Principles of Exercise Prescription

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Principles of Exercise Prescription

• Mansoori MD
• G. Reza Raissi MD
• Physiatrist

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FITT Principle

• Frequency
• Intensity
• Duration/Time
• Mode/Type

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Example

• Frequency
• 2-3 times daily
• Intensity
• Resting HR20bpm
• RPElt11(6-10 Borg scale)
• To individual tolerance (symptom limited by
  excess breathlessness/fatigue at or below
  suggested targets)
• Time
• 5-20 minutes intermittent bouts of activitylt5
  minutesinterspersed with rest periods
• Type
• Sitting/standing functional activitiesROM
  exercises Walking

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Intensity

• Heart rate
• ETT
• Maximal test has been achieved 60-75 of Maximal
  Heart rate
• Symptom limited 10-20 beats per minute below the
  heart rate at which symptoms were apparent
  monitoring
• Age adjusted Predicted Maximal heart rate (if ETT
  not available)
• 60-75(220-age)40-65VO2 max

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• Heart Rate Reserve (HRR)
• Maximal HR-Resting HR
• Training Rate60-75HRRResting HR
• 60-75HRR60-75 VO2 max
• If patient receives Medication (Beta blocker)
  maximal heart rate must be established from an
  ETT performed on medication

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• Perceived Exertion
• Valid and reproducible indicator of the intensity
  of steady state exercise
• 15 point Borg scale a rate of 12-13 corresponds
  to approximately 60 of hear rate reserve or VO2
  max and a rating of 15 corresponds to 75

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Metabolic Equivalent Value METs

• MET is equivalent to a metabolic rate consuming
  3.5 milliliters of oxygen per kilogram of body
  weight per minute.
• 1 MET is equivalent to a metabolic rate consuming
  1 kilocalorie per kilogram of body weight per
  hour.

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Exercise Program

• Warm-up
• Cardiovascular conditioning
• Resistance training
• Cool-down

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Warm-up

• Preparation for activity must be more gradual
• 15 minutes recommended
• Low-impact, dynamic movements which use large
  muscle groups and take all major joint complexes
  through their normal ROM
• Stretching Exercise (Static pulse rate and body
  temperature must maintained)
• At the end of warm-up the heart rate should be
• within 20bpm of prescribed training heart rate
• 10-11 Original Borg scale

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Cardiovascular conditioning

• Continuous/Interval
• Continuous
• Easy for prescription and monitoring
• Walking, jogging, cycling, rowing, bench
  stepping, swimming
• Interval
• Bouts of relatively intense activity separated by
  periods of rest or less intense activity

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Interval exercise

• Specially in debilitated persons, the total
  volume of work accomplished is generally greater
  than when exercise in continues
• Possibility of social interaction
• 30 Second-2 minutes in each station then rest or
  do a lower intensity exercise

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• Individualization of the program
• The duration of each station
• The intensity(changing resistant or speed or ROM)
• The period of rest between stations
• The overall duration of conditioning

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• Recumbent position exercise is discouraged
• Some older participants have difficulty in
  getting up and down
• Preload enhancesd and so workeload increases
• Increased risk of orthostatic hypotension
• ANY RECUMBENT WORK(FOR ABDOMINALS OR ERECTOR
  SPINAE)SHOULD BE PERFORMED AFTER COMPLETION OF
  THE CIRCUIT AND A COLL DOWN PERIOD

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Resistance training

• Under debate
• UKTwo set of 8-10 exercises involving major
  muscle groupsminimum twice per week
• US Single set of 10-12 exercises using 10-12
  repitionsperformed comfortabley

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• Contraindications
• Abnormal haemodynamics response with exercise
• Ischemic changes during hraded exercise training
• Poor left venticular function
• Uncontrolled hypertension or arrhythmias
• Exercise capacity less than 6 METs

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Cool-down

• 10 minutes is recommended
• Risk of hypotension
• Higher risk of arrhytmias during immediate period
  following cessation of exercise
• In older adults HR take a longer time to return
  to pre-exercise rates

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Cool-down

• Movements of deminishing intensity and
  streatching
• Patient observation up to 30 minutes is
  recommended
• Relaxation period
• Education

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Progression of exercise

• Serial ETT
• HR monitoring and rating of preceived exertion at
  reference workloads

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Exercise in respiratory disease

• Follows same principles
• Types of exercise
• High intensity aerobic
• endurance and strengthening
• outdoor circuit walking
• high repetition contraction and cycle ergometry
• Continuous /interval
• Continuous more oxidative adaptive cahnges

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• Weight training may be useful
• Increase muscle strength and mass but no effect
  on maximal exercise capacity or walking distance
• In choosing exercise consider
• specificity of exercise what is patients needs?
• Patient condition
• Complains of dyspnea Endurance exercise
• Complains of fatigue strength training

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Intensity

• Symptom limited
• Problems when patient have very severe
  dyspneathus limiting the intensity ofexercise
• Fear and anxiety at the start of a program
  mayheighten scores so if using this method,
  reasses the level
• VO2 max
• More reliable
• Cycle ergometry/ shuttle walk test
• IN COPD a true VO2 max may be unattainable due to
  ventilatory limitations
• START WITH 70-80 OF THE DERIVED VO2MAX AND THEN
  USE BREATHLESSNESS SCORES TO MONITOR THE TRAINING
  AND ADJUST ACCORDINGLY

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Physiological training responses

• Learning effect (improved neuromuscular
  coordination)
• Increase gait efficiency and stride length
• Improved mechanical efficiency (Most in exercise
  tolerance)
• Cardiovascular
• Muscle changes depends on exercise protocol

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Measurement of Exercise in PR

• All Patients should perform a standardized test
  of exercise capacity befor and aftertraining
• GOLD STANDARD
• VO2 max, HR, work load, arterial oxigenation and
  blood lactate level

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• Field Tests
• Tests of exercise tolerance applied in the
  clinical setting rather than the laboratory
• When resources are limited
• More suceptible to bias
• Lab tests may offer limited information
  particullarly in severe states where work
  capacity is very reduced resulting in an
  inability to reach ventilatory treshold level

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• Field test are superior to Lab
• Simplicity
• Functional appropriateness
• Disadvantage
• Effects of motivation
• Lack of physiological correlates

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12-minute walking disance

• Susceptible to practice effects
• Lacks standardization
• Needs patients motivation

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Shuttle Walking test

• Less susceptible to motivation
• Standardized
• Externally paced, does not include patients
  stops
• Requires one practice walk
• Requires tape and recorder
• Correlates with VO2 max
• Sensitive measure of change after rehabilitation

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• Thank you