motion abnormalities, ischemia, or both (10). 80 msec 2.0 mm Normal Abnormal Millimeters Classic Upsloping 20 5 10 15 0 2.0 4.0 ■ FIGURE 6.1. ST-segment changes during exercise. Classic ST-segment depression (first com- plex) is defined as a horizontal or downsloping ST-segment that is ⱖ1.0 mm below the baseline 60–80 ms past the J point. Slowly upsloping ST-segment depression (second complex) should be considered a borderline response, and added emphasis should be placed on other clinical and exercise variables.
- 175. CHAPTER 6 Interpretation of Clinical Exercise Test Results 149 • Exercise-induced ST-segment elevation on an otherwise normal ECG (except in augmented voltage right [aVR] or chest leads V1 and V2) generally indi- cates significant myocardial ischemia and localizes the ischemia to a specific area of myocardium (48). This response may also be associated with ventricu- lar arrhythmias and myocardial injury. ST-Segment Depression • ST-segment depression (i.e., depression of the J point and the slope at 80 ms past the J point) is the most common manifestation of exercise-induced myo- cardial ischemia. • Horizontal or downsloping ST-segment depression is more indicative of myo- cardial ischemia than is upsloping depression. • The standard criterion for a positive test is ⱖ1.0 mm (0.1 mV) of horizontal or downsloping ST-segment at the J point extending for 60–80 ms. • Slowly upsloping ST-segment depression should be considered a borderline response, and added emphasis should be placed on other clinical and exercise variables. • ST-segment depression does not localize ischemia to a specific area of myocardium. • The more leads with (apparent) ischemic ST-segment shifts, the more severe the disease. • Significant ST-segment depression occurring only in recovery likely repre- sents a true positive response and should be considered an important diag- nostic finding (34). • Adjustment of the ST-segment relative to the HR may provide additional diagnostic information. The ST/HR index is the ratio of the maximal ST- segment change (V) to the maximal change in HR from rest to peak exercise (beats ⭈ min⫺1 ). An ST/HR index of ⬎1.6 V ⭈ beats⫺1 ⭈ min⫺1 is defined as abnormal. The ST/HR slope reflects the maximal slope relating the amount of the ST-segment depression (V) to HR (beats ⭈ min⫺1 ) during exercise. An ST/HR slope of ⱖ2.4 V ⭈ beats⫺1 ⭈ min⫺1 is defined as abnormal (29,30). ST-Segment Normalization or Absence of Change • Ischemia may be manifested by normalization of resting ST-segments. ECG abnormalities at rest including T-wave inversion and ST-segment depression may return to normal during anginal symptoms and during exercise in some patients (36). Dysrhythmias Exercise-associated dysrhythmias occur in healthy individuals as well as pa- tients with CVD. Increased sympathetic drive and changes in extracellular and intracellular electrolytes, pH, and oxygen tension contribute to disturbances in
- 176. 150 GUIDELINES FOR EXERCISE TESTING • www.acsm.org myocardial and conducting tissue automaticity and reentry, which are major mechanisms of dysrhythmias. Supraventricular Dysrhythmias Isolated premature atrial contractions (PACs) are common and require no special precautions. Atrial flutter or atrial fibrillation may occur in organic heart disease or may reflect endocrine, metabolic, or medication effects. Sustained supraven- tricular tachycardia (SVT) occasionally is induced by exercise and may require pharmacologic treatment or electroconversion if discontinuation of exercise fails to abolish the rhythm. Patients who experience paroxysmal atrial tachycardia may be evaluated by repeating the exercise test after appropriate treatment. Ventricular Dysrhythmias Isolated premature ventricular complexes or contractions (PVCs) can occur dur- ing exercise in apparently healthy or asymptomatic individuals as well as those diagnosed with CVD. In some individuals, progressive exercise to maximal exer- tion induces PVCs, whereas in others, it reduces their occurrence. The clinical significance of exercise-induced PVCs remains a matter of debate, although there are data to suggest the occurrence of ventricular ectopy during exercise warrants clinical consideration (9). The suppression of PVCs that are present at rest with exercise testing does not exclude the presence of CVD, and PVCs that increase in frequency, complexity, or both do not necessarily signify underlying ischemic heart disease (9,16). Serious forms of ventricular ectopy include paired or mul- tiform PVCs or runs of ventricular tachycardia (ⱖ3 PVCs in succession). These dysrhythmias are likely to be associated with significant CVD, a poor prognosis, or both, if they occur in conjunction with signs or symptoms of myocardial ischemia, or in patients with a history of resuscitated sudden cardiac death, car- diomyopathy, or valvular heart disease. Some data indicate that exercise-induced PVCs are associated with a higher mortality in asymptomatic individuals (27). In a cohort referred for clinical exercise testing who were free of heart failure, the occurrence of PVCs during recovery rather than during exercise was prognostically significant (14). Another investigation assessing a large cohort referred for exercise testing (n ⬎ 29,000) defined frequent ventricular ectopy as, “the presence of ⬎7 PVCs per minute, ventricular bigeminy or trigeminy, ventricular couplets or triplets, ventricular tachycardia, ventricular flutter, torsade de pointes, or ventricular fibrillation” (20). Frequent ventricular ectopy in this study during exercise and recovery was a significant predictor of mortality, although its occurrence in recovery was a significantly stronger prognostic marker. Criteria for terminating exercise tests based on ventricular ectopy include sustained ventricular tachycardia, multifocal PVCs, and short runs of ventricular tachycardia. The decision to terminate an exercise test should also be influenced by simultaneous evidence of myocardial ischemia and/or adverse signs or symp- toms (see Box 5.2).
- 177. CHAPTER 6 Interpretation of Clinical Exercise Test Results 151 LIMITING SIGNS AND SYMPTOMS Although patients with exercise-induced ST-segment depression can be asymp- tomatic, when concomitant angina occurs, the likelihood that the ECG changes result from CVD is significantly increased (59). In addition, angina pectoris without ischemic ECG changes may be as predictive of CVD as ST-segment changes alone (12). Angina pectoris and ST-segment changes are currently con- sidered independent variables that identify patients at increased risk for subse- quent coronary events. Moderate-to-severe angina (i.e., rating of 3–4 on a 4-point scale) is an absolute indication for exercise test termination (17). Individuals undergoing exercise testing for the assessment of CVD who complain of dyspnea with physical exertion may have a poorer prognosis compared to those who com- plain of other (i.e., angina) or no exertional symptoms (2). Lastly, termination of exercise testing secondary to dyspnea as opposed to lower extremity fatigue may indicate a worse prognosis in patients with heart disease (11). In the absence of untoward signs or symptoms, patients generally should be encouraged to give their best effort so that maximal exercise tolerance can be determined. However, the determination of what constitutes “maximal” effort, although important for interpreting test results, can be difficult. Various criteria have been used to confirm that a maximal effort has been elicited during graded exercise testing (GXT). However, all of the following criteria for maximal effort can be subjective and therefore possess limitations to varying degrees: • Failure of HR to increase with further increases in exercise intensity. • A plateau in V̇O2 (or failure to increase V̇O2 by 150 mL ⭈ min⫺1 ) with in- creased workload (58). This criterion has fallen into disfavor because a pla- teau is inconsistently seen during GXT and is confused by various definitions and how data are sampled during exercise (46). • A respiratory exchange ratio (RER) ⱖ1.10 is a minimal threshold that may be obtained in most individuals putting forth a maximal effort, although there may be considerable interindividual variability with an RER ⱖ1.10 (37). • Various postexercise venous lactic acid concentrations (e.g., 8–10 mmol ⭈ L⫺1 ) have been used; however, there is also significant interindividual variability in this response. • A rating of perceived exertion (RPE) ⬎17 on the 6–20 scale or ⬎9 on the 0–10 scale. Although all of the aforementioned criteria possess limitations, peak RER is perhaps the most accurate and objective noninvasive indicator of subject effort during a GXT (8,52). VENTILATORY EXPIRED GAS RESPONSES TO EXERCISE Direct measurement of ventilatory expired gas during exercise provides a more precise assessment of exercise capacity and prognosis and helps to distinguish causes of exercise intolerance. The combination of this technology with stan-
- 178. 152 GUIDELINES FOR EXERCISE TESTING • www.acsm.org dard GXT procedures is typically referred to as cardiopulmonary exercise testing (CPX) (8). These responses can be used to assess client/patient effort during an exercise test, particularly when a reduction in maximal exercise capacity is suspected. Submaximal efforts from the client/patient on a maximal GXT can interfere with the interpretation of the test results and subsequent patient management. Moreover, the use of CPX may be advantageous when serial test- ing is needed for either research or clinical purposes to ensure consistent effort among assessments (6). Maximal oxygen uptake (V̇O2max ) or peak oxygen uptake (V̇O2peak ) provides important information about cardiorespiratory fitness and is a powerful marker of prognosis. Population-specific nomograms (see Figure 5.2) and/or population norms (see Table 4.9) may be used to compare V̇O2peak with the expected value according to age, sex, and physical fitness status (28,47). Additionally, the assessment of ventilatory efficiency (i.e., V̇E/V̇CO2 slope and partial pressure of end-tidal carbon dioxide [PETCO2 ]) provides robust prognos- tic and/or diagnostic information in patients with congestive heart failure (CHF) and pulmonary hypertension (4,5). Ventilatory expired gas responses often are used in clinical settings as an estimation of the point at which lactate accumulation in the blood occurs, sometimes referred to as the lactate or anaerobic threshold. Assessment of this physiologic phenomenon through ventilatory expired gas is typically referred to as ventilatory threshold (VT). Several different methods using ventilatory expired gas responses exist for the estimation of this point. These include the ventilatory equivalents and V-slope method (6). Whichever approach is used, it should be remembered VT provides only an estimation, and the concept of an- aerobic threshold during exercise is controversial (45). Because exercise beyond the lactate threshold is associated with metabolic acidosis, hyperventilation, and a reduced capacity to perform work, its estimation is a useful physiologic measurement when evaluating interventions in patients with heart and pulmo- nary disease as well as studying the limits of performance in apparently healthy individuals. However, it should be noted that secondary to abnormal ventilatory responses observed in a significant proportion of patients with CHF (i.e., exercise oscillatory ventilation), determination of VT may not be possible (13). In addition to estimating when blood lactate values begin to increase, maxi- mal minute ventilation (V̇Emax ) can be used in conjunction with the maximal voluntary ventilation (MVV) to assist in determining if there is a ventilatory limitation to maximal exercise. A comparison between V̇Emax and MVV can be used when evaluating responses to a CPX. MVV can be directly measured by a 12–15 s deep and rapid breathing maneuver or estimated from the equation: forced expiratory volume in 1 s [(FEV1.0 ) ⫻ 40] (8). MVV is preferred to [FEV1.0 ⫻ 40] to ensure a precise quantification of ventilatory capacity. The relationship between V̇Emax and MVV, typically referred to as the ventilatory reserve, tradi- tionally is defined as the percentage of the MVV achieved at maximal exercise (i.e., the V̇Emax /MVV ratio). In most normal healthy individuals, the V̇Emax /MVV ratio is ⱕ0.80 (6). Values surpassing this threshold are indicative of a reduced ventilatory reserve and a possible pulmonary limitation to exercise.
- 179. CHAPTER 6 Interpretation of Clinical Exercise Test Results 153 Pulse oximetry should also be assessed when CPX is used to assess possible pulmonary limitations to exercise. A decrease in pulse oximeter saturation ⬎5% during exercise also indicates a pulmonary limitation. Lastly, most currently available ventilatory expired gas systems also possess capabilities for pulmo- nary function testing. Obstructive or restrictive patterns on baseline pulmonary function testing provide insight into the mechanism of limitations to exercise. Moreover, a ⱖ15% decrease in FEV1.0 and/or peak expiratory flow following CPX compared to baseline values is indicative of exercise-induced bronchospasm (6). DIAGNOSTIC VALUE OF EXERCISE TESTING The diagnostic value of conventional exercise testing for the detection of CVD is influenced by the principles of conditional probability (see Box 6.2). The factors that determine the predictive outcomes of exercise testing (and other diagnostic tests) are the sensitivity and specificity of the test procedure and prevalence of CVD in the population tested (50). Sensitivity and specificity determine how effective the test is in making correct diagnoses in individuals with and without disease, respectively. Disease prevalence is an important determinant of the pre- dictive value of the test. Moreover, non-ECG criteria (e.g., duration of exercise or maximal metabolic equivalent [MET] level, hemodynamic responses, symp- toms of angina or dyspnea) should be considered in the overall interpretation of exercise test results. SENSITIVITY Sensitivity refers to the percentage of patients tested with known CVD who dem- onstrate significant ST-segment (i.e., positive) changes. Exercise ECG sensitivity sensitivity ⫽ TP/(TP ⫹ FN) ⫽ the percentage of patients with CVD who have a positive test specificity ⫽ TN/(TN ⫹ FP) ⫽ the percentage of patients without CVD who have a negative test predictive value (positive test) ⫽ TP/(TP ⫹ FP) ⫽ the percentage of patients with a positive test result who have CVD predictive value (negative test) ⫽ TN/(TN ⫹ FN) ⫽ the percentage of patients with a negative test who do not have CVD CVD, cardiovascular disease; FN, false negative (negative exercise test and CVD); FP , false positive (positive exercise test and no CVD); TN, true negative (negative exercise test and no CVD); TP , true positive (positive exercise test and CVD). Sensitivity, Specificity, and Predictive Value of Diagnostic Graded Exercise Testing BOX 6.2
- 180. 154 GUIDELINES FOR EXERCISE TESTING • www.acsm.org for the detection of CVD usually is based on subsequent angiographically determined coronary artery stenosis of ⱖ70% in at least one vessel. A true posi- tive (TP) exercise test reveals horizontal or downsloping ST-segment depression of ⱖ1.0 mm and correctly identifies a patient with CVD. False negative (FN) test results show no or nondiagnostic ECG changes and fail to identify patients with underlying CVD. Common factors that contribute to FN exercise tests are summarized in Box 6.3. Test sensitivity is decreased by inadequate myocardial stress, medica- tions that attenuate cardiac demands to exercise or reduce myocardial ischemia (e.g., -blockers, nitrates, calcium channel blocking agents), and insufficient ECG lead monitoring. Preexisting ECG changes such as LVH, left bundle- branch block (LBBB), or the preexcitation syndrome (Wolff-Parkinson-White syndrome [W-P-W]) limit the ability to interpret exercise-induced ST-segment changes as ischemic ECG responses. The exercise test is most accurate for de- tecting CVD by applying validated multivariate scores (i.e., pretest risk mark- ers in addition to ST-segment changes and other exercise test responses) (7). SPECIFICITY The specificity of exercise tests refers to the percentage of patients without CVD who demonstrate nonsignificant (i.e., negative) ST-segment changes. A true neg- ative test correctly identifies an individual without CVD. Many conditions may cause abnormal exercise ECG responses in the absence of significant obstructive CVD (see Box 6.4). Reported values for the specificity and sensitivity of exercise ECG testing vary because of differences in patient selection, test protocols, ECG criteria for a positive test, and the angiographic definition of CVD. In studies that controlled for these variables, the pooled results show a sensitivity of 68% and specificity of 77% (22). Sensitivity, however, is somewhat lower, and specificity is higher when workup bias (i.e., only assessing individuals with a higher likelihood for a given disease) is removed (19,42). • Failure to reach an ischemic threshold • Monitoring an insufficient number of leads to detect ECG changes • Failure to recognize non-ECG signs and symptoms that may be associated with underlying CVD (e.g., exertional hypotension) • Angiographically significant CVD compensated by collateral circulation • Musculoskeletal limitations to exercise preceding cardiac abnormalities • Technical or observer error CVD, cardiovascular disease; ECG, electrocardiographic. Causes of False Negative Test Results BOX 6.3
- 181. CHAPTER 6 Interpretation of Clinical Exercise Test Results 155 PREDICTIVE VALUE The predictive value of exercise testing is a measure of how accurately a test result (positive or negative) correctly identifies the presence or absence of CVD in tested patients. For example, the predictive value of a positive test is the per- centage of those individuals with an abnormal test who have CVD. Nevertheless, a test should not be classified as “negative” unless the patient has attained an adequate level of myocardial stress, generally defined as having achieved ⱖ85% of predicted HRmax during the test, although this criterion is inherently flawed given the large variability in the HR response at maximal exercise (52). Predictive value cannot be estimated directly from a test’s specificity or sensitivity because it depends on the prevalence of disease in the population being tested. COMPARISON WITH IMAGING STRESS TESTS Several imaging tests including echocardiography and nuclear techniques are often used in association with exercise testing to diagnose CVD. Guidelines are available that describe these techniques and their accuracy for detecting CVD (15,31). A recent meta-analysis suggests stress echocardiography is superior to nuclear imaging in detecting left main or triple vessel CVD (38). Patients with nuclear imaging studies positive for reversible perfusion defects appear to have a worse prognosis compared to individuals with a normal study (1). An abnormal echocardiography response during exercise (i.e., increased left ventricular filling pressure) also appears to be indicative of an increased risk for future adverse events (25). • Resting repolarization abnormalities (e.g., left bundle-branch block) • Cardiac hypertrophy • Accelerated conduction defects (e.g., Wolff-Parkinson-White syndrome) • Digitalis • Nonischemic cardiomyopathy • Hypokalemia • Vasoregulatory abnormalities • Mitral valve prolapsed • Pericardial disorders • Technical or observer error • Coronary spasm in the absence of significant coronary artery disease • Anemia • Being a woman a Selected variables simply may be associated with rather than be causes of abnormal test results. Causes of Abnormal ST-Segment Changes in the Absence of Obstructive Cardiovascular Diseasea BOX 6.4
- 182. 156 GUIDELINES FOR EXERCISE TESTING • www.acsm.org PROGNOSTIC APPLICATIONS OF THE EXERCISE TEST Risk or prognostic evaluation is an important activity in medical practice on which many patient management decisions are based. In patients with CVD, several clinical factors contribute to patient outcome including (a) severity and stability of symptoms; (b) left ventricular function; (c) angiographic extent and severity of CVD; (d) electrical stability of the myocardium; and (e) the presence of other comorbid conditions. Unless cardiac catheterization and immediate coronary revascularization are indicated, an exercise test should be performed in individuals with known or suspected CVD to assess risk of future cardiac events and to assist in subsequent management decisions. As stated in Chapter 5, data derived from the exercise test are most useful when considered in the context of other clinical information. Important prognostic variables that can be derived from the exercise test are summarized in Box 6.1. 4 mm 3 mm 2 mm 1 mm 0 mm ST-Segment deviation during exercise Angina during exercise Prognosis Exercise Ischemia- reading line None Nonlimiting Exercise- limiting 5-year survival Average annual mortality Exercise METs 0.99 0.96 0.95 0.93 0.90 0.85 0.80 0.75 0.70 0.55 9% 6% 5% 4% 3% 2% 1.5% 1% 0.4% 0.2% 20 17 13 10 7 5 0 ■ FIGURE 6.2. Duke nomogram uses five steps to estimate prognosis for a given individual from the parameters of the Duke score. First, the observed amount of ST depression is marked on the ST-segment deviation line. Second, the observed degree of angina is marked on the line for angina, and these two points are connected. Third, the point where this line intersects the ischemia reading line is noted. Fourth, the observed exercise tolerance is marked on the line for exercise capacity. Finally, the mark on the ischemia reading line is connected to the mark on the exercise capacity line, and the estimated 5-yr survival or average annual mortality rate is read from the point at which this line intersects the prognosis scale (40).
- 183. CHAPTER 6 Interpretation of Clinical Exercise Test Results 157 Several multivariate prognostic scores such as the Veteran’s Administration score (43) (validated for the male veteran population) and the Duke nomogram (39) (validated for the general population including women) (see Figure 6.2) can be helpful when applied appropriately. The Duke nomogram does not appear to be valid in patients ⬎75 yr (33). Patients who recently have suffered an acute MI and received thrombolytic therapy and/or have undergone coronary revascu- larization generally have a low subsequent cardiac event rate. Exercise testing still can provide prognostic information in this population, as well as assist in physical activity counseling and Ex Rx . THE BOTTOM LINE • Interpreting the results of a clinical exercise test requires a multivariable approach. • The HR, hemodynamic, and ECG response to exercise are key objective pa- rameters that require intricate assessment from an experienced clinician. In addition, the subjective symptoms including RPE, angina, and dyspnea are important components of exercise test interpretation. • When ventilatory expired gas is assessed during the clinical exercise test, a highly accurate determination of aerobic capacity is possible in addition to a potentially more accurate quantification of exercise effort (i.e., peak RER) and assessment of submaximal exercise performance and ventilatory efficiency. • Clinical exercise testing assists in the diagnosis of CVD as well as the physi- ologic mechanisms for abnormal functional limitations such as unexplained exertional dyspnea. • The diagnostic accuracy of clinical exercise testing depends on the charac- teristics of the patient who is undergoing the assessment and the quality of the test. • Clinical exercise testing data, and in particular aerobic capacity, provide valuable prognostic information in virtually all individuals undergoing this procedure. ACSM Position Stands: http://journals.lww.com/acsm-msse/pages/default.aspx The American Heart Association: http://www.americanheart.org/ Online Resources
- 184. 158 GUIDELINES FOR EXERCISE TESTING • www.acsm.org REFERENCES 1. Abidov A, Hachamovitch R, Hayes SW, et al. Are shades of gray prognostically useful in reporting myocardial perfusion single-photon emission computed tomography? Circ Cardiovasc Imaging. 2009; 2(4):290–8. 2. Abidov A, Rozanski A, Hachamovitch R, et al. Prognostic significance of dyspnea in patients referred for cardiac stress testing. N Engl J Med. 2005;353(18):1889–98. 3. Antzelevitch C, Yan GX. J wave syndromes. Heart Rhythm. 2010;7(4):549–58. 4. Arena R, Lavie CJ, Milani RV, Myers J, Guazzi M. Cardiopulmonary exercise testing in patients with pulmonary arterial hypertension: an evidence-based review. J Heart Lung Transplant. 2010;29(2): 159–73. 5. Arena R, Myers J, Guazzi M. The clinical and research applications of aerobic capacity and ventila- tory efficiency in heart failure: an evidence-based review. Heart Fail Rev. 2008;13(2):245–69. 6. Arena R, Myers J, Williams MA, et al. Assessment of functional capacity in clinical and research settings: a scientific statement from the American Heart Association Committee on Exercise, Rehabilitation, and Prevention of the Council on Clinical Cardiology and the Council on Cardiovascular Nursing. Circulation. 2007;116(3):329–43. 7. Ashley E, Myers J, Froelicher V. Exercise testing scores as an example of better decisions through science. Med Sci Sports Exerc. 2002;34(8):1391–8. 8. Balady GJ, Arena R, Sietsema K, et al. Clinician’s guide to cardiopulmonary exercise testing in adults. A scientific statement from the American Heart Association. Circulation. 2010;122(2):191–225. 9. Beckerman J, Wu T, Jones S, Froelicher VF . Exercise test-induced arrhythmias. Prog Cardiovasc Dis. 2005;47(4):285–305. 10. Bruce RA, Fisher LD, Pettinger M, Weiner DA, Chaitman BR. ST segment elevation with exercise: a marker for poor ventricular function and poor prognosis. Coronary Artery Surgery Study (CASS) confirmation of Seattle Heart Watch results. Circulation. 1988;77(4):897–905. 11. Chase P , Arena R, Myers J, et al. Prognostic usefulness of dyspnea versus fatigue as reason for exer- cise test termination in patients with heart failure. Am J Cardiol. 2008;102(7):879–82. 12. Cole JP , Ellestad MH. Significance of chest pain during treadmill exercise: correlation with coronary events. Am J Cardiol. 1978;41(2):227–32. 13. Corra U, Giordano A, Bosimini E, et al. Oscillatory ventilation during exercise in patients with chronic heart failure: clinical correlates and prognostic implications. Chest. 2002;121(5):1572–80. 14. Dewey FE, Kapoor JR, Williams RS, et al. Ventricular arrhythmias during clinical treadmill testing and prognosis. Arch Intern Med. 2008;168(2):225–34. 15. Douglas PS, Khandheria B, Stainback RF , et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography: a report of the American College of Cardiology Foundation Appropriateness Criteria Task Force, American Society of Echocardiography, American College of Emergency Physicians, American Heart Association, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance: endorsed by the Heart Rhythm Society and the Society of Critical Care Medicine. Circulation. 2008;117(11):1478–97. 16. Evans CH, Froelicher V. Some common abnormal responses to exercise testing: what to do when you see them. Prim Care. 2001;28(1):219–32, ix. 17. Fletcher GF , Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation. 2001;104(14):1694–740. 18. Fletcher GF , Mills WC, Taylor WC. Update on exercise stress testing. Am Fam Physician. 2006; 74(10):1749–54. 19. Froelicher VF , Lehmann KG, Thomas R, et al. The electrocardiographic exercise test in a population with reduced workup bias: diagnostic performance, computerized interpretation, and multivariable prediction. Veterans Affairs Cooperative Study in Health Services #016 (QUEXTA) Study Group. Quantitative Exercise Testing and Angiography. Ann Intern Med. 1998;128(12 Pt 1):965–74. 20. Frolkis JP , Pothier CE, Blackstone EH, Lauer MS. Frequent ventricular ectopy after exercise as a predictor of death. N Engl J Med. 2003;348(9):781–90. 21. Gellish RL, Goslin BR, Olson RE, McDonald A, Russi GD, Moudgil VK. Longitudinal modeling of the relationship between age and maximal heart rate. Med Sci Sports Exerc. 2007;39(5):822–9. 22. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: sum- mary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106(14):1883–92. 23. Gulati M, Shaw LJ, Thisted RA, Black HR, Merz CN, Arnsdorf MF . Heart rate response to exercise stress testing in asymptomatic women. The St. James Women Take Heart project. Circulation. 2010; 122(2):130–7.
- 185. CHAPTER 6 Interpretation of Clinical Exercise Test Results 159 24. Higgins JP . Normal resting electrocardiographic variants in young athletes. Phys Sportsmed. 2008; 36(1):69–75. 25. Holland DJ, Prasad SB, Marwick TH. Prognostic implications of left ventricular filling pressure with exercise. Circ Cardiovasc Imaging. 2010;3(2):149–56. 26. Huang CL, Su TC, Chen WJ, et al. Usefulness of paradoxical systolic blood pressure increase after exercise as a predictor of cardiovascular mortality. Am J Cardiol. 2008;102(5):518–23. 27. Jouven X, Zureik M, Desnos M, Courbon D, Ducimetiere P . Long-term outcome in asymptomatic men with exercise-induced premature ventricular depolarizations. N Engl J Med. 2000;343(12): 826–33. 28. Kim ES, Ishwaran H, Blackstone E, Lauer MS. External prognostic validations and comparisons of age- and gender-adjusted exercise capacity predictions. J Am Coll Cardiol. 2007;50(19):1867–75. 29. Kligfield P , Ameisen O, Okin PM. Heart rate adjustment of ST segment depression for improved detection of coronary artery disease. Circulation. 1989;79(2):245–55. 30. Kligfield P . Principles of simple heart rate adjustment of ST segment depression during exercise electrocardiography. Cardiol J. 2008;15(2):194–200. 31. Klocke FJ, Baird MG, Lorell BH, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radio- nuclide imaging—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). Circulation. 2003;108(11): 1404–18. 32. Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA. 2009; 301(19):2024–35. 33. Kwok JM, Miller TD, Hodge DO, Gibbons RJ. Prognostic value of the Duke treadmill score in the elderly. J Am Coll Cardiol. 2002;39(9):1475–81. 34. Lachterman B, Lehmann KG, Abrahamson D, Froelicher VF . “Recovery only” ST-segment depres- sion and the predictive accuracy of the exercise test. Ann Intern Med. 1990;112(1):11–6. 35. Lauer M, Froelicher ES, Williams M, et al. Exercise testing in asymptomatic adults: a statement for professionals from the American Heart Association Council on Clinical Cardiology, Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation. 2005;112(5):771–6. 36. Lavie CJ, Oh JK, Mankin HT, Clements IP, Giuliani ER, Gibbons RJ. Significance of T-wave pseudo- normalization during exercise. A radionuclide angiographic study. Chest. 1988;94(3):512–6. 37. Lucia A, Rabadan M, Hoyos J, et al. Frequency of the VO2max plateau phenomenon in world-class cyclists. Int J Sports Med. 2006;27(12):984–92. 38. Mahajan N, Polavaram L, Vankayala H, et al. Diagnostic accuracy of myocardial perfusion imaging and stress echocardiography for the diagnosis of left main and triple vessel coronary artery disease: a comparative meta-analysis. Heart. 2010;96(12):956–66. 39. Mark DB, Hlatky MA, Harrell FE,Jr, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for pre- dicting prognosis in coronary artery disease. Ann Intern Med. 1987;106(6):793–800. 40. Mark DB, Shaw L, Harrell FE,Jr, et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med. 1991;325(12):849–53. 41. Mirvis DM, Ramanathan KB, Wilson JL. Regional blood flow correlates of ST segment depression in tachycardia-induced myocardial ischemia. Circulation. 1986;73(2):365–73. 42. Morise AP. Accuracy of heart rate-adjusted ST segments in populations with and without posttest referral bias. Am Heart J. 1997;134(4):647–55. 43. Morrow K, Morris CK, Froelicher VF , et al. Prediction of cardiovascular death in men undergoing noninvasive evaluation for coronary artery disease. Ann Intern Med. 1993;118(9):689–95. 44. Myers J, Ahnve S, Froelicher V, Sullivan M. Spatial R wave amplitude changes during exercise: rela- tion with left ventricular ischemia and function. J Am Coll Cardiol. 1985;6(3):603–8. 45. Myers J, Froelicher VF . Hemodynamic determinants of exercise capacity in chronic heart failure. Ann Intern Med. 1991;115(5):377–86. 46. Noakes TD. Maximal oxygen uptake: “classical” versus “contemporary” viewpoints: a rebuttal. Med Sci Sports Exerc. 1998;30(9):1381–98. 47. Normal values. In: Wasserman K, Hansen JE, Sue DY, Stringer W, Whipp BJ, editors. Principles of Exercise Testing and Interpretation: Including Pathophysiology and Clinical Applications. 4th ed. Baltimore: Lippincott Williams Wilkins; 2005. p. 160–82. 48. Nosratian FJ, Froelicher VF . ST elevation during exercise testing. Am J Cardiol. 1989;63(13):986–8. 49. Okin PM, Kligfield P. Heart rate adjustment of ST segment depression and performance of the exer- cise electrocardiogram: a critical evaluation. J Am Coll Cardiol. 1995;25(7):1726–35. 50. Patterson RE, Horowitz SF . Importance of epidemiology and biostatistics in deciding clinical strate- gies for using diagnostic tests: a simplified approach using examples from coronary artery disease. J Am Coll Cardiol. 1989;13(7):1653–65.
- 186. 160 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 51. Pescatello LS, Franklin BA, Fagard R, et al. American College of Sports Medicine position stand. Exercise and hypertension. Med Sci Sports Exerc. 2004;36(3):533–53. 52. Pinkstaff S, Peberdy MA, Kontos MC, Finucane S, Arena R. Quantifying exertion level during exer- cise stress testing using percentage of age-predicted maximal heart rate, rate pressure product, and perceived exertion. Mayo Clin Proc. 2010;85(12):1095–100. 53. Rosso R, Kogan E, Belhassen B, et al. J-point elevation in survivors of primary ventricular fibril- lation and matched control subjects: incidence and clinical significance. J Am Coll Cardiol. 2008; 52(15):1231–8. 54. Swain DP, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams Wilkins; 2014. 55. Syme AN, Blanchard BE, Guidry MA, et al. Peak systolic blood pressure on a graded maximal exer- cise test and the blood pressure response to an acute bout of submaximal exercise. Am J Cardiol. 2006;98(7):938–43. 56. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol. 2001;37(1):153–6. 57. Tikkanen JT, Anttonen O, Junttila MJ, et al. Long-term outcome associated with early repolarization on electrocardiography. N Engl J Med. 2009;361(26):2529–37. 58. Wasserman K, Whipp BJ, Koyl SN, Beaver WL. Anaerobic threshold and respiratory gas exchange during exercise. J Appl Physiol. 1973;35(2):236–43. 59. Whinnery JE, Froelicher VF ,Jr, Longo MR Jr, Triebwasser JH. The electrocardiographic response to maximal treadmill exercise of asymptomatic men with right bundle branch block. Chest. 1977;71(3):335–40.
- 187. SECTION 161 Exercise Prescription III SECTION III DEBORAH RIEBE, PHD, FACSM, ACSM-HFS, Associate Editor
- 188. 162 CHAPTER General Principles of Exercise Prescription 7 AN INTRODUCTION TO THE PRINCIPLES OF EXERCISE PRESCRIPTION The scientific evidence demonstrating the beneficial effects of exercise is indisput- able, and the benefits of exercise far outweigh the risks in most adults (20,38) (see Chapters 1 and 2). An exercise training program ideally is designed to meet individual health and physical fitness goals. The principles of exercise prescrip- tion (Ex Rx ) presented in this chapter are intended to guide health/fitness, public health, clinical exercise, and health care professionals in the development of an individually tailored Ex Rx for the apparently healthy adult whose goal is to improve physical fitness and health and also may apply to adults with certain chronic diseases, disabilities, or health conditions, when appropriately screened (see Chapters 2, 8–10). Recreational and competitive athletes will benefit from more advanced training techniques than are presented in this chapter. This edi- tion of the Guidelines employs the Frequency (how often), Intensity (how hard), Time (duration or how long), and Type (mode or what kind), with the addition of total Volume (amount) and Progression (advancement) or the FITT-VP principle of Ex Rx to be consistent with the American College of Sports Medicine (ACSM) recommendations made in its companion evidence-based position stand (20). The FITT-VP principles of Ex Rx presented in this chapter are based on the application of the existing scientific evidence on the physiologic, psychological, and health benefits of exercise (20) (see Chapter 1). Nonetheless, some indi- viduals may not respond as expected because there is appreciable individual variability in the magnitude of response to a particular exercise regimen (20). Furthermore, the FITT-VP principle of Ex Rx may not apply because of indi- vidual characteristics (e.g., health status, physical ability, age) or athletic and performance goals. For individuals with clinical conditions and healthy indi- viduals with special considerations, accommodations should be made to the Ex Rx as indicated in other related chapters of the Guidelines (see Chapters 8–10). For most adults, an exercise program including aerobic, resistance, flexibil- ity, and neuromotor exercise training is indispensable to improve and maintain physical fitness and health (20). Details of the FITT-VP principle of the Ex Rx are provided later in this chapter. These Ex Rx guidelines present recommended
- 189. CHAPTER 7 General Principles of Exercise Prescription 163 targets for exercise derived from the available scientific evidence showing most individuals will realize benefit when following the stated quantity and quality of exercise. However, some individuals will want to or need to include only some of the health-related components of physical fitness in their training regimen or exercise less than suggested by the guidelines presented in this chapter. Even if an individual cannot meet the recommended targets in this chapter, performing some exercise is beneficial, especially in inactive or deconditioned individuals, and, for that reason, should be encouraged except where there are safety concerns. The guidelines presented in Chapter 7 are consistent with other evidence- based exercise recommendations including relevant ACSM position stands (5,17,20,25,32) and other professional scientific statements (7,38,51,54). GENERAL CONSIDERATIONS FOR EXERCISE PRESCRIPTION A program of regular exercise for most adults should include a variety of exer- cises beyond activities performed as part of daily living (20). The optimal Ex Rx should address the health-related physical fitness components of cardiorespira- tory (aerobic) fitness (CRF), muscular strength and endurance, flexibility, body composition, and neuromotor fitness. Reduction in the time spent in sedentary activities (e.g., television watching, computer use, sitting in a car or at a desk) in addition to regular exercise is important for the health of physically active and inactive individuals. As detailed elsewhere, long periods of sedentary activity are associated with elevated risks of cardiovascular disease (CVD) mortality, wors- ened cardiometabolic disease biomarkers, and depression (20,34). Even in physi- cally active individuals who meet the recommended targets for exercise, periods of physical inactivity are detrimental to health (20,34). When periods of physical inactivity are broken up by short bouts of standing or physical activity (e.g., a very short walk around the office or home), the adverse effects of physical inactivity are reduced (20,34). Therefore, the Ex Rx should include a plan to decrease peri- ods of physical inactivity in addition to an increase in physical activity (20,31,34). Overuse injuries (i.e., tissue damage resulting from repetitive demand over time, termed cumulative trauma disorders) and other musculoskeletal injuries are of concern to adults. To reduce the potential for overuse disorders and injury, an assortment of exercise modalities may be helpful (20). Common components of the Ex Rx seem to be helpful at least under some circumstances to reduce muscu- loskeletal injury and complications. These include the warm-up and cool-down, stretching exercises, and gradual progression of volume and intensity (20). The serious risk of CVD complications, which is of particular concern in middle-aged and older adults, can be minimized by (a) following the preparticipation health screening and evaluation procedures outlined in Chapters 2 and 3, respectively; (b) beginning a new program of exercise at light-to-moderate intensity; and (c) employing a gradual progression of the quantity and quality of exercise (20). Also important to the Ex Rx are behavioral factors that may enhance the adoption and adherence to exercise participation (see Chapter 11). Bone health is of great importance to younger and older adults (see Chapters 8 and 10), especially among women. The ACSM recommends loading exercises
- 190. 164 GUIDELINES FOR EXERCISE TESTING • www.acsm.org (i.e., weight bearing and resistance exercise) to maintain bone health (4,5,7,20,32), and these types of exercises should be part of an exercise program, particularly in individuals at risk for low bone density (i.e., osteopenia) and osteoporosis. An individual’s goals, physical ability, physical fitness, health status, schedule, physical and social environment, and available equipment and facilities should be considered when designing the FITT-VP principle of Ex Rx for a client or patient. Box 7.1 provides general recommendations for the components to be included in an exercise training session for apparently healthy adults. This chapter presents the scientific evidence-based recommendations for aerobic, resistance, flexibility, and neuromotor exercise training based on a combination of the FITT-VP principles of Ex Rx . The following sections present specific rec- ommendations for the Ex Rx to improve health and fitness. COMPONENTS OF THE EXERCISE TRAINING SESSION A single exercise session should include the following phases: • Warm-up. • Conditioning and/or sports-related exercise. • Cool-down. • Stretching. The warm-up phase consists of a minimum of 5–10 min of light-to-moderate intensity aerobic and muscular endurance activity (see Table 7.1 for definitions of exercise intensity). The warm-up is a transitional phase that allows the body to adjust to the changing physiologic, biomechanical, and bioenergetic demands placed on it during the conditioning or sports phase of the exercise session. Warming up also improves range of motion (ROM) and may reduce the risk of injury (20). For the purpose of enhancing the performance of cardiorespiratory Warm-up: at least 5–10 min of light-to-moderate intensity cardiorespiratory and muscular endurance activities Conditioning: at least 20–60 min of aerobic, resistance, neuromotor, and/ or sports activities (exercise bouts of 10 min are acceptable if the individual accumulates at least 20–60 min ⭈ d⫺1 of daily aerobic exercise) Cool-down: at least 5–10 min of light-to-moderate intensity cardiorespiratory and muscular endurance activities Stretching: at least 10 min of stretching exercises performed after the warm-up or cool-down phase Adapted from (20,52). Components of the Exercise Training Session BOX 7.1
- 191. CHAPTER 7 General Principles of Exercise Prescription 165 TABLE 7.1. Methods of Estimating Intensity of Cardiorespiratory and Resistance Exercise Cardiorespiratory Endurance Exercise Resistance Exercise Relative Intensity Intensity (%V . O2max ) Relative to Maximal Exercise Capacity in MET Absolute Intensity Absolute Intensity (MET) by Age Relative Intensity Intensity %HRR or %V . O2 R %HRmax %V . O2max Perceived Exertion (Rating on 6–20 RPE Scale) 20 METs %V . O2max 10 METs %V . O2max 5 METs %V . O2max MET Young (20–39 yr) Middle Age (40–64 yr) Older (ⱖ65 yr) % One Repetition Maximum Very light ⬍30 ⬍57 ⬍37 Very light (RPE ⱕ9) ⬍34 ⬍37 ⬍44 ⬍2 ⬍2.4 ⬍2.0 ⬍1.6 ⬍30 Light 30–⬍40 57–⬍64 37–⬍45 Very light to fairly light (RPE 9–11) 34–⬍43 37–⬍46 44–⬍52 2.0–⬍3 ⬍4.8 ⬍4.0 ⬍3.2 30–⬍50 Moderate 40–⬍60 64–⬍76 46–⬍64 Fairly light to somewhat hard (RPE 12–13) 43–⬍62 46–⬍64 52–⬍68 3.0–⬍6 4.8–⬍7 .2 4.0–⬍6.0 3.2–⬍4.8 50–⬍70 Vigorous 60–⬍90 76–⬍96 64–⬍91 Somewhat hard to very hard (RPE 14–17) 62–⬍91 64–⬍91 68–⬍92 6.0–⬍8.8 7 .2–⬍10.2 6.0–⬍8.5 4.8–⬍6.8 70–⬍85 Near maximal to maximal ⱖ90 ⱖ96 ⱖ91 ⱖ Very hard (RPE ⱖ18) ⱖ91 ⱖ91 ⱖ92 ⱖ8.8 ⱖ10.2 ⱖ8.5 ⱖ6.8 ⱖ85 HRmax , maximal heart rate; HRR, heart rate reserve; MET, metabolic equivalent; RPE, rating of perceived exertion; V̇O2max , maximum oxygen consumption; V̇O2 R, oxygen uptake reserve. Adapted from (20).
- 192. 166 GUIDELINES FOR EXERCISE TESTING • www.acsm.org endurance, aerobic exercise, sports, or resistance exercise, especially activities that are of long duration or with many repetitions, a dynamic, cardiorespiratory endurance exercise warm-up is superior to flexibility exercise (20). The conditioning phase includes aerobic, resistance, flexibility, and neuro- motor exercise, and/or sports activities. Specifics about these modes of exercise are discussed in subsequent sections of this chapter. The conditioning phase is followed by a cool-down period involving aerobic and muscular endurance activ- ity of light-to-moderate intensity lasting at least 5–10 min. The purpose of the cool-down period is to allow for a gradual recovery of heart rate (HR) and blood pressure (BP) and removal of metabolic end products from the muscles used during the more intense exercise conditioning phase. The stretching phase is distinct from the warm-up and cool-down phases and may be performed following the warm-up or cool-down phase or following the application of heat packs, because warming the muscles improves ROM (20). AEROBIC (CARDIORESPIRATORY ENDURANCE) EXERCISE FREQUENCY OF EXERCISE The frequency of physical activity (i.e., the number of days per week dedicated to an exercise program) is an important contributor to health/fitness benefits that result from exercise. Aerobic exercise is recommended on 3–5 d ⭈ wk⫺1 for most adults, with the frequency varying with the intensity of exercise (20,25,32,38,52). Improvements in CRF are attenuated with exercise frequencies ⬎3 d ⭈ wk⫺1 and a plateau in improvement with exercise done ⬎5 d ⭈ wk⫺1 (20). Vigorous intensity exercise performed ⬎5 d ⭈ wk⫺1 might increase the incidence of musculoskeletal injury, so this amount of vigorous intensity, physical activity is not recommended for most adults (20). However, if a variety of exercise modes placing different impact stresses on the body (e.g., running, cycling) or using dif- ferent muscle groups (e.g., swimming, running) are included in the exercise pro- gram, daily vigorous intensity, physical activity may be recommended for some individuals. Alternatively, a weekly combination of 3 to 5 d ⭈ wk⫺1 of moderate and vigorous intensity exercise can be performed (20,32,52). Health/fitness benefits can occur in some individuals who exercise once or twice per week at moderate-to-vigorous intensity, especially with large volumes of exercise as can occur in the “weekend warrior” pattern of exercise (20). In spite of the possible benefits, exercising 1–2 times ⭈ wk⫺1 is not recommended for the most adults because the risk of musculoskeletal injury and adverse car- diovascular events is higher in individuals who are not physically active on a regular basis and those who engage in unaccustomed exercise (20). AEROBIC EXERCISE FREQUENCY RECOMMENDATION Moderate intensity, aerobic exercise done at least 5 d ⭈ wk⫺1 ; or vigorous intensity, aerobic exercise done at least 3 d ⭈ wk⫺1 ; or a weekly
- 193. CHAPTER 7 General Principles of Exercise Prescription 167 INTENSITY OF EXERCISE There is a positive dose response of health/fitness benefits that results from in- creasing exercise intensity (20). The overload principle of training states exercise below a minimum intensity, or threshold, will not challenge the body sufficiently to result in changes in physiologic parameters, including increased maximal oxygen consumption (V̇O2max ) (20). However, more recent findings demonstrate the minimum threshold of intensity for benefit seems to vary depending on an individual’s CRF level and other factors such as age, health status, physiologic differences, genetics, habitual physical activity, and social and psychological fac- tors (20,46,47). Therefore, it may be difficult to precisely define an exact thresh- old to improve CRF (20,46). For example, individuals with an exercise capacity of 11–14 metabolic equivalents (METs) seemingly require an exercise intensity of at least 45% oxygen uptake reserve (V̇O2 R) to increase V̇O2max , but no threshold is apparent in individuals with a baseline fitness of ⬍11 METs (20,46). Highly trained athletes may need to exercise at “near maximal” (i.e., 95%–100% V̇O2max ) training intensities to improve V̇O2max , whereas 70%–80% V̇O2max may provide a sufficient stimulus in moderately trained athletes (20,46). Interval training involves varying the exercise intensity at fixed intervals dur- ing a single exercise bout. The duration and intensity of the intervals can be varied depending on the goals of the training session and physical fitness level of the client or patient. Interval training can increase the total volume and/or av- erage exercise intensity performed during an exercise session. Improvements in CRF and cardiometabolic biomarkers with short-term (ⱕ3 mo) interval training are similar to or greater than with single intensity exercise in healthy adults and individuals with metabolic, cardiovascular, or pulmonary disease (20). The use of interval training in adults appears beneficial, but the long-term effects and the safety of interval training remain to be evaluated. AEROBIC EXERCISE INTENSITY RECOMMENDATION Moderate (e.g., 40%–⬍60% heart rate reserve [HRR] or V̇O2 R) to vigor- ous (e.g., 60%–⬍90% HRR or V̇O2 R) intensity aerobic exercise is recom- mended for most adults, and light (e.g., 30%–⬍40% HRR or V̇O2 R) to moderate intensity aerobic exercise can be beneficial in individuals who are deconditioned. Interval training may be an effective way to increase the total volume and/or average exercise intensity performed during an exercise session and may be beneficial for adults. combination of 3–5 d ⭈ wk⫺1 of moderate and vigorous intensity exercise is recommended for most adults to achieve and maintain health/fitness benefits.
- 194. 168 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Methods of Estimating Intensity of Exercise Several effective methods for prescribing exercise intensity result in improve- ments in CRF that can be recommended for individualized Ex Rx (20). Table 7.1 shows the approximate classification of exercise intensity commonly used in practice. One method of determining exercise intensity is not necessarily equiva- lent to the intensity derived using another method, because no studies have com- pared all of the methods of measurement of exercise intensity simultaneously. In addition, the relationships among measures of actual energy expenditure (EE) and the absolute (i.e., V̇O2 and METs) and relative methods to prescribe exercise intensity (i.e., %HRR, %HRmax [maximal heart rate], and %V̇O2max ) can vary con- siderably depending on exercise test protocol, exercise mode, exercise intensity, and characteristics of the client or patient (i.e., resting HR, physical fitness level, age, and body composition) as well as other factors (20). The HRR or V̇O2 R methods may be preferable for Ex Rx because exercise intensity can be underestimated or overestimated when using the HR (i.e., %HRmax ) or V̇O2 (i.e., %V̇O2max ) methods (20,44). However, the advantage of the HRR or V̇O2 R methods is not universally accepted (20,44). Furthermore, the accuracy of any of these methods may be influenced by the method of mea- surement or estimation used (20). The formula “220 ⫺ age” is commonly used to predict HRmax (19). This for- mula is simple to use, but it can underestimate or overestimate measured HRmax (21,23,48,58). Specialized regression equations for estimating HRmax may be su- perior to the equation of 220 ⫺ age, at least in some individuals (21,26,48,58). Although these equations are promising, they cannot yet be recommended for universal application, although they may be applied to populations similar to those in which they were derived (20). Table 7.2 shows some of the more com- monly used equations to estimate HRmax . For greater accuracy in determining exercise intensity for the Ex Rx , using the directly measured HRmax is preferred to estimated methods; but when not feasible, estimation of exercise intensity is acceptable. Measured or estimated measures of absolute exercise intensity include caloric expenditure (kcal ⭈ min⫺1 ), absolute oxygen uptake (mL ⭈ min⫺1 or L ⭈ min⫺1 ), and METs. These absolute measures can result in misclassification TABLE 7.2. Commonly Used Equations for Estimating Maximal Heart Rate Author Equation Population Fox (19) HRmax ⫽ 220 ⫺ age. Small group of men and women Astrand (9) HRmax ⫽ 216.6 ⫺ (0.84 ⫻ age) Men and women ages 4⫺34 yr Tanaka (48) HRmax ⫽ 208 ⫺ (0.7 ⫻ age) Healthy men and women Gellish (21) HRmax ⫽ 207 ⫺ (0.7 ⫻ age) Men and women participants in an adult fitness program with broad range of age and fitness levels Gulati (23) HRmax ⫽ 206 ⫺ (0.88 ⫻ age) Asymptomatic middle-aged women referred for stress testing HRmax , maximum heart rate.
- 195. CHAPTER 7 General Principles of Exercise Prescription 169 of exercise intensity (e.g., moderate and vigorous intensity) because they do not take into consideration individual factors such as body weight, sex, and fitness level (1,2,27). Measurement error, and consequently misclassification, is greater when using estimated rather than directly measured absolute EE and under free living compared to laboratory conditions (1,2,27). For example, an older individual working at 6 METs may be exercising at a vigorous-to- maximal intensity, whereas a younger individual working at the same absolute intensity will be exercising moderately (27). Therefore, for individual Ex Rx , a relative measure of intensity (i.e., the energy cost of the activity relative to the individual’s maximal capacity such as % V̇O2 [i.e., V̇O2 mL ⭈ kg⫺1 ⭈ min⫺1 ], HRR, and V̇O2 R) is more appropriate, especially for older and deconditioned individuals (27,32). A summary of methods for calculating exercise intensity using HR, V̇O2 , and METs are presented in Box 7.2. Intensity of exercise training is usually determined as a range so the calculation using the formulae presented in Box 7.2 need to be repeated twice (i.e., once for the lower limit of the desired in- tensity range and once for the upper limit of the desired intensity range). The prescribed exercise intensity range for an individual should be determined by taking various factors into consideration, including age, habitual physical ac- tivity level, physical fitness level, and health status. Examples illustrating the use of several methods for prescribing exercise intensity are found in Figure 7.1. The reader is directed to other ACSM publications (e.g., [20,45] for fur- ther explanation and examples using these additional methods of prescribing exercise intensity). • HRR method: Target HR (THR) ⫽ [(HRmax/peak a ⫺ HRrest ) ⫻ % intensity desired] ⫹ HRrest • V̇O2 R method: Target V̇O2 Rc ⫽ [(V̇O2max/peak b ⫺ V̇O2rest ) ⫻ % intensity desired] ⫹ V̇O2rest • HR method: Target HR ⫽ HRmax/peak a ⫻ % intensity desired • V̇O2 method: Target V̇O2 c ⫽ V̇O2max/peak b ⫻ % intensity desired • MET method: Target METc ⫽ [(V̇O2max/peak b )/3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ] ⫻ % intensity desired a HRmax/peak is the highest value obtained during maximal/peak exercise or it can be estimated by 220 ⫺ age or some other prediction equation (see Table 7 .2). b V̇O2max/peak is the highest value obtained during maximal/peak exercise or it can be estimated from a submaximal exercise test. Please see The Concept of Maximal Oxygen Uptake in Chapter 4 for the distinction between V̇O2max and V̇O2peak . c Activities at the target V̇O2 and MET can be determined using a compendium of physical activity (1, 2) or metabolic calculations (22) (Table 7 .3). HRmax/peak , maximal or peak heart rate; HRrest , resting heart rate; HRR, heart rate reserve; V̇O2 R, oxygen uptake reserve. Summary of Methods for Prescribing Exercise Intensity Using Heart Rate (HR), Oxygen Uptake (V̇O2 ), and Metabolic Equivalents (METs) BOX 7.2
- 196. 170 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Heart Rate Reserve (HRR) Method Available test data: HRrest : 70 beats ⭈ min⫺1 HRmax : 180 beats ⭈ min⫺1 Desired exercise intensity range: 50%–60% Formula: Target Heart Rate (THR) ⫽ [(HRmax ⫺ HRrest ) ⫻ % intensity] ⫹ HRrest 1) Calculation of HRR: HRR ⫽ (HRmax ⫺ HRrest ) HRR ⫽ (180 beats ⭈ min⫺1 ⫺ 70 beats ⭈ min⫺1 ) ⫽ 110 beats ⭈ min⫺1 2) Determination of exercise intensity as %HRR: Convert desired %HRR into a decimal by dividing by 100 %HRR ⫽ desired intensity ⫻ HRR %HRR ⫽ 0.5 ⫻ 110 beats ⭈ min⫺1 ⫽ 55 beats ⭈ min⫺1 %HRR ⫽ 0.6 ⫻ 110 beats ⭈ min⫺1 ⫽ 66 beats ⭈ min⫺1 3) Determine THR range: THR ⫽ (%HRR) ⫹ HRrest To determine lower limit of THR range: THR ⫽ 55 beats ⭈ min⫺1 ⫹ 70 beats ⭈ min⫺1 ⫽ 125 beats ⭈ min⫺1 To determine upper limit of THR range: THR ⫽ 66 beats ⭈ min⫺1 ⫹ 70 beats ⭈ min⫺1 ⫽ 136 beats ⭈ min⫺1 THR range: 125 beats ⭈ min⫺1 to 136 beats ⭈ min⫺1 V̇O2 Reserve (V̇O2 R) Method Available test data: V̇O2max : 30 mL ⭈ kg⫺1 ⭈ min⫺1 V̇O2rest : 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 Desired exercise intensity range: 50%–60% Formula: Target V̇O2 ⫽ [(V̇O2max ⫺ V̇O2rest ) ⫻ % intensity] ⫹ V̇O2rest 1) Calculation of V̇O2 R: V̇O2 R ⫽ V̇O2max ⫺ V̇O2rest V̇O2 R ⫽ 30 mL ⭈ kg⫺1 ⭈ min⫺1 ⫺ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 V̇O2 R ⫽ 26.5 mL ⭈ kg⫺1 ⭈ min⫺1 2) Determination of exercise intensity as %V̇O2 R: Convert desired intensity (%V̇O2 R) into a decimal by dividing by 100 %V̇O2 R ⫽ desired intensity ⫻ %V̇O2 R Calculate %V̇O2 R: %V̇O2 R ⫽ 0.5 ⫻ 26.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 13.3 mL ⭈ kg⫺1 ⭈ min⫺1 %V̇O2 R ⫽ 0.6 ⫻ 26.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 15.9 mL ⭈ kg⫺1 ⭈ min⫺1 3) Determine target V̇O2 R range: (%V̇O2 R) ⫹ V̇O2rest To determine the lower target V̇O2 range: Target V̇O2 ⫽ 13.3 mL ⭈ kg⫺1 ⭈ min⫺1 ⫹ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 16.8 mL ⭈ kg⫺1 ⭈ min⫺1 To determine upper target V̇O2 range: Target V̇O2 ⫽ 15.9 mL ⭈ kg⫺1 ⭈ min⫺1 ⫹ 3.5 mL ⭈ kg1 ⭈ min⫺1 ⫽ 19.4 mL ⭈ kg⫺1 ⭈ min⫺1 Target V̇O2 range: 16.8 mL ⭈ kg⫺1 ⭈ min⫺1 to 19.4 mL ⭈ kg⫺1 ⭈ min⫺1 ■ FIGURE 7.1. Examples of the application of various methods for prescribing exercise intensity. HRmax, , maximal heart rate; HRrest , resting heart rate; MET, metabolic equivalent; V̇O2 , volume of oxygen consumed per unit of time; V̇O2max , maximal volume of oxygen consumed per unit of time. Adapted from (49).
- 197. CHAPTER 7 General Principles of Exercise Prescription 171 4) Determine MET target range (optional): 1 MET ⫽ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 Calculate lower MET target: 1 MET/3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ ⫻ MET/16.8 mL ⭈ kg⫺1 ⭈ min⫺1 ⫻ MET ⫽ 16.8 mL ⭈ kg⫺1 ⭈ min⫺1 /3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 4.8 METs Calculate upper MET target: 1 MET/3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ ⫻ MET/19.4 mL ⭈ kg⫺1 ⭈ min⫺1 ⫻ MET ⫽ 19.4 mL ⭈ kg⫺1 ⭈ min⫺1 /3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 5.5 METs 5) Identify physical activities requiring EE within the target range from compendium of physical activities (1,2) or by using metabolic calcula- tions shown in Table 7 .3 or reference (22). Also see the following exam- ples of use of metabolic equations. %HRmax (Measured Or Estimated) Method: Available data: A man 45 yr of age Desired exercise intensity: 70%–80% Formula: THR ⫽ HRmax ⫻ desired % Calculate estimated HRmax (if measured HRmax not available): HRmax ⫽ 220 ⫺ age HRmax ⫽ 220 ⫺ 45 ⫽ 175 beats ⭈ min⫺1 1) Determine THR range: THR ⫽ Desired % ⫻ HRmax Convert desired % HRmax into a decimal by dividing by 100 Determine lower limit of THR range: THR ⫽ 175 beats ⭈ min⫺1 ⫻ 0.70 ⫽ 123 beats ⭈ min⫺1 Determine upper limit of THR range: THR ⫽ 175 beats ⭈ min⫺1 ⫻ 0.80 ⫽ 140 beats ⭈ min⫺1 THR range: 123 beats ⭈ min⫺1 to 140 beats ⭈ min⫺1 %V̇O2 (Measured or Estimated) Method Available data: A woman 45 yr of age Estimated V̇O2max : 30 mL ⭈ kg⫺1 ⭈ min⫺1 Desired V̇O2 range: 50%–60% Formula: V̇O2max ⫻ desired % Determine target V̇O2 range: Target V̇O2 ⫽ Desired % ⫻ V̇O2max Convert desired intensity (%V̇O2 ) into a decimal by dividing by 100 Determine lower limit of target V̇O2 range: Target V̇O2 ⫽ 0.50 ⫻ 30 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 15 mL ⭈ kg⫺1 ⭈ min⫺1 Determine upper limit of target V̇O2max range: Target V̇O2 ⫽ 0.60 ⫻ 30 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 18 mL ⭈ kg⫺1 ⭈ min⫺1 Target V̇O2 range: 15 mL ⭈ kg⫺1 ⭈ min⫺1 to 18 mL ⭈ kg⫺1 ⭈ min⫺1 1) Determine MET target range (optional): 1 MET ⫽ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 Calculate lower MET target: 1 MET/3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ ⫻ MET/15.0 mL ⭈ kg⫺1 ⭈ min⫺1 ⫻ MET ⫽ 15.0 mL ⭈ kg⫺1 ⭈ min⫺1 /3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 4.3 METs Calculate upper MET target: 1 MET/3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ ⫻ MET/18.0 mL ⭈ kg⫺1 ⭈ min⫺1 ⫻ MET ⫽ 18.0 mL ⭈ kg⫺1 ⭈ min⫺1 /3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 5.1 METs ■ Figure 7.1. (Continued)
- 198. 172 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 2) Identify physical activities requiring EE within the target range from compendium of physical activities (1,2) or by using metabolic calcula- tions shown in Table 7 .3 and reference (22). See the following examples of use of metabolic equations. Using metabolic calculations (22) or (Table 7 .3) to determine running speed on a treadmill Available data: A man 32 yr of age Weight: 130 lb (59 kg) Height: 70 in (177 .8 cm) V̇O2max : 54 mL ⭈ kg⫺1 ⭈ min⫺1 Desired treadmill grade: 2.5% Desired exercise intensity: 80% Formula: V̇O2 ⫽ 3.5 ⫹ (0.2 ⫻ speed) ⫹ (0.9 ⫻ speed ⫻ % grade) 1. Determine target V̇O2 : Target V̇O2 ⫽ desired % ⫻ V̇O2max Target V̇O2 ⫽ 0.80 ⫻ 54 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 43.2 mL ⭈ kg⫺1 ⭈ min⫺1 2. Determine treadmill speed: V̇O2 ⫽ 3.5 ⫹ (0.2 ⫻ speed) ⫹ (0.9 ⫻ speed ⫻ % grade) 43.2 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 3.5 ⫹ (0.2 ⫻ speed) ⫹ (0.9 ⫻ speed ⫻ 0.025) 39.7 ⫽ (0.2 ⫻ speed) ⫹ (0.9 ⫻ speed ⫻ 0.025) 39.7 ⫽ (0.2 ⫻ speed) ⫹ (0.0225 ⫻ speed) 39.7 ⫽ 0.2225 ⫻ speed 178.4 m ⭈ min⫺1 ⫽ speed Speed on treadmill: 10.7 km ⭈ h⫺1 (6.7 mi ⭈ h1 ) Using metabolic calculations (22) (Table 7 .2) to determine % grade during walking on a treadmill Available data: A man 54 yr of age who is moderately physically active Weight: 190 lb (86.4 kg) Height: 70 in (177 .8 cm) Desired walking speed: 2.5 mi ⭈ h⫺1 (4 km ⭈ h⫺1 ; 67 m ⭈ min⫺1 ) Desired MET: 5 METs Formula: V̇O2 ⫽ 3.5 ⫹ (0.1 ⫻ speed) ⫹ (1.8 ⫻ speed ⫻ % grade) 1. Determine target V̇O2 : Target V̇O2 ⫽ MET ⫻ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 Target V̇O2 ⫽ 5 ⫻ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 17 .5 mL ⭈ kg⫺1 ⭈ min⫺1 2. Determine treadmill grade: V̇O2 ⫽ 3.5 ⫹ (0.1 ⫻ speed) ⫹ (1.8 ⫻ speed ⫻ % grade) 17 .5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 3.5 ⫹ (0.1 ⫻ 67 m ⭈ s⫺1 ) ⫹ (1.8 ⫻ 67 m ⭈ s⫺1 ⫻ % grade) 14 ⫽ (0.1 ⫻ 67 m ⭈ s⫺1 ) ⫹ (1.8 ⫻ 67 m ⭈ s⫺1 ⫻ % grade) 14 ⫽ 6.7 ⫹ (120.6 ⫻ % grade) 7 .3 ⫽ 120.6 ⫻ % grade 0.06 ⫽ % grade % grade ⫽ 6% ■ Figure 7.1. (Continued)
- 199. CHAPTER 7 General Principles of Exercise Prescription 173 Using metabolic calculations (22) (Table 7 .3) to determine target work rate (kg ⭈ m ⭈ min⫺1 ) on a Monarch leg cycle ergometer Available data: A woman 42 yr of age Weight: 190 lb (86.4 kg) Height: 70 in (177 .8 cm) Desired V̇O2 : 18 kg ⭈ m ⭈ min⫺1 Formula: V̇O2 ⫽ 7 .0 ⫹ (1.8 ⫻ work rate)/body mass 1. Calculate work rate on cycle ergometer: V̇O2 ⫽ 7 .0 ⫹ (1.8 ⫻ work rate)/body mass) 18 mL ⭈ kg⫺1 ⭈ min⫺1 ⫽ 7 .0 ⫹ (1.8 ⫻ work rate)/86.4 kg 11 ⫽ (1.8 ⫻ work rate)/86.4 950.4 ⫽ 1.8 ⫻ work rate 528 ⫽ work rate Work rate ⫽ 528 kg ⭈ m ⭈ min⫺1 ⫽ 86.6 W ■ Figure 7.1. (Continued) TABLE 7.3. Metabolic Calculations for the Estimation of Energy Expenditure (V̇O2max [mL ⭈ kg⫺1 ⭈ min⫺1 ]) During Common Physical Activities Sum of Resting ⫹ Horizontal ⫹ Vertical/Resistance Components Activity Resting Component Horizontal Component Vertical Component/ Resistance Component Limitations Walking 3.5 0.1 ⫻ speeda 1.8 ⫻ speeda ⫻ gradeb Most accurate for speeds of 1.9–3.7 mi ⭈ h⫺1 (50–100 m ⭈ min⫺1 ) Running 3.5 0.2 ⫻ speed a 0.9 ⫻ speed a ⫻ gradeb Most accurate for speeds ⬎5 mi ⭈ h⫺1 (134 m ⭈ min⫺1 ) Stepping 3.5 0.2 ⫻ steps ⭈ min⫺1 1.33 ⫻ (1.8 ⫻ step heightc ⫻ steps ⭈ min⫺1 ) Most accurate for stepping rates of 12–30 steps ⭈ min⫺1 Leg cycling 3.5 3.5 (1.8 ⫻ work rated )/ body masse Most accurate for work rates of 300– 1,200 kg ⭈ m ⭈ min⫺1 (50–200 W) Arm cycling 3.5 (3 ⫻ work rated )/ body masse Most accurate for work rates between 150–750 kg ⭈ m ⭈ min⫺1 (25–125 W) a Speed in m ⭈ min⫺1 . b Grade is percent grade expressed in decimal format (e.g., 10% ⫽ 0.10). c Step height in m. Multiply by the following conversion factors: lb to kg: 0.454; in to cm: 2.54; ft to m: 0.3048; mi to km: 1.609; mi ⭈ h⫺1 to m ⭈ min⫺1 : 26.8; kg ⭈ m ⭈ min⫺1 to W: 0.164; W to kg ⭈ m ⭈ min⫺1 : 6.12; V̇O2max L ⭈ min⫺1 to kcal ⭈ min⫺1 : 4.9; V̇O2 MET to mL ⭈ kg⫺1 ⭈ min⫺1 : 3.5. d Work rate in kilogram meters per minute (kg ⭈ m ⭈ min⫺1 ) is calculated as resistance (kg) ⫻ distance per revolution of flywheel ⫻ pedal frequency per minute. Note: Distance per revolution is 6 m for Monark leg ergometer, 3 m for the Tunturi and BodyGuard ergometers, and 2.4 m for Monark arm ergometer. e Body mass in kg V̇O2max , maximal volume of oxygen consumed per unit of time. Adapted from (8).
- 200. 174 GUIDELINES FOR EXERCISE TESTING • www.acsm.org When using V̇O2 or METs to prescribe exercise, health/fitness, public health, clinical exercise, and health care professionals can identify activities within the desired V̇O2 or MET range by using a compendium of physical activities (1,2) or metabolic calculations (22) (see Table 7.3 and Figure 7.1). There are metabolic equations for estimation of EE during walking, running, cycling, and stepping. Although there are preliminary equations for other modes of exercise such as the elliptical trainer, there is insufficient data to recommend these for universal use at this time. A direct method of Ex Rx by plotting the relationship between HR and V̇O2 may be used when HR and V̇O2 are measured during an exercise test (see Figure 7.2). This method may be particularly useful when prescribing exercise in individuals taking medications such as -blockers or who have a chronic disease or health conditions such as diabetes mellitus or atherosclerotic CVD that alters the HR response to exercise (see Appendix A and Chapters 9 and 10). Measures of perceived effort and affective valence (i.e., the pleasantness of exercise) can be used to modulate or refine the prescribed exercise intensity (see Chapter 11). These include the Borg Rating of Perceived Exertion (RPE) Scales (12–14,33), OMNI Scales (40,41,55), Talk Test (35), and Feeling Scale (24). These methods have been validated against several physiologic markers, but the evidence is insufficient to support using these methods as a primary method of prescribing exercise intensity (20). EXERCISE TIME (DURATION) Exercise time/duration is prescribed as a measure of the amount of time physical activity is performed (i.e., time ⭈ session⫺1 , d⫺1 , and wk⫺1 ). It is recommended that most adults accumulate 30–60 min ⭈ d⫺1 (ⱖ150 min ⭈ wk⫺1 ) of moderate intensity exercise, 20–60 min ⭈ d⫺1 (ⱖ75 min ⭈ wk⫺1 ) of vigorous intensity exercise, or a combination of moderate and vigorous intensity exercise per day to attain the volumes of exercise recommended in the following discus- sion (20,52). However, less than 20 min of exercise per day can be beneficial, especially in previously sedentary individuals (20,52). For weight management, longer durations of exercise (ⱖ60–90 min ⭈ d⫺1 ) may be needed, especially in individuals who spend large amounts of time in sedentary behaviors (17). (See Chapter 10 and the ACSM position stand on overweight and obesity (17) for additional information regarding the Ex Rx recommendations for promoting and maintaining weight loss.) METHODS OF ESTIMATING INTENSITY Several methods can be used to estimate intensity during exercise. There are no studies available comparing all exercise in- tensity prescription methods simultaneously. Thus, the various methods described in this chapter to quantify exercise intensity may not necessarily be equivalent to each other (see Box 7.2).
- 201. CHAPTER 7 General Principles of Exercise Prescription 175 The recommended time/duration of physical activity may be performed continuously (i.e., one session) or intermittently and can be accumulated over the course of a day in one or more sessions of physical activity that total at least 10 min ⭈ session⫺1 . Exercise bouts of ⬍10 min may yield favorable adaptations in very deconditioned individuals, but further study is needed to confirm the effectiveness of these shorter bouts of exercise (20). 5 10 15 20 25 30 35 40 Heart rate (beats • min -1 ) VO2 (mL • kg-1 • min-1) 130 140 150 100 110 120 90 80 170 180 160 ■ FIGURE 7.2. Prescribing exercise heart rate using the relationship between heart rate and V̇O2 . A line of best fit has been drawn through the data points on this plot of HR and V̇O2 dur- ing a hypothetical exercise test in which V̇O2max was observed to be 38 mL ⭈ kg⫺1 ⭈ min⫺1 and HRmax was 184 beats ⭈ min⫺1 . A THR range was determined by finding the HR that corresponds to 50% and 85% V̇O2max . For this individual, 50% V̇O2max was ⬃19 mL ⭈ kg⫺1 ⭈ min⫺1 , and 85% V̇O2max was ⬃32 mL ⭈ kg⫺1 ⭈ min⫺1 . The corresponding THR range is 130–168 beats ⭈ min⫺1 (8). AEROBIC EXERCISE TIME (DURATION) RECOMMENDATION Most adults should accumulate 30–60 min ⭈ d⫺1 (ⱖ150 min ⭈ wk⫺1 ) of moderate intensity exercise, 20–60 min ⭈ d⫺1 (ⱖ75 min ⭈ wk⫺1 ) of vigor- ous intensity exercise, or a combination of moderate and vigorous intensity exercise daily to attain the recommended targeted volumes of exercise. This recommended amount of exercise may be accumulated in one continuous exercise session or in bouts of ⱖ10 min over the course of a day. Durations of exercise less than recommended can be beneficial in some individuals.
- 202. 176 GUIDELINES FOR EXERCISE TESTING • www.acsm.org EXERCISE VOLUME (QUANTITY) Exercise volume is the product of Frequency, Intensity, and Time (duration) or FIT of exercise. Evidence supports the important role of exercise volume in real- izing health/fitness outcomes, particularly with respect to body composition and weight management. Thus, exercise volume may be used to estimate the gross EE of an individual’s Ex Rx . MET-min ⭈ wk⫺1 and kcal ⭈ wk⫺1 can be used to esti- mate exercise volume in a standardized manner. Box 7.3 shows the definition and calculations for METs, MET-min, and kcal ⭈ min⫺1 for a wide array of physical activities. These variables can also be estimated using previously published tables (1, 2). MET-min and kcal ⭈ min⫺1 can then be used to calculate MET-min ⭈ wk⫺1 and kcal ⭈ wk⫺1 that is accumulated as part of an exercise program to evaluate whether the exercise volume is within the ranges described later in this chapter that will likely result in health/fitness benefits. The results of epidemiological studies and randomized clinical trials have shown there is a dose-response association between the volume of exercise and health/fitness outcomes (i.e., with greater amounts of physical activity, the Metabolic Equivalents (METs): An index of EE. “[A MET is the ratio of the rate of energy expended during an activity to the rate of energy expended at rest. . . . (One) MET is the rate of EE while sitting at rest . . . by convention, [1 MET is equal to] an oxygen uptake of 3.5 [mL ⭈ kg⫺1 ⭈ min⫺1 ]” (38). MET-min: An index of EE that quantifies the total amount of physical activity performed in a standardized manner across individuals and types of activities (38). Calculated as the product of the number of METs associated with one or more physical activities and the number of minutes the activities were performed (i.e., METs ⫻ min); usually standardized per week or per day as a measure of exercise volume. Kilocalorie (kcal): The energy needed to increase the temperature of 1 kg of water by 1° C. To convert METs to kcal ⭈ min⫺1 , it is necessary to know an individual’s body weight, kcal ⭈ min⫺1 ⫽ [( METs ⫻ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫻ body wt in kg) ⫼ 1000)] ⫻ 5. Usually standardized as kilocalorie per week or per day as a measure of exercise volume. Example: Jogging ( at ⬃7 METs) for 30 min on 3 d ⭈ wk⫺1 for a 70 kg male: 7 METs ⫻ 30 min ⫻ 3 times per week ⫽ 630 MET-min · wk⫺1 [(7 METs ⫻ 3.5 mL ⭈ kg⫺1 ⭈ min⫺1 ⫻ 70 kg) ⫼ 1000)] ⫻ 5 ⫽ 8.575 kcal· min⫺1 8.575 kcal ⭈ min⫺1 ⫻ 30 min ⫻ 3 times per week ⫽ 771.75 kcal · wk⫺1 Adapted from (20). Calculation of METs, MET-Min⫺1 , and Kcal ⭈ Min⫺1 BOX 7.3
- 203. CHAPTER 7 General Principles of Exercise Prescription 177 health/fitness benefits also increase) (16,20,52). It is not clear whether or not there is a minimum or maximum amount of exercise that is needed to attain health/fitness benefits. However, a total EE of ⱖ500–1,000 MET-min ⭈ wk⫺1 is consistently associated with lower rates of CVD and premature mortality. Thus, ⱖ500–1,000 MET-min ⭈ wk⫺1 is a reasonable target volume for an exercise pro- gram for most adults (20,52). This volume is approximately equal to (a) 1,000 kcal ⭈ wk⫺1 of moderate intensity, physical activity (or about 150 min wk⫺1 ); (b) an exercise intensity of 3–5.9 METs (for individuals weighing ⬃68–91 kg [⬃150–200 lb]); and (c) 10 MET-h ⭈ wk⫺1 (20,52). It should be noted that lower volumes of exercise (i.e., 4 kcal ⭈ kg⫺1 ⭈ wk⫺1 or 330 kcal ⭈ wk⫺1 ) can result in health/fitness benefits in some individuals, especially in individuals who are de- conditioned (16,20,52). Even lower volumes of exercise may also have benefit, but evidence is lacking to make definitive recommendations (20). Pedometers are effective tools for promoting physical activity and can be used to approximate exercise volume in steps per day (50). The goal of 10,000 steps ⭈ d⫺1 is often cited, but it appears that achieving a pedometer step count of at least 5,400–7,900 steps ⭈ d⫺1 can meet recommended exercise targets (20,50). To achieve step counts of 5,400–7,900 steps ⭈ d⫺1 , one can estimate total exercise volume by considering the following: (a) walking 100 steps ⭈ min⫺1 provides a very rough approximation of moderate intensity exercise; (b) walking 1 mile ⭈ d⫺1 yields about 2,000 steps ⭈ d⫺1 ; and (c) walking at a moderate intensity for 30 min ⭈ d⫺1 yields about 3,000–4,000 steps ⭈ d⫺1 (10,20,28,50). For weight management, higher step counts may be necessary, and a population-based study estimated men may require 11,000–12,000 steps ⭈ d⫺1 , and women 8,000–12,000 steps ⭈ d⫺1 , respectively, to maintain a normal weight (20,50). Because of the substantial errors of prediction when using pedometer step counts, using steps ⭈ min⫺1 combined with currently recommended time/durations of exercise (e.g., 100 steps ⭈ min⫺1 for 30 min ⭈ session⫺1 and 150 min ⭈ wk⫺1 ) is judicious (20). TYPE (MODE) Rhythmic, aerobic type exercises involving large muscle groups are recom- mended for improving CRF (20). The modes of physical activity that result in improvement and maintenance of CRF are found in Table 7.4. The principle of AEROBIC EXERCISE VOLUME RECOMMENDATION A target volume of ⱖ500–1,000 MET-min ⭈ wk⫺1 is recommended for most adults. This volume is approximately equal to 1,000 kcal ⭈ wk⫺1 of moderate intensity, physical activity, ⬃150 min ⭈ wk⫺1 of moderate intensity exercise, or pedometer counts of ⱖ5,400–7,900 steps ⭈ d⫺1 . Because of the substan- tial errors in prediction when using pedometer step counts, use steps ⭈ d⫺1 combined with currently recommended time/durations of exercise. Lower ex- ercise volumes can have health/fitness benefits for deconditioned individu- als, and greater volumes may be needed for weight management.
- 204. 178 GUIDELINES FOR EXERCISE TESTING • www.acsm.org specificity of training should be kept in mind when selecting the exercise modali- ties to be included in the Ex Rx . The specificity principle states that the physi- ologic adaptations to exercise are specific to the type of exercise performed (20). Table 7.4 shows aerobic or cardiorespiratory endurance exercises categorized by the intensity and skill demands. Type A exercises, recommended for all adults, require little skill to perform, and the intensity can easily be modified to accommo- date a wide range of physical fitness levels. Type B exercises are typically performed at a vigorous intensity and are recommended for individuals who are at least of average physical fitness and who have been doing some exercise on a regular basis. Type C exercises require skill to perform, and therefore are best for individuals who have reasonably developed motor skills and physical fitness to perform the exercises safely. Type D exercises are recreational sports that can improve physical fitness but which are generally recommended as ancillary physical activities per- formed in addition to recommended conditioning physical activities. Type D physi- cal activities are recommended only for individuals who possess adequate motor skills and physical fitness to perform the sport; however, many of these sports may be modified to accommodate individuals of lower skill and physical fitness levels. TABLE 7.4. Modes Of Aerobic (Cardiorespiratory Endurance) Exercises to Improve Physical Fitness Exercise Group Exercise Description Recommended for Examples A Endurance activities requiring minimal skill or physical fitness to perform All adults Walking, leisurely cycling, aqua-aerobics, slow dancing B Vigorous intensity endurance activities requiring minimal skill Adults (as per the prepar- ticipation screening guide- lines in Chapter 2) who are habitually physically active and/or at least average physical fitness Jogging, running, rowing, aerobics, spinning, elliptical exercise, stepping exercise, fast dancing C Endurance activities requiring skill to perform Adults with acquired skill and/or at least average physical fitness levels Swimming, cross- country skiing, skating D Recreational sports Adults with a regular exer- cise program and at least average physical fitness Racquet sports, basketball, soccer, down-hill skiing, hiking Adapted from (8). AEROBIC EXERCISE TYPE RECOMMENDATION Rhythmic, aerobic exercise of at least moderate inten- sity that involves large muscle groups and requires little skill to perform is recommended for all adults to improve health and CRF . Other exercise and sports requiring skill to perform or higher levels of fitness are rec- ommended only for individuals possessing adequate skill and fitness to perform the activity.
- 205. CHAPTER 7 General Principles of Exercise Prescription 179 RATE OF PROGRESSION The recommended rate of progression in an exercise program depends on the individual’s health status, physical fitness, training responses, and exercise pro- gram goals. Progression may consist of increasing any of the components of the FITT principle of Ex Rx as tolerated by the individual. During the initial phase of the exercise program, increasing exercise time/duration (i.e., min ⭈ session⫺1 ) is recommended. An increase in exercise time/duration per session of 5–10 min every 1–2 wk over the first 4–6 wk of an exercise training program is reasonable for the average adult (20). After the individual has been exercising regularly for ⱖ1 mo, the FIT of exercise is gradually adjusted upward over the next 4–8 mo — or longer for older adults and very deconditioned individuals — to meet the recommended quantity and quality of exercise presented in the Guidelines. Any progression in the FITT-VP principle of Ex Rx should be made gradually avoiding large increases in any of the FITT-VP components to minimize risks of muscular soreness, injury, undue fatigue, and the long-term risk of overtraining. Following any adjustments in the Ex Rx , the individual should be monitored for any adverse effects of the increased volume, such as excessive shortness of breath, fatigue, and muscle soreness, and downward adjustments should be made if the exercise is not well tolerated (20). MUSCULAR FITNESS The health benefits of enhancing muscular fitness (i.e., the functional param- eters of muscle strength, endurance, and power) are well established (5,20,52). Higher levels of muscular strength are associated with a significantly better cardiometabolic risk factor profile, lower risk of all cause mortality, fewer CVD events, lower risk of developing physical function limitations, and lower risk for nonfatal disease (20). In addition to greater strength, there is an impres- sive array of changes in health-related biomarkers that can be derived from regular participation in resistance training, including improvements in body composition, blood glucose levels, insulin sensitivity, and BP in individuals THE FITT-VP PRINCIPLE OF EX RX SUMMARY The FITT-VP principle of Ex Rx features an individu- ally tailored exercise program that includes specification of the Frequency (F), Intensity (I), Time or duration (T), Type or mode (T), Volume (V), and Progression (P) of exercise to be performed. The exact composition of FITT-VP will vary depending on the characteristics and goals of the indi- vidual. The FITT-VP principle of Ex Rx will need to be revised according to the individual response, need, limitation, and adaptations to exercise as well as evolution of the goals and objectives of the exercise program. Table 7.5 summarizes the FITT-VP principle of Ex Rx recommendations for aerobic exercise.
- 206. 180 GUIDELINES FOR EXERCISE TESTING • www.acsm.org with pre-hypertension to Stage 1 hypertension (6,17,20,36) (see Chapter 10). Accordingly, resistance training may be effective for preventing and treating the “metabolic syndrome” (20) (see Chapter 10). Importantly, exercise that promotes muscle strength and mass also effectively increases bone mass (i.e., bone mineral density and content) and bone strength of the specific bones stressed and may serve as a valuable measure to prevent, slow, or even reverse the loss of bone mass in individuals with osteoporosis (3,4,20,52) (see Chapter 10). Because muscle weakness has been identified as a risk factor for the development of osteoarthritis, resistance training may reduce the chance of developing this mus- culoskeletal disorder (20,43) (see Chapter 10). In individuals with osteoarthritis, resistance training can reduce pain and disability (20,31). Preliminary work sug- gests that resistance training may prevent and improve depression and anxiety, increase vigor, and reduce fatigue (20). Each component of muscular fitness improves consequent to an appropri- ately designed resistance training regimen and correctly performed resistance exercises. As the trained muscles strengthen and enlarge (i.e., hypertrophy), the resistance must be progressively increased if additional gains are to be accrued. TABLE 7.5. Aerobic (Cardiovascular Endurance) Exercise Evidence-Based Recommendations FITT-VP Evidence-Based Recommendation Frequency • ⱖ5 d ⭈ wk⫺1 of moderate exercise, or ⱖ3 d ⭈ wk⫺1 of vigorous exercise, or a combination of moderate and vigorous exercise on ⱖ3–5 d ⭈ wk⫺1 is recom- mended. Intensity • Moderate and/or vigorous intensity is recommended for most adults. • Light-to-moderate intensity exercise may be beneficial in deconditioned individuals. Time • 30–60 min ⭈ d⫺1 of purposeful moderate exercise, or 20–60 min ⭈ d⫺1 of vigorous exercise, or a combination of moderate and vigorous exercise per day is recommended for most adults. • ⬍20 min of exercise per day can be beneficial, especially in previously sedentary individuals. Type • Regular, purposeful exercise that involves major muscle groups and is continuous and rhythmic in nature is recommended. Volume • A target volume of ⱖ500–1,000 MET-min ⭈ wk⫺1 is recommended. • Increasing pedometer step counts by ⱖ2,000 steps ⭈ d⫺1 to reach a daily step count ⱖ7 ,000 steps ⭈ d⫺1 steps is beneficial. • Exercising below these volumes may still be beneficial for individuals unable or unwilling to reach this amount of exercise. Pattern • Exercise may be performed in one (continuous) session per day or in multiple sessions of ⱖ10 min to accumulate the desired duration and volume of exercise per day. • Exercise bouts of ⬍10 min may yield favorable adaptations in very deconditioned individuals. Progression • A gradual progression of exercise volume by adjusting exercise duration, frequency, and/or intensity is reasonable until the desired exercise goal (maintenance) is attained. • This approach may enhance adherence and reduce risks of musculoskeletal injury and adverse cardiac events. Adapted from (20).
- 207. CHAPTER 7 General Principles of Exercise Prescription 181 To optimize the efficacy of resistance training, the FITT-VP principle of Ex Rx should be tailored to the individual’s goals (5, 20). Although muscular power is important for athletic events such as the shot put or javelin throw, muscular strength and endurance are of greater importance in a general training regimen focusing on health/fitness outcomes for young and middle-aged adults. In addition to focusing on muscular strength and endurance, older adults (ⱖ65 yr) may benefit from power training because this element of muscle fitness declines most rapidly with aging and insufficient power has been associated with a greater risk of accidental falls (11,15). The guidelines described in this chapter for resistance training are dedicated to improving health and most appropriate for an overall or general physical fitness pro- gram that includes but does not necessarily emphasize muscle development (5,20). FREQUENCY OF RESISTANCE EXERCISE For general muscular fitness, particularly among those who are untrained or rec- reationally trained (i.e., not engaged in a formal training program), an individual should resistance train each major muscle group (i.e., the muscle groups of the chest, shoulders, upper and lower back, abdomen, hips, and legs) 2–3 d ⭈ wk⫺1 with at least 48 h separating the exercise training sessions for the same muscle group (5,20). Depending on the individual’s daily schedule, all muscle groups to be trained may be done so in the same session (i.e., whole body), or each session may “split” the body into selected muscle groups so that only a few of groups are trained in any one session (5,20). For example, muscles of the lower body may be trained on Mondays and Thursdays, and upper body muscles may be trained on Tuesdays and Fridays. This split weight training routine entails 4 d ⭈ wk⫺1 to train each muscle group 2 times ⭈ wk⫺1 ; however, each session is of shorter duration than a whole body session used to train all muscle groups. The split and whole body methods are effective as long as each muscle group is trained 2–3 d ⭈ wk⫺1 . Having these different resistance training options provides the individual with more flexibility in scheduling, which may help to improve the likelihood of adherence to a resistance training regimen. GOALS FOR A HEALTH-RELATED RESISTANCE TRAINING PROGRAM For adults of all ages, the goals of a health-related resistance training program should be to (a) make activities of daily living (ADL) (e.g., stair climbing, carrying bags of groceries) less stressful physiologically; and (b) effectively manage, attenuate, and even prevent chronic diseases and health conditions such as osteoporosis, Type 2 diabetes mellitus, and obesity. For these reasons, although resistance training is important across the age span, its importance becomes even greater with age (7,20,32).
- 208. 182 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TYPES OF RESISTANCE EXERCISES Many types of resistance training equipment can effectively be used to improve muscular fitness including free weights, machines with stacked weights or pneu- matic resistance, and even resistance bands. Resistance training regimens should include multijoint or compound exercises that affect more than one muscle group (e.g., chest press, shoulder press, pull-down, dips, lower back extension, abdominal crunch/curl-up, leg press, squats). Single joint exercises targeting major muscle groups such as biceps curls, triceps extensions, quadriceps ex- tensions, leg curls, and calf raises can also be included in a resistance training program (5,20). To avoid creating muscle imbalances that may lead to injury, opposing muscle groups (i.e., agonists and antagonists), such as the lower back and abdomen or the quadriceps and hamstring muscles, should be included in the resistance training routine (5,20). Examples of these types of resistance exercises are low back extensions and abdominal crunches to target the muscles in the lower back and abdomen, and leg presses and leg curls to exercise the quadriceps and hamstring muscles. VOLUME OF RESISTANCE EXERCISE (SETS AND REPETITIONS) Each muscle group should be trained for a total of two to four sets. These sets may be derived from the same exercise or from a combination of exercises affecting the same muscle group (5,20). For example, the pectoral muscles of the chest region may be trained either with four sets of bench presses or with two sets of bench presses and two sets of dips (37). A reasonable rest interval between sets is 2–3 min. Using different exercises to train the same muscle group adds RESISTANCE TRAINING FREQUENCY RECOMMENDATION Resistance training of each major muscle group 2–3 d ⭈ wk⫺1 with at least 48 h separating the exercise training sessions for the same muscle group is recommended for all adults. TYPES OF RESISTANCE EXERCISES Many types of resistance training equipment can effectively be used to improve muscular fitness. Multijoint exercises affect- ing more than one muscle group and targeting agonist and antagonist mus- cle groups are recommended for all adults. Single joint exercises targeting major muscle groups may also be included in a resistance training program.
- 209. CHAPTER 7 General Principles of Exercise Prescription 183 variety, may prevent long-term mental “staleness,” and may improve adherence to the training program, although evidence that these factors improve adherence is lacking (20). Four sets per muscle group is more effective than two sets; however, even a single set per exercise will significantly improve muscular strength, particularly among novices (5,20,37). By completing one set of two different exercises that affect the same muscle group, the muscle has executed two sets. For example, bench presses and dips affect the pectoralis muscles of the chest so that by completing one set of each the muscle group has performed a total of two sets. Moreover, compound exercises such as the bench press and dips also train the triceps muscle group. From a practical standpoint of program adherence, each individual should carefully assess her/his daily schedule, time demands, and level of commitment to determine how many sets per muscle should be performed during resistance training sessions. Of paramount importance is the adoption of a resistance training program that will be realistically maintained over the long term. The resistance training intensity and number of repetitions performed with each set are inversely related. That is, the greater the intensity or resistance, the fewer the number of repetitions that will need to be completed. To improve muscular strength, mass, and — to some extent — endurance, a resistance ex- ercise that allows an individual to complete 8–12 repetitions per set should be selected. This translates to a resistance that is ⬃60%–80% of the individual’s one repetition maximum (1-RM) or the greatest amount of weight lifted for a single repetition. For example, if an individual’s 1-RM in the shoulder press is 100 lb (45.5 kg), then, when performing that exercise during the training sessions, he/ she should choose a resistance between 60 and 80 lb (27–36 kg). If an individual performs multiple sets per exercise, the number of repetitions completed before fatigue occurs will be at or close to 12 repetitions with the first set and will de- cline to about 8 repetitions during the last set for that exercise. Each set should be performed to the point of muscle fatigue but not failure because exerting muscles to the point of failure increases the likelihood of injury or debilitating residual muscle soreness, particularly among novices (5,20,37). If the objective of the resistance training program is mainly to improve mus- cular endurance rather than strength and mass, a higher number of repetitions, perhaps 15–25, should be performed per set along with shorter rest intervals and fewer sets (i.e., 1 or 2 sets per muscle group) (5,20). This regimen necessitates a lower intensity of resistance typically of no more than 50% 1-RM. Similarly, older and very deconditioned individuals who are more susceptible to musculotendi- nous injury should begin a resistance training program conducting more repeti- tions (i.e., 10–15) at a moderate intensity of 60%–70% of 1-RM, or an RPE of 5–6 on a 10-point scale (5,20,32) assuming the individual has the capacity to use this intensity while maintaining proper lifting technique. Subsequent to a period of adaptation to resistance training and improved musculotendinous conditioning, older individuals may choose to follow guidelines for younger adults (i.e., higher intensity with 8–12 repetitions per set) (20) (see Chapter 8).
- 210. 184 GUIDELINES FOR EXERCISE TESTING • www.acsm.org RESISTANCE EXERCISE TECHNIQUE To ensure optimal health/fitness gains and minimize the chance of injury, each resistance exercise should be performed with proper technique regardless of training status or age. The exercises should be executed using correct form and technique, including performing the repetitions deliberately and in a controlled manner, moving through the full ROM of the joint, and employing proper breathing techniques (i.e., exhalation during the concentric phase and inhalation during the eccentric phase and avoid the Valsalva maneuver) (5,20). However, it is not recommended resistance training be composed exclusively of eccentric or lengthening contractions conducted at very high intensities (e.g., ⬎100% 1-RM) because of the significant chance of injury and severe muscle soreness as well as serious complications such as rhabdomyolysis (i.e., muscle damage resulting in excretion of myoglobin into the urine that may harm kidney function) that can ensue (5,20). Individuals who are naïve to resistance training should receive instruction on proper technique from a qualified health/fitness professional (e.g., ACSM Certified Health Fitness SpecialistSM , ACSM Certified Personal Trainer® ) on each exercise used during resistance training sessions (5,20). PROGRESSION/MAINTENANCE As muscles adapt to a resistance exercise training program, the participant should continue to subject them to overload or greater stimuli to continue to increase muscular strength and mass. This “progressive overload” principle may be per- formed in several ways. The most common approach is to increase the amount of resistance lifted during training. For example, if an individual is using 100 lb (45.5 kg) of resistance for a given exercise, and her/his muscles have adapted to the point to which 12 repetitions are easily performed, then the resistance should be increased so that no more than 12 repetitions are completed without significant VOLUME OF RESISTANCE EXERCISE (SETS AND REPETITIONS) RECOMMENDATION Adults should train each muscle group for a total of 2–4 sets with 8–12 repetitions per set with a rest interval of 2–3 min between sets to improve muscular fitness. For older adults and very deconditioned individuals, ⱖ1 set of 10–15 repetitions of moderate intensity (i.e., 60%– 70% 1-RM), resistance exercise is recommended. RESISTANCE EXERCISE TECHNIQUE RECOMMENDATIONS All individuals should perform resistance training using correct technique. Proper resistance exercise techniques employ controlled movements through the full ROM and involve concentric and eccentric muscle actions.
- 211. CHAPTER 7 General Principles of Exercise Prescription 185 muscle fatigue and difficulty in completing the last repetition of that set. Other ways to progressively overload muscles include performing more sets per muscle group and increasing the number of d ⭈ wk⫺1 the muscle groups are trained (5,20). On the other hand, if the individual has attained the desired levels of muscu- lar strength and mass, and he/she seeks to simply maintain that level of muscular fitness, it is not necessary to progressively increase the training stimulus. That is, increasing the overload by adding resistance, sets, or training sessions per week is not required during a maintenance resistance training program. Muscular strength may be maintained by training muscle groups as little as 1 d ⭈ wk⫺1 as long as the training intensity or the resistance lifted is held constant (5,20). The FITT-VP principle of Ex Rx for resistance training is summarized in Table 7.6. Because these guidelines are most appropriate for a general fitness program, a more rigorous training program must be employed if one’s goal is to maximally increase muscular strength and mass, particularly among competitive athletes in sports such as football and bodybuilding. If the reader is interested in more than health/fitness TABLE 7.6 Resistance Exercise Evidence-Based Recommendations FITT-VP Evidence-Based Recommendation Frequency • Each major muscle group should be trained on 2–3 d ⭈ wk⫺1 . Intensity • 60%–70% 1-RM (moderate-to-vigorous intensity) for novice to intermediate exercisers to improve strength • ⱖ80% 1-RM (vigorous-to-very vigorous intensity) for experienced strength trainers to improve strength • 40%–50% RM (very light-to-light intensity) for older individuals beginning exercise to improve strength • 40%–50% 1-RM (very light-to-light intensity) may be beneficial for improving strength in sedentary individuals beginning a resistance training program • ⬍50% 1-RM (light-to-moderate intensity) to improve muscular endurance • 20%–50% 1-RM in older adults to improve power Time • No specific duration of training has been identified for effectiveness. Type • Resistance exercises involving each major muscle group are recommended. • Multijoint exercises affecting more than one muscle group and targeting agonist and antagonist muscle groups are recommended for all adults. • Single joint exercises targeting major muscle groups may also be included in a resistance training program, typically after performing multijoint exercise(s) for that particular muscle group. • A variety of exercise equipment and/or body weight can be used to perform these exercises. Repetitions • 8–12 repetitions is recommended to improve strength and power in most adults. • 10–15 repetitions is effective in improving strength in middle-aged and older individuals starting exercise. • 15–20 repetitions are recommended to improve muscular endurance. Sets • 2–4 sets are recommended for most adults to improve strength and power. • A single set of resistance exercise can be effective especially among older and novice exercisers. • ⱕ2 sets are effective in improving muscular endurance. Pattern • Rest intervals of 2–3 min between each set of repetitions are effective. • A rest of ⱖ48 h between sessions for any single muscle group is recommended. Progression • A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended. 1-RM, one repetition maximum. Adapted from (20).
- 212. 186 GUIDELINES FOR EXERCISE TESTING • www.acsm.org and general outcomes or instead desires to maximally develop muscular strength and mass, he/she is referred to the ACSM position stand on progression models in resistance training for healthy adults for additional information (5,20). PROGRESSION/MAINTENANCE OF RESISTANCE TRAINING RECOMMENDATION As muscles adapt to a resistance exercise training program, the participant should continue to subject them to overload to continue to increase mus- cular strength and mass by gradually increasing resistance, number of sets, or frequency of training. FLEXIBILITY EXERCISE RECOMMENDATION ROM is improved acutely and chronically follow- ing flexibility exercises. Flexibility exercises are most effective when the FLEXIBILITY EXERCISE (STRETCHING) Joint ROM or flexibility can be improved across all age groups by engaging in flexibility exercises (20,32). The ROM around a joint is improved immediately after performing flexibility exercise and shows chronic improvement after about 3–4 wk of regular stretching at a frequency of at least 2–3 times ⭈ wk⫺1 (20). Postural stability and balance can also be improved by engaging in flexibility exercises, especially when combined with resistance exercise (20). It is possible that regular flexibility exercise may result in a reduction of musculotendinous injuries, prevention of low back pain, or delayed onset of muscle soreness, but the evidence is far from being definitive (20). The goal of a flexibility program is to develop ROM in the major muscle/ tendon groups in accordance with individualized goals. Certain performance standards discussed later in this chapter enhance the effectiveness of flexibility exercises. It is most effective to perform flexibility exercise when the muscle temperature is increased through warm-up exercises or passively through meth- ods such as moist heat packs or hot baths, although this benefit may vary across muscle tendon units (20). Stretching exercises may result in an immediate, short-term decrease in muscle strength, power, and sports performance performed after stretching, with the negative effect particularly apparent when strength and power is im- portant to performance (20, 29). Before specific recommendations can be made, more research is needed on the immediate effects of flexibility exercises on the performance of fitness-related activities. Nevertheless, it is reasonable based on the available evidence to recommend when feasible, individuals engaging in a general fitness program perform flexibility exercise following cardiorespiratory or resistance exercise — or alternatively — as a stand alone program (20).
- 213. CHAPTER 7 General Principles of Exercise Prescription 187 TYPES OF FLEXIBILITY EXERCISES Flexibility exercise should target the major muscle tendon units of the shoulder girdle, chest, neck, trunk, lower back, hips, posterior and anterior legs, and ankles (20). Box 7.4 shows the several types of flexibility exercises that can improve ROM. Although often considered “contraindicated,” properly performed ballistic stretch- ing may be considered for adults, particularly for individuals engaging in activities that involve ballistic movements such as basketball and is equally effective as static stretching in increasing joint ROM (20). Proprioceptive neuromuscular facilita- tion (PNF) techniques that require a partner to perform and static stretching are superior to dynamic or slow movement stretching in increasing ROM around a joint (20). PNF techniques typically involve an isometric contraction followed by a static stretch in the same muscle/tendon group (i.e., contract-relax). muscles are warm. Flexibility exercises may acutely reduce power and strength so it is recommended that flexibility exercises be performed after exercise and sports where strength and power are important for performance. Ballistic methods or “bouncing” stretches use the momentum of the moving body segment to produce the stretch (57). Dynamic or slow movement stretching involves a gradual transition from one body position to another, and a progressive increase in reach and range of motion as the movement is repeated several times (30). Static stretching involves slowly stretching a muscle/tendon group and holding the position for a period of time (i.e., 10–30 s). Static stretches can be active or passive (56). Active static stretching involves holding the stretched position using the strength of the agonist muscle as is common in many forms of yoga (20). Passive static stretching involves assuming a position while holding a limb or other part of the body with or without the assistance of a partner or device (such as elastic bands or a ballet barre) (20). Proprioceptive neuromuscular facilitation (PNF) methods take several forms but typically involve an isometric contraction of the selected muscle/ tendon group followed by a static stretching of the same group (i.e., contract- relax) (39,42). Adapted from (20). Flexibility Exercise Definitions BOX 7.4
- 214. 188 GUIDELINES FOR EXERCISE TESTING • www.acsm.org VOLUME OF FLEXIBILITY EXERCISE (TIME, REPETITIONS, AND FREQUENCY) Holding a stretch for 10–30 s to the point of tightness or slight discomfort enhances joint ROM, and there seems to be little additional benefit resulting from holding the strength for a longer duration, except for older individuals (20). In older adults, stretching for 30–60 s may result in greater flexibility gains than shorter duration stretches (20) (see Chapter 8). For PNF stretches, it is recommended that the in- dividuals of all ages hold a light-to-moderate contraction (i.e., 20%–75% of maxi- mum voluntary contraction) for 3–6 s, followed by an assisted stretch for 10–30 s (20). Flexibility exercises should be repeated 2–4 times to accumulate a total of 60 s of stretching for each flexibility exercise by adjusting time/duration and repeti- tions according to individual needs (20). The goal of 60 s of stretch time can be attained by, for example, two, 30 s stretches or four, 15 s stretches (20). Performing flexibility exercises ⱖ2–3 d ⭈ wk⫺1 will improve ROM but stretching exercises are most effective when performed daily (20). A stretching routine following these guidelines can be completed by most individuals in ⱕ10 min (20). A summary of the FITT-VP principle of Ex Rx for flexibility exercise is found in Table 7.7. FLEXIBILITY TYPE RECOMMENDATION A series of flexibility exercises targeting the major muscle tendon units should be performed. A variety of static, dynamic, and PNF flexibility exercises can improve ROM around a joint. TABLE 7.7. Flexibility Exercise Evidence-Based Recommendations FITT-VP Evidence-Based Recommendation Frequency • ⱖ2–3 d ⭈ wk⫺1 with daily being most effective Intensity • Stretch to the point of feeling tightness or slight discomfort Time • Holding a static stretch for 10–30 s is recommended for most adults. • In older individuals, holding a stretch for 30–60 s may confer greater benefit. • For proprioceptive neuromuscular facilitation (PNF) stretching, a 3–6 s light-to-moderate contraction (e.g., 20%–75% of maximum voluntary contraction) followed by a 10–30 s assisted stretch is desirable. Type • A series of flexibility exercises for each of the major muscle-tendon units is recommended. • Static flexibility (i.e., active or passive), dynamic flexibility, ballistic flexibility, and PNF are each effective. Volume • A reasonable target is to perform 60 s of total stretching time for each flexibility exercise. Pattern • Repetition of each flexibility exercise 2–4 times is recommended. • Flexibility exercise is most effective when the muscle is warmed through light-to-moderate aerobic activity or passively through external methods such as moist heat packs or hot baths. Progression • Methods for optimal progression are unknown. PNF , proprioceptive neuromuscular facilitation.
- 215. CHAPTER 7 General Principles of Exercise Prescription 189 NEUROMOTOR EXERCISE Neuromotor exercise training involves motor skills such as balance, coordination, gait, and agility, and proprioceptive training and is sometimes called functional fitness training. Other multifaceted physical activities sometimes considered to be neuromotor exercise involve varying combinations of neuromotor exercise, resistance exercise, and flexibility exercise and include physical activities such as tai ji (tai chi), qigong, and yoga. For older individuals, the benefits of neuromotor exercise training are clear. Neuromotor exercise training results in improvements in balance, agility, and muscle strength, and reduces the risk of falls and the fear of falling (7,20,32) among older adults (see Chapter 8). There are few studies of the benefits of neuromotor training in younger adults, although limited study suggests that balance and agility training may result in reduced injury in athletes (20). Because of a lack of research on middle age and younger adults, definitive recommendations for benefit of neuromotor exercise training cannot be made; nonetheless, there may be benefit especially for individuals participating in physi- cal activities requiring agility, balance, and other motor skills (20). The optimal effectiveness of the various types of neuromotor exercise, doses (i.e., FIT), and training regimens are not known for adults of any age (20,32). Studies that have resulted in improvements have mostly employed training fre- quencies of ⱖ2–3 d wk⫺1 with exercise sessions of ⱖ20–30 min duration for a total of ⱖ60 min of neuromotor exercise per week (20,32). There is no available evidence concerning the number of repetitions of exercises needed, the intensity of the exercise, or optimal methods for progression. A summary of the FITT-VP principle of Ex Rx for neuromotor exercise is found in Table 7.8. FLEXIBILITY VOLUME RECOMMENDATION A total of 60 s of flexibility exercise per joint is rec- ommended. Holding a single flexibility exercise for 10–30 s to the point of tightness or slight discomfort is effective. Older adults can benefit from holding the stretch for 30–60 s. A 20%–75% maximum voluntary contrac- tion held for 3–6 s followed by a 10–30 s assisted stretch is recommended for PNF techniques. Performing flexibility exercises ⱖ2–3 d ⭈ wk⫺1 is recommended with daily flexibility exercise being most effective. NEUROMOTOR EXERCISE RECOMMENDATIONS Neuromotor exercises involving balance, agility, coor- dination, and gait are recommended on ⱖ2–3 d ⭈ wk⫺1 for older individu- als and are likely beneficial for younger adults as well. The optimal dura- tion or number of repetitions of these exercises is not known, but neuro- motor exercise routines of ⱖ20–30 min in duration for a total of ⱖ60 min of neuromotor exercise per week are effective.
- 216. 190 GUIDELINES FOR EXERCISE TESTING • www.acsm.org EXERCISE PROGRAM SUPERVISION The health/fitness and clinical exercise professional may determine the level of su- pervision that is optimal for an individual by evaluating information derived from the preparticiption health screening (see Chapter 2) and the preexercise evalua- tion (see Chapter 3) that may include health screening, medical evaluation, and/ or exercise testing as indicated by the individual’s exercise goals and health status. Supervision by an experienced exercise leader can enhance adherence to exercise and may improve safety for individuals with chronic diseases and health condi- tions (20,32) (see Chapter 11). Individualized exercise instruction may be helpful for sedentary adults initiating a new exercise program (20,32). THE BOTTOM LINE • An exercise program that includes aerobic, resistance, flexibility, and neuro- motor exercise training beyond ADL to improve and maintain physical fitness and health is essential for health/fitness benefits among most adults. • This edition of the Guidelines employs the FITT-VP principle of Ex Rx , that is, Frequency (how often), Intensity (how hard), Time (duration or how long), and Type (mode or what kind), with the addition of total Volume (amount) and Progression (advancement). • The ACSM recommends that most adults engage in moderate intensity, aero- bic exercise training ⱖ30 min ⭈ d⫺1 , ⱖ5 d ⭈ wk⫺1 to total ⱖ150 min ⭈ wk⫺1 ; vigorous intensity cardiorespiratory exercise training ⱖ20 min ⭈ d⫺1 , ⱖ3 d ⭈ wk⫺1 to total ⱖ75 min ⭈ wk⫺1 ; or a combination of moderate and vigorous intensity exercise to total an EE of ⱖ500–1,000 MET-min ⭈ wk⫺1 . TABLE 7.8. Neuromotor Exercise Evidence-Based Recommendations FITT-VP Evidence-Based Recommendation Frequency • ⱖ2–3 d ⭈ wk⫺1 is recommended Intensity • An effective intensity of neuromotor exercise has not been determined. Time • ⱖ20–30 min ⭈ d⫺1 may be needed Type • Exercises involving motor skills (e.g., balance, agility, coordination, gait), proprioceptive exercise training, and multifaceted activities (e.g., tai ji, yoga) are recommended for older individuals to improve and maintain physical function and reduce falls in those at risk for falling. • The effectiveness of neuromotor exercise training in younger and middle-aged individuals has not been established but there is prob- able benefit. Volume • The optimal volume (e.g., number of repetitions, intensity) is not known. Pattern • The optimal pattern of performing neuromotor exercise is not known. Progression • Methods for optimal progression are not known. Adapted from (20).
- 217. CHAPTER 7 General Principles of Exercise Prescription 191 • On 2–3 d ⭈ wk⫺1 , adults should also perform resistance exercises for each of the major muscle groups and neuromotor exercise involving balance, agility, gait, and coordination (e.g., such as standing on one leg, walking or running through cones, dance steps). • A series of flexibility exercises for each of the major muscle tendon groups ⱖ2–3 d ⭈ wk⫺1 is recommended to maintain joint ROM. • The exercise program should be modified according to an individual’s habitual physical activity, physical function, physical fitness level, health status, exer- cise responses, and stated goals. • Adults, including physically active adults, should concurrently reduce total time engaged in sedentary behaviors and intersperse frequent, short bouts of standing and physical activity between periods of sedentary activity throughout the day. 2008 Physical Activity Guidelines for All Americans (52): http://www.health.gov/PAguidelines/ ACSM/AMA ExeRxcise is Medicine: http://www.exerciseismedicine.org American College of Sports Medicine position stand on progression models in resistance training (18): http://www.acsm.org American College of Sports Medicine position stand on the quantity and quality of Exercise (20): http://www.acsm.org American Heart Association: http://www.heart.org National Institutes on Aging Exercise and Physical Activity Guide (53): http://www.nia.nih.gov/HealthInformation/Publications/ National Strength and Conditioning Association: http://www.nsca-lift.org Shape Up America: http://www.shapeup.org Online Resources REFERENCES 1. Ainsworth BE, Haskell WL, Leon AS, et al. Compendium of physical activities: classification of energy costs of human physical activities. Med Sci Sports Exerc. 1993;25(1):71–80. 2. Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: an update of activ- ity codes and MET intensities. Med Sci Sports Exerc. 2000;32(9 Suppl):S498–504. 3. American College of Sports Medicine. American College of Sports Medicine Position Stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 1998;30(6):992–1008. 4. American College of Sports Medicine. American College of Sports Medicine position stand. Osteoporosis and exercise. Med Sci Sports Exerc. 1995;27(4):i–vii. 5. American College of Sports Medicine. American College of Sports Medicine position stand. Progression models in resistance training for healthy adults. Med Sci Sports Exerc. 2009;41(3): 687–708. 6. American College of Sports Medicine, American Diabetes Association. Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position state- ment. Exercise and type 2 diabetes. Med Sci Sports Exerc. 2010;42(12):2282–303.
- 218. 192 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 7. American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510–30. 8. Armstrong LE, Brubaker PH, Whaley MH, Otto RM, American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams Wilkins; 2005. 366 p. 9. Astrand PO. Experimental Studies of Physical Working Capacity in Relation to Sex and Age. Copenhagen (Denmark): Musksgaard; 1952. 171 p. 10. Bassett DR Jr, Wyatt HR, Thompson H, Peters JC, Hill JO. Pedometer-measured physical activity and health behaviors in U.S. adults. Med Sci Sports Exerc. 2010;42(10):1819–25. 11. Bonnefoy M, Jauffret M, Jusot JF . Muscle power of lower extremities in relation to functional ability and nutritional status in very elderly people. J Nutr Health Aging. 2007;11(3):223–8. 12. Borg GA. Perceived exertion. Exerc Sport Sci Rev. 1974;2:131–53. 13. Borg G, Hassmen P , Lagerstrom M. Perceived exertion related to heart rate and blood lactate during arm and leg exercise. Eur J Appl Physiol Occup Physiol. 1987;56(6):679–85. 14. Borg G, Ljunggren G, Ceci R. The increase of perceived exertion, aches and pain in the legs, heart rate and blood lactate during exercise on a bicycle ergometer. Eur J Appl Physiol Occup Physiol. 1985;54(4):343–9. 15. Chan BK, Marshall LM, Winters KM, Faulkner KA, Schwartz AV, Orwoll ES. Incident fall risk and physical activity and physical performance among older men: the Osteoporotic Fractures in Men Study. Am J Epidemiol. 2007;165(6):696–703. 16. Church TS, Earnest CP , Skinner JS, Blair SN. Effects of different doses of physical activity on car- diorespiratory fitness among sedentary, overweight or obese postmenopausal women with elevated blood pressure: a randomized controlled trial. JAMA. 2007;297(19):2081–91. 17. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41(2):459–71. 18. Ehrman JK, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Baltimore (MD): Lippincott Williams Wilkins; 2009. 868 p. 19. Fox SM 3rd, Naughton JP , Haskell WL. Physical activity and the prevention of coronary heart dis- ease. Ann Clin Res. 1971;3(6):404–32. 20. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine Position Stand. The quantity and quality of exercise for developing and maintaining cardiorespiratory, musculo- skeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–59. 21. Gellish RL, Goslin BR, Olson RE, McDonald A, Russi GD, Moudgil VK. Longitudinal modeling of the relationship between age and maximal heart rate. Med Sci Sports Exerc. 2007;39(5):822–9. 22. Glass S, Dwyer GB, American College of Sports Medicine. ACSM’s Metabolic Calculations Handbook. Baltimore (MD): Lippincott Williams Wilkins; 2007. 128 p. 23. Gulati M, Shaw LJ, Thisted RA, Black HR, Merz CN, Arnsdorf MF . Heart rate response to exercise stress testing in asymptomatic women. The St. James Women Take Heart Project. Circulation. 2010; 122(2):130–7. 24. Hardy CJ, Rejeski WJ. Not what, but how one feels: the measurement of affect during exercise. J Sport Exer Psych. 1989;11:304–17. 25. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1423–34. 26. Hawkins S, Wiswell R. Rate and mechanism of maximal oxygen consumption decline with aging: implications for exercise training. Sports Med. 2003;33(12):877–88. 27. Howley ET. Type of activity: resistance, aerobic and leisure versus occupational physical activity. Med Sci Sports Exerc. 2001;33(6 Suppl):S364,9; discussion S419–20. 28. Kang M, Marshall SJ, Barreira TV, Lee JO. Effect of pedometer-based physical activity interventions: a meta-analysis. Res Q Exerc Sport. 2009;80(3):648–55. 29. McHugh MP, Cosgrave CH. To stretch or not to stretch: the role of stretching in injury prevention and performance. Scand J Med Sci Sports. 2010;20(2):169–81. 30. McMillian DJ, Moore JH, Hatler BS, Taylor DC. Dynamic vs. static-stretching warm up: the effect on power and agility performance. J Strength Cond Res. 2006;20(3):492–9. 31. Messier SP. Obesity and osteoarthritis: disease genesis and nonpharmacologic weight management. Med Clin North Am. 2009;93(1):145,59, xi–xii. 32. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recom- mendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1435–45.
- 219. CHAPTER 7 General Principles of Exercise Prescription 193 33. Noble BJ, Borg GA, Jacobs I, Ceci R, Kaiser P . A category-ratio perceived exertion scale: relationship to blood and muscle lactates and heart rate. Med Sci Sports Exerc. 1983;15(6):523–8. 34. Owen N, Healy GN, Matthews CE, Dunstan DW. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev. 2010;38(3):105–13. 35. Persinger R, Foster C, Gibson M, Fater DC, Porcari JP . Consistency of the talk test for exercise prescription. Med Sci Sports Exerc. 2004;36(9):1632–6. 36. Pescatello LS, Franklin BA, Fagard R, et al. American College of Sports Medicine position stand. Exercise and hypertension. Med Sci Sports Exerc. 2004;36(3):533–53. 37. Peterson MD, Rhea MR, Alvar BA. Applications of the dose-response for muscular strength develop- ment: a review of meta-analytic efficacy and reliability for designing training prescription. J Strength Cond Res. 2005;19(4):950–8. 38. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008. 78 p. [cited 2011 Jan 6]. Available from: http:// www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf 39. Rees SS, Murphy AJ, Watsford ML, McLachlan KA, Coutts AJ. Effects of proprioceptive neuromus- cular facilitation stretching on stiffness and force-producing characteristics of the ankle in active women. J Strength Cond Res. 2007;21(2):572–7. 40. Robertson RJ, Goss FL, Dube J, et al. Validation of the adult OMNI scale of perceived exertion for cycle ergometer exercise. Med Sci Sports Exerc. 2004;36(1):102–8. 41. Robertson RJ, Goss FL, Rutkowski J, et al. Concurrent validation of the OMNI perceived exertion scale for resistance exercise. Med Sci Sports Exerc. 2003;35(2):333–41. 42. Sharman MJ, Cresswell AG, Riek S. Proprioceptive neuromuscular facilitation stretching: mecha- nisms and clinical implications. Sports Med. 2006;36(11):929–39. 43. Slemenda C, Heilman DK, Brandt KD, et al. Reduced quadriceps strength relative to body weight: a risk factor for knee osteoarthritis in women? Arthritis Rheum. 1998;41(11):1951–9. 44. Swain DP . Energy cost calculations for exercise prescription: an update. Sports Med. 2000;30(1):17–22. 45. Swain DP, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams Wilkins; 2014. 46. Swain DP, Franklin BA. VO(2) reserve and the minimal intensity for improving cardiorespiratory fitness. Med Sci Sports Exerc. 2002;34(1):152–7. 47. Swain DP, Leutholtz BC. Heart rate reserve is equivalent to %VO2 reserve, not to %VO2max. Med Sci Sports Exerc. 1997;29(3):410–4. 48. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol. 2001;37(1):153–6. 49. Thompson WR, Gordon NF , Pescatello LS, American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 8th ed. Baltimore (MD): Lippincott Williams Wilkins; 2010. 400 p. 50. Tudor-Locke C, Hatano Y, Pangrazi RP, Kang M. Revisiting “how many steps are enough?” Med Sci Sports Exerc. 2008;40(7 Suppl):S537–43. 51. U.S. Department of Agriculture. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010 [Internet]. Washington (DC): U.S. Goverment Printing Office; 2010. 453 p. [cited 2011 Jan 6]. Available from: http://www.cnpp.usda.gov/DGAs2010-DGACReport.htm 52. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans [Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008. 78 p. [cited 2011 Jan 6]. Available from: http://www.health.gov/paguidelines/pdf/paguide.pdf 53. U.S. Department of Health and Human Services. Exercise Physical Activity: Your Everyday Guide from the National Institute on Aging [Internet]. Bethesda (MD): National Institute on Aging, U.S. National Institutes of Health; 2011. 126 p. [cited 2011 Apr 15]. Available from: http://www.nia.nih .gov/HealthInformation/Publications/ExerciseGuide/ 54. U.S. Department of Health and Human Services, United States Department of Agriculture, United States Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans, 2005. 6th ed. Washington (DC): G.P .O; 2005. 71 p. 55. Utter AC, Robertson RJ, Green JM, Suminski RR, McAnulty SR, Nieman DC. Validation of the Adult OMNI Scale of perceived exertion for walking/running exercise. Med Sci Sports Exerc. 2004;36(10): 1776–80. 56. Winters MV, Blake CG, Trost JS, et al. Passive versus active stretching of hip flexor muscles in sub- jects with limited hip extension: a randomized clinical trial. Phys Ther. 2004;84(9):800–7. 57. Woolstenhulme MT, Griffiths CM, Woolstenhulme EM, Parcell AC. Ballistic stretching increases flexibility and acute vertical jump height when combined with basketball activity. J Strength Cond Res. 2006;20(4):799–803. 58. Zhu N, Suarez-Lopez JR, Sidney S, et al. Longitudinal examination of age-predicted symptom- limited exercise maximum HR. Med Sci Sports Exerc. 2010;42(8):1519–27.
- 220. 194 Benefits and Risks Associated with Physical Activity CHAPTER 1 Exercise Prescription for Healthy Populations with Special Considerations and Environmental Considerations CHAPTER xerci 8 PREGNANCY The acute physiologic responses to exercise are generally increased during preg- nancy compared with nonpregnancy (121) (see Table 8.1). Healthy, pregnant women without exercise contraindications (2) (see Box 8.1) are encouraged to exercise throughout pregnancy. Regular exercise during pregnancy provides health/fitness benefits to the mother and child (2,34). Exercise may also reduce the risk of developing conditions associated with pregnancy such as pregnancy- induced hypertension and gestational diabetes mellitus (34,60). The American College of Sports Medicine (ACSM) endorses guidelines (76) regarding exercise in pregnancy and the postpartum period set forth by the American College of Obstetricians and Gynecologists (2,11), the Joint Committee of the Society of Obstetricians and Gynecologists of Canada (32), and the Canadian Society for Exercise Physiology (CSEP) (32). Collectively, these guidelines outline the impor- tance of exercise during pregnancy and also provide guidance on exercise prescrip- tion (Ex Rx ) and contraindications to beginning and continuing exercise during pregnancy. The CSEP Physical Activity Readiness Medical Examination, termed the PARmed-X for Pregnancy, should be used for the health screening of pregnant women before their participation in exercise programs (88) (see Figure 8.1). EXERCISE TESTING Maximal exercise testing should not be performed on women who are pregnant unless medically necessary (2,11,32). If a maximal exercise test is warranted, the test should be performed with physician supervision after the woman has been medically evaluated for contraindications to exercise (see Figure 8.1). A woman who was sed- entary before pregnancy or who has a medical condition (see Box 8.1) should receive clearance from her physician or midwife before beginning an exercise program. EXERCISE PRESCRIPTION The recommended Ex Rx for women who are pregnant should be modified according to the woman’s symptoms, discomforts, and abilities during pregnancy. It is impor- tant to be aware of contraindications for exercising during pregnancy (see Box 8.1).
- 221. 195 CHAPTER 8 Exercise Prescription for Healthy Populations TABLE 8.1. Physiologic Responses to Acute Exercise during Pregnancy Compared to Nonpregnancy (121) Oxygen uptake (during weight-dependent exercise) Increase Heart rate Increase Stroke volume Increase Cardiac output Increase Tidal volume Increase Minute ventilation Increase Ventilatory equivalent for oxygen (V . E/V . O2 ) Increase Ventilatory equivalent for carbon dioxide (V . O2max /V . CO2 ) Increase Systolic blood pressure No change/decrease Diastolic blood pressure No change/decrease RELATIVE • Severe anemia • Unevaluated maternal cardiac dysrhythmia • Chronic bronchitis • Poorly controlled Type 1 diabetes mellitus • Extreme morbid obesity • Extreme underweight • History of extremely sedentary lifestyle • Intrauterine growth restriction in current pregnancy • Poorly controlled hypertension • Orthopedic limitations • Poorly controlled seizure disorder • Poorly controlled hyperthyroidism • Heavy smoker ABSOLUTE • Hemodynamically significant heart disease • Restrictive lung disease • Incompetent cervix/cerclage • Multiple gestation at risk for premature labor • Persistent second or third trimester bleeding • Placenta previa after 26 wk of gestation • Premature labor during the current pregnancy • Ruptured membranes • Preeclampsia/pregnancy-induced hypertension Reprinted with permission from (2). Contraindications for Exercising during Pregnancy BOX 8.1
- 222. 196 GUIDELINES FOR EXERCISE TESTING • www.acsm.org ■ FIGURE 8.1. Physical Activity Readiness (PARmed-X) for Pregnancy. Reprinted with permission from (88).
- 223. 197 CHAPTER 8 Exercise Prescription for Healthy Populations ■ FIGURE 8.1. (Continued) FITT RECOMMENDATIONS FOR WOMEN WHO ARE PREGNANT Aerobic Exercise Frequency: 3–4 d ⭈ wk⫺1 . Research suggests an ideal frequency of 3–4 d ⭈ wk⫺1 because frequency has been shown to be a determinant of birth weight. Women who do not exercise within the recommended fre- quency (i.e., ⱖ5 d ⭈ wk⫺1 or ⱕ2 d ⭈ wk⫺1 ) increase their risk of having a low-birth-weight baby (19). Infants with a low birth weight for gestational age are at risk for perinatal complications and developmental problems (19), thus prevention of low birth weight is an important health goal. Intensity: Because maximal exercise testing is rarely performed with women who are pregnant, heart rate (HR) ranges that correspond to mod- erate intensity exercise have been developed and validated for low-risk pregnant women based on age while taking fitness levels into account (see Box 8.2) (32,76). Moderate intensity exercise is recommended for women with a prepregnancy body mass index (BMI) ⬍25 kg ⭈ m2 . Light intensity exercise is recommended for women with a prepregnancy BMI ⱖ25 kg ⭈ m2 (31,32,76). Time: ⱖ15 min ⭈ d⫺1 gradually increasing to a maximum of 30 min ⭈ d⫺1 of accumulated moderate intensity exercise to total 120 min ⭈ wk⫺1 . A 10–15 min warm-up and a 10–15 min cool-down of light intensity, physical activity is suggested before and after the exercise session, respec- tively (32), resulting in approximately 150 min ⭈ wk⫺1 of accumulated
- 224. 198 GUIDELINES FOR EXERCISE TESTING • www.acsm.org BMI ⬍25 kg ⴢ m2 Age (yr) Fitness Level Heart Rate Range (beats ⭈ minⴚ1 )a ⬍20 — 140–155 20–29 Low 129–144 Active 135–150 Fit 145–160 30–39 Low 128–144 Active 130–145 Fit 140–156 BMI ⱖ25 kg ⴢ m2 Age (yr) Heart Rate Range (beats ⭈ minⴚ1 )a 20–29 102–124 30–39 101–120 BMI, body mass index. a Target HR ranges were derived from peak exercise tests in medically prescreened low-risk women who were pregnant (76). Heart Rate Ranges That Correspond to Moderate Intensity Exercise for Low-Risk Normal Weight Women Who Are Pregnant and to Light Intensity Exercise for Low-Risk Women Who Are Pregnant and Overweight or Obese (32,76) BOX 8.2 exercise. Women with a prepregnancy BMI of ⱖ25 kg ⭈ m2 who have been medically prescreened can exercise at a light intensity start- ing at 25 min ⭈ d⫺1 , adding 2 min ⭈ wk⫺1 until 40 min 3–4 d ⭈ wk⫺1 is achieved (77). Type: Dynamic, rhythmic physical activities that use large muscle groups such as walking and cycling. Progression: The optimal time to progress is after the first trimester (13 wk) because the discomforts and risks of pregnancy are lowest at that time. Gradual progression from a minimum of 15 min ⭈ d⫺1 , 3 d ⭈ wk⫺1 (at the appropriate target HR or RPE) to a maximum of approximately 30 min ⭈ d⫺1 , 4 d ⭈ wk⫺1 (at the appropriate target HR or RPE) (32).
- 225. 199 CHAPTER 8 Exercise Prescription for Healthy Populations SPECIAL CONSIDERATIONS • Women who are pregnant and sedentary or have a medical condition should gradually increase physical activity levels to meet the recommended levels earlier as per preparticipation completion of the PARmed-X for Pregnancy (88) (see Figure 8.1). • Women who are pregnant and severely obese and/or have gestational diabetes mellitus or hypertension should consult their physician before beginning an exercise program and have their Ex Rx adjusted to their medical condition, symptoms, and physical fitness level. • Women who are pregnant should avoid contact sports and sports/activities that may cause loss of balance or trauma to the mother or fetus. Examples of sports/ activities to avoid include soccer, basketball, ice hockey, roller blading, horseback riding, skiing/snow boarding, scuba diving, and vigorous intensity, racquet sports. • Exercise should be terminated immediately with medical follow-up should any of these signs or symptoms occur: vaginal bleeding, dyspnea before exertion, dizziness, headache, chest pain, muscle weakness, calf pain or swelling, preterm labor, decreased fetal movement (once detected), and amniotic fluid leakage (2). In the case of calf pain and swelling, thrombophlebitis should be ruled out. • Women who are pregnant should avoid exercising in the supine position after 16 wk of pregnancy to ensure that venous obstruction does not occur (32). • Women who are pregnant should avoid performing the Valsalva maneuver during exercise. • Women who are pregnant should avoid exercising in a hot humid environ- ment, be well hydrated, and dressed appropriately to avoid heat stress. See this chapter and the ACSM position stands on exercising in the heat (6) and fluid replacement (8) for additional information. • During pregnancy, the metabolic demand increases by ⬃300 kcal ⭈ d⫺1 . Women should increase caloric intake to meet the caloric costs of pregnancy and exercise. To avoid excessive weight gain during pregnancy, consult appropriate weight gain guidelines based on prepregnancy BMI available from the Institute of Medicine and the National Research Council (118). • Women who are pregnant may participate in a strength training program that incorporates all major muscle groups with a resistance that permits multiple submaximal repetitions (i.e., 12–15 repetitions) to be performed to a point of moderate fatigue. Isometric muscle actions and the Valsalva maneuver should be avoided as should the supine position after 16 wk of pregnancy (32). Kegel exercises and those that strengthen the pelvic floor are recommended to decrease the risk of incontinence (75). • Generally, gradual exercise in the postpartum period may begin ⬃4–6 wk after a normal vaginal delivery or about 8–10 wk (with medical clearance) after a cesarean section delivery (75). Deconditioning typically occurs during the initial postpartum period so women should gradually increase physical activity levels until prepregnancy physical fitness levels are achieved. Light- to-moderate intensity exercise does not interfere with breastfeeding (75).
- 226. 200 GUIDELINES FOR EXERCISE TESTING • www.acsm.org CHILDREN AND ADOLESCENTS Children and adolescents (defined as individuals 6–17 yr) are more physically active than their adult counterparts. However, only our youngest children are as physically active as recommended by experts (114), and most young individuals above the age of 10 yr do not meet prevailing physical activity guidelines. The 2008 Physical Activity Guidelines call for children and adolescents to engage in at least 60 min ⭈ day⫺1 of moderate-to-vigorous intensity, physical activity and to include vigorous intensity, physical activity, resistance exercise, and bone load- ing activity on at least 3 d ⭈ wk⫺1 (114). In the United States, the prevalence of meeting this guideline was 42% in children aged 6–11 yr, and in adolescents aged 12–19 yr the prevalence was only 8% (113). Children and adolescents are physiologically adaptive to endurance exercise training (52,85), resistance training (14,69), and bone loading exercise (66,68). Further, exercise training produces improvements in cardiometabolic risk fac- tors (63,80). Thus, the benefits of exercise are much greater than the risks. However, because prepubescent children have immature skeletons, younger children should not participate in excessive amounts of vigorous intensity exercise. Most young individuals are healthy, and it is safe for them to start moderate intensity exercise training without medical screening. Clinical exercise testing THE BOTTOM LINE • Women who are pregnant and healthy are encouraged to exercise throughout pregnancy with the Ex Rx modified according to symptoms, discomforts, and abilities. Women who are pregnant should exercise 3–4 d ⭈ wk⫺1 for ⱖ15 min ⭈ d⫺1 gradually increasing to a maximum of 30 min ⭈ d⫺1 for each exercise session, accumulating a total of 150 min ⭈ wk⫺1 of physical activity that includes the warm up and cool down. Moderate intensity exercise is rec- ommended for women with a prepregnancy BMI ⬍25 kg ⭈ m2 . Light intensity exercise is recommended for women with a prepregnancy BMI of ⱖ25 kg ⭈ m2 . The American Congress of Obstetricians and Gynecologists: http://www.acog.org The Canadian Society for Exercise Physiology (PARmed-X for Pregnancy): http://www.csep.ca/english/view.asp?x=698 The Society of Obstetricians and Gynecologists of Canada: http://www.sogc.org Online Resources
- 227. 201 CHAPTER 8 Exercise Prescription for Healthy Populations should be reserved for children in whom there is a specific clinical indication. Physiologic responses to acute, graded exercise are qualitatively similar to those seen in adults. However, there are important quantitative differences, many of which are related to the effects of body mass, muscle mass, and height. In ad- dition, it is notable children have a much lower anaerobic capacity than adults limiting their ability to perform sustained vigorous intensity exercise (14). EXERCISE TESTING Generally, the adult guidelines for standard exercise testing apply to children and adolescents (see Chapter 5). However, the physiologic responses during exercise differ from those of adults (see Table 8.2) so that the following issues should be considered (87,121): • Exercise testing for clinical or health/fitness purposes is generally not indi- cated for children or adolescents unless there is a health concern. • The exercise testing protocol should be based on the reason the test is being performed and the functional capability of the child or adolescent. • Children and adolescents should be familiarized with the test protocol and procedure before testing to minimize stress and maximize the potential for a successful test. • Treadmill and cycle ergometers should be available for testing. Treadmills tend to elicit a higher peak oxygen uptake (V̇O2peak ) and maximum HR (HRmax ). Cycle ergometers provide less risk for injury but need to be correctly sized for the child or adolescent. • Compared to adults, children and adolescents are mentally and psycho- logically immature and may require extra motivation and support during the exercise test. In addition, health/fitness testing may be performed outside of the clinical setting. In these types of settings, the Fitnessgram test battery may be used to TABLE 8.2. Physiologic Responses to Acute Exercise in Children Compared to Adults (56,111) Variable Absolute oxygen uptake Lower Relative oxygen uptake Higher Heart rate Higher Cardiac output Lower Stroke volume Lower Systolic blood pressure Lower Diastolic blood pressure Lower Respiratory rate Higher Tidal volume Lower Minute ventilation Lower Respiratory exchange ratio Lower
- 228. 202 GUIDELINES FOR EXERCISE TESTING • www.acsm.org assess the components of health-related fitness in youth (39). The components of the Fitnessgram test battery include body composition (i.e., BMI or skinfold thicknesses), cardiorespiratory fitness (CRF) (i.e., 1-min walk/run and PACER), muscular fitness (i.e., curl-up test and pull-up/push-up tests), and flexibility (i.e., sit-and-reach test). EXERCISE PRESCRIPTION The Ex Rx guidelines outlined in this chapter for children and adolescents estab- lish the minimal amount of physical activity needed to achieve the health/fitness benefits associated with regular physical activity (114). Children and adolescents should be encouraged to participate in various physical activities that are enjoy- able and age appropriate. FITT RECOMMENDATIONS FOR CHILDREN AND ADOLESCENTS Aerobic Exercise Frequency: Daily. Intensity: Most should be moderate-to-vigorous intensity aerobic exercise and should include vigorous intensity at least 3 d ⭈ wk⫺1 . Moderate intensity corresponds to noticeable increases in HR and breathing. Vigorous intensity corresponds to substantial increases in HR and breathing. Time: ⱖ60 min ⭈ d⫺1 . Type: Enjoyable and developmentally appropriate aerobic physical activities, including running, brisk walking, swimming, dancing, and bicycling. Muscle Strengthening Exercise Frequency: ⱖ3 d ⭈ wk⫺1 . Time: As part of their 60 min ⭈ d⫺1 or more of exercise. Type: Muscle strengthening physical activities can be unstructured (e.g., playing on playground equipment, climbing trees, tug-of-war) or structured (e.g., lifting weights, working with resistance bands). Bone Strengthening Exercise Frequency: ⱖ3 d ⭈ wk⫺1 . Time: As part of 60 min ⭈ d⫺1 or more of exercise. Type: Bone strengthening activities include running, jumping rope, basketball, tennis, resistance training, and hopscotch.
- 229. 203 CHAPTER 8 Exercise Prescription for Healthy Populations SPECIAL CONSIDERATIONS • Children and adolescents may safely participate in strength training ac- tivities provided they receive proper instruction and supervision. Generally, adult guidelines for resistance training may be applied (see Chapter 7). Eight to 15 submaximal repetitions of an exercise should be performed to the point of moderate fatigue with good mechanical form before the resis- tance is increased. • Because of immature thermoregulatory systems, youth should avoid exercise in hot humid environments and be properly hydrated. See this chapter and the ACSM position stands on exercising in the heat (6) and fluid replacement (8) for additional information. • Children and adolescents who are overweight or physically inactive may not be able to achieve 60 min ⭈ d⫺1 of moderate-to-vigorous intensity, physical activity. These individuals should start out with moderate intensity, physical activity as tolerated and gradually increase the frequency and time of physical activity to achieve the 60 min ⭈ d⫺1 goal. Vigorous intensity, physical activity can then be gradually added at least 3 d ⭈ wk⫺1 . • Children and adolescents with diseases or disabilities such as asthma, dia- betes mellitus, obesity, cystic fibrosis, and cerebral palsy should have their Ex Rx tailored to their condition, symptoms, and physical fitness level (see Chapter 10). • Efforts should be made to decrease sedentary activities (i.e., television watch- ing, surfing the Internet, and playing video games) and increase activities that promote lifelong activity and fitness (i.e., walking and cycling). THE BOTTOM LINE • Most children ⬎10 yr do not meet the recommended physical activity guide- lines. Children and adolescents should participate in a variety of age appro- priate physical activities to develop CRF and muscular and bone strength. Exercise supervisors and leaders should be mindful of the external tempera- ture and hydration levels of children who exercise because of their immature thermoregulatory systems. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans (2008). U.S. Department of Health and Human Services [Internet]: http://www.health.gov/paguidelines/default/aspx U.S. Department of Health and Human Services (2008). Physical Activity Guidelines Advisory Committee Report, 2008. Washington (DC): USDHHS (91): http://www.health.gov/paguidelines/committeereport.aspx Online Resources
- 230. 204 GUIDELINES FOR EXERCISE TESTING • www.acsm.org OLDER ADULTS The term older adult (defined as individuals ⱖ65 yr and individuals 50–64 yr with clinically significant conditions or physical limitations that affect movement, physical fitness, or physical activity) represents a diverse spectrum of ages and physiologic capabilities (107). Because physiologic aging does not occur uniformly across the population, individuals of similar chronological age may differ dramati- cally in their response to exercise. In addition, it is difficult to distinguish the ef- fects of aging on physiologic function from the effects of deconditioning or disease. Health status is often a better indicator of ability to engage in physical activity than chronological age. Individuals with chronic disease should be in consultation with a health care provider who can guide them with their exercise program. Overwhelming evidence exists that supports the benefits of physical activity in (a) slowing physiologic changes of aging that impair exercise capacity; (b) op- timizing age-related changes in body composition; (c) promoting psychological and cognitive well-being; (d) managing chronic diseases; (e) reducing the risks of physical disability; and (f) increasing longevity (7,106). Despite these benefits, older adults are the least physically active of all age groups. Although recent trends indicate a slight improvement in reported physical activity, only about 22% of individuals ⱖ65 yr engage in regular physical activity. The percentage of reported physical activity decreases with advancing age with fewer than 11% of individuals ⬎85 yr engaging in regular physical activity (38). TosafelyadministeranexercisetestanddevelopasoundExRx requiresknowledge of the effects of aging on physiologic function at rest and during exercise. Table 8.3 provides a list of age-related changes in key physiologic variables. Underlying disease and medication use may alter the expected response to acute exercise. TABLE 8.3. Effects of Aging on Selected Physiologic and Health-Related Variables (107) Variable Change Resting heart rate Unchanged Maximum heart rate Lower Maximum cardiac output Lower Resting and exercise blood pressure Higher Absolute and relative maximum oxygen uptake reserve (V . O2 Rmax L ⭈ min⫺1 and mL ⭈ kg⫺1 ⭈ min⫺1 ) Lower Residual volume Higher Vital capacity Lower Reaction time Slower Muscular strength Lower Flexibility Lower Bone mass Lower Fat-free body mass Lower % Body fat Higher Glucose tolerance Lower Recovery time Longer
- 231. 205 CHAPTER 8 Exercise Prescription for Healthy Populations EXERCISE TESTING Most older adults do not require an exercise test prior to initiating a moderate intensity, physical activity program. For older adults with multiple risk factors as defined in Table 2.2, an individual is considered at moderate risk for adverse responses to exercise and is advised to undergo medical examination and exercise testing before initiating vigorous intensity exercise (see Figure 2.4). Exercise testing may require subtle differences in protocol, methodology, and dosage. The following list details the special considerations for testing older adults (107): • The initial workload should be light (i.e., ⬍3 metabolic equivalents [METs]) and workload increments should be small (i.e., 0.5–1.0 MET) for those with low work capacities. The Naughton treadmill protocol is a good example of such a protocol (see Figure 5.3). • A cycle ergometer may be preferable to a treadmill for those with poor bal- ance, poor neuromotor coordination, impaired vision, impaired gait patterns, weight-bearing limitations, and/or foot problems. However, local muscle fatigue may be a factor for premature test termination when using a cycle ergometer. • Adding a treadmill handrail support may be required because of reduced bal- ance, decreased muscular strength, poor neuromotor coordination, and fear. However, handrail support for gait abnormalities will reduce the accuracy of estimating peak MET capacity based on the exercise duration or peak work- load achieved. • Treadmill workload may need to be adapted according to walking ability by increasing grade rather than speed. • For those who have difficulty adjusting to the exercise protocol, the initial stage may need to be extended, the test restarted, or the test repeated. In these situations, also consider an intermittent protocol (see Chapter 5). • Exercise-induced dysrhythmias are more frequent in older adults than in individuals in other age groups. • Prescribed medications are common and may influence the electrocardio- graphic (ECG) and hemodynamic responses to exercise (see Appendix A). • The exercise ECG has higher sensitivity (i.e., ⬃84%) and lower specificity (i.e., ⬃70%) than in younger age groups (i.e., ⬍50% sensitivity and ⬎80% specificity). The higher rate of false positive outcomes may be related to the greater frequency of left ventricular hypertrophy (LVH) and the presence of conduction disturbances among older rather than younger adults (45). There are no specific exercise test termination criteria for older adults beyond those presented for all adults in Chapter 5. The increased prevalence of cardio- vascular, metabolic, and orthopedic problems among older adults increases the likelihood of an early test termination. In addition, many older adults exceed the age-predicted HRmax during a maximal exercise test.
- 232. 206 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Exercise Testing for the Oldest Segment of the Population The oldest segment of the population (ⱖ75 yr and individuals with mobility limitations) most likely has one or more chronic medical conditions. The likeli- hood of physical limitations also increases with age. The approach described earlier is not applicable for the oldest segment of the population and for indi- viduals with mobility limitations because (a) a prerequisite exercise test may be perceived as a barrier to physical activity promotion; (b) exercise testing is advocated before initiation of vigorous intensity exercise, but relatively few individuals in the oldest segment of the population are capable or likely to par- ticipate in vigorous intensity exercise, especially upon initiation of an exercise program; (c) the distinction between moderate and vigorous intensity exercise among older adults is difficult (e.g., a moderate walking pace for one individual may be near the upper limit of capacity for an older, unfit adult with multiple chronic conditions); and (d) there is a paucity of evidence of increased mortality or cardiovascular event risk during exercise or exercise testing in this segment of the population. Therefore, the following recommendations are made for the aging population: • In lieu of an exercise test, a thorough medical history and physical examina- tion should serve to determine cardiac contraindications to exercise. • Individuals with cardiovascular disease (CVD) symptoms or diagnosed dis- ease can be risk classified and treated according to standard guidelines (see Chapter 2). • Individuals free from CVD symptoms and disease should be able to initiate a light intensity (⬍3 METs) exercise program without undue risk (46). Physical Performance Testing Physical performance testing has largely replaced exercise stress testing for the assessment of functional status of older adults (50). Some test batteries have been developed and validated as correlates of underlying fitness domains, whereas others have been developed and validated as predictors of subsequent disability, institutionalization, and death. Physical performance testing is appeal- ing in that most performance tests require little space, equipment, and cost; can be administered by lay or health/fitness personnel with minimal training; and are considered extremely safe in healthy and clinical populations (24,96). The most widely used physical performance tests have identified cut points indicative of functional limitations associated with poorer health status that can be targeted for an exercise intervention. Some of the most commonly used physical per- formance tests are described in Table 8.4. Before performing these assessments, (a) carefully consider the specific population for which each test was developed; (b) be aware of known floor or ceiling effects; and (c) understand the context (i.e., the sample, age, health status, and intervention) in which change scores or predictive capabilities are attributed.
- 233. 207 CHAPTER 8 Exercise Prescription for Healthy Populations The Senior Fitness Test was developed using a large, healthy community dwell- ing sample and has published normative data for men and women 60–94 yr for items representing upper and lower body strength, upper and lower body flex- ibility, cardiorespiratory endurance, agility, and dynamic balance (96). The Short Physical Performance Battery (SPPB) (51), a test of lower extremity functioning, is best known for its predictive capabilities for disability, institutionalization, and death but also has known ceiling effects that limit its use as an outcome for exercise interventions in generally healthy older adults. A change of 0.5 points in the SPPB is considered a small meaningful change, whereas a change of 1.0 points is considered a substantial change (49). Usual gait speed, widely considered the simplest test of walking ability, has comparable predictive validity to the SPPB (90), but its sensitivity to change with exercise interventions has not been consis- tent. A change in usual gait speed of 0.05 m ⭈ s⫺1 is considered a small meaning- ful change and a change of 0.10 m ⭈ s⫺1 is considered a substantial change (49). TABLE 8.4. Commonly Used Physical Performance Tests Measure and Description Administration Time Cut-point Indicative of Lower Function Senior Fitness Test (96) 30 min total ⱕ25th percentile of age-based norms Seven items: 30 s chair stand, 30 s arm curls, 8 ft up and go, 6-min walk, 2-min step test, sit and reach, and back scratch with normative scales for each test. Individual items range from 2 to 10 min each Short Physical Performance Battery (51) 10 min 10 points A test of lower extremity functioning that combines scores from usual gait speed and timed tests of balance and chair stands. Scores range from 0 to 12 with higher score indicating better functioning. Usual Gait Speed ⬍2 min 1 m ⭈ s⫺1 Usually assessed as the better of two trials of time to walk a short distance (3–10 m) at a usual pace. 6-Min Walk Test ⬍10 min ⱕ25th percentile of age-based norms (97) Widely used as an indicator of cardiorespiratory endurance. Assessed as the most distance an individual can walk in 6 min. A change of 50 m is considered a substantial change (49). Continuous Scale Physical Performance Test (29) 60 min 57 points Two versions — long and short — are available. Each consists of serial performance of daily living tasks such as carrying a weighted pot of water, donning and removing a jacket, getting down and up from the floor, climbing stairs, carrying groce- ries, and others, performed within an environ- mental context that represent underlying physical domains. Scores range from 0 to 100 with higher scores representing better functioning.
- 234. 208 GUIDELINES FOR EXERCISE TESTING • www.acsm.org EXERCISE PRESCRIPTION The general principles of Ex Rx apply to adults of all ages (see Chapter 7). The relative adaptations to exercise and the percentage of improvement in the compo- nents of physical fitness among older adults are comparable with those reported in younger adults and are important for maintaining health and functional ability and attenuating many of the physiologic changes that are associated with aging (see Table 8.3). Low functional capacity, muscle weakness, and deconditioning are more common in older adults than in any other age group and contribute to loss of independence (7). An Ex Rx should include aerobic, muscle strengthening/ endurance, and flexibility exercises. Individuals who are frequent fallers or have mobility limitations may also benefit from specific neuromotor exercises to improve balance, agility, and proprioceptive training in addition to the other components of health-related physical fitness. However, age should not be a barrier to physical activity promotion because positive improvements are attainable at any age. For Ex Rx , an important distinction between older adults and their younger counterparts should be made relative to intensity. For apparently healthy adults, moderate and vigorous intensity, physical activities are defined relative to METs, with moderate intensity activities defined as 3–⬍6 METs and vigorous intensity activities as ⱖ6 METs. In contrast for older adults, activities should be defined relative to an individual’s physical fitness within the context of perceived physi- cal exertion using a 10-point scale, on which 0 is considered an effort equivalent to sitting and 10 is considered an all out effort, a moderate intensity, physical activity is defined as 5 or 6, and a vigorous intensity, physical activity as 7 or 8. A moderate intensity, physical activity should produce a noticeable increase in HR and breathing, whereas a vigorous intensity, physical activity should produce a substantial increase in HR or breathing (82). FITT RECOMMENDATIONS FOR OLDER ADULTS Aerobic Exercise To promote and maintain health, older adults should adhere to the following Ex Rx for aerobic (cardiorespiratory) physical activities. When older adults cannot do these recommended amounts of physical activity because of chronic conditions, they should be as physically active as their abilities and conditions allow. Frequency: ⱖ5 d ⭈ wk⫺1 for moderate intensity, physical activities or ⱖ3 d ⭈ wk⫺1 for vigorous intensity, physical activities or some combina- tion of moderate and vigorous intensity exercise 3–5 d ⭈ wk⫺1 . Intensity: On a scale of 0–10 for level of physical exertion, 5–6 for moderate intensity and 7–8 for vigorous intensity (82).
- 235. 209 CHAPTER 8 Exercise Prescription for Healthy Populations Neuromotor (Balance) Exercises for Frequent Fallers or Individuals with Mobility Limitations There are no specific recommendations for exercises that incorporate neuromo- tor (balance) training into an Ex Rx . However, neuromotor exercise training, which combines balance, agility, and proprioceptive training, is effective in reducing and preventing falls if performed 2–3 d ⭈ wk⫺1 (7,44). General recom- mendations include using the following: (a) progressively difficult postures that gradually reduce the base of support (e.g., two-legged stand, semitandem stand, tandem stand, one-legged stand); (b) dynamic movements that perturb the center of gravity (e.g., tandem walk, circle turns); (c) stressing postural muscle Time: For moderate intensity, physical activities, accumulate at least 30 or up to 60 (for greater benefit) min ⭈ d⫺1 in bouts of at least 10 min each to total 150–300 min ⭈ wk⫺1 , or at least 20–30 min ⭈ d⫺1 of more vigorous intensity, physical activities to total 75–100 min ⭈ wk⫺1 or an equivalent combination of moderate and vigorous intensity, physical activity. Type: Any modality that does not impose excessive orthopedic stress — walking is the most common type of activity. Aquatic exercise and stationary cycle exercise may be advantageous for those with limited tolerance for weight-bearing activity. Muscle Strengthening/Endurance Exercise Frequency: ⱖ2 d ⭈ wk⫺1 . Intensity: Moderate intensity (i.e., 60%–70% one repetition maximum [1-RM]). Light intensity (i.e., 40%–50% 1-RM) for older adults beginning a resistance training program. When 1-RM is not measured, intensity can be prescribed between moderate (5–6) and vigorous (7–8) intensity on a scale of 0–10 (82). Type: Progressive weight-training program or weight-bearing calisthenics (8–10 exercises involving the major muscle groups; ⱖ1 set of 10–15 repetitions each), stair climbing, and other strengthening activities that use the major muscle groups. Flexibility Exercise Frequency: ⱖ2 d ⭈ wk⫺1 . Intensity: Stretch to the point of feeling tightness or slight discomfort. Time: Hold stretch for 30–60 s. Type: Any physical activities that maintain or increase flexibility using slow movements that terminate in sustained stretches for each major muscle group using static stretches rather than rapid ballistic movements.
- 236. 210 GUIDELINES FOR EXERCISE TESTING • www.acsm.org groups (e.g., heel, toe stands); (d) reducing sensory input (e.g., standing with eyes closed); and (e) tai chi. Supervision of these activities may be warranted (5). SPECIAL CONSIDERATIONS There are numerous considerations that should be taken into account to maxi- mize the effective development of an exercise program including the following: • Intensity and duration of physical activity should be light at the beginning in particular for older adults who are highly deconditioned, functionally lim- ited, or have chronic conditions that affect their ability to perform physical tasks. • Progression of physical activities should be individualized and tailored to tolerance and preference; a conservative approach may be necessary for the most deconditioned and physically limited older adults. • Muscular strength decreases rapidly with age, especially for those ⬎50 yr. Although resistance training is important across the lifespan, it becomes more rather than less important with increasing age (7,44,82). • For strength training involving use of weightlifting machines, initial training sessions should be supervised and monitored by personnel who are sensitive to the special needs of older adults (see Chapter 7). • In the early stages of an exercise program, muscle strengthening/endurance physical activities may need to precede aerobic training activities among very frail individuals. Individuals with sarcopenia, a marker of frailty, need to increase muscular strength before they are physiologically capable of enga- ging in aerobic training. • Older adults should gradually exceed the recommended minimum amounts of physical activity and attempt continued progression if they desire to im- prove and/or maintain their physical fitness. • If chronic conditions preclude activity at the recommended minimum amount, older adults should perform physical activities as tolerated to avoid being sedentary. • Older adults should consider exceeding the recommended minimum amounts of physical activity to improve management of chronic diseases and health conditions for which a higher level of physical activity is known to confer a therapeutic benefit. • Moderate intensity, physical activity should be encouraged for individuals with cognitive decline given the known benefits of physical activity on cogni- tion. Individuals with significant cognitive impairment can engage in physical activity but may require individualized assistance. • Structured physical activity sessions should end with an appropriate cool-down, particularly among individuals with CVD. The cool-down should include a gradual reduction of effort and intensity and optimally, flexibility exercises. • Incorporation of behavioral strategies such as social support, self-efficacy, the ability to make healthy choices, and perceived safety all may enhance partici- pation in a regular exercise program (see Chapter 11).
- 237. 211 CHAPTER 8 Exercise Prescription for Healthy Populations • The health/fitness and clinical exercise professional should also provide regular feedback, positive reinforcement, and other behavioral/programmatic strategies to enhance adherence. THE BOTTOM LINE All older adults should be guided in the development of a personalized Ex Rx or physical activity plan that meets their needs and personal preferences. The Ex Rx should include aerobic, muscle strengthening and endurance, flexibility, and neuromotor exercises, and focus on maintaining and improving functional abi- lity. In addition to standard physical fitness assessments, physical performance tests can be used. These tests identify functional limitations associated with poorer heath status that can be targeted for exercise intervention. Continuous Scale Physical Functional Performance Battery (28): http:/www.coe.uga.edu/cs-pfp/index.html Short Physical Performance Battery (12): http://www.grc.nia.nih.gov/branches/ledb/sppb/index.htm Online Resources LOW BACK PAIN Low back pain (LBP) is traditionally described as pain that is primarily localized to the lumbar and lumbosacral area that may or may not be associated with leg pain. However, LBP is actually a complex multidimensional phenomenon. For some individuals, LBP is a recurrent and uncomfortable inconvenience, whereas for others, chronic LBP is a major cause of chronic disability and distress. The mere description of the problem of LBP based on spatial characteristics of pain belies the complexity of the problem and its impact. Best evidence clinical guidelines now recommend physical activity as a key component of management across the spectrum of the condition (4,27,115). Most cases of LBP show rapid improvement in pain and symptoms within the first month of symptom occurrence (89). Roughly one-half to three-quarters of individuals, however, will experience some level of persistent or recurrent symptoms, with the prevalence of LBP being twice as high for individuals with a prior history of LBP (57). Furthermore, recurrent episodes tend toward increased severity and duration, and higher levels of disability including work disability and higher medical and indemnity costs (117). Individuals with LBP can be subgrouped into one of three general categories: (a) LBP associated with a potentially serious pathology (e.g., cancer or fracture);
- 238. 212 GUIDELINES FOR EXERCISE TESTING • www.acsm.org (b) LBP with specific neurological signs and symptoms (e.g., radiculopathy or spinal stenosis); and (c) nonspecific LBP (17), the latter of which accounts for up to 90% of cases (57). For the purposes of management, LBP may be fur- ther subgrouped according to the duration of symptoms: (a) acute (the initial 4–6 wk); (b) subacute (⬍3 mo); and (c) chronic (ⱖ3 mo) (27,115). It should be noted, however, that LBP is often characterized by remission and exacerbation of symptoms that may or may not be attributable to known physical or psycho- logical stressors. When LBP is a symptom of another serious pathology (e.g., cancer), exercise testing and Ex Rx should be guided by considerations related to the primary condition. For all other causes, and in the absence of a comorbid condition (e.g., CVD with its associated risk factors), recommendations for exercise testing and Ex Rx are similar as for healthy individuals (see Chapters 2 and 7). Some considerations, however, must be given to individuals with LBP who are fear- ful of pain and/or reinjury, and thus avoid physical activity, as well as to those individuals who persist in physical activity despite worsening symptoms (54). Individuals with LBP who are fearful of pain and/or reinjury often misinterpret any aggravation of symptoms as a worsening of their spinal condition, and hold the mistaken belief that pain equates with tissue damage (103). In contrast, those with LBP who persist in physical activity may not allow injured tissues the time that is needed to heal. Both behaviors are associated with chronic pain. EXERCISE TESTING Exercise and physical fitness testing is common in individuals with chronic LBP with little to no evidence of contraindication based on LBP alone. If LBP is acute, guidelines generally recommend a gradual return to physical activity. As such, exercise testing should be symptom limited in the first weeks following symptom onset (1). Cardiorespiratory Fitness Many clients/patients with chronic LBP have reduced CRF levels compared to the normal population. Current evidence, however, has failed to find a clear relationship between CRF and pain (116). What is clear, however, is that chronic LBP cannot be fully explained by deconditioning or avoidance of physical acti- vity for fear of pain. Despite this, the advice to stay physically active is nearly universal in current clinical practice guidelines for LBP (4,27,115). The guidelines for standard CRF testing apply to individuals with LBP (see Chapter 4) with the following considerations: • Compared to cycle and upper extremity ergometry, treadmill testing produces the highest V̇O2peak in individuals with LBP . Actual or anticipated pain may limit performance (120). • Actual or anticipated pain may limit submaximal testing as often as maximal testing (36,59,109,110). Therefore, the choice of maximal versus submaximal
- 239. 213 CHAPTER 8 Exercise Prescription for Healthy Populations testing in individuals with LBP should be guided by the same considerations as for the general population. Muscular Strength and Endurance Reduced muscle strength and endurance in the trunk has been associated with LBP (1), as have changes in strength and endurance ratios (e.g., flexors vs. ex- tensors) (15). There has also been the suggestion neuromotor imbalances may exist between paired muscles such as the erector spinae in individuals with LBP (94). How these muscular and neuromotor changes relate to the development, progression, and potential treatment of LBP symptoms remains unclear and may be multifactorial. General testing of muscular strength and endurance in individuals with LBP should be guided by the same considerations as for the general population (see Chapter 4). In addition, tests of the strength and endurance of the trunk mus- culature are common in individuals with LBP (48). When interpreting these results, however, several factors must be kept in mind: • Assessments using isokinetic dynamometers with back attachments, selector- ized machines, and back hyperextension benches specifically test the trunk muscles in individuals with LBP. The reliability of these tests is questionable because of considerable learning effect in particular between the first and second sessions (33,64,92). • For individuals with LBP, performance is often limited by actual or antici- pated fear of reinjury (65). Flexibility There is no clear relationship between gross spinal flexibility and LBP or associ- ated disability (4). A range of studies have shown associations between measures of spine flexibility, hip flexibility, and LBP (72). The nature of these associations, however, is likely complex, and requires further study. Assessing spine flexibility is still recommended as part of a standard clinical evaluation in LBP (13) and may provide insight into the condition of the individual. Furthermore, there ap- pears to be some justification, although based on relatively weak evidence, for flexibility testing in the lower limbs, and in particular the hips of individuals with LBP. In general, flexibility testing in individuals with LBP should be guided by the same considerations as for the general population (see Chapter 4). It is essential, however, to identify whether the assessment is limited by stretch tolerance of the target structures or exacerbation of LBP symptoms. Physical Performance Physical performance tests afford another indicator of the functional impact of LBP when added to the traditional impairment-based measures such as muscle strength and flexibility (105) for they assess the impact of LBP and its associated
- 240. 214 GUIDELINES FOR EXERCISE TESTING • www.acsm.org psychomotor slowing. Such testing is complementary to self-reports of function. Examples of such tests mostly include a timed component and are presented in Box 8.3. EXERCISE PRESCRIPTION Clinical practice guidelines for the management of LBP consistently recommend staying physically active and avoiding bed rest (17). Although it may be best to avoid exercise in the very immediate aftermath of an acute and severe episode of LBP so as not to exacerbate symptoms (1,27), individuals with subacute and chronic LBP as well as recurrent LBP are encouraged to be physically active (1). Current evidence does not provide any consensus on the type of exercise that should be promoted in individuals with LBP or on how to best manage the pro- gram variables for these individuals (17). When recommendations are provided, they should follow very closely the recommendations for the general population (see Chapter 7) combining resistance, aerobic, and flexibility exercise (1). In chronic LBP, exercise programs that incorporate individual tailoring, supervision, stretching, and strengthening are associated with the best outcomes (27,55). A complete exercise program based on the exercise preferences of the individual Physical Performance Measures for Low Back Pain (9,104,105) BOX 8.3 Test Reliable Valid Responsive Repeated Trunk Flexion — from standing, the participant flexes the lumbar spine to end-range and returns to the upright position 10 times as fast as possible, self-selecting a speed that does not aggravate symp- toms. Time to completion is recorded (s). Averaging two trials improves reliability. ✓ ✓ Repeated Sit-to-Stand — the participant stands up five times from a chair without the use of the arms as fast as possible. Time to completion is recorded (s). Averaging two tri- als improves reliability. ✓ ✓ ✓ 50-Foot Walk — the participant walks 50 ft as fast as possible without a walking aid. Time to completion is recorded (s). ✓ ✓ 5-Min Walk — the participant walks as far as possible in 5 min without a walking aid. Distance is recorded (ft or m). ✓ ✓ 1-Min Stair Climbing—the participant walks up and down 5 stairs for 1 min as fast as possible using the rail for support if required. The total amount of steps climbed is recorded. ✓ ✓ ✓
- 241. 215 CHAPTER 8 Exercise Prescription for Healthy Populations and health/fitness, clinical exercise, and/or health care professional may be most appropriate (4). Minimum levels for intensity and volume should be the same as for a healthy population (see Chapter 7). SPECIAL CONSIDERATIONS • Exercises to promote spinal stabilization (71,95) are often recommended based on the suggestion that intervertebral instability may be a cause of cer- tain cases of LBP (86). • This approach provides no clear additional benefit over other approaches to the management of nonspecific LBP (67). • This approach may be beneficial when LBP is related to a mechanical instability (58), however, further research is required. • There does not appear to be any detrimental effect of including spinal stabilization exercises within a general exercise program for individuals with LBP based on the preference of the individual and the health/fitness, clinical exercise, and/or health care professional. • Certain exercises or positions may aggravate symptoms of LBP . • Walking, especially walking downhill, may aggravate symptoms in indi- viduals with spinal stenosis (62). • Certain individuals with LBP may experience a “peripheralization” of symptoms, that is, a distal spread of pain into the lower limb with certain sustained or repeated movements of the lumbar spine (3). In such a situ- ation, exercise or activities that aggravate peripheralization should tempo- rarily be avoided. • Exercises or movements that result in a “centralization” of symptoms (i.e., a reduction of pain in the lower limb from distal to proximal) should be encouraged (3,108,119). • Flexibility exercises are generally encouraged as part of an overall exercise program. • Hip and lower limb flexibility should be promoted, although no stretching intervention studies have shown efficacy in treating or preventing LBP (35). • It is generally not recommended to use trunk flexibility as a treatment goal in LBP (112). THE BOTTOM LINE LBP is a complex multidimensional phenomenon. Recommendations for exer- cise testing and Ex Rx are similar to those for healthy individuals when LBP is not associated with another serious pathology (e.g., cancer). It may be best to avoid exercise in the very immediate aftermath of an acute and severe episode of LBP so as not to exacerbate symptoms. However, individuals with subacute and chronic LBP as well as recurrent LBP should participate in physical acti- vity. Performance is often limited by actual or anticipated fear of reinjury and/ or pain.
- 242. 216 GUIDELINES FOR EXERCISE TESTING • www.acsm.org ENVIRONMENTAL CONSIDERATIONS EXERCISE IN HOT ENVIRONMENTS Muscular contractions produce metabolic heat that is transferred from the active muscles to the blood and then to the body’s core. Subsequent body temperature elevations elicit heat loss responses of increased skin blood flow and increased sweat secretion so that heat can be dissipated to the environment via evapora- tion (100). Thus, the cardiovascular system plays an essential role in temperature regulation. Heat exchange between skin and environment via sweating and dry heat exchange is governed by biophysical properties dictated by surrounding temperature, humidity and air motion, sky and ground radiation, and clothing (43). However, when the amount of metabolic heat exceeds heat loss, hyperther- mia (i.e., elevated internal body temperature) may develop. Sweat that drips from the body or clothing provides no cooling benefit. If secreted sweat drips from the body and is not evaporated, a higher sweating rate will be needed to achieve the evaporative cooling requirements (100). Sweat losses vary widely and depend on the amount and intensity of physical activity and environmental conditions (46). Other factors can alter sweat rates and ultimately fluid needs. For example, heat ac- climatization results in higher and more sustained sweating rates, whereas aerobic exercise training has a modest effect on enhancing sweating rate responses (100). Dehydration increases physiologic strain as measured by core temperature, HR, and perceived exertion responses during exercise-induced heat stress (98). The greater the body water deficit, the greater the increase in physiologic strain for a given exercise task (74). Dehydration can augment core temperature eleva- tions during exercise in temperate (83) as well as in hot environments (102). The typical reported core temperature augmentation with dehydration is an increase of 0.1° to 0.2° C (0.2° to 0.4° F) with each 1% of dehydration (99). The greater heat storage with dehydration is associated with a proportionate decrease in heat loss. Thus, decreased sweating rate (i.e., evaporative heat loss) and decreased cutaneous blood flow (i.e., dry heat loss) are responsible for greater heat storage observed during exercise when hypohydrated (79). Counteracting Dehydration Dehydration (i.e., 3%–5% body mass loss) likely does not degrade muscular strength (37) or anaerobic performance (25). Dehydration ⬎2% of body mass decreases aerobic exercise performance in temperate, warm, and hot environments; National Institute of Neurological Disorders and Stroke: http://www.NINDS.NIH.gov/disorders/backpain/detail_backpain.htm Online Resources
- 243. 217 CHAPTER 8 Exercise Prescription for Healthy Populations and as the level of dehydration increases, aerobic exercise performance is reduced proportionally (61). The critical water deficit (i.e., ⬎2% body mass for most indi- viduals) and magnitude of performance decrement are likely related to environmen- tal temperature, exercise task, and the individuals’ unique biological characteristics (e.g., tolerance to dehydration). Acute dehydration impairs endurance performance regardless of whole body hyperthermia or environmental temperature; and endu- rance capacity (i.e., time to exhaustion) is reduced more in a hot environment than in a temperate or cold one. Individuals have varying sweat rates, and as such, fluid needs for indi- viduals performing similar tasks under identical conditions can be different. Determining sweat rate (L ⭈ h⫺1 or q ⭈ h⫺1 ) by measuring body weight before and after exercise provides a fluid replacement guide. Active individuals should drink at least 1 pt of fluid for each pound of body weight lost. Meals can help stimulate thirst resulting in restoration of fluid balance. Snack breaks during longer train- ing sessions can help replenish fluids and be important in replacing sodium and other electrolytes. In a field setting, the additive use of first morning body mass measurements in combination with some measure of first morning urine con- centration and gross thirst perception can provide a simple and inexpensive way to dichotomize euhydration from gross dehydration (see Figure 8.2) (26). Paler color urine indicates adequate hydration; the darker yellow/brown the urine color, the greater the degree of dehydration. Urine color can provide a simple and inexpensive way to dichotomize euhydration from gross dehydration (26). Box 8.4 provides recommendations for hydration prior to, during, and following exercise or physical activity (8). W U T Likely Likely Likely Very likely ■ FIGURE 8.2. W stands for “weight. ” U stands for “urine. ” T stands for “thirst. ” When two or more simple markers are present, dehydration is likely. If all three markers are present, dehydra- tion is very likely. Reprinted with permission from (26).
- 244. 218 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Overdrinking hypotonic fluid is the mechanism that leads to exercise- associated hyponatremia, a state of lower than normal blood sodium concen- tration (typically ⬍135 mEq ⭈ L⫺1 ) accompanied by altered cognitive status. Hyponatremia tends to be more common in long duration physical activities and is precipitated by consumption of hypotonic fluid (water) alone in excess of sweat losses (typified by body mass gains). The syndrome can be prevented by not drinking in excess of sweat rate and by consuming salt-containing fluids or foods when participating in exercise events that result in many hours of con- tinuous or near continuous sweating. For additional information, see the ACSM position stand on fluid replacement (8). Medical Considerations: Exertional Heat Illnesses Heat illnesses range from muscle cramps to life-threatening hyperthermia and are described in Table 8.5. Dehydration may be either a direct (i.e., heat cramps and heat exhaustion) (101) or indirect (i.e., heatstroke) (22) factor in heat illness. Heat cramps are muscle pains or spasms most often in the abdomen, arms, or legs that may occur in association with strenuous activity. Muscle fatigue, water loss, and significant sweat sodium are contributing factors. Heat cramps respond Fluid Replacement Recommendations before, during, and after Exercise BOX 8.4 Fluid Comments Before exercise • Drink 5–7 mL ⭈ kg⫺1 (0.08–0.11 oz ⭈ lb⫺1 ) at least 4 h before exercise (12–17 oz for 154-lb individual). • If urine is not produced or very dark, drink another 3–5 mL ⭈ kg⫺1 (0.05–0.08 oz ⭈ lb⫺1 ) 2 h before exercise. • Sodium-containing beverages or slated snacks will help retain fluid. During exercise • Monitor individual body weight changes during exercise to estimate sweat loss. • Composition of fluid should include 20–30 mEq ⭈ L⫺1 of sodium, 2–5 mEq ⭈ L⫺1 of potassium, and 5%–10% of carbohydrate. • Prevent a ⬎2% loss in body weight. • Amount and rate of fluid replacement depends on individual sweating rate, environment, and exercise duration. After exercise • Consumption of normal meals and beverages will restore euhydration. • If rapid recovery is needed, drink 1.5 L ⭈ kg⫺1 (23 oz ⭈ lb⫺1 ) of body weight lost. • Goal is to fully replace fluid and electrolyte deficits. • Consuming sodium will help recovery by stimulating thirst and fluid retention. Adapted from (6,8).
- 245. 219 CHAPTER 8 Exercise Prescription for Healthy Populations well to rest, prolonged stretching, dietary sodium chloride (i.e., 1⁄8–¼ tsp of table salt or one to two salt tablets added to 300–500 mL of fluid, bullion broth, or salty snacks), or intravenous normal saline fluid. Heat syncope is a temporary circulatory failure caused by the pooling of blood in the peripheral veins, particularly of the lower extremities. Heat syncope tends to occur more often among physically unfit, sedentary, and nonacclimatized individuals. It is caused by standing erect for a long period; or at the cessation of strenuous, prolonged, upright exercise because maximal cutaneous vessel dila- tion results in a decline of blood pressure (BP) and insufficient oxygen delivery to the brain. Symptoms range from light-headedness to loss of consciousness; however, recovery is rapid once individuals sit or lay supine. Complete recovery of stable BP and HR may take a few hours. See the ACSM position stand on heat illness during exercise for additional information (6). Heat exhaustion is the most common form of serious heat illness. It occurs during exercise/physical activity in the heat when the body cannot sustain the level of cardiac output (Q̇) needed to support skin blood flow for thermoregulation and blood flow for metabolic requirements of exercise. It is characterized by prominent fatigue and progressive weakness without severe hyperthermia. Oral fluids are pre- ferred for rehydration in individuals who are conscious, able to swallow, and not losing fluid (i.e., vomiting and diarrhea). Intravenous fluid administration facili- tates recovery in those unable to ingest oral fluids or who have severe dehydration. Exertional heatstroke is caused by hyperthermia and is characterized by elevated body temperature (⬎40° C or 104° F), profound central nervous system dysfunction, and multiple organ system failure that can result in de- lirium, convulsions, or coma. The greatest risk for heatstroke exists during high TABLE 8.5. A Comparison of the Signs and Symptoms of Illnesses that Occur in Hot Environments (6) Disorder Prominent Signs and Symptoms Mental Status Changes Core Temperature Elevation Exertional heatstroke Disorientation, dizziness, irratio- nal behavior, apathy, headache, nausea, vomiting, hyperventila- tion, wet skin Marked (disoriented, unresponsive) Marked (⬎40° C) Exertional heat exhaustion Low blood pressure, elevated heart rate and respiratory rates, skin is wet and pale, headache, weakness, dizziness, decreased muscle coordination, chills, nausea, vomiting, diarrhea Little or none, agitated None to moderate (37° to 40° C) Heat syncope Heart rate and breathing rates are slow; skin is pale; patient may experience sensations of weakness, tunnel vision, vertigo, or nausea before syncope Brief fainting episode Little or none Exertional heat cramps Begins as feeble, localized, wandering spasms that may progress to debilitating cramps None Moderate (37° to 40° C)
- 246. 220 GUIDELINES FOR EXERCISE TESTING • www.acsm.org intensity prolonged exercise when the ambient wet-bulb globe temperature (WBGT) exceeds 28° C (82° F). It is a life-threatening medical emergency that requires immediate and effective whole body cooling with cold water and ice water immersion therapy. Inadequate physical fitness, excess adiposity, improper clothing, protective pads, incomplete heat acclimatization, illness, or medica- tions also increase risk. Exercise Prescription Health/fitness and clinical exercise professionals may use standards established by the National Institute for Occupational Safety and Health to define WBGT lev- els at which the risk of heat injury is increased, but exercise may be performed if preventive steps are taken (81). These steps include required rest breaks between exercise periods. Individuals whose Ex Rx specifies a target heart rate (THR) will achieve this THR at a lower absolute workload when exercising in a warm/hot versus a cooler environment. For example, in hot or humid weather, an individual will achieve their THR with a reduced running speed. Reducing one’s workload to maintain the same THR in the heat will help to reduce the risk of heat illness during acclimatization. As heat acclimatization develops, a progressively higher exercise intensity will be required to elicit the THR. The first exercise session in the heat may last as little as 5–10 min for safety reasons but can be increased gradually. Developing a Personalized Plan Adults and children who are adequately rested, nourished, hydrated, and accli- matized to heat are at less risk for exertional heat illnesses. The following factors should be considered when developing an individualized plan to minimize the effects of hyperthermia and dehydration along with the questions in Box 8.5 (26): • Monitor the environment: Use the WBGT index to determine appropriate action. • Modify activity in extreme environments: Enable access to ample fluid, pro- vide longer and/or more rest breaks to facilitate heat dissipation, and shorten or delay playing times. Perform exercise at times of the day when conditions will be cooler compared to midday (early morning, later evening). Children and older adults should modify activities in conditions of high-ambient tem- peratures accompanied by high humidity (see Box 8.6). • Consider heat acclimatization status, physical fitness, nutrition, sleep depri- vation, and age of participants; intensity, time/duration, and time of day for exercise; availability of fluids; and playing surface heat reflection (i.e., grass vs. asphalt). Allow at least 3 h, and preferably 6 h, of recovery and rehydra- tion time between exercise sessions. • Heat acclimatization: These adaptations include decreased rectal temperature, HR, and RPE; increased exercise tolerance time; increased sweating rate; and a reduction in sweat salt. Acclimatization results in the following: (a) improved
- 247. 221 CHAPTER 8 Exercise Prescription for Healthy Populations Adults should ask the following questions to evaluate readiness to exercise in a hot environment. Corrective action should be taken if any question is answered “no. ” • Have I developed a plan to avoid dehydration and hyperthermia? • Have I acclimatized by gradually increasing exercise duration and intensity for 10–14 d? • Do I limit intense exercise to the cooler hours of the day (early morning)? • Do I avoid lengthy warm-up periods on hot, humid days? • When training outdoors, do I know where fluids are available, or do I carry water bottles in a belt or a backpack? • Do I know my sweat rate and the amount of fluid that I should drink to replace body weight loss? • Was my body weight this morning within 1% of my average body weight? • Is my 24 h urine volume plentiful? • Is my urine color “pale yellow” or “straw colored”? • When heat and humidity are high, do I reduce my expectations, my exercise pace, the distance, and/or duration of my workout or race? • Do I wear loose-fitting, porous, lightweight clothing? • Do I know the signs and symptoms of heat exhaustion, exertional heatstroke, heat syncope, and heat cramps (see Table 8.4)? • Do I exercise with a partner and provide feedback about his/her physical appearance? • Do I consume adequate salt in my diet? • Do I avoid or reduce exercise in the heat if I experience sleep loss, infectious illness, fever, diarrhea, vomiting, carbohydrate depletion, some medications, alcohol, or drug abuse? Questions to Evaluate Readiness to Exercise in a Hot Environment (10) BOX 8.5 Modifications to Activities for Children BOX 8.6 WBGT °F MODIFICATION ⬍75.0 All activities allowed, be alert for signs or symptoms of heat-related illness in prolonged events. 75.0–78.6 Longer rest periods in the shade; enforce drinking every 15 min 79.0–84.0 Stop activity of unacclimatized individuals and those in high-risk categories; limit activities of all others (disallow long-distance races, cut duration of other activities) ⬎85.0 Cancel all athletic activities Adapted from (8).
- 248. 222 GUIDELINES FOR EXERCISE TESTING • www.acsm.org heat transfer from the body’s core to the external environment; (b) improved cardiovascular function; (c) more effective sweating; and (d) improved exercise performance and heat tolerance. Seasonal acclimatization will occur gradu- ally during late spring and early summer months with sedentary exposure to the heat. However, this process can be facilitated with a structured program of moderate exercise in the heat across 10–14 d to stimulate adaptations to warmer ambient temperatures. • Clothing: Clothes that have a high wicking capacity may assist in evapora- tive heat loss. Athletes should remove as much clothing and equipment (especially headgear) as possible to permit heat loss and reduce the risks of hyperthermia, especially during the initial days of acclimatization. • Education: The training of participants, personal trainers, coaches, and com- munity emergency response teams enhances the reduction, recognition (see Table 8.5), and treatment of heat-related illness. Such programs should em- phasize the importance of recognizing signs/symptoms of heat intolerance, being hydrated, fed, rested, and acclimatized to heat. Educating individuals about dehydration, assessing hydration state, and using a fluid replacement program can help maintain hydration. Organizational Planning When clients exercise in hot/humid conditions, personnel in fitness facilities and organizations should formulate a standardized heat stress management plan that incorporates the following considerations: • Screening and surveillance of at-risk participants. • Environmental assessment (i.e., WBGT index) and criteria for modifying or canceling exercise. • Heat acclimatization procedures. • Easy access to fluids and bathroom facilities. • Optimized but not maximized fluid intake that (a) matches the volume of fluid consumed to the volume of sweat lost; and (b) limits body weight change to ⬍2% of body weight. • Awareness of the signs and symptoms of heatstroke, heat exhaustion, heat cramps, and heat syncope (see Table 8.5). • Implementation of specific emergency procedures. THE BOTTOM LINE Metabolic heat produced by muscular contractions increases body temperature during exercise. Heat illness ranges from muscle cramps to life-threatening hyperthermia. In addition, dehydration has been associated with an increased risk for heat exhaustion and is a risk factor for heatstroke. Sweat losses vary widely among individuals and depend on exercise intensity and environmental conditions. Thus, fluid needs will be highly variable among individuals. The risk
- 249. 223 CHAPTER 8 Exercise Prescription for Healthy Populations of dehydration and hyperthermia can be minimized by monitoring the environ- ment; modifying activities in hot, humid environments; wearing appropriate clothing; and knowing the signs and symptoms of heat illness. American College of Sports Medicine position stands on exertional heat illness during training and competition (6) and exercise and fluid replacement (8): http://www.acsm.org National Strength and Conditioning Association position stand on exertional heat illness (16): http://www.nata.org/position-statements Online Resources EXERCISE IN COLD ENVIRONMENTS Individuals exercise and work in many cold weather environments (i.e., low temperature, high winds, low solar radiation, and rain/water exposure). For the most part, cold temperatures are not a barrier to performing physical activity, although some individuals may perceive them to be. Many factors including the environment, clothing, body composition, health status, nutrition, age, and exercise intensity interact to determine if exercising in the cold elicits additional physiologic strain and injury risk beyond that associated with the same exercise done under temperate conditions. In most cases, exercise in the cold does not increase cold injury risk. However, there are scenarios (i.e., immersion, rain, and low-ambient temperature with wind) where whole body or local thermal bal- ance cannot be maintained during exercise-related cold stress that contributes to hypothermia, frostbite, and diminished exercise capability and performance. Furthermore, exercise-related cold stress may increase the risk of morbidity and mortality in at-risk populations such as those with CVD and asthmatic condi- tions. Inhalation of cold air may also exacerbate these conditions. Hypothermia develops when heat loss exceeds heat production causing the body heat content to decrease (93). The environment, individual characteristics, and clothing all impact the development of hypothermia. Some specific factors that increase the risk of developing hypothermia include immersion, rain, wet clothing, low body fat, older age (i.e., ⱖ60 yr), and hypoglycemia (23). Medical Considerations: Cold Injuries Frostbite occurs when tissue temperatures fall lower than 0° C (32° F) (30,73). Frostbite is most common in exposed skin (i.e., nose, ears, cheeks, and exposed wrists) but also occurs in the hands and feet. Contact frostbite may occur by touching cold objects with bare skin, particularly highly conductive metal or stone that causes rapid heat loss.
- 250. 224 GUIDELINES FOR EXERCISE TESTING • www.acsm.org The principal cold stress determinants for frostbite are air temperature, wind speed, and wetness. Wind exacerbates heat loss by facilitating convec- tive heat loss and reduces the insulative value of clothing. The Wind Chill Temperature Index (WCT) (see Figure 8.3) integrates wind speed and air temperature to provide an estimate of the cooling power of the environment. WCT is specific in that its correct application only estimates the danger of cooling for the exposed skin of individuals walking at 1.3 m ⭈ s⫺1 (3 mi ⭈ h⫺1 ). Important information about wind and the WCT incorporates the following considerations: • Wind does not cause an exposed object to become cooler than the ambient temperature. • Wind speeds obtained from weather reports do not take into account man- made wind (e.g., running, skiing). • The WCT presents the relative risk of frostbite and predicted times to freezing (see Figure 8.3) of exposed facial skin. Facial skin was chosen because this area of the body is typically not protected. • Frostbite cannot occur if the air temperature is ⬎0° C (32° F). • Wet skin exposed to the wind cools faster. If the skin is wet and exposed to wind, the ambient temperature used for the WCT table should be 10° C lower than the actual ambient temperature (18). • The risk of frostbite is ⬍5% when the ambient temperature is greater than ⫺15° C (5° F), but increased safety surveillance of exercisers is warranted when the WCT falls lower than ⫺27° C (⫺8° F). In those conditions, frostbite can occur in 30 min or less in exposed skin (23). 25 60 17 10 3 -4 -11 -19 -26 -33 -40 -48 -55 -62 -69 -76 -84 -91 -98 25 55 18 11 4 -3 -11 -18 -25 -32 -39 -46 -54 -61 -68 -75 -82 -89 -97 26 50 19 12 4 -3 -10 -17 -24 -31 -38 -45 -52 -60 -67 -74 -81 -88 -95 26 45 19 12 5 -2 -9 -16 -23 -30 -37 -44 -51 -58 -65 -72 -79 -86 -93 27 40 20 13 6 -1 -8 -15 -22 -29 -36 -43 -50 -57 -64 -71 -78 -84 -91 28 35 21 14 7 0 -7 -14 -21 -27 -34 -41 -48 -55 -62 -69 -76 -82 -89 28 30 22 15 8 1 -5 -12 -19 -26 -33 -39 -46 -53 -60 -67 -73 -80 -87 29 25 23 16 9 3 -4 -11 -17 -24 -31 -37 -44 -51 -58 -64 -71 -78 -84 30 20 24 17 11 4 -2 -9 -15 -22 -29 -35 -42 -48 -55 -61 -68 -74 -81 32 15 25 19 13 6 0 -7 -13 -19 -26 -32 -39 -45 -51 -58 -64 -71 -77 34 10 27 21 15 9 3 -4 -10 -16 -22 -28 -35 -41 -47 -53 -59 -66 -72 36 5 31 25 19 13 7 1 -5 -11 Frostbite times: Frostbite could occur in 30 min Frostbite could occur in 10 min Frostbite could occur in 5 min -16 -22 -28 -34 -40 -46 -52 -57 -63 40 35 30 25 20 15 10 5 0 Air Temperature (˚F) Wind Speed (mph) -5 -10 -15 -20 -25 -30 -35 -40 -45 ■ FIGURE 8.3. Wind Chill Temperature Index in Fahrenheit and Celsius and frostbite times for exposed facial skin (20,84).
- 251. 225 CHAPTER 8 Exercise Prescription for Healthy Populations Clothing Considerations Cold weather clothing protects against hypothermia and frostbite by reducing heat loss through the insulation provided by the clothing and trapped air within and between clothing layers (23). Typical cold weather clothing consists of three layers: (a) an inner layer (i.e., lightweight polyester or polypropylene); (b) a middle layer (i.e., polyester fleece or wool) that provides the primary insulation; and (c) an outer layer designed to allow moisture transfer to the air while repel- ling wind and rain. Recommendations for clothing wear include the following considerations (23): • Adjust clothing insulation to minimize sweating. • Use clothing vents to reduce sweat accumulation. • Do not wear an outer layer unless rainy or very windy. • Reduce clothing insulation as exercise intensity increases. • Do not impose a single clothing standard on an entire group of exercisers. • Wear appropriate footwear to minimize the risks of slipping and falling in snowy or icy conditions. Exercise Prescription Whole body and facial cooling theoretically lower the threshold for the onset of angina during aerobic exercise. The type and intensity of exercise-related cold stress also modifies the risk for an individual with CVD. Activities that involve the upper body or increase metabolism potentially increase risk: • Shoveling snow raises the HR to 97% HRmax and systolic BP increases to 200 mm Hg (40). • Walking in snow that is either packed or soft significantly increases energy requirements and myocardial oxygen demands so that individuals with atherosclerotic CVD may have to slow their walking pace. • Swimming in water ⬍25° C (77° F) may be a threat to individuals with CVD because they may not be able to recognize angina symptoms; and therefore may place themselves at greater risk (23). THE BOTTOM LINE In general, cold temperatures are not a barrier to performing physical activ- ity. However, exercise-related cold stress may increase the risk of morbidity and mortality in individuals with CVD and asthmatic conditions. The risk of frostbite is ⬍5% when the ambient temperature is greater than ⫺15° C (5° F). Frostbite can occur when the WCT is lower than ⫺27° C (⫺8° F). Dressing appropriately for the type of weather expected and understanding the risks most likely to be encountered during exercise will reduce the risk of cold injuries substantially.
- 252. 226 GUIDELINES FOR EXERCISE TESTING • www.acsm.org EXERCISE IN HIGH ALTITUDE ENVIRONMENTS The progressive decrease in atmospheric pressure associated with ascent to higher altitudes reduces the partial pressure of oxygen in the inspired air, resulting in decreased arterial oxygen levels. Immediate compensatory responses include in- creased ventilation and Q̇, the latter usually through elevated HR (70). For most individuals, the effects of altitude appear at and above 3,950 ft (1,200 m). In this section, low altitude refers to locations ⬍3,950 ft (1,200 m), moderate altitude to locations between 3,950 and 7,900 ft (1,200–2,400 m), high altitude between 7,901 and 13,125 ft (2,400–4,000 m), and very high altitude ⬎13,125 ft (4,000 m) (78). Physical performance decreases with increasing altitude ⬎3,950 ft (1,200 m). In general, the physical performance decrement will be greater as elevation, physical activity duration, and muscle mass increases, but is lessened with altitude acclimatization. The most common altitude effect on physical task per- formance is an increased time for task completion or more frequent rest breaks. With altitude exposure of ⱖ1 wk, significant altitude acclimatization occurs. The time to complete a task is reduced but the time remains longer relative to sea level. The estimated percentage increases in performance time to complete tasks of various durations during initial altitude exposure and after 1 wk of altitude acclimatization are given in Table 8.6 (42). Medical Considerations: Altitude Illnesses Rapid ascent to high and very high altitude increases individual susceptibility to altitude illness. The primary altitude illnesses are acute mountain sickness American College of Sports Medicine position stand on the prevention of cold injuries (23): http://www.acsm.org National Strength and Conditioning Association position statement on environmental cold injuries (21): http://www.nata.org/position-statements Online Resources TABLE 8.6. Estimated Impact of Increasing Altitude on Time to Complete Physical Tasks at Various Altitudes (42) Percentage Increase in Time To Complete Physical Tasks Relative to Sea Level Tasks Lasting ⬍2 min Tasks Lasting 2–5 min Tasks Lasting 10–30 min Tasks Lasting ⬎3 h Altitude Initial ⬎1 wk Initial ⬎1 wk Initial ⬎1 wk Initial ⬎1 wk Moderate 0 0 2–7 0–2 4–11 1–3 7–18 3–10 High 0–2 0 12–18 5–9 20–45 9–20 40–65 20–45 Very high 2 0 50 25 90 60 200 90
- 253. 227 CHAPTER 8 Exercise Prescription for Healthy Populations (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). Additionally, many individuals develop a sore throat and bronchitis that may produce disabling, severe coughing spasms at high altitudes. Susceptibility to altitude sickness is increased in individuals with a prior history and by prolonged physical exertion and dehydration early in the altitude exposure. AMS is the most common form of altitude sickness. Symptoms include headache, nausea, fatigue, decreased appetite, and poor sleep, and in severe cases, poor balance and mild swelling in the hands, feet, or face. AMS develops within the first 24 h of altitude exposure. Its incidence and severity increases in direct proportion to ascent rate and altitude. The estimated incidence of AMS in unacclimatized individuals rapidly ascending directly to moderate altitudes is 0%–20%; to high altitudes, 20%–60%; and to very high altitudes, 50%–80% (97). In most individuals, if ascent is stopped and physical exertion is limited, recovery from AMS occurs over 24–48 h after symptoms have peaked. HACE is a potentially fatal, although not common, illness that occurs in ⬍2% of individuals ascending ⬎12,000 ft (3,658 m). HACE is an exacerbation of unresolved, severe AMS. HACE most often occurs in individuals who have AMS symptoms and continue to ascend. HAPE is a potentially fatal, although not common, illness that occurs in ⬍10% of individuals ascending ⬎12,000 ft (3,658 m). Individuals making re- peated ascents and descents ⬎12,000 ft (3,658 m) and who exercise strenuously early in the exposure have an increased susceptibility to HAPE. The presence of crackles and rales in the lungs may indicate increased susceptibility to develop- ing HAPE. Blue lips and nail beds may be present with HAPE. Prevention and Treatment of Altitude Sickness Altitude acclimatization is the best countermeasure to all altitude sickness. Minimizing sustained exercise/physical activity and maintaining adequate hydra- tion and food intake will reduce susceptibility to altitude sickness and facilitate recovery. When moderate to severe symptoms and signs of an altitude-related sickness develop, the preferred treatment is to descend to a lower altitude. Descents of 1,000–3,000 ft (305–914 m) with an overnight stay are effective in prevention and recovery of all altitude sickness. AMS may be significantly diminished or prevented with prophylactic or therapeutic use of acetazolamide (i.e., acetazolamide [Diamox]). Headaches may be treated with aspirin, acetaminophen, ibuprofen, indomethacin, or naproxen (see Appendix A). Oxygen or hyperbaric chamber therapy will usually relieve some symptoms such as headache, fatigue, and poor sleep. Prochlorperazine (Compazine) may be used to help relieve nausea and vomiting. Dexamethasone (Decadron, Hexadrol) may be used if other treatments are not available or effective (53). Acetazolamide (Diamox) may be helpful (53). Treatment of indi- viduals diagnosed with HACE or HAPE includes descent, oxygen therapy, and/ or hyperbaric bag therapy. Dexamethasone (Decadron, Hexadrol) and acetazol- amide (Diamox) are also helpful.
- 254. 228 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Rapid Ascent Many unacclimatized individuals travel directly to high mountainous areas for skiing or trekking vacations. Beginning within hours after rapid ascent to a given altitude up to about 14,000 ft (4,300 m), and lasting for the first couple of days, AMS may be present and physical and cognitive performances will be at their nadir for these individuals. During this time, voluntary physical activ- ity should not be excessive, whereas endurance exercise training should be stopped or its intensity greatly reduced to minimize the possibility that AMS will be exacerbated. After this time when AMS subsides because of partial altitude acclimatization, individuals may resume all normal activities and exercise train- ing, if desired. Monitoring exercise HR provides a safe, easy, and objective means to quantify exercise intensity at altitude, as it does at sea level. For example, using an age-predicted maximal HR equation such as “220 ⫺ age” and multiply- ing the result by the same percentage intensity desired at altitude as at sea level provides a similar training stimulus as long as the weekly number and durations of the training sessions are also maintained. Be mindful that for the same per- ceived effort, jogging or running pace will be reduced at altitude relative to sea level, independent of altitude acclimatization status. Altitude Acclimatization With altitude acclimatization, individuals can achieve optimal physical and cognitive performance for the altitude to which they are acclimatized. Altitude acclimatization consists of physiologic adaptations that develop in a time- dependent manner during repeated or continuous exposures to moderate or high altitudes and decreases susceptibility to altitude sickness. In addition to achieving acclimatization by residing continuously at a given target altitude, at least partial altitude acclimatization can develop by living at a moderate eleva- tion, termed staging, before ascending to a higher target elevation. The goal of staged ascents is to gradually promote development of altitude acclimatization while averting the adverse consequences (e.g., altitude sickness) of rapid ascent to high altitudes. Breathing low concentrations of oxygen using masks, hoods, or rooms (i.e., normobaric hypoxia) is not as effective as being exposed to the natural altitude environment (i.e., hypobaric hypoxia) for inducing functionally useful altitude acclimatization (41). For individuals ascending from low altitude, the first stage of all staged ascent protocols should be ⱖ3 d of residence at moderate altitude. At this altitude, individuals will experience small decrements in physical performance and a low incidence of altitude sickness. At any given altitude, almost all of the acclimatization response is attained between 7 and 12 d of residence at that altitude. Short stays of 3–7 d at moderate altitudes will decrease susceptibility to altitude sickness at higher altitudes. Stays of 6–12 d are required to improve physical work performance. The magnitude of the acclimatization response is increased with additional higher staging elevations or a longer duration at a given staging elevation. The final staging elevation should be as close as
- 255. 229 CHAPTER 8 Exercise Prescription for Healthy Populations possible to the target elevation. See Box 8.7 for the staging guideline for exer- cise at high altitudes. Assessing Individual Altitude Acclimatization Status The best indices of altitude acclimatization over time at a given elevation is a decline (or absence) of altitude sickness, improved physical performance, de- creased HR, and an increase in arterial oxygen saturation (SaO2 ). The presence and severity of AMS may be evaluated by the extent of its symptoms (i.e., head- ache, nausea, fatigue, decreased appetite, and poor sleep) and signs (i.e., poor balance, and mild swelling in the hands, feet, or face). The uncomplicated resolution of AMS or its absence in the first 3–4 d following ascent indicates a normal acclimatization response. After about 1–2 wk of acclimatization, physical performance improves such that most tasks can be performed for longer periods of time and with less perceived effort relative to the initial exposure to the same elevation. Another early sign of appropriate adaptation to altitude is increased urine volume, which generally occurs during the first several days at a given elevation. Urine volume will continue to increase with additional ascent and decrease with subsequent adaptation. Measurement of SaO2 by noninvasive pulse oximetry is a very good indica- tor of acclimatization. Pulse oximetry should be performed under quiet, rest- ing conditions. From its nadir on the first day at a given altitude, SaO2 should progressively increase over the first 3–7 d before stabilizing. For example, with initial exposure to an altitude of 14,000 ft (4,300 m), resting SaO2 is 81%; after a week of continuous residence at the same elevations, resting SaO2 progressively rises to ⬃88%. Exercise Prescription During the first few days at high altitudes, individuals should minimize their exercise/physical activity to reduce susceptibility to altitude illness. After this period, individuals whose Ex Rx specifies a THR should maintain the same exer- cise HR at higher altitudes. The personalized number of weekly training sessions The general staging guideline is as follows: For every day spent ⬎3,950 ft (1,200 m), an individual is prepared for a subsequent rapid ascent to a higher altitude equal to the number of days at that altitude times 1,000 ft (305 m). For example, if an individual stages at 6,000 ft (1,829 m) for 6 d, physical performance will be improved and altitude sickness will be reduced at altitudes to 12,000 ft (3,637 m). This guideline applies to altitudes up to 14,000 ft (4,267 m). Staging Guideline for Exercise at High Altitudes BOX 8.7
- 256. 230 GUIDELINES FOR EXERCISE TESTING • www.acsm.org and the duration of each session at altitude can remain similar to those used at sea level for a given individual. This approach reduces the risk of altitude illness and excessive physiologic strain. For example, at high altitudes, reduced speed, distance, or resistance will achieve the same THR as at lower altitudes. Because altitude acclimatization develops, the THR will be achieved at progressively higher exercise intensity. Developing a Personalized Plan Adults and children who are acclimatized to altitude, adequately rested, nour- ished, and hydrated minimize their risk for developing altitude sickness and maximize their physical performance capabilities for the altitude to which they are acclimatized. The following factors should be considered to further minimize the effects of high altitude: • Monitor the environment: High altitude regions usually are associated with more daily extremes of temperature, humidity, wind, and solar radiation. Follow appropriate guidelines for hot (8) and cold (23) environments. • Modify activity at high altitudes: Consider altitude acclimatization status, physical fitness, nutrition, sleep quality and quantity, age, exercise time and intensity, and availability of fluids. Provide longer and/or more rest breaks to facilitate rest and recovery and shorten activity times. Longer duration activi- ties are affected more by high altitude than shorter duration activities. • Develop an altitude acclimatization plan: Monitor progress. • Clothing: Individual clothing and equipment need to provide protection over a greater range of temperature and wind conditions. • Education: The training of participants, personal trainers, coaches, and com- munity emergency response teams enhances the reduction, recognition, and treatment of altitude-related illnesses. Organizational Planning When clients exercise in high altitude locations, physical fitness facilities and organizations should formulate a standardized management plan that includes the following procedures: • Screening and surveillance of at-risk participants. • Using altitude acclimatization procedures to minimize the risk of altitude sickness and enhance physical performance. • Consideration of the hazards of mountainous terrain when designing exercise programs and activities. • Awareness of the signs and symptoms of altitude illness. • Develop organizational procedures for emergency medical care of altitude illnesses. • Team physicians should consider maintaining a supply of oxygen and phar- maceuticals for preventing and treating altitude sickness.
- 257. 231 CHAPTER 8 Exercise Prescription for Healthy Populations THE BOTTOM LINE Physical performance decreases with increasing altitude ⬎3,950 ft (1,200 m), with greater decrements associated with higher elevation, longer activity duration, and larger muscle mass. During the first few days at high altitudes, individuals should minimize their physical activity to reduce susceptibility to altitude illness. After this period, individuals whose Ex Rx specifies a THR should maintain the same exercise HR at higher altitudes. United States Army Institute of Environmental Medicine (USARIEM): http://www.usariem.army.mil Online Resources REFERENCES 1. Abenhaim L, Rossignol M, Valat J, et al. The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain. Spine. 2000;25(4):1S–33S. 2. ACOG Committee Obstetric Practice. ACOG Committee opinion. Number 267, January 2002: exercise during pregnancy and the postpartum period. Obstet Gynecol. 2002;99(1):171–3. 3. Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms—a systematic review. Man Ther. 2004;9:134–43. 4. Airaksinen O, Brox J, Cedraschi C, et al. Chapter 4 European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15:s192–300. 5. American College of Sports Medicine. Position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 1998;30(6):992–1008. 6. American College of Sports Medicine, Armstrong LE, Casa DJ, et al. American College of Sports Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3):556–72. 7. American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510–30. 8. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377–90. 9. Andersson EI, Lin CC, Smeets RJ. Performance tests in people with chronic low back pain: respon- siveness and minimal clinically important change. Spine (Phila Pa 1976). 2010;35(26):E1559–63. 10. Armstrong LE. Heat and humidity. In: Armstrong LE, editor. Performing in Extreme Environments. Champaign: Human Kinetics; 2000. p. 15–70. 11. Artal R, O’Toole M. Guidelines of the American College of Obstetricians and Gynecologists for exer- cise during pregnancy and the postpartum period. Br J Sports Med. 2003;37(1):6–12; discussion 12. 12. Assessing Physical Performance in the Older Patient [Internet]. Bethesda (MD): National Institute on Aging, U.S. National Institutes of Health; [cited 2011 Feb 4]. Available from: http://www.grc.nia.nih. gov/branches/ledb/sppb/index.htm 13. Atlas S, Deyo R. Evaluating and managing acute low back pain in the primary care setting. J Gen Intern Med. 2001;16(2):120–31. 14. Bar-Or O, Rowland TW. Pediatric Exercise Medicine: From Physiological Principles to Health Care Application. Champaign (IL): Human Kinetics; 2004. 501 p. 15. Beimborn D, Morrissey M. A review of the literature related to trunk muscle performance. Spine. 1988;13(6):655–60. 16. Binkley HM, Beckett J, Casa DJ, Kleiner DM, Plummer PE. National Athletic Trainers’ Association Position Statement: exertional heat illnesses. J Athl Train. 2002;37(3):329–43. 17. Bouwmeester W, van Enst A, van Tulder M. Quality of low back pain guidelines improved. Spine. 2009;34(23):2563–7.
- 258. 232 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 18. Brajkovic D, Ducharme MB. Facial cold-induced vasodilation and skin temperature during exposure to cold wind. Eur J Appl Physiol. 2006;96(6):711–21. 19. Campbell MK, Mottola MF . Recreational exercise and occupational activity during pregnancy and birth weight: a case-control study. Am J Obstet Gynecol. 2001;184(3):403–8. 20. Canada’s Windchill Index: Windchill Hazards and What To Do [Internet]. Gatineau (Quebec): Environment Canada; [cited 2011 Feb 4]. Available from: http://www.ec.gc.ca/meteo-weather/ default.asp?lang=Enn=5FBF816A-1 21. Cappaert TA, Stone JA, Castellani JW, et al. National Athletic Trainers’ Association position state- ment: environmental cold injuries. J Athl Train. 2008;43(6):640–58. 22. Carter R,3rd, Cheuvront SN, Williams JO, et al. Epidemiology of hospitalizations and deaths from heat illness in soldiers. Med Sci Sports Exerc. 2005;37(8):1338–44. 23. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine position stand: prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012–29. 24. Cesari M, Kritchevsky SB, Newman AB, et al. Added value of physical performance measures in predicting adverse health-related events: results from the health, aging and body composition study. J Am Geriatr Soc. 2009;57(2):251–9. 25. Cheuvront SN, Carter R,3rd, Haymes EM, Sawka MN. No effect of moderate hypohydration or hyperthermia on anaerobic exercise performance. Med Sci Sports Exerc. 2006;38(6):1093–7. 26. Cheuvront SN, Sawka MN. Hydration assessment of athletes. Gatorade Sports Sci Exch. 2005;18(2):1–5. 27. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–91. 28. Continuous Scale Physical Functional Performance: Evaluation of Functional Performance in Older Adults [Internet]. Athens (GA): University of Georgia; [cited 2011 Feb 4]. Available from: http:// www.coe.uga.edu/cs-pfp/index.html 29. Cress ME, Buchner DM, Questad KA, Esselman PC, deLateur BJ, Schwartz RS. Continuous-scale physical functional performance in healthy older adults: a validation study. Arch Phys Med Rehabil. 1996;77(12):1243–50. 30. Danielsson U. Windchill and the risk of tissue freezing. J Appl Physiol. 1996;81(6):2666–73. 31. Davenport MH, Charlesworth S, Vanderspank D, Sopper MM, Mottola MF . Development and valida- tion of exercise target heart rate zones for overweight and obese pregnant women. Appl Physiol Nutr Metab. 2008;33(5):984–9. 32. Davies GA, Wolfe LA, Mottola MF , et al. Joint SOGC/CSEP clinical practice guideline: exercise in pregnancy and the postpartum period. Can J Appl Physiol. 2003;28(3):330–41. 33. Demoulin C, Vanderthommen M, Duysens C, Crielaard J. Spinal muscle evaluation using the Sorensen test: a critical appraisal of the literature. Joint Bone Spine. 2004;73(1):43–50. 34. Dempsey JC, Butler CL, Williams MA. No need for a pregnant pause: physical activity may reduce the occurrence of gestational diabetes mellitus and preeclampsia. Exerc Sport Sci Rev. 2005; 33(3):141–9. 35. Dugan S. The role of exercise in the prevention and management of acute low back pain. Clin Occup Environ Med. 2006;5(3):615–32. 36. Duque I, Parra J, Duvallet A. Aerobic fitness and limiting factors of maximal performance in chronic low back pain patients. J Back Musculoskelet Rehabil. 2009;22(2):113–9. 37. Evetovich TK, Boyd JC, Drake SM, et al. Effect of moderate dehydration on torque, electromyogra- phy, and mechanomyography. Muscle Nerve. 2002;26(2):225–31. 38. Federal Interagency Forum on Aging-Related Statistics (U.S.). Older Americans 2004: Key Indicators of Well-Being. Washington (DC): Federal Interagency Forum on Aging-Related Statistics; 2004. 141 p. 39. Fitnessgram/Activitygram Reference Guide [Internet]. Dallas (TX): The Cooper Institute; 2008 [cited 2011 Jan 26]. 206 p. Available from: http://www.cooperinstitute.org/ourkidshealth/fitnessgram/ documents/FITNESSGRAM_ReferenceGuide.pdf 40. Franklin BA, Hogan P , Bonzheim K, et al. Cardiac demands of heavy snow shoveling. JAMA. 1995;273(11):880–2. 41. Fulco CS, Muza SR, Beidleman BA, et al. Effect of repeated normobaric hypoxia exposures during sleep on acute mountain sickness, exercise performance, and sleep during exposure to terrestrial altitude. Am J Physiol Regul Integr Comp Physiol. 2011;300(2):R428–36. 42. Fulco CS, Rock PB, Cymerman A. Maximal and submaximal exercise performance at altitude. Aviat Space Environ Med. 1998;69(8):793–801. 43. Gagge AP , Gonzalez RR. Mechanisms of heat exchange: biophysics and physiology. In: Fregly MJ, editor. Handbook of Physiology/Section 4, Environmental Physiology. Bethesda: American Physiological Society; 1996. p. 45–84. 44. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal,
- 259. 233 CHAPTER 8 Exercise Prescription for Healthy Populations and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–559. 45. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: sum- mary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106(14):1883–92. 46. Gill TM, DiPietro L, Krumholz HM. Role of exercise stress testing and safety monitoring for older persons starting an exercise program. JAMA. 2000;284(3):342–9. 47. Gonzalez RR, Cheuvront SN, Montain SJ, et al. Expanded prediction equations of human sweat loss and water needs. J Appl Physiol. 2009;107(2):379–88. 48. Gruther W, Wick F , Paul B, et al. Diagnostic accuracy and reliability of muscle strength and endu- rance measurements in patients with chronic low back pain. J Rehabil Med. 2009;41(8):613–9. 49. Guralnik JM, Ferrucci L, Pieper CF , et al. Lower extremity function and subsequent disability: con- sistency across studies, predictive models, and value of gait speed alone compared with the short physical performance battery. J Gerontol A Biol Sci Med Sci. 2000;55(4):M221–31. 50. Guralnik JM, Leveille S, Volpato S, Marx MS, Cohen-Mansfield J. Targeting high-risk older adults into exercise programs for disability prevention. J Aging Phys Activ. 2003;11(2):219–28. 51. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49(2):M85–94. 52. Gutin B, Barbeau P , Owens S, et al. Effects of exercise intensity on cardiovascular fitness, total body composition, and visceral adiposity of obese adolescents. Am J Clin Nutr. 2002;75(5):818–26. 53. Hackett PH, Roach RC. High-altitude illness. N Engl J Med. 2001;345(2):107–14. 54. Hasenbring M, Hallner D, Rusu A. Fear-avoidance- and endurance-related responses to pain: devel- opment and validation of the Avoidance-Endurance Questionnaire (AEQ). European Journal of Pain [Internet]. 2008 [cited 2012 Jan 7]. doi:10.1016/j.ejpain.2008.11.001 55. Hayden J, van Tulder M, Tomlinson G. Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Ann Intern Med. 2005;142:776–85. 56. Hebestreit HU, Bar-Or O. Differences between children and adults for exercise testing and prescrip- tion. In: Skinner JS, editor. Exercise Testing and Exercise Prescription for Special Cases: Theoretical Basis and Clinical Application. 3rd ed. Baltimore: Lippincott Williams Wilkins; 2005. p. 68–84. 57. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J. 2003;12(2):149–65. 58. Hicks G, Fritz J, Delitto A, McGill S. Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil. 2005;86:1753–62. 59. Hodselmans A, Dijkstra P, Geertzen J, van der Schans C. Exercise capacity in non-specific chronic low back pain patients: a lean body mass-based Astrand bicycle test; reliability, validity and feasibil- ity. J Occup Rehabil. 2008;18(3):282–9. 60. Impact of physical activity during pregnancy and postpartum on chronic disease risk. Med Sci Sports Exerc. 2006;38(5):989–1006. 61. Institute of Medicine (É.U.). Panel on Dietary Reference Intakes for Electrolytes and Water. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Washington (DC): National Academies Press; 2005. 617 p. 62. Jensen O, Schmidt-Olsen S. A new functional test in the diagnostic evaluation of neurogenic inter- mittent claudication. Clin Rheumatol. 1989;8(3):363–7. 63. Kang HS, Gutin B, Barbeau P , et al. Physical training improves insulin resistance syndrome markers in obese adolescents. Med Sci Sports Exerc. 2002;34(12):1920–7. 64. Larivière C, Da Silva R, Arsenault B, Nadeau S, Plamondon A, Vadeboncoeur R. Specificity of a back muscle exercise machine in healthy and low back pain subjects. Med Sci Sports Exerc. 2010;42(3):592–9. 65. Lee C, Simmonds M, Novy D, Jones S. Functional self-efficacy, perceived gait ability and perceived exertion in walking performance of individuals with low back pain. Physiother Theory Pract. 2002;18(4):193–203. 66. Macdonald HM, Kontulainen SA, Khan KM, McKay HA. Is a school-based physical activity inter- vention effective for increasing tibial bone strength in boys and girls? J Bone Miner Res. 2007; 22(3):434–46. 67. Macedo LG, Maher CG, Latimer J, McAuley JH. Motor control exercise for persistent, nonspecific low back pain: a systematic review. Phys Ther. 2009;89(1):9–25. 68. MacKelvie KJ, Petit MA, Khan KM, Beck TJ, McKay HA. Bone mass and structure are enhanced fol- lowing a 2-year randomized controlled trial of exercise in prepubertal boys. Bone. 2004;34(4):755–64. 69. Malina RM. Weight training in youth-growth, maturation, and safety: an evidence-based review. Clin J Sport Med. 2006;16(6):478–87.
- 260. 234 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 70. Mazzeo RS, Fulco CS. Physiological systems and their responses to conditions to hypoxia. In: Tipton CM, editor. ACSM’s Advanced Exercise Physiology. Baltimore: Lippincott Williams Wilkins; 2006. p. 564–580. 71. McGill S, Karpowicz A. Exercises for spine stabilization: motion/motor patterns, stability progres- sions, and clinical technique. Arch Phys Med Rehabil. 2009;90(1):118–26. 72. McGregor AH, Hukins DW. Lower limb involvement in spinal function and low back pain. J Back Musculoskelet Rehabil. 2009;22(4):219–22. 73. Molnar GW, Hughes AL, Wilson O, Goldman RF . Effect of skin wetting on finger cooling and freez- ing. J Appl Physiol. 1973;35(2):205–7. 74. Montain SJ, Latzka WA, Sawka MN. Control of thermoregulatory sweating is altered by hydration level and exercise intensity. J Appl Physiol. 1995;79(5):1434–9. 75. Mottola MF . Exercise in the postpartum period: practical applications. Curr Sports Med Rep. 2002; 1(6):362–8. 76. Mottola MF , Davenport MH, Brun CR, Inglis SD, Charlesworth S, Sopper MM. VO2peak prediction and exercise prescription for pregnant women. Med Sci Sports Exerc. 2006;38(8):1389–95. 77. Mottola MF , Giroux I, Gratton R, et al. Nutrition and exercise prevent excess weight gain in over- weight pregnant women. Med Sci Sports Exerc. 2010;42(2):265–72. 78. Muza SR, Fulco C, Beidleman BA, Cymerman A. Altitude Acclimatization and Illness Management. Washington (DC): Department of the Army Technical Bulletin: TB MED 505; 2010. 120 p. 79. Nadel ER, Fortney SM, Wenger CB. Circulatory adjustments during heat stress. In: Cerretelli P, Whipp BJ, editors. Exercise Bioenergetics and Gas Exchange: Proceedings of the International Symposium on Exercise Bioenergetics and Gas Exchange, Held in Milan, Italy, July 7–9, 1980, a Satellite of the XXVIII International Congress of Physiological Sciences. Amsterdam (NY): Elsevier/North- Holland Biomedical Press; sole distributors for the USA and Canada, Elsevier North Holland; 1980. p. 303–313. 80. Nassis GP , Papantakou K, Skenderi K, et al. Aerobic exercise training improves insulin sensitivity without changes in body weight, body fat, adiponectin, and inflammatory markers in overweight and obese girls. Metabolism. 2005;54(11):1472–9. 81. National Institute for Occupational Safety and Health, Division of Standards Development and Technology Transfer. Working in Hot Environments. Cincinnati (OH): NIOSH; 1992. 12 p. 82. Nelson ME, Rejeski WJ, Blair SN, et al. Physical activity and public health in older adults: recom- mendation from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1435–45. 83. Neufer PD, Young AJ, Sawka MN. Gastric emptying during exercise: effects of heat stress and hypo- hydration. Eur J Appl Physiol Occup Physiol. 1989;58(4):433–9. 84. NWS Windchill Chart [Internet]. Silver Spring (MD): NOAA, National Weather Service; 2009 [cited 2011 Feb 4]. Available from: http://www.nws.noaa.gov/om/windchill/index.shtml 85. Obert P , Mandigouts S, Nottin S, Vinet A, N’Guyen LD, Lecoq AM. Cardiovascular responses to endurance training in children: effect of gender. Eur J Clin Invest. 2003;33(3):199–208. 86. Panjabi M, Lydon C, Vasavada A, Grob D, Crisco J, Dvorak J. On the understanding of clinical instability. Spine. 1994;19(23):2642–50. 87. Paridon SM, Alpert BS, Boas SR, et al. Clinical stress testing in the pediatric age group: a statement from the American Heart Association Council on Cardiovascular Disease in the Young, Committee on Atherosclerosis, Hypertension, and Obesity in Youth. Circulation. 2006;113(15):1905–20. 88. PARmed-X for Pregnancy [Internet]. Ottawa (Ontario): Canadian Society for Exercise Physiology; 2002 [cited 2011 Feb 4]. 4 p. Available from: http://www.csep.ca/english/view.asp?x=698 89. Pengel L, Herbert R, Maher C, Refshauge K. Acute low back pain: systematic review of its prognosis. BMJ. 2003;327:323. 90. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in com- mon physical performance measures in older adults. J Am Geriatr Soc. 2006;54(5):743–9. 91. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008 [cited 2011 Jan 6]. 683 p. Available from: http:// www.health.gov/paguidelines/Report/pdf/CommitteeReport.pdf 92. Pincus T, Burton A, Vogel S, Field A. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27(5):E109–20. 93. Pozos RS, Danzl DF . Human physiological responses to cold stress and hypothermia. In: Pandolf KB, editor. Textbooks of Military Medicine: Medical Aspects of Harsh Environments. Falls Church: Office of the Surgeon General, United States Army; 2002. p. 351–382. 94. Renkawitz T, Boluki D, Grifka J. The association of low back pain, neuromuscular imbalance, and trunk extension strength in athletes. Spine J. 2006;6(6):673–783. 95. Richardson C, Jull G, Hodges P, Hides J. Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. Toronto (Ontario): Churchill Livingstone; 1999.
- 261. 235 CHAPTER 8 Exercise Prescription for Healthy Populations 96. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign (IL): Human Kinetics; 2001. 161 p. 97. Roach R, Stepanek J, Hackett P. Acute mountain sickness and high-altitute cerebral edema. In: Pandolf KB, Burr RE, editors. Textbooks of Military Medicine: Medical Aspects of Harsh Environments. Falls Church: Office of the Surgeon General, United States Army; 2002. p. 760–88. 98. Sawka MN, Coyle EF . Influence of body water and blood volume on thermoregulation and exercise performance in the heat. Exerc Sport Sci Rev. 1999;27:167–218. 99. Sawka MN, Francesconi RP , Young AJ, Pandolf KB. Influence of hydration level and body fluids on exercise performance in the heat. JAMA. 1984;252(9):1165–9. 100. Sawka MN, Young AJ. Physiological systems and their responses to conditions of heat and cold. In: Tipton CM, American College of Sports Medicine, editors. ACSM’s Advanced Exercise Physiology. Baltimore: Lippincott Williams Wilkins; 2006. p. 535–63. 101. Sawka MN, Young AJ, Latzka WA, Neufer PD, Quigley MD, Pandolf KB. Human tolerance to heat strain during exercise: influence of hydration. J Appl Physiol. 1992;73(1):368–75. 102. Senay LC,Jr. Relationship of evaporative rates to serum [Na⫹], [K⫹], and osmolarity in acute heat stress. J Appl Physiol. 1968;25(2):149–52. 103. Simmonds MJ, Goubert L, Moseley GL, Verbunt JA. Moving with pain. In: Flor H, Kalso E, Dostrovsky JO, editors. Proceedings of the 11th World Congress on Pain, Sydney, Australia, August 21–26, 2005. Seattle: IASP Press; 2006. p. 799–811. 104. Simmonds MJ, Lee CE. Physical performance tests: an expanded model of assessment and out- come. In: Liebenson C, Czech School of Manual Medicine, editors. Rehabilitation of the Spine: A Practitioner’s Manual. Baltimore: Lippincott, Williams Wilkins; 2006. p. 260–275. 105. Simmonds MJ, Olson S, Jones S, et al. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine. 1998;23(22):2412–21. 106. Singh MA. Exercise comes of age: rationale and recommendations for a geriatric exercise prescrip- tion. J Gerontol A Biol Sci Med Sci. 2002;57(5):M262–82. 107. Skinner JS. Aging for exercise testing and exercise prescription. In: Skinner JS, editor. Exercise Testing and Exercise Prescription for Special Cases: Theoretical Basis and Clinical Application. 3rd ed. Baltimore: Lippincott Williams Wilkins; 2005. p. 85–99. 108. Skytte L, May S, Petersen P. Centralization: its prognostic value in patients with referred symptoms and sciatica. Spine. 2005;30(11):E293–9. 109. Smeets R, van Geel K, Verbunt J. Is the fear avoidance model associated with the reduced level of aerobic fitness in patients with chronic low back pain? Arch Phys Med Rehabil. 2009;90(1): 109–17. 110. Smeets R, Wittink H, Hidding A, Knottnerus J. Do patients with chronic low back pain have a lower level of aerobic fitness than healthy controls?: are pain, disability, fear of injury, working status, or level of leisure time activity associated with the difference in aerobic fitness level? Spine. 2006;31(1):90–7. 111. Strong WB, Malina RM, Blimkie CJ, et al. Evidence based physical activity for school-age youth. J Pediatr. 2005;146(6):732–7. 112. Sullivan M, Shoaf L, Riddle D. The relationship of lumbar flexion to disability in patients with low back pain. Phys Ther. 2000;80(3):240–50. 113. Troiano RP , Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc. 2008;40(1):181–8. 114. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans [Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008 [cited 2011 Jan 6]. 76 p. Available from: http://www.health.gov/paguidelines/pdf/paguide.pdf 115. van Tulder M, Becker A, Bekkering T, et al. Chapter 3 European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15:s169–91. 116. Verbunt JA, Smeets RJ, Wittink HM. Cause or effect? Deconditioning and chronic low back pain. Pain. 2010;149(3):428–30. 117. Wasiak R, Kim J, Pransky G. Work disability and costs caused by recurrence of low back pain: longer and more costly than in first episodes. Spine. 2006;31(2):219–25. 118. Weight Gain During Pregnancy: Reexamining the Guideline. Report Brief [Internet]. Washington (DC): National Academy of Sciences; 2009 [cited 2011 Jan 13]. 4 p. Available from: http://www. iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx 119. Werneke M, Hart D, Cook D. A descriptive study of the centralization phenomenon: a prospective analysis. Spine. 1999;24(7):676–83. 120. Wittink H, Michel T, Kulich R, et al. Aerobic fitness testing in patients with chronic low back pain: which test is best? Spine. 2000;25(13):1704–10. 121. Wolfe LA. Pregnancy. In: Skinner JS, editor. Exercise Testing and Exercise Prescription for Special Cases: Theoretical Basis and Clinical Application. 3rd ed. Baltimore: Lippincott Williams Wilkins; 2005. p. 377–391.
- 262. 236 Exercise Prescription for Patients with Cardiovascular and Cerebrovascular Disease CHAPTER 9 The intent of this chapter is to describe the guidelines for developing an exercise prescription (Ex Rx ) among individuals with cardiovascular (CVD) and cerebro- vascular disease (see Box 9.1). Specifically, this chapter will focus on (a) exercise training procedures for inpatient and outpatient cardiac rehabilitation programs; (b) resistance training guidelines; and (c) procedures for preparing patients to return to work. INPATIENT REHABILITATION PROGRAMS Following a documented physician referral, patients hospitalized after a cardiac event or procedure associated with coronary artery disease (CAD), cardiac valve replacement, or myocardial infarction (MI) should be provided with a program consisting of early assessment and mobilization, identification of and education regarding CVD risk factors, assessment of the patient’s level of readiness for physical activity, and comprehensive discharge planning. The goals for inpatient rehabilitation programs are as follows: • Identify patients with significant cardiovascular, physical, or cognitive impairments that may influence the performance of physical activity. • Offset the deleterious physiologic and psychological effects of bed rest. • Provide additional medical surveillance of patients and their responses to physical activity. • Evaluate and begin to enable patients to safely return to activities of daily living (ADL) within the limits imposed by their CVD. • Prepare the patient and support system at home or in a transitional setting to optimize recovery following acute care hospital discharge. • Facilitate physician referral and patient entry into an outpatient cardiac reha- bilitation program. Before beginning formal physical activity in the inpatient setting, a baseline assessment should be conducted by a health care provider who possesses the skills and competencies necessary to assess and document vital signs, heart and lung sounds, and musculoskeletal strength and flexibility. Initiation and progres- sion of physical activity depends on the findings of the initial assessment and
- 263. CHAPTER 9 Exercise Prescription for Patients with CVD 237 varies with level of risk. Thus, inpatients should be risk stratified as early as possible following their acute cardiac event or procedure. The American College of Sports Medicine (ACSM) has adopted the risk stratification system established by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) for patients with known CVD because it considers the overall prog- nosis of the patient and their potential for rehabilitation (31) (see Box 2.4). The indications and contraindications for inpatient and outpatient cardiac rehabilitation are listed in Box 9.2. Exceptions should be considered based on the clinical judgment of the physician and the rehabilitation team. Shortened length of hospital stay after the acute event or intervention limits the time available for patient assessment and the rehabilitation intervention. Patients who undergo elective percutaneous coronary intervention are usually discharged within 24 h from admission, and patients with uncomplicated MI or coronary artery bypass graft (CABG) surgery are often discharged within 5 d. Activities and programs during the early recovery period will depend on the size of the MI and the occurrence of any complications and include self-care activities, arm and leg range of motion (ROM), and postural changes. Simple exposure to orthostatic or gravitational stress, such as intermittent sitting or standing during hospital convalescence, reduces much of the deterioration in exercise performance that often follows an acute cardiac event (12). Patients may progress from self-care activities to walking short to moderate distances of 50–500 ft (15–152 m) with minimal or no assistance three to four times per day to independent ambulation on the hospital unit. The optimal dose of exercise for inpatients remains to be better defined. Nevertheless, it depends in part on the patient’s medical history, Acute coronary syndromes: the manifestation of coronary artery disease (CAD) as increasing symptoms of angina pectoris, myocardial infarction (MI), or sudden death Cardiovascular disease (CVD): diseases that involve the heart and/or blood vessels; includes hypertension, CAD, peripheral arterial disease; includes but not limited to atherosclerotic arterial disease Cerebrovascular disease (stroke): diseases of the blood vessels that supply the brain CAD: disease of the arteries of the heart (usually atherosclerotic) Myocardial ischemia: temporary lack of adequate coronary blood flow relative to myocardial oxygen demands; it is often manifested as angina pectoris MI: injury/death of the muscular tissue of the heart Peripheral arterial disease (PAD): diseases of arterial blood vessels outside the heart and brain Manifestations of Cardiovascular Disease BOX 9.1
- 264. 238 GUIDELINES FOR EXERCISE TESTING • www.acsm.org clinical status, and symptoms. The rating of perceived exertion (RPE) provides a useful and complementary guide to heart rate (HR) in gauging exercise inten- sity (see Chapter 7). In general, the criteria for terminating an inpatient exercise session are similar to or slightly more conservative than those for terminating a low-level exercise test (see Box 9.3) (2). Although not all patients may be suitable candidates for inpatient exercise, virtually all benefit from some level of inpatient INDICATIONS • Medically stable post–myocardial infarction (MI) • Stable angina • Coronary artery bypass graft (CABG) surgery • Percutaneous transluminal coronary angioplasty (PTCA) • Stable heart failure caused by either systolic or diastolic dysfunction (cardiomyopathy) • Heart transplantation • Valvular heart surgery • Peripheral arterial disease (PAD) • At risk for coronary artery disease (CAD) with diagnoses of diabetes mellitus, dyslipidemia, hypertension, or obesity • Other patients who may benefit from structured exercise and/or patient education based on physician referral and consensus of the rehabilitation team CONTRAINDICATIONS • Unstable angina • Uncontrolled hypertension — that is, resting systolic blood pressure (SBP) ⬎180 mm Hg and/or resting diastolic BP (DBP) ⬎110 mm Hg • Orthostatic BP drop of ⬎20 mm Hg with symptoms • Significant aortic stenosis (aortic valve area ⬍1.0 cm2 ) • Uncontrolled atrial or ventricular arrhythmias • Uncontrolled sinus tachycardia (⬎120 beats ⭈ min⫺1 ) • Uncompensated heart failure • Third-degree atrioventricular (AV) block without pacemaker • Active pericarditis or myocarditis • Recent embolism • Acute thrombophlebitis • Acute systemic illness or fever • Uncontrolled diabetes mellitus (see Chapter 10) • Severe orthopedic conditions that would prohibit exercise • Other metabolic conditions, such as acute thyroiditis, hypokalemia, hyperkalemia, or hypovolemia (until adequately treated) Indications and Contraindications for Inpatient and Outpatient Cardiac Rehabilitation BOX 9.2
- 265. CHAPTER 9 Exercise Prescription for Patients with CVD 239 intervention including the assessment of CVD risk factors (see Table 2.2), physical activity counseling, and patient and family education. Recommendations for inpatient exercise programming include the Frequency, Intensity, Time, and Type of Exercise or the FITT principle of Ex Rx as well as progression. Activity goals should be built into the overall plan of care. The exercise program components for patients with CVD are essentially the same as for individuals who are apparently healthy (see Chapter 7) or for individuals in the low-risk category (see Box 2.4). • Diastolic blood pressure (DBP) ⱖ110 mm Hg • Decrease in systolic blood pressure (SBP) ⬎10 mm Hg during exercise with increasing workload • Significant ventricular or atrial arrhythmias with or without associated signs/ symptoms • Second- or third-degree heart block • Signs/symptoms of exercise intolerance including angina, marked dyspnea, and electrocardiogram (ECG) changes suggestive of ischemia Used with permission from (2). Adverse Responses to Inpatient Exercise Leading to Exercise Discontinuation BOX 9.3 FITT RECOMMENDATIONS FOR INPATIENT PROGRAMS Frequency: Mobilization: two to four times per day for the first 3 d of the hospital stay. Intensity: Seated or standing resting heart rate (HRrest ) ⫹20 beats ⭈ min⫺1 for patients with an MI and ⫹30 beats ⭈ min⫺1 for patients recovering from heart surgery; with an upper limit 120 beats ⭈ min⫺1 that corre- sponds to an RPE 13 on a scale of 6–20 (6). Time: Begin with intermittent walking bouts lasting 3–5 min as tolerated with exercise bouts of progressively increasing duration. The rest period may be a slower walk (or complete rest at the patient’s discretion) that is shorter than the duration of the exercise bout. Attempt to achieve a 2:1 exercise/rest ratio. Type: Walking. Progression: When continuous exercise duration reaches 10–15 min, increase intensity as tolerated within the recommended RPE and HR limits.
- 266. 240 GUIDELINES FOR EXERCISE TESTING • www.acsm.org By hospital discharge, the patient should demonstrate an understanding of physical activities that may be inappropriate or excessive. Moreover, a safe, progressive plan of exercise should be formulated before leaving the hospital. A predischarge low-level submaximal exercise test is useful for prognostic assessment (see Chapter 5), evaluation of medical therapy or coronary inter- ventions, Ex Rx , and physical activity counseling (16). Until evaluated with an exercise test or entry into a clinically supervised outpatient cardiac rehabilitation program, the upper limit of exercise should not exceed those levels observed dur- ing the inpatient program while closely monitoring for signs and symptoms of exercise intolerance. Patients should be counseled to identify abnormal signs and symptoms suggesting exercise intolerance and the need for medical evaluation. All patients also should be educated and encouraged to investigate outpatient exercise program options with appropriately qualified staff and be provided with information regarding the use of home exercise equipment. All patients, especially moderate- to high-risk patients (see Box 2.4), should be strongly encouraged to participate in a clinically supervised outpatient cardiac rehabilitation program. OUTPATIENT EXERCISE PROGRAMS Outpatient cardiac rehabilitation programs may begin as soon as possible after hospital discharge (32). The goals for outpatient rehabilitation are listed in Box 9.4. At program entry, the following assessments should be performed: • Medical and surgical history including the most recent cardiovascular event, comorbidities, and other pertinent medical history. • Physical examination with an emphasis on the cardiopulmonary and muscu- loskeletal systems. • Review of recent cardiovascular tests and procedures including 12-lead electrocardiogram (ECG), coronary angiogram, echocardiogram, stress test • Develop and assist the patient to implement a safe and effective formal exercise and lifestyle physical activity program. • Provide appropriate supervision and monitoring to detect change in clinical status. • Provide ongoing surveillance data to the patient’s health care providers in order to enhance medical management. • Return the patient to vocational and recreational activities or modify these activities based on the patient’s clinical status. • Provide patient and spouse/partner/family education to optimize secondary prevention (e.g., risk factor modification) through aggressive lifestyle management and judicious use of cardioprotective medications. Goals for Outpatient Cardiac Rehabilitation BOX 9.4
- 267. CHAPTER 9 Exercise Prescription for Patients with CVD 241 (exercise or imaging studies), revascularization, and pacemaker/implantable defibrillator implantation. • Current medications including dose, route of administration, and frequency • CVD risk factors (see Table 2.2). Exercise training is safe and effective for most patients with CVD; however, all patients should be stratified based on their risk for occurrence of a cardiac- related event during exercise training (see Box 2.4). Routine preexercise assess- ment of risk for exercise (see Chapters 3 and 5) should be performed before, during, and after each rehabilitation session, as deemed appropriate by the quali- fied staff and include the following: • HR. • Blood pressure (BP). • Body weight (weekly). • Symptoms or evidence of change in clinical status not necessarily related to activity (e.g., dyspnea at rest, light-headedness or dizziness, palpitations or irregular pulse, chest discomfort). • Symptoms and evidence of exercise intolerance. • Change in medications and adherence to the prescribed medication regimen. • Consideration of ECG surveillance that may consist of telemetry or hardwire monitoring, “quick-look” monitoring using defibrillator paddles, or periodic rhythm strips depending on the risk status of the patient and the need for accurate rhythm detection. EXERCISE PRESCRIPTION The “American College of Cardiology (ACC)/American Heart Association (AHA) 2002 Guideline Update for Exercise Testing” (16) states exercise testing at base- line is essential for the development of an Ex Rx in patients who suffered from MI with (Class I recommendation) or without (Class IIa recommendation) revascu- larization, as well as those patients who have undergone coronary revasculariza- tion alone (Class IIa recommendation). The test should be completed while the patient is stable on guideline-based medications. Prescriptive techniques for determining exercise dosage or the FITT principle of Ex Rx for the general apparently healthy population are detailed in Chapter 7. The Ex Rx techniques used for the apparently healthy adult population classified as low-to-moderate risk for occurrence of a cardiac-related event during exercise training (see Figure 2.3) may be applied to many low- and moderate-risk patients with CVD. This chapter provides specific considerations and modifications of the Ex Rx for patients with known CVD. Key variables to be considered in the development of an Ex Rx for patients with CVD include the following: • Safety factors including clinical status, risk stratification category (see Box 2.4), exercise capacity, ischemic/anginal threshold, musculoskeletal limitations,
- 268. 242 GUIDELINES FOR EXERCISE TESTING • www.acsm.org and cognitive/psychological impairment that might result in nonadherence and/or inability to meet exercise guidelines. • Associated factors including premorbid activity level, vocational and avoca- tional requirements, and personal health/fitness goals. FITT RECOMMENDATIONS FOR OUTPATIENT PROGRAMS Frequency: Exercise should be performed at least 3 d but preferably on most days of the week. Frequency of exercise depends on several factors including baseline exercise tolerance, exercise intensity, fitness and other health goals, and types of exercise that are incorporated into the overall program. For patients with very limited exercise capacities, multiple short (1–10 min) daily sessions may be prescribed. Patients should be encouraged to perform some of these exercise sessions independently (i.e., without direct supervision) following the recommendations outlined in this chapter. Intensity: Exercise intensity may be prescribed using one or more of the following methods: • Based on results from the baseline exercise test, 40%–80% of exercise capacity using the HR reserve (HRR), oxygen uptake reserve (V . O2 R), or peak oxygen uptake (V . O2peak ) methods • RPE of 11–16 on a scale of 6–20 (6) • Exercise intensity should be prescribed at a HR below the ischemic threshold; for example, ⬍10 beats, if such a threshold has been deter- mined for the patient. The presence of classic angina pectoris that is induced with exercise and relieved with rest or nitroglycerin is sufficient evidence for the presence of myocardial ischemia For the purposes of the Ex Rx , it is preferable for individuals to take their prescribed medications at their usual time as recommended by their health care providers. Individuals on a -adrenergic blocking agent (i.e., -blocker) may have an attenuated HR response to exercise and an increased or decreased maximal exercise capacity. For patients whose -blocker dose was altered after an exercise test or during the course of rehabilitation, a new graded exercise test may be helpful, particularly in patients who have not undergone a coronary revascularization procedure or who have been incom- pletely revascularized (i.e., residual obstructive coronary lesions are present) or who have rhythm disturbances. However, another exercise test may not be medically necessary in patients who have undergone complete coronary revascularization, or when it is logistically impractical.
- 269. CHAPTER 9 Exercise Prescription for Patients with CVD 243 When patients whose -blocker dose has been altered exercise without a new exercise test, signs and symptoms should be monitored, and RPE and HR responses should be recorded at previously performed workloads. These new HRs may serve as the patient’s new exercise target HR (THR) range. Patients on diuretic therapy may become volume depleted, have hy- pokalemia, or demonstrate orthostatic hypotension particularly after bouts of exercise. For these patients, the BP response to exercise, symptoms of dizziness or light-headedness, and arrhythmias should be monitored while providing education regarding proper hydration (3). See Appendix A for other medications that may influence the hemodynamic response during and after exercise. Time: Warm-up and cool-down activities of 5–10 min, including static stretching, ROM, and light intensity (i.e., ⬍40% V . O2 R, ⬍64% peak heart rate [HRpeak ], or ⬍11 RPE) aerobic activities, should be a component of each exercise session and precede and follow the conditioning phase. The goal for the duration of the aerobic conditioning phase is generally 20–60 min per session. After a cardiac-related event, patients may begin with as little as 5–10 min of aerobic conditioning with a gradual increase in aerobic exercise time of 1–5 min per session or an increase in time per session of 10%–20% per week. Type: The aerobic exercise portion of the session should include rhyth- mic, large muscle group activities with an emphasis on increased caloric expenditure for maintenance of a healthy body weight and its many other associated health benefits (see Chapters 1, 7, and 10). To promote whole body physical fitness, conditioning that includes the upper and lower extremities and multiple forms of aerobic activities and exercise equipment should be incorporated into the exercise program. The different types of exercise equipment may include the following: • Arm ergometer • Combination of upper or lower (dual action) extremity cycle ergometer • Upright and recumbent cycle ergometer • Recumbent stepper • Rower • Elliptical • Stair climber • Treadmill for walking Aerobic interval training (AIT) involves alternating 3–4 min pe- riods of exercise at high intensity (90%–95% HRpeak ) with exercise at moderate intensity (60%–70% HRpeak ). Such training for approximately 40 min, three times per week has been shown to yield a greater improve- ment in V . O2peak in patients with heart failure (44) and greater long-term
- 270. 244 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Continuous Electrocardiographic Monitoring ECG monitoring during supervised exercise sessions may be helpful during the first several weeks. The following recommendations for ECG monitoring are related to patient-associated risks of exercise training (see Chapter 1) and are in agreement with those of the AACVPR (2): • Low-risk cardiac patients may begin with continuous ECG monitoring and decrease to intermittent ECG monitoring after six sessions or sooner as deemed appropriate by the rehabilitation staff. • Moderate-risk patients may begin with continuous ECG monitoring and decrease to intermittent ECG monitoring after 12 sessions or sooner as deemed appropriate by the rehabilitation staff. • High-risk patients may begin with continuous ECG monitoring and decrease to intermittent ECG monitoring after 18 sessions or sooner as deemed appro- priate by the rehabilitation staff. improvements in V . O2peak in patients after CABG (27) compared to stan- dard continuous, moderate intensity exercise. Although AIT has routinely been used in athletes, its use in patients with CVD appears to have poten- tial but cannot yet be universally recommended until further data regard- ing safety and efficacy are available. Progression: There is no standard format for the rate of progression in exercise session duration. Thus, progression should be individualized to patient tolerance. Factors to consider in this regard include initial physical fitness level, patient motivation and goals, symptoms, and musculoskeletal limitations. Exercise sessions may include continuous or intermittent exer- cise depending on the capability of the patient. Table 9.1 provides a sample progression using intermittent exercise. TABLE 9.1. Sample Exercise Progression Using Intermittent Exercise (5) Functional Capacity ⱖ4 METs Week % FC Total ExerciseTime (min) at % FC Exercise Bout (min) Rest Bout (min) Number of Exercise/ Rest Bouts 1–2 50–60 15–20 3–10 2–5 3–4 3–4 60–70 20–40 10–20 Optional 2 Functional Capacity ⱖ4 METs Week % FC Total ExerciseTime (min) at % FC Exercise Bout (min) Rest Bout (min) Number of Exercise/ Rest Bouts 1–2 40–50 10–20 3–7 3–5 3–4 3–4 50–60 15–30 7–15 2–5 2–3 5 60–70 25–40 12–20 2 2 Continue with two repetitions of continuous exercise with one rest period or progress to a single continuous bout. FC, functional capacity; MET, metabolic equivalent.
- 271. CHAPTER 9 Exercise Prescription for Patients with CVD 245 Exercise Prescription without a Preparticipation Exercise Test Exercise testing at baseline is important for the development of an Ex Rx in patients experiencing an MI or undergoing a coronary revascularization (16). However, with shorter hospital stays, more aggressive interventions, and greater sophistication of diagnostic procedures, it is not unusual for patients to begin cardiac rehabilitation before having an exercise test (see Box 9.5). Until an exer- cise test is performed, Ex Rx procedures can be based on the recommendations of these Guidelines and what was accomplished during the inpatient phase, home exercise activities, and RPE. The rehabilitation staff should closely monitor for signs and symptoms of exercise intolerance such as excessive fatigue, dizziness or light-headedness, chronotropic incompetence, and signs or symptoms of ischemia. Lifestyle Physical Activity In addition to formal exercise sessions, patients should be encouraged to gradually return to general ADL such as household chores, yard work, shop- ping, and hobbies as evaluated and appropriately modified by the rehabilitation staff. Participation in competitive sports should be guided by the recommenda- tions of the ACC Bethesda Conference (42). Relatively inexpensive pedometers can be useful to monitor physical activity and may enhance adherence with walking programs (8). Walking for 30 min ⭈ d⫺1 equates to 3,000–4,000 steps, whereas a 1-mi (1.6 km) walk equates to ⬃2,000 steps. To meet current recom- mendations for physical activity, adding ⬃2,000 steps ⭈ d⫺1 to reach a daily step count of 5,400–7,000 steps ⭈ d⫺1 is beneficial. Pedometers are most effective in increasing physical activity when accompanied by a goal for achieving specific daily step count, such as a goal of 10,000 steps ⭈ d⫺1 (8) (see Chapter 7). TYPES OF OUTPATIENT EXERCISE PROGRAMS Participation in cardiac rehabilitation after suffering or undergoing an indexed cardiac-related event represents guideline-based care to reduce the risk for experiencing a second event, improving exercise tolerance, managing symptoms, and facilitating healthier lifestyle changes. However, cardiac rehabilitation is • Extreme deconditioning • Orthopedic limitations • Recent successful percutaneous intervention or revascularization surgery without residual obstructive coronary artery disease Reasons for No Available Preparticipation Exercise Test BOX 9.5
- 272. 246 GUIDELINES FOR EXERCISE TESTING • www.acsm.org underused. For example, among Medicare beneficiaries, in 1997, only 14% of patients experiencing an MI and 31% who had undergone CABG received cardiac rehabilitation (41). However, many patients may be unable to participate for various reasons including program location and accessibility, transportation, and work or personal schedules. Accordingly, creative programming that incorpo- rates a mix of supervised and unsupervised sessions (i.e., hybrid design) and/or regular telephone, Internet, or mail contact should be considered as alternatives. In some cases, an independent program with follow-up by the patient’s health care providers may be the only option. It is important that patients eventually transition from a medically supervised program to an independent one (i.e., self-monitored and unsupervised home ex- ercise program). The optimal number of weeks of attendance at a supervised pro- gram before entering an independent program is unknown and is likely patient specific. Insurance reimbursement is often a factor that determines the length of time of participation in a supervised program. In any case, the rehabilitation team should develop a program that appropriately prepares the patient for even- tual transfer to unsupervised exercise. Some centers offer extended short-term transition programs or long-term maintenance programs. The following issues should be considered in the determination of appropriateness for independent exercise: • Cardiac symptoms that are stable or absent. • Appropriate HR, BP, and rhythm responses to exercise (see Chapters 4 and 5). • Demonstrated knowledge of proper exercise principles and awareness of abnormal symptoms. • Motivation to continue to exercise regularly without close supervision. SPECIAL CONSIDERATIONS Patients with Peripheral Artery Disease Peripheral artery disease (PAD) affects approximately 8 million adults in the United States (34) and increases in prevalence with advancing age (40). Major risk factors for PAD include diabetes mellitus, hypertension, smoking, dyslip- idemia, hyperhomocysteinemia, non-Caucasian race, high levels of C-reactive protein, and renal insufficiency (28). Patients with PAD have a 6.6 times greater risk of dying from CVD compared with individuals without PAD (40). Intermittent claudication, the major symptom of PAD, is characterized by a reproducible aching or cramping sensation in one or both legs that typically is triggered by weight-bearing exercise (38). Intermittent claudication is reported in 5% of the population in the United States older than 55 yr. On initial clinical presentation, up to 35% of individuals with PAD have typical claudication and up to 50% have atypical leg pain (20,28). Because those with either typical or atypical claudication have similar changes in ankle systolic BP (SBP) during treadmill exercise (13), patients with any description of leg pain should be considered to have intermittent claudication until proven otherwise. As the
- 273. CHAPTER 9 Exercise Prescription for Patients with CVD 247 symptoms worsen, they may become severe enough to limit the individual from performing ADL (14). PAD is caused by the development of atherosclerotic plaque in systemic arteries that leads to significant stenosis, resulting in the reduction of blood flow to regions distal to the area of occlusion. This reduction in blood flow creates a mismatch between oxygen supply and demand causing ischemia to develop in the affected areas that typically are the calf, thigh, or buttocks (18). PAD is staged based on the presence of symptoms as described in Table 9.2 and by the ankle-brachial index (ABI), with values ranging from ⬎1.0 to ⬍0.5 (see Table 9.3) (38). If arterial lesions in the lower extremities progress to severe PAD, resulting in severe claudication or pain at rest, peripheral intervention may be indicated (18,40). In the most severe cases in which critical limb ischemia develops resulting in gangrene or tissue loss, amputation of the lower extremity may be indicated. The recommended treatments for PAD include an initially conservative approach using medications (e.g., cilostazol) (see Appendix A) and exercise followed by peripheral revascularization if conservative therapy is not successful (18). ExerciseTesting Exercise testing is performed in patients with PAD to determine the time of onset of claudication pain pretherapeutic and posttherapeutic intervention, to measure the postexercise ABI, and to diagnose the presence of CVD (45): • Patients with PAD are classified as high risk (see Table 2.3); therefore, exercise testing under medical supervision is indicated (see Figure 2.4). • Medication dose should be noted and repeated in an identical manner in subsequent exercise tests. TABLE 9.2. Fontaine Classification of Peripheral Artery Disease (38) Stage Symptoms 1 Asymptomatic 2 Intermittent claudication 2a Distance to pain onset ⬎200 m 2b Distance to pain onset ⬍200 m 3 Pain at rest 4 Gangrene, tissue loss TABLE 9.3. Ankle-Brachial Index Scale for Peripheral Arterial Disease (38) Supine Resting Ankle-Brachial Index Postexercise Ankle-Brachial Index ⬎1.0 No change or increase 0.8–0.9 ⬎0.5 0.5–0.8 ⬎0.2 ⬍0.5 ⬍0.2
- 274. 248 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • Ankle and brachial artery SBP should be measured bilaterally after 5–10 min of rest in the supine position. The ABI should be calculated by dividing the higher ankle SBP reading by the higher brachial artery SBP reading. • A treadmill protocol beginning with a slow speed with gradual increments in grade is recommended (45) (see Chapter 5). • Claudication pain perception may be monitored using the following scale: 0 ⫽ no pain, 1 ⫽ onset of pain, 2 ⫽ moderate pain, 3 ⫽ intense pain, and 4 ⫽ maximal pain (45), or the Borg CR10 Scale (7) (see Figure 9.1). The time and distance to the onset of pain and the time and distance to maximal pain should be recorded. • Following the completion of the exercise test, patients should recover in the supine position for up to 15 min, and ABI should be calculated during this time. The time taken for the pain to resolve after exercise should also be recorded (45). • In addition to the symptom-limited graded exercise test, the 6-min walking test may be used to assess ambulatory function in patients with PAD (45). 0 0.3 0.5 0.7 1 1.5 2 2.5 3 4 5 6 7 8 9 10 11 • Nothing at all Extremely weak Very weak Weak Moderate Strong Very strong Extremely strong Absolute maximum Just noticeable Light Heavy “Maximal” Highest possible ~ ■ FIGURE 9.1. The Borg CR10 Scale. The scale with correct instructions can be obtained from Borg Perception, Radisvagen 124, 16573 Hasselby, Sweden. See also the home page: www.borgperception.se/index.html. © Gunnar Borg. Reprinted with permission from (7). Note: This scale is a pain scale that can be adapted to determine dyspnea and most other symptoms.
- 275. CHAPTER 9 Exercise Prescription for Patients with CVD 249 FITT Recommendations for Individuals with Peripheral Artery Disease Exercise training is effective in the treatment of individuals with PAD. Training using an interval approach leads to increases in the times and distances to onset of pain and to maximal pain (14). The exercise program should also be designed to target the CVD risk factors that are often associated with PAD (45). The following FITT principle of Ex Rx is recommended for individuals with PAD. Other Considerations • The optimal work to rest ratio has not been determined for individuals with PAD. Nonetheless, the work to rest ratio may need to be adjusted for each patient. • A cold environment may aggravate the symptoms of intermittent claudica- tion; therefore, a longer warm-up may be necessary (10). • Encourage patients to stop smoking if they are current smokers. • For optimal benefit, patients should participate in a supervised exercise pro- gram for a minimum of 6 mo (15). Following exercise training programs of this length, improvements in pain-free walking of 106%–177% and 64%–85% in absolute walking ability may occur (9). FITT RECOMMENDATIONS FOR PATIENTS WITH PAD Frequency: Weight-bearing aerobic exercise 3–5 d ⭈ wk⫺1 ; resistance exercise at least 2 d ⭈ wk⫺1 Intensity: Moderate intensity (i.e., 40%–⬍60% V . O2 R) that allows the patient to walk until he or she reaches a pain score of 3 (i.e., intense pain) on the 4-point pain scale (45). Between bouts of activity, individuals should be given time to allow ischemic pain to subside before resuming exercise (19,45). Time: 30–60 min ⭈ d⫺1 , but initially, some patients may need to start with 10 min bouts and exercise intermittently to accumulate a total of 30–60 min ⭈ d⫺1 . Many patients may need to begin the program by accumulating only 15 min ⭈ d⫺1 , gradually increasing time by 5 min ⭈ d⫺1 biweekly. Type: Weight-bearing aerobic exercise, such as walking, and non–weight- bearing exercise, such as arm and leg ergometry. Cycling may be used as a warm-up but should not be the primary type of activity. Resistance training is recommended to enhance and maintain muscular strength and endurance (see Chapter 7).
- 276. 250 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Patients with a Sternotomy Median sternotomy is usually performed as part of CABG and valve replacement surgery in order to gain access to the heart. Although there are various surgical techniques that are used to close the sternum upon completion of the operation, the figure-of-eight interlocking closures with sternal wires, is commonly per- formed to secure the sternum during the early postoperative period (24). Sternal bone healing to attain adequate sternal stability is usually achieved by 8 wk (35). Healing-related complications that include infection, nonunion, and instability occur in about 2%–5% of cases (24). Several clinical factors such as diabetes mellitus, obesity, immunosuppressive therapy, advanced age, and osteoporosis predispose patients to such complications (24). In any case, caution must be used in developing an exercise program in patients with a sternotomy, particularly within the first 8–12 wk following the procedure. There are no clinical studies that have adequately evaluated the effect of specific activities and exercise programming on sternal healing and stability. Hence, clinical judgment on the part of the rehabilitation team must be used. The patient’s surgeon, health care provider, or appropriately trained rehabilita- tion staff should routinely evaluate the sternal wound for infection, healing, and stability during the first 8–12 wk following surgery and longer if any unusual symptoms of sternal pain or other complications occur. Upper body movements that exert tension on the sternal wound should be avoided during this early period. Because each patient differs in muscular strength and other factors that may affect healing, no standard weight limits can be recommended during this early period. Subsequently, after appropriate evaluation, ROM exercises and other activities that involve sternal muscles can be gradually introduced and progressed as long as there is no evidence of sternal instability as detected by movement in the sternum, pain, cracking, or popping. Recent Pacemaker or Implantable Cardioverter Defibrillator Implantation Cardiac pacemakers are used to restore an optimal HR and to synchronize atrial and ventricular filling and contraction in the setting of abnormal rhythms. Specific indications for pacemakers include sick sinus syndrome with symptomatic bradycardia, acquired atrioventricular (AV) block, and persistent advanced AV block after MI. Cardiac resynchronization pacemakers, some- times called biventricular pacemakers, are used in patients with left ventricular systolic dysfunction who demonstrate ventricular dyssynchrony during con- traction of the left and right ventricles. The different types of pacemakers are the following: • Rate-responsive pacemakers that are programmed to increase or decrease HR to match the level of physical activity (e.g., sitting rest or walking). • Single-chambered pacemakers that have only one lead placed into the right atrium or the right ventricle.
- 277. CHAPTER 9 Exercise Prescription for Patients with CVD 251 • Dual-chambered pacemakers that have two leads; one placed in the right atrium and one in the right ventricle. • Cardiac resynchronization therapy pacemakers that have three leads; one in right atrium, one in right ventricle, and one in coronary sinus or, less com- monly, the left ventricular myocardium via an external surgical approach. The type of pacemaker is identified by a four-letter code as indicated in the following section: • The first letter of the code describes the chamber paced (e.g., atria [A], ventricle [V], dual [D]). • The second letter of the code describes the chamber sensed. • The third letter of the code describes the pacemaker’s response to a sensed event. • The fourth letter of the code describes the rate response capabilities of the pacemaker, (e.g., inhibited [I], rate responsive [R]). For example, a VVIR code pacemaker means (a) the ventricle is paced (V) and sensed (V); (b) when the pacemaker senses a normal ventricular contrac- tion, it is inhibited (I); and (c) the pulse generator is rate responsive (R). Implantable cardiac defibrillators (ICDs) are devices that monitor heart rhythms and deliver shocks if life-threatening rhythms are detected. ICDs are used for high-rate ventricular tachycardia or ventricular fibrillation in patients who are at risk for these conditions as a result of previous cardiac arrest, cardio- myopathy, heart failure, or ineffective drug therapy for abnormal heart rhythms. When ICDs detect a too rapid or irregular heartbeat, they may first try to pace the heart into a normal rate and rhythm (i.e., antitachycardia pacing). If unsuccess- ful, they can then deliver a shock that resets the heart to a more normal HR and electrical pattern (i.e., cardioversion). Thus, ICDs aim to protect against sudden cardiac death from ventricular tachycardia and ventricular fibrillation. Ex Rx considerations for those with pacemakers are as follows: • Programmed pacemaker modes, HR limits, and ICD rhythm detection algo- rithms should be obtained from the patient’s cardiologist prior to exercise testing or training. • Exercise testing should be used to evaluate HR and rhythm responses prior to beginning an exercise program. • When an ICD is present, the HRpeak during the exercise test and exercise training program should be maintained at least 10 beats ⭈ min⫺1 below the programmed HR threshold for antitachycardia pacing and defibrillation. • After the first 24 h following the device implantation, mild upper extremity ROM activities can be performed and may be useful to avoid subsequent joint complications. • To maintain device and incision integrity, for 3–4 wk after implant, rigorous upper extremity activities such as swimming, bowling, lifting weights, elliptical machines, and golfing should be avoided. However, lower extremity activities are allowable.
- 278. 252 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Patients with Heart Failure Exercise training in patients with heart failure has consistently been shown to improve functional capacity, symptoms, and quality of life (21). Furthermore, recent data suggest a modest reduction of rehospitalization rates and mortality (29). Most studies include only patients with left ventricular systolic dysfunc- tion. Data on patients with heart failure and normal ejection fraction (diastolic heart failure) are limited to a few small observational studies. The standard recommendations for exercise training in patients with heart failure are similar to those for patients with known CVD, as defined earlier in this chapter (see Box 9.1). Although aerobic exercise remains the mainstay of clinical training programs, resistance training has been shown to increase muscle strength and endurance, reduce symptoms, and improve quality of life (17,30,33,36). Exercise training in patients with heart failure is generally well tolerated and safe (29). A recent large randomized trial has demonstrated that among 490 patients with an ICD in the exercise group, only one experienced ICD firing during an exercise session. Overall, the adverse event rates during the entire study period did not differ between the exercise and control groups (29). Patients after Cardiac Transplantation The Ex Rx for patients with cardiac transplantation offers a unique set of chal- lenges. For the first several months after surgery, the transplanted heart does not respond normally to sympathetic nervous stimulation. The cardiac rehabilitation team should be aware of the following hemodynamic alterations that are com- monly present during this time: (a) HRrest is elevated; and (b) the HR response to exercise is abnormal such that the increase in HR during exercise is delayed and HRpeak is below normal. Ex Rx for these patients does not include use of a THR but rather should include (a) an extended warm-up and cool-down to patient tolerance if the patient is limited by muscular deconditioning; (b) using RPE to monitor exercise intensity aiming for an RPE of 11–16; and (c) incorporation of stretching and ROM exercises (see Chapter 7). However, at 1 yr after surgery, approximately one- third of patients exhibit a partially normalized HR response to exercise and may be given a THR based on results from an exercise test (39). Medical management of the patient with cardiac transplant is aimed at preventing immune system rejection of the transplanted heart while avoiding the many possible adverse side effects of immunosuppressive therapy such as infections, dyslipidemia, hyper- tension, obesity, osteoporosis, renal dysfunction, and diabetes mellitus. RESISTANCE TRAINING FOR CARDIAC PATIENTS Resistance training is now a standard part of the overall exercise training pro- gram for most, if not all, patients with CVD (43). Such training yields many benefits, which are outlined in Box 9.6. The development of muscular strength
- 279. CHAPTER 9 Exercise Prescription for Patients with CVD 253 • Improve muscular strength and endurance • Decrease cardiac demands of muscular work (i.e., reduced rate pressure product) during daily activities • Prevent and treat other diseases and conditions, such as osteoporosis, Type 2 diabetes mellitus, and obesity • Increase ability to perform activities of daily living • Improve self-confidence • Maintain independence • Slow age and disease-related declines in muscle strength and mass Purposes of Resistance Training for Patients with Cardiac Disease (43) BOX 9.6 • All patients entering cardiac rehabilitation should be considered for resistance training exercise (see Box 9.8); particularly those who require strength improvements to perform activities of daily living, work, or recreational activities; and those with controlled heart failure, obesity, or diabetes. • No evidence of congestive heart failure (CHF), uncontrolled arrhythmias, severe valvular disease, uncontrolled hypertension, and unstable symptoms. Patient Criteria for a Resistance Training Program (43) BOX 9.7 and endurance facilitates resumption of work and efficient performance of ADL. Patient criteria for participation in resistance training are provided in Box 9.7 with guidelines for resistance training in Box 9.8. See Chapter 7 for additional information on resistance training. EXERCISE TRAINING FOR RETURN TO WORK For those planning to return to work, exercise training should consider the muscle groups and energy systems required to perform occupational tasks, par- ticularly for those patients whose jobs involve manual labor. Exercise training leads to an improved ability to perform physical work, a better perception of job demands, an enhanced self-efficacy, and a greater willingness to resume work and to remain employed following a cardiac event (23,37). Box 9.9 presents the Ex Rx regarding preparation for return to work.
- 280. 254 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • Equipment (Type) • Elastic bands • Cuff and hand weights • Free weights • Wall pulleys • Machines (dependent on weight of lever arms and range of motion) • Proper techniques • Raise and lower weights with slow, controlled movements to full extension. • Maintain regular breathing pattern and avoid breath holding. • Avoid straining. • Avoid sustained, tight gripping, which may evoke an excessive blood pressure (BP) response. • A rating of perceived exertion (RPE) of 11–14 (“light” to “somewhat hard”) on a scale of 6–20 may be used as a subjective guide to effort. • Terminate exercise if warning signs or symptoms occur including dizziness, arrhythmias, unusual shortness of breath, or anginal discomfort. • Initial load should allow 10–15 repetitions that can be lifted without straining (⬃30%–40% one repetition maximum [1-RM] for the upper body; ⬃50%–60% for the lower body). 1-RM is the maximum load that can be lifted one time. When determination of 1-RM is deemed inappropriately, multiple trials using progressively higher loads can be performed until the patient can perform no more than 10 repetitions without straining. That load can then be used for training. • Exercise dosage can be progressed by increasing the resistance, increasing the number of repetitions, or decreasing the rest period between sets or exercises. • Increase loads by 5% increments when the patient can comfortably achieve the upper limit of the prescribed repetition range (e.g., 12–15 repetitions). • Low-risk patients may progress to 8–12 repetitions with a resistance of ⬃60%–80% 1-RM. • Because of the potential for an elevated BP response, the rate pressure product (RPP) should not exceed that during prescribed endurance exercise as determined from the exercise test. • Each major muscle group (i.e., chest, shoulders, arms, abdomen, back, hips, and legs) should be trained initially with one set; multiple set regimens may be introduced later as tolerated. • Sets may be of the same exercise or from different exercises affecting the same muscle group. Resistance Training Guidelinesa (43) BOX 9.8
- 281. CHAPTER 9 Exercise Prescription for Patients with CVD 255 • Perform 8–10 exercises of the major muscle groups. • Exercise large muscle groups before small muscle groups. • Include multijoint exercises or “compound” exercises that affect more than one muscle group. • Frequency: 2–3 d ⭈ wk⫺1 with at least 48 h separating training sessions for the same muscle group. All muscle groups to be trained may be done in the same session, that is, whole body or each session may “split” the body into selected muscle groups so that only a few are trained in any one session. Resistance training should be performed after the aerobic component of the exercise session to allow for adequate warm-up. • Progression: Increase slowly as the patient adapts to the program (⬃2–5 lb ⭈ wk⫺1 [0.91–2.27 kg] for upper body and 5–10 lb ⭈ wk⫺1 for lower body [0.91–4.5 kg]). a For additional information on resistance training, see Chapter 7. Resistance Training Guidelinesa (43) (Continued) BOX 9.8 • Assessment of patient’s work demands and environment • Nature of work • Muscle groups used at work • Work demands that primarily involve muscular strength and endurance • Primary movements performed during work • Periods of high metabolic demands vs. periods of low metabolic demands • Environmental factors including temperature, humidity, and altitude • Exercise prescription • Emphasize exercise modalities that use muscle groups involved in work tasks. • If possible, use exercises that mimic movement patterns used during work tasks. • Balance resistance vs. aerobic training relative to work tasks. • If environmental stress occurs at work, educate the patient about appropriate precautions including avoidance if need be, and, if possible, expose them to similar environmental conditions while performing activities similar to work tasks (see the American College of Sports Medicine Position Stands [1,2,10] and Chapter 8 for additional information on environmental precautions). • If possible, monitor the physiologic responses to a simulated work environment. Exercise Prescription for Return to Work BOX 9.9
- 282. 256 GUIDELINES FOR EXERCISE TESTING • www.acsm.org EXERCISE PRESCRIPTION FOR PATIENTS WITH CEREBROVASCULAR DISEASE (STROKE) Stroke is a brain injury that is caused by either vascular ischemia or intracerebral hemorrhage and is a leading cause of disability in the United States (34). Stroke leads to the adverse combination of reduced functional capacity and increased energy demands to perform routine activities (i.e., diminished physiologic fitness reserve) (34). Among patients suffering from a hemiparetic stroke, the V̇O2peak is approximately half that of age-matched individuals (22), a level that is near the minimum range required for ADL. Standard stroke care during the initial 3–6 mo postevent period focuses on basic mobility function and recovery of ADL. Many patients are discharged from standard physical therapy care without having achieved full recovery and suffer further decline in mobility within a year (22). Hence, exercise interventions that go beyond the early subacute period are needed to optimize functional capacity for the long term. Randomized exercise training studies using a wide variety of modalities and protocols have demonstrated an 8%–23% improvement in V̇O2peak after 2–6 mo of training (22). However, most research has focused on patients with hemipare- sis who have mild-to-moderate gait impairment. Among such patients, treadmill training using progressive intensity and duration appears to offer promising results (25,26). However, at this time, no specific training protocol has been adequately studied or can be recommended for these patients or those with more limiting neuromuscular deficits. THE BOTTOM LINE • Following a documented physician referral, patients hospitalized after a cardiac-related event or procedure associated with CAD, cardiac valve replacement, or MI should be provided with a program consisting of early assessment and mobilization, identification of and education regarding CVD risk factors, assessment of the patient’s level of readiness for physical activity, and comprehensive discharge planning. • Inpatients should be educated and encouraged to investigate outpatient exercise program options and be provided with information regarding the use of home exercise equipment. All patients, especially moderate- to high-risk patients with CVD, should be strongly encouraged to participate in a clini- cally supervised outpatient cardiac rehabilitation program. • Exercise training is safe and effective for most patients with CVD; however, all patients should be classified according to future risk for occurrence of cardiac-related events during exercise training. • In addition to formal outpatient exercise sessions, patients should be en- couraged to gradually return to general ADL such as household chores, yard work, shopping, and hobbies as evaluated and appropriately modified by the rehabilitation staff.
- 283. CHAPTER 9 Exercise Prescription for Patients with CVD 257 • It is important that outpatients eventually transition from a medically su- pervised program to an independent (i.e., self-monitored and unsupervised) home exercise program. The optimal number of weeks of attendance at a supervised program before entering an independent program is unknown and is likely patient specific. • PAD is a common disorder with increasing prevalence in older adults. Conservative management of patients with asymptomatic PAD and patients with intermittent claudication is recommended to modify risk factors and improve ambulatory ability, whereas patients with more severe PAD typically require revascularization of the lower extremities. Exercise rehabilitation is a highly effective, conservative treatment to improve ambulation in patients with intermittent claudication. • Resistance training is now a standard part of the overall exercise training program for most, if not all, patients with CVD (see Chapter 7). • Standard stroke care during the initial 3–6 mo postevent period focuses on basic mobility function and recovery of ADL. Exercise interventions that go beyond the early subacute period are needed to optimize functional capacity for the long term. American Association for Cardiovascular and Pulmonary Rehabilitation (1): http://www.aacvpr.org American Heart Association (4): http://www.americanheart.org Clinical Exercise Physiology Association (11): http://www.acsm-cepa.org Society for Vascular Medicine: http://www.svmb.org VascularWeb: http://www.vascularweb.org Online Resources REFERENCES 1. American Association for Cardiovascular and Pulmonary Rehabilitation Web site [Internet]. Chicago (IL): American Association for Cardiovascular and Pulmonary Rehabilitation; [cited 2011 Jan 6]. Available from: http://www.aacvpr.org/ 2. American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiac rehabilitation in the inpatient and transitional setting. In: Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign: Human Kinetics; 2004. p. 31–52. 3. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports Medicine Position Stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377–90. 4. American Heart Association Web site [Internet]. Dallas (TX): American Heart Association; [cited 2011 Jan 6]. Available from: http://www.americanheart.org/ 5. Armstrong LE, Brubaker PH, Whaley MH, Otto RM, American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 7th ed. Baltimore (MD): Lippincott Williams Wilkins; 2005. 366 p.
- 284. 258 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 6. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–81. 7. Borg G. Scaling pain and related subjective somatic symptoms. In: Borg’s Perceived Exertion and Pain Scales. Champaign: Human Kinetics; 1998. p. 63–67. 8. Bravata DM, Smith-Spangler C, Sundaram V, et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA. 2007;298(19):2296–304. 9. Bulmer AC, Coombes JS. Optimising exercise training in peripheral arterial disease. Sports Med. 2004;34(14):983–1003. 10. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine Position Stand: prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012–29. 11. Clinical Exercise Physiology Association Web site [Internet]. Indianapolis (IN): Clinical Exercise Physiology Association; [cited 2011 Jun 7]. Available from: http://www.acsm-cepa.org/ 12. Convertino VA. Blood volume response to physical activity and inactivity. Am J Med Sci. 2007; 334(1):72–9. 13. Gardner AW, Montgomery PS, Afaq A. Exercise performance in patients with peripheral arterial disease who have different types of exertional leg pain. J Vasc Surg. 2007;46(1):79–86. 14. Gardner AW, Montgomery PS, Flinn WR, Katzel LI. The effect of exercise intensity on the response to exercise rehabilitation in patients with intermittent claudication. J Vasc Surg. 2005; 42(4):702–9. 15. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 1995;274(12):975–80. 16. Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). J Am Coll Cardiol. 2002;40(8):1531–40. 17. Hare DL, Ryan TM, Selig SE, Pellizzer AM, Wrigley TV, Krum H. Resistance exercise training increases muscle strength, endurance, and blood flow in patients with chronic heart failure. Am J Cardiol. 1999;83(12):1674–7, A7. 18. Hiatt WR, Cox L, Greenwalt M, Griffin A, Schechter C. Quality of the assessment of primary and secondary endpoints in claudication and critical leg ischemia trials. Vasc Med. 2005;10(3):207–13. 19. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286(11):1317–24. 20. Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation. 2006;113(11):e463–654. 21. Hunt SA, American College of Cardiology, American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2005;46(6):e1–82. 22. Ivey FM, Hafer-Macko CE, Macko RF . Exercise rehabilitation after stroke. NeuroRx. 2006;3(4): 439–50. 23. Leon AS, Franklin BA, Costa F , et al. Cardiac rehabilitation and secondary prevention of coronary heart disease: an American Heart Association scientific statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in collabora- tion with the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2005;111(3):369–76. 24. Losanoff JE, Jones JW, Richman BW. Primary closure of median sternotomy: techniques and prin- ciples. Cardiovasc Surg. 2002;10(2):102–10. 25. Luft AR, Macko RF , Forrester LW, et al. Treadmill exercise activates subcortical neural networks and improves walking after stroke: a randomized controlled trial. Stroke. 2008;39(12):3341–50. 26. Macko RF , Ivey FM, Forrester LW, et al. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: a randomized, controlled trial. Stroke. 2005;36(10):2206–11.
- 285. CHAPTER 9 Exercise Prescription for Patients with CVD 259 27. Moholdt TT, Amundsen BH, Rustad LA, et al. Aerobic interval training versus continuous moder- ate exercise after coronary artery bypass surgery: a randomized study of cardiovascular effects and quality of life. Am Heart J. 2009;158(6):1031–7. 28. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;(45 Suppl S):S5–67. 29. O’Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439–50. 30. Oka RK, De Marco T, Haskell WL, et al. Impact of a home-based walking and resistance training program on quality of life in patients with heart failure. Am J Cardiol. 2000;85(3):365–9. 31. Outpatient cardiac rehabilitation and secondary prevention. In: American Association of Cardiovascular and Pulmonary Rehabilitation, editor. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4th ed. Champaign: Human Kinetics; 2004. p. 53–68. 32. Paker K. An early cardiac access clinic significantly improves cardiac rehabilitation participation and completion rates in low risk STEMI patients. Can J Cardiol. 2011;27(5):619–27. 33. Pu CT, Johnson MT, Forman DE, et al. Randomized trial of progressive resistance training to coun- teract the myopathy of chronic heart failure. J Appl Physiol. 2001;90(6):2341–50. 34. Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: A report from the American Heart Association. Circulation. 2012;125(1):e2–e220. 35. Sargent LA, Seyfer AE, Hollinger J, Hinson RM, Graeber GM. The healing sternum: a comparison of osseous healing with wire versus rigid fixation. Ann Thorac Surg. 1991;52(3):490–4. 36. Selig SE, Carey MF , Menzies DG, et al. Moderate-intensity resistance exercise training in patients with chronic heart failure improves strength, endurance, heart rate variability, and forearm blood flow. J Card Fail. 2004;10(1):21–30. 37. Sheldahl LM, Wilke NA, Tristani FE. Evaluation and training for resumption of occupational and leisure-time physical activities in patients after a major cardiac event. Med Exerc Nutr Health. 1995;4:273–89. 38. Squires RW. Pathophysiology and clinical features of cardiovascular diseases. In: Kaminsky LA, editor. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore: Lippincott Williams Wilkins; 2006. p. 411–438. 39. Squires RW, Leung TC, Cyr NS, et al. Partial normalization of the heart rate response to exercise after cardiac transplantation: frequency and relationship to exercise capacity. Mayo Clin Proc. 2002; 77(12):1295–300. 40. Stein R, Hriljac I, Halperin JL, Gustavson SM, Teodorescu V, Olin JW. Limitation of the resting ankle-brachial index in symptomatic patients with peripheral arterial disease. Vasc Med. 2006; 11(1):29–33. 41. Suaya JA, Shepard DS, Normand SL, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilita- tion by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation. 2007;116(15):1653–62. 42. Thompson PD, Balady GJ, Chaitman BR, Clark LT, Levine BD, Myerburg RJ. Task Force 6: coronary artery disease. J Am Coll Cardiol. 2005;45(8):1348–53. 43. Williams MA, Haskell WL, Ades PA, et al. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007;116(5):572–84. 44. Wisloff U, Stoylen A, Loennechen JP, et al. Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation. 2007;115(24):3086–94. 45. Womack CJ, Gardner AW. Peripheral arterial disease. In: Durstine JL, editor. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign: Human Kinetics; 2003. p. 81–5.
- 286. 260 Exercise Prescription for Populations with Other Chronic Diseases and Health Conditions CHAPTER xerci ise 10 This chapter contains the exercise prescription (Ex Rx ) guidelines and recom- mendations for individuals with chronic diseases and other health conditions. The Ex Rx guidelines and recommendations are presented using the Frequency, Intensity, Time, and Type (FITT) principle of Ex Rx based on the available litera- ture. For information relating to volume and progression, health/fitness, public health, clinical exercise, and health care professionals are referred to Chapter 7. Information is often lacking regarding volume and progression for the chronic diseases and health conditions presented in this chapter. In these instances, the guidelines and recommendations provided in Chapter 7 for apparently healthy populations should be adapted with good clinical judgment for the chronic disease(s) and health condition(s) being targeted. ARTHRITIS Arthritis and rheumatic diseases are leading causes of pain and disability. Among adults in the United States 18 yr, 22.2% (49.9 million) reported having a doctor’s diagnosis of arthritis and 9.4% (21.1 million) reported having an arthritis-related activity limitation (32). The prevalence of arthritis is expected to increase sub- stantially by 2030 because of the aging population and rising prevalence of obesity (14,77,109). There are over 100 rheumatic diseases — the two most common being osteoarthritis and rheumatoid arthritis. Osteoarthritis is a local degenerative joint disease that can affect one or multiple joints (i.e., most commonly the hands, hips, spine, and knees). Rheumatoid arthritis is a chronic, systemic inflammatory disease in which there is pathological activity of the immune system against joint tissues (130). Other common rheumatic diseases include fibromyalgia (discussed later in this chapter), systemic lupus erythematosus, gout, and bursitis. Medications are core components of the treatment of arthritis that includes anal- gesics, nonsteroidal anti-inflammatory drugs, and disease-modifying antirheumatic drugs for rheumatoid arthritis. However, optimal treatment of arthritis involves a multidisciplinary approach including patient education in self-management, physi- cal therapy, and occupational therapy (200,274). In the later stages of disease when pain is refractory to conservative management, total joint replacement and other surgeries can provide substantial relief. Although pain and functional limitations can present challenges to physical activity among individuals with arthritis, regular
- 287. CHAPTER 10 Exercise Prescription for Other Clinical Populations 261 exercise is essential for managing these conditions. Specifically, exercise reduces pain, maintains muscle strength around affected joints, reduces joint stiffness, pre- vents functional decline, and improves mental health and quality of life (208,274). EXERCISE TESTING Most individuals with arthritis tolerate symptom-limited exercise testing consis- tent with recommendations for apparently healthy adults (see Chapters 4 and 5). The following are special considerations for individuals with arthritis: • High intensity exercise is contraindicated when there is acute inflammation (i.e., hot, swollen, and painful joints). If individuals are experiencing acute in- flammation, exercise testing should be postponed until the flare has subsided. • Although some individuals with arthritis tolerate treadmill walking, use of cycle leg ergometry alone or combined with arm ergometry may be less painful for some and allow better assessment of cardiorespiratory function. The mode of exercise chosen should be the least painful for the individual being tested. • Allow ample time for individuals to warm up at a light intensity level prior to beginning the graded exercise test. • Monitor pain levels during testing. There are many validated scales available including the Borg CR10 Scale (see Figure 9.1) (27) and visual numeric scale (see Figure 10.1) (205). Testing should be stopped if the patient indicates pain is too severe to continue. • Muscle strength and endurance can be measured using typical protocols (see Chapter 4). However, pain may limit maximum muscle contraction in affected joints. EXERCISE PRESCRIPTION Pain can be a major barrier to beginning and maintaining a regular exercise program. Therefore, when prescribing exercise for individuals with arthritis, a key guiding principle should be identifying a program that minimizes pain while gradually progressing toward levels that provide greater health benefits (155). In general, recommendations for Ex Rx are consistent with those for apparently ■ FIGURE 10.1. Visual numeric pain scale. (Reprinted with permission from [205].) No pain Severe pain 0 10 9 8 7 6 5 4 3 2 1
- 288. 262 GUIDELINES FOR EXERCISE TESTING • www.acsm.org healthy adults (see Chapter 7), but FITT recommendations should take into account an individual’s’ pain, stability, and functional limitations. FITT RECOMMENDATIONS FOR INDIVIDUALS WITH ARTHRITIS Aerobic, Resistance, and Flexibility Exercise Frequency: Aerobic exercise 3–5 d ⭈ wk1 ; resistance exercise 2–3 d ⭈ wk1 ; flexibility/range of motion (ROM) exercises are essential and should be performed daily if possible. Intensity: Although an optimal intensity of aerobic exercise has not been determined, light-to-moderate intensity, physical activities are recommended because they are associated with lower risk of injury or pain exacerbation compared to higher intensity activities. A 40%–60% oxygen consumption reserve (V̇O2 R) or heart rate reserve (HRR) is appropriate for most individu- als with arthritis. Very light intensity, aerobic exercise (e.g., 30%–40% V̇O2 R or HRR) is appropriate for individuals with arthritis who are deconditioned. The appropriate intensity for resistance exercise for patients with arthri- tis has not been determined, and both light and higher intensity resistance training have shown improvements in function, pain, and strength among patients with rheumatoid arthritis and osteoarthritis (60,104,112,117,255). However, most studies have focused on light or moderate intensity resis- tance training; that is, a higher number of repetitions (10–15) at a lower percentage of one repetition maximum (1-RM) (40%–60% 1-RM). For pa- tients with rheumatoid arthritis and considerable damage in weight-bearing joints, there is some evidence that more intense physical activity may result in greater progression of joint damage (48). Therefore, lower intensity resis- tance exercise or physical activity is recommended for these patients (75). Time: A goal of 150 min ⭈ wk1 of aerobic exercise is appropriate for many individuals with arthritis, but long continuous bouts of exercise may be difficult for some of these individuals. Therefore, it is appropriate to start with short bouts of 10 min (or less if needed), according to an indi- vidual’s pain levels. The optimal number of sets and repetitions of resis- tance exercise is not known. Guidelines for healthy adults typically apply (see Chapter 7) with consideration of pain levels. Type: Aerobic exercise activities with low joint stress are appropriate includ- ing walking, cycling, or swimming. High-impact activities such as running, stair climbing, and those with stop and go actions are not recommended if limited by lower body arthritis. Resistance exercise should include all major muscle groups as recommended for healthy adults (see Chapter 7). Include flexibility exercise with ROM exercises of all major muscle groups. Progression: Progression of aerobic, resistance, and flexibility exercises should be gradual and individualized based on an individual’s pain and other symptoms.
- 289. CHAPTER 10 Exercise Prescription for Other Clinical Populations 263 SPECIAL CONSIDERATIONS Additional considerations when prescribing exercise for individuals with arthri- tis are the following (155,157): • Avoid strenuous exercises during acute flare ups and periods of inflamma- tion. However, it is appropriate to gently move joints through their full ROM during these periods. • Adequate warm-up and cool-down periods (5–10 min) are critical for mini- mizing pain. Warm-up and cool-down activities can involve slow movement of joints through their ROM. • Individuals with significant pain and functional limitation may need interim goals of lower than the recommended 150 min ⭈ wk1 of aerobic exercise and should be encouraged to undertake and maintain any amount of physical activity that they are able to perform. • Inform individuals with arthritis that a small amount of discomfort in the muscles or joints during or immediately after exercise is common, and this does not necessarily mean joints are being further damaged. However, if the patient’s pain rating 2 h after exercising is higher than it was prior to exer- cise, the duration and/or intensity of exercise should be reduced in future sessions. • Encourage individuals with arthritis to exercise during the time of day when pain is typically least severe and/or in conjunction with peak activity of pain medications. • Appropriate shoes that provide shock absorption and stability are particularly important for individuals with arthritis. Shoe specialists can provide recom- mendations for appropriate shoes to meet individual biomechanical profiles. • Incorporate functional exercises such as the sit-to-stand and step-ups as tole- rated to improve neuromotor control, balance, and maintenance of activities of daily living (ADL). • For water exercise, the temperature should be 83° to 88° F (28° to 31° C) because warm water helps to relax muscles and reduce pain. THE BOTTOM LINE • Exercise is an essential tool for managing osteoarthritis pain and other symptoms. Moderate aerobic activities with low joint stress are appropriate. Adequate warm-up, cool-down, and stretching are important for minimizing pain. The FITT principle of Ex Rx should accommodate individuals’ pain levels. Arthritis Foundation: http://www.arthritis.org Online Resources
- 290. 264 GUIDELINES FOR EXERCISE TESTING • www.acsm.org CANCER Cancer is a group of nearly 200 diseases characterized by the uncontrolled growth and spread of abnormal cells resulting from damage to deoxyribonucleic acid (DNA) by internal factors (e.g., inherited mutations) and environmental exposures (e.g., tobacco smoke). Most cancers are classified according to the cell type from which they originate. Carcinomas develop from the epithelial cells of organs and compose at least 80% of all cancers. Other cancers arise from the cells of the blood (leukemias), immune system (lymphomas), and connective tissues (sarcomas). The lifetime prevalence of cancer is one in two for men and one in three for women (5). Cancer affects all ages but is most common in older adults. About 76% of all cancers are diagnosed in individuals 55 yr (5); hence, there is a strong likelihood that individuals diagnosed with cancer will have other chronic diseases (e.g., cardiopulmonary disease, diabetes mellitus, osteoporosis, arthritis). Treatment for cancer may involve surgery, radiation, chemotherapy, hormones, and immunotherapy. In the process of destroying cancer cells, some treatments also damage healthy tissue. Patients may experience side effects that limit their ability to exercise during treatment and afterward. These long-term and late effects of cancer treatment are described elsewhere (152). Furthermore, overall physical function is generally diminished because of losses of aerobic capacity, muscle tissue, and ROM. Even among cancer survivors who are 5 yr or more posttreatment, more than half report physical performance limitations including crouching/kneeling, standing for 2 h, lifting/carrying 10 lb (4.5 kg), and walk- ing 0.25 mi (0.4 km) (170). In the following sections, the National Coalition for Cancer Survivorship definition of cancer survivor is used; that is, from the time of diagnosis to the balance of life including the time period during treatment (165). EXERCISE TESTING A diagnosis of cancer and curative cancer treatments pose challenges for mul- tiple body systems involved in performing exercise and/or affected by exercise. For example, survivors of breast cancer who have had lymph nodes removed may respond differently to inflammation and injury on the side of the body that underwent surgery, having implications for exercise testing and Ex Rx . Cancer and cancer therapy have the potential to affect the health-related components of physical fitness (i.e., cardiorespiratory fitness [CRF], muscular strength and endurance, body composition, and flexibility) as well as neuromotor function. Understanding how an individual has been affected by his or her cancer expe- rience is important prior to exercise testing and designing the Ex Rx for survivors of cancer during and after treatment (121). Every individual with cancer can have a unique experience and response. Because of the diversity in this patient population, the safety guidance for preexercise evaluations of cancer survivors focuses on general as well as cancer site–specific recommendations of the medi- cal assessments (see Table 10.1) (221).
- 291. CHAPTER 10 Exercise Prescription for Other Clinical Populations 265 TABLE 10.1. Preexercise Medical Assessments for Individuals with Cancer Cancer Site Breast Prostate Colon Adult Hematologic (No HSCT) Adult HSCT Gynecologic General medical assessments recommended prior to exercise Recommend evaluation for peripheral neuropathies and musculoskeletal morbidities secondary to treatment regardless of time since treatment. If there has been hormonal therapy, recommend evaluation of fracture risk. Individuals with known metastatic disease to the bone will require evaluation to discern what is safe prior to starting exercise. Individuals with known cardiac conditions (secondary to cancer or not) require medical assessment of the safety of exercise prior to starting. There is always a risk that metastasis to the bone or cardiac toxicity secondary to cancer treatments will be undetected. This risk will vary widely across the population of survi- vors. Fitness professionals may want to consult with the patient’s medical team to discern this likelihood. However, requiring medical assessment for metastatic disease and cardiotoxicity for all survivors prior to exercise is not recommended, as this would create an unnecessary barrier to obtaining the well-established health benefits of exercise for the majority of survivors, for whom metastasis and cardiotoxicity are unlikely to occur. Cancer site specific medical assessments recommended prior to starting an exercise program Recommend evalua- tion for arm/shoulder morbidity prior to upper body exercise. Evaluation of muscle strength wasting. Patient should be evaluated as having established consis- tent and proactive infection prevention behaviors for an existing ostomy prior to engaging in exercise training more vigorous than a walking program. None None Patients with morbid obesity may require additional medi- cal assessment for the safety of activity beyond cancer- specific risk. Recommend evaluation for lower extremity lymphedema prior to vigorous aerobic exercise or resistance training. HSCT, hematopoietic stem cell transplantation. Reprinted with permission from (221).
- 292. 266 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Standard exercise testing methods are generally appropriate for patients with can- cer who have been medically cleared for exercise with the following considerations: • Ideally, patients with cancer should receive a comprehensive assessment of all components of health-related physical fitness (see Chapter 4). However, re- quiring a comprehensive physical fitness assessment prior to starting exercise may create an unnecessary barrier to starting activity. For this reason, no as- sessments are required to start a light intensity walking, progressive strength training, or flexibility program in survivors. • Be aware of a survivor’s health history, comorbid chronic diseases and health conditions, and any exercise contraindications before commencing health- related fitness assessments or designing the Ex Rx . • Health-related fitness assessments may be valuable for evaluating the degree to which musculoskeletal strength and endurance or CRF may be affected by cancer-related fatigue or other commonly experienced symptoms that impact function (150). • There is no evidence the level of medical supervision required for symptom-limited or maximal exercise testing needs to be different for patients with cancer than for other populations (see Chapter 2). • Understanding the most common toxicities associated with cancer treatments including increased risk for fractures, cardiovascular events, and neuropa- thies related to specific types of treatment and musculoskeletal morbidities secondary to treatment is important (152). • The evidence-based literature indicates 1-RM testing is safe among survivors of breast cancer (221). EXERCISE PRESCRIPTION Survivors of cancer should avoid inactivity during and after treatment; however, there is insufficient evidence to provide precise recommendations regarding the FITT principle of Ex Rx . The recent American College of Sports Medicine (ACSM) expert panel on guidelines for exercise in adult survivors of cancer con- cluded there is ample evidence exercise is safe both during and after treatment for all types of cancer reviewed (i.e., breast, prostate, colon, hematologic, and gynecologic cancers) (221). Overall recommendations for survivors of cancer are consistent with the guidelines provided in Chapter 7 and with the American Cancer Society’s recommendation of 30–60 min of moderate-to-vigorous inten- sity, physical activity at least 5 d ⭈ wk1 (56). It is important to note, however, that the FITT principle of Ex Rx recommendations for individuals with cancer that follow are based on limited literature. Special considerations needed to en- sure the safety of this potentially vulnerable population are in Table 10.2 (221). To date, there are no recommendations regarding the supervision of exercise across the continuum of survivorship and/or in various exercise settings (e.g., home, health/fitness, clinical). Health/fitness, clinical exercise, and health care professionals should use good judgment in deciding the level of exercise supervi- sion needed on an individual basis.
- 293. CHAPTER 10 Exercise Prescription for Other Clinical Populations 267 FITT RECOMMENDATIONS FOR INDIVIDUALS WITH CANCER Aerobic, Resistance, and Flexibility Exercise The appropriate FITT recommendations will vary across the cancer experi- ence and requires individualization of the Ex Rx . Frequency: For those who have completed treatment, the goal for aerobic exercise should be to increase gradually from the current physical activ- ity level to 3–5 d ⭈ wk1 with resistance training 2–3 d ⭈ wk1 . Flexibility activities can occur daily, even during treatment. Evidence indicates even those currently undergoing systemic cancer treatments can increase daily physical activity sessions over the course of 1 mo (221). Intensity: Exercise tolerance may be highly variable during active treatment. Survivors who have completed treatment may increase intensity slowly for all physical activities. Heart rate (HR) may be less reliable for monitoring inten- sity for cancer survivors currently undergoing treatment. Therefore, educating survivors to use perceived exertion to monitor intensity may be advisable (see Chapter 7). If tolerated without adverse effects of symptoms or side effects, exercise intensity need not differ from healthy populations. Aerobic exercise should be moderate (i.e., 40%–60% V̇O2 R or HRR; rating of perceived exer- tion [RPE] of 12–13 on a scale of 6–20 [27]) to vigorous (60%–85% V̇O2 R or HRR or RPE of 12–16 on a scale of 6–20 [27]) intensity. Moderate intensity resistance exercise should be 60%–70% 1-RM. Flexibility intensity should be mindful of ROM restrictions resultant to surgery and/or radiation therapy (151). Time: Several short bouts per day rather than a single bout may be useful, particularly during active treatment. Survivors who have completed treatment can increase duration as tolerated for all activities. When tolerated without exacerbation of symptoms or side effects, exercise session duration should be no different than that for healthy populations. Aerobic exercise should be 75 min ⭈ wk1 of vigorous intensity or 150 min ⭈ wk1 of moderate intensity activity or an equivalent combination of the two. Resistance training should be at least 1 set of 8–12 repetitions. Type: Aerobic exercise should be prolonged, rhythmic activities using large muscle groups (e.g., walking, cycling, swimming). Resistance exer- cise should be weights, resistance machines, or weight-bearing functional tasks (e.g., sit-to-stand) targeting all major muscle groups. Flexibility ex- ercise should be stretching or ROM exercises of all major muscle groups also addressing specific areas of joint or muscle restriction that may have resulted from treatment with steroids, radiation, or surgery. Progression: Slower progression may be needed among survivors of cancer compared to healthy adults. Awareness of the highly variable impact of ex- ercise on symptoms in survivors of cancer undergoing treatment is needed (222). If exercise progression leads to an increase in fatigue or other com- mon adverse symptoms as a result of prescribed exercise, the FITT principle of Ex Rx should be reduced to a level that is better tolerated.
- 294. 268 GUIDELINES FOR EXERCISE TESTING • www.acsm.org TABLE 10.2. Review of U.S. DHHS Physical Activity Guidelines (PAGs) for Americans and Alterations Needed for Cancer Survivors Breast Prostate Colon Adult Hematologic (No HSCT) Adult HSCT Gynecologic General Statement Avoid inactivity, return to normal daily activities as quickly as possible after surgery. Continue normal daily activities and exercise as much as possible during and after non-surgical treatments. Individuals with known metastatic bone disease will require modifications to avoid fractures. Individuals with cardiac conditions (secondary to cancer or not) may require modifications and may require greater supervision for safety. Aerobic exercise training (volume, intensity, progression) Recommendations are the same as age appropriate guidelines from the PAGs for Americans. Ok to exercise every day, lighter inten- sity and lower progression of intensity recommended. Recommendations are the same as age appropriate guidelines from the PAGs for Americans. Women with morbid obesity may require additional supervision and altered programming. Cancer site specific comments on aerobic exercise training prescriptions Be aware of fracture risk. Be aware of increased potential for fracture. Physician permis- sion recommended for patients with an ostomy prior to participation in contact sports (risk of blow). None Care should be taken to avoiding over- training given immune effects of vigorous exercise. If peripheral neuropathy is present, a stationary bike might be preferable over weight bearing exercise. Resistance training (volume, intensity, progression) Altered recommendations. See below. Recommendations same as age appropriate PAGs. Altered recom- mendations. See below. Recommendations same as age appropriate PAGs. Altered recommenda- tions. See below. Cancer site specific comments on resistance training prescription Start with a supervised program of at least 16 sessions and very low resistance, progress resistance at small increments. No upper limit on the amount of weight to which sur- vivors can progress. Watch for arm/ shoulder symptoms, including Add pelvic floor exercises for those who undergo radical prostatectomy. Be aware of risk for fracture. Recommendations same as age- appropriate PAGs. For patients with a stoma, start with low resistance and progress None Resistance training might be more important than aerobic exer- cise in BMT patients. See There is no data on the safety of resistance training in women with lower limb lymphedema secondary to gyneco- logic cancer. This
- 295. CHAPTER 10 Exercise Prescription for Other Clinical Populations 269 lymphedema, and reduce resis- tance or stop specific exercises according to symptom response. If a break is taken, lower the level of resistance by 2 wk worth for every wk of no exercise (e.g., a 2 wk exercise vacation lower to the resistance used 4 wk ago). Be aware of risk for fracture in this population. resistance slowly to avoid herniation at the stoma. text for further discussion on this point. condition is very complex to manage. It may not be possible to extrapolate from the findings on upper limb lymphedema. Proceed with caution if the patient has had lymph node removal and/or radiation to lymph nodes in the groin. Flexibility training (volume, intensity, progression) Recommendations are the same as age appropriate PAGs for Americans. Recommendations same as age ap- propriate PAGs, with care to avoid excessive intraab- dominal pressure for patients with ostomies. Recommendations are the same as age appropriate PAGs for Americans. Exercises with special considerations (e.g., yoga, organized sports, and Pilates) Yoga appears safe as long as arm and shoulder morbidities are taken into consideration. Dragon boat racing not empirically tested, but the volume of participants pro- vides face validity of safety for this activity. No evidence on organized sport or Pilates. Research gap. If an ostomy is present, modifications will be needed for swimming or contact sports. Research gap. Research gap. Research gap. Research gap. BMT, bone marrow transplantation; HSCT, hematopoietic stem cell transplantation, PAGS, physical activities guidelines; U.S. DHHS, U.S. Department of Health and Human Services. Reprinted with permission from (221).
- 296. 270 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SPECIAL CONSIDERATIONS • Up to 90% of all survivors of cancer will experience cancer-related fatigue at some point (238). Cancer-related fatigue is prevalent in patients receiving chemotherapy and radiation and may prevent or restrict the ability to exer- cise. In some cases, fatigue may persist for months or years after treatment completion. However, survivors are advised to avoid physical inactivity, even during treatment. • Bone is a common site of metastases in many cancers, particularly breast, prostate, and lung cancer. Survivors with metastatic disease to the bone will require modification of their exercise program (e.g., reduced impact, intensity, volume) given the increased risk of bone fragility and fractures. • Cachexia or muscle wasting is prevalent in individuals with advanced gastro- intestinal cancers and may limit exercise capacity, depending on the extent of muscle wasting. • Identify when a patient/client is in an immune suppressed state (e.g., taking immunosuppressive medications after a bone marrow transplant or those undergoing chemotherapy or radiation therapy). There may be times when exercising at home or a medical setting would be more advisable than exercis- ing in a public fitness facility. • Swimming should not be prescribed for patients with indwelling catheters or central lines and feeding tubes, those with ostomies, those in an immune suppressed state, or those receiving radiation. • Patients receiving chemotherapy may experience fluctuating periods of sick- ness and fatigue during treatment cycles that require frequent modifications to the Ex Rx such as periodically reducing the intensity and/or time (duration) of the exercise session during symptomatic periods. • Safety considerations for exercise training for patients with cancer are pre- sented in Table 10.3. As with other populations, the risks associated with physical activity must be balanced against the risks of physical inactivity for survivors of cancer. As with other populations, exercise should be stopped if unusual symptoms are experienced (e.g., dizziness, nausea, chest pain). THE BOTTOM LINE • Individuals who have had a diagnosis of cancer should avoid physical in- activity as long as physical activity does not worsen symptoms/side effects. Daily exercise is generally safe, even during intensive active therapies such as bone marrow transplant. The appropriate exercise testing, prescription, and supervision recommendations will vary across the cancer experience, with the greatest need for caution during periods of active treatment, as exercise tolerance will vary during periods of adjuvant curative therapy (e.g., chemo- therapy, radiotherapy). Symptom response should be the primary guide to the Ex Rx during active treatment. Even after treatment is over, starting at light
- 297. CHAPTER 10 Exercise Prescription for Other Clinical Populations 271 TABLE 10.3. Contraindications for Starting Exercise, Stopping Exercise, and Injury Risk for Cancer Survivors Breast Prostate Colon Adult Hematologic (No HSCT) Adult HSCT Gynecologic General contraindications for starting an exercise program common across all cancer sites Allow adequate time to heal after surgery. The number of weeks required for surgical recovery may be as high as 8. Do not exercise individuals who are experiencing fever, extreme fatigue, significant anemia, or ataxia. Follow ACSM Guidelines for exercise prescrip- tion with regard to cardiovascular and pulmonary contraindications for starting an exercise program. However, the potential for an adverse cardiopulmonary event might be higher among cancer survivors than age matched comparisons given the toxicity of radiotherapy and chemotherapy and long term/late effects of cancer surgery. Cancer specific contraindications for starting an exercise program Women with acute arm or shoulder problems secondary to breast cancer treatment should seek medical care to resolve those issues prior to exercise training with the upper body. None Physician permission recommended for patients with an ostomy prior to participation in contact sports (risk of blow), weight training (risk of hernia). None None Women with swelling or inflammation in the abdomen, groin, or lower extremity should seek medical care to resolve these issues prior to exercise training with the lower body. Cancer spe- cific reasons for stopping an exercise program. (Note: General ACSM Guidelines for stopping exercise remain in place for this population.) Changes in arm/shoulder symptoms or swelling should result in reductions or avoidance of upper body exercise until after appropriate medical evaluation and treatment resolves the issue. None Hernia, ostomy related systemic infection. None None Changes in swelling or inflammation of the abdomen, groin, or lower extremities should result in reductions or avoidance of lower body exercise until after appropriate medical evaluation and treatment resolves the issue. (continued)
- 298. 272 GUIDELINES FOR EXERCISE TESTING • www.acsm.org General injury risk issues in common across cancer sites Patients with bone metastases may need to alter their exercise program with regard to intensity, duration, and mode given increased risk for skeletal fractures. Infection risk is higher for patients that are currently undergoing chemotherapy or radiation treatment or have compromised immune function after treatment. Care should be taken to reduce infection risk in fitness centers frequented by cancer survivors. Patients currently in treatment and immediately following treatment may vary from exercise session to exercise session with regard to exercise tolerance, depending on their treatment schedule. Individuals with known metastatic disease to the bone will require modifications and increased supervision to avoid fractures. Individuals with cardiac conditions (secondary to cancer or not) will require modifications and may require increased supervision for safety. Cancer specific risk of injury, emergency procedures The arms/shoulders should be exercised, but proactive injury prevention approaches are encouraged, given the high incidence of arm/shoulder morbidity in breast cancer survivors. Women with lymph- edema should wear a well-fitting compression garment during exercise. Be aware of risk for fracture among those treated with hormonal therapy, a diagnosis of osteoporosis, or bony metastases. Be aware of risk for frac- ture among patients treated with ADT, a diagnosis of osteoporo- sis or bony metastases Advisable to avoid excessive intra-abdominal pressures for patients with an ostomy. Multiple myeloma patients should be treated as if they are osteoporotic. None The lower body should be exercised, but proactive injury prevention approaches are encouraged, given the potential for lower extremity swelling or inflammation in this population. Women with lymph- edema should wear a well-fitting compression garment during exer- cise. Be aware of risk for fractures among those treated with hormonal therapies, with diagnosed osteoporo- sis, or with bony metastases. ADT, androgen deprivation therapy; HSCT, hematopoietic stem cell transplantation. Reprinted with permission from (221). TABLE 10.3. Contraindications for Starting Exercise, Stopping Exercise, and Injury Risk for Cancer Survivors (Continued ) Breast Prostate Colon Adult Hematologic (No HSCT) Adult HSCT Gynecologic
- 299. CHAPTER 10 Exercise Prescription for Other Clinical Populations 273 intensity for a short period of time (duration) and progressing slowly will assist with avoiding the onset or exacerbation of, and may assist with treat- ment or prevention of, persistent adverse treatment effects such as fatigue or lymphedema. American Cancer Society: http://www.cancer.org American College of Sports Medicine: http://www.acsm.org to access the expert panel report on exercise and cancer National Academies Press (85): http://www.nap.edu/catalog.php?record_id=11468#toc From Cancer Patient to Survivor: Lost in Transition Online Resources CEREBRAL PALSY Cerebral palsy (CP) is a nonprogressive lesion of the brain occurring before, at, or soon after birth that interferes with normal brain development. CP is caused by damage to areas of the brain that control and coordinate muscle tone, reflexes, posture, and movement. The resulting impact on muscle tone and reflexes depends on the location and extent of the injury within the brain. Consequently, the type and severity of dysfunction varies considerably among individuals with CP. In developed countries, the incidence of CP is reported to be between 1.5 and 5 live births per 1,000. Despite its diverse manifestations, CP predominantly exists in two forms: spastic (70% of those with CP) (142) and athetoid (248). Spastic CP is char- acterized by an increased muscle tone typically involving the flexor muscle groups of the upper extremity (e.g., biceps brachii, brachialis, pronator teres) and extensor muscle groups of the lower extremities (e.g., quadriceps, triceps surae). The antagonistic muscles of the hypertonic muscles are usually weak. Spasticity is a dynamic condition decreasing with slow stretching, warm exter- nal temperature, and good positioning. However, quick movements, cold exter- nal temperature, fatigue, or emotional stress increases hypertonicity. Athetoid CP is characterized by involuntary and/or uncontrolled movement that occurs primarily in the extremities. These extraneous movements may increase with effort and emotional stress. CP can further be categorized topographically (e.g., quadriplegia, diplegia, hemiplegia); however, in the context of Ex Rx , a functional classification as developed by the Cerebral Palsy International Sport and Recreation Association (CP-ISRA) is more relevant (33). CP-ISRA has developed an eight-part com- prehensive functional classification scheme for sports participation based on the degree of neuromotor function (see Table 10.4). Athletes are classified in
- 300. 274 GUIDELINES FOR EXERCISE TESTING • www.acsm.org eight classes, with Class 1 representing an athlete with severe spasticity and/or athetosis resulting in poor functional ROM and poor functional strength in all extremities and the trunk. The athlete will be dependent on a power wheelchair or assistance for mobility. An athlete classified in Class 8 will demonstrate mini- mal neuromotor involvement and may appear to have near normal function (33). The variability in motor control pattern in CP is large and becomes even more complex because of the persistence of primitive reflexes. In normal motor development, reflexes appear, mature, and disappear; whereas other reflexes become controlled or mediated at a higher level (i.e., the cortex). In CP , primitive reflexes (e.g., the palmar and tonic labyrinthine reflexes) may persist and higher level reflex activity (i.e., postural reflexes) may be delayed or absent. Severely involved individuals with CP may primarily move in reflex patterns, whereas those with mild involvement may be only hindered by reflexes during extreme effort or emotional stress (142). EXERCISE TESTING The hallmark of CP is disordered motor control; however, CP is often as- sociated with other sensory (e.g., vision, hearing impairment) or cognitive (e.g., intellectual disability, perceptual motor disorder) disabilities that may limit participation as much as or perhaps more than the motor limitations (45). Associated conditions such as convulsive seizures (i.e., epilepsy), which occur in about 25% of those with CP, may significantly interfere with exercise testing and programming. Exercise testing may be done in individuals with CP to un- cover challenges or barriers to regular physical activity, to identify risk factors for secondary health conditions, to determine the functional capacity of the TABLE 10.4. Cerebral Palsy International Sports and Recreation Association (CP-ISRA) Functional Classification System (33) Class Functional Ability 1 Severe involvement in all four limbs; limited trunk control; unable to grasp; poor func- tional strength in upper extremities, often necessitating the use of an electric wheel- chair for independence. 2 Severe-to-moderate quadriplegic, normally able to propel a wheelchair very slowly with arms or by pushing with feet; poor functional strength and severe control problems in the upper extremities. 3 Moderate quadriplegia, fair functional strength and moderate control problems in upper extremities and torso; uses wheelchair. 4 Lower limbs have moderate-to-severe involvement; good functional strength and minimal control problem in upper extremities and torso; uses wheelchair. 5 Good functional strength and minimal control problems in upper extremities; may walk with or without assistive devices for ambulatory support. 6 Moderate-to-severe quadriplegia; ambulates without walking aids; less coordination; balance problems when running or throwing; has greater upper extremity involvement. 7 Moderate-to-minimal hemiplegia; good functional ability in nonaffected side; walks/runs with noted limp. 8 Minimally affected; may have minimal coordination problems; able to run and jump freely; has good balance.
- 301. CHAPTER 10 Exercise Prescription for Other Clinical Populations 275 individual, and/or to prescribe the appropriate exercise intensity for aerobic and strengthening exercises. Individuals with CP have decreased physical fitness levels compared with their able-bodied peers. However, investigation in this area is limited focus- ing almost entirely on children and adolescents and involving primarily indi- viduals with minimal or moderate involvement (i.e., those who are ambulatory) (46,53,187,248). As they age, adolescents with CP may show a decline in gross motor capacity related to loss of ROM, postural changes, or pain as well as reduced aerobic capacity. The decline in aerobic capacity with age appears to be greater in girls than boys (19,258). There are several documented disability- related changes in older adults with CP such as greater physical fatigue, impaired motion/problematic joint contractures, and loss of mobility, which would impact the overall fitness level of the older adult with CP (239). When exercise testing individuals with CP , consider the following issues: • Initially, a functional assessment should be taken of the trunk and upper and lower extremity involvement that includes measures of functional ROM, strength, flexibility, and balance. This assessment will facilitate the choice of exercise testing equipment, protocols, and adaptations. Medical clearance should be sought before any physical fitness testing. • All testing should be conducted using appropriate, and if necessary, adaptive equipment such as straps and holding gloves, and guarantee safety and opti- mal testing conditions for mechanical efficiency. • The testing mode used to assess CRF is dependent on the functional capacity of the individual and — if an athlete with CP — the desired sport. In general, • Arm and leg ergometry are preferred for individuals with athetoid CP be- cause of the benefit of moving in a closed chain. • In individuals with significant involvement (Classes 1 and 2), minimal ef- forts may result in work levels that are above the anaerobic threshold and in some instances may be maximal efforts. • Wheelchair ergometry is recommended for individuals with moderate involvement (Classes 3 and 4) with good functional strength and minimal coordination problems in the upper extremities and trunk. • In highly functioning individuals (Classes 5 through 8) who are ambula- tory, treadmill testing may be recommended, but care should be taken at the final stages of the protocol when fatigue occurs and the individual’s walking or running skill may deteriorate. • Because of the heterogeneity of the CP population, a maximal exercise test protocol cannot be generalized. It is recommended to test new participants at two or three submaximal levels, starting with a minimal power output before determining the maximal exercise protocol. • Because of poor economy of movement in this population, true maximal CRF testing may not be appropriate or accurate. Therefore, maximal CRF testing should involve submaximal steady state workloads at levels comparable with sporting conditions. Movement during these submaximal workloads should be controlled to optimize economy of movement (i.e., mechanical efficiency).
- 302. 276 GUIDELINES FOR EXERCISE TESTING • www.acsm.org For example, with cycle leg ergometry, the choice of resistance or gearing is extremely important in individuals with CP . Some individuals will benefit from a combination of low resistance and high segmental velocity, whereas others will have optimal economy of movement with a high resistance, low segmental velocity combination. • In individuals with moderate and severe CP , motion is considered a series of discrete bursts of activity. Hence, the assessment of anaerobic power derived from the Wingate anaerobic test gives a good indication of the performance potential of the individual. • In individuals with athetoid CP , strength tests should be performed through movement in a closed chain (e.g., exercise machines that control the path of the movement). Before initiating open kinetic chain strengthening exercises (e.g., dumbbells, barbells, other free weights), always check the impact of primitive reflexes on performance (i.e., position of head, trunk, and proximal joints of the extremities) and whether the individual has adequate neuromo- tor control to exercise with free weights. • In children with CP, eccentric strength training increases eccentric torque production throughout the ROM while decreasing electromyographic (EMG) activity in the exercising muscle. Eccentric training may decrease cocontrac- tion and improve net torque development in muscles exhibiting increased tone (197). • Results from any exercise test in the same individual with CP may vary con- siderably from day to day because of fluctuations in muscle tone. EXERCISE PRESCRIPTION/SPECIAL CONSIDERATIONS Generally, the FITT principle of Ex Rx recommendations for the general popu- lation should be applied to individuals with CP (see Chapter 7) (87,102). It is important to note, however, that the FITT principle of Ex Rx recommendations for individuals with CP that follow are based on a very limited literature. For this reason and because of the impact of CP on the neuromotor function, the following FITT principle of Ex Rx recommendations and special considerations are combined in this section: • The FITT principle of Ex Rx needed to elicit health/fitness benefits in in- dividuals with CP is unclear. Even though the design of exercise training programs to enhance health/fitness benefits should be based on the same principles as the general population, modifications to the training protocol may have to be made based on the individual’s functional mobility level, number and type of associated conditions, and degree of involvement of each limb (204). • Because of lack of movement control, energy expenditure (EE) is high even at low power output levels. In individuals with severe involvement (Classes 1 and 2), aerobic exercise programs should start with frequent but short bouts of moderate intensity (i.e., 40%–50% V̇O2 R or HRR or RPE of 12–13 on a
- 303. CHAPTER 10 Exercise Prescription for Other Clinical Populations 277 scale of 6–20). Recovery periods should begin each time this intensity level is exceeded. Exercise bouts should be progressively increased to reach an inten- sity of 50%–85% V̇O2 R for 20 min. Because of poor economy of movement, some severely involved individuals will not be able to work at these intensity levels for 20 min, so shorter durations that can be accumulated should be considered. • In moderately to minimally involved individuals, aerobic exercise training should follow the FITT principle of Ex Rx including progression for the general population (see Chapter 7). If balance deficits during exercise are an issue, leg ergometry with a tricycle or recumbent stationary bicycle (82) for the lower extremities and hand cycling for the upper extremities are recom- mended because (a) they allow for a wide range of power output; (b) move- ments occur in a closed chain; (c) muscle contraction velocity can be changed without changing the power output through the use of resistance or gears; and (d) there is minimal risk for injuries caused by lack of movement or balance control. • Individuals with CP fatigue easily because of poor economy of movement. Fatigue has a disastrous effect on hypertonic muscles and will further dete- riorate the voluntary movement patterns. Training sessions will be more ef- fective, particularly for individuals with high muscle tone, if (a) several short training sessions are conducted rather than one longer session; (b) relaxation and stretching routines are included throughout the session; and (c) new skills are introduced early in the session (30,209). • Resistance training increases strength in individuals with CP without an adverse effect on muscle tone (53,179). However, the effects of resistance training on functional outcome measures and mobility in this population are inconclusive (158,223). Emphasize the role of flexibility training in conjunc- tion with any resistance training program designed for individuals with CP . • Resistance exercises designed to target weak muscle groups that oppose hypertonic muscle groups improve the strength of the weak muscle group and normalize the tone in the opposing hypertonic muscle group through reciprocal inhibition. For example, slow concentric elbow extensor activ- ity will normalize the tone in a hypertonic elbow flexor. Other techniques, such as neuromuscular electrical stimulation (179) and whole body vibra- tion (1), increase muscle strength without negative effects on spasticity. Dynamic strengthening exercises over the full ROM that are executed at slow contraction speeds to avoid stretch reflex activity in the opposing muscles are recommended. • Hypertonic muscles should be stretched slowly to their limits throughout the workout program to maintain length. Stretching for 30 s improves muscle activation of the antagonistic muscle group, whereas sustained stretching for 30 min is effective in temporarily reducing spasticity in the muscle being stretched (269). Ballistic stretching should be avoided. • Generally, the focus for children with CP is on inhibiting abnormal reflex activity, normalizing muscle tone, and developing reactions to increase
- 304. 278 GUIDELINES FOR EXERCISE TESTING • www.acsm.org equilibrium. The focus with adolescents and adults is more likely to be on functional outcomes and performance. Experienced athletes will learn to use hyperactive stretch reflexes and primitive reflexes to better execute sport specific tasks. • During growth, hypertonicity in the muscles — and consequently, muscle balance around the joints — may change significantly because of inadequate adaptations in muscle length. Training programs should be adapted continu- ously to accommodate these changing conditions (179). Medical interven- tions such as Botox injections, a medication which decreases spasticity, may drastically change the functional potential of the individual. • For athletes with CP, sport-specific fitness testing may be effective in deter- mining fitness/performance areas for improvement and in planning a fitness- related intervention program for addressing the specific sports-specific goals of the athlete (125). • Good positioning of the head, trunk, and proximal joints of extremities to control persistent primitive reflexes is preferred to strapping. Inexpensive modifications that enable good position such as Velcro gloves to attach the hands to the equipment should be used whenever needed. • Individuals with CP are more susceptible to overuse injuries because of their higher incidence of inactivity and associated conditions (i.e., hypertonicity, contractures, and joint pain) (1). THE BOTTOM LINE • Exercise provides improvements in the health-related components of physical fitness among individuals with CP (i.e., CRF , muscular strength and endur- ance, and flexibility). The relationships among the FITT principle of Ex Rx and associated short- and long-term functional improvements have yet to be established. National Institutes of Neurological Disorders and Stroke: http://www.ninds.nih.gov/disorders/cerebral_palsy/cerebral_palsy.htm Online Resources DIABETES MELLITUS Diabetes mellitus (DM) is a group of metabolic diseases characterized by an elevated blood glucose concentration (i.e., hyperglycemia) as a result of defects in insu- lin secretion and/or an inability to use insulin. Sustained elevated blood glucose levels place patients at risk for microvascular and macrovascular diseases as well as neuropathies (peripheral and autonomic). Currently, 7% of the United States
- 305. CHAPTER 10 Exercise Prescription for Other Clinical Populations 279 population has DM, with 1.5 million new cases diagnosed each year (12). Four types of diabetes are recognized based on etiologic origin: Type 1, Type 2, gestational (i.e., diagnosed during pregnancy), and other specific origins (i.e., genetic defects and drug induced); however, most patients have Type 2 (90% of all cases) followed by Type 1 (5%–10% of all cases) (6). Type 1 DM is most often caused by the autoimmune destruction of the in- sulin producing  cells of the pancreas, although some cases are idiopathic in origin. The primary characteristics of individuals with Type 1 DM are absolute insulin deficiency and a high propensity for ketoacidosis. Type 2 DM is caused by insulin-resistant skeletal muscle, adipose tissue, and liver combined with an insulin secretory defect. A common feature of Type 2 DM is excess body fat with fat distributed in the upper body (i.e., abdominal or central obesity) (6). Central obesity and insulin resistance often progress to prediabetes. Prediabetes is a condition characterized by (a) elevated blood glucose in response to dietary carbohydrate, termed impaired glucose tolerance (IGT); and/ or (b) elevated blood glucose in the fasting state, termed impaired fasting glucose (IFG) (see Table 10.5). Individuals with prediabetes are at very high risk to de- velop diabetes as the capacity of the  cells to hypersecrete insulin diminishes over time and becomes insufficient to restrain elevations in blood glucose. It is also increasingly recognized many individuals with DM do not fit neatly into the Type 1 and Type 2 delineations, especially individuals with little or no capac- ity to secrete insulin but without the obvious presence of antibodies to insulin producing  cells (10). The fundamental goal for the management of DM is glycemic control using diet, exercise, and, in many cases, medications such as insulin or oral hypo- glycemic agents (see Appendix A). Intensive treatment to control blood glucose reduces the risk of progression of diabetic complications in adults with Type 1 and Type 2 DM (6). The criteria for diagnosis of DM and prediabetes (12) are presented in Table 10.5. Glycosylated hemoglobin (HbA1C) reflects mean blood glucose control over the past 2–3 mo with a general patient goal of 7%. HbA1C may be used as an additional blood chemistry test for patients with DM to pro- vide information on long-term glycemic control (6) (see Chapter 3). Although the American Diabetes Association and World Health Organization endorse TABLE 10.5. Diagnostic Criteria for Diabetes Mellitus (12) Normal Prediabetes Diabetes Mellitus Fasting plasma glucose 100 mg ⭈ dL1 (5.55 mmol ⭈ L1 ) IFG Fasting plasma glucose 100 mg ⭈ dL1 (5.55 mmol ⭈ L1 )– 125 mg ⭈ dL1 (6.94 mmol ⭈ L1 ) Symptomatic with casual glucose 200 mg ⭈ dL1 (11.10 mmol ⭈ L1 ) IGT 2-h plasma glucose 140 mg ⭈ dL1 (7 .77 mmol ⭈ L1 )– 199 mg ⭈ dL1 (11.04 mmol ⭈ L1 ) during an OGTT Fasting plasma glucose 126 mg ⭈ dL1 (6.99 mmol ⭈ L1 ) 2-h plasma glucose 200 mg ⭈ dL1 (11.10 mmol ⭈ L1 ) during an OGTT IFG, impaired fasting glucose (at least 8 h); IGT, impaired glucose tolerance; OGTT, oral glucose tolerance test.
- 306. 280 GUIDELINES FOR EXERCISE TESTING • www.acsm.org using HbA1c ⬎6.5% as a diagnostic tool for diabetes, most diagnoses are still based on elevated fasting glucose. EXERCISE TESTING The following are special considerations for exercise testing in individuals with DM: • When beginning an exercise program of light-to-moderate intensity (i.e., equiv- alent to noticeable increases in HR and breathing such as walking), exercise testing may not be necessary for individuals with DM or prediabetes who are asymptomatic for cardiovascular disease (CVD) and low risk (10% risk of cardiac event over a 10-yr period) (252) (see Tables 2.1 and 2.3). • Individuals with DM or prediabetes with 10% risk of a cardiac event over a 10-yr period and who want to begin a vigorous intensity exercise program (i.e., 60% V̇O2 R that substantially increases HR and breathing) should un- dergo a medically supervised graded exercise test (GXT) with electrographic (ECG) monitoring (6,39). • If positive or nonspecific ECG changes in response to exercise are noted or nonspecific ST and T wave changes at rest are observed, follow-up testing may be performed (227). However, consider the Detection of Ischemia in Asymptomatic Diabetes (DIAD) trial involving 1,123 individuals with Type 2 DM and no symptoms of coronary artery disease (CAD) found screening with adenosine-stress radionuclide myocardial perfusion imaging for myocardial ischemia over a 4.8 yr follow-up period did not alter rates of cardiac events (273); thus, the cost-effectiveness and diagnostic value of more intensive test- ing remains in question. • SilentischemiainpatientswithDMoftengoesundetected(262).Consequently, annual CVD risk factor assessment should be conducted by a health care provider (6). EXERCISE PRESCRIPTION The benefits of regular exercise in individuals with Type 2 DM and prediabetes include improved glucose tolerance, increased insulin sensitivity, and decreased HbA1C. In individuals with Type 1 DM and those with Type 2 DM using insulin, regular exercise reduces insulin requirements. Important exercise benefits for individuals with either Type 1 or Type 2 DM or prediabetes include improve- ment in CVD risk factors (i.e., lipid profiles, blood pressure [BP], body weight, and functional capacity) and well-being (2,6). Regular exercise participation may also prevent or at least delay the transition to Type 2 DM for individuals with prediabetes who are at very high risk for developing DM (132) (see Table 10.5). The FITT principle of Ex Rx for healthy adults generally applies to indi- viduals with DM (see Chapter 7). Participating in an exercise program confers benefits that are extremely important to individuals with Type 1 and Type 2 DM. Maximizing the cardiovascular health–related benefits resulting from exercise is
- 307. CHAPTER 10 Exercise Prescription for Other Clinical Populations 281 a key outcome for both diabetes subtypes. For those with Type 2 DM and pre- diabetes, exercise enhances sensitivity to the insulin increasing cellular uptake of glucose from the blood that facilitates improved control of blood glucose (49). For those with Type 1 DM, greater insulin sensitivity has little impact on pancre- atic function but often lowers requirements for exogenous insulin (50). Healthy weight loss and maintenance of appropriate body weight are often more pressing issues for those with Type 2 DM and prediabetes, but excess body weight and fat can be present in those with Type 1 DM as well, and an exercise program can be useful in either context (see the sections of this chapter on overweight, obesity, and the metabolic syndrome). FITT RECOMMENDATIONS FOR INDIVIDUALS WITH DIABETES MELLITUS Aerobic, Resistance, and Flexibility Exercise The aerobic exercise training FITT principle of Ex Rx recommendations for those with DM are the following: Frequency: 3–7 d ⭈ wk1 . Intensity: 40%–60% V̇O2 R corresponding to an RPE of 11–13 on a 6–20 scale (27). Better blood glucose control may be achieved at higher exercise intensities (60% V̇O2 R), so individuals who have been partici- pating in regular exercise may consider raising the exercise intensity to this level of physical exertion. Time: Individuals with Type 2 DM should engage in a minimum of 150 min ⭈ wk1 of exercise undertaken at moderate intensity or greater. Aerobic activity should be performed in bouts of at least 10 min and be spread throughout the week. Moderate intensity exercise totaling 150 min ⭈ wk1 is associated with reduced morbidity and mortality in observational studies in all populations. Additional benefits are accrued by increasing to 300 min ⭈ wk1 of moderate-to-vigorous intensity, physical activity. Type: Emphasize activities that use large muscle groups in a rhythmic and continuous fashion. Personal interest and desired goals of the exercise program should be considered. Progression: Because maximizing caloric expenditure will always be a high priority, progressively increase exercise duration (either continuous or accumulated). As individuals improve physical fitness, adding higher intensity physical activity to promote beneficial adaptations and combat boredom may be warranted. Resistance training should be encouraged for individuals with DM or prediabetes in the absence of contraindications (see Chapters 2 and 3),
- 308. 282 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SPECIAL CONSIDERATIONS • Hypoglycemia is the most serious problem for individuals with DM who exercise and is mainly a concern for individuals taking insulin or oral hypo- glycemic agents that increase insulin secretion (e.g., sulfonylurea drugs) (6) (see Appendix A). Hypoglycemia, that is, blood glucose level 70 mg ⭈ dL1 (3.89 mmol ⭈ L1 ), is relative (6). Rapid drops in blood glucose may occur with exercise and render patients symptomatic even when blood glucose is well above 70 mg ⭈ dL1 . Conversely, rapid drops in blood glucose may occur without generating noticeable symptoms. Common symptoms as- sociated with hypoglycemia include shakiness, weakness, abnormal sweat- ing, nervousness, anxiety, tingling of the mouth and fingers, and hunger. Neuroglycopenic symptoms may include headache, visual disturbances, mental dullness, confusion, amnesia, seizures, and coma (3). Importantly, hypoglycemia may be delayed and can occur up to 12 h postexercise. • Blood glucose monitoring before and for several hours following exercise, especially when beginning or modifying the exercise program, is prudent. • The timing of exercise should be considered in individuals taking insulin or hypoglycemic agents. For individuals with diabetes using insulin, changing insulin timing, reducing insulin dose, and/or increasing carbohydrate con- sumption are effective strategies to prevent hypoglycemia both during and after exercise. • Physical activity combined with oral hypoglycemic agents has not been well studied and little is known about the potential for interactions. retinopathy, and recent treatments using laser surgery. The recommen- dations for healthy individuals generally apply to individuals with DM (see Chapter 7). Given that many patients may present with comorbidities, it may be necessary to tailor the resistance Ex Rx accordingly. There is some evidence that a combination of aerobic and resistance training improves blood glucose control more than either modality alone (50). Whether the added benefits are caused by a greater overall caloric expenditure or are specific to the combination of aerobic and resistance training has not yet been resolved. No more than two consecutive days of physical inactivity per week should be allowed. A greater emphasis should eventually be placed on vigorous intensity exercise if CRF is a primary goal. On the other hand, greater amounts of moderate intensity exercise that result in a caloric EE of 2,000 kcal ⭈ wk1 (⬎7 hr ⭈ wk1 ), including daily exercise, may be required if weight loss maintenance is the goal, as is the case for most in- dividuals with Type 2 DM (54) (see this chapter and other relevant ACSM position stands [6,54]).
- 309. CHAPTER 10 Exercise Prescription for Other Clinical Populations 283 Sulfonylurea drugs, glucagon-like peptide 1 (GLP-1) agonists, and other compounds that enhance insulin secretion probably do increase the risk for hypoglycemia because the effects of insulin and muscle contraction on blood glucose uptake are additive (86). The few data that exist on the common biguanide (e.g., metformin) and thiazolidinedione drugs suggest the interactions are complex and may not be predictable based on indi- vidual effects of the drug or exercise alone (226) (see Appendix A). Extra blood glucose monitoring is prudent when beginning a program of regular exercise in combination with oral agents to assess whether changes in medication dose are necessary or desirable. • Adjust carbohydrate intake and/or medications before and after exercise based on blood glucose levels and exercise intensity to prevent hypoglycemia associated with exercise (230). • For individuals with Type 1 DM using insulin pumps, insulin delivery during exercise can be markedly reduced or the pump can be discon- nected depending on the intensity and duration of exercise. Reducing basal delivery rates for up to 12 h postexercise may be necessary to avoid hypoglycemia. • The use of continuous glucose monitoring can be very useful to detect pat- terns in blood glucose across multiple days and evaluate both the immediate and delayed effects of exercise (4). Adjustments to insulin dose, oral medica- tions, and/or carbohydrate intake can be fine-tuned using the detailed infor- mation provided by continuous glucose monitoring. • Exercise with a partner or under supervision to reduce the risk of problems associated with hypoglycemic events. • Hyperglycemia with or without ketosis is a concern for individuals with Type 1 DM who are not in glycemic control. Common symptoms associated with hyperglycemia include polyuria, fatigue, weakness, increased thirst, and acetone breath (3). Individuals who present with hyperglycemia, pro- vided they feel well and have no ketone bodies present in either the blood or urine, may exercise; but they should test blood sugar often and refrain from vigorous intensity exercise until they see that blood glucose concentrations are declining (10,230). • Dehydration resulting from polyuria, a common occurrence of hyperglyce- mia, may contribute to a compromised thermoregulatory response (259). Thus, a patient with hyperglycemia should be treated as having an elevated risk for heat illness requiring more frequent monitoring of signs and symp- toms (see Chapter 8 and other relevant ACSM positions stands [7,9]). • Individuals with DM and retinopathy are at risk for retinal detachment and vitreous hemorrhage associated with vigorous intensity exercise. However, risk may be minimized by avoiding activities that dramatically elevate BP. Thus, for those with severe nonproliferative and proliferative diabetic retinopathy, vigorous intensity aerobic and resistance exercise should be avoided (6,230).
- 310. 284 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • During exercise, autonomic neuropathy may cause chronotropic incompe- tence (i.e., a blunted BP response), attenuated V̇O2 kinetics, and anhydrosis (i.e., water deprivation) (6,259). In these situations, the following should be considered: • Monitor the signs and symptoms of hypoglycemia because of the inability of the individual to recognize them. Also, monitor the signs and symp- toms of silent ischemia such as unusual shortness of breath or back pain because of the inability to perceive angina. • Monitor BP before and after exercise to manage hypotension and hyper- tension associated with vigorous intensity exercise (259) (see the section on hypertension in this chapter). • The HR and BP responses to exercise may be blunted. RPE should also be used to assess exercise intensity (259). • Given the likelihood thermoregulation in hot and cold environments is impaired, additional precautions for heat and cold illness are warranted (see Chapter 8 and other relevant ACSM positions stands [7,9,31]). • For individuals with peripheral neuropathy, take proper care of the feet to prevent foot ulcers (6). Special precautions should be taken to prevent blisters on the feet. Feet should be kept dry and the use of silica gel or air midsoles as well as polyester or blend socks should be used. • For individuals with nephropathy (6,11), although protein excretion acutely increases postexercise, there is no evidence vigorous intensity exercise accel- erates the rate of progression of kidney disease. Although there are no current exercise intensity restrictions for individuals with diabetic nephropathy, it is prudent to encourage sustainable exercise programming that more likely includes tolerable moderate intensity. • Most individuals with Type 2 DM and prediabetes are overweight (see the section on overweight and obesity in this chapter and the relevant ACSM position stand [54]). • Most individuals with prediabetes or either subtype of DM are at high risk for or have CVD (see Chapter 9). THE BOTTOM LINE • The benefits of regular exercise in individuals with prediabetes and Type 2 DM include improved glucose tolerance and increased insulin sensitivity. Regular exercise reduces insulin requirements in individuals with Type 1 DM. The general FITT principle of Ex Rx generally applies to individuals with DM. Individuals with retinopathy or recent treatments using laser sur- gery may need to avoid resistance training. Hypoglycemia is the most seri- ous problem for individuals with DM who exercise and is mainly a concern for those taking insulin or oral hypoglycemic agents that increase insulin secretion.
- 311. CHAPTER 10 Exercise Prescription for Other Clinical Populations 285 DYSLIPIDEMIA Dyslipidemia refers to abnormal blood lipid and lipoprotein concentrations. Dyslipidemia exists when there are elevations in low-density lipoprotein cho- lesterol (LDL) or triglyceride concentrations or when there is a reduction in high-density lipoprotein cholesterol (HDL). Table 3.2 provides the National Cholesterol Education Program (NCEP) blood lipid and lipoprotein classifica- tion scheme (164). Severe forms of dyslipidemia are usually caused by genetic defects in cholesterol metabolism, but marked dyslipidemia can be “secondary” or caused by other systemic disease. Substantial increases in LDL are often caused by genetic defects related to the hepatic LDL receptor activity but can also be produced by hypothyroidism and the nephritic syndrome. Similarly, some of the highest triglyceride concentrations are produced by insulin resistance and/or DM and marked reductions in HDL are caused by the use of oral anabolic steroids. Dyslipidemia is a major modifiable cause of CVD (164). Improvements in cholesterol awareness and more effective treatments pri- marily using statins or hydroxymethylglutaryl-CoA (HMG-CoA) reductase inhibitors are responsible for the decline in the prevalence of elevated blood cholesterol levels in recent years. These improvements have contributed to a 30% decline in CVD (244). Recent clinical trials indicate the added value of cholesterol lowering therapy in high risk individuals (see Chapters 2 and 3), individuals with DM, and older individuals with a treatment goal to lower base- line LDL concentrations by 30%–40% (92). Current detection, evaluation, and treatment guidelines for dyslipidemia are available in the NCEP Adult Treatment Panel (ATP) III report (92) (see Chapter 3). The NCEP ATP III report recog- nizes the importance of lifestyle modification in the treatment of dyslipidemia (164). These recommendations include increased physical activity and weight reduction if warranted, but except for the hypertriglyceridemia associated with insulin resistance, most hyperlipidemia requires medication therapy in addition to diet and exercise modification. Nevertheless, exercise is valued for controlling other CVD risk factors and should be a primary component to leading a healthy lifestyle. The ACSM makes the following recommendations regarding exercise testing and training of individuals with dyslipidemia. American College of Sports Medicine: http://www.acsm.org to access the position stand on exercise and Type 2 DM American Diabetes Association: http://www.diabetes.org National Institute of Diabetes and Digestive and Kidney Diseases: http://www2.niddk.nih.gov/ Online Resources
- 312. 286 GUIDELINES FOR EXERCISE TESTING • www.acsm.org EXERCISE TESTING • Individuals with dyslipidemia should be screened and risk classified prior to exercise testing (see Chapters 2 and 3). • Use caution when testing individuals with dyslipidemia because underlying CVD may be present. • Standard exercise testing methods and protocols are appropriate for use with individuals with dyslipidemia cleared for exercise testing. Special consider- ation should be given to the presence of other chronic diseases and health conditions (e.g., metabolic syndrome, obesity, hypertension) that may require modifications to standard exercise testing protocols and modalities (see the sections of this chapter and other relevant ACSM positions stands on these chronic diseases and health conditions [54,183]). EXERCISE PRESCRIPTION The FITT principle of Ex Rx for individuals with dyslipidemia without comorbities is very similar to the Ex Rx for healthy adults (87,102) (see Chapter 7). A major difference in the FITT principle of Ex Rx for individuals with dyslipidemia com- pared to healthy adults is that healthy weight maintenance should be emphasized. Accordingly, aerobic exercise becomes the foundation of the Ex Rx . Resistance and flexibility exercises are adjunct to an aerobic training program designed for the treatment of dyslipidemia primarily because these modes of exercise do not substantially contribute to the overall caloric expenditure goals that appear to be beneficial for improvements in blood lipid and lipoprotein concentrations. FITT RECOMMENDATIONS FOR INDIVIDUALS WITH DYSLIPIDEMIA Aerobic Exercise The FITT principle of Ex Rx recommended for individuals with dylipidemia: Frequency: 5 d ⭈ wk1 to maximize caloric expenditure. Intensity: 40%–75% V̇O2 R or HRR. Time: 30–60 min ⭈ d1 . However, to promote or maintain weight loss, 50–60 min ⭈ d1 or more of daily exercise is recommended (54). Performance of intermittent exercise of at least 10 min in duration to accumulate these duration recommendations is an effective alternative to continuous exercise. Type: The primary mode should be aerobic physical activities that involve the large muscle groups. As part of a balanced exercise program, resistance training and flexibility exercise should be incorporated. Individuals with dyslipidemia without comorbidities may follow the resistance training and flexibility guidelines for healthy adults (see Chapter 7).
- 313. CHAPTER 10 Exercise Prescription for Other Clinical Populations 287 The FITT recommendations for individuals with dyslipidemia are consistent with the recommendations for healthy weight loss maintenance of ⬎250 min ⭈ wk1 (see the sections on overweight and obesity in this chapter and the relevant ACSM position stand [54]). SPECIAL CONSIDERATIONS • The FITT principle of Ex Rx may need to be modified should the individuals with dyslipidemia present with other chronic diseases and health conditions such as metabolic syndrome, obesity, and hypertension (see the sections in this chapter and other relevant ACSM position stands on these chronic dis- eases and health conditions [54,183]). • Individuals taking lipid-lowering medications that have the potential to cause muscle damage (i.e., HMG-CoA reductase inhibitors or statins and fibric acid) may experience muscle weakness and soreness termed myalgia (see Appendix A). Physicians should be consulted if an individual experiences unusual or persis- tent muscle soreness when exercising while taking these medications. THE BOTTOM LINE • Dyslipidemia is a major modifiable cause of CVD. Cholesterol-lowering ther- apy and lifestyle behavioral modifications are important in the management of individuals with dyslipidemia. The FITT principle of Ex Rx for individuals with dyslipidemia without comorbidities is similar to that of healthy adults, although healthy weight maintenance should be emphasized. National Heart Lung and Blood Institute: http://www.nhlbi.nih.gov/guidelines/cholesterol/atp4/index.htm Online Resources FIBROMYALGIA Fibromyalgia is a syndrome characterized by widespread chronic nonarticular (soft tissue) musculoskeletal pain. Fibromyalgia affects approximately 2%–4% of the population in the United States (137). Individuals with fibromyalgia do not show signs of inflammation or neurological abnormalities and do not develop joint deformities or joint disease. Therefore, fibromyalgia is not considered a true form of arthritis. Fibromyalgia is primarily diagnosed in women (i.e., seven women for every one man), and its prevalence increases with age. Signs and symptoms of fibromyalgia include chronic diffuse pain and ten- derness, fatigue, sleep disturbance, morning stiffness, and depression. Irritable
- 314. 288 GUIDELINES FOR EXERCISE TESTING • www.acsm.org bowel syndrome, tension headaches, cognitive dysfunction, fine motor weak- ness, restless leg syndrome, temperature chemical sensitivities, and paresthesia (i.e., burning, prickling, tingling, or itching of the skin with no apparent physi- cal cause) may also be present. Pain has typically been present for many years, but there is no pattern (i.e., fibromyalgia can appear and subside and present in different areas of the body at different times). Fatigue affects approximately 75%–80% of individuals with fibromyalgia and often is linked to poor sleep. Approximately 30% of individuals with fibromyalgia have a diagnosis of depres- sion. Fibromyalgia symptoms may become worse caused by emotional stress, poor sleep, high humidity, physical inactivity, or excessive physical activity (44). Because of the nature of fibromyalgia, a confirmed diagnosis can be difficult. The 2010 preliminary diagnostic criteria (271) include (a) determining where the individual has pain; (b) the severity of symptoms; (c) if the symptoms have been present at the same level for a minimum of 3 mo; and (d) confirming an individu- al’s pain cannot be attributed to another disorder. Specific areas of the body where pain is assessed are the shoulder girdle, upper and lower arms and legs, hips, jaw, chest, abdomen, upper and lower back, and neck. Level of severity is determined for three symptoms: fatigue, waking unrefreshed, and cognitive symptoms. Individuals with fibromyalgia have reduced aerobic capacity, muscle function (i.e., strength and endurance), and ROM, as well as overall reductions in physical activity, functional performance (e.g., walking, stair climbing), and physical fit- ness (29,76). In general, these reductions are caused by the chronic widespread pain that limits the individual’s abilities to complete his or her everyday activities, ultimately resulting in continued deconditioning and a loss of physiologic reserve. Treatment for individuals with fibromyalgia includes medications for pain, sleep, and mood, as well as educational programs, cognitive behavioral therapy, and exercise. Aerobic exercise is beneficial for improving physical function and overall well-being in individuals with fibromyalgia (29). There is also evidence resistance exercise, especially strength training, improves pain, tenderness, depression, and overall well-being (29). In general, exercise improves flexibil- ity, neuromotor function, cardiorespiratory function, functional performance, physical activity levels, pain, and other symptoms of fibromyalgia as well as self-efficacy, depression, anxiety, and quality of life. Lifestyle physical activity, de- fined as accumulating 30 min of moderate intensity, physical activity above one’s regular physical activity 5–7 d ⭈ wk1 , improves function and reduces pain (79). Based on the potential for pain and exacerbation of symptoms, an individual’s medical history and current health status must be reviewed prior to conducting exercise tests or prescribing an exercise program. Objectively assessing physi- ologic and functional limitations will allow for the proper exercise testing and most optimal exercise training. EXERCISE TESTING Individuals with fibromyalgia can generally participate in symptom-limited exer- cise testing as described in Chapter 5. In this population, the 6-min walk test is
- 315. CHAPTER 10 Exercise Prescription for Other Clinical Populations 289 also frequently used to measure aerobic performance (29). However, some spe- cial precautions should be considered when conducting exercise testing among those with fibromyalgia. These include the following: • Review symptoms prior to testing to determine the severity and location of pain and the individual’s level of fatigue. • Assess previous and current exercise experience to determine the probability of the individual having an increase in symptoms after testing. • For individuals with depression, provide high levels of motivation using constant verbal encouragement and possibly rewards for reaching certain intensity levels to have the individual perform to a peak level during testing. • For individuals with cognitive dysfunction, determine their level of under- standing when following through with verbal and written testing and training directions. • The appropriate testing protocol (see Chapters 4 and 5) should be selected based on an individual’s symptomatology. Individualize test protocols as needed. • The order of testing must be considered to allow for adequate rest and re- covery of different physiologic systems and/or muscle groups. For example, depending on the most prevalent symptoms (e.g., pain, fatigue) and their locations on the day of testing, endurance testing may be completed before strength testing and alternate between upper and lower extremities. • Monitor pain and fatigue levels continuously throughout the tests. Visual analog scales (see Figure 10.1) are available for these symptoms and easy to administer during exercise. The Fibromyalgia Impact Questionnaire is most often used for individuals with fibromyalgia to assess physical function, gen- eral well-being, and symptoms (28). • Care should be taken to position the individual correctly on the testing or training equipment to allow for the most pain-free exercise possible. This ac- commodation may require modification to equipment such as adjusting the seat height and types of pedals on a cycle leg ergometer, raising an exercise bench to limit the amount of joint (e.g., hip, knee, back) flexion or extension when getting on or off the equipment, or providing smaller weight increments on standard weight machines. • If the individual with fibromyalgia has pain in the lower extremities prior to testing, consider a non–weight-bearing type of exercise (e.g., cycle leg ergome- try) to achieve a more accurate measurement of CRF , thereby allowing the individual to perform to a higher intensity prior to stopping because of pain. • Prior to exercise testing and training, educate the individual on the differ- ences between postexercise soreness and fatigue and normal fluctuations in pain and fatigue experienced as a result of fibromyalgia. EXERCISE PRESCRIPTION It is important to note the FITT principle of Ex Rx recommendations for indi- viduals with fibromyalgia are based on very limited literature. For this reason,
- 316. 290 GUIDELINES FOR EXERCISE TESTING • www.acsm.org the FITT principle of Ex Rx is generally consistent with the Ex Rx for apparently healthy adults (see Chapter 7) with the following considerations: • Monitor an individual’s pain level and location. • Give appropriate recovery time between exercises within a session and be- tween days of exercise. Exercises should be alternated between different parts of the body or different systems (e.g., musculoskeletal vs. cardiorespiratory). • Individuals with fibromyalgia are commonly physically inactive because of their symptoms. Prescribe exercise, especially at the beginning, at a physical exertion level that the individual will be able to do or do without undue pain. • Begin the exercise progression at a low enough level and progress slowly so as to allow for physiologic adaptation without an increase in symptoms (44). In general, this population has poor exercise adherence that is not only because of an increase in symptoms but also because of the mixed and sometimes con- tradictory information they receive from their various health care providers (212). Individuals with fibromyalgia typically have several different profes- sionals on their health care team (i.e., rheumatologist, primary care physician, clinical exercise physiologist, nurse practitioner, and physical therapist) and may get conflicting advice from several members (212). • The individual’s symptoms always determine the starting point and rate of progression for any type of exercise (27,76,211,242). FITT RECOMMENDATIONS FOR INDIVIDUALS WITH FIBROMYALGIA Aerobic Exercise (29,76) Frequency: Begin 2–3 d ⭈ wk1 and progress to 3–4 d ⭈ wk1 . Intensity: Begin at 30% V̇O2 R or HRR and progress to 60% V̇O2 R or HRR. Time: Begin with 10 min increments and accumulate to a total of at least 30 min ⭈ d1 and progress to 60 min ⭈ d1 . Type: Low impact/non–weight-bearing exercise (e.g., water exercise [147], cycling, walking, swimming) initially to minimize pain that may be caused by exercise. Resistance Exercise Resistance exercise generally includes muscular strength and endurance to train the muscles for improved performance of functional activities. Resistance training improves muscular strength and endurance in indi- viduals with fibromyalgia, although the level of evidence is less than that for aerobic exercise (129,211,213,242).
- 317. CHAPTER 10 Exercise Prescription for Other Clinical Populations 291 Frequency: 2–3 d ⭈ wk1 . Intensity: 50%–80% 1-RM. If the individual cannot complete at least 3 repetitions easily and without pain at 50% 1-RM, it is advised the start- ing intensity be reduced to a level where no pain is experienced. Time: If the goal is muscular strength, perform 3–5 repetitions per muscle group, increasing to 2–3 sets. If the goal is muscular endurance, perform 10–20 repetitions per muscle group, increasing to 2–3 sets; or some com- bination thereof as long as the muscle groups are alternated. Typically, the strength exercises are completed first followed by a 15–20 min rest period before completing endurance exercises (76). Type: Elastic bands, cuff/ankle weights, and weight machines. Flexibility Exercise Simple stretching exercises in combination with other exercises improve functional activities, symptoms, and self-efficacy in individuals with fibro- myalgia (120,211), but the evidence is very limited. Frequency: 1–3 times ⭈ wk1 , progress to 5 times ⭈ wk1 . Intensity: Active and gentle ROM stretches for all muscle tendon groups in the pain-free range. The stretch should be held to the point of tightness or slight discomfort. Time: Initially hold the stretch for 10–30 s. Progress to holding each stretch for up to 60 s. Type: Elastic bands and unloaded (non–weight-bearing) stretching. Functional Activity Recommendation Functional activities (e.g., walking, stair climbing, rising from chair, dancing) are daily activities that can be performed without using specialized equipment. For individuals with symptoms such as pain and fatigue, functional activities are recommended to allow for main- tenance of light-to-moderate intensity, physical activity even when symptomatic. Progression The rate of progression of the FITT principle of Ex Rx for individuals with fibromyalgia will depend entirely on their symptoms and recovery from or reduction in symptoms on any particular day. They should be educated on how to reduce or avoid certain exercises when their symptoms are ex- acerbated. Individuals with fibromyalgia should be advised to attempt low levels of exercise during flare ups but listen to their bodies regarding their symptoms in order to minimize the chance of injury.
- 318. 292 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SPECIAL CONSIDERATIONS • Teach and have individuals with fibromyalgia demonstrate the correct me- chanics for performing each exercise to reduce the potential for injury. • Teach individuals with fibromyalgia to avoid improper form and exercising when they are excessively fatigued because these factors can lead to long-term exacerbation of symptoms. • Consider lesser amounts of exercise if symptoms increase during or after exercise. Good judgment should be used to determine which aspect of the FITT principle of Ex Rx needs to be adjusted. • Avoid the use of free weights for individuals with fibromyalgia when they are fatigued or experiencing excessive pain. • Individuals with fibromyalgia should exercise in a temperature and humidity controlled room to prevent exacerbation of symptoms. • Consider group exercise classes because they have been shown to provide a so- cial support system for individuals with fibromyalgia for reducing physical and emotional stress. In addition, they assist in promoting exercise adherence (212). • Consider including complementary therapies such as tai chi (265) and yoga because they have been shown to reduce symptoms in individuals with fibromyalgia. THE BOTTOM LINE • In general, the FITT principle of Ex Rx for healthy adults generally applies to individuals with fibromyalgia. However, it is recommended that symptoms, es- pecially pain and fatigue, are closely monitored because they are tightly linked to the ability to exercise effectively. Including appropriate rest and recovery as part of the Ex Rx is important. In addition, progression should be slower regard- ing intensity and time (duration) than for healthy individuals so as to minimize the exacerbation of symptoms and promote long-term exercise adherence. Arthritis Foundation: http://www.arthritis.org National Fibromyalgia Association: http://www.FMaware.org Online Resources HUMAN IMMUNODEFICIENCY VIRUS Broad use of antiretroviral therapy (ART) by industrialized countries to reduce the viral load of human immunodeficiency virus (HIV) has signifi- cantly increased life expectancy following diagnosis of HIV infection (263).
- 319. CHAPTER 10 Exercise Prescription for Other Clinical Populations 293 ART dramatically reduces the prevalence of the wasting syndrome and im- munosuppression. However, ART is associated with metabolic and anthro- pomorphic health conditions including dyslipidemia, abnormal distribution of body fat (i.e., abdominal obesity and subcutaneous fat loss), and insulin resistance (15). Emerging data suggest an association of HIV infection, cardiac dysfunction, and an increased risk of CVD among individuals living with HIV. With the migration of HIV infection into predominantly minority and lower socioeconomic classes, individuals with HIV are now beginning therapy with higher body mass index (BMI) and reduced muscle strength and mass. They are also more likely to have personal and environmental conditions that pre- dispose them to high visceral fat and obesity (169,229). It is unclear how the aging process will interact with HIV status, sociodemographic characteristics, chronic disease risk, and the extended life expectancy associated with ART use. In addition to standard pharmacological interventions for HIV, physical activ- ity and dietary counseling are treatment options. Additional treatment options include anabolic steroids, growth hormone, and growth factors (272). Aerobic and resistance exercise provide important health benefits for indi- viduals with HIV/acquired immunodeficiency syndrome (AIDS) (100). Exercise training enhances functional aerobic capacity, cardiorespiratory and muscular endurance, and general well-being. Additionally, physical activity can reduce body fat and indices of metabolic dysfunction. Although there are less data on effects of resistance training, progressive resistance exercise increases lean tissue mass and improves muscular strength. There is also evidence of enhanced mood and psychological status with regular exercise training. Of importance, there is no evidence to suggest regular participation in an exercise program will sup- press immune function of asymptomatic or symptomatic individuals with HIV (100,101). EXERCISE TESTING The increased prevalence of cardiovascular pathophysiology, metabolic disor- ders, and the complex medication routines of individuals with HIV/AIDS require physician consultation before exercise testing. The following list of issues should be considered with exercise testing: • Exercise testing should be postponed in individuals with acute infections. • Variability of results will be higher for individuals with HIV than in a healthy population. • When conducting cardiopulmonary exercise tests, infection control measures should be employed (123). Although HIV is not transmitted through saliva, a high rate of oral infections necessitates thorough sterilization of reusable equipment and supplies when disposables are not available. • The increased prevalence of cardiovascular impairments and particularly car- diac dysfunction requires monitoring of BP and the ECG. • Because of the high prevalence of peripheral neuropathies, testing should be adjusted if necessary to the appropriate exercise type, intensity, and ROM.
- 320. 294 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • Typical limitations to stress testing by stage of disease include the following: • Asymptomatic — normal GXT with reduced exercise capacity likely rela- ted to sedentary lifestyle. • Symptomatic — reduced exercise time, peak oxygen consumption (V̇O2peak ), and ventilatory threshold (VT) • AIDS will dramatically reduce exercise time and V̇O2peak . Reduced exercise time will likely preclude reaching VT, and achieving V̇O2peak will poten- tially produce abnormal nervous and endocrine responses EXERCISE PRESCRIPTION The chronic disease and health conditions associated with HIV infection suggest health benefits would be gained by regular participation in a program of combined aerobic and resistance exercise. Indeed, numerous clinical studies have shown participation in habitual physical activity results in physical and mental health benefits among this population (98,99). The varied presentation of individuals with HIV requires a flexible approach. Notably, no clinical study of the effects of physical activity on symptomatology of HIV infection has shown an immunosup- pressive effect. Further, data indicate individuals living with HIV adapt readily to exercise training, with some studies showing more robust responses than would be expected in a healthy population (101). Therefore, the general FITT principle of Ex Rx is consistent with that for apparently healthy adults (see Chapter 7), but the management of CVD risk should be emphasized. However, health/fitness, clinical exercise, and health care professionals should be mindful of the potentially rapid change in health status of this population, particularly the high incidence of acute infections, and should adjust the FITT principle of Ex Rx accordingly. FITT RECOMMENDATIONS FOR INDIVIDUALS WITH HUMAN IMMUNODEFICIENCY VIRUS Aerobic, Resistance, and Flexibility Exercise Frequency: Aerobic exercise 3–5 d ⭈ wk1 ; resistance exercise 2–3 d ⭈ wk1 . Intensity: Aerobic exercise 40%–60% V̇O2 R or HRR. Resistance exercise 8–10 repetitions at approximately 60% 1-RM. Time: Aerobic exercise, begin with 10 min and progress to 30–60 min ⭈ d1 . Resistance exercise, approximately 30 min to complete 2–3 sets of 10–12 exercises that target major muscle groups. Flexibility activities should be incorporated into exercise sessions following the guidelines for healthy adults (see Chapter 7). Type: Modality will vary with the health status and interests of the in- dividual. Presence of osteopenia will require weight-bearing physical activities. Contact and high-risk (e.g., skateboarding, rock climbing) sports are not recommended because of risk of bleeding.
- 321. CHAPTER 10 Exercise Prescription for Other Clinical Populations 295 SPECIAL CONSIDERATIONS • There are no currently established guidelines regarding contraindications for exercise for individuals with HIV/AIDS. For asymptomatic individuals with HIV/AIDS, ACSM Guidelines for healthy individuals should generally apply (see Chapter 7). The FITT principle of Ex Rx should be adjusted accordingly based on the individual’s current health status. • Supervised exercise, whether in the community or at home, is recommended for symptomatic individuals with HIV/AIDS or those with diagnosed comorbidities. • Individuals with HIV/AIDS should report increased general feelings of fatigue or perceived effort during activity, lower gastrointestinal distress, and short- ness of breath if they occur. • Minor increases in feelings of fatigue should not preclude participation but dizziness, swollen joints, or vomiting should. The high incidence of peripheral neuropathy may require adjustment of exercise type, intensity, and ROM. • Regularly monitoring the health/fitness benefits related to physical activity and CVD risk factors is critical for clinical management and continued exer- cise participation. THE BOTTOM LINE • Aerobic and resistance exercises provide important health benefits for indi- viduals with HIV/AIDS. No clinical study has demonstrated an immunosup- pressive effect of exercise in this population. With exercise testing and Ex Rx , it is important to be mindful of the potential rapid changes in health status. The exercise program should be initiated at a lower volume and intensity, and progression will likely occur at a slower rate than in healthy populations. Centers for Disease Control: http://www.cdc.gov/hiv/ Online Resources Progression: Aerobic and resistance exercise programs for this population should be initiated at a low volume and intensity. Because of virus and drug side effects, progression will likely occur at a slower rate than in healthy populations. However, the long-term goals for asymptomatic individuals with HIV/AIDS should be to achieve the ACSM FITT principle of Ex Rx recommendations for aerobic and resistance exercise for healthy adults with appropriate modifications for symptomatic individuals with HIV/AIDS.
- 322. 296 GUIDELINES FOR EXERCISE TESTING • www.acsm.org HYPERTENSION Approximately 76 million Americans have hypertension defined as having a rest- ing systolic blood pressure (SBP) 140 mm Hg and/or diastolic blood pressure (DBP) 90 mm Hg, taking antihypertensive medication, or being told by a physi- cian or other health care professional on at least two occasions that an individual has high BP (see Chapter 3 Table 3.1) (224). Hypertension leads to an increased risk of CVD, stroke, heart failure, peripheral artery disease (PAD), and chronic kidney disease (CKD) (183,224). BP readings as low as 115/75 mm Hg are associ- ated with a higher than desirable risk of ischemic heart disease and stroke. The risk of CVD doubles for each incremental increase in SBP of 20 mm Hg or DBP of 10 mm Hg (35,214). The underlying cause of hypertension is not known in ap- proximately 90% of the cases (i.e., essential hypertension). In the other 5%–10% of cases, hypertension is secondary to a variety of known diseases including CKD, coarctation of the aorta, Cushing syndrome, and pheochromocytoma (35). Recommended lifestyle changes include smoking cessation, weight man- agement, reduced sodium intake, moderation of alcohol consumption, an overall healthy dietary pattern consistent with the Dietary Approaches to Stop Hypertension diet, and participation in habitual physical activity (35,214). There are a variety of medications that are effective in the treatment of hypertension (see Appendix A). Most patients may need to be on at least two medications to achieve targeted BP levels (35,214). EXERCISE TESTING Recommendations regarding exercise testing for individuals with hypertension vary depending on their BP level and the presence of other CVD risk factors, target organ disease, or clinical CVD (183) (see Chapter 2 Figures 2.3 and 2.4 and Chapter 3 Table 3.1). Recommendations include the following: • Individuals with hypertension whose BP is not controlled (i.e., resting SBP 140 mm Hg and/or DBP 90 mm Hg) should consult with their physician prior to initiating an exercise program. When medical evaluation and man- agement is taking place, the majority of these individuals may begin light-to- moderate intensity (40%–60% V̇O2 R) exercise programs such as walking without consulting their physician. • Individuals with hypertension in the high risk category (see Chapters 2 and 3) should have a medical evaluation before exercise testing. The extent of the evaluation will vary depending on the exercise intensity to be performed and the clinical status of the individual being tested. • Individuals with hypertension in the high risk category (see Chapters 2 and 3) or with target organ disease (e.g., left ventricular hypertrophy, retinopathy) who plan to perform moderate (40%–60% V̇O2 R) to vigorous intensity exercise (60% V̇O2 R) should have a medically supervised symptom-limited exercise test.
- 323. CHAPTER 10 Exercise Prescription for Other Clinical Populations 297 • Resting SBP 200 mm Hg and/or DBP 110 mm Hg are relative contraindi- cations to exercise testing (see Chapter 3 Box 3.5). • If the exercise test is for nondiagnostic purposes, individuals may take their prescribed medications at the recommended time. When exercise testing is performed for the specific purpose of designing the Ex Rx , it is preferred individuals take their usual antihypertensive medications as recommended. When testing is for diagnostic purposes, BP medication may be withheld before testing with physician approval. • Individuals on -blockers will have an attenuated HR response to exercise and reduced maximal exercise capacity. Individuals on diuretic therapy may experience hypokalemia and other electrolyte imbalances, cardiac dysrhyth- mias, or potentially a false-positive exercise test (see Appendix A). • The exercise test should generally be stopped with SBP ⬎250 mm Hg and/or DBP ⬎115 mm Hg. EXERCISE PRESCRIPTION Aerobic exercise training leads to reductions in resting BP of 5–7 mm Hg in individuals with hypertension (183). Exercise training also lowers BP at fixed submaximal exercise workloads. Emphasis should be placed on aerobic activities; however, these may be supplemented with moderate intensity resis- tance training. Flexibility exercise should be performed after a thorough warm- up and/or during the cool-down period following the guidelines for healthy adults (see Chapter 7). In individuals with hypertension, the following Ex Rx is recommended. FITT RECOMMENDATIONS FOR INDIVIDUALS WITH HYPERTENSION Aerobic and Resistance Exercise Frequency: Aerobic exercise on most, preferably all days of the week; resistance exercise 2–3 d ⭈ wk1 . Intensity: Moderate intensity, aerobic exercise (i.e., 40%–60% V̇O2 R or HRR; RPE 11–13 on a 6–20 scale) supplemented by resistance training at 60%–80% 1-RM. Time: 30–60 min ⭈ d1 of continuous or intermittent aerobic exercise. If intermittent, use a minimum of 10 min bouts accumulated to total 30–60 min ⭈ d1 of exercise. Resistance training should consist of at least one set of 8–12 repetitions for each of the major muscle groups. Type: Emphasis should be placed on aerobic activities such as walking, jogging, cycling, and swimming. Resistance training using either machine weights or free weights may supplement aerobic training. Such training
- 324. 298 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SPECIAL CONSIDERATIONS • Patients with uncontrolled severe hypertension (i.e., resting SBP 180 mm Hg and/or DBP 110 mm Hg) should add exercise training to their treatment plan only after first being evaluated by their physician and being prescribed appropriate antihypertensive medication. • For individuals with documented CVD such as ischemic heart disease, heart failure, or stroke, vigorous intensity exercise training is best initiated in reha- bilitation centers under medical supervision (see Chapter 9). • Resting SBP ⬎200 mm Hg and/or DBP ⬎110 mm Hg, is a relative contrain- dication to exercise testing. When exercising, it appears prudent to maintain SBP ⱕ220 mm Hg and/or DBP ⱕ105 mm Hg. • -Blockers and diuretics may adversely affect thermoregulatory function. -Blockers may also increase the predisposition to hypoglycemia in certain individuals (especially patients with DM who take insulin or insulin secre- tagogues) and mask some of the manifestations of hypoglycemia (particu- larly tachycardia). In these situations, educate patients about the signs and symptoms of heat intolerance (7,9) and hypoglycemia, and the precautions that should be taken to avoid these situations (see the section on DM in this chapter and Appendix A). • -Blockers, particularly the nonselective types, may reduce submaximal and maximal exercise capacity primarily in patients without myocardial ischemia (see Appendix A). Using perceived exertion to monitor exercise intensity is especially beneficial in these individuals (see Chapters 4 and 7). • Antihypertensive medications such as ␣-blockers, calcium channel blockers, and vasodilators may lead to sudden excessive reductions in postexercise BP . Extend and carefully monitor the cool-down period in these individuals. • Individuals with hypertension are often overweight or obese. Ex Rx for these individuals should focus on increasing caloric expenditure coupled with reducing caloric intake to facilitate weight reduction (see the section on overweight and obesity in this chapter and the relevant ACSM position stand [54]). programs should consist of 8–10 different exercises targeting the major muscle groups (see Chapter 7). Progression: The FITT principle of Ex Rx relating to progression for healthy adults, generally apply to those with hypertension. However, consideration should be given to the level of BP control, recent changes in antihypertensive drug therapy, medication-related adverse effects, and the presence of target organ disease and/or other comorbidities, and adjustments should be made accordingly. Progression should be gradual, avoiding large increases in any of the FITT components of the Ex Rx , especially intensity for most individuals with hypertension.
- 325. CHAPTER 10 Exercise Prescription for Other Clinical Populations 299 • A majority of older individuals will have hypertension. Older individuals ex- perience similar exercise induced BP reductions as younger individuals (see Chapter 8 and the relevant ACSM position stand [8]). • The BP-lowering effects of aerobic exercise are immediate, a physiologic response referred to as postexercise hypotension. To enhance exercise adher- ence, educate these individuals about the acute or immediate BP-lowering effects of exercise, although investigation is limited that education about BP effects of acute exercise will improve adherence. • For individuals with documented episodes of ischemia during exercise, the exercise intensity should be set below the ischemic threshold (ⱕ10 beats ⭈ min1 ). • Avoid the Valsalva maneuver during resistance training. THE BOTTOM LINE • Recommendations regarding exercise testing for individuals with hyperten- sion vary depending on their BP level and the presence of other CVD risk factors, target organ disease, or CVD, as well as the intensity of the exercise program. Patients with uncontrolled severe hypertension (i.e., resting SBP 180 mm Hg and/or DBP 110 mm Hg) should add exercise training to their treatment plan only after first being evaluated by their physician and being prescribed appropriate antihypertensive medication. Although vigor- ous intensity aerobic exercise (i.e., 60% V̇O2 R) is not necessarily contra- indicated in patients with hypertension, moderate intensity aerobic exercise (i.e., 40%–60% V̇O2 R) is generally recommended in preference to vigorous intensity aerobic exercise to optimize the benefit to risk ratio. American College of Sports Medicine: http://www.acsm.org to access the position stand on exercise and hypertension American Heart Association: http://www.american heart.org National Heart Lung and Blood Institute: http://www.nhlbi.nih.gov/hbp Online Resources INTELLECTUAL DISABILITY AND DOWN SYNDROME Intellectual disability (ID) (older terminology referred to ID as mental retarda- tion) is the most common developmental disorder in the Unites States with an estimated prevalence of 3% of the total population (66). ID is defined as (a) significant subaverage intelligence (i.e., two standard deviations below the
- 326. 300 GUIDELINES FOR EXERCISE TESTING • www.acsm.org mean or an IQ 70 for mild ID and 35 for severe/profound ID); (b) having limitations in two or more adaptive skills areas such as communication, self- care, home living, social skills, community use, self-direction, health and safety, functional academics, leisure and work, and the level of care the individual re- quires (66); and (c) evident before 18 yr. Over 90% of all individuals with ID are classified with mild ID (17,69). The cause of ID is often not known, but genetic disorders, birth trauma, infectious disease, and maternal factors contribute, in addition to behavioral and societal factors including maternal drug and alcohol use, malnutrition, and poverty (17). The most commonly identified cause is fetal alcohol syndrome followed by Down syndrome (DS) or trisomy 21 (17,134). Most individuals with ID live in the community either at home or in group homes. Furthermore, although mortality is much higher in individuals with ID than in the general population, life expectancy has been increasing rapidly in this population approaching that of the general population (181). Thus, it is highly likely that health/fitness and clinical exercise professionals will encounter individuals with ID in need of both exercise testing and training. Although there are many subpopulations of individuals with ID with their own unique attributes and considerations, the existing literature has focused on two main subpopula- tions — those with and without DS. Cardiovascular and pulmonary disorders are the most common medical problems in individuals with ID except for individu- als with DS (103,210). For individuals with DS, infections, leukemia, and early development of Alzheimer disease are the most frequent causes of mortality and morbidity. However, as in individuals with ID but without DS, life expectancy for individuals with DS has also been increasing to ⬃60 yr with case reports of individuals living into their 80s (20). In general, individuals with ID are perceived to have low levels of physical fitness and physical activity and high levels of obesity compared to the general population (20). However, supporting data are inconsistent, and these perceptions may only apply to individuals with DS and not to individuals with ID but without DS (20). EXERCISE TESTING Individuals with DS are unique as their response to exercise is clearly different from individuals without DS. Thus, concerns and considerations for exercise testing and Ex Rx are often different for individuals with and without DS. Exercise testing in general appears to be fairly safe in individuals with ID, and safety related to cardiovascular complications may not differ from the general population (68). However, although reports of exercise complications are rare or nonexistent, there is no scientific evidence either for or against the safety of exer- cise testing in individuals with ID. Concerns have been raised regarding validity and reliability of exercise testing in this population, but individualized treadmill laboratory tests appear to be reliable and valid, as do tests using the Schwinn Airdyne (see Box 10.1) (69). However, only a few field tests are valid for estimat- ing CRF in this population (see Box 10.1) (69). It is recommended individuals with ID receive a full health-related physical fitness assessment including CRF , muscle strength and endurance, and body composition (see Chapter 4).
- 327. CHAPTER 10 Exercise Prescription for Other Clinical Populations 301 Nevertheless, the following general points should be considered in order to ensure appropriate test outcomes (67,73): • Preparticipation health screening should follow general ACSM Guidelines (see Chapter 2), with the exception of individuals with DS. Because up to 50% of individuals with DS also have congenital heart disease and there is a high incidence of atlantoaxial instability (i.e., excessive movement of the joint between C1 and C2 usually caused by ligament laxity in DS), a careful history and physical evaluation of these individuals is needed. In addition, physician supervision of preparticipation health screening exercise tests is also recom- mended for these individuals regardless of age. • Familiarization with test procedures and personnel is usually required. Test validity and reliability have only been demonstrated following appropriate familiarization. The amount of familiarization will depend on the level of understanding and motivation of the individual being tested. Demonstration and practice is usually preferred. Thus, several visits to the test facility may be required. Recommended Not Recommended Cardiorespiratory fitness • Walking treadmill protocols with individualized walking speeds • Schwinn Airdyne using both arms and legs with 25-W stages • 20-m shuttle run • Rockport 1-mi walk • Treadmill running protocols • Cycle ergometry • Arm ergometry • 1–1.5-mi runs Muscular strength and endurance • 1-RM using weight machines • Isokinetic testing • Isometric maximal voluntary contraction • 1-RM using free weights • Push-ups • Flexed arm hang Anthropometrics and body composition • Body mass index • Waist circumference • Skinfolds • Air plethysmography • DEXA Flexibility • Sit and reach • Joint-specific goniometry 1-RM, one repetition maximum; DEXA, dual energy X-ray. Fitness Tests Recommendations for Individuals with Intellectual Disability (69) BOX 10.1
- 328. 302 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • Provide an environment in which the participant feels valued and like a participating member. Give simple, one-step instructions and reinforce them verbally and regularly. Provide safety features to ensure participants do not fall or have a fear of falling. • Select appropriate tests (see Box 10.1) and individualize test protocols as needed. Only some tests of CRF have been shown to be valid and reliable in individuals with ID, whereas others have been shown to be of poor value because of poor reliability or questionable validity. Apply the population- specific formulas in Table 10.6 when using CRF field tests. • CRF field tests are reliable but not valid for individual prediction of aerobic capacity in individuals with DS. • Because maximal heart rate (HRmax ) is different in individuals with ID, espe- cially in individuals with DS, the standard formula of 220 age to predict HRmax should never be used. It is recommended that the following popula- tion-specific formula be used as a guide during exercise testing but should not be used for Ex Rx (71): HRmax 210 0.56 (age) 15.5 (DS); (insert 1 for no DS and 2 for DS into the equation). • Individuals with ID but without DS may not differ from their peers without disabilities except in muscle strength, which is low in this population (69). • Conversely, individuals with DS exhibit low levels of aerobic capacity and muscle strength and are often overweight and obese (20,42). EXERCISE PRESCRIPTION The FITT principle of Ex Rx for individuals with ID is very similar to an Ex Rx for healthy adults (102). However, because physical activity levels are low and body weight is often greater than desired, especially in individuals with DS, a focus on daily physical activity and caloric expenditure is desirable (68). The aerobic exercise training recommendations that follow are consistent with achieving an EE of 2,000 kcal ⭈ wk1 . However, it is likely that several months of participa- tion is needed before this EE can be achieved. TABLE 10.6. Formulas for Predicting V̇O2max from Field Test Performance in Individuals with Intellectual Disability 20-m shuttle run (72): V̇O2max (mL ⭈ kg1 ⭈ min1 ) 0.35 (number of 20-m laps) 0.59 (BMI) 4.5 (gender: 1 boys, 2 girls) ⫹ 50.8 600-yard run/walk (72): V̇O2max (mL ⭈ kg1 ⭈ min1 ) 5.24 (600-yard run time in min) 0.37 (BMI) 4.61 (gender: 1 boys, 2 girls) ⫹ 73.64 1-mi Rockport Walk Fitness Test (240): V̇O2max (L ⭈ min1 ) 0.18 (walk time in min) 0.03 (body weight in kg) 2.90 BMI, body mass index; V̇O2max , maximal oxygen consumption.
- 329. CHAPTER 10 Exercise Prescription for Other Clinical Populations 303 SPECIAL CONSIDERATIONS FOR INDIVIDUALS WITH INTELLECTUAL DISABILITY • Most individuals with ID require more encouragement during both exercise testing and training than individuals without ID. Motivation can be a prob- lem. Asking if they are tired will automatically yield an answer of “yes” in most individuals with ID, regardless of exercise intensity or amount of work performed. For this reason, this question should be avoided. Instead, ask or suggest, “you don’t look tired, you can keep going can’t you?” • Many individuals with ID are on various types of medications. These include such medications as antidepressants, anticonvulsants, hypnotics, neurolep- tics, and thyroid replacement (see Appendix A). • Many individuals with ID have motor control problems and poor coordina- tion creating balance and gait problems. Thus, most individuals with ID need to use the handrail during treadmill testing. Exercise activities that do not require substantial motor coordination should be chosen or attention to FITT RECOMMENDATIONS FOR INDIVIDUALS WITH INTELLECTUAL DISABILITY Aerobic Exercise Frequency: 3–7 d ⭈ wk⫺1 is encouraged to maximize caloric expenditure but 3–4 d ⭈ wk⫺1 should include moderate and vigorous intensity exercise, whereas light intensity, physical activity should be emphasized on the remaining days. Intensity: 40%–80% V̇O2 R or HRR; RPE may not be an appropriate indicator of intensity in this population. Time: 30–60 min ⭈ d⫺1 . To promote or maintain weight loss, as much daily activity as tolerated is recommended. Use of intermittent exercise bouts of 10–15 min in duration to accumulate these duration recom- mendations may be an attractive alternative to continuous exercise. Type: Walking is recommended as a primary activity, especially in the begin- ning of the program. Progression to running with use of intermittent runs is recommended. Swimming and combined arm/leg ergometry are also effective. Because muscle strength is low in individuals with ID, a focus on muscle strength exercise is desirable (68). Resistance Exercise Frequency: 2–3 d ⭈ wk⫺1 . Intensity: Begin with 12 repetitions at 15–20-RM for 1–2 wk; progress to 8–12-RM (75%–80% of 1-RM). Time: 2–3 sets with 1–2 min rest between sets. Type: Use machines targeting 6–8 major muscle groups. Closely supervise the program for the first 3 mo.
- 330. 304 GUIDELINES FOR EXERCISE TESTING • www.acsm.org correctly performing complex movements should be minimized (e.g., if using dance movements, allow each individual to just do what they can). • Most individuals with ID have a short attention span. Plan exercise testing and programming accordingly. • Provide appropriate familiarization and practice before actual testing because individuals with ID are often not able to adequately perform exercise tests or exercise training. • During exercise testing and training, careful supervision is required. Some individuals with ID will eventually be able to perform exercise training in an unsupervised setting but most will require supervised exercise sessions. • Careful spotting and supervision is needed during the beginning phases of resistance exercise training even when using machines. • Because individuals with ID have limited attention span and limited exposure to exercise, varied activities are suggested to maximize enjoyment and adherence. Consider using music and simple games as part of the exercise training program. Also consider encouraging participation in sports programs such as Special Olympics. • Individualize exercise training as much as possible. Large group-based programs are likely to be less effective. SPECIAL CONSIDERATIONS FOR INDIVIDUALS WITH DOWN SYNDROME • Individuals with DS have very low levels of aerobic capacity and muscle strength, often at levels approximately 50% of the level expected based on age and sex. • Individuals with DS are often obese, and severe obesity is not uncommon (see the section on overweight and obesity in this chapter and the relevant ACSM position stand [54]). • Almost all individuals with DS have low HRmax likely caused by reduced catecholamine response to exercise (70). • The likelihood of congenital heart disease is high in individuals with DS. • It is not unusual for individuals with DS to have atlantoaxial instability. Thus, ac- tivities involving hyperflexion or hyperextension of the neck are contraindicated. • Many individuals with DS exhibit skeletal muscle hypotonia coupled with excessive joint laxity. Increasing muscle strength, especially around major joints (e.g., knee), is a priority. Also, caution should be used regarding in- volvement in contact sports. • Physical characteristics such as short stature, limbs, and digits commonly coupled with malformations of feet and toes, and small mouth and nasal cavities with a large protruding tongue may negatively impact exercise performance. THE BOTTOM LINE • Individuals with and without DS have different responses to exercise, and individuals with DS often exhibit a greater number of special considerations such as congenital heart disease, atlantoaxial instability, low levels of physical
- 331. CHAPTER 10 Exercise Prescription for Other Clinical Populations 305 fitness, and reduced HRmax . Exercise testing is generally safe but should be con- ducted with physician supervision for individuals with congenital heart disease and atlantoaxial instability. Exercise tests need to be carefully selected because some tests are not valid and reliable in this population. The FITT principle of Ex Rx is very similar to individuals without disabilities but supervision is recommended. Issues with attention span, motivation, and behavior may also be present, and the FITT principle of Ex Rx should be appropriately adjusted. American Association for Physical Activity and Recreation/Adapted Physical Education and Activity: http://www.aahperd.org/aapar/careers/adapted-physical-education.cfm American Association on Intellectual and Developmental Disabilities: http://www.aamr.org National Association for Down Syndrome: http:// www.nads.org National Center on Physical Activity and Disability (NCPAD): http://www.ncpad.org National Consortium for Physical Education and Recreation for Individuals with Disabilities: http://www.ncperid.org National Down Syndrome Society: http://www.ndss.org Online Resources TABLE 10.7. Stages of Chronic Kidney Disease (166) Stage Description GFR (mL ⭈ minⴚ1 ⭈ 1.73 mⴚ2 ) 1 Kidney damage with normal or ↑ GFR 90 2 Kidney damage with mild ↓ GFR 60–89 3 Moderate ↓ GFR 30–59 4 Severe ↓ GFR 15–29 5 Kidney failure 15 (or dialysis) GFR, glomerular filtration rate. KIDNEY DISEASE Individuals are diagnosed with CKD if they have kidney damage evidenced by microalbuminuria or have a glomerular filtration rate 60 mL ⭈ min1 ⭈ 1.73 m2 for 3 mo (166). Based on National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (K/DOQI) Guidelines, CKD is divided into five stages primarily depending on the glomerular filtration rate of the individual and the presence of kidney damage (166) (see Table 10.7). Approximately 23 million Americans have CKD, and the prevalence of the disease is estimated to be 11.5% (139). Hypertension, DM, and CVD are very common in the CKD population with the prevalence of these comorbidities rising incrementally from stage 1 to stage
- 332. 306 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 5 CKD (254). When individuals progress to stage 5 CKD (i.e., glomerular filtra- tion rate 15 mL ⭈ min1 ⭈ 1.73 m2 ) their treatment options include renal re- placement therapy (hemodialysis or peritoneal dialysis) or kidney transplantation. EXERCISE TESTING Because CVD is the major cause of death in individuals with CKD, diagnostic exercise testing is indicated. Exercise testing is included in the pretransplanta- tion workup for kidney recipients (140). However, some authorities believe diagnostic testing for patients with end-stage renal disease (i.e., stage 5 CKD) is not warranted because their performance on a symptom-limited exercise test is affected by muscle fatigue, and such testing may act as an unnecessary barrier to their participation in a training program (177). Exercise testing of individuals with CKD should be supervised by trained medical personnel, with the use of standard test termination criteria and test termination methods (see Chapter 5). Most research on patients with CKD has been done on individuals classified with stage 5 CKD. Current evidence suggests these individuals tend to have low functional capacities with values that are approximately 60%–70% of those seen in healthy age and sex-matched controls (175). V̇O2peak ranges between 17–28.6 mL ⭈ kg1 ⭈ min1 (175), and can be increased with training by approximately 17% but never reach the values achieved by age and sex-matched controls (119). This reduced functional capacity is thought to be related to several factors including a sedentary lifestyle, cardiac dysfunction, anemia, and musculoskeletal dysfunction. The following exercise testing considerations should be noted: • Medical clearance should be obtained from both the patient’s primary care physician and nephrologist. • Individuals with CKD are likely to be on multiple medications including those that are commonly used in the treatment of hypertension and DM (see Appendix A). • When performing a graded exercise test on individuals with stage 1–4 CKD, standard testing procedures should be followed (see Chapter 5). However, in patients receiving maintenance hemodialysis, testing should be scheduled for nondialysis days and BP should be monitored in the arm that does not contain the arteriovenous fistula (177). • Patients receiving continuous ambulatory peritoneal dialysis should be tested without dialysate fluid in their abdomen (177). Standard procedures are used to test patients that are transplant recipients. • Both treadmill and cycle leg ergometry protocols have been used to test indi- viduals with kidney diseases, with the treadmill being more popular. Because of the low functional capacity in this population, more conservative treadmill protocols such as the modified Bruce protocol, Balke, Naughton, or branch- ing protocols are appropriate (176) (see Chapter 5). If cycle leg ergometry is used, initial warm-up work rates should be 20–25 W with the work rate increased by 10–30 W increments every 1–3 min (38,260). • In patients receiving maintenance hemodialysis, peak heart rate (HRpeak ) is approximately 75% of age-predicted maximum (178). Because HR may not
- 333. CHAPTER 10 Exercise Prescription for Other Clinical Populations 307 always be a reliable indicator of exercise intensity in patients with CKD, RPE should always be monitored (see Chapter 4). • Isotonic strength testing should be done using a 3-RM or higher load (e.g., 10–12-RM) because 1-RM testing is generally thought to be contrain- dicated in patients with CKD because of the fear of spontaneous avulsion fractures (25,119,177,215). • Muscular strength and endurance can be safely assessed using isokinetic dynamometers employing angular velocities ranging from 60 degrees to 180 degrees ⭈ s1 is recommended (52,105,176). • As a result of the very low functional capacities of individuals with CKD, with an estimated 50% not being able to perform symptom-limited testing, tradi- tional exercise tests may not always yield the most valuable information (175). Consequently, a variety of physical performance tests that have been used in other populations (e.g., older adults) can be used (see Chapter 8). Tests can be chosen to assess CRF , muscular strength, balance, and flexibility (174,175). EXERCISE PRESCRIPTION The ideal FITT principle of Ex Rx for individuals with CKD has not been fully developed, but based on the research that has been done, programs for these patients should consist of a combination of aerobic and resistance training (37,119). It seems prudent to modify the recommendations for the general popu- lation; initially using light-to-moderate intensities and gradually progressing over time based on individual tolerance. Medically cleared recipients of kidney transplants can initiate exercise training as early as 8 d following the transplant operation (156,175). FITT RECOMMENDATIONS FOR INDIVIDUALS WITH CHRONIC KIDNEY DISEASE Aerobic, Resistance, and Flexibility Exercise The following FITT principle of Ex Rx is recommended for individuals with CKD: Frequency: Aerobic exercise 3–5 d ⭈ wk1 ; resistance exercise 2–3 d ⭈ wk1 . Intensity: Moderate intensity, aerobic exercise (40%–60% V̇O2 R, RPE 11–13 on a scale of 6–20); resistance exercise, 70%–75% 1-RM. Time: Aerobic exercise 20–60 min of continuous activity; however, if this amount cannot be tolerated, 3–5 min bouts of intermittent exercise aiming to accumulate 20–60 min ⭈ d1 is recommended; Resistance training, a minimum of 1 set of 10–15 repetitions. Choose 8–10 different exercises to work the major muscle groups. Flexibility exercise should be performed fol- lowing the guidelines for healthy adults (see Chapter 7). Type: Walking, cycling, and swimming are recommended aerobic activities. Use either machine weights or free weights for resistance exercise.
- 334. 308 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SPECIAL CONSIDERATIONS • Individuals with CKD should be gradually progressed to a greater exercise volume over time. Depending on the clinical status and functional capacity of the individual, the initial intensity selected for training should be light (i.e., 30%–40% V̇O2 R) and for as little as 10–15 min of continuous activity or whatever amount the individual can tolerate. The duration of the physical ac- tivity should be increased by 3–5 min increments weekly until the individual can complete 30 min of continuous activity before increasing the intensity. • The clinical status of the individual is important to consider. The progression may need to be slowed if the individual has a medical setback. • Some individuals with CKD are unable to do continuous exercise and there- fore should perform intermittent exercise with intervals as short as 3 min interspersed with 3 min of rest (i.e., 1:1 work-to-rest ratio). As the individual adapts to training, the duration of the work interval can be increased, whereas the rest interval can be decreased. Initially, a total exercise time of 15 min can be used, and this can be increased within tolerance to achieve up 20–60 min of continuous activity. • Individuals with CKD performing resistance exercise should be asked to perform at least 1 set of 10 repetitions at 70% 1-RM twice per week. Consider adding a second set when the individual can easily complete 15 repetitions at a specific weight. • Hemodialysis. • Exercise can be performed on nondialysis days and should not be done immediately postdialysis. • If exercise is done during dialysis, exercise should be attempted during the first half of the treatment to avoid hypotensive episodes. • Place great emphasis on the RPE because HR is unreliable. • Patients may exercise the arm with the arteriovenous access as long as they do not directly rest weight on that area (119). Measure BP in the arm that does not contain the fistula. • Peritoneal Dialysis. • Patients on continuous ambulatory peritoneal dialysis may attempt exercising with fluid in their abdomen; however, if this produces discomfort then they should be encouraged to drain the fluid before exercising (119). • Recipients of Kidney Transplants. • During periods of rejection, the FITT principle of Ex Rx should be reduced but exercise can still be continued (174). THE BOTTOM LINE • Individuals with CKD tend to be very deconditioned depending on their age and disease status. Based on current evidence, exercise is safe for these indi- viduals if performed at moderate intensity and if progression occurs gradually. Exercise testing should be done under medical supervision and may involve the use of functional tests rather than the traditional GXT.
- 335. CHAPTER 10 Exercise Prescription for Other Clinical Populations 309 METABOLIC SYNDROME The metabolic syndrome is characterized by a constellation of risk factors that are associated with increased incidence of CVD, DM, and stroke. A consensus on the definition of the metabolic syndrome has been somewhat controversial; however, the criteria set by the NCEP ATP III Guidelines are most commonly used for diagnosis (164). Typically, individuals with the metabolic syndrome are overweight/obese and have elevated plasma triglycerides, hypertension, and elevated plasma glucose. Diagnosis is made when at least three of the risk factors shown in Table 3.3 are present. At this time, it is underdetermined whether the metabolic syndrome represents a distinct pathophysiologic condition or disease (83). Nonetheless, the metabolic syndrome as a clinical entity is useful in clinical and health/fitness settings. Although the primary cause is debatable, the root causes of the metabolic syndrome are overweight/obesity, physical inactivity, insulin resistance, and genetic factors. Age-adjusted prevalence data from the National Health and Nutrition Examination Survey (NHANES) 2003–2006 indicates 34% of adults in the United States meet the criteria for the metabolic syndrome (59), an increase compared with the prevalence of 27% in NHANES 1999–2000 (81). The International Diabetes Federation (IDF) proposed a new definition for the metabolic syndrome in 2005 (113) that was based on the presence of abdominal adiposity and two additional CVD risk factors shown in Table 3.3. When the metabolic syndrome classifications are compared, the NCEP and IDF definitions provide the same classification of 93% of individuals having the metabolic syn- drome (80), indicating their compatibility. The treatment guidelines for the metabolic syndrome recommended by NCEP ATPIII focus on three interventions including weight control, physical activity, and treatment of the associated CVD risk factors that may include pharmacotherapy (164) (see Chapter 3). The IDF Guidelines for primary in- tervention include (113) (a) moderate restriction in energy intake to achieve a 5%–10% weight loss within 1 yr; (b) moderate increases in physical activity consistent with the consensus public health recommendations of 30 min of moderate intensity, physical activity on most days of the week (102,250); and (c) change in dietary intake composition that may require changes in macro- nutrient composition consistent with modifying specified CVD risk factors. National Institute of Diabetes and Digestive and Kidney Diseases: http://www2.niddk.nih.gov/ National Kidney Foundation: http://www.kidney.org/ United States Renal Data System: http://www.usrds.org/atlas.htm Online Resources
- 336. 310 GUIDELINES FOR EXERCISE TESTING • www.acsm.org The IDF secondary intervention includes pharmacotherapy for associated CVD risk factors (49,113). EXERCISE TESTING • Special consideration should be given to associated CVD risk factors as outlined in Chapters 2 and 3 on exercise testing and in this chapter for indi- viduals with dyslipidemia, hypertension, and hyperglycemia. • Because many individuals with the metabolic syndrome are either overweight or obese, exercise testing considerations specific to those individuals should be followed (see the section on overweight and obesity in this chapter and the relevant ACSM position stand [54]). • The potential for low exercise capacity in individuals who are overweight or obese may necessitate a low initial workload (i.e., 2–3 metabolic equivalents [METs]) and small increments per testing stage (0.5–1.0 MET). • Because of the potential presence of elevated BP, strict adherence to protocols for assessing BP before and during exercise testing should be followed (183) (see Chapters 3 and 5). EXERCISE PRESCRIPTION/SPECIAL CONSIDERATIONS The FITT principle of Ex Rx is consistent with the recommendations for healthy adults regarding aerobic, resistance, and flexibility exercise (see Chapter 7). Similarly, the minimal dose of physical activity to improve health/fitness outcomes is consistent with the consensus public health recommendations of 150 min ⭈ wk1 or 30 min of physical activity on most days of the week (102,249). For these reasons and because of the impact of the clustering of chronic diseases and health conditions that accompany the metabolic syndrome, the following FITT principle of Ex Rx and special considerations are combined in this section: • Individuals with the metabolic syndrome will likely present with multiple CVD and DM risk factors (i.e., dyslipidemia, hypertension, obesity, and hyperglycemia). Special consideration should be given to the FITT principle of Ex Rx recommendations based on the presence of these associated CVD risk factors and the goals of the participant and/or health care provider (see other sections of this chapter on the FITT principle Ex Rx for these other chronic diseases and health conditions as well as relevant ACSM position stands [6,54,183]). • To reduce risk factors associated with CVD and DM, initial exercise training should be performed at a moderate intensity (i.e., 40%–60% V̇O2 R or HRR) and when appropriate, progress to a more vigorous intensity (i.e., 60% V̇O2 R or HRR), totaling a minimum of 150 min ⭈ wk1 or 30 min ⭈ d1 most days of the week to allow for optimal health/fitness improvements. • To reduce body weight, most individuals with the metabolic syndrome may benefit by gradually increasing their physical activity levels to approximately
- 337. CHAPTER 10 Exercise Prescription for Other Clinical Populations 311 300 min ⭈ wk1 or 50–60 min on 5 d ⭈ wk1 when appropriate (54,216,251). This amount of physical activity may be accumulated in multiple daily bouts of at least 10 min in duration or through increases in other forms of moder- ate intensity lifestyle physical activities. For some individuals to promote or maintain weight loss, progression of 60–90 min ⭈ d1 may be necessary (see the Ex Rx recommendations for those with overweight and obesity in this chapter and the relevant ACSM position stand [54]). THE BOTTOM LINE • The prevalence of the metabolic syndrome in the United States is increas- ing. Many individuals with the metabolic syndrome are overweight or obese and present with multiple CVD and DM risk factors. Special consideration should be given to exercise testing and the FITT principle of Ex Rx based on the clustering of these chronic diseases and health conditions. The goal of the Ex Rx is to reduce the risk factors associated with CVD and DM and reduce body weight. American College of Sports Medicine: http://www.acsm.org to access relevant position stands to the metabolic syndrome American Heart Association: http://www.heart.org Online Resources MULTIPLE SCLEROSIS Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system (CNS) that currently affects an estimated 2.1 million in- dividuals worldwide (167). The onset of MS usually occurs between 20 and 50 yr and affects women at a rate two to three times more than men. Initial symptoms often include transient neurological deficits such as numbness or weakness and blurred or double vision. Although the exact cause of MS is still unknown, most researchers believe it involves an autoimmune response that is influenced by a combination of environmental, infectious, and genetic factors. During an exac- erbation, activated T cells cross the blood–brain barrier precipitating an autoim- mune attack on myelin in the CNS. Following the initial inflammatory response, damaged myelin forms scarlike plaques that can impair nerve conduction and transmission (167). This can lead to a wide variety of symptoms; the most com- mon of which include visual disturbances, weakness, sensory loss, fatigue, pain, coordination deficits, bowel or bladder dysfunction, and cognitive and emotional changes (144,225).
- 338. 312 GUIDELINES FOR EXERCISE TESTING • www.acsm.org The disease course of MS is highly variable from individual to individual and within a given individual over time. However, several distinct disease courses are now recognized as well as the relative frequency of each including (a) relapsing remitting MS (RRMS; 85%) characterized by periodic exacerbations followed by full or partial recovery of deficits; (b) primary progressive MS (PPMS; 10%) char- acterized by continuous disease progression from onset with little or no plateaus or improvements; and (c) progressive relapsing MS (PRMS; 5%) characterized by a progression from onset with distinct relapses superimposed on the steady progression (144). For the 85% of individuals who have an initial disease course of RRMS, many will eventually (10–25 yr later) develop a secondary progressive MS (SPMS) disease course, which is characterized by a slow but steady decline in function. The level of disability related to the progression of MS is commonly documented using the Kurtzke Expanded Disability Status Scale (EDSS), which ranges from 0 to 10. EDSS scores from 0 to 2.5 are indicative of no to minimal disability, 3–5.5 moderate disability and ambulatory without device, 6–7 signifi- cant disability but still ambulatory with a device, 7.5–9 essentially chairbound or bedbound, and 10 death because of MS (135). With respect to CRF , individuals with MS generally have lower maximal aero- bic capacity than age- and sex-matched adults without MS. Furthermore, aerobic capacity continues to decrease with increasing levels of disability (189,191). HR and BP responses to GXT are generally linear with respect to work rate but tend to be blunted compared to healthy controls (189). This attenuation of HR and BP may be a result of cardiovascular dysautonomia (236). Following 3–6 mo of progressive aerobic training, individuals with MS who have mild-to-moderate disability have consistently demonstrated improvements in V̇O2peak , functional capacity, lung function, and delayed onset of fatigue (162,184,190). Decreased muscle performance is also a common impairment associated with MS. Individuals with MS have lower isometric and isokinetic force production as well as total work of the quadriceps muscle when compared to age- and sex- matched norms (47,136,190). Changes in muscle performance appear to be as- sociated with central (neural drive and conduction) and peripheral (decreased oxidative capacity) factors associated with the disease process as well as the sec- ondary effects of disuse atrophy (124,199). Although limited, current research demonstrates individuals with MS can improve strength and function with pro- gressive resistance training with greater gains being realized by individuals with less disability because of MS (268). EXERCISE TESTING • Generalized fatigue is common in individuals with MS. Because fatigue gener- ally worsens throughout the day, performing exercise testing earlier in the day is likely to yield a more accurate and consistent response. • Avoid testing during an acute exacerbation of MS symptoms. • Problems with balance and coordination may require use of an upright or recumbent cycle leg ergometer. When using a cycle leg ergometer, the use
- 339. CHAPTER 10 Exercise Prescription for Other Clinical Populations 313 of foot straps may be needed to prevent the foot from falling off the pedal because of weakness and/or spasticity. • A recumbent stepping ergometer (e.g., NuStep) that allows for the use of upper and lower extremities may be advantageous because it distributes work to all extremities, thus minimizing the potential influence of local muscle fatigue on maximal aerobic testing. • Depending on the disability and physical fitness level of the individual, use a continuous or discontinuous protocol of 3–5 min stages increasing work rate for each stage from 12 to 25 W. • Heat sensitivity is common in individuals with MS so it is important to use a fan or other cooling strategies during testing. • Assessment of joint ROM and flexibility is important because increased tone and spasticity can lead to contracture formation. • Isokinetic dynamometry can be used to accurately evaluate muscle perfor- mance. However, use of an 8–10-RM or functional testing (e.g., 30 s sit-to-stand test) can also be used to measure muscular strength and endurance in the clini- cal or community setting. • Use physical performance tests as needed to assess endurance (6-min walk test) (see Chapter 4), strength (5 repetition sit-to-stand), gait (walking speed) (see Chapter 8), and balance (Berg Balance Scale [23], and Dynamic Gait Index [107]). EXERCISE PRESCRIPTION For individuals with minimal disability (EDSS 0–2.5), the FITT principle of Ex Rx is generally consistent with those outlined in Chapter 7 for healthy adults. As MS symptoms and level of disability increase, the following modifications outlined may be required. FITT RECOMMENDATIONS FOR INDIVIDUALS WITH MULTIPLE SCLEROSIS Aerobic Exercise Frequency: 3–5 d ⭈ wk1 . Intensity: 40%–70% V̇O2 R or HRR; RPE 11–14. Time: Increase exercise time initially to a minimum of 10 min before increasing intensity. Progress to 20–60 min. In individuals with excessive fatigue, begin with lower intensity and discontinuous bouts of exercise. Resistance Exercise Frequency: 2 d ⭈ wk1 . Intensity: 60%–80% 1-RM.
- 340. 314 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SPECIAL CONSIDERATIONS • In spastic muscles, increase the frequency and time of flexibility exercises. Muscles and joints with significant tightness or contracture may require longer duration (several minutes to several hours), and lower load positional stretching to achieve lasting improvements. • Whenever possible, incorporate functional activities (e.g., stairs, sit-to-stand) into the exercise program to promote optimal carryover. • Use RPE in addition to HR to evaluate exercise intensity. With individuals who have significant paresis, consider assessing RPE of the extremities separately using the 6–20 scale (27) to evaluate effects of local muscle fatigue on exercise tolerance. • During an acute exacerbation of MS symptoms, decrease the FITT of the Ex Rx to the level of tolerance. If the exacerbation is severe, focus on main- taining functional mobility and/or focus on activities such as aerobic exercises and flexibility. • Commonly used disease-modifying medications such as Avonex, Betaseron, Rebif, and Copaxone can have transient side effects such as flu-like symptoms and localized irritation at the injection site. Take medication side effects into consideration with exercise testing and scheduling. • Systemic fatigue is common in MS but tends to improve with increased physi- cal fitness. It is important to help the individual understand the difference between more general centrally mediated MS fatigue and temporary periph- eral exercise-related fatigue. Tracking the effects of fatigue may be helpful using an instrument such as the Modified Fatigue Impact Scale (168). • Heat sensitivity is common in MS. Use of fans, evaporative cooling garments, and cooling vests can increase exercise tolerance and reduce symptoms of fatigue. • HR and BP responses may be blunted because of dysautonomia so that HR may not be a valid indicator of exercise intensity. RPE can be used in addition to HR to evaluate exercise intensity (see Chapters 4 and 7). • Some individuals may restrict their daily fluid intake because of bladder control problems. They should be counseled to increase fluid intake with increased physical activity levels to prevent dehydration. Time: 1–2 sets of 8–15 repetitions. When strengthening weaker muscle groups or easily fatigued individuals, increase rest time (e.g., 2–5 min) between sets and exercises as needed to allow for full muscle recovery. Focus on large antigravity muscle groups and minimize total number of exercises performed. Flexibility Exercise Frequency: 5–7 d ⭈ wk1 , 1–2 times ⭈ d1 . Intensity: Stretch to the point of feeling tightness or mild discomfort. Time: Hold static stretch 30–60 s, 2–4 repetitions.
- 341. CHAPTER 10 Exercise Prescription for Other Clinical Populations 315 • Many individuals with MS have some level of cognitive deficit that may affect their understanding of testing and training instructions. They may also have short-term memory loss that requires written instructions and frequent verbal cueing and reinforcement. • Watch for signs and symptoms of the Uhthoff Phenomenon. Uhthoff phe- nomenon typically involves a transient (24 h) worsening of neurological symptoms, most commonly visual impairment associated with exercise and elevation of body temperature. Symptoms can be minimized by using cooling strategies and adjusting exercise time and intensity as appropriate. THE BOTTOM LINE • Individuals with MS generally have a lower V̇O2peak compared to a healthy population. Fatigue is common in individuals with MS but can be improved with exercise training in individuals who have mild-to-moderate disability. The HR response to exercise may be blunted; RPE can be used in addition to HR to evaluate exercise intensity. National Center on Physical Activity and Disability: http://www.ncpad.org National Institute for Neurological Disorders and Stroke: http://www.ninds.nih.gov/multiple_sclerosis/multiple_sclerosis.htm National MS Society: http://www.nationalmssociety.org Online Resources OSTEOPOROSIS Osteoporosis is a skeletal disease that is characterized by low bone mineral density (BMD) and changes in the microarchitecture of bone that increase sus- ceptibility to fracture. The burden of osteoporosis on society and the individual is significant. More than 10 million individuals in the United States 50 yr have osteoporosis, and another 34 million are at risk (253). Hip fractures, in particular, are associated with increased risk of disability and death. The 2007 official position of the International Society of Clinical Densitometry, which has been endorsed by the American Association of Clinical Endocrinologists, the American Society for Bone and Mineral Research, the Endocrine Society, the North American Menopause Society, and the National Osteoporosis Foundation, defines osteoporosis in postmenopausal women and in men 50 yr as a BMD T-score of the lumbar spine, total hip, or femoral neck of 2.5 (18). However, it is important to recognize that osteoporotic fractures may occur at BMD levels above this threshold, particularly in the elderly.
- 342. 316 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Physical activity may reduce the risk for osteoporotic fractures by enhancing the peak bone mass achieved during growth and development, by slowing the rate of bone loss with aging, and/or by reducing the risk of falls via benefits on muscle strength and balance (21,133,206,253). Accordingly, physical activity plays a prominent role in primary and secondary prevention of osteoporosis (253). Physical activity is inversely associated with risk of hip and spine fracture, and exercise training can increase or slow the decrease in spine and hip BMD (186). EXERCISE TESTING There are no special considerations for exercise testing of individuals at risk for osteoporosis regarding when a test is clinically indicated beyond those for the general population. However, when exercise tests are performed in individuals with osteoporosis, the following issues should be considered: • Use of cycle leg ergometry as an alternative to treadmill exercise testing to assess CRF may be indicated in patients with severe vertebral osteoporosis for whom walking is painful. • Vertebral compression fractures leading to a loss of height and spinal defor- mation can compromise ventilatory capacity and result in a forward shift in the center of gravity. The latter may affect balance during treadmill walking necessitating handrail support or an alternative modality. • Maximal muscle strength testing may be contraindicated in patients with severe osteoporosis, although there are no established guidelines for contra- indications for maximal muscle strength testing. EXERCISE PRESCRIPTION The FITT principle of Ex Rx for individuals with osteoporosis are categorized into two types of populations: (a) individuals at risk for osteoporosis defined as having 1 risk factor for osteoporosis (e.g., current low bone mass, age, being female) (253); and (b) individuals with osteoporosis. FITT RECOMMENDATIONS FOR INDIVIDUALS AT RISK FOR AND WITH OSTEOPOROSIS Aerobic and Resistance Exercise Individuals at Risk for Osteoporosis In individuals at risk for osteoporosis, the following FITT principles of Ex Rx are recommended to help preserve bone health: Frequency: Weight-bearing aerobic activities 3–5 d ⭈ wk1 and resistance exercise 2–3 d ⭈ wk1 . Intensity: Aerobic: Moderate (e.g., 40%–60% V̇O2 R or HRR) to vigorous 60% (V̇O2 R or HRR) intensity; resistance: moderate (e.g., 60%–80%
- 343. CHAPTER 10 Exercise Prescription for Other Clinical Populations 317 SPECIAL CONSIDERATIONS • It is difficult to quantify exercise intensity in terms of bone loading forces. However, the magnitude of bone loading force generally increases in parallel with exercise intensity quantified by conventional methods (e.g., %HRmax or %1-RM). • There are currently no established guidelines regarding contraindications for exercise for individuals with osteoporosis. The general recommendation is to prescribe moderate intensity exercise that does not cause or exacerbate pain. Exercises that involve explosive movements or high-impact loading should be avoided. Exercises that cause twisting, bending, or compression of the spine should also be avoided. • BMD of the spine may appear normal or increased after osteoporotic compression fractures have occurred or in individuals with osteoarthritis of the spine. Hip BMD is a more reliable indicator of risk for osteoporosis than spine BMD (141). • For older women and men at increased risk for falls, the Ex Rx should also include activities that improve balance (see Chapter 8 and the relevant ACSM position stand [8]). 1-RM, 8–12 repetitions with exercises involving each major muscle group) to vigorous (e.g., 80%–90% 1-RM, 5–6 repetitions with exercises involving each major muscle group) intensity in terms of bone loading forces. Time: 30–60 min ⭈ d⫺1 of a combination of weight-bearing aerobic and resistance activities. Type: Weight-bearing aerobic activities (e.g., tennis, stair climbing/ descending, walking with intermittent jogging), activities that involve jumping (e.g., volleyball, basketball), and resistance exercise (e.g., weight lifting). Individuals with Osteoporosis In individuals with osteoporosis, the following FITT principle of Ex Rx is recommended to help prevent disease progression: Frequency: Weight-bearing aerobic activities 3–5 d ⭈ wk⫺1 and resistance exercise 2–3 d ⭈ wk⫺1 . Intensity: Moderate intensity (i.e., 40%–⬍60% V̇O2 R or HRR) for weight- bearing aerobic activities and moderate intensity (e.g., 60%–80% 1-RM, 8–12 repetitions of exercises involving each major muscle group) in terms of bone loading forces, although some individuals may be able to tolerate more intense exercise. Time: 30–60 min ⭈ d⫺1 of a combination of weight-bearing aerobic and resistance activities. Type: Weight-bearing aerobic activities (e.g., stair climbing/descending, walking, other activities as tolerated) and resistance exercise (e.g., weight lifting).
- 344. 318 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • In light of the rapid and profound effects of immobilization and bed rest on bone loss and poor prognosis for recovery of mineral after remobilization, even the frailest elderly should remain as physically active as his or her health permits to preserve musculoskeletal integrity. THE BOTTOM LINE • Physical activity plays an important role in the primary and secondary pre- vention of osteoporosis by enhancing peak bone mass during growth, slowing the rate of bone loss with aging, and preventing falls. Weight-bearing aerobic and resistance exercise are essential to individuals at risk for and with osteo- porosis. It is difficult to quantify the magnitude of bone loading forces, but they generally increase in parallel with exercise intensity. American College of Sports Medicine: http://www.acsm.org to access the position stand on osteoporosis National Osteoporosis Foundation: http://www.nof.org Online Resources OVERWEIGHT AND OBESITY Overweight and obesity are characterized by excess body weight with BMI com- monly used as the criterion to define these conditions. Recent estimates indicate that more than 68% of adults are classified as overweight (BMI 25 kg ⭈ m2 ), 32% as obese (BMI 30 kg ⭈ m2 ), and 5% extremely obese (BMI 40 kg ⭈ m2 ) (77). Obesity is also an increasing concern in youth with ⬃14%–18% of children and adolescents classified as overweight, defined as 95th percentile of BMI for age and sex (173). Overweight and obesity are linked to numerous chronic diseases including CVD, DM, many forms of cancer, and numerous musculosk- eletal problems (36). It is estimated obesity-related conditions account for ⬃7% of total health care costs in the United States, and the direct and indirect costs of obesity are in excess of $113.9 billion annually (245). The management of body weight is dependent on energy balance that is determined by energy intake and EE. For an individual who is overweight or obese to reduce body weight, EE must exceed energy intake. A weight loss of 5%–10% provides significant health benefits (36), and these benefits are more likely to be sustained through the maintenance of weight loss and/or participa- tion in habitual physical activity (241). Weight loss maintenance is challenging with weight regain averaging approximately 33%–50% of initial weight loss within 1 yr of terminating treatment (270).
- 345. CHAPTER 10 Exercise Prescription for Other Clinical Populations 319 Lifestyle interventions for weight loss that combine reductions in energy intake with increases in EE through exercise and other forms of physical activity typically result in an initial 9%–10% reduction in body weight (270). However, physical activity appears to have a modest impact on the magnitude of weight loss observed across the initial weight loss intervention compared with reduc- tions in energy intake (36). The level of impact of exercise on weight loss further decreases when energy intake is reduced to levels that are insufficient to meet the resting metabolic rate (54). Thus, the combination of moderate reductions in energy intake with adequate levels of physical activity maximizes weight loss in individuals with overweight and obesity (36,115). Physical activity appears nec- essary for most individuals to prevent weight regain (36,115,216,251). However, the literature is absent of well-designed, randomized controlled trials with super- vised exercise, known EE of exercise, and energy balance measures upon which to provide evidence-based recommendations for quantity and quality of exercise to prevent weight regain (54). Based on the existent scientific evidence and practical clinical guidelines (54), the ACSM makes the following recommendations regarding exercise testing and training for individuals with overweight and obesity. EXERCISE TESTING • The presence of other comorbidities (e.g., dyslipidemia, hypertension, hyperinsulinemia, hyperglycemia) may increase the risk classification for individuals with overweight and obesity, resulting in the need for additional medical screening before exercise testing and/or appropriate medical supervi- sion during exercise testing (see Chapters 2 and 3). • The timing of medications to treat comorbidities relative to exercise testing should be considered. • The presence of musculoskeletal and/or orthopedic conditions may require modifications to the exercise testing procedure that may necessitate the need for leg or arm ergometry. • The potential for low exercise capacity in individuals with overweight and obesity may necessitate a low initial workload (i.e., 2–3 METs) and small increments per testing stage of 0.5–1.0 MET. • Because of the ease of test administration, consider a cycle leg ergometer (with an oversized seat) versus a treadmill. • Exercise equipment must be adequate to meet the weight specification of individuals with overweight and obesity for safety and calibration purposes. • Adults with overweight and obesity may have difficulty achieving tra- ditional physiologic criteria indicative of maximal exercise testing so that standard termination criteria may not apply to these individuals (see Chapter 5). • The appropriate cuff size should be used to measure BP in individuals who are overweight and obese to minimize the potential for inaccurate measure- ment.
- 346. 320 GUIDELINES FOR EXERCISE TESTING • www.acsm.org EXERCISE PRESCRIPTION FITT RECOMMENDATIONS FOR INDIVIDUALS WITH OVERWEIGHT AND OBESITY Aerobic, Resistance, and Flexibility Exercise Frequency: 5 d ⭈ wk1 to maximize caloric expenditure. Intensity: Moderate-to-vigorous intensity aerobic activity should be encour- aged. Initial exercise training intensity should be moderate (i.e., 40%–60% V̇O2 R or HRR). Eventual progression to more vigorous exercise intensity (i.e., 60% V̇O2 R or HRR) may result in further health/fitness benefits. Time: A minimum of 30 min ⭈ d1 (i.e., 150 min ⭈ wk1 ) progressing to 60 min ⭈ d1 (i.e., 300 min ⭈ wk1 ) of moderate intensity, aerobic activity. Incorporating more vigorous intensity exercise into the total volume of exercise may provide additional health benefits. However, vigorous intensity exercise should be encouraged in individuals who are both capable and willing to exercise at a higher than moderate intensity levels of physical exertion with recognition that vigorous intensity exercise is asso- ciated with the potential for greater injuries (182). Accumulation of inter- mittent exercise of at least 10 min is an effective alternative to continuous exercise and may be a particularly useful way to initiate exercise (116). Type: The primary mode of exercise should be aerobic physical activities that involve the large muscle groups. As part of a balanced exercise program, resistance training and flexibility exercise should be incorporated (see Chapter 7 on the FITT principle Ex Rx recommendations for resis- tance training and flexibility). SPECIAL CONSIDERATIONS Weight Loss Maintenance Clear evidence from correctly designed studies is lacking for the amount of physical activity that may be required to prevent weight regain. However, there is literature that suggests it may take more than the consensus public health recommendation for physical activity of 150 min ⭈ wk1 or 30 min of physical activity on most days of the week (54,102,250) to prevent weight regain. For these reasons, the following special considerations should be noted: • Adults with overweight and obesity may benefit from progression to approxi- mately ⬎250 min ⭈ wk1 because this magnitude of physical activity may enhance long-term weight loss maintenance (54,115,216,251). • Adequate amounts of physical activity should be performed on 5–7 d ⭈ wk1 . • The duration of moderate-to-vigorous intensity, physical activity should initially progress to at least 30 min ⭈ d1 (102,250) and when appropriate progress to ⬎250 min ⭈ wk1 to enhance long-term weight management (54).
- 347. CHAPTER 10 Exercise Prescription for Other Clinical Populations 321 • Individuals with overweight and obesity may accumulate this amount of physical activity in multiple daily bouts of at least 10 min in duration or through increases in other forms of moderate intensity lifestyle physical activ- ities. Accumulation of intermittent exercise may increase the volume of physi- cal activity achieved by previously sedentary individuals and may enhance the likelihood of adoption and maintenance of physical activity (145). • The addition of resistance exercise to energy restriction does not appear to prevent the loss of fat-free mass or the observed reduction in resting EE (55). However, resistance exercise may enhance muscular strength and physical function in individuals with overweight and obesity. Moreover, there may be additional health benefits of participating in resistance exercise such as improvements in CVD and DM risk factors and other chronic disease risk fac- tors (55,243) (see Chapter 7 for additional information on the FITT principle of Ex Rx recommendations for resistance training). WEIGHT LOSS PROGRAM RECOMMENDATIONS (115) • Target a minimal reduction in body weight of at least 5%–10% of initial body weight over 3–6 mo. • Incorporate opportunities to enhance communication between health care professionals, dietitians, and health/fitness and clinical exercise professionals and individuals with overweight and obesity following the initial weight loss period. • Target changing eating and exercise behaviors because sustained changes in both behaviors result in significant long-term weight loss. • Target reducing current energy intake by 500–1,000 kcal ⭈ d1 to achieve weight loss. This reduced energy intake should be combined with a reduction in dietary fat to 30% of total energy intake. • Progressively increase to a minimum of 150 min ⭈ wk1 of moderate intensity, physical activity to optimize health/fitness benefits for adults with overweight and obesity. • Progress to greater amounts of physical activity (i.e., ⬎250 min ⭈ wk1 ) to promote long-term weight control. • Include resistance exercise as a supplement to the combination of aerobic exercise and modest reductions in energy intake to lose weight. • Incorporate behavioral modification strategies to facilitate the adoption and maintenance of the desired changes in behavior (see Chapter 11). BARIATRIC SURGERY Surgery for weight loss may be indicated for individuals with a BMI 40 kg ⭈ m2 or those with comorbid risk factors and BMI 30 kg ⭈ m2 . Comprehensive treatment following surgery includes exercise; however, this has not been studied systematically. Exercise will likely facilitate the achievement and main- tenance of energy balance postsurgery. A multicenter National Institutes of Health–sponsored trial is underway (i.e., Longitudinal Assessment of Bariatric
- 348. 322 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Surgery or “LABS”) (143). When the results are published, they will provide the most comprehensive findings for exercise and bariatric surgery to date (128). Individuals with severe obesity do not perform a great deal of exercise; and in similar fashion with the general population, the amount of exercise is inversely related to weight (114,128). Likewise, the achievement of a minimum of 150 min ⭈ wk1 has been associated with greater postoperative weight loss at 6 and 12 mo (61). Once individuals are cleared for exercise by their physician after surgery, a progressive exercise program should follow the FITT principle of Ex Rx for healthy adults (see Chapter 7). Because of the weight placed on joints and probable history of previous low levels of exercise, intermittent exercise or non–weight-bearing exercise may initially contribute to a successful exercise program. Subsequently, continuous exercise and weight-bearing exercise such as walking can make up a greater portion of the exercise program. Because the goal of exercise postbariatric surgery is the prevention of weight regain, the ACSM recommends 250 min ⭈ wk1 of moderate-to-vigorous intensity exercise (54). THE BOTTOM LINE • Weight management relies on the relative contributions of energy intake and expenditure or “energy balance.” To achieve weight loss, reduce current energy intake by 500–1,000 kcal ⭈ d1 , progressively increase to a minimum of 150 min ⭈ wk1 of moderate intensity, physical activity to optimize health/ fitness benefits for overweight and obese adults, and progress to greater amounts of exercise (i.e., ⬎250 min ⭈ wk1 ) of physical activity to promote long-term weight control. American College of Sports Medicine: http://www.acsm.org to access the position stand on overweight and obesity National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, eval- uation, and treatment of overweight and obesity in adults; The evidence report: National Institutes of Health, 1998: http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm Physical Activity Guidelines Advisory Committee Report to the Secretary of Health and Human Services, 2008: http:www.health.gov/PAGuidelines/committeereport.aspx Online Resources PARKINSON DISEASE Parkinson disease (PD) is one of the most common neurodegenerative diseases. More than 1.5 million individuals in the United States are believed to have PD, and 70,000 new cases are diagnosed each year (97). It is estimated 6 million
- 349. CHAPTER 10 Exercise Prescription for Other Clinical Populations 323 individuals worldwide are currently living with PD (247). PD is a chronic, pro- gressive neurological disorder characterized clinically by symptoms consisting of resting tremor, bradykinesia, rigidity, postural instability, and gait abnormali- ties (see Box 10.2). PD is the result of damage to the dopaminergic nigrostriatal pathway, which results in a reduction in the neurotransmitter dopamine. The cause of PD is unknown; however, genetics and the environment are thought to be factors. Aging, autoimmune responses, and mitochondrial dysfunction may also contribute to the disease process (193). The severity of PD can be classified as (a) early disease, characterized by minor symptoms of tremor or stiffness; (b) moderate disease, characterized by mild-to-moderate tremor and limited movement; and (c) advanced disease, char- acterized by significant limitations in activity regardless of treatment or medica- tion (193). The progression of symptoms is described more comprehensively by the Hoehn and Yahr scale (108) (see Table 10. 8). The symptoms of PD affect movement, and individuals with moderate and severe PD may have difficulty performing ADL. Resting tremors are often evi- dent but can be suppressed by voluntary activity, sleep, and complete relaxation of axial muscles. Stress and anxiety increase resting tremors. Rigidity makes Bradykinesia Reduced movement speed and amplitude; at the extreme, it is known as hypokinesia, which refers to “poverty” of movement Akinesia Difficulty initiating movements Episodes of freezing Motor blocks/sudden inability to move during the execution of a movement sequence Impaired balance and postural instability Difficulty maintaining upright stance with narrow base of support in response to a perturbation to the center of mass or with eyes closed; difficulty maintaining stability in sitting or when transferring from one position to another; can manifest as frequent falling Dyskinesia Overreactivity of muscles; wriggling/writhing movements Tremor Rhythmic activity alternating in antagonistic muscles, resembling a pill-rolling movement; usually resting tremor Rigidity Muscular stiffness throughout the range of passive movement in both extensor and flexor muscle groups in a given limb Adaptive responses Reduced activity, muscle weakness, reduced muscle length, contractures, deformity, reduced aerobic capacity Common Movement Disorders in Individuals with Parkinson Disease (160) BOX 10.2
- 350. 324 GUIDELINES FOR EXERCISE TESTING • www.acsm.org movement difficult and may increase EE. This increases the patient’s perception of effort on movement and may be related to feelings of fatigue, especially postexercise fatigue. Bradykinesia and akinesia are characterized by a reduction or inability to initiate and perform purposeful movements. Postural instability or impaired balance is a serious problem in PD that leads to increased episodes of falling and exposes individuals with PD to the serious consequences of falls. Generally, patients with PD demonstrate slowed, short-stepped, shuffling walk with decreased arm swing and forward-stooped posture. Difficulties and slow- ness in performing turning, getting up, transfer, and ADL are common. Other problems including excessive salivation or drooling, soft, slurred speech, and small handwriting also impact quality of life. Drug therapy is the primary intervention for the treatment of symptoms related to PD. Levodopa remains the mainstay of treatment for PD and is the single most effective drug available to treat all cardinal features of the disease. Despite its significant benefit, the effectiveness is limited to an average of approximately 10 yr. Long-term use is associated with motor complications in- cluding motor fluctuations and dyskinesias in about 50% of patients within 5 yr (185, 237). Other side effects include nausea, sedation, orthostatic hypotension, and psychiatric symptoms (especially hallucinations). Levodopa is now always combined with carbidopa to prevent systemic adverse effects (198). Other ad- junctive drug groups are catechol-O-methyltransferase inhibitors, monoamine oxidase B inhibitors (selegiline, rasagiline), amantadine, anticholinergics, and dopamine agonists. These drugs are used as a monotherapy or adjunct therapy to provide symptomatic relief in PD. Individuals with severe PD may undergo surgical treatment. Deep brain stimu- lation (DBS) is an electrical stimulation of the deep brain nuclei. The internal globus pallidus and subthalamic nucleus are two main stimulation targets in PD. It is the surgical intervention of choice when motor complications are in- adequately managed with the medications. The stimulation is adjustable and re- versible. Improvement in motor function after either stimulation target is similar (78). DBS is more effective than medical therapy in advanced PD in improving dyskinesia, motor function, and quality of life (266). Exercise is a crucial adjunct treatment in PD management. Regular exercise will decrease or delay secondary sequelae affecting musculoskeletal and cardio- respiratory systems that occur as a result of reduced physical activity. Because PD is a chronic progressive disease, sustained exercise is necessary to maintain TABLE 10.8. The Hoehn and Yahr Staging Scale of Parkinson Disease (108) Stage 0.0 No signs of disease Stage 1.0 Unilateral disease Stage 2.0 Bilateral disease, without impairment of balance Stage 2.5 Mild bilateral disease, with recovery on pull test Stage 3.0 Mild-to-moderate bilateral disease; some postural instability; physical independent Stage 4.0 Severe disability; still able to walk or stand unassisted Stage 5.0 Wheelchair bound or bedridden unless aided
- 351. CHAPTER 10 Exercise Prescription for Other Clinical Populations 325 benefits. Evidence demonstrates exercise improves gait performance, quality of life, reduces disease severity, and improves aerobic capacity in individuals with PD (24,106,219). Exercise might also play a neuroprotective role in individu- als with PD. EXERCISE TESTING Most individuals with PD have impaired mobility and problems with gait, bal- ance, and functional ability, which vary from individual to individual. These impairments are often accompanied by low levels of physical fitness (e.g., CRF , muscular strength and endurance, flexibility). The following are special consid- erations in performing exercise testing for individuals with PD: • Tests of balance, gait, general mobility, ROM, flexibility, and muscular strength are recommended before exercise testing is performed. Results of the tests can guide how to safely exercise test the individual with PD. • Fall history should also be recorded. Patients with PD with more than one fall in the previous year are likely to fall again within the next 3 mo (126). • Manual muscle testing, arm curl tests, weight machines, dynamometers, and chair rise tests (89) can be used for strength evaluation. • Flexibility can be measured by using goniometry, the sit-and-reach test, and the back scratch test (202). • The 6-min walk test can be used to assess CRF (63). • The Timed Get Up and Go test (146) and chair sit-to-stand test (228) can be used to measure functional mobility. Gait observation can be done during the 10-m walk test at a comfortable walking speed (127,218). • Balance evaluation and physical limitations of the individual should be used in making decisions regarding testing modes for test validity and safety. Clinical balance tests include the Functional Reach test (57), the Get Up and Go test (146,148,149), tandem stance (180), single limb stance (233), and pull tests (163,180,233). Static and dynamic balance evaluation of sitting and standing should be performed prior to the exercise test for safety. • Decisions regarding exercise testing protocols may be influenced by the severity of PD (see Table 10.8) or physical limitations of the individual. Use of a cycle leg ergometer alone or combined with arm ergometry may be more suitable for individuals with severe gait and balance impairment or with a history of falls (192) because they reduce fear of falling on a treadmill and increase confidence during the test. However, use of leg/arm ergometers may preclude individuals with PD from achieving a maximum cardiorespiratory response because of early muscular fatigue before the maximal cardiorespi- ratory levels are attained (267). Treadmill protocols can be used safely in individuals with a mild stage of PD (Hoehn and Yahr [HY] stage 1–2) (267). Submaximal tests may be most appropriate in advanced cases (HY stage 3) or with severe mobility impairment. • Individuals with very advanced PD (HY stage 4) and those unable to per- form a GXT for various reasons, such as inability to stand without falling,
- 352. 326 GUIDELINES FOR EXERCISE TESTING • www.acsm.org severe stooped posture, and deconditioning, may require a radionuclide stress test or stress echocardiography. • For an individual who is deconditioned, demonstrates lower extremity weak- ness, or has a history of falling, care and precautions should be taken, especially at the final stages of the treadmill protocol when fatigue occurs and the indi- vidual’s walking may deteriorate. A gait belt should be worn and an individual should stand by close to the subject to guard during the treadmill test. • Use of symptom-limited exercise testing is strongly recommended. Symptoms include fatigue, shortness of breath, abnormal BP responses, and deteriorations in general appearance. Monitoring physical exertion levels during testing by using a scale such as the Borg perceived exertion scale (26) is recommended. • Individuals with PD may experience orthostatic hypotension because of the severity of PD and medications (234). Antiparkinsonian medication intake should be noted prior to performing the exercise test. Different medications have different adverse effects (see Table 10.9). • Issues to consider when conducting a GXT in individuals with PD include conducting the test during peak medication effect when an individual has op- timal mobility, providing practice walking on a treadmill prior to testing, and using the modified Bruce protocol (see Chapter 5). These factors allow indi- viduals with PD the opportunity to achieve maximal exercise (267). Although the Bruce protocol is the most commonly used protocol for exercise testing on a treadmill (122), it is an aggressive protocol that may be too strenuous for individuals with PD (267). TABLE 10.9. Antiparkinsonian Medications (118,198,234) Drug Adverse Effects Levodopa Nausea, hypotension, and diaphoresis Rasagiline Weight loss, vomiting, anorexia, balance difficulty Oral selegiline Nausea, dizziness, sleep disorder, impaired cognition, orthostatic hypotension Selegiline Dizziness, dyskinesias, hallucinations, headache, dyspepsia Bromocriptine Nausea, hypotension, hallucinations, psychosis, peripheral edema, pulmonary fibrosis, sudden onset of sleep Pergolide Nausea, hypotension, hallucinations, psychosis, peripheral edema, pulmonary fibrosis, sudden onset of sleep, restrictive valvular heart disease Cabergoline Nausea, hypotension, hallucinations, psychosis, peripheral edema, pulmonary fibrosis, sudden onset of sleep, dyskinesia Lisuride Nausea, headaches, tiredness, dizziness, drowsiness, sweating, dry mouth, vomiting, sudden decreases in blood pressure (BP), nightmares, hallucinations, paranoid reactions, states of confusion, weight gain, sleep disorders Pramipexole Nausea, hypotension, hallucinations, psychosis, peripheral edema, sudden onset of sleep Ropinirole Nausea, hypotension, hallucinations, psychosis, peripheral edema, sudden onset of sleep Tolcapone Diarrhea, dyskinesia, liver toxicity (monitoring required) Entacapone Exacerbation of levodopa side effects, diarrhea, discolored urine Amantadine Cognitive dysfunction, hallucinations, peripheral edema, skin rash, anticholinergic effects
- 353. CHAPTER 10 Exercise Prescription for Other Clinical Populations 327 • For individuals with DBS, the signal from the DBS pulse generator inter- feres with the ECG recording. It is possible to perform the test when the DBS is deactivated; however, without the stimulation, the patient will be at a compromised mobile state and will not be able to achieve maximal toler- ance. Potential risks when the DBS is deactivated are physical discomfort, tremor, cramping, and emotional symptoms (e.g., nervousness, anxiety, pain). Clinicians should consult with a neurologist prior to performing the exercise test in these patients. Deactivation of the DBS should be done by a trained cli- nician or neurologist. HR monitoring can be used when DBS is not activated. RPE should be used to monitor during exercise testing. • In addition to the aforementioned concerns, standard procedures, contraindi- cations to exercise testing, recommended monitoring intervals, and standard termination criteria are used to exercise test individuals with PD (see Chapter 5). EXERCISE PRESCRIPTION Individualized programming should be used when prescribing exercise for individuals with PD. The main goal of exercise is to delay disability, prevent secondary complications, and improve quality of life as PD progresses. The FITT principle of Ex Rx should address flexibility, CRF , muscle strength, functional training, and motor control. Because PD is a chronic and progressive disorder, an exercise program should be prescribed early when the individual is first diag- nosed and continued on a regular, long-term basis. The Ex Rx should be reviewed and revised as PD progresses because different physical problems occur at differ- ent stages of the disease. Four key health outcomes of an exercise program designed for individuals with PD are improved (a) gait; (b) transfers; (c) balance; and (d) joint mobility and muscle power to improve functional capacity (126). However, it is important to note the FITT principle of Ex Rx recommendations for individuals with PD are based on a very limited literature. FITT RECOMMENDATIONS FOR INDIVIDUALS WITH PARKINSON DISEASE Aerobic Exercise The FITT principle of Ex Rx for healthy adults generally applies to those with PD (207); however, the limitations imposed by the disease process should be assessed and the Ex Rx should be tailored accordingly. Frequency: 3 d ⭈ wk1 . Intensity: 40%–60% V̇O2 R or HRR or RPE of 11–13 on a scale of 6–20 (27). Time: 30 min of continuous or accumulated exercise.
- 354. 328 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Type: Aerobic activities such as walking, cycling, swimming, or dancing. Dance provides cardiorespiratory and neuromotor exercise. Tango dancing and waltz/foxtrot improves endurance in PD more than tai chi or no exercise (95). However, the selection of the exercise type is dependent on the individual’s clinical presentation of PD severity. A stationary bicycle, recumbent bicycle, or arm ergometer are safer modes for individuals with more advanced PD. Resistance Exercise It is important to note that the FITT principle of Ex Rx recommendations for resistance training in individuals with PD are based on a very limited literature. In general, resistance training increases strength in individuals with PD, but the majority of interventions has been conservative (64). After a resistance training program, strength improvements are similar in individuals with PD compared to neurologically normal controls (217). Therefore, recommendations for resistance exercise in neurologically healthy, older adults may be applied to individuals with PD (217). Frequency: 2–3 d ⭈ wk1 . Intensity: 40%–50% of 1-RM for individuals with PD beginning to im- prove strength; 60%–70% 1-RM for more advanced exercisers. Time: 1 set of 8–12 repetitions; 10–15 repetitions in adults with PD starting an exercise program. Type: Emphasize extensor muscles of the trunk and hip to prevent faulty posture, and on all major muscles of lower extremities to maintain mobility. Flexibility Exercise Frequency: 1–7 d ⭈ wk1 . Intensity: Full extension, flexion, rotation, or stretch to the point of slight discomfort. Time: Perform flexibility exercises for each major muscle–tendon unit. Hold stretches for 10–30 s. Type: Slow static stretches for all major muscle groups should be per- formed. Flexibility and ROM exercises should be emphasized for the upper extremities and trunk as well as all major joints in all severity stages of the disease (192). Spinal mobility and axial rotation exercises are recommended for all severity stages (218). Neck flexibility exercises should be emphasized as neck rigidity is correlated with posture, gait, balance, and functional mobility (84).
- 355. CHAPTER 10 Exercise Prescription for Other Clinical Populations 329 RECOMMENDATIONS FOR NEUROMOTOR EXERCISE FOR INDIVIDUALS WITH PARKINSON DISEASE Balance impairment and falls are major problems in individuals with PD. Balance training is a crucial exercise in all individuals with PD. A recent systemic review reported physical activity and exercise improved postural instability and balance performance in individuals with mild-to-moderate PD (51). Static, dynamic, and balance training during functional activities should be included. Clinicians should take steps to ensure the individual’s safety (e.g., using a gait belt and nearby rails or parallel bars and removing clutter on the floor) when using physical activities that challenge balance. Training programs may include a variety of challenging physical activities (e.g., stepping in all directions, step up and down, reaching forward and sideways, obstacles, turning around, walking with suitable step length, standing up and sitting down) (131,160). Tai chi, tango, and waltz are other forms of exercise to improve balance in PD (58,94). SPECIAL CONSIDERATIONS • Incorporate functional exercises such as the sit-to-stand, step-ups, turning over, and getting out of bed as tolerated to improve neuromotor control, bal- ance, and maintenance of ADL. • Individuals with PD also suffer from autonomic nervous system dysfunc- tion including cardiovascular dysfunction, especially in advanced stages. Orthostatic hypotension, cardiac arrhythmias, sweating disturbances, HR, and BP should be observed carefully during exercise. • Some medications used to treat PD further impair autonomic nervous system functions (93) (see Table 10.9). Levodopa/carbidopa may produce exercise bradycardia and transient peak dose tachycardia and dyskinesia. Caution should be used in testing and training an individual who has had a recent change in medications because the response may be unpredictable (194). Several nonmotor symptoms may burden exercise performance (34,188) (see Box 10.3). • The outcome of exercise training varies significantly among individuals with PD because of the complexity and progressive nature of the disease (193). • Cognitive decline and dementia are common nonmotor symptoms in PD and burden the training and progression (234). • Incorporate and emphasize fall prevention/reduction and education into the exercise program. Instruction on how to break falls should be given and prac- ticed to prevent serious injuries. Most falls in PD occur during multiple tasks or long and complex movement (159,161). • Avoid using dual tasking or multitasking with novice exercisers. Individuals with PD have difficulty in paying full attention to all tasks. One activ-
- 356. 330 GUIDELINES FOR EXERCISE TESTING • www.acsm.org Domains Symptoms Cardiovascular Symptomatic orthostasis; fainting; light-headedness Sleep/fatigue Sleep disorders; excessive daytime sleepiness; insomnia; fatigue; lack of energy; restless legs Mood/cognition Apathy; depression; loss of motivation; loss of interest; anxiety syndromes and panic attacks; cognitive decline Perceptual problems/ hallucinations Hallucinations; delusion; double vision Attention/memory Difficulty in concentration; forgetfulness; memory loss Gastrointestinal Drooling; swallowing; choking; constipation Urinary Incontinence; excessive urination at night; increased frequency of urination Sexual function Altered interest in sex; problems having sex Miscellaneous Pain; loss of smell/taste and appetite/weight; excessive sweating; fluctuating response to medication Nonmotor Symptoms in Parkinson Disease (34,189) BOX 10.3 ity should be completed before commencing of the next activity (127). Multitasking may better prepare an individual with PD for responding to a balance perturbation (231) and can be incorporated into training when they perform well in a single task. • Although no reports exist suggesting resistive exercise may exacerbate symp- toms of PD, considerable attention must be paid to the development and management of fatigue (88). THE BOTTOM LINE • The symptoms of PD include resting tremors, slow movement, rigidity, pos- tural instability, and gait abnormalities. Prior to conducting an exercise test, balance, gait, mobility, ROM, muscular strength, and fall history should be assessed to guide the selection of the testing protocol. Limited research has been conducted regarding the most effective Ex Rx for individuals with PD. In general, the FITT principle of Ex Rx for healthy adults applies to those with PD but may require tailoring because of limitations imposed by the disease process. Balance training should be emphasized in all individuals with PD.
- 357. CHAPTER 10 Exercise Prescription for Other Clinical Populations 331 American Parkinson Disease Association: http://www.apdaparkinson.org/userND/index.asp Davis Phinney Foundation: http://www.davisphinneyfoundation.org/site/c.mvKWLaMOIqG/b.5109589/k.BFE6/Home.htm Michael J. Fox Foundation for Parkinson’s Research: http://www.michaeljfox.org National Institute of Neurological Disorders and Stroke: http://www.ninds.nih.gov/parkinsons_disease/parkinsons_disease.htm National Parkinson Foundation: http://www.parkinson.org/ WE MOVE: http://www.wemove.org/ Online Resources PULMONARY DISEASES Chronic pulmonary diseases are significant causes of morbidity and mortality. Individuals with these diseases are increasingly referred to pulmonary rehabilita- tion of which exercise is the cornerstone. The majority of the research supporting exercise as an adjunct treatment for patients with chronic respiratory disease has been done in individuals with chronic obstructive pulmonary disease (COPD). However, evidence is now accumulating that shows exercise is of benefit to those with other respiratory diseases. A list of respiratory diseases in which exercise is of potential benefit is shown in Box 10.4. ASTHMA Asthma is a chronic inflammatory disorder of the airways that is characterized by episodes of bronchial hyperresponsiveness, airflow obstruction, and recurring wheeze, dyspnea, chest tightness, and coughing that occur particularly at night or early morning and are variable and often reversible (90). Asthma symptoms can be provoked or worsened by exercise, which may contribute to reduced par- ticipation in sports and physical activity and ultimately to deconditioning and lower CRF . With deconditioning, the downward cycle continues with asthma symptoms being triggered by less intense physical activity and subsequent worsening of exercise tolerance. Although pharmacologic treatment should prevent exercise-induced bron- choconstriction and associated symptoms, individuals with moderate-to-severe persistent asthma may be referred to pulmonary rehabilitation programs to improve exercise tolerance. Systematic review (195) of exercise training studies indicates the primary exercise-related benefits are increased CRF , work capacity, and decreased exertional dyspnea with little or no effect on resting pulmonary
- 358. 332 GUIDELINES FOR EXERCISE TESTING • www.acsm.org function. Several recent randomized controlled trials suggest exercise train- ing may also reduce airway inflammation, severity of asthma, number of days with symptoms, number of visits to the emergency department, and symp- toms of anxiety and depression, and also improve health-related quality of life (65,153,154,246,264). EXERCISE TESTING • Assessment of physiologic function should include cardiopulmonary capa- city, pulmonary function (preexercise and postexercise), and oxyhemoglobin saturation via noninvasive methods. • The mode of exercise testing is typically a motor-driven treadmill or an elec- tronically braked cycle leg ergometer. • Age-appropriate (i.e., child, adult, and older adult) standard progressive maximal testing protocols may be used (see Chapter 5). • Administration of an inhaled bronchodilator (i.e., 2 -agonists) (see Appendix A) prior to testing may be indicated to prevent exercise-induced bronchoconstric- tion, thus providing optimal assessment of cardiopulmonary capacity. • Assessment of exercise-induced bronchoconstriction should be assessed via vigorous intensity exercise (i.e., 80% of predicted HRmax or 40%–60% of measured or estimated maximal voluntary ventilation) lasting 4–6 min on a motor-driven treadmill or an electronically braked cycle leg ergometer • Chronic obstructive pulmonary disease (COPD) — a mostly irreversible airflow limitation consisting of • Bronchitis — a chronic productive cough for 3 mo in each of two successive years in a patient in whom other causes of productive chronic cough have been excluded. • Emphysema — the presence of permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis. • Asthma — airway obstruction because of inflammation and bronchospasm that is mostly reversible. • Cystic fibrosis — a genetic disease causing excessive, thick mucus that obstructs the airways (and other ducts) and promotes recurrent and ultimately chronic respiratory infection. • Bronchiectasis — abnormal chronic enlargement of the airways with impaired mucus clearance. • Pulmonary fibrosis — scarring and thickening of the parenchyma of the lungs. • Lung cancer — one of the deadliest cancers with cigarette smoking being a common etiology. Patients with Pulmonary Disease Benefitting from Pulmonary Rehabilitation and Exercise BOX 10.4
- 359. CHAPTER 10 Exercise Prescription for Other Clinical Populations 333 and may be facilitated by inhalation of cold, dry air. The testing should be accompanied by spirometry performed prior to and 5, 10, 15, and 20 min fol- lowing the exercise challenge (13,43). Use of age-predicted HRmax for setting exercise intensity or for estimation of V̇O2peak may not be appropriate because of possible ventilatory limitation to exercise. • Evidence of oxyhemoglobin desaturation ⱕ80% should be used as test termi- nation criteria in addition to standard criteria (13). • Measurement of exertional dyspnea may also be useful by adapting the Borg CR10 Scale to determine dyspnea versus its intended purpose (see Figure 9.1) (171). Patients and clients should be instructed to relate the wording on the scale to their level of breathlessness. Patients and clients should be informed that 0 or nothing at all corresponds to no discomfort with your breathing, whereas 10 or maximal corresponds to the most severe discomfort with your breathing that you have ever experienced or could imagine experiencing. • 6-min walk testing may be used in individuals with moderate-to-severe per- sistent asthma when other testing equipment is not available (16). EXERCISE PRESCRIPTION The following Ex Rx for aerobic exercise is suitable for all levels of disease sever- ity (mild-to-severe persistent) (195). FITT RECOMMENDATIONS FOR INDIVIDUALS WITH ASTHMA Aerobic Exercise Frequency: At least 2–3 d ⭈ wk1 (65,153,154,195). Intensity: Approximately at the ventilatory anaerobic threshold or at least 60% V̇O2peak determined from progressive exercise testing with measurement of expired gases (153,195) or 80% of maximal walking speed determined from the 6-min walk test (246). Time: At least 20–30 min ⭈ d1 (65,153,195,246). Type: Aerobic activities using large muscle groups such as walking, running, or cycling. Swimming (preferably in a nonchlorinated pool) is less asthmogenic, and therefore a better tolerated form of exercise. Progression: After the first month, if the Ex Rx is well tolerated, greater health/fitness benefits may be gained by increasing the intensity to approximately 70% V̇O2peak , the time of each exercise session to 40 min ⭈ d1 , and frequency to 5 d ⭈ wk1 . Resistance Exercise The Ex Rx for resistance training and flexibility should follow the same FITT principles of Ex Rx for healthy adults (see Chapter 7).
- 360. 334 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SPECIAL CONSIDERATIONS • Individuals experiencing exacerbations of their asthma should not exercise until symptoms and airway function have improved. • Use of short-acting bronchodilators may be necessary before or after exercise to prevent or treat exercise-induced bronchoconstriction (see Appendix A). • Individuals on prolonged treatment with oral corticosteroids may experience peripheral muscle wasting and may benefit from strength training as pre- sented in Chapter 7. • Exercise in cold environments or those with airborne allergens or pollutants should be limited to avoid triggering bronchoconstriction in susceptible individuals. Exercise-induced bronchoconstriction can also be triggered by prolonged exercise durations or high intensity exercise sessions. • There is insufficient evidence supporting individuals with asthma have clini- cal benefit from inspiratory muscle training in individuals with asthma (196). CHRONIC OBSTRUCTIVE PULMONARY DISEASE COPD is defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) program as a preventable and treatable disease with some significant extrapulmonary effects that are characterized by an airflow limitation that is not fully reversible (see Box 10.4) (91). COPD consists of chronic bronchitis and/ or emphysema, and patients may be staged into one of four disease severities based on the results of pulmonary function tests (see Table 10.10). Dyspnea or shortness of breath with exertion is a cardinal symptom of COPD resulting in physical activity limitations. Consequently, deconditioning occurs causing COPD patients to experience dyspnea at even lower levels of physical exertion further limiting their activity. This adverse downward spiral can lead to eventual functional impairment and disability. Exercise is an effective and potent inter- vention that lessens the development of functional impairment and disability in all patients with COPD regardless of disease severity (171,201). The beneficial effects of exercise occur mainly through adaptations in the musculoskeletal and cardiovascular systems that in turn reduce stress on the pulmonary system during exercise (232). TABLE 10.10. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Classification of Disease Severity in Patients with Chronic Obstructive Pulmonary Disease Based on the FEV1.0 Obtained from Pulmonary Function Tests (91) Disease Severity Postbronchodilator FEV1 /FVC Postbronchodilator FEV1 % Mild 0.70 FEV1.0 80% of predicted Moderate 0.70 50% FEV1.0 80% of predicted Severe 0.70 30% FEV1.0 50% of predicted Very severe 0.70 FEV1.0 30% of predicted or FEV1.0 50% of predicted with respiratory failure FEV1.0 , forced expiratory volume in 1 s; FVC, forced vital capacity.
- 361. CHAPTER 10 Exercise Prescription for Other Clinical Populations 335 EXERCISE TESTING • Assessment of physiologic function should include CRF , pulmonary function, and determination of arterial blood gases or arterial oxyhemoglobin satura- tion (SaO2 ) via direct or indirect methods. • Perceptions of dyspnea should be measured during exercise testing using the Borg CR10 Scale (see Figure 9.1). • Modifications of traditional protocols (e.g., smaller increments, slower progres- sion) may be warranted depending on functional limitations and the early onset of dyspnea. Additionally, it is now recommended the duration of the GXT be between 5 and 9 min in patients with severe and very severe disease (22). • The measurement of flow volume loops using commercially available in- struments may help identify individuals with dynamic hyperinflation and increased dyspnea because of expiratory airflow limitations. Use of broncho- dilator therapy may be beneficial for such individuals (172). • Submaximal exercise testing may be used depending on the reason for the test and the clinical status of the patient. However, it should be noted individu- als with pulmonary disease may have ventilatory limitations to exercise; thus, prediction of V̇O2peak based on age-predicted HRmax may not be appropriate. In recent years, the 6-min walk test has become popular for assessing functional exercise capacity in individuals with more severe pulmonary disease and in set- tings that lack exercise testing equipment (16). • In addition to standard termination criteria, exercise testing may be terminated because of severe arterial oxyhemoglobin desaturation (i.e., SaO2 ⱕ80%) (13). • The exercise testing mode is typically walking or stationary cycling. Walking protocols may be more suitable for individuals with severe disease who may lack the muscle strength to overcome the increasing resistance of cycle leg ergometers. Furthermore, if arm ergometry is used, upper extremity aerobic exercise may re- sult in increased dyspnea that may limit the intensity and duration of the activity. EXERCISE PRESCRIPTION Because individuals with COPD are typically older adults, the FITT principle of Ex Rx presented in Chapter 8 for older adults generally applies. For detailed guidelines for the FITT principle of Ex Rx for individuals with COPD, see the following resources (171,201,232). FITT RECOMMENDATIONS FOR INDIVIDUALS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE Aerobic Exercise Frequency: At least 3–5 d ⭈ wk1 . Intensity: For patients with COPD, vigorous (60%–80% of peak work rates) and light (30%–40% of peak work rates) intensities have been
- 362. 336 GUIDELINES FOR EXERCISE TESTING • www.acsm.org SPECIAL CONSIDERATIONS • Pulmonary diseases and their treatments not only affect the lungs but skeletal muscles as well (232). Resistance training of skeletal muscle should be an integral part of Ex Rx for individuals with COPD. The Ex Rx for resistance training with pulmonary patients should follow the same FITT principle of Ex Rx for healthy adults and older adults (see Chapters 7 and 8, respectively). • Because individuals with COPD may experience greater dyspnea while per- forming ADL involving the upper extremities, it may be beneficial for these individuals to focus on the muscles of the shoulder girdle when performing resistance exercises. • Inspiratory muscle weakness is a contributor to exercise intolerance and dyspnea in those with COPD. In patients receiving optimal medical therapy who still present with inspiratory muscle weakness and breathlessness, inspi- ratory muscle training is recommended. Training of the inspiratory muscles recommended (171,201). Light intensity training results in improvements in symptoms, health-related quality of life, and performance of ADL, whereas vigorous intensity training has been shown to result in greater physiologic improvements (e.g., reduced minute ventilation and HR at a given workload). Because of these greater physiologic improvements, high intensity training can be encouraged if tolerated. However, it should be recognized that some patients may not be able to exercise at these in- tensities, and light intensity exercise is recommended for such patients. Intensity may be based on a dyspnea rating of between 4 and 6 on the Borg CR10 Scale (see Figure 9.1) (171). Time: Individuals with moderate or severe COPD may be able to exercise only at a specified intensity for a few minutes at the start of the training program. Intermittent exercise may also be used for the initial training sessions until the individual tolerates exercise at sustained higher intensi- ties and durations of activity. Shorter periods of vigorous intensity exercise separated by periods of rest (i.e., interval training) have been used with those with COPD and shown to result in lower symptom scores despite high training work rates (261). Type: Walking and/or cycling. Resistance and Flexibility Exercise Resistance and flexibility training should be encouraged for individuals with COPD. The Ex Rx for resistance and flexibility training with pulmo- nary patients should follow the same FITT principle of Ex Rx for healthy adults and/or older adults (see Chapters 7 and 8).
- 363. CHAPTER 10 Exercise Prescription for Other Clinical Populations 337 increases respiratory muscle strength and endurance and may lead to im- provements in exercise tolerance (171,201). • The guidelines for inspiratory muscle training are the following: • Frequency: A minimum of 4–5 d ⭈ wk1 . • Intensity: 30% of maximal inspiratory pressure measured at functional residual capacity. • Time: 30 min ⭈ d1 or two 15 min sessions ⭈ d1 . • Type: Three types of inspiratory muscle training have been used in pa- tients with COPD. These are inspiratory resistive training, threshold load- ing, and normocapnic hyperpnea. There are no data to suggest that one method is superior to the other (171). • Regardless of the prescribed exercise intensity, the health/fitness, clinical ex- ercise, or health care professional should closely monitor initial exercise ses- sions and adjust intensity and duration according to individual responses and tolerance. In many cases, the presence of symptoms, particularly dyspnea/ breathlessness, supersedes objective methods of Ex Rx . • The traditional method for monitoring the exercise intensity is HR as dis- cussed in Chapter 7. As previously mentioned, an alternative approach to HR is using the dyspnea rating obtained from a GXT test as a “target” intensity for exercise training (111). Most patients with COPD accurately and reliably produce a dyspnea rating obtained from an incremental exercise test as a target to regulate/monitor exercise intensity. A dyspnea rating between 4 and 6 on a scale of 0–10 is the recommended exercise intensity (see Figure 9.1) (171). • Unlike most healthy individuals and individuals with CVD, patients with moderate-to-severe COPD may exhibit oxyhemoglobin desaturation with exercise. Therefore, a measure of blood oxygenation, either the partial pres- sure of arterial oxygen (Pa O2 ) or %SaO2 , should be made during the initial GXT. In addition, oximetry is recommended for the initial exercise training sessions to evaluate possible exercise-induced oxyhemoglobin desaturation and to identify the workload at which desaturation occurred. • Based on the recommendations of the Nocturnal Oxygen Therapy Trial (40), supplemental oxygen (O2 ) is indicated for patients with a Pa O2 55 mm Hg or a %SaO2 88% while breathing room air. These same guidelines apply when considering supplemental oxygen during exercise. Additionally, there is evidence to suggest the administration of supplemental O2 to those who do not experience exercise-induced hypoxemia may lead to greater gains in exercise endurance (201). • In selected patients with severe COPD, using noninvasive positive pres- sure ventilation as an adjunct to exercise training produces modest gains in exercise performance. Because of the difficulty administering such an intervention, it is only recommended in those patients with advanced disease (171,201). • Individuals suffering from acute exacerbations of their pulmonary disease should limit exercise until symptoms have subsided.
- 364. 338 GUIDELINES FOR EXERCISE TESTING • www.acsm.org THE BOTTOM LINE • Exercise training is beneficial for improving CRF and exercise tolerance in individuals with asthma, and growing evidence suggests training may reduce inflammation and disease severity and improve health-related quality of life. COPD is a treatable disease characterized by nonreversible airflow limitation. In addition to its damage to the lungs, the disease has significant extrapulmo- nary effects. These extrapulmonary effects should be considered when using exercise as a treatment for COPD. American Lung Association: http://www.lungusa.org/lung-disease/copd/ Expert Panel Report 3 (EPR3) American Thoracic Society (41): http://www.thoracic.org/clinical/copd-guidelines/index.php EPR3: Guidelines for the Diagnosis and Management of Asthma (62): http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm Global Initiative for Asthma: http://www.ginasthma.org Global Initiative for Chronic Obstructive Lung Disease: http://www.goldcopd.com/guidelinesresources.asp?l1=2l2=0 Online Resources SPINAL CORD INJURY Spinal cord injury (SCI) results in a complete or incomplete loss of somatic, sensory, and autonomic functions below the lesion level. Lesions in the cervi- cal (C) region typically result in tetraplegia, whereas lesions in the thoracic (T), lumbar (L), and sacral (S) regions lead to paraplegia. Approximately 50% of those with SCI have tetraplegia, and 80% are men (235). SCI of traumatic origin often occurs at an early age. Individuals with SCI have a high risk for the development of secondary complications (e.g., shoulder pain, urinary tract infections, skin pressure ulcers, osteopenia, chronic pain, problematic spastic- ity, depression, CVD, obesity, Type 2 DM). Proper exercise and physical activity reduce the prevalence of secondary complications and improve the quality of life for individuals with SCI. The SCI level has a direct impact on physical function and metabolic and cardiorespiratory responses to exercise. It is crucial to take into account the SCI lesion level when exercise testing and prescribing exercise for those with SCI. Those with complete SCI lesions from: • L2–S2 lack voluntary control of the bladder, bowels, and sexual function; however, the upper extremities and trunk usually have normal function.
- 365. CHAPTER 10 Exercise Prescription for Other Clinical Populations 339 • T6–L2 have respiratory and motor control that depends on the functional capacity of the abdominal muscles (i.e., minimal control at T6 to maximal control at L2). • T1–T6 can experience autonomic dysreflexia (i.e., an uncoordinated, spinally mediated reflex response called the mass reflex), poor thermoregulation, and orthostatic hypotension. In instances in which there is no sympathetic inner- vation to the heart, HRpeak is limited to ⬃115–130 beats ⭈ min1 . Breathing capacity is further diminished by intercostal muscle paralysis; however, arm function is normal. • C5–C8 are tetraplegic. Those with C8 lesions have voluntary control of the shoulder, elbow, and wrist but decreased hand function; whereas those with C5 lesions rely on the biceps brachii and shoulder muscles for self-care and mobility. • C4 require artificial support for breathing. EXERCISE TESTING When exercise testing individuals with SCI, consider the following issues. • Initially, a functional assessment should be taken including trunk ROM, wheelchair mobility, transfer ability, and upper and lower extremity involve- ment. This assessment will facilitate the choice of exercise testing equipment, protocols, and adaptations. • Consider the purposes of the exercise test, the level of SCI, and the physical fitness level of the participant to optimize equipment and protocol selection. • Voluntary arm ergometry is the easiest to perform and is norm referenced for the assessment of CRF (96). This form of exercise testing, however, is not wheelchair propulsion sport specific, and the equipment may not be accurate in the lower work rate ranges needed for quadriplegics (i.e., 0–25 W). • If available, a stationary wheelchair roller system and motor-driven treadmill should be used with the participant’s properly adjusted wheelchair. Motor- driven treadmill protocols allow for realistic simulation of external conditions such as slope and speed alterations (257). • Incremental exercise tests for the assessment of CRF in the laboratory should begin at 0 W with incremental increases of 5–10 W per stage among tetraplegics. Depending on function and fitness, individuals with paraplegia can begin at 20–40 W with incremental increases of 10–25 W per stage. • For sport-specific indoor CRF assessments in the field, an incremental test adapted from the Léger and Boucher shuttle test around a predetermined rect- angular court is recommended. Floor surface characteristics and wheelchair user interface should be standardized (138,257). • After maximal effort exercise in individuals with tetraplegia, it may be neces- sary to treat postexercise hypotension and exhaustion with rest, recumbency, leg elevation, and fluid ingestion. • There are no special considerations for the assessment of muscular strength regarding the exercise testing mode beyond those for the general population
- 366. 340 GUIDELINES FOR EXERCISE TESTING • www.acsm.org with the exception of the lesion level, which will determine residual motor function, need for stabilization, and accessibility of testing equipment. • Individuals with SCI requiring a wheelchair for mobility may develop joint contractures because of muscle spasticity and their position in the wheelchair (i.e., tight hip flexors, hip adductors, and knee flexors) and excessive wheelchair pushing and manual transfers (i.e., anterior chest and shoulder). Therefore, intensive sport-specific training must be comple- mented with an upper extremity stretching (e.g., the prime movers) and strengthening (e.g., the antagonists) program to promote muscular balance around the joints. EXERCISE PRESCRIPTION/SPECIAL CONSIDERATIONS The FITT principle of Ex Rx recommendations for the general population should be applied (see Chapter 7) (88,102). For this reason and because of the impact of SCI on neuromotor, cardiorespiratory, and metabolic function, the following FITT principle of Ex Rx recommendations and special considerations are com- bined in this section: • Participants should empty their bowels and bladder or urinary bag before exercising because autonomic dysreflexia can be triggered by a full bladder or bowel distension. • Skin pressure sores should be avoided at all times and potential risk areas should be checked on a regular basis. • Decreased cardiovascular performance may be found in individuals with complete SCIs above T6, particularly among those with complete tetraple- gia who have no cardiac sympathetic innervation with HRpeak limited to ⬃115–130 beats ⭈ min1 . Individuals with high spinal lesions may reach their peak HR, cardiac output (Q̇), and V̇O2 at lower exercise levels than those with paraplegia with lesion levels below T5 to T6 (110). • During exercise, autonomic dysreflexia results in an increased release of catecholamines that increases HR, V̇O2 , BP, and exercise capacity (220). BP may be elevated to excessively high levels (i.e., SBP 250–300 mm Hg and/or DBP 200–220 mm Hg). In these situations, immediate emergency responses is needed (i.e., stopping exercise, sitting upright to decrease BP, and identi- fying and removing the irritating stimulus such as a catheter, leg bag, tight clothing, or braces). If the symptoms (i.e., headache, piloerection, flushing, gooseflesh, shivering, sweating above the lesion level, nasal congestion, and bradycardia) persist, medical attention should be sought. In competition, athletes with a resting SBP 180 mm Hg should not be allowed to start the event. • Novice unfit but healthy participants with SCI will probably experience muscu- lar fatigue before achieving substantial central cardiovascular stimulus. Initially, the exercise sessions should consist of short bouts of 5–10 min of moderate in- tensity (i.e., 40%–60% V̇O2 R) alternated with active recovery periods of 5 min.
- 367. CHAPTER 10 Exercise Prescription for Other Clinical Populations 341 As a starting point and on the basis of proven efficacy and specificity to daily activity patterns, Rimaud et al. (203) has recommended interval wheelchair ergometry training at 70% HRpeak for 30 min ⭈ session1 , 3 sessions ⭈ wk1 . • Individuals with tetraplegia who have a very small active musculature will also experience muscular fatigue before exhausting central cardiorespiratory capacity. Aerobic exercise programs should start with 5–10 min bouts of mod- erate intensity (i.e., 40%–60% V̇O2 R), alternated with 5 min active recovery periods. As exercise tolerance improves, training can progress to 10–20 min bouts of vigorous intensity (i.e., 60 V̇O2 R) alternated with 5 min active recovery periods. • Individuals with higher SCI levels, especially those with tetraplegia, may benefit from use of lower body positive pressure by applying compres- sive stockings, an elastic abdominal binder, or electrical stimulation to leg muscles. Beneficial hemodynamic effects may include maintenance of BP, lower HR, and higher stroke volume during arm work to compensate for blood pooling below the lesion. Electrical stimulation of paralyzed lower limb muscles can increase venous return and Q̇. These responses usually occur only in individuals with spastic paralysis above T12 who have sub- stantial sensory loss and respond to the stimulation with sustainable static or dynamic contractions. • Muscular strength training sessions from a seated position in the wheelchair should be complemented with nonwheelchair exercise bouts to involve all trunk stabilizing muscles. However, transfers (e.g., from wheelchair to the exercise apparatus) should be limited because they result in a significant hemodynamic load and increase the glenohumeral contact forces, and the risk of repetitive strain injuries such as shoulder impingement syndrome and rotator cuff strain/tear, especially in individuals with tetraplegia (256). Special attention should be given to shoulder muscle imbalance and the prevention of repetitive strain injuries. The prime movers of wheelchair propulsion should be lengthened (i.e., muscles of the anterior shoulder and chest) and antago- nists should be strengthened (i.e., muscles of the posterior shoulder, scapula, and upper back [74]). • Tenodesis (i.e., active wrist extensor driven finger flexion) allows functional grasp in individuals with tetraplegia who do not have use of the hand mus- cles. To retain the tenodesis effect, these individuals should never stretch the finger flexor muscles (i.e., maximal and simultaneous extension of wrist and fingers). • Individuals with SCI tend to endure higher core temperatures during endur- ance exercise than their able-bodied counterparts. Despite this enhanced thermoregulatory drive, they generally have lower sweat rates. The following factors reduce heat tolerance and should be avoided: lack of acclimatization, dehydration, glycogen depletion, sleep loss, alcohol, and infectious disease. During training and competition, the use of light clothing, ice vests, protec- tive sunscreen cream, and mist spray are recommended (7,9).
- 368. 342 GUIDELINES FOR EXERCISE TESTING • www.acsm.org THE BOTTOM LINE • Proper exercise and physical activity reduce the prevalence of secondary complications associated with SCI and improve quality of life. The level of the SCI lesion must be taken into account for exercise testing and the FITT principle of Ex Rx . Individuals with SCI have compromised ther- moregulatory responses to exercise so caution must be taken, especially during endurance exercise. National Spinal Cord Injury Association: http://www.spinalcord.org Online Resources INDIVIDUALS WITH MULTIPLE CHRONIC DISEASES AND HEALTH CONDITIONS The aging and increasing prevalence of overweight and obesity in the population make it increasingly likely health/fitness, clinical exercise, and health care pro- fessionals will be designing Ex Rx for clients and patients with multiple chronic diseases and health conditions. The focus of the Guidelines has traditionally been on Ex Rx for healthy and special populations with one chronic disease or health condition. This final section of this chapter presents guidelines for prescribing exercise for individuals with multiple comorbidities. PREPARTICIPATION HEALTH SCREENING Exercise training is generally safe for the majority of individuals with multiple diseases and chronic conditions wishing to participate in a light-to-moderate intensity exercise programs (see Chapters 1 and 2). For individuals with mul- tiple comorbidities that fall into the high risk category as designated in Table 2.3, referral to a health care provider is recommended prior to participating in an exercise program (see Figure 2.4). Individuals with multiple CVD risk factors (see Table 2.2 and Figure 2.3) that do not fall into the high risk category should be encouraged to consult with their physician prior to initiating a vigorous intensity exercise program as part of good medical care and should progress gradually with their exercise program of any exercise intensity. EXERCISE TESTING Exercise stress testing is recommended only for the highest risk individuals including those with diagnosed CVD, symptoms suggestive of new or changing CVD, DM and additional CVD risk factors (see Table 2.2), end-stage renal disease,
- 369. CHAPTER 10 Exercise Prescription for Other Clinical Populations 343 and specified lung disease (see Table 2.3). Nonetheless, the information gathered from an exercise test may be useful in establishing a safe and effective Ex Rx for low- to moderate-risk individuals. Recommending an exercise test for low- to moderate-risk individuals should not be viewed as inappropriate if the purpose of the test is to design an effective Ex Rx . The Guidelines also recommends health/ fitness, clinical exercise, and health care professionals consult with their medical colleagues when there are questions about clients and patients with known dis- ease and health conditions that may limit their participation in exercise programs. EXERCISE PRESCRIPTION In general, the FITT principle of Ex Rx for individuals with multiple diseases and health conditions will follow the recommendations for healthy adults (see Chapter 7). Table 10.11 summarizes the aerobic exercise FIT (i.e., frequency, intensity, and time) principle of Ex Rx recommendations for special populations with one chronic disease, health condition, or CVD risk factor as discussed in this chapter. However, the challenge is determining the specifics of the FITT principle of Ex Rx that should be recommended for the client or patient that presents with multiple chronic diseases, health conditions, and/or CVD risk factors, especially when there is variability in the exercise dose that can most favorably impact a par- ticular disease, health condition, or CVD risk factor (e.g., BP requires lower doses of exercise to improve than does HDL, abdominal adiposity, or bone density). SPECIAL CONSIDERATIONS • A large body of scientific evidence supports the role of physical activity in delaying premature mortality and reducing the risks of many chronic diseases and health conditions. There is also clear evidence for a dose-response rela- tionship between physical activity and health. Thus, any amount of physical activity should be encouraged. TABLE 10.11. Summary of the Aerobic Exercise Frequency, Intensity, and Type Recommendations for a Single Disease, Health Condition, or Cardiovascular Disease (CVD) Risk Factora Condition Frequency Intensity Time Arthritis 3–5 d ⭈ wk1 40%–59% HRR or V̇O2 R 20–30 min ⭈ d1 Cardiac disease 4–7 d ⭈ wk1 40%–80% HRR or V̇O2 R 20–60 min ⭈ d1 Dyslipidemia 5 d ⭈ wk1 40%–75% HRR or V̇O2 R 30–60 min ⭈ d1 Hypertension 5 d ⭈ wk1 40%–59% HRR or V̇O2 R 30–60 min ⭈ d1 Obesity 5 d ⭈ wk1 40%–59% HRR or V̇O2 R 30–60 min ⭈ d1 Osteoporosis 3–5 d ⭈ wk1 40%–59% HRR or V̇O2 R 30–60 min ⭈ d1 Type 2 diabetes 3–7 d ⭈ wk1 50%–80% HRR or V̇O2 R 20–60 min ⭈ d1 a Moderate intensity resistance exercise is generally recommended 2–3 d ⭈ wk1 in addition to the amount of aerobic exercise specified previously for each chronic disease, health condition, and CVD risk factor (see Chapter 7). HRR, heart rate reserve; V̇O2 R, maximal oxygen consumption reserve.
- 370. 344 GUIDELINES FOR EXERCISE TESTING • www.acsm.org • Begin with the FITT principle of Ex Rx for the single disease and health condition that confers the greatest risk and/or is the most limiting regarding ADL, quality of life, and/or starting or maintaining an exercise program. Also consider client and patient preference and goals. • Alternatively, begin with the FITT that is the most conservative FITT pre- scribed for the multiple diseases, health conditions, and/or CVD risk factors the client and patient presents with as listed in Table 10.11. • Know the magnitude and time course of response of the various health outcome(s) that can be expected as a result of the FITT principle of Ex Rx that is prescribed in order to progress the client and patient safely and appropriately. • Frequently monitor signs and symptoms to ensure safety and proper adapta- tion and progression. REFERENCES 1. Ahlborg L, Andersson C, Julin P . Whole-body vibration training compared with resistance training: effect on spasticity, muscle strength and motor performance in adults with cerebral palsy. J Rehabil Med. 2006;38(5):302–8. 2. Albright A, Franz M, Hornsby G, et al. American College of Sports Medicine position stand. Exercise and type 2 diabetes. Med Sci Sports Exerc. 2000;32(7):1345–60. 3. Albright AL. Diabetes. In: Ehrman JK, editor. Clinical Exercise Physiology. Champaign: Human Kinetics; 2003. p. 191–210. 4. Allen NA, Fain JA, Braun B, Chipkin SR. Continuous glucose monitoring counseling improves physical activity behaviors of individuals with type 2 diabetes: a randomized clinical trial. Diabetes Res Clin Pract. 2008;80(3):371–9. 5. American Cancer Society. Cancer Facts and Figures 2010 [Internet]. Atlanta (GA): American Cancer Society; [cited 2011 Feb 15]. Available from: http://www.cancer.org/acs/groups/content/@nho/ documents/document/acspc-024113.pdf 6. American College of Sports Medicine, American Diabetes Association. Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Exercise and type 2 diabetes. Med Sci Sports Exerc. 2010;42(12):2282–303. 7. American College of Sports Medicine, Armstrong LE, Casa DJ, et al. American College of Sports Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3):556–72. 8. American College of Sports Medicine, Chodzko-Zajko WJ, Proctor DN, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510–30. 9. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377–90. 10. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010; 33 Suppl 1:S62–9. 11. American Diabetes Association. Standards of medical care in diabetes—2007. Diabetes Care. 2007; 30 Suppl 1:S4–41. 12. American Diabetes Association. Standards of medical care in diabetes—2012. Diabetes Care. 2012; 35 Suppl 1:S11–63. 13. American Thoracic Society, American College of Chest Physicians. ATS/ACCP Statement on cardio- pulmonary exercise testing. Am J Respir Crit Care Med. 2003;167(2):211–77. 14. Anandacoomarasamy A, Caterson I, Sambrook P, Fransen M, March L. The impact of obesity on the musculoskeletal system. Int J Obes (Lond). 2008;32(2):211–22. 15. Anuurad E, Semrad A, Berglund L. Human immunodeficiency virus and highly active antiretroviral therapy-associated metabolic disorders and risk factors for cardiovascular disease. Metab Syndr Relat Disord. 2009;7(5):401–10. 16. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002;166(1):111–7. 17. Auxter D, Pyfer J, Huettig C. Principles and Methods of Adapted Physical Education and Recreation. 9th ed. Boston (MA): McGraw-Hill; 2001. 718 p.
- 371. CHAPTER 10 Exercise Prescription for Other Clinical Populations 345 18. Baim S, Leonard MB, Bianchi ML, et al. Official positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD Pediatric Position Development Conference. J Clin Densitom. 2008;11(1):6–21. 19. Bartlett DJ, Hanna SE, Avery L, Stevenson RD, Galuppi B. Correlates of decline in gross motor capacity in adolescents with cerebral palsy in Gross Motor Function Classification System levels III to V: an exploratory study. Dev Med Child Neurol. 2010;52(7):e155–60. 20. Baynard T, Pitetti KH, Guerra M, Unnithan VB, Fernhall B. Age-related changes in aerobic capacity in individuals with mental retardation: a 20-yr review. Med Sci Sports Exerc. 2008;40(11):1984–9. 21. Beck BR, Snow CM. Bone health across the lifespan—exercising our options. Exerc Sport Sci Rev. 2003;31(3):117–22. 22. Benzo RP, Paramesh S, Patel SA, Slivka WA, Sciurba FC. Optimal protocol selection for cardio- pulmonary exercise testing in severe COPD. Chest. 2007;132(5):1500–5. 23. Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can. 1989;41(6):304–11. 24. Bergen JL, Toole T, Elliott RG,3rd, Wallace B, Robinson K, Maitland CG. Aerobic exercise intervention improves aerobic capacity and movement initiation in Parkinson’s disease patients. NeuroRehabilitation. 2002;17(2):161–8. 25. Bhole R, Flynn JC, Marbury TC. Quadriceps tendon ruptures in uremia. Clin Orthop Relat Res. 1985;(195):200–6. 26. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–81. 27. Borg GA. Scaling pain and related subjective somatic symptoms. In: Borg GA, editor. Borg’s Perceived Exertion and Pain Scales. Champaign: Human Kinetics; 1998. p. 63–7. 28. Burckhardt CS, Clark SR, Bennett RM. The fibromyalgia impact questionnaire: development and validation. J Rheumatol. 1991;18(5):728–33. 29. Busch AJ, Barber KA, Overend TJ, Peloso PM, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev. 2007;(4):CD003786. 30. Butler JM, Scianni A, Ada L. Effect of cardiorespiratory training on aerobic fitness and carryover to activity in children with cerebral palsy: a systematic review. Int J Rehabil Res. 2010;33(2):97–103. 31. Castellani JW, Young AJ, Ducharme MB, et al. American College of Sports Medicine position stand: prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006;38(11):2012–29. 32. Centers for Disease Control and Prevention. Prevalence of doctor-diagnosed arthritis and arthritis- attributable activity limitation—United States, 2007–2009. MMWR Morb Mortal Wkly Rep. 2010; 59(39):1261–5. 33. Cerebral Palsy International Sports Recreation Association. Classification and Sports Rules Manual. 9th ed. Nottingham, England: CPISRA; 2006. 34. Chaudhuri KR, Martinez-Martin P , Brown RG, et al. The metric properties of a novel non-motor symptoms scale for Parkinson’s disease: results from an international pilot study. Mov Disord. 2007;22(13):1901–11. 35. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension. 2003;42(6): 1206–52. 36. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults—The Evidence Report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S–209S. 37. Clyne N, Ekholm J, Jogestrand T, Lins LE, Pehrsson SK. Effects of exercise training in predialytic uremic patients. Nephron. 1991;59(1):84–9. 38. Clyne N, Jogestrand T, Lins LE, Pehrsson SK. Factors influencing physical working capacity in renal transplant patients. Scand J Urol Nephrol. 1989;23(2):145–50. 39. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care. 2010;33(12):2692–6. 40. Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med. 1980;93(3):391–8. 41. COPD Guidelines (2004) [Internet]. New York (NY): American Thoracic Society; [cited 2011 Mar 11]. Available from: http://www.thoracic.org/clinical/copd-guidelines/index.php 42. Cowley PM, Ploutz-Snyder LL, Baynard T, et al. Physical fitness predicts functional tasks in indi- viduals with Down syndrome. Med Sci Sports Exerc. 2010;42(2):388–93. 43. Crapo RO, Casaburi R, Coates AL, et al. Guidelines for methacholine and exercise challenge testing-1999. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med. 2000;161(1):309–29. 44. Dadabhoy D, Clauw DJ. Musculoskeletal signs and symptoms. E. The Fibromyalgia Syndrome. In: Klippel JH, editor. Primer on the Rheumatic Diseases. 13th ed. New York: Springer; 2008. p. 87–93.
- 372. 346 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 45. Damiano DL. Activity, activity, activity: rethinking our physical therapy approach to cerebral palsy. Phys Ther. 2006;86(11):1534–40. 46. Darrah J, Wessel J, Nearingburg P , O’Connor M. Evaluation of a community fitness program for adolescents with cerebral palsy. Ped Phys Ther. 1999;11(1):18–23. 47. de Haan A, de Ruiter CJ, van Der Woude LH, Jongen PJH. Contractile properties and fatigue of quadriceps muscles in multiple sclerosis. Muscle Nerve. 2000;23(10):1534–41. 48. de Jong Z, Munneke M, Zwinderman AH, et al. Is a long-term high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Results of a randomized controlled trial. Arthritis Rheum. 2003;48(9):2415–24. 49. Dela F , Larsen JJ, Mikines KJ, Ploug T, Petersen LN, Galbo H. Insulin-stimulated muscle glucose clearance in patients with NIDDM. Effects of one-legged physical training. Diabetes. 1995;44(9): 1010–20. 50. D’hooge R, Hellinckx T, Van Laethem C, et al. Influence of combined aerobic and resistance training on metabolic control, cardiovascular fitness and quality of life in adolescents with type 1 diabetes: a randomized controlled trial. Clin Rehabil. 2011;25(4):349–59. 51. Dibble LE, Addison O, Papa E. The effects of exercise on balance in persons with Parkinson’s disease: a systematic review across the disability spectrum. J Neurol Phys Ther. 2009;33(1):14–26. 52. Diesel W, Noakes TD, Swanepoel C, Lambert M. Isokinetic muscle strength predicts maximum exercise tolerance in renal patients on chronic hemodialysis. Am J Kidney Dis. 1990;16(2):109–14. 53. Dodd KJ, Taylor NF , Damiano DL. A systematic review of the effectiveness of strength-training programs for people with cerebral palsy. Arch Phys Med Rehabil. 2002;83(8):1157–64. 54. Donnelly JE, Blair SN, Jakicic JM, et al. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41(2):459–71. 55. Donnelly JE, Jakicic JM, Pronk NP , et al. Is resistance exercise effective for weight management? Evid Based Prev Med. 2004;1(1):21–9. 56. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323–53. 57. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol. 1990;45(6):M192–7. 58. Earhart GM. Dance as therapy for individuals with Parkinson disease. Eur J Phys Rehabil Med. 2009; 45(2):231–8. 59. Ervin RB. Prevalence of metabolic syndrome among adults 20 years of age and over, by sex, age, race and ethnicity, and body mass index: United States, 2003–2006. Natl Health Stat Report. 2009;13(13):1–7. 60. Ettinger WH,Jr, Burns R, Messier SP, et al. A randomized trial comparing aerobic exercise and resis- tance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). JAMA. 1997;277(1):25–31. 61. Evans RK, Bond DS, Wolfe LG, et al. Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery. Surg Obes Relat Dis. 2007; 3(5):526–30. 62. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma [Internet]. Bethesda (MD): National Institutes of Health; National Heart, Lung, and Blood Institute; [cited 2011 Mar 11]. Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm 63. Falvo MJ, Earhart GM. Six-minute walk distance in persons with Parkinson disease: a hierarchical regression model. Arch Phys Med Rehabil. 2009;90(6):1004–8. 64. Falvo MJ, Schilling BK, Earhart GM. Parkinson’s disease and resistive exercise: rationale, review, and recommendations. Mov Disord. 2008;23(1):1–11. 65. Fanelli A, Cabral AL, Neder JA, Martins MA, Carvalho CR. Exercise training on disease control and quality of life in asthmatic children. Med Sci Sports Exerc. 2007;39(9):1474–80. 66. Fernhall B. Mental retardation. In: American College of Sports Medicine, editor. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Champaign: Human Kinetics; 1997, p. 221–226. 67. Fernhall B. Mental retardation. In: American College of Sports Medicine, editor. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign: Human Kinetics; 2003. p. 304–310. 68. Fernhall B. Mental retardation. In: LeMura LM, Von Duvillard SP , editors. Clinical Exercise Physiology: Application and Physiological Principles. Baltimore: Lippincott Williams Wilkins; 2004. p. 617–27. 69. Fernhall B. The young athlete with a mental disability. In: Hebestreit H, Bar-Or O, IOC Medical Commission, International Federation of Sports Medicine, editors. The Young Athlete. Malden: Blackwell Pub; 2008. p. 403–12.
- 373. CHAPTER 10 Exercise Prescription for Other Clinical Populations 347 70. Fernhall B, Baynard T, Collier SR, et al. Catecholamine response to maximal exercise in persons with Down syndrome. Am J Cardiol. 2009;103(5):724–6. 71. Fernhall B, McCubbin JA, Pitetti KH, et al. Prediction of maximal heart rate in individuals with mental retardation. Med Sci Sports Exerc. 2001;33(10):1655–60. 72. Fernhall B, Pitetti KH, Vukovich MD, et al. Validation of cardiovascular fitness field tests in children with mental retardation. Am J Ment Retard. 1998;102(6):602–12. 73. Fernhall B, Tymeson G. Graded exercise testing of mentally retarded adults: a study of feasibility. Arch Phys Med Rehabil. 1987;68(6):363–5. 74. Figoni SF . Overuse shoulder problems after spinal cord injury: a conceptual model of risk and protective factors. Clin Kinesiol. 2009;63(2):12–22. 75. Finckh A, Iversen M, Liang MH. The exercise prescription in rheumatoid arthritis: primum non nocere. Arthritis Rheum. 2003;48(9):2393–5. 76. Fisher NM. Osteoarthritis, rheumatoid arthritis, and fibromyalgia. In: Myers J, Nieman DC, American College of Sports Medicine, editors. ACSM’s Resources for Clinical Exercise Physiology: Musculoskeletal, Neuromuscular, Neoplastic, Immunologic, and Hematologic Conditions. 2nd ed. Baltimore: Lippincott Williams Wilkins; 2010. p. 132–43. 77. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999–2008. JAMA. 2010;303(3):235–41. 78. Follett KA, Weaver FM, Stern M, et al. Pallidal versus subthalamic deep-brain stimulation for Parkinson’s disease. N Engl J Med. 2010;362(22):2077–91. 79. Fontaine KR, Conn L, Clauw DJ. Effects of lifestyle physical activity on perceived symptoms and physical function in adults with fibromyalgia: results of a randomized trial. Arthritis Res Ther. 2010;12(2):R55. 80. Ford ES. Prevalence of the metabolic syndrome defined by the International Diabetes Federation among adults in the U.S. Diabetes Care. 2005;28(11):2745–9. 81. Ford ES, Giles WH, Mokdad AH. Increasing prevalence of the metabolic syndrome among U.S. adults. Diabetes Care. 2004;27(10):2444–9. 82. Fowler EG, Knutson LM, Demuth SK, et al. Pediatric endurance and limb strengthening (PEDALS) for children with cerebral palsy using stationary cycling: a randomized controlled trial. Phys Ther. 2010;90(3):367–81. 83. Franks PW, Olsson T. Metabolic syndrome and early death: getting to the heart of the problem. Hypertension. 2007;49(1):10–2. 84. Franzen E, Paquette C, Gurfinkel VS, Cordo PJ, Nutt JG, Horak FB. Reduced performance in balance, walking and turning tasks is associated with increased neck tone in Parkinson’s disease. Exp Neurol. 2009;219(2):430–8. 85. From Cancer Patient to Survivor: Lost in Transition [Internet]. Washington (DC): National Academies Press; [cited 2011 Mar 11]. Available from: http://www.nap.edu/catalog.php?record_id=11468#toc 86. Gao J, Ren J, Gulve EA, Holloszy JO. Additive effect of contractions and insulin on GLUT-4 translocation into the sarcolemma. J Appl Physiol. 1994;77(4):1597–601. 87. Garber CE, Blissmer B, Deschenes MR, et al. American College of Sports Medicine position stand. The quantity and quality of exercise for developing and maintaining cardiorespiratory, musculo- skeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–559. 88. Garber CE, Friedman JH. Effects of fatigue on physical activity and function in patients with Parkinson’s disease. Neurology. 2003;60(7):1119–24. 89. Gill TM, Williams CS, Tinetti ME. Assessing risk for the onset of functional dependence among older adults: the role of physical performance. J Am Geriatr Soc. 1995;43(6):603–9. 90. GINA Report, Global Strategy for Asthma Management and Prevention Report [Internet]. Global Initiative for Asthma; [cited 2010 Dec 22]. Available from: http://www.ginasthma.org 91. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease [Internet]. Medical Communications Resources, Inc.; [cited 2012 Jan 7]. Available from: http://www.goldcopd.com/download.asp?intId=554 92. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol. 2004; 44(3):720–32. 93. Haapaniemi TH, Kallio MA, Korpelainen JT, et al. Levodopa, bromocriptine and selegiline modify cardiovascular responses in Parkinson’s disease. J Neurol. 2000;247(11):868–74. 94. Hackney ME, Earhart GM. Effects of dance on gait and balance in Parkinson’s disease: a comparison of partnered and nonpartnered dance movement. Neurorehabil Neural Repair. 2010;24(4):384–92. 95. Hackney ME, Earhart GM. Effects of dance on movement control in Parkinson’s disease: a comparison of Argentine tango and American ballroom. J Rehabil Med. 2009;41(6):475–81.
- 374. 348 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 96. Haisma JA, van der Woude LH, Stam HJ, Bergen MP , Sluis TA, Bussmann JB. Physical capacity in wheelchair-dependent persons with a spinal cord injury: a critical review of the literature. Spinal Cord. 2006;44(11):642–52. 97. Hampton T. Parkinson disease registry launched. JAMA. 2005;293(2):149. 98. Hand GA, Jaggers JR, Lyerly GW, Dudgeon WD. Physical activity for CVD prevention in patients with HIV/AIDS. Curr Cardiovasc Risk Rep. 2009;3(4):288–95. 99. Hand GA, Lyerly GW, Dudgeon WD. Acquired immune deficiency syndrome (AIDS). In: Durstine JL, American College of Sports Medicine, ACSM’s exercise management for persons with chronic diseases and disabilities, editors. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. 3rd ed. Champaign: Human Kinetics; 2009. p. 219–25. 100. Hand GA, Lyerly GW, Jaggers JR, Dudgeon WD. Impact of aerobic and resistance exercise on the health of HIV-infected persons. Am J Lifestyle Med. 2009;3(6):489–99. 101. Hand GA, Phillips KD, Dudgeon WD, William LG, Durstine LJ, Burgess SE. Moderate intensity exercise training reverses functional aerobic impairment in HIV-infected individuals. AIDS Care. 2008;20(9):1066–74. 102. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Med Sci Sports Exerc. 2007;39(8):1423–34. 103. Hayden MF . Mortality among people with mental retardation living in the United States: research review and policy application. Ment Retard. 1998;36(5):345–59. 104. Hazes JM, van den Ende CH. How vigorously should we exercise our rheumatoid arthritis patients? Ann Rheum Dis. 1996;55(12):861–2. 105. Headley S, Germain M, Mailloux P, et al. Resistance training improves strength and functional measures in patients with end-stage renal disease. Am J Kidney Dis. 2002;40(2):355–64. 106. Herman T, Giladi N, Gruendlinger L, Hausdorff JM. Six weeks of intensive treadmill training improves gait and quality of life in patients with Parkinson’s disease: a pilot study. Arch Phys Med Rehabil. 2007;88(9):1154–8. 107. Herman T, Inbar-Borovsky N, Brozgol M, Giladi N, Hausdorff JM. The Dynamic Gait Index in healthy older adults: the role of stair climbing, fear of falling and gender. Gait Posture. 2009; 29(2):237–41. 108. Hoehn MM, Yahr MD. Parkinsonism: onset, progression and mortality. Neurology. 1967;17(5):427–42. 109. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006;54(1):226–9. 110. Hopman MT, Oeseburg B, Binkhorst RA. Cardiovascular responses in persons with paraplegia to prolonged arm exercise and thermal stress. Med Sci Sports Exerc. 1993;25(5):577–83. 111. Horowitz MB, Littenberg B, Mahler DA. Dyspnea ratings for prescribing exercise intensity in patients with COPD. Chest. 1996;109(5):1169–75. 112. Hurley BF , Roth SM. Strength training in the elderly: effects on risk factors for age-related diseases. Sports Med. 2000;30(4):249–68. 113. The IDF Concensus Worldwide Definition of the Metabolic Syndrome. 2006 [Internet]. Brussels, Belgium: International Diabetes Federation; [cited 2008 Jul 23]. Available from: http://www.idf.org/webdata/ docs/IDF_Meta_def_final.pdf 114. Jacobi D, Ciangura C, Couet C, Oppert JM. Physical activity and weight loss following bariatric surgery. Obes Rev. 2011;12(5):366–77 115. Jakicic JM, Clark K, Coleman E, et al. American College of Sports Medicine position stand. Appropriate intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2001;33(12):2145–56. 116. Jakicic JM, Winters C, Lang W, Wing RR. Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women: a randomized trial. JAMA. 1999;282(16):1554–60. 117. Jan MH, Lin JJ, Liau JJ, Lin YF , Lin DH. Investigation of clinical effects of high- and low-resistance training for patients with knee osteoarthritis: a randomized controlled trial. Phys Ther. 2008; 88(4):427–36. 118. Jankovic J, Stacy M. Medical management of levodopa-associated motor complications in patients with Parkinson’s disease. CNS Drugs. 2007;21(8):677–92. 119. Johansen KL. Exercise and chronic kidney disease: current recommendations. Sports Med. 2005; 35(6):485–99. 120. Jones KD, Burckhardt CS, Clark SR, Bennett RM, Potempa KM. A randomized controlled trial of muscle strengthening versus flexibility training in fibromyalgia. J Rheumatol. 2002;29(5):1041–8. 121. Jones LW, Eves ND, Peppercorn J. Pre-exercise screening and prescription guidelines for cancer patients. Lancet Oncol. 2010;11(10):914–6.
- 375. CHAPTER 10 Exercise Prescription for Other Clinical Populations 349 122. Kaminsky LA, American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore (MD): Lippincott Williams Wilkins; 2005. 749 p. 123. Kendrick AH, Johns DP, Leeming JP. Infection control of lung function equipment: a practical approach. Respir Med. 2003;97(11):1163–79. 124. Kent-Braun JA, Sharma KR, Weiner MW, Miller RG. Effects of exercise on muscle activation and metabolism in multiple sclerosis. Muscle Nerve. 1994;17(10):1162–9. 125. Kenyon LK, Sleeper MD, Tovin MM. Sport-specific fitness testing and intervention for an adolescent with cerebral palsy: a case report. Pediatr Phys Ther. 2010;22(2):234–40. 126. Keus SH, Bloem BR, Hendriks EJ, Bredero-Cohen AB, Munneke M, Practice Recommendations Development Group. Evidence-based analysis of physical therapy in Parkinson’s disease with recommendations for practice and research. Mov Disord. 2007;22(4):451–60; quiz 600. 127. Keus SHJ, Hendriks HJM, Bloem BR, et al. KNGF Guidelines for physical therapy in Parkinson’s disease. Ned Tijdschr Fysiother. 2004;114(Suppl 3):5–86. 128. King WC, Belle SH, Eid GM, et al. Physical activity levels of patients undergoing bariatric surgery in the Longitudinal Assessment of Bariatric Surgery study. Surg Obes Relat Dis. 2008;4(6):721–8. 129. Kingsley JD, McMillan V, Figueroa A. The effects of 12 weeks of resistance exercise training on disease severity and autonomic modulation at rest and after acute leg resistance exercise in women with fibromyalgia. Arch Phys Med Rehabil. 2010;91(10):1551–7. 130. Klippel JH. Primer on the Rheumatic Diseases. 13th ed. New York (NY): Springer; 2008. 721 p. 131. Kloos AD, Heiss DG. Exercise for impaired balance. In: Kisner C, Colby LA, editors. Therapeutic Exercise: Foundations and Techniques. 5th ed. Philadelphia: F .A. Davis; 2007. p. 251–72. 132. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403. 133. Kohrt WM, Bloomfield SA, Little KD, Nelson ME, Yingling VR, American College of Sports Medicine. American College of Sports Medicine position stand: physical activity and bone health. Med Sci Sports Exerc. 2004;36(11):1985–96. 134. Krebs P . Mental retardation. In: Winnick JP , editor. Adapted Physical Education and Sport. Champaign: Human Kinetics; 1990. p. 153–76. 135. Kurtzke JF . Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology. 1983;33(11):1444. 136. Lambert CP , Archer RL, Evans WJ. Muscle strength and fatigue during isokinetic exercise in individuals with multiple sclerosis. Med Sci Sports Exerc. 2001;33(10):1613–9. 137. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26–35. 138. Leger L, Boucher R. An indirect continuous running multistage field test: the Universite de Montreal track test. Can J Appl Sport Sci. 1980;5(2):77–84. 139. Levey AS, Tangri N, Stevens LA. Classification of chronic kidney disease: a step forward. Ann Intern Med. 2011;154(1):65–7. 140. Lin K, Stewart D, Cooper S, Davis CL. Pre-transplant cardiac testing for kidney-pancreas transplant candidates and association with cardiac outcomes. Clin Transplant. 2001;15(4):269–75. 141. Liu G, Peacock M, Eilam O, Dorulla G, Braunstein E, Johnston CC. Effect of osteoarthritis in the lumbar spine and hip on bone mineral density and diagnosis of osteoporosis in elderly men and women. Osteoporos Int. 1997;7(6):564–9. 142. Lockette KF , Keyes AM. Conditioning with Physical Disabilities. Champaign (IL): Human Kinetics; 1994. 272 p. 143. Longitudinal Assessment of Bariatric Surgery [Internet]. University of Pittsburgh, Epidemiology Data Center; [cited 2012 Jan 7]. Available from: http://www.edc.gsph.pitt.edu/labs/ 144. Lublin FD, Reingold SC, National Multiple Sclerosis Society (USA) Advisory Committee on Clinical Trials of New Agents in Multiple Sclerosis. Defining the clinical course of multiple sclerosis: results of an international survey. Neurology. 1996;46(4):907–11. 145. Macfarlane DJ, Taylor LH, Cuddihy TF . Very short intermittent vs continuous bouts of activity in sedentary adults. Prev Med. 2006;43(4):332–6. 146. Mak MK, Pang MY. Balance confidence and functional mobility are independently associated with falls in people with Parkinson’s disease. J Neurol. 2009;256(5):742–9. 147. Mannerkorpi K, Nordeman L, Ericsson A, Arndorw M, GAU Study Group. Pool exercise for patients with fibromyalgia or chronic widespread pain: a randomized controlled trial and subgroup analyses. J Rehabil Med. 2009;41(9):751–60. 148. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67(6):387–9. 149. Matinolli M, Korpelainen JT, Korpelainen R, Sotaniemi KA, Matinolli VM, Myllyla VV. Mobility and balance in Parkinson’s disease: a population-based study. Eur J Neurol. 2009;16(1):105–11.
- 376. 350 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 150. McNeely ML, Courneya KS. Exercise programs for cancer-related fatigue: evidence and clinical guidelines. J Natl Compr Canc Netw. 2010;8(8):945–53. 151. McNeely ML, Peddle C, Parliament M, Courneya KS. Cancer rehabilitation: recommendations for integrating exercise programming in the clinical practice setting. Curr Cancer Ther Rev. 2006; 2(4):351–60. 152. The medical and psychological concerns of cancer survivors after treatment. In: Hewitt M, Greenfield S, Stovall E, editors. From Cancer Patient to Survivor: Lost in Transition. Washington: National Academies Press; 2006. p. 66–186. 153. Mendes FA, Almeida FM, Cukier A, et al. Effects of aerobic training on airway inflammation in asthmatic patients. Med Sci Sports Exerc. 2011;43(2):197–203. 154. Mendes FA, Goncalves RC, Nunes MP, et al. Effects of aerobic training on psychosocial morbidity and symptoms in patients with asthma: a randomized clinical trial. Chest. 2010;138(2):331–7. 155. Messier SP. Arthritic diseases and conditions. In: Kaminsky LA, editor. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 5th ed. Baltimore: Lippincott Williams Wilkins; 2006. p. 500–13. 156. Miller TD, Squires RW, Gau GT, Ilstrup DM, Frohnert PP , Sterioff S. Graded exercise testing and training after renal transplantation: a preliminary study. Mayo Clin Proc. 1987;62(9):773–7. 157. Minor MA, Kay DR. Arthritis. In: American College of Sports Medicine, editor. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign: Human Kinetics; 2003. p. 210–16. 158. Mockford M, Caulton JM. Systematic review of progressive strength training in children and adolescents with cerebral palsy who are ambulatory. Pediatr Phys Ther. 2008;20(4):318–33. 159. Morris ME. Locomotor training in people with Parkinson disease. Phys Ther. 2006;86(10): 1426–35. 160. Morris ME. Movement disorders in people with Parkinson disease: a model for physical therapy. Phys Ther. 2000;80(6):578–97. 161. Morris ME, Martin CL, Schenkman ML. Striding out with Parkinson disease: evidence-based physical therapy for gait disorders. Phys Ther. 2010;90(2):280–8. 162. Mostert S, Kesselring J. Effects of a short-term exercise training program on aerobic fitness, fatigue, health perception and activity level of subjects with multiple sclerosis. Mult Scler; 2002;8(2):161–8. 163. Munhoz RP , Li JY, Kurtinecz M, et al. Evaluation of the pull test technique in assessing postural instability in Parkinson’s disease. Neurology. 2004;62(1):125–7. 164. National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106(25):3143–421. 165. National Coalition for Cancer Survivorship Web site [Internet]. Silver Spring (MD): National Coalition for Cancer Survivorship; [cited 2011 Feb 14]. Available from: http://www.canceradvocacy.org/about/ org/history.html 166. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39(2 Suppl 1):S1–266. 167. National Multiple Sclerosis Society Web site [Internet]. New York (NY): National Multiple Sclerosis Society; [cited 2010 Oct 18]. Available from: http://www.nationalmssociety.org/index.aspx 168. National Multiple Sclerosis Society. Clinical Study Measures: Modified Fatigue Impact Scale (MFIS) [Internet]. New York (NY): National Multiple Sclerosis Society; [cited 2011 Feb 6]. Available from: http://www.nationalmssociety.org/for-professionals/researchers/clinical-study-measures/mfis/index .aspx 169. Needle RH, Trotter RT,2nd, Singer M, et al. Rapid assessment of the HIV/AIDS crisis in racial and ethnic minority communities: an approach for timely community interventions. Am J Public Health. 2003;93(6):970–9. 170. Ness KK, Wall MM, Oakes JM, Robison LL, Gurney JG. Physical performance limitations and participation restrictions among cancer survivors: a population-based study. Ann Epidemiol. 2006; 16(3):197–205. 171. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12):1390–413. 172. O’Donnell DE, Laveneziana P , Ora J, Webb KA, Lam YM, Ofir D. Evaluation of acute bronchodilator reversibility in patients with symptoms of GOLD stage I COPD. Thorax. 2009;64(3):216–23. 173. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA. 2010;303(3):242–9. 174. Painter PL. Exercise after renal transplantation. Adv Ren Replace Ther. 1999;6:159–64.
- 377. CHAPTER 10 Exercise Prescription for Other Clinical Populations 351 175. Painter PL. Physical functioning in end-stage renal disease patients: update 2005. Hemodial Int. 2005;9(3):218–35. 176. Painter PL, Hector L, Ray K, et al. A randomized trial of exercise training after renal transplanta- tion. Transplantation. 2002;74(1):42–8. 177. Painter PL, Krasnoff JB. End-stage metabolic disease: renal failure and liver failure. In: Durstine JL, editor. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign: Human Kinetics; 2003. p. 126–32. 178. Painter P, Moore GE. The impact of recombinant human erythropoietin on exercise capacity in hemodialysis patients. Adv Ren Replace Ther. 1994;1(1):55–65. 179. Palisano RJ, Snider LM, Orlin MN. Recent advances in physical and occupational therapy for children with cerebral palsy. Semin Pediatr Neurol. 2004;11(1):66–77. 180. Pastor MA, Day BL, Marsden CD. Vestibular induced postural responses in Parkinson’s disease. Brain. 1993;116(Pt 5):1177–90. 181. Perkins EA, Moran JA. Aging adults with intellectual disabilities. JAMA. 2010;304(1):91–2. 182. Perri MG, Anton SD, Durning PE, et al. Adherence to exercise prescriptions: effects of prescribing moderate versus higher levels of intensity and frequency. Health Psychol. 2002;21(5):452–8. 183. Pescatello LS, Franklin BA, Fagard R, et al. American College of Sports Medicine position stand. Exercise and hypertension. Med Sci Sports Exerc. 2004;36(3):533–53. 184. Petajan JH, Gappmaier E, White AT, Spencer MK, Mino L, Hicks RW. Impact of aerobic training on fitness and quality of life in multiple sclerosis. Ann Neurol. 1996;39(4):432–41. 185. Pezzoli G, Zini M. Levodopa in Parkinson’s disease: from the past to the future. Expert Opin Pharmacother. 2010;11(4):627–35. 186. Physical Activity Guidelines Advisory Committee Report, 2008 [Internet]. Washington (DC): U.S. Department of Health and Human Services; [cited 2011 Jan 6]. Available from: http://www.health .gov/paguidelines/Report/pdf/CommitteeReport.pdf 187. Pitetti K, Fernandez J, Lanciault M. Feasibility of an exercise program for adults with cerebral palsy a pilot study. Adapt Phys Act Q. 1991; 8(4):333–41. 188. Politis M, Wu K, Molloy S, G Bain P, Chaudhuri KR, Piccini P. Parkinson’s disease symptoms: the patient’s perspective. Mov Disord. 2010;25(11):1646–51. 189. Ponichtera-Mulcare JA, Glaser RM, Mathews T, Camaione D. Maximal aerobic exercise in persons with MS. Clin Kinesiol. 1983;46(4):12–21. 190. Ponichtera-Mulcare JA, Mathews T, Barrett PJ, Gupta SC. Changes in aerobic fitness of patients with multiple sclerosis during a 6-month training program. Sports Med Train Rehabil. 1997;7(3): 265–72. 191. Ponichtera-Mulcare JA, Mathews T, Glaser RM, Mathrews T, Gupta SC. Maximal aerobic exercise of individuals with MS using three modes of ergometry. Clin Kinesiol. 1995;49:4–13. 192. Protas EJ, Stanley RK. Parkinson’s disease. In: Myers J, Herbert WG, Humphrey RH, editors. ACSM’s Resources for Clinical Exercise Physiology: Musculoskeletal, Neuromuscular, Neoplastic, Immunologic, and Hematologic Conditions. Baltimore: Lippincott Williams Wilkins; 2002. p. 38–47. 193. Protas EJ, Stanley RK. Parkinson’s disease. In: Myers J, Nieman DC, American College of Sports Medicine, editors. ACSM’s Resources for Clinical Exercise Physiology: Musculoskeletal, Neuromuscular, Neoplastic, Immunologic, and Hematologic Conditions. 2nd ed. Baltimore: Lippincott Williams Wilkins; 2010. p. 44–57. 194. Protas EJ, Stanley RK, Jankovic J. Parkinson’s disease. In: American College of Sports Medicine, editor. ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities. Champaign: Human Kinetics; 1997. p. 212–18. 195. Ram FS, Robinson SM, Black PN, Picot J. Physical training for asthma. Cochrane Database Syst Rev. 2005;(4):CD001116. 196. Ram FS, Wellington SR, Barnes NC. Inspiratory muscle training for asthma. Cochrane Database Syst Rev. 2003;(4):CD003792. 197. Reid S, Hamer P, Alderson J, Lloyd D. Neuromuscular adaptations to eccentric strength training in children and adolescents with cerebral palsy. Dev Med Child Neurol. 2010;52(4):358–63. 198. Rezak M. Current pharmacotherapeutic treatment options in Parkinson’s disease. Dis Mon. 2007; 53(4):214–22. 199. Rice CL, Vollmer TL, Bigland-Ritchie B. Neuromuscular responses of patients with multiple sclerosis. Muscle Nerve. 1992;15(10):1123–32. 200. Richmond J, Hunter D, Irrgang J, et al. American Academy of Orthopaedic Surgeons clinical prac- tice guideline on the treatment of osteoarthritis (OA) of the knee. J Bone Joint Surg Am. 2010;92(4): 990–3. 201. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence- Based Clinical Practice Guidelines. Chest. 2007;131(5 Suppl):4S–42S.
- 378. 352 GUIDELINES FOR EXERCISE TESTING • www.acsm.org 202. Rikli RE, Jones CJ. Senior Fitness Test Manual. Champaign (IL): Human Kinetics; 2001. 161 p. 203. Rimaud D, Calmels P, Devillard X. Training programs in spinal cord injury. Ann Readapt Med Phys. 2005;48(5):259–69. 204. Rimmer JH. Physical fitness levels of persons with cerebral palsy. Dev Med Child Neurol. 2001; 43(3):208–12. 205. Ritter PL, Gonzalez VM, Laurent DD, Lorig KR. Measurement of pain using the visual numeric scale. J Rheumatol. 2006;33(3):574–80. 206. Robertson MC, Campbell AJ, Gardner MM, Devlin N. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc. 2002;50(5):905–11. 207. Robertson RJ, Goss FL, Dube J, et al. Validation of the adult OMNI scale of perceived exertion for cycle ergometer exercise. Med Sci Sports Exerc. 2004;36(1):102–8. 208. Roddy E, Zhang W, Doherty M. Aerobic walking or strengthening exercise for osteoarthritis of the knee? A systematic review. Ann Rheum Dis. 2005;64(4):544–8. 209. Rogers A, Furler BL, Brinks S, Darrah J. A systematic review of the effectiveness of aerobic exercise interventions for children with cerebral palsy: an AACPDM evidence report. Dev Med Child Neurol. 2008;50(11):808–14. 210. Roizen NJ, Patterson D. Down’s syndrome. Lancet. 2003;361(9365):1281–9. 211. Rooks DS. Fibromyalgia treatment update. Curr Opin Rheumatol. 2007;19(2):111–7. 212. Rooks DS. Talking to patients with fibromyalgia about physical activity and exercise. Curr Opin Rheumatol. 2008;20(2):208–12. 213. Rooks DS, Silverman CB, Kantrowitz FG. The effects of progressive strength training and aerobic exercise on muscle strength and cardiovascular fitness in women with fibromyalgia: a pilot study. Arthritis Rheum. 2002;47(1):22–8. 214. Rosendorff C, Black HR, Cannon CP , et al. Treatment of hypertension in the prevention and manage- ment of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention. Circulation. 2007;115(21):2761–88. 215. Ryuzaki M, Konishi K, Kasuga A, et al. Spontaneous rupture of the quadriceps tendon in patients on maintenance hemodialysis—report of three cases with clinicopathological observations. Clin Nephrol. 1989;32(3):144–8. 216. Saris WH, Blair SN, van Baak MA, et al. How much physical activity is enough to prevent unhealthy weight gain? Outcome of the IASO 1st Stock Conference and consensus statement. Obes Rev. 2003;4(2):101–14. 217. Scandalis TA, Bosak A, Berliner JC, Helman LL, Wells MR. Resistance training and gait function in patients with Parkinson’s disease. Am J Phys Med Rehabil. 2001;80(1):38–43; quiz 44–6. 218. Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to improve spinal flexibility and func- tion for people with Parkinson’s disease: a randomized, controlled trial. J Am Geriatr Soc. 1998; 46(10):1207–16. 219. Schenkman M, Hall D, Kumar R, Kohrt WM. Endurance exercise training to improve economy of movement of people with Parkinson disease: three case reports. Phys Ther. 2008;88(1):63–76. 220. Schmid A, Schmidt-Trucksass A, Huonker M, et al. Catecholamines response of high performance wheelchair athletes at rest and during exercise with autonomic dysreflexia. Int J Sports Med. 2001;22(1):2–7. 221. Schmitz KH, Courneya KS, Matthews C, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010;42(7):1409–26. 222. Schneider CM, Dennehy CA, Roozeboom M, Carter SD. A model program: exercise intervention for cancer rehabilitation. Integr Cancer Ther. 2002;1(1):76–82; discussion 82. 223. Scholtes VA, Becher JG, Comuth A, Dekkers H, Van Dijk L, Dallmeijer AJ. Effectiveness of func- tional progressive resistance exercise strength training on muscle strength and mobility in children with cerebral palsy: a randomized controlled trial. Dev Med Child Neurol. 2010;52(6):e107–13. 224. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure [Internet]: Bethesda (MD): U.S. Department of Health and Human Services, National High Blood Pressure Education Program; 2004 [cited 2012 Jan 7]. Available from: http://www.ncbi.nlm.nih.gov.ezproxy.lib.uconn.edu/books/bv.fcgi?rid=hbp7.TOC 225. Shapiro R. Managing the Symptoms of Multiple Sclerosis. 4th ed. New York (NY): Demos Medical Publishers; 2003. 192 p. 226. Sharoff CG, Hagobian TA, Malin SK, et al. Combining short-term metformin treatment and one bout of exercise does not increase insulin action in insulin-resistant individuals. Am J Physiol Endocrinol Metab. 2010;298(4):E815–23. 227. Sharples L, Hughes V, Crean A, et al. Cost-effectiveness of functional cardiac testing in the diagnosis and management of coronary artery disease: a randomised controlled trial. The CECaT trial. Health Technol Assess. 2007;11(49):iii–iv, ix–115.
- 379. CHAPTER 10 Exercise Prescription for Other Clinical Populations 353 228. Shrier I. Flexibility versus stretching. Br J Sports Med. 2001;35(5):364. 229. Sidney S, Lewis CE, Hill JO, et al. Association of total and central adiposity measures with fasting insulin in a biracial population of young adults with normal glucose tolerance: the CARDIA study. Obes Res. 1999;7(3):265–72. 230. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C, White RD. Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006;29(6):1433–8. 231. Silsupadol P, Shumway-Cook A, Lugade V, et al. Effects of single-task versus dual-task training on balance performance in older adults: a double-blind, randomized controlled trial. Arch Phys Med Rehabil. 2009;90(3):381–7. 232. Skeletal muscle dysfunction in chronic obstructive pulmonary disease. A statement of the American Thoracic Society and European Respiratory Society. Am J Respir Crit Care Med. 1999; 159(4 Pt 2):S1–40. 233. Smithson F , Morris ME, Iansek R. Performance on clinical tests of balance in Parkinson’s disease. Phys Ther. 1998;78(6):577–92. 234. Stacy M. Medical treatment of Parkinson disease. Neurol Clin. 2009;27(3):605–31, v. 235. Steadward R. Musculoskeletal and neurological disabilities: implications for fitness appraisal, programming, and counselling. Can J Appl Physiol. 1998;23(2):131–65. 236. Sterman AB, Coyle PK, Panasci DJ, Grimson R. Disseminated abnormalities of cardiovascular autonomic functions in multiple sclerosis. Neurology. 1985;35(11):1665. 237. Stoessl AJ. Continuous dopaminergic therapy in Parkinson disease: time to stride back? Ann Neurol. 2010;68(1):3–5. 238. Stone PC, Minton O. Cancer-related fatigue. Eur J Cancer. 2008;44(8):1097–104. 239. Svien LR, Berg P , Stephenson C. Issues in aging with cerebral palsy. Top Geriatr Rehabil. 2008; 24(1):26–40. 240. Teo-Koh SM, McCubbin JA. Relationship between peak VO2 and 1-mile walk test performance of adolescent males with mental retardation. Pediatr Exerc Sci. 1999;11(2):144–57. 241. Thomas TR, Warner SO, Dellsperger KC, et al. Exercise and the metabolic syndrome with weight regain. J Appl Physiol. 2010;109(1):3–10. 242. Tomas-Carus P, Gusi N, Hakkinen A, Hakkinen K, Raimundo A, Ortega-Alonso A. Improvements of muscle strength predicted benefits in HRQOL and postural balance in women with fibromyalgia: an 8-month randomized controlled trial. Rheumatology (Oxford). 2009;48(9):1147–51. 243. Tresierras MA, Balady GJ. Resistance training in the treatment of diabetes and obesity: mechanisms and outcomes. J Cardiopulm Rehabil Prev. 2009;29(2):67–75. 244. Troosters T, Casaburi R, Gosselink R, Decramer M. Pulmonary rehabilitation in chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2005;172(1):19–38. 245. Tsai AG, Williamson DF, Glick HA. Direct medical cost of overweight and obesity in the USA: a quantitative systematic review. Obes Rev. 2011;12(1):50–61. 246. Turner S, Eastwood P, Cook A, Jenkins S. Improvements in symptoms and quality of life follow- ing exercise training in older adults with moderate/severe persistent asthma. Respiration. 2011; 81(4):302–10. 247. Twelves D, Perkins KS, Counsell C. Systematic review of incidence studies of Parkinson’s disease. Mov Disord. 2003;18(1):19–31. 248. Unnithan VB, Clifford C, Bar-Or O. Evaluation by exercise testing of the child with cerebral palsy. Sports Med. 1998;26(4):239–51. 249. U.S. Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans [Internet]. Washington (DC): U.S. Department of Health and Human Services; 2008 [cited 2011 Jan 6] 78 p. Available from: http://www.health.gov/paguidelines/pdf/paguide.pdf 250. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996. 278 p. Available from: U.S. GPO, Washington. 251. U.S. Department of Health and Human Services, United States Department of Agriculture, United States Dietary Guidelines Advisory Committee. Dietary Guidelines for Americans, 2005. 6th ed. Washington (DC): G.P .O; 2005. 71 p. 252. U.S. Preventive Services Task Force. Screening for coronary heart disease: recommendation statement. Ann Intern Med. 2004;140(7):569–72. 253. U.S. Public Health Service, Office of the Surgeon General. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2004. 404 p. 254. U.S. Renal Data System. USRDS 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End- Stage Renal Disease in the United States [Internet]. Bethesda (MD): National Institutes of Health,
- 380. 354 GUIDELINES FOR EXERCISE TESTING • www.acsm.org National Institute of Diabetes and Digestive and Kidney Diseases; [cited 2012 Jun 9]. Available from: http://www.usrds.org/atlas09.aspx 255. van den Ende CH, Hazes JM, le Cessie S, et al. Comparison of high and low intensity training in well controlled rheumatoid arthri