Exercise Testing & Prescription Flashcards
Pre-Exercise Testing
Purpose & Includes (5)
Purpose: To sccreen for patients at risk of adverse effects with exercise who require further assessment prior to starting an exercise program
Pre-exercise Testing may include:
1. Detailed history
2. Physical Examination
3. Laboratory Tests
4. Risk stratification processing
5. Test selection
Risk Stratification
High risk (3), S/S & CV RF
Review Flow Chart on pg. 92
Guidelines for test selection - possible supervision level
HIGH RISK:
1. Cardiovascular: CVD, PVD, cerebrovascular
2. Metabolic: diabetes or renal disease
3. Pulmonary: COPD, asthma, cystic fibrosis or interstitial lung disease
S/S
1. Pain in: chest, neck, jaw, or arm
2. SOB or SOBOE
3. Dizziness/syncope
4. Orthopnea/ nocturnal dyspnea
5. Ankle edema
6. Palpitations/tachycardia
7. Intermittent claudification
8. Heart murmur
9. Unusual fatigue or SOB w/ usual activities
Risk Factors - LOW RISK:
1. Age
2. Family Hx
3. Smoking/ Alcohol
4. Sedentary life style
5. Obesity
6. HTN
7. Prediabetes
8. Dyslipidemia
Review Flow Chart on pg. 92
RF: Age
Criteria
Men: > 45 years old
Female: > 55 years old
RF: Family Hx
Criteria
Sudden death, MI, or coronary revascularization
- Before 55 years od in father/brother
- Before 65 years old in mother/sister
** Immediate family
RF: Physical Activity Level
Criteria
Not engaging in at least 30 minutes of moderate physical activity least 3 x/week in the last 3 months
“any exercise that causes shortness of breath but still allows you to talk comfortable”
RF: Obesity
Criteria
BMI > 30 kg/m2
Waist Circumference:
- Male: > 102 cm
- Female: > 88 cm
** Muscle vs carrying fat
Need to take both as BMI can give a false (+)
RF: Pre-Diabetes
Criteria
- “Any Hx of diabetes”
- “Any blood tests looking into your glucose levels”
- ** If patient is unaware count as a risk if:
- > 45 years old
- BMI: > 25 kg/m2
RF: Dyslipidemia
Criteria
LDL: > 130 mg/dL - bad cholestrol
HDL: < 40 mg/dL (if it is >60 then it counts for a negative risk factor)
Patient is on Statin medication
Total hypertension medication
RF: HTN
Criteria
Systolic BP > 140 mmHg & Diastolic BP > 90
Taking hypertension medications
RF: Stress / Psychosocial
Criteria
Depression / anxiety / stress levels
SF-36: QoL
Beck Depression Inventory: Depression
RF: Smoker
Criteria
Current smoker
Quit within last 6 months
Exposure to second hand smoke (tobacco or work environment)
Alcohol Consumption
Criteria
Male: >14 drinks/week
Female: > 9 drinks/week
RF: Diet
Criteria
N/A - Poor diet = risk factor
Risk Stratification: Screening Requirements
LOW Risk - Does NOT require medical screen prior to exercise, exercise test prior to exercise, or MD supervision of exercise test
MOD Risk - Requires a medical screen prior to exercise (VIGOROUS)
HIGH RISK - Requires a medical screen, exercise test, and MD supervision of exercise test prior to MOD & VIG exercise
Risk Stratification: Exercise Intensities
Mod & Vig
MOD Exercise:
- Intensity is 40-60% VO2 or 2-6 METs or intensity causing noticable increase in HR & breathing
VIG Exercise:
- >60% VO2 or >6 METs or intensity that causes substantial increase in HR & breathing
Exercise Testing: Indications
(3)
- Diagnostic
- Prognostic
- Prescription
More related to scope of practive & pt we may see
More details on pg. 94
Contraindications to Exercise Testing:
ABSOLUTE
(9)
- A recent significant change in resting ECG suggesting significant ischema, recent myocardial infarction (w/in 2 days), or other acute cardiac events
- 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 know dissecting aneurysm
- Acute systematic infection, accompanied by fever, body aches, or swollen lymph nodes
Contraindications to Exercise Testing:
RELATIVE
Supersede if benefits > adverse event that could occur
- Left main coronary stenosis
- Moderate stenotic valvular heart disease
- Electrolyte abnormalities
- Severe arterial hypertension at rest
SBP > 200 mm Hg
DBP > 110 mm Hg - Tachydysrhythmia or bradydysrhythemia
- Hypertrophic cardiomyopathy & other forms of outflow tract obstruction
- Neuromotor, MSK, or rheumatoid disorders that are exacerbatde by exercise
- High-degree atrioventricular block
- Ventricular aneurysm
- Uncontrolled metabolic disease (DM)
Do require a pre-screening - could have other comorbidities - assess risk - Chronic infectious disease (HIV < would benefit from exercise)
- Mental or physical impairment leading to inability to exercise adequately
Maximal Exercise Testing
(3)
Also known as a stress test
Administered by Physicians (not in scope)
Graded Exercise Tests
- used to predict Vo2max - predictor
- Treadmill Tests (ie Bruce protocol)
Submaximal Exercise Testing
May be administered by a PT
Evaluative (Performance) Submaximal Exercise Tests
- Used as a mesure of endurance & exercise capacity
6-minute Walk Test (6MWT):
- The distance covered by the client walking at a comfortable pace for 6 minutes
- Subject is allowed to take breask as needed during testing
- 2 practice trials are required (learning effect < not worried about skill rather endurance & capacity)
2MWT, 10MWT, 12 MWT
** ^MWT = most validated for various populations
Predictive Submaximal Exercise Test:
- Used to predict VO2max
- Not taking patients ot complete exhaustion
Treadmill Test: Modified Bruce Protocol
Cycle Ergometer Tests: Astrand-Rhyming Cycle Ergometer Test
Indications to Prematurely Terminate an Exercise Test
General S/S (4 + 7) & Cardiovasc S/S (6) & Other (2)
General S/S:
- Fatigue (physical & verbal manifestations)
NOT good - too tired & cannot continue = STOP EXERCISE
- Signs of poor perfusion:
1. Lightheadness
2. Confusion
3. Ataxia
4. Pallor
5. Cyanosis
6. Nausea
7. Cold & clammy skin
- Shortness of breath
- Wheezing
Cardiovascular S/S:
- Onset of angina or angina-like symptoms
- Leg cramps or claudication (intermittent)
- Drop in SBP:
>10 mm Hg with an increase in work rate
Drops below the value obstained in the same position prior to testing
- Excessive increase in BP:
SBP > 250 mm Hg
DBP > 115 mm Hg
- Failure of HR to increase w/ increasing exercise intensity
- Noticeable change in heart rhythm by palpation or auscultation
Other:
- Subject requests to stop (autonomy)
- Failure of testing equipment
Coulf put someone at risk & test is no longer valid
Exercise Prescription: Components
(5)
- Exercise Selection
- Parameters
- Monitoring
- Safety
- Indications to stop exercise
Standard Intensity Ranges & High Risk Intensity Ranges
Standard Intensity = 60-85%
High Risk Intensity = 50-75%
Percentage of Maximum Heart Rate
(HR Max)
Measured (out of scope) vs Predictive
The most common method to calculate HR max is though the predictive equation:
HRmax = 220-age
Target HR = HRmax x %intensity desired
** Predictive equations may overestimate or underestimate measure HR max
ISCHEMIC HRmax = whenever pt get ischemia = STOP test & consider that their ischemic max HR THEN use that to prescribe exercise
Percentage of Heart Rate Reserve (HRR)
This method gives an equivalent exercise intensity to the VO2R
HRR is calculated using the Karvonen Equation
- Target HE = [(HR max - HR rest) x % intensity desired] + HR rest
Percentage of Maximal Oxygen Uptake
(VO2 max)
Target VO2max = VO2max x % intensity desired
Percentage of Maximal Oxygen Uptake Reserve
(VO2R)
This method gives an equivalent exercise intensity to the HR Reserve
Target VO2R = [(VO2max - VO2 rest) x % intensity desired] + Vo2 rest
Similar to Karvonen equation
Percentage of Meximal Metabolic Equivalents
(METs max)
1 MET is defined as the amount of oxygen consumed while sitting at rest
1 MET = 3.5 ml/kg/min
Target MET = (Vo2max/ 3.5 ml/kg/min) x % intensity desired
What equations are the more accurate predictors to use (determine intensity)?
VO2R & HRR
Time (duration) Recommendations?
- Accumulate 30-60 minutes of moderate-intensity exercise per day
- > 150 m/week
- Accumulate 20-60 minutes of vigorous-intensity exercise per day
- > 75 min/week
Canadian Physical Activity Guidelines
Adults should accumulate at least 150 minutes of moderate-to-vigorous intensity aerobic physical activity per week, in bouts of 10 minutes or more to achieve health benefits
It is also suggested to add muscle & bone strengthening activities using major mm groups, at least 2 days/week
Safety
(4)
PCE TIP
- Appropriate screening & testing should take place prior to beginning an exercise program
- All contraindications for exercise testing also apply to exercise training
- All patients should refrain from using a Valsalva manuever
- Upper body exercises may increase SBP, hypertensive individuals should be cautious when performing any UPPER body exercises & avoid high intensive upper body exercises
INC BP > degree compared to L/E
** May avoid strenuous exercise (rowing) if you are dealing with someone w/ a INC risk > especially if it comes up on a vignette if UE & LE exercises - then cross out UE answers
Indications to Terminate Exercise Session
S/S (6) + Abnormal Responses (4)
S/S:
1. Moderately severe or increasing angina
2. Marked dyspnea (respiratory distress)
3. Dizziness, light-headedness, or ataxia
4. Cyanosis or pallor
5. Excessive fatigue
6. Leg cramps or claudification
Abnormal Responses: Canot see or have ppl tell you
1. Failure of SBP to rise as exercise continues
2. Progressive fall in SBP of 10-15 mm Hg
3. Hypertensive BP response (SBP >200 mm Hg &/or DBP > 110 mmHg)
4. Significant change in cardiac rhythm detected by palpation or ECG (ie arrythmias, ST-T wave change elevation)
