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CardioPulm Final > Exercise Prescription > Flashcards

Exercise Prescription Flashcards

1
Q

what is the purpose of exercise testing

A

to observe physiological responses to increasing or sustained metabolic demand.

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2
Q

how long does the test last

A

continues until the pt. reaches a sign such as ST segment depression or a symptom such as angina or fatigue that limits the maximal level of exertion

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3
Q

why should we use exercise testing

A

determines a diagnosis such as CAD or abnormal physiologic response
Helps to guide decisions regarding medical treatment and surgical intervention
Evaluates the severity of the disease and provides accurate answers to a patients questions
Evaluates the physiological repsonse to exercise by assessing medical therapy effectiveness and provides appropriate activity guidelines
Provides functional capacity and entrance criteria for CR which helps in determining return to work and writing an appropriate exercise prescription

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4
Q

what are the determinants of prognosis

A 
number of diseased arteries
degree of LVD
>10 METs is good prognosis
< 5 METs is poor prognosis
<3 METs is very poor prognosis
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5
Q

What does each MET increase mean

A

each increase in exercise capacity= a 13% decrease in all cause mortality and 15% decrease in CV events

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6
Q

what needs to be done prior to clinical testing

A

get informed consent
educate the pt. on what they may experience (fatigue SOB angina)
obtain a medical hx
resting ECG

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7
Q

what are the relative contraindications to symptom limited max exercise testing

A
  1. Known obstructive left main coronary artery stenosis.
  2. Moderate to severe aortic stenosis w/uncertain relationship to symptoms.
  3. Tachyarrhythmias w/uncontrolled ventricular rates.
  4. Acquired advanced or complete heart block.
  5. Recent stroke or transient ischemia attack.
  6. Mental impairment w/limited ability to cooperate.
  7. Resting HTN w/systolic >200 mmHg or diastolic > 110 mmHg.
  8. Uncorrected medical conditions such as significant anemia, important electrolyte imbalance & hyperthyroidism.
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8
Q

what are the absolute contraindications to symptom limited max exercise

A

Acute myocardial infarction w/in 2 days
Ongoing unstable angina
Uncontrolled cardiac arrhythmia w/hemodynamic compromise.
Active endocarditis
Symptomatic severe aortic stenosis
Decompensated heart failure
Acute pulmonary embolism, pulmonary infarction or DVT
Acute myocarditis or pericarditis
Acute aortic dissection
Physical disability that precludes safe and adequate testing

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9
Q

what to consider when choosing an exercise modality and protocol

A

consider the purpose of the test, the specific outcomes desired adn the individual being tested
should you do a submax vs max?
large vs. small increments?
continuous, staged or ramped protocl?

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10
Q

VO2 for TM, bike and UBE

A

the bike is 5-20% lower VO2 peak than TM

UBE is 20-30% lower VO2 peak than TM

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11
Q

What makes the TM the best mode

A

it is better able to detect ST segment changes and elicit angina
It also gives a higher peak VO2 and HR

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12
Q

advantages of the bike

A

less money
less space
BP and ECG are easier to obtain
balance is less of an issue
the RPM on an electronically braked bike gives a more accurate work rate
BUT it may be unfamiliar and end prematurely because of localized leg fatigue

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13
Q

when would it be appropriate to use a UBE

A

spinal cord injury
amoutation
post polio syndrome
just remember that the VO2 is 20-30% lower than TM

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14
Q

what is the most widely used protocol

A

the Bruce TM protocol

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15
Q

what are the disadvantages to the bruce protocol

A

low function and orthopedic difficulties
the MET increments are large and uneven
it severely limits the # of submax responses

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16
Q

how many stages are there

A

there are 4 three minute stages

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17
Q

Bruce TM protocol

A

Bruce Stage I=1.7 mph & 10% grade (4.6 METS)
Bruce Stage II=2.5 mph & 12% grade (7 METS)
Bruce Stage III=3.4 mph & 14% grade (10.5 METS)
Bruce Stage IV=4.2 mph & 16% grade (13 METS)

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18
Q

modified bruce protocol

A

has 2 stages that can be used prior to starting the bruce
Mod Bruce Stage I=1.7 mph & 0% grade (2.4 METS)
Mod Bruce Stage II=1.7 mph & 5% grade (3.4 METS)

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19
Q

What are the downfalls of the bruce protocol because of its excessive, rapid increments in rate of work

A

Overestimation of exercise capacity (handrail use, exercise duration or peak workload achieved).

  1. Less reliable assessment of therapy effects.
  2. Reduced accuracy for detecting CAD.

not reflective of functional capacity due to pt. flunking out early with large jump incline

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20
Q

additional protocols to choose from

A

Balke-Ware-constant TM speed at 2.0 or 3.3 mph with grade increasing 5% every 2-3 minutes
Unit MET protocol-start at 2.0 METS and increase 1 MET every 3 minutes

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21
Q

when is the ramped protocol used

A

best used with bicycle or UBE

uses the constant and continuous increase in metabolic demand instead of staning

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22
Q

benefits of ramped protocol

A

uniform increase in workload results in a steady rise in physiological response and permits a more accurate estimate of VO2
can individualize the ramp rate depending on the pt. characteristics

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23
Q

what measurements are taken during testing

A 
ECG
HR
BP
signs and symptoms
RPE
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24
Q

why do the most adverse events occur during the cool down stage

A

redistribution of blood flow to the body

perfusion issues with less functioning muscle pump

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25
Q

what does the accuracy of the test depend on

A

presence of physiological indicators for ischemia
achievement of at least 85% of APMHR
multiple ECG leads
meds

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26
Q

how can the sensitivity of a test be increased

A

if the pt. is placed in a seated or supine position immediately following exercise

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27
Q

Interpreting HR Results

A

normal 10 bpm/1 MET increase. HRmax decrease w/age & meds. Recovery-decrease 12 bpm w/in 1st min or 22bpm w/in 2 min, strongly assoc. w/increased risk of mortality in pts. w/IHD or increased risk for IHD.

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28
Q

interpreting BP results

A

BP: normal 10mmHg/1 MET increase. Increase w/age, more in men & meds. SBP >250 or increase >140 during test assoc. w/risk for HTN. Hypotensive: SBP below rest or < w/increase work often assoc. w/ischemia, LVD & risk of cardiac events. SBP return to rest w/in 6 min of recovery—poorer prognosis

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29
Q

interpreting ECG results

A

ECG: dysrhythmias that increase in frequency or complexity assoc. w/ischemia or hemodynamic instability. Ventricular ectopy during exercise but esp. recovery assoc. w/increased risk cardiac arrest.

30
Q

ECG exercise stress test

A

high reliability and cost effective
major limitation is ability to obtain adequate workload and HR response
when used alone not as sensitive as other tests for diagnosis of CAD

31
Q

Stress Echo

A

provides spatial information on cardiac structure and function noninvasive
looks at regurgitation, stenosis, mitral valve prolapse
can estimate SV and EF

32
Q

advantages of stress echo

A

non-invasive, no radiation

lower cost then nuclear testing

33
Q

what med can be used to induce stress in individuals who are oribidly obese or have severe orthopedic limitations, extremely sendenaty or other chronic disease that impedes exercise

A

Dobutamine

34
Q

reason for pharm stress testing

A

unable to undergo exercise test d/t deconditioning, peripheral vascular disease, orthopedic disabilities, neurological disease or concomitant illness.

35
Q

what are the objectives of exercise nuclear imaging

A

assessment of myocardial perfusion and ventricular function- cardiac viability

36
Q

results of a pharm stress test with nuclear imaging

A

if there is no vasodilation experienced in the arteries then stenotic segments are present.
decreased blood flow is also seen

37
Q

rationale of using expired gas analysis (metabolic cart)

A

accurate assessment of VO2 max as opposed to estimation

directly related to peak CO

38
Q

what is RER an indicator of?

A

respiratory exchange ration is an indicator of ventilatory efficiency

39
Q

absolute indications for terminating an exercise test

A
  1. ST elevation >1.0mm in leads w/out preexisting Q waves because of prior MI.
  2. Drop in SBP of >10mm Hg despite increase workload when accompanied by other evidence of ischemia.
  3. Moderate to severe angina
  4. CNS symptoms-ataxia, dizziness, near syncope
  5. Signs of poor perfusion (cyanosis or pallor)
  6. Sustained V-tach or other arrhythmia including 2nd or 3rd degree AV block that interferes w/normal maintenance of CO during exercise.
  7. Technical difficulties monitoring ECG or BP.
  8. Subject’s request to stop
40
Q

relative indications to stop an exercise test

A
  1. Marked ST displacement (horizontal or down sloping >2mm)
  2. Drop in SBP >10mm Hg despite an increase in workload in absence of other evidence of ischemia.
  3. Increasing chest pain.
  4. Fatigue, shortness of breath, wheezing, leg cramps, or claudication.
  5. Arrhythmias other than sustained V-tach including SVT, ventricular triplets, and bradyarrhythmias that have potential to become more complex or to interfere with hemodynamic stability.
  6. Exaggerated hypertensive response (SBP > 250mm Hg or DBP >115mm Hg)
  7. Development of bundle branch block that cannot be distinguished from ventricular tachycardia.
  8. SpO2 < 80%
41
Q

what distinguishes a maximal versus submaximal test?

A

the termination point of the test

42
Q

how is an endpoint determined for maximal stress testing

A

end point point is predicted maximal HR or when pt. limited by symptoms. Measure functional capacity as well as diagnose CAD

43
Q

how is an endpoint determined for submaximal stress testing

A

predetermined end point– % PMHR or attainment of certain workload. Do not need physician supervision. Practical clinical application. Used in acute care situations. Max exercise testing not always feasible in health settings.

44
Q

rationale for using submax testing

A

though not as predictive as maximal but provides estimate of fitness at a lower cost, potentially reduced risk for adverse events, less time & effort for subject.

45
Q

what are the principles of exercise prescription

A 
Frequency (how often)
Intensity (how hard)
Time (duration or how long)
Type (mode or what kind)
Total Volume (amount)
Progression (advancement)
46
Q

what are the components of exercise training session

A

warm- up= 5-10 min of light to moderate intensity cardio
conditioning= at least 20-60 min of aerobic, resistance or sport activities
cool-down= at least 5-10 min of light to mod intenstiy
stretching= at least 10 min

47
Q

Aerobic Exercise Frequency Recommendation

A

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 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.

48
Q

Aerobic Exercise Intensity Recommendation

A

Moderate (e.g., 40%–59% heart rate reserve [HRR] or VO2R) to vigorous (e.g., 60%–89% HRR or VO2R) intensity aerobic exercise is recommended for most adults, and light (e.g., 30%–39% HRR or VO2R) 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.

49
Q

HRR=

A

MHR-RHR

50
Q

Methods of estimating the absolute intensity of exercise

A 
Caloric expenditure (kcal · min−1)
Absolute oxygen uptake (VO2; mL ∙ min−1 or L ∙ min−1)
Metabolic equivalents (METs)
51
Q

Methods of estimating the relative intensity of exercise

A 
%HRR
%HRmax
%VO2R 
 %VO2
 %METs
RPE
Talk Test
52
Q

Aerobic Exercise Time (Duration) Recommendation

A

Most adults should accumulate 30–60 min ∙ d−1 (≥150 min ∙ wk−1) of moderate intensity exercise, 20–60 min ∙ d−1 (≥75 min ∙ wk−1) of vigorous 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 ≥10 min over the course of a day.
Durations of exercise less than recommended can be beneficial in some individuals.

53
Q

Aerobic Exercise Type Recommendation

A

Rhythmic, aerobic exercise of at least moderate intensity that involves large muscle groups and requires little skill to perform is recommended for all adults to improve health and CRF.

54
Q

Exercise volume (quantity)

A

Product of Frequency, Intensity, and Time (duration) or FIT of exercise

55
Q

Aerobic Exercise Volume Recommendation

A

A target volume of ≥500–1,000 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 ≥5,400–7,900 steps ∙ d−1.

56
Q

How Do I Determine Initial CR Intensity?

A
  1. Results from a CP Stress Test (exercise): peak HR, BP, METS, total test time, protocol, reason for stopping, symptoms, ECG.
  2. HRR, %HRmax , usually will not have VO2 measure.
  3. Patient Activity Feedback: activities can/cannot do, how long can you walk before stopping? Why would you stop? What activities do you find challenging? Duke Activity Status Index—self administered questionnaire consisting of 12 questions that yields a rough estimate of MET level.
  4. Functional testing: TUG, 6-minute walk test, Step test.
  5. RPE during exercise: Borg 6-20 scale moderate approx. 12-13 vigorous 15-17 “Talk Test”—moderate activity
57
Q

Individuals on diuretic meds are at an elevated risk for

A

volume depletion, hypokalemia or orthostatic hypotension. Monitor s/s dizziness, light headedness

58
Q

Purpose of Resistance Training for Patients with Cardiac Disease

A

Improve muscle strength & endurance
Decrease cardiac demands of muscular work during daily activities.
Prevent & treat other diseases & conditions, such as osteoporosis, Type II DM, and obesity.
Increase ability to perform ADL’s
Improve self confidence & QOL
Maintain independence
Slow age & disease related declines in muscle strength & mass.

59
Q

HF characterized by

A

Exertional dyspnea & fatigue with w/reduced ejection fraction (systolic dysfunction)

  1. Exertional dyspnea & fatigue w/a preserved left ventricular ejection fraction (diastolic dysfunction)
  2. A combination of both
60
Q

ExRx—Patients with Heart Failure

A

Aerobic: 3-5 d/wk; if stress test 60-80% HRR; if no stress test RPE 11-14; progressively increase to 30min/day to 60 min/day; treadmill, walking or stationary cycling.
Resistance: 1-2 nonconsecutive days; start 40% 1-RM upper & 50% 1-RM lower body and gradually increase to 70% over several weeks-month; 2 sets 10-15 reps major muscle groups; machines?? d/t reduced strength & balance.
Flexibility: > 2-3 d/wk; point of feeling tightness; 10-30s static; 2-4 reps/stretch. PNF or dynamic also can be used.

61
Q

duration & frequency of effort should be increased before…

A

exercise intensity

62
Q

ExRx—Patients w/Sternotomy

A

Limitation or restriction of upper body activities usually involves activity type, load amount (e.g., unloaded, restriction set at a weight limit), and allowable degrees of movement throughout a ROM.
Five to 6 wk after hospital discharge in the outpatient setting, most patients have returned to pain-free, unloaded upper limb ROM.
The instructions regarding lifting limits are usually conveyed prior to hospital discharge and might vary but are usually set at a 5- to 10-lb limit (or <50% of maximal voluntary contraction) for 10–12 wk.
A general objective for patient care during 10–12 wk of CR for individuals with median sternotomy is to advance and progress through a pain-free ROM before focusing on regaining/improving muscle strength/endurance

63
Q

ExRx–Cardiac Transplant

A

Aerobic: 3-5 d/wk; RPE 11-14; progressively increase from 15-20 min/d to 30-60 min/d; treadmill, walking, stationary bike or dual action bike.
Resistance: 1-2 nonconsecutive d/wk; slowly increase upper body from weeks-months from 40% 1-RM to 70% 1-RM; lower begin at 50% 1-RM; 1-2 sets 10-15 reps; weight machines preferred but dumbbells, bands & BW can be used.
Flexibility: >2-3 d/wk w/daily preferred; stretch to point of tightness; 10-30s static, 2-4 reps per exercise; static, dynamic or PNF.

64
Q

ExRx–Pacemaker and Implantable Cardiovascular Defibrillator

A

When an ICD is present, the peak heart rate (HRpeak) during the exercise test and exercise training program should be maintained 10–15 beats  min-1 below the programmed HR threshold for antitachycardia pacing and defibrillation.

65
Q

PAD is caused by

A

plaque causes stenosis & limited vasodilation so reduced blood flow

66
Q

ExRx—Peripheral Artery Disease

A 
Intermittent claudication (major symptom)—aching, cramping in one or both legs typically initiated with weight bearing exercise.
Aerobic: 3-5 d/wk; moderate intensity to point of moderate pain ¾ on claudication scale; 30-45 min can progress to 60 min; weight bearing intermittent exercise w/seated rest when moderate pain reached—resumption when pain alleviated.
Resistance: 2 d/wk nonconsecutive days; 60-80% 1-RM; 2-3 sets 8-12 reps; 6-8 exercises major  muscle groups emphasize lower limbs if time limited.
Flexibility: >2-3 days/wk but daily most effective; stretch to point of feeling tightness; 10-30s hold; 2-4 reps; static, dynamic or PNF.
67
Q

Exercise Prescription for CVA

A

Aerobic: 3-5 d/wk; if HR from stress test, 40-70% HRR or no stress test RPE 11-14; progress increase from 20 min/d to 60 min/d but consider multiple shorter sessions if needed; cycle ergometry & NuStep—modifications d/t functional or cognitive limitations. TM if sufficient balance.
Resistance: 2 nonconsecutive d/wk; 50-70% 1-RM; 1-3 sets of 8-15 reps; equipment & exercises that improve safety in those w/deficits (strength, endurance, balance). Type of equip as indicated
Flexibility: >2-3 d/wk w/daily most effective; stretch to point of tightness; 10-30s hold for static 2-4 reps/exercise; static, dynamic or PNF.

68
Q

ExRx—Diabetes

A

Frequency: 3-7 days/week
Intensity: moderate (40-59% VO2R with RPE 11-12 to vigorous (60-89% VO2R or 14-17 RPE).
Time: T1DM–Minimum 150 min/wk at moderate intensity or 75 min/wk vigorous or combination.T2DM—150 min/wk at mod to vigorous intensity.
Type: prolonged, rhythmic activities using large muscle groups.

69
Q

Special considerations for DM

A

Monitor signs/symptoms of hypoglycemia—most common complication. Can be delayed up to 12 hours post exercise.
BG monitoring before/immediately after/several hours after exercise when beginning or modifying exercise program if taking insulin or meds that increase secretion of insulin.
Timing of exercise & oral meds/insulin should be considered.
Adjust carbohydrate intake, meds based on BG levels & exercise intensity.
Individuals with retinopathy have increased risk for retinal detachment & hemorrhage so decrease activities that dramatically increase BP. Neuropathy—foot ulcers.
Autonomic neuropathy may cause chronotropic incompetence (blunted HR & BP response), decreased VO2.

70
Q

ExRx—Asthma

A

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 EIB.
Individuals on prolonged treatment with oral corticosteroids may experience peripheral muscle wasting and may benefit from resistance training.

71
Q

ExRx—COPD

A

Include inspiratory muscle training—weakness is contributor to exercise intolerance & dyspnea.
Oximetry monitoring indicated for patients who have SaO2 < 88% on room air

CardioPulm Final (6 decks)

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