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ACSM's
Guidelines for

Exercise Testing
and Prescription

NINTH EDITION

ACSM's

Guidelines for

Exercise Testing and Prescription
NINTH EDITION

SENIOR EDITOR

Unda 5. Pescatall, PhD, FACSM.FAMA,ACSM-PD, ACSM-ETT
Department of Kinesiology 6 Human Peformance Laboratory
[Nea School of Education

Uhirerty of Connect

ASSOCIATE EDITORS

Ross Arena PAD, PT, FACSM, FAACVPR, FAMA, ACSM.CES.
Disco and Profesor

Physical Therapy Program

Department of Oropucdic e Retablo

"Univers ol New Mexico Head Sciences Center
Albuquerque, New Mexico

Deborah Riebe, PRD, FACSM,ACSM.NFS
Chair and Profesor

Department of Kinesiology

Univers of Rhode Hand

Kingston, Rhode sand

Pau D-Thompson, MO, FACSM, racc
Chef a Candil

Hanford Hop

Hanford, Connecticut

ACSM's

Guidelines for
Exercise Testing and Prescription
NINTH EDITION

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This boo is dedicated o the hundreds of volunteer professional who have,
since 1975, contributed ther valuable time and expertise to develop and update
the Guidelines. Now in its ninth edition, tis the most widely circulated set of
guidelines used by professionals performing exercise esting or exercise programs
Specifically this edition is dedicated to the dior, contributing authors, and
reviewers of his and previous edition, who have not only provided their collective
experts but also their valuable time o ensure the Guidelines mec the highest
standards in exercise science and practice.

The American Collegeof Sports Medicine (
ACSM Committe on Cerüfication and Registry Boards (CRB, formerly known as
nd Education Committe and the Preventive and Rehabilitative
Exercise Committee), Today the Guidelines remain under the auspices ofthe CCRB,
and have become the primary resource for anyone conducting exercise esting or
exercise programs. The Guidelines provide the foundation of content fr ls sup.
porting companion texts produced by ACSM, which include the seventh edition of
ACSMS Resource Manual for Guidelines or Exercise Testing and Prescription, fourth
tation of ACSMS Certification Review, fourth edition of ACSM Resources forthe
Personal Trainer, rt edition of ACSMS Resaues for the Health Funes Specialist,
fourth edition of ACSMS Health-Related Physical Fness Assessment Manual, and
second edition of ACSM Resources for Clinical Exercise Physiology: Musculoskeletal,
Newonuscular Neoplastic, Immunologic and Hematologic Conditions.

The first edition ofthe Guidelines was published in 1975, with updated ed
tions published approximately every 4to 6 years. The outstanding sciemists and
clinicians who have served in leadership postions as chairs and editors of the
Guidelines since 1975 ar

First Edition, 1975 Edward T. Howley PRD, FACSM
Karl G. Suede, PD, FACSM, — Asociate Editor Finess
Cochair Seventh Edition, 2005

John A. Faulkner, PAD, FACSM, Mitchell, Whaley, PRD, FACSM
Cochair Senior Editor

Second Edition, 1980 Peter H. Brubaker, PHD, FACSM,

Anne R. Abbott, PhD, FACSM, Chair he eas sal

‘Third Edition, 1986
Steven N. Blair, PED, FACSM, Chait Eighth Edition, 2009,

ue Editor Fitness

Fourth Edition, 1991 Walter R Thompson, PhD, FACSM,
Russell Pate, PAD, FACSM,Chair Senior Editor

[Neil Gordon, MD, PhD, FACSM,
Fifth Edition, 1995 Associate Editor
Larry W Kenney, PhD, FACSM, Lindas, Pescatelo, PAD, FACSM,
Senior Editor Associate Editor
Reed H, Humphrey PhD, PT, FACSM, int Edition, 2013

Associate Editor Clinical

SN Lindas, Pescatelo, PAD, FACSM,

Associate Editor Fitness aang:

Ross Arena, PRD, PT, FACSA
Sixth Edition, 2000 Associate Editor
Barry A. Franklin, PhD, FACSM, Deborah Riche, PhD, FACSM,
Senior Editor Associate Editor
Mitchell Waley PRD, FACSM, Paul D. Thompson, MD, FACSM,

Associate Editor Clinical Associate Editor

This edition of ACSMS Guidelines for Exercise Testing and Prescription wil con
tinue the ellos of the editors and contributing authors ofthe eighth edition 10
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
accesible, and a current primary resource for professionals that conduct exer
«ise testing and exercise programs. To this effect, in this edition, text descrip
tions have been minimized; more ables, 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 ACSMS Guidelines for Exercise Testing and
Prescription will notice several new themes, Fist and foremost, the ninth edi
tion supports the public health message that all people should adopt a physically
active Mestle by reducing the emphasis on the need for medical evaluation
(e, medical examination and exercise testing) as part of the preparticipaion
Fath screening process prior to initiating a progressive exercise regimen among
heathy, asymptomatic persons. Ths edition of the Guidelines seeks to simplify
the preparicipaton health sereening process in onder to remove unnecessary and
mproven barriers to adopting a physically active Westy. 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
ime in the future, We have integrated the most recent guidlines and recom:
‘mendations available from ACSM position stands and other relevant profesional
rganizadons scientific statements so thatthe Guidelines are the most current,
primary resource for professionals that conduct exercise testing and exercise pro:
grams in academic, corporate, healtvfitness, health care, and research settings. It
À important for the readership to know these new themes and the more specific
Innovations ofthe ninth edition that follows were developed with input rom the
ACSM membership prior o he initiation ofthis projet via an eectonie survey
and in-house focus group that asked respondents and participants, respectively
for their suggestions regarding the content of the ninth edition,
specific, noteworthy innovations of the ninth edition include the

+ 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

Several ofthe appendices have undergone significant changes. Appendix A,
Common Medication, is now authored by registered pharmacists in academie
settings with clinical expertise in the pharmacology of medications likely 10
be used by patients and clients in exercise testing and programmatie settings.
The content of Appendix B, Medical Emergency Management, is now based
primarily on the fourth edition of ACSMS Healh/Fimes Facility Standards and
Guidelines, The Icaming objectives have been removed from Appendix D, ACSM
Certifications, because these are now available via the ACSM Certification link
Wwwacsmeenificaion.ongexam-content.outhnes. Appendix E, which sts the
contibuting authors 10 the two previous editions of the Guidelines, has been
added.

Any updates made in this edition ofthe Guidelines alter their publication and
prior tothe publication ofthe next edition of the Guidelines, can be accessed
from the ACSM Certification link (wwwaesmcertiiation ony/etp9-updates)
Furthermore, the reader is refered to the ACSM Access Public Information
Books and Medialink for a list of ACSM books (ar waesm.ongaceess public:
informatiowbooks-multimedia), and to the ACSM Get Certified link fora isting
of ACSM certifications (awwacsmeertiieation ogget-eriied)

ACKNOWLEDGMENTS:

1 in this preface thatthe editors of the ninth edition have the opportunity
to thank the many people who helped to see his project to competion. To be
consistent with the theme of the Guidelines, our thanks will remain short, tothe
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 thee yeas

We thank our publisher, and in particular Emily Lupash, senior acquisitions
ator; Meredith Brittain, senior product manager; Christen Murphy and Sarah
Schuesler, marketing manager; and Zachary Shapito, editorial assistant.

We thank Richard T Coton, ACSM National Director of Cerifcation: Trac
Sue Rush, ACSM Assistant Director of Cenifcation Programs; Kela Webster,
ACSM Certificacion Coordinator, Robin Ashman and Dru Romanini, ACSM
Certification Department Assistants; Angela Chastain, ACSM Editorial Services
Offie; Kerry ORourke, ACSM Director of Publishing; Walter R. Thompson,
ACSM Publications Committee Chair; and the extraordinary hardworking
Publications Commitee

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
seing this project to completion. The ACSM CCRB ticles reviewed man:
script drafts 1o 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 ACSMS Resource Manual for Guidelines
for Exercise Testing and Prescription, for his very careful and sgh review of

the Guidelines and collegial assistance with seing this project to completion
We thank Dr Jonathan Ehrman, the umbrella editor of this projet, who made
At his mission to ensure congruenoy between the ninth edition of the Guidelines
and seventh edition of ACSMS Resource Manual or Guidelines fr Exercise Testing
and Prescription. We thank the University of Connecticut Medical Librarian, Jl
Livingston, for her patience and guidance with implementing the ACSM evi
dence-based RefWorks ihrary and teaching the edtors 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 serutiny to ensure the highest quality of content. We thank the external and
(CRD reviewers ol the ninth edition for ther careful reviews, These reviewers
ae listed later in this front matter

We are in great debt 10 the contributing authors of the ninth edition of the
udelines for volunteering their expertise and valuable time to ensure the
videlnes meet the highest standards in exercise science and practice. The ninth
edition contributing authors ar listed in the following section

On a more personal note, 1 thank my three associate editors — Dr. Ross
Arena, De Deborah Rice, and Dr Paul D, Thompson — who sellessly devoted
their valuable time and expertise 10 the ninth edition of the Guidelines. Their
strong sense of selfless commitment tothe Guideline emanated from an underly
ing belief held by the editorial team of the profound imponance 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 1 se this projet to completion

Lindas, Pescaello, PAD, FACSM
Senior Fduor

ADDITIONAL RESOURCES

ACSMS Guidelines for Exercise Testing and Prescription, Ninth Eon includes
additional resources for instructors that are available on the book’ companion
Web site at htp/thepoint.ivw:convACSMGETP9e,

INSTRUCTORS

Approved adopting insteuctors will be given access 10 the following additional

Brownstone test generator
PowerPoint presentations

Image bank

WebCT/AngeVBlackbourd ready cartridge

“Price ETMIES

In addition, purchasers of the text ca acces he searchable FullText Online
by going to the ACSMS Guidelines for Exercise Testing and Prescription, Ninh
Edition Web ste at hups/thepoint IwveconvACSMGETIVE, See the inside Front
cover ofthis text for more details, including the passcode you wil need to gain
acces to the Web site

NOTA BENE

“The views and information contained inthe ninth edition of ACSMS Guidelines
for Exercise Testing and Prescription are provided as guidlines as opposed to
Standards of practice. This distinction san important one because specific legal
‘connotations may be attached to standards of practice that ate not attached 10
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. ACSMS Guidelines for Exercise Testing and Prescription
presents a framework whereby the professional may certainly — and in some
tases has the obligation to — tailor to individual client or patient needs while
balancing institutional or legal requirements

Contributing Authors to the Ninth Edition*

at ten, PO
Durham, North Carol
Char sen ripio

A Ha Conditions

Mark Anderson PT PAO
Chap nr rain er,
an Heh Condon

ory Balay mo.

Bon Unica Schoo of Modine

ton, Maas

Chap 3 Ese Prien for Patents
Wh Canosa and Cebra

ich Ber, PRD
Wake ore Une
And Heh Condon

ryan isamer PRD
Unters al ode sand
ington Role land

Chap Rat Tr nd

Kim Bons, MSA FACSM
Grand Bune, cn
Agen CEectearogra nep

Bury Braun, PRO, FACS
Andere Macame
Populations with Or Chronic Des

Monthapom S Bryant PT PAO
Chap Bene Prion
tnd Hes Condon

rae Bucky MPH, BPR
pen A Common Motions

John Cast PRD
‘iad Sut Army Rescate of
pons ah a Conde

in Costanzo, MA, FAGSH,AGSM ACER,
BEM PO accent
penis D Amencan Coleg of Sports

Manse Deschene, PRO, FACE
Chap 7 General ciple

Joseph: Domel EdD, FACSM
‘ery a amas Meal Comer
Chap 10 Exercise Prescription for

tnd Hea Condens

Bo Feral PRO, ACSIA
‘Chagos
option with Orr Chronic Discs

a Sen Sia) === |

‘Stephen Figen, RD, FACSM

VA West Los Angels Herce Center

Los Angles, Calflora

hag Ei rion
Heh Condon

Nadine Fisher Eso

ent a Bulla

Ba, New Yr

Chap 10 Exes Pression for
Populations with Other Chron Diseases
nd Heh Condon

hates Falco, Seo

Unite Sat Army Resa tte of

Chapter 8 Exercise Prescription for Healy
Populations with Spsal Conse

Carl Ewing Garber, PO, FRCSM,
ACSMRCER ACSILNFS ACSMPD
Ken York New York

Chapur 7 General Price of

University of Oklaboma Health Sciences

Oklahoma Ci: atom

ape Ence Presion fr Patients
wrth Canosa and Cebroacular

Ni Gordon, Mo, PRO. MPH, ACSA
har 10: Exess Pscron for

ical PhO, cs
pie Behavioral Theos and
‘Sep fr Promos Exec

Gregory Hand PRO, MPH, FACS
er oath Crea
(Chop 0 Exec Precio for

tnd Heath Condos

Samuel Handy, PRD, FACS, ACSI RCE

Spang Cole

Sri Mascus

Cr 10: Exeo Presciption for
option with Other Chee Diseases
tnd Hes Codions

ur Jon, PTO
Universi of Dayton
hp 1 Een raion

tnd Hes Condon

Robert enn, RO, ACSI
Unite Sat Army Rese Ie of
Timronnenultekine
Populations with Special Considero

‘University of Connecticut Schoo of
Appelt A Common Mains

Wendy Kar PRO, racsın
en a Colorado —Arschus Mee
Aston Colorado

option vi Orr Chronic Discs

in Lo, BES, MPH 50
igh and Womens Hostal Hara
perl Bees and Risks Acid with

Univesity of Minis at Chicago
(Caper 1: Behavioral Theos and
Stags romo Eure

ye Mois, ep, FACHA
North Andover Masche

Append Emergency Rsk Management

Paso Morey PD, FACS

Wand Duke Mo Cenes

Durham, Noch are

Char Exerc Pein for Heaty
Populations with Seal Considers

‘The University of Westem Ontario

ha Exec Previn freaky
Populations with Social Consideration
and Enstonmental Consideration

‘Unite States Army Research insite of
"Environmental Modine

‘Chapt Exec Prien (or Maty
Populations with Seal Consider

Patria Non, PRO
Wal Fre Une
Chapter 10. Exercise Prescription for

and Mel Condon

“ami ONIL. PO, MPH ACS HES,

Columbia, Soh Cann

Char En recio Er Healy
oplatns with Seca! Cons emir

ners a South Carola

Columbia, Sou Cala

(Chapter Encre Prescription or Hay
"opos wih Spcal Condor
And Enronmenl Consideran

Monreal Quer, Canada

(Cher Exeo Prescription o Hay
options sh Spa Consdentins
sd Eminem Cone

Kathryn Schmitz, PRD, MPA, CSM,

Bess

Char Eerie Pen for
options wth Or Chronic Des

Comie Shar PhD

sons See Univer

(Chop 10 Bree Precio for
option with Orr Cree Pisces
tnd Heath Condon

Maureen Simmonds, PRD, PT

Vries ol Tous Heh Schnee Gener

‘Chapter Exe Propio fo Hal
opinions wih Spcal Connor
And Enron! Consideran

Pau Tompson, MO, FACSM, FACE

Hanford oa

Hanford, Conner

(Caper Benchs and Risks Acid with
Physio Any

Chap 2 Peparpaion Het Sereno

tapeo Exec Peon for
opt wu Other Orni Diseases
tnd Hea Condens

Reviewers for the Ninth Edition”

ober Axel, PRD. FACS, ACSM-ETT

‘chvitopher Borge PhD, ACSHA.HES
The Gor Vision Unwenly
gen, Dest of Columba

"OinonA Brauner. MS, ACSMACER
Devo, Shiga

Barbara A (Kotter Busha, PRD,
FACSIACSMPO,ACSMICES,ACSIMMFS,
ACSMPTACSM. EM

Sr E AC Recre
Spring. Asa

on. Come MEd, ACSMLACEP
Morte Noh Car

Lance Dac, PhD ACSMLRCEP
Auckland New Zend

sul J Downing, PRD, FACS,
Bend, Oreo

Gregory 8. Dwyer PRD, FACS,
ACSMPD.ACSNERCER ACSIACES,
Beer

Sr Fr ACM Conc
Fa Sour, Penman

Ca Foster PH, FACSME

Paty room, PRO. FACS

Laonar A Kaminsky PRD, FACS!
BCSM-PD.ACSMETT

‘Soir Ftc of ACM Heath at
tall Ste Unie

Steven otero, PRD, FACSIN
Henry Ford Hp

(ary Mt. Uguod, PRD, FACSMACSMACES,

BOSS

Sir Eier of A Reus forthe
Heath Fine Sei, Fst Eon

Fag, Non Ds

‘Randi S. Lie, MA,ACSM.ACEP

ud Nig, PRO

“Madeline Paremesto Bats, PO,
ACSW, CSM FD, ACSM-CES

“Peter J. Rona MS, FACSM ACSM-D,
CSM RCEP ACSM.CES, ACSMETT
pet

‘Milford, Connect

ober Sali MO, FACS
Rancho Cucamonga, Clot

“they Soukup, PRO, ACSICES
‘ne, Nh Cala

Sean Wath PO
Devi, Zucker MO, PHO

Contents

Section I: Health Appraisal and Risk Assessment 1

Associate Editor Paul D, Thompson, MD, FACSM, FACC

1 Bonofits and Risks Associated with Physical Activity 2
Phys Achty md Fines Terminology 2
Public Heath Pespectie for Curent Recommendatons 5
Penes al Regalar Physical Activity andor Er 5
Rs Associated with Exec o
Sudden Cardiac Death Among Young Individual "
Exercise Related Cardiac Evens in Adal 12
Eee Tosingand the RS of Cardiac Events a
Risks of Cade Evens Dring Cadac Rehabilitation mn
Prevention of Exercise Relted Cadi Events mn

2. Preparticipation Health Serooning 19
Preparation Hel Screening, »
Sal Guided Methods, »
‘Alhcroseotc Cardiovascular Discs Risk Factor Ascent »
Recommendations for a Medical Examination Prior to
Tata Pisa Aci a
Recommendation for Exerc Teatng ri
Inti Phys Act 2
Recommendauonsfor Supervision of Exerc Testing »
Rik Stratton for Pains with Cardiovascular Diese a

Section I: Exercise Testing 2

Associate Editor Ros Arena, PAD, PT, FACSM, FAACVPR, FAHA, ACSM-CES

3 Preexercias Evaluation so
Medical History, Physical Examination, and Labor Teas a
Blood Pres a
Lipids and Lippi =
Blood Profile Analyses »
Pukaonany Panel »
Informed Consent En
Participar fran 5

4 Health-Related Physical Fitness Testing and Interpretation so
Pusposs of lea Related Physical Fes Testing so
ise Principles and Guidelines a

Pretest Insrucions a

mi Comm ETMIES

Tes Organization a
Body Composition ®
Anıhopomeue Methods 8
Densitometry. E
Other Techn. n
Body Compson Norms 2
CandorespratryFlnss n
“The Concept of Maximal Oxygen Uptake »
Mania versus Suhmanimal Exerc esting 5
Modes of esting 76
Cariorespiratony Test Sequence and Meat ss
Te Termination Cri. se
Interpretation of Rests 87
Muscular Sen and Masclar Endurance ”
Route >
Principles. 9
Muscular eng se
Muscular Endurance E
Special Comideraons in Muscular Fates 9
rex 105
A Comprehensive Heath Fans Evaluation 107
5 Clinical Exercise Testing m
Indications and Purposes us
Fem Testing fr Disease Seve and Frogs 7
Exe Tsing Aer Myocadal Inacio. ur
Funcional Exercise Testing, ue
Eve Text Modal m
Ene Protocol. 12
Upper Body Exc Testing 15
Teig for Rear o Work ur
easements Dring Exec Tong 128
Hear Rate and Blood Pure. EN
Flecrocardographi Monitoring do
Subjective Ratings and Symptons no
‘Gas Exchange and Vento) Responses in
‘Aner Hod Gas Assesment During Execs 1
Indications for Bere Tet Termination 1
Posen Bed 13
aging Modalities Use Conjunction wih Exe Testing 14
Exe Echocardography 1
Garde Raionucide taping be
Imaging Modales not Used Conjunction wih Exercise Testing 135
Pharmacologie ss Testing, 15
‘Computed Tomography in Ihe Asesnen of
Cardiovascular Discs ne

Supero of ere Testing 107

6 Interpretation of Clinical Exorciso Test Results, 12
Exercise Testing asa Serenig Tol for Coromey Artery Dis ns
Tmerpreation el Responses 1 Graded Exes Testing. 1

ear Rate Response ma
Hood Pressure Response 16
lectrocardiograph Waveforms 7
Liming Sigs and Symptoms il
entry Expired Gas Responses to Ener 1
Diagnostic Vl of Exercise Teng 15
Sens 15
Spey 154
Predictive Vale 155
Comparison wi Imaging Sues Tests 155
Prognost Applications ofthe Exec Test be
Section Il: Exercise Prescription 161

Associate Editor Deborah Rice, PHD, FACSM, ACSM-HES

7 ve
a don the Pipes of Exe Pre. ie
Genen! Conran or Berk Prepon 1
‘Soponcts of te Ese Tella Eon ie
‘etic (Carrer Endurance) Er 100

que of rete 16
luc of Eee ier
tere ie Duration) me
tere Vane (Quant) ve
Type ade mm
Ea ol ropesion 1
Musee Fine 1
Frequency of Reine Ente m
Tipos ol Rene Bien i
ame ot testes Execs ess Been) in
Restece mi Tag 194
lesbi Exess Gti) 196
es of Fen Exess i
ame of nly Execs ne Eq. and
Frequency. mn
Er Prop Spero, 10

8 Exerciso Prescription for Healthy Populations with Special
Considerations and Environmental Consderalone m
Pregnancy 14

rece eng 105
Bee rect i

Special Consideran 199

mi Comme ETMIES

‘Caden and Adolescent 200
Entre Tong 201
Encre satin. 202
Spec Consiertons 205

Oder Adu 20
ner Toi 205
Ener rein 208
Special Consietatons no

Lo ack Pain au
Ener Testing 22
sere Psp 2
Spec Considerations 25

Environmental Considero die
seri Hot Environment, =
Ener in Cold Emvinument. 2s
sera gh luted Environments 2

9 Exoreis Prescription for Patients with Cardiovascular

‘and Cerebrovascular Disease 2

Tepatient Rebaaliaton Programs 236
ExerdiePrecrpion 21
Types ol Oupaten Exec Programs 25
spec Constetatons 26

Resistance Training fr Cardia Pants 232

Exercise Training or Return to Work 23
Encre Prescription for Patents with Cerebrovascular Diese (Ske)... 256

10 Exercise Prescription for Populations with Other

Chronic Diseases and Health Conditions. 260
Aris 260
Encre Prscrpion 261
Special Consietations 263
serie Teng det
Specal Consietaons zo
Cerebral Palsy a
Ener Prsnipionspecal Considerations me
Diabetes Melt 8
xeric Testing 260
serie Procrpion 20
Special Comideraons, m
Dyslipidemia 25
Exec Tong 286
Ener satin 2

Special Consideran 287

Finale
Encre esatpin
Spec Cnsieratons
Human mmunodeficiency Vins
Ea Tote
Specal Cnsietatons
Hypertension
serie Ting
sere Procepion
Specal Consieratons
mel Disa Down Syndrome
xeric Testing
Enis Prescrplon
Special Conran or Individual tua Débit
Specie Considerations for Individual with Down Syndrome
kidney Disease
Exercise Testing
Er Prescot
Specal Cnsieratons
Metabolic Syndrome
xeric Testing
Exereise Preston Special Considerations
Male Sclerosis
Exercise Testing
Encre Prcrpion
Special Consietatons
Osecporos
Exerc Prescrpion
Special Consieratons
Overweight and Obesity
xeric Testing
Ener sep,
Specal Consieratons
Wight Los Program Recommendations
arte Sareny
Parkinson Diese
Ener Prescrpion,
Specal Cnsieratons
Pulmonary Dissen
Ama
Exerc Tsing
Ener Presi,
Specal Consietatons
Chronic Obstructive Pulmonary Dace

319
20
sn
52
pa
320
zn
m
5
a

Connie ETMIES

Ever Precip
Spec Consiertons
Spiral Cod jun
Exercise Testing
Exercise Preston Special Considerations
Init with Male Chronic Discs and Heath Conditions
Preparation Hell Screening
Exec Testing
Encre Pracriion
Special Consileraon

11. Behavioral Theo
reguero
meray
"coria Foundations fr Understand erie Behavior
Socia Cognitive Theory and SC)
Transbcoreuc Model
eats li Model
SlbDeterination Theory
Theory of Planned Behavior
Socal Ecologia
"cor Sres and Approaches io Change
Bebaviowncrese adherence
‘uli Sly
Bre Couch and Mouton interviewing
Sag of Change Tale Coursing
‘Group Lade rations
Copie Behavioral Approaches
Social Sopot
‘social vers Dissociation
fit Regalo
Reine Prevention,
Special Populations
“Cah Diversity
Older Ada
Cde
Indias with Obesity
India wih Crone Dieses and eh Conditions

Appendices

‘Common Medications
Emergency Risk Management

Eloctrocardiogram Interpretation

American Collegeof Sports Medicine Certifications
Contibuting Authors tothe Previous Two Editions

nd Strategies for Promoting Exercs

moon»

Index

355
355
356
357

302
20
365

365
307
yo
370
m
En
373
E
Ed
mT
ye

ae
a0
os

m

Abbreviations

AcsM

wor

aus

ar
ARB

ant
as
ae

Cardiovascular and
Pulmonary Relabitation
ane bal ide
American Collegeof
American College of Chest
Physicians

‘rayne lbs
hand card Me
American College of Sports
Malin

actes o ly living
Aleneine diponphate
those
androgendepevaton
deiner

‘American Hospital
Forma Save
sured immunodeficiency
rime

robe interval ining
anne Lames

Angiotensin cor
Hocker

nova therapy
‘Adu Treatment Panel
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SECTION

PAULD. THOMPSON, MD, FACSM, FACC, Associate Editor

‘The purpose of ths chapter so provide current information on the benefits and
risks of physical activity andor exercise. For clarification purposes, key terms
sed throughout the Guidelines related to physical activity and fumes are defined
in this chapter Additional information specii oa disease, disability or health
condition are explained within the context ofthe chapter in which they ae dis
‘ssa in the Guidelines. Physical activity continues to take on an increasingly

tant role in the prevention and treatment of multiple chronic diseases,
Heath conditions, and their risk factors, Therefore, Chapter 1 focuses on the
public health perspective that forms the basis or the current physical activity
recommendations (3,1823,37,56). Chapter 1 concludes with recommendations
for reducing the incidence and severity of exereise-rlated 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
mot synonymous, Physical activity is defined as any bodily movement produced
by the contraction of skeletal muscles tht results in a substantial increase in
calorie requirements over resting energy expenditure (8,43). Exercise is a ype of
physical activity consisting of planned, structure, and repetitive bodily move:
‘ment done to improve and/or maintain one or more components of physica fl
ess. Physical fess is defined as a sn of attributs or characteristics individuals
Ihave or achieve that relates to their ability to perform physical activi These
characteristics are usually separated into the health-related and skll-weated
‘components of physical fitness (ee Box 1.1).

In addition to defining physical activity, exercise, and physical ess, iis
portan 1 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 (VO,R), heart rate reserve
GARR), oxygen consumption (VO), 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 à left tothe eal fitness and clinical exercise professional

MEN coccion

HEALTH-RELATED PHYSICAL FITNESS COMPONENTS |

+ Cordorospiatory endurance Me ality ol Ih cieuatory and respiatoy
System to supply Oxygen during sustained physica activity.

+ Body composition: The relative amounts of muscle, ft, bone, and other
vital parts of the body

«+ Muscuar strong: The abiity of muscle to exert fre.

«+ Muscuar endurance: The ablity of muscle to continue to prform without
fatigue.

+ Floxbilty: The range of motion avaiable at aint

SKILLRELATED PHYSICAL FITNESS COMPONENTS

+ Aglty The ability to change he poston of the body in space with speed
‘and acourey.

+ Coordination: The abit to se the senses, such as sight and heating,
together wth body parts in performing tasks smoothiy and accurately

+ Balance: The maintenance of oqukbrum white stationary oe mon.

+ Poner: The aby oe ato at which one can perform work

+ Recon time: The time elapsed between stimulation and the begining of
the rosction 1 à

+ Speed: The aby o perform a movomont witha a short period of timo.

Chapter 7 provides the methodology and guidelines for selecting a suitable
method

METS ae a useful, convenient, and standarized way to describe the absolute
intensity ofa varity of physical activities. Light physical activity is defined as
requiring <3 MET, moderate as 3-<6 METs, and vigorous as =6 METs (42)
Table 1. gives specific examples of activites in METS for cach of the intensi
ranges fairly complete lst of physical activites and their associated estimates
of energy expenditure can be found inthe companion book of these Guidelines,
ACSMS Resource Manual for Guidelines for Exercise Testing and Prescription
Seventh Edition (50)

Maximum aerobie capacity usually declines with age (14,37) For this reason,
when older and younger individuals work a the same absolute MET lve, the
relative exercise intensity (e, 96VO,,,,) Wil usually be diferent In other words,
the older individual wil be working at a greater VO, than their younger
counterpart (see Chapter 8). Nonetheless, physically active elder adults may have
‘serobic capacities comparable o or greater than those of sedentary younger aduls
Table 12 shows the approximate relationships among relative and absolute exercise
intense for various ness levels ranging fom 6 to 12 MER.

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‘HAPTER 1 Benett and A ===:

‘Classification of Physical Activity Intensity

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PUBLIC HEALTH PERSPECTIVE FOR CURRENT
RECOMMENDATIONS.

Over 25 yr ago, the American College of Sports Medicine (ACSM) in conjune:

ion with the US. Centers for Disease Control and Prevention (CDC) (40), the
US. Surgeon General (53), 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 (eg. <20 min session of
moderat rather than vigorous intensi))

An important goal of these reports was 10 clarify for public health, health
mess, clinical exercise, and health ere professionals the amount and intensity
of physical activity needed to improve health, lower susceptibility to disease
(morbidity), and decrease premature monaliy (40,41,55) In addition, these re.
pons documented the dose-response relationship between physical activity and
health (ie, some activity is beter than none, and more activity: up to a point
‘better than les), Wiliams (64) performed a meta-analysis of 23 sex-specific
cohorts reporting varying levels of physical activity or finess representing
1,325,004 individual years of follow-up and showed a dose-response relation:
ship between physical activity or physical fess and the risks of coronary artery
disease (CAD) and cardiovascular disease (CVD) (see Figure 1.D. is clear that
{greater amounts of physical activity or increased physical fitness levels provide
Auditional heath benefits, Table 1.3 provides ihe strength of evidence forthe
dose-response relationships among physical activity and numerous heath out

More recently the federal government convened an exper pane, the 2008
Physical Activity Guidelines Advisory Committe, to review the sciemifi
evidence on physical activity and health published since the 1996 US. Surgeon
Generals Repor (42). This committee found compelling evidence on the

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‘HAPTER 1 Benett and A === |

benefits of physical activity for health (described in he following section) as
well ste presence of a dose-response relationship for many diseases and health
conditions

“wo 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, sf not all, days ofthe week

+ Additional heath benefits result from greater amounts of physical activi
Individuals who maintain a regular program of physical activity that is longer
{induration andor of more vigorous intensity are likely to derive greater ben:
efit than those who engage in lesser amount.

In 1995, the CDC and ACSM issued the recommendation, “every US.
adult should accumulate 30 minutes or more of moderate physical activity on
most, preferably al, days ofthe week” (40). The iment 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 Sates ina recent survey indicated that they met the minimum
CDC-ACSM physical activity recommendation of participating in moderate
intensity physical activity for 30 min d "on 25d + uk‘! or vigorous intensity
for 20 min + on 23 d+ wk (10),

As indicated carie, the inverse relationship between physical activity
and chronic disease and premature mortality is well established. Since the
release of the U.S. Surgeon Generals 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 i sufficent to reduce the risk
of developing chronic diseases and delaying morality is Wk elem
to prevent or reverse weight gain and/or obesity given the typical American
liesyle. Physical activity beyond the minimum recommendations is likely
needed in many individuals to manage and/or prevent weight gain and
obesity.

Since the orginal 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 morality
(29,31,3945,51,66). Asa result ofan increasing awareness of the adverse health
effects of sedentary behavior and because of some confusion and misinterpreu

on ofthe original physical activity recommendations, the ACSM and American
ear Association (AHA) issued updated recommendations for physical activity
and health in 2007 (see Box 1.2) (23)

M

| + Albo adult aged 18-65 y shoul participate in moderate intensity.

À robe pha city for minimum of 20 min on 5d» wk or vigorous
| intensiy, aerobic activity ora minimum of 20 min on 3 + we

| + Combinaions of moderate and vigorous intensity exorcise can be

À pertomad to meet tis recommendation

| + Moderate intensity, aerobic activity can be accumulated 10 tot the 30 min
À minimum by performing bouts each isting =10 min,

‘Every adult should perorm activites that maintain o increase muscular
Strength and endurance fora minimum of 2 d+ we

| © Bocause ofthe dosesesponse atonshpbetweon physical activity and
host, vis who wie to furor improve thor fans, dues thai ik
for denle diseases and sables, adr revert unheathy weight gan may
bonoft by excoodng minimum recommended amaunts of physical ct.

Similar recommendations have been made inthe 2008 federal physical activity
guidelines (hup:/twwwhealth gov/PAguidelines) (56) based onthe 2008 Physical
Activity Guidelines Advisory Committee Report (42) (se Box 1.3). Regarding aero-
bie physical activity, rather than recommending a specific frequency of acti
per week, the committe decided the scientific evidence supported a oral volume
‘of physical activity per week for health

‘The Primary Physical Activity
it

+ Al Amoñcans shoud patcpate in an amount of energy expenditure equivalent
19150 min «wi of moderat intensity, aerobic acti, 75 min «wh of
90045 intensity, aro act, or combination ofboth that gonerates
energy equivalency 1 ir vegenen fr substantia heath Denes

+ These guidelines further spect a doseesponse relationship, indian,
‘dona heath benefits are obtained with 300 min - wk" or more of

moderate intensity, robe acy 150 mi «wor move of vigorous
intensity robe atviy; or an equivalen combination of moderate and
‘igorousintonsty, aerobic activity.

“The 2008 federal physical activity guidelines als recommend breaking
the total amount of physical activity into regla sessions during the weok
Lg. 30 min on 5.4» wk! of moderate intensity, aerobic actviy) in order to
{reduce the risk of musculoskoletal injure.

‘HAPTER 1 Benett and A === |

BENEFITS OF REGULAR PHYSICAL ACTIVITY AND/OR EXERCISE

Evidence to support the inverse relationship between physical activity and pre
‘mature morality; CVDICAD, hypertension, stroke, osteoporosis, Type 2 diabetes
ells, metabolic syndrome, obesity, colon cancer, breast cancer, depresion,
functional health, fall, and cognitive function continues to accumulate (42),
For many ofthese diseases and heath conditions, there is also strong evidence
of a dose-esponse 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 3055.62)

Since the lat 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:
mendaton, several lage scale observational epidemiologic studies, enrolling
thousands to tens of thousands of individuals, ave clearly documented a dose:
response relationship between physical activity and risk o cardiovascular disease
and premature morality 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). I is alo important 10 note
aerobic capacity (Le, cardiorespiratry fitness [CRFI) has an inverse relation
Ship with risk of premature death fom all causes and specifically from CVD,
and higher levels of CRE are associated with higher levels of habitual physical
activity, which in turn are associated with many health benefits (6,7.2847.61)
Box 1.4 summarizes the benefits of regular physical activity and/or exercise

CSM and AHA have released statements

fre similar to the updated guidlines for adults (18,23), but the recommended
intensity of aerobic activity ls related tothe older adults CRF level In addition,
age-specific recommendations are made conceming 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
(Gos yr) as well as children and adolescents (6-17 y) tp health gov/
PAguideines) (56),

RISKS ASSOCIATED WITH EXERCISE

In general, exercise does not provoke cardiovascular events in healthy ind
viduals with normal cardiovascular systems, The isk of sudden cardiac atest or
myocardial infarction (MI) i very low in apparently healthy individuals perform
ing moderate intensity, physical activity (60.63). However, there san acute and
transient increase in he risk ol sudden cardiac death and/or MI in individuals
performing vigorous intensity exercise with either diagnosed or occult CVD
(20,3548 52,60,55). Therefore, the risk ofthese events during exercise increases

10 EU) === |

D — _

IMPROVEMENT IN CARDIOVASCULAR AND RESPIRATORY FUNCTION

+ Increased maximal oxygen upako resulting fom both conta and
peripheral adaptations

‘Decreased minute ventilation a à given absolute Submaximalintonsity
Decreased myacadal oxygen cost for a gon absolute submaximal

+ Docreased heart rate and blood pressure at a given submaximal intensity

+ Increased copllry density in skeletal muscle

* Increased exercise heshold fr the accumulation of lactate inthe blood

+ Increased exercise tweshold fo the onset of disease signs o symptoms
(6. angina pocirs, ischemic Stsogmont depression, claudication)

REDUCTION IN CARDIOVASCULAR DISEASE RISK FACTORS

+ Reduced resting systaldastol pressure

+ Increased serum high-density Ipoprton cholestrol and docreased sorum
tigcerides

Roducod total body a, reduced ina abdominal fat

Reduced insuin needs, improved glucose tolerance

Reduced tood paolo adhesivenoss and aggrogation

Reduced nfammation

DECREASED MORBIDITY AND MORTALITY

+. Primary prevention (io, interventons 19 prevent tho tal occurence)

2 Higher ae andor fines vos are associated with Iowor ath rates
from coronary artery disease

‘+ Higher actviy andor fitness levels are associated with lower incidonce
rats for CVD, CAD, stoke, Type 2 dabotes malus, metabolic syndtome,
ostecporati fractures, cancer ofthe colon and breast and glbladder
dacase

+ Secondary prevention (io, inorventon aora carding event to prevent
another

+ Based on moteandhoes Ue, poled data across studies) cardiovascular
‘and ak couse mortality are reduced in patients with postnyocardal
infrcton M) who parcipato in cardac rehabiltaion exorcise training,
especialy a a component of mulifactral risk factor reduction

+ Randomized controled tals of ara reablitaton exercise traning
invohing pationts with post Ml do nt support a reduction in the rat of
nonfatal einareton

OTHER BENEFITS.

+ Decreased amiety and depression
+ Improved cognitive funeton

‘HAPTER 1 Benett and A === |

PAP Beneit of Regular Physical Acti
and/or Exercise (Cominued)

Enhanced physical function and independent living in der individuals
Enhanced eeings of wellbeing
Enhanced performance of work recreational and spon activites
Reduced sk ol fl and inure from fa in older indivduais
Prevention or mitigation of functional imitations in older adults
Efecto horapy fr many chronie diseases in odor asis

Garen oe 0 am

with the prevalence of CVD in the population. Chapter 2 includes the prepar

cipaion health screening guidelines for individuals who wish tobe physically
active in order to maximize the many health benefits associated with physical
ati 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
AMA 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 exeris-relted sudden death
in young athletes. Its 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 ofexerise-related death among high
school and college athletes one per 133,000 men and 769,000 women (37)
1 should be noted that these rates, although low, include all sports-related
nontraumatie deaths. OF the 136 total identifiable causes of death, 100 were
‘used by CVD. À more recent estimate places the annual incidence of cardio:
vascular deaths among young competitive athletes inthe United States as one
death per 185,000 men and 1.5 million women. (32). Some experts, however,
believe the incidence of exerise-related sudden death in young sport panic.
pants is as high as one per 50,000 athletes per year. (15). Experts debate on
‘why estimates ofthe incidence of excreise-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 assign

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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 individual, This sde to the higher prevalence of CVD in
the older population. The absolute risk of sudden cardiac death during vigorous
nens, physical activity has been estimated at one per year for every 15,000
18.000 previously asymptomatic individuals (48,53). Although these ates ae 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 (20,3548 53,63) In addon, the rates
of sudden cardiac death and acute MI are dsproporionatly higher in the most
sedentary individuals when they perform unaccustomed or ifrequent exercise (2)

Healhitness 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 Bit adult has about 30%4%
Tower risk of developing CVD compared to those who are inactive (36), The

‘HAPTER 1 Benett and A === |

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 ofthe
coronary arteries produces bending and flexing of the coronary arteries may be
the underlying cause. This response may cause cracking ofthe atherosclerotic
plague with resulting platelet aggregation and possible acute thrombosis and has
been documented angiographically in individual with exercise-induced cardiac
events 61121).

EXERCISE TESTING AND THE RISK OF CARDIAC EVENTS

As with vigorous intensity exercise, the ik of candle events during exercise
testing vares dec with the prevalence of diagnosed or occult CVD in the
study population. Seven studies have documented the risks ol exercise testing
(419.2527.34,4.49). Table 15 summarizes the risks of various cardiac events
including acute MI, ventricular fbrlaton, hospitalization, and death, These data
indicate in a mixed population the sk of exercise testing slow with approximately
six cardiac events per 10,000 tests. One ofthese studies includes data for which the
exercise testing was supervise by nonphysicians (27). In addition. the majority of
these studies used symptom limited exercise test, Therefore, it would be expected
that the risk of submaximal sting in a similar population would be lower

Care

somplicatons during Exercise Testing

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1 EU) === |

RISKS OF CARDIAC EVENTS DURING CARDIAC REHABILITATION

‘The highest ik of cardiovascular events occus 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 ares per 116.906
patient-hours, one MI per 219,970 patient hours one aualiy per 752,365 patient
hours, and one major complication per 81,670 paient-hours (13,17,5839)
These studies are presented in Table 1.6 (2). Although these complication rates
are Tow it should be noted that patients were screened and exercised in medially
Supervised settings equipped to handle cardiac emergencies, The monaliy rate
appears to be six times higher when patients exercised in facilities without the
abilty to successfully manage cardiac arrest (2,13,17 38,39). Inerstingl; how
‘vera review of home-based cardiac rehabilitation programs found no increase in
‘diovascular complications versus formal center based exercise programs (62).

PREVENTION OF EXERCISE-RELATED CARDIAC EVENTS

Because ofthe low incidence of cardiac events related to vigorous intensity exercise,
itis very dificult 0 test the ellectiveness of suntegxs to reduce the occurence of
these events, According toa recent statement by the ACSM and AHA, “Physicians
should not overestimate the risks of exerise because the benefits of habits
Physical activa substantially outweigh the sks.” This report also recommends sev-
ea strategies to reduce these cardiac events during vigorous intensity exerise (2)
‘+ Heath care professionals should know the pathologic conditions associated
with exereise-elated events so that physically active children and adults can
be appropriately evaluated.

Summary of Contemporary Ex

tation Program Complication Ra
om CR Ce cr Ft ie

ás a Compan

Tac DIN 261018 VINO VAIO MENT BIO

si

‘gaa TEEN AERO MAO OS

fa

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CE SEAT

‘HAPTER 1 Benett and A ===:

+ Physically active individuals should know the nature of cardiac prodromal
symptoms (excessive, unusual fatigue and pain in the chest and/or upper
Ick) and seck prompt medical care i such symptoms develop (se Tae 21)

+ High school and college athletes should undergo prepartcipaion screening
by qualified profesional.

+ Athletes with known cardiac conditions or a family history should be
evaluated prior to competition using established guidelines.

‘+ Health care faites should ensure their staf 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

tions in theif exercise capaci; habitual activity lev

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, i is incumbent
on the healivfiness and clinical exeris professional to tke reasonable pre
Cautions when working with individuals who wish to become more physically
cv andor increase thei physical activiy/fmess levels, These precautions
are particularly tue when the exercise program will be of vigorous intensity.
Although many sedentary individual can safely begin a Iighto-moderae in

sity, physical activity program, individuals of all ages should undergo risk clas:
sification to determine the need for further medical evaluation and/or clearance,
reed for and type of exercise testing (maximal or submasimal), and need for
medical supervision during testing (sce Chapter 2).

Sedemary individual or those who exercise infrequently should begin their
programs at lower intensities and progress at a slower rate because à dispros
portonate number of canine events occur i this population, Individual with
known or suspected cardiovascular, pulmonary metabolic, o renal disease shold
obtain medical learanc before beginning a vigorous intensity exercise program,
Healvfaness and clinical exercise professionals who supervise vigorous intensity
exercise programs should have current training in basic and/or advanced cardiac
lie support and emergency procedures. These emergency procedures should be
reviewed and practiced at regular intervals (se Appendix ). Finally; individuals
Should be educated on the signs and symptoms of CVD and should be relerred 10
a physician for fanher evaluation should these symptoms occur

THE BOTTOM LINE

+ A large body of sciemii evidence supports the role of physical activity in
delaying premature mortality and reducing the risks of many chronic diseases
and health conditions. There also cleat evidence for a dose-response rela
tionship between physical activity and health. Thus, any amount of physical
activity should be encouraged,

‘+ Ideally a initial target should be 150 min + kof moderat intensity aerobic
activity 75 min» wh" of wigorous intensity acrobi activity: or an equivale

6 EU) === |

combination of moderate and vigorous intens arabic activity To minimize
musculoskeletal injures, physical activity bouts should be broken up during
the week (eg. 30 min of moderate intensiy, aerobic activity on 5 d= we),

+ Additional heath henelus 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
exerising, especially exercising at vigorous intensity the benefits of habitual
physical activity substantially outweigh the risks. In addition, the transient
Increase in risk i of leser magnitude among individuals who are regularly
physically active compared with those who ae inactive

REFERENCES

1 Armor E, Hall WL Whit MC, a. Compendia o yas: an apie of
Sy codes and MET ine Malt Soma En 2090320 Sapp 6-98

2 mean Cater sora ede Amen con tne acca

ES pt i ree Aa pee PASS, cas
Sees pro sl Eesha py way ores Mdr re

a, hl fi Jono, Sanar E. xr tn: ppt sd complican mes.

5 RGA Back A Gem Deren ad au rey ju Ange. 19752600

6 Ba SN, Kb OR, Bar CE, Pla RS Go IN! Mera CA. Chang in
ia ms and ns may up dy of hs dam men PEU
ae

7. Mt NR UN, Paca RS, ke DG Conor Kins ysl ins and
‘Bsn moray A progeny of hy mc and vom AMA 190017) 95-401

a Capen) owe KE Cto GM Pac ty ox ad php os: Sn
‘Sd iin fr Wear xe Parl rp 1081000 263

9. Comer Dice Com ad ren, A pro renden pha
inane ond DU i a yp BO a

1. Caprice R.Deches JW, Taverne Rel Gamal M, Rein Wehr L, Pool J. Characteristics of

1 D yen ou ay os Cod, O 20

À nd oc nd ome sul Am Col Cal 3010702

2 Dig So Deak Mon fae ia aa ral
The him cence Sajid} 19 OT

24 Dany I. Bl Se bce M, es Amen Cale sl pere Meine Poison Sand
App pea mon ee mes Un D pro weigh pa
A er ine RC

‘HAPTER 1 Benett and A === |

Fe dd cad es oth SONO Hear A IO

10 GA Wie Cs Wag sa time ay el lp re a
pme nom, JAMAS TO

ir. Fan a Ruhe K Goo mis CC y made poten cd
iio ee haps los ooo Che. IBAMOS O.

in Gare Ci fran, Dee MR al in Clef Sp ine Pic Sa.
‘ie quan and quays crise fr drop and marin coran: sie
‘kul ma nono nc ape BY ioe pnt hr retin onto ed
See

19. Gm i SNK IN Cooper K. The say of mi! ex ss, Caton

20 Gn Homo PD Kean). al lac al ro tc rc olsen
‘Sow ma nr JA RENTE

Reed A) Co pl rape nace cnaay promo gr y sre

2 a alo mcr complentos ang a pas Chain,

2. We BM Pat Rc Ml ay ad pa a up menden
tn Ac aig Wo bo A

24 Howley ET Type of ati: reste, abc and ur versus occupational phys act
A 4 Sons Eu, ANS) 33023 in 49-20

tng bce Ken rom land ian fyi proue din mana

‘re eal ening tn) Can 107380 RN

26 Reames Y. ml Je Jen MO opc PG eke Race BA, De
{soc enconng rica sty ad han ens bd pen M So E.
SES Sn

27. RU. Le CA Rice R Mae EL Speo of ea xc te by
‘ent ilps An) Cl 3130 I

a, Es So and Set al Capa ss 3 quinine pedro al
‘Gus malty ad cacao Hoy men and son à mom JA,
Fo

29. sc Mode Kt, Cook NR Mam JE tig JE Php cti dom ar ne
les emo al to gl: pe! JAA BOLD

o. am M iy E, lc WC cat Reese pl y andthe ce
Lea women Nn) 1 11 OA

an. Man JE Grand Pacts A a Wali cored vir sete se pe
‘eto drain ccoo vom. N En Ma 200 STO TOD,

2 ra. ae la Ter ON Mac FS den ng impo at:
‘auc e e Un. 00.206 Coat, AO IBOR

39. a sh Pla LC Mae R Ra WC Mae FO Sole dc ang co
Pen ml Cal demon and pag pola, 150.200 3,

35 sem Nk Ne er Ch, Sms alg J als J. Taig a
{Sew cla il y ny pa caren ren gun weg Oy
iar, Ds à cal no Ou Say crono À EN)

36. Vol Hed Cone (U). Diary freie for Ener Candas, Fe a,
Pett on nto A Wagon DO Nor Andi 008191 y

vy Re ME Rh Sa Pac st he eth ler as eo
Seren Lo de Adern Cll Src td An Ha ar Ned
SE MOSS ls

D Pa Se thd Win AL Lc Jung, Kaper hacian lg
fase ate a ay sg ee

39. alee a Le A moin, pk ci an ce Me expect nor Mad
ne

20. Pac RR a SV cal Sa! acy al pu ah, Aeneon he
{De Co al Prva Aa er re JU

41. Pay al costaba Cases Dement Fac Phys Atty
‘bi Crore ANA ISTMO,

1 EU) === |

yt ty Geet Cm at a fe
es ea a tc a
Er Te en came oe
ny
D oa fag un num
eee ed orale ee nes gs
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14. US unen rt US erre ein Hamann Diary Gt
sc ope ctor cree enn
‘eral ener fo Cec Disc Prevention and el Pot 196. 278, Ñ
ee io
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‘The previous version of Chapter 2 have recommended cardiovascular disease (CVD)
sis ascessment and statiieation ofall individual, and a medial examination and
symptomlimited exercise testing a par of the prepancipaion health screening
roe to nating vigorous intensity physical activity in individuals at increased ile
for occult CVD. Individuals a increased risk in these recommendations were men
45 and women 255 yr those with two oF more major CVD risk actos indvichuls
with signs and symptoms of CVD, and those with known cardiac, pulmonary or
metabok disease, These recommendations were designed to avoid exposing psi
cally uni individuals wo dhe documented risks of exerese including sudden cardiac
death and acute myocardial infarction (MI) as discussed in Chapter L
Compared to previous editions of the Guidelines, the present version of
Chapter 2 regarding he prepariipation health screening proces

+ Reduces the emphasis on the need for medical evaluation (Le, medical exam
ination and exercise testing) as part ofthe prepatcipation heath screening
process prior to initiating a progressive exercise regimen in health, 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 idenulying those with known disease because they ae at greatest
risk for an exercise-related cadiz event

+ Adopts the American Assocation of Cardiovascular and Pulmonary Rehabi-
lation (AACVPR) risk stratification scheme for individuals with known
{CVD because considers overall patient prognosis and potential for rehab:
tation (32) (ce Chapter 9),

+ Support the public health message tata individuals should adopt a phys

y active este

This ction ofthe Guidelines continues o encourage atherosclerotic CVD risk
factor assessment because such measurements a an important art of the prepa
cation health screening process and good medical care, but does seek to sin
lite preparation health screening process in onder to remove unnecessary
“and unproven barriers to adopting a physically active ifesyle (24. This edition of
the Guidelines also recommends healhitness and clinical exercise professionals
19

m GUOEUNES FoR! u. Stratus) === |

consult with their medical collegues when there are questions about patients with
‘known disease and thei ability to participate in exercise programs.

There ae multiple considerations that have prompted these diferent points of
emphass in the present version of Chaper2. The risk ofa cardiovascular event is
increased during vigorous intensity exercise relative to rest, but the absolute tsk
ofa cardiac event is low in heathy individuals (see Chapter 1). Recommending a
‘medical examination and/or stes estas part of the prepancipation health scren-
ing proces forall individuals at moderate to high risk prior to insight
moderate intensity exercise programs implies being physically active confers grat
sick than a sedentary fete (7). Ye, dhe cardioasclar health benefits of regular
exercise far ouweigh the rks of exercise fr he general population 28,29). There
ds alo an increased appreciation that exercise testing i a poor predictor of CVD.
vents in asymptomatic individuals probably because such testing detees Now
limiting coronary lesions, whereas sudden cardiac death and acute MI are usually
produced by the rapid progression of a previeusly nonobstructive lesion (29).

Furthermore, there is ack of consensus regarding the extent ofthe medial evalu
ation (Le, medial examination, tes testing) needed as par of the preprtcpation
nal screening proces prior to initating an exercise program even fof vigorous
intensity. The American College of Caology (ACCYAmerican Hear Association
(ANA) recommend exercise testing prior to moderate or vigrous intensity exercise
programs when the risk of CVD is increased but recognize these recommendations
are based on conflicting evidence and divergent opinions (12. The US. Preventive
Services Task Force (USPSTE) concluded tha here is an inaficiem evidence 10
late the benefits and harm of exes testing before ntting a physical activi
program and did not make specific recommendation regarding he need fr exercise
testing (31), The 2008 Physical Activity Guidelines Advisory Comite Report 10 the
Secretary of Health and Human Services (24) states tha even “symptomatic persons
orthose with erdovascular disease, diabetes, or other active chronic conditions who
‘rant o begin engiging in vigorous physical activity and who have not already devel:
‘oped a physical activity plan ith thei ha cate provider may wish o do so, but
¿les not mandate such medical conc, There is also evidence from decision analysis
modeling routine screening that using eerie testing prior Lo initing an exerce
program is not warranted regale of hasline individual ik (16). These conside
rations form the basis forthe present American Coleg of Spots Medicine (ACSM)
recommendations made in Chapter 2 ofthis din of the Guidelines

“The present version of Chapter 2 does not recommend abandoning all medi
cal evaluation as part ofthe preparicipaion health screening process as implicd
by the Physical Activity Guidelines Advisory Committee Report (24). Such changes
would be a radical departure from prior editions of the Guidelines, I addition
individual a highest risk and those with possible CVD symptoms may bene
rom an evaluation by a health cate provider.

“The present chapter provides guidance for

+ Identifying individuals with unstable symptoms of CVD who could benefit
From medical evaluation and treatment (se Table 2.0,

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2 GuOcuNes FoR! u. Stratus) === |

Pibttors LMD Papioions (ci a on usa mareas: af Mo Toral or
(39 bean he har) may bo inc y ars doo 1
rocas la net bapa lin
Sot ola rnuting rom ata reguganon Paptsiors
9 oo est fom any Sta an gh cda cut
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+ Identifying those with diagnosed disease who could benefit from a medical
valuation that includes an exercise test.

+ Providing appropriate recommendations regarding the initiation, continua
tion, or progression of an individuals physical activity program 10 minimize
the potential for eaastophic cardiac events.

Potential participants should be screened for the presence of ik factors for
various cardiovascular, pulmonary, and metabolic diseases as well as other health
conditions (e. pregnancy; orhopedic limitations) that require special attention
(14.17.18) 1 (a) optimize safety during exerise testing; and (D) aid in the deve:
lopment ofa safe and effecive exercise prescription (xR).

The purposes of the prepanicipaion health screening include the following:

+ Identification of individuals with medical contrsindications that require ex
clusion from exercise programs until those conditions have been abated or
controlled.

‘+ Recognition of individuals with clinically significa dicase() or conditions
‘who should participate in a medicallysupervied exeris program.

. Fer

+ Detection of individuals who should undergo a medical evaluation andor
exercise testing as part of the prepartcipation health screening process before
iniiating an exercise program or increasing the frequency and intensity of
their current program.

PREPARTICIPATION HEALTH SCREENING

Preparticipation health screening before initiating physical activity oran exercise
program sa multistage process that may include

1. Self-guided methods such as the Physical Activity Readiness Questionnaire
(PARQ) (8) (ee Figure 21) or the modified AHAACSM Healy Fitness
Facility Prepartcipation Screening Questionnaire (4) (see Figure 22);

2. CVD risk factor assessment and classification by qualified hea finess,
clinical exeris, or health care profesional; and

3. Medical evaluation including a physical examination and stress test by a
qualified heath care provider

Prepartiipation health screening before intiatingan exercise program should
be distinguished from a periodic medical examination (24). A perodic heath
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
turelated 0 exercise,

SELF-GUIDED METHODS

Preparticipation health screening by self-repored medical history or health risk
appraisal should be done for ll individuals wishing to initiate a physical activity
program. These seleguided 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 HeallvFiness Facility Preparticipation Screening Questionnaire (4)
(Gee Figure 22). Patients with cardiac symptoms ofen perceive chest discom-
fort rather than pain. The AHAVACSM Health/Finess Facility Prepatcipation
Screening Questionnaire may be more useful in these situations because it
{inquires about “chest discomfort” rather than “chest pain” as docs the PAR-Q.

ATHEROSCLEROTIC CARDIOVASCULAR DISEASE RISK
FACTOR ASSESSMENT

ACSM risk clasifcation as delineated in Figure 23 is based in part on the pres
ence or absence ofthe CVD risk factors sted in Table 22 (59.12.21 22.26.3031).
The completed PARQ or ANAVACSM HcaldvFitnes Facility: Preparicpuion
Screening Questionnaire should be reviewed by a qualified healdvfimes, clinica
exercise, or health cae professional to determine the individual meet any ofthe
teria for positive CVD risk actors shown in Tale 2.2 Ifthe presence or absence

2 EU) === |

PAR- R-Q & YOU

E
pl

EICHTIEET EN!

a:

oe ACER pu

FIGURE 21, Psa Actviy Rones Questions PAR) fom. Rep a 1,
‘eth person famine Conan Soy for Extra Pyle, Papa sop.
oto,

MN Fe

‘Assess your ha stats by marin ll tru statement

net

You experience chest disconton with exertion EEE
tere ecc,
a

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ang
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rein, m

ely np ea
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MFIGURE 22. AHWACSM Heat ness Fly Presriopan Serena Questonnare,
Indivaun win ale CVO ak ators eo ede 22 shoud be encourage o comi
‘hee pac prt BENQ oros mena eur program pa 006 mosca!
Car ad sh ross gratuly wih tar oc propa of oy eee any ACSM,
‘even Colega Sports Madi: AHA, Amerean Host Hesocaton: CVD, edo
seas, PTCA percutaraous tonsil cron onpepasy. Media om

= EU) >=:

Review Heath
Medea toy,
tor Known Disease,
‘Sign Symptoms,
CVO Rik Factors

T

‘Cardoso Casas. pup asa or

rom cy gene
wanna ano EMB
at oe
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| a
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pb E A
en

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Fam ary
Number o CVO Risk
Factors
22 <2.
y y
High Risk | el Fr

1 GURE 23. Loge meda fr casino se CU exons CVD, cristo

of CVD risk factor is not disclosed ri ot avale, that CVD risk Factor shoul
be counted asa risk factor except for prediabetes. Ifthe predabetes criteria are
‘missing or unknown, preiabets should be counted asa sk factor for those (a)
45 yr, especially for those with a body mass index (BMD =25 kg m “and (b)
2245 yr witha BMI =25 hg mand addtional CVD risk factors for prediabetes
(eg. family history of diabetes mellitus). The number of postive risk actors is

on y, women ZB, 2
oral inician cron 1 EDEN er aden aa
‘efor Se rn la tea fst anges rate or ol
‘Cont sate mor e those who au wba o TUE
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ponent Sole od pres = 160 mm Ho Er gaste 200 mm Mo

is stat ovat a sta e
denon,
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BB nd. ET hard pa HOD cos
Pre nr rason,
ee re
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then summed. Because of the cardioprotective effect of Mgh-density lipoprotein
cholesterol (HDL), HDL is considered a negative CVD risk cor. For individuals
having HDL =60 mg « AL? (1.53 mmol + 1), one postive CVD risk factor is
subtracted from the sum of positive CVD risk factors.

CVD risk factor assessment provides the heallvíimess, clinical exercise, and
Heath care professionals with important information for the development of a
client or patents Ex R, CVD risk factor assessment in combination with the
determination of the presence of various cardiovascular, pulmonary real, and
metabolic diseases is important when making decisions about (a) the level of
medical clearance; (b) the need for exercise testing; and () the level of super.
vision for exercise testing and exercise program participation (see Figures 23
and 2.4, Please refer to the case studies in Box 2.1 that provide a framework for
conducting CVD risk factor assessment and clasificacion

2 EU) >=:

Rak
(tassiteation
igh Rsk
Low Risk Moderate Risk Symptamaic.or
Aeymplomate Asymolomaso kroun cardovascla
2 Faces, 22 Ra Factors pulmonary ena or
maabole deeace
(soo Table 231
Wesical am Rec | [Medical Exam Reo Magica Exam oe
Bolore Exercise? Belore Exercise? ‘Bolte Exercise?
Mod Ex- No Mod Ex No Mod Ex we
Vg Ex. No Va En Yes Vs ves
Exercise Test Rec Exercise Test Rec Exercise Ta Roe
Before Exerc? Belore Exerc? Flore Exercise’?
Mod Ex No Mod Ex-No Mod Env
Va Ex No Va Ex -No Von ve
mo Supervision ot | [MO Supurvisionor | [HD Supervision of
ExercisoTes ‘Exercise Test Exercio Test
4 Done? Done? Done?
Sama No Sumar = No Sama Vos
Man No Mae No Manes

Mod Ex: Moderato intensty ere: 40% <60% VOR: METS
“Am onsty that causes ROC incroes in HR and breathing”

Mg Ex: Vigorous ions exercise: 260% VOL: 26 METE
An menaty ta causes substances in Hand breating:

Not Ree: Rates the sation a medical examination, exis ost, and physician
supervision of exar testing are nol ecommanded inthe
Propartipaton scaring: however, they may be considered whon thre
Sto conenns about ek mao oration naedod fr ne Ex Ry, ane
‘af requoste bythe paient or cont

Fee: Ratects the nation a medical examination, exis ost and physician
supervision e recommended in he prepariopaton heath cesen
process.

M RGURE 24. Madea examinan, enc tesing and supero for ating
Preprtpatenraconmensitons tases on gain of sk EX, exeoas pesergton:
Fanart rate, METE metal anus VO omg pio resi

Coso Studies to Con
Factor Assessment and

80xz

a
eM

Female, ag 21 y. smokes soialy on weekends (10-20 cigarettes. Drinks
“lohan or two nights a weak, sualy on weotends. Hot = 63 i (160 cm,
weight = 1241 664 kg, BMI = 22.0kg - m2, RHR = 76 boats min”). resting
BP = 11/72 mm Hg, Total colesterol = 178 mg: dL-" 1461 mena.

LOL = 98 mg dl." 2.54 mmalL-1, HDL = 57 mg dL (1.48 mmol 1-1,
FBG unknown. Curenty taking ral contraceptives. Atonds group execs class
{wo to woo times a week. Reports no symptoms, Both parents hingandin
good heath,

case STUDY I
Man, age 54 y, nonsmoter Height = 72 in (182.9 cm) weight = 168 1b
(76.4 4g), BMI = 22.8 kg -m 3, BHR = 64 beste « mín, esting BP =
124/78 mm Hg. Total cholestrol = 187 mg = dL" 14.34 mmol L-, LOL =
109 mg 1 (2.67 mmol-L- Y, HDL = 62 mg - dL! (1.38 mmel + UY,

FG = 88 mg = dL (484 mmol L'). Recreational competitive runner
runs 4-7 d wht, completes one to two marathons and numerous other
‘oad races very oot. No medications othr than owerthecountr ibuprofen
as needed. Reports no symptoms. Father ded at age 77 y of @ hear atack
mother died at age 81 ye of cancer

‘case STUDY
Man, ago 44 yt, nonsmokor Height = 70 n (1778 cm) weight = 216
198.2 kg, BMI = 310 kg m2 RHR = 62 boas min", esting BP
126/84 mem Hg, Total serum cheesterol = 184 mg = 1.77 mmol +,
LOL = 106 mg ="! (2.75 mmol L"),HOL = 44 mg = dt?

(1.18 mmal LY. FBG unknown. Walks 2-3 mi two 1 vee times a week
Father had Type 2 diabetos and ied at age 67 y ofa har attack: mother
living, no CVD. No medications reports no symptoms

‘CASE STUDY IV
Women, ago 36 yr nonsmoker. Height = 64 in (162.6 cm) weight = 106 lo
169.1 kg. BMI = 185 kg = 2. AMA = 61 beats - min, resting BP =

114/62 men Hg, Total cholesterol = 174 mg = dL! (451 mma L-Y, blood
(30050 normal with insulin npctns. Type 1 diabetes diagnosed at age 7 y.
“Teaches dance aerobic classes tree times a week. walks aproximately

45 min four times a wook. Reports no symptoms. Both parents in good haath
with no history of CVD,

(eonvnved)

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All individuals wanting to initiate a physical actvity program should be
screened at minimum by a self-reported medical history or health risk appraisal
{questionnaire such asthe PAR-Q (8) (see Figure 2.1) or the modified AHVACSM
calmes Facility Prepaticipaion Screening Questionnaire (4) (see Figure
22) forthe presence of risk fctors for various cardiovascular, pulmonary, renal
“and metabolic diseases as well as other conditions (eg, pregnancy, ohopedic

. Fer

injury that require special attention when developing he Ex R, (14.17.18). The
answers tothe self-guided methods ofthe preparticipation health screening pro:
«ess then determine the need for and degee of follow-up by a qualified heathy
fines, clinical exercise, or health cate provider before initating physical activity
oran 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 exereise-related event such a sudden cardiac death (27) or acute
MI 13.19.27) is greatest in those individuals performing wnaccustomed physical
activity and is greatest during vigorous intensity, physical activity However, the
VD risk ofight-o-moderate intensity, physical activity approsimates that at
3) Consequently, physically uni individuals initiating a physical acuity pro-
gram should start with lghtto-moderate intensity levels of exercise and progress
gradually a thei fitness improves. Moderate intensity in most studies of exercise:
Felted CVD evens is defined as activity requiring 3 to <6 metabolic equivalents
(METS), but the relative intensity of any specific acuvty varies with the ness and
age ofthe subject. Moderate intensity, physica activity can also be defined as that
requiring 40% to <60% oxygen uptake reserve (VO,R). This physical exertion
level an be estimated without exerise testing and diet measurement of maximal
oxygen consumption (VO) by instructing subjects o us a rating of pereived
exertion scale (see Chapter 7) or by exereising to the point of developing moderate
shortnes of breath or dyspnea but sil able o alk comfortably (6.23).
The present ACSM recommendations (sce Bax 22) ate based on the observ
ons thatthe absolute risk of an exereie-related CVD event slow especialy for

+ Invite at moderato sk with two or more CVD risk factors (ses
Table 22 ond Figure 2.9 shoud be encouraged to consult wt their
physician pro oinitatng 9 vigorous intensity exercise program as prt
01 good medical care and should progress gral with their exercise
Program of any exercise intensity (see Figure 2.9. Although medical
valuation taking place forthe ination of vigorous intensity exercise,
the majority of these individuals can begin ight tomoderat intensity.
entre programs such a walking without consuling à pican

+ Individual at high isk with symptoms or diagnosed disease (see Tab 2.1)
should consult with thei physican pro o nilaung an exercise program
(soe Fo 2,

32 GUOEUNES FoR! u. Stratus) === |

{individuals willing to initiate light-to-moderate intensity exercise and to progress
sgradally, The exceptions to these observations ar individuals ah diagnosed
disease, with unstable symptoms, or at extremely high risk for occult disease
(ee Table 2.1).

RECOMMENDATIONS FOR EXERCISE TESTING PRIOR TO
INITIATING PHYSICAL ACTIVITY

See Table 23 for recommendations for exercise testing prior to initiating physi
cal activity

No set of guidelines for exeris testing prior to initiation of physical activity
covers al situations Local circumstances and polices vary. and specific program
procedures re also properly diverse. To provide guidance onthe need fora med
«al examination and exercise test before participation in a mederat-to-igorous
intensity exerise program, ACSM suggests the recommendations presented in
Figure 24 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 fs not routinely
recommended except for individuals at high risk as defined caler (see Tables 2.1
and 23). Nevertheless, the information gathered from an exercise test may
be useful in establishing a safe and effective Ex R, for lower risk individuals
Recommending an exercise test fr lower risk individuals may be considered if
the purpose ofthe test iso designan effective Ex R, The exerese testing econ
‘mendations found in Figure 24 reflect the notion thatthe risk of cardiovascular
events increases a a direct function of exercise intensity (Le vigorous > moder
ate > light intensity exercise) and the number of CVD risk actors (see Table 22

[ast one e coeur deere es D 22
ie 238 y 0
Type sabes male STO AN OR
Tap sabes mals STE y mon OF
parrcistenioma dats chats «280g "U TSR amor D TOR
Hypertonic cd peer = 10 or dante 00 men OR.
‘Sotng OR
Frey nator ol CAD a ere laa ZEB OR
Presence of miro lr deste OR
Puerca ster Sas OF
oname raza
End age ool esse
Patents win item o aogrased parva dose cian avon cisco
palomar Seon COPD, sca, ments ng eses, cyte ens.
ESA ntc Gage of Sos Maser A, ry an Soe

.’ Fer

and Figure 23). Although Figure 24 provides both absolute (METS) and relative
(VO...) theesholds for moderate and vigorous intensity exercise, healthy
fiess and clinical exercise professionals should choose the most appropriate
absolute or relative intensity threshold for thei setting and population when
making decisions about the level of preparicipaton health screening needed
before initiating an exerise program.

RECOMMENDATIONS FOR SUPERVISION OF EXERCISE TESTING

‘The degree of medical supervision of exercise testing varie appropriately from
physiciansupervised tests 10 situations in which there is no physician pres
(I is important to distinguish between patients who require an exerie 1
before exercise paicipaion and patents who require a physician to supervise
the exeris test. Exercise tess as part of the preparicipaton health screening for
individuals at moderate to high risk are often maximal tests done in those without
por exercise training. Both factors probably increase the risk ofa cardiac event.
Furthermore, there ate legal implications for the testing (city if complication
‘ccs during testing and the testing isnot physician or professionally supervise.
There is consensus that exercise testing of all patient risk groups can be su-
pervised by nonphysiian health cate professionals he professionali specially
tained 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 nonphysicans 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 nota physician must be immediately available
for exercise testing of patients at moderate risk will depend on local polices and
circumstances, the heath stats of the patients, and the training and experience
‘ofthe laboratory stall, See Box 23 fr a summary of these recommendations.

Exercise testing of individuals at high risk can be supervised by nonphys-
an heath car professionals tthe professional s specially trained in circa!
exercise testing with à physician immediately male needed. Exercise
testing o inavidals at moderate sk can be Superisad by nonphysican
health coro professionals i the profesional is specially aine in cnica
exorcise testing, but whether or not a physician must be mmedataly ava
bl for exercise testing is dependent on local polices and cicumstances,
the healt status ofthe patient, and the traning and experience of the
laboratory stat.

A EU) === |

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 i
performed, site personnel should at least be certified at a level of basic Me
support (cardiopulmonary resuscitation [CPR]) and have automated external
Aefibrilator (AED) training. Preferably, one or more staff members should
also be certified in frst aid and advanced cardiac life support (ACLS) (15). All
exercise testing facilities with or without physician supervision (a) should also
have a writen medical emergency response plan with procedures and contact
numbers: (b) should practice this plan atleast quarterly: and (0 be equipped
with a defibrillator or an AED depending on safing competencies (20)

RISK STRATIFICATION FOR PATIENTS WITH
CARDIOVASCULAR DISEASE

Patents with CVD may be further stratified regarding salıy during exercise
using published guidelines (2). Risk stratification criteria from the AACVPR are
presented in Box 2.4 (2)

American Association of Cardiovase

LOWEST RISK
Characteristics of patents at lowest isk for exorcise participation (all
characteristics ited must be present for patents to remain at lowest Hs)

+ Absence of complex ventricular dystytmias during exercise testing and
recovery

‘Absence of angina or other significant symptoms (ag. unusul shoriness
of breath, lightheadedness, or diziness, during eerie testing and
recovery)

+ Presence of normal hemodynamics during exercise testing and ecovery|
(io, appropriate increases and deeronsos in hor rato ond systole Blood
pressure with increasing workbads and recovery)

+ Funcional capacity =7 metabolc equivalent (MET)

Nonexorcise Testing Findings
Resting join action =50%

Uncomplicated myocardel infarction or revasculazation procedure

[Absence of completed venticular dysthythmas at est

‘Absence of congosive hear faire

[Absence of signs or symptoms of postoventpostorocedure ischemia

‘Absence of cnica! depresion

nd

I: co

80x24

À MODERATE RISK

{Gharactaristes of patients at moderate risk for exercise participation (any
‘ono or combination of these findings places a patient at moderate risk)

‘Presence ol angina or other significant symptoms (2.9. unusual shortness
of breath, lightheadedness, or dzzness occuring oly at high levels of
xorion [27 METS)

+ Mi to moderat love of sont schamia during exercise testing or
recovery (STsogment depression <2 mm trom basoline)

+ Funcional capacity <5 METS

Nonexereso Testing Findings
Rest ejection faction 40% to 49%
HIGHEST RISK.

{Gharactarsties of patients at high ak for exercise participation [any one
or combination of these findings places a patient at high risk)

‘+ Presence of complex venticlar dormia during oxorcis testing o

+ Presence of angina or other significant symptoms (e.g. unusual shortness
of breath, lightheadedness, or dizziness at lw loves of ern
1<5 MET] or during covery

+ High level of sent ischomi (SFsogment depression =2 mm fom
bosolno) during exes tos o covery

+. Presence ol anormal homodynamies wih exorcise testing
Lie. chronoopieincompolonce or Ha or decreasing systl BP with
increasing workcads) 0 recovery (ie, severe postoxrciso hypotension)

NonexorcisoTesting Findings
Rest ojecton action <40%
+ History of cardac armes ar sudden deat

Complex dstythmias at rest
Complicated myocar infarction or ovascularizationprocoduro
Presance of congostv heart faire
Presanco a signs or symptoms of Postevon!postprocndure chomia
Presence of lnical depression

= EU) >=:

The AACVPR guidelines provide recommendations for participant and/or
patient monitoring and supervision and for activity restriction. Clinical exer
‘ise profesional should recognize the AACVPR guidelines do not consider
comorbidities (eg, Type 2 diabetes mellitus, morbid obesity, severe pulmonary
disease, debilitating neurologie, orthopedic conditions) that could result in
modification of the recommendations for monitoring and supervision during
exercise training,

THE BOTTOM LINE

‘The ACSM Preparcipation Health Screening Recommendations are the following

+ AI individuals wishing to inate a physical activity program should be
screened at minimum by a sellxeponted medical history or heath risk ap
prasal questionnaire. The need and degree of follow-up 1 determined by the
answers to these self-guided methods,

‘+ Individuals at moderate risk with wo or more CVD risk factors (see Table 22
and Figures 2 3 and 24) should be encouraged to consult with their physician
prior o initiating a vigorous intensity. physical activity program. Although
‘medical evaluation is taking place, the majority of thes individuals can begin
light-tosmoderate intensity exercise programs such as walking without con
sulting thee physician,

‘+ Individuals at high risk with symptoms or dlagnosed disease (see Table 2.1)
should consult with their physician prior to iniiaing a physical activity pro
gram (see Figure 2).

+ Routine exercise testing is recommended only for individuals at high risk
(see Table 23 and Figures 2.3 and 24) including those with diagnosed
CX, symptoms suggestive of new or changing CVD, diabetes mellitus,
and additional CVD risk factors, end-stage renal disease, and specified hung
disease

+ Exercise testing of individuals at high risk can be supervised by nonphy.
sician health care professionals i 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 to reduce barriers to the adoption of
a physially active lifestyle because (a) much of the risk associated with
exercise can be mitigated by adopting a progressive exercise traning regi
‘men; and (b) there isan overall low risk of participation in physical activity
programs (24)

Acs Es la Media
cm

200 Pal Ati ileso Ames):
AS

REFERENCES

1.208 Phyl Ati Cs fr Amero [mme Rachie (MD): Ole of Diem
Penn ai Promotor. US Beymer ea and Haman Servo 206 ted 2010

EDEL Top. nal en tape at palas

Forn Aca à Corsi ad Famoso) Relea. Gaddis fe Conc

BE cl Sey sen Pape ign: Haman Ka:

‘ran Rn dnc al uy bin, as cay

‘MSs sang md en ples fens ca Med Sa

Sect Dub Acer Dos nd dienen of dks men Die Cs

men CA Vacs MA, Ehrman JK a. Going er wing e taming ens

wth coronary ay dol ese 202015 que To.

hac Da pal acy tno er dilo) sd ol ads re

303250 opp a

8 nai Pa tin Geo ety Act ig ra) On (Canal): ube Het
an mp ae me

9. nn A GL. ck HR a Te sah cpr lb Jot Nan Comic en
Frein. Decor, Polo dome ol Hh Bod Pour NC ee J
Sao 72
han a alt Ah fr Me. OLI SO

I. her GBC) Amacda EX aa Er sans fr tg and ag a
ment Roue pul fe die Amon Hae Caio, 0

hon Ra ce Ja ACCU 2002 ge wpe freee sing

mm aie A ep of he Aan Cole of Come ean An Io

Feen hace Coun (Computo Upa 1109 tac aig Cad) jin

1. ns Thonpen PD Renan? Cina nd soggy chars oes che
‘Sete mota más Jas IDO O

14 Condo US Heath spat in o al sting le Darin Ler. AC Roo
Al fr ans Es Tg má Propio 28 Pili Ve à

23 Km KR Hagen Fi YN gins cepa reso ad emergency
da one ching nthe agent ol ondas anos JA OL SOT.

16 Dar Cc neat fr eee ree na e hala
Aeon al J Gen tan Md 200 269 SD

un. ce imi hapa, Rms peptone nd
im the working groupe th Word Heat Federation. he email Fede of Sp

= GUOEUNES FoR! u. Stratus) === |

N succor nah pas Sen Dah Comm Ga or
Be ge ec Ds ier arn dene he oun), eon

19 Mie MA, clr tole GH Mig acte myocar min y my
payo un rocio auna ige hy o ren, Duele of Mal
[eos De suo vean. NE Ma LET

20. Mora). ena Reno Bal Kamen er ni ce ane sena

Nina choot cn frog (EP Pape Ft on Desc. Ea

Tenner a gh Mod Cet (Uses on) hd Ron oe

‘iter! Cole Eaton Fog (NCLP) pe Fae on Den alias and

Tenner tig tino Chaser deme Pod on Osten

RON Der

22 ate RR rat SNL ta Misa ig nd pa a. A recommendation fo be
Cr Doce Cons and Petron al Aa Calg of Spas eine A
ME.

2 erg. R o €. ben M, Ft DE, Fra Come lb uk lr cx
Frown hel o eure 200010326

2 Rl in Calo Al, Comm An 200 a, Wet DO, US
arme Hd aan Cons, 208 Ic On 48). Anke kn u
ates pp rpm

2. gor GE nb Baby. a Aneto alee of Cndog/menan Han
‘ecto inal compete atmen on are testa, A por a he mon Cl
eignen Hort Aci amenos Cale lynn American Sony 1
incl ne fs Foren lc Competence. Coto 0 OCIO

an Rig GAS on Da eae Dn re HU pon

27. Seco Wess N che BE Ls Thence pr ia as during or
tus ce NE ted DAL

as. Theron O, bute DR al Ena ad phn ay presets and et
en lero rms Ines sar e Conc a in Cul,
Somme on sect asin tn Pecan aa Comal on Nuon: Pac
‘chan Metin Seen Pi Ay) Caton 2001020 o.

2», Tempe PD, Fin EX ad) eal Tee ad ae cana ce plang
‘ion’ tev and Mota ade Cooma Cl Cano Ct:
EEE

0. US animent te and aman ers, a At nt Ha Reg Ue Sorgo
‘Stemi Corr Chen Be evenson nd Prom 998. 8p

vn het son hon Ex rr a go Ce

23, Sich SN Lew M Laws, Ar RSet Shoe R Phare ol
moin. ger nd channel natn Sy Gn ag
AS

SECTION

ROSS ARENA, PHD, PT, FACSM, FAACVPR, FAHA, ACSM-CES, Associate Editor

‘This chapter contains information elated tothe preexercise evaluation and serves
as a bridge among the preparucipaion health screening concepts presented in
Chapter 2, the fess assessment in Chapter 4, and the clinical exercise testing
concepts in Chapters 5 and 6. Although Chapter 3 contents (eg, medical history
physical examination, identification of exercise contraindication, informed con:
Sent procedures) relat o healhitness and clinical exerie settings, lower risk
populations typically encountered in healthfitness settings will llow for ales
sophisticated appreach o the preesereise evaluation, Therefore, ablnevated ver
sions ofthe preexeris evaluation described within this chapter are appropriate
for low and moderate-risk individuals wishing to engage in light-io-moderate
intensity exerise within healthfitness settings. However, high-risk individuals
‘whether in healtfitness or clinical settings wll quire a more intensive medical
‘valuation prior to initiating an exercise program (sce Chapter 2).

The extent ofthe preexercs evaluation depends on the assessment of risk as
‘outlined in Chapter 2 and the proposed exercise intensity ofthe physical activity
program. For individuals at high risk (ce Tales 2.1 and 2.3), a physical exam
ation and exeris test are recommended as part of the precxercise evaluation
by aquaified health care profesional to develop a safe and effective exercise pre
scription (Ex R,). For individuals at low and moderate risk wishing to perform
light-to-moderate intensity exercise such as walking, a preexercse evaluation
that includes an exercise test generally not recommended (see Figures 23 and

heless, a preexercse evaluation that includes a physical examina.

sc test, and/or laboratory tests may be waranted or these lower

risk individuals whenever the healvfiness and clinical exercise profesional

Jas concerns about an individuals cardiovascular disease (CVD) risk, requires

additional information to design an Ex R, or when the exercise participant has

concerns about starting an exercise program of any intensity without such a
medical evaluation,

À comprehensive preexercis tet evaluation inthe clinical setting generally
includes medical history physical examination, and laboratory tests, the results,
of which should be documented in the clients or patients file. The goal of
Chapter is not to be totally inclusive orto supplant more specific considerations
that may surround the exerisepartiipant, but rather to provide a concise set of
guidelines for the various components ofthe preexercise evaluation.

MEDICAL HISTORY, PHYSICAL EXAMINATION, AND
LABORATORY TESTS

‘The preexerise medical history should be thorough and include past and cur-
rent information. Appropriate components of the med
in Box 3.1. A preliminary physical examination should
an or other qualified heal care profesional before exercise testing individual
at high risk as outlined in Chapter 2. Appropriate components of the physical
examination specific to subsequent exeris testing ae presented in Bex 32. An
expanded discussion and alternatives can be found in ACSMS Resource Manual
for Guidlines for Exercise Testing and Prescription, Seventh Edition (26)
Identficaion and risk stratification of individuals with CVD and those at
igh risk of developing CVD are lactated by review of previous tet results
such as coronary angiography, nuclear imaging, echocardiography, or coronary
artery calcium score studies (13) (se Box 22). Additional testing may include
ambulatory electrocandiogram (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 revascularzaton procedures,
or determine the need for addtional assessment. As outlined in Box 33, other
Laboratory tess may be warranted based on the level of risk and clinical status
ofthe patent, especially for those with diabetes mellitus, These laboratory tes
‘may include, but ae not limited to, serum chemises, complete blood count,
serum lipids and lipoproteins, inflammatory markers, fasting plasma glucose,
hemoglobin AIC, and pulmonary function. Deuailed exercise tsting/training
sidelines for a number ol chronic discass can be found in Chapters 5 6, 9, and
10 wihin the Guidelines,

Although a detailed description ofall the physical examination procedures
listed in Box 3.2 and the recommended laboratory tests listed in Bax 3.3 are
beyond the scope of the Guidelines, addtional basic information related to
assessment of blood pressure (BP, lipids and lipoproteins, ther blood chemis-

es, and pulmonary function are provided in the following section, For more
detailed descriptions of these assessments, the reader is referred 10 the work of
Bickley (D)

BLOOD PRESSURE

Measurement of esting BPs an integralcomponento the preexercise evaluation
Subsequent decisions should he based on the average of two or more properly
‘measured, seated BP readings recorded during each of two or more ofie visi
(21). Specific techniques for measuring BP are critical to accuracy and detec
jon of high BP and are presented in Box 3:4. In addition to high BP readings,
‘unusually low readings should also be evaluated for clinica significance, The
Seventh Report of the Jot National Commitee on Prevention, Detection, Evaluation,
and Tcatment of High Blood Pressure UNCT) provides guidelines for hypertension

a ----—-

1 appropriate components of the medical history may include the folowing:

+ Modical dignas. Codirasculrdisoso sk factors incuding hypertension,
obesity, dytoidomia, diabetes, and etapa syndrome, crdiovasculr
(Sspase clung heart fluro, velar dysfunction (0. cote stenosisimitral
vale disease), myecarda infrcton, and other acute coronary syndromes
percutaneous coronary interventions indudng angoplasty and coronary
tenis, coronary artery bypass surgery and other cardiac sugeres such
as var sugery(cadac vanslantatin: pacemaker andor implantable
carovorr dolor ablation procedures for dsthythmias; peripheral
vasc iso; pulmonary d09se neidng asthma, omprysoma, aná
‘bronchi cerebrovascular oe incudiag stroke and vansiont ischemic
atacks anemia and other blood dyscresis e. lupus erythematosus:
‘ibis, deop vin tvombosi, or embol; cancer pregnancy osteoporosis;
muscuoslelta disorders: emotional dsorors and eating isrders

“+ Previous physical examination findings. Murmus, cs, galop hm,
‘other obnormal hart Sounds, and thor unusual cardiac and ver
findings; abnomal pulmonary indings (0. wheeze, rls, cache);
plasma glucose, hemoglobin AIC, gh senstviy Creactvo protein, serum
ids and Ipoprotois, or thorsignihcot ibortory anormal, gh
‘lod pressure; and edema,

+ History of symptoms. Discomfort eg. pressure. Unging sensation, pain.
heaviness, bung, tightness, squeerg, numbness) in th ches, aw,
neck back, or arms: ight-headodess, dizziness, or fining: temporary
loss of val aut oF spooch; transit unilateral numbnoss o weakness
shociness of bath pi heartbeat or paptations, especialy if assocatod
‘th physical activity, eating a argo meal, emotional upset. or exposure to
(ol (or any combination of those actes.

“+ cont nos, hosptlzaion, now medical dagnases, or sugica procedure,

+ Onhopadie problems including artis, it swelig, and any condition
{hat would make ambulation or use of cera test modalities dit,

‘Medication uso Induding Getaryloutitional supplements and dg allies.

+ Other habits including can, cor, tobacen, recreational ci drug use.

+ Exerciso history: Information on reinos for change and habia! evel of
actvay: frequency. duration or tene, type, and intensity o FIT of exercise.

‘+ Wea istry with emphasis on eurent or expected physical demands,
‘ating upper and lower oxtromity requirements.

“+ Family history of cada, pulmonary, metabolic disease, stoke, or
sudden ath

Iren ny Fri.

Ea
D mene

Appropriat components o ho physical examination may incio the flowing

+ Body weigh: in many instances determination of body mass index wast
rt, andor body composition (percent body fal is desirable

+ Apical pulse rte and rm

+ Resting blood pressure: sated, supine, and standing

«+ Ausculation of te longs with specti attention to unlormity of breath
Sounds in a aras (absence of rales, wheeze, and ther breathing sounds)

+ Papaton ofthe cardiac apical impulse and paint of maximal impulse

+ Auscuitation ofthe heart with spocifi tention to murmus,galops dis,
and ube

+ Papation and ausestavon of arti, abdominal and femora anis

«+ Evaluation ofthe abdomen for bowel sounds, masses, vscoromegah, and
tendemess

+ Papation and inspection of ower extremos fr edema and presence of
arora pulsos

‘Absence or presence of tendon anthoma and skin xantrolasmo

+ Folowup examination elated to orhopeci or other medica conditions
{that would ist exercise testing

+ Tests of neurologie funcion including relxos ond cognition las indicate)

+ Inspection of he skin, especial ofthe lower extremities in known
patents with diabetes meltus

Peer

detection and management (23). Tale 3.1 summarizes the JNCT recommend
ons forthe classification and management of BP or adults

“The relationship between BP and risk for cardiovascular events is continuous,
consistent, and independent of other risk actors, For individuals 40-70 y, 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 entre BP range of 115/75 to 185/115 mm
lg, 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 Dictary
Approaches to Stop Hypertension (DASH) cating plan (Le, a dit rich in fru
‘vegetables, low-fat dary products with a reduced content of saturated and total
fa), dietary sodium reduction (no more than 100 mmol or 24 g sodium + 4),
and moderation of alcohol consumption remains the cornerstone of antihyper:
tensive therapy (423). However, JNC7 emphasizes the fact that most patents
with hypertension who require drug therapy in addition to lifestyle modification

de quoeunes ror! u. Stratus) === |

À INDIVIDUALS AT LOW-TO-MODERATE RISK
+ Fasting serum total holesteol LOL cholesterol HOL cholesterl, and
tigycerdes

+. Fasting plasma glucosa, especially in individuals 245 yr and younger
individuals who ao overweight (body mass index =25 k m) and have
one oF more ofthe folowing risk actor for Type 2 abetos mits: a
fist-dgreo relativo with abetos, member 01a igh-sk ethnic population
(eg, Alan American, Latino, Nabve American, Asian America, Pac
Islandor), dolvorod a baby weighing >91 (8.08 kg or history of gostatonal
dabotes, hypertension (BP =140990 mm Hg in adults), HOL choestoot
<40 ma = dL-"(<104 mmol +L) andor vigycrides = 180 mg» al.
(2169 mmol L-), previously ido impaired glucose tolerance
or impaired fasting glucose (fasting gucoso = 100 mg aL"; 28.55,

‘mmol L-, habitual physica inactivity, poyopsti ovary disease, and
history of vasco disease

+ Thyroid function, asa screening evluaion especialy l dysipidemi is present

INDIVIDUALS AT HIGH RISK.
+ Procoding tests pls partent previous cardiovascular laboratory tests
(e.g, resting 121604 ECG, Holter monitoring, coronary angry

radionudide or echocardiography studies. previous exercise test)

«+ Corot utrasound and other paripheral vascular studies

| + Considor moasures of ipopretintl, high sansiviy Creactve protein,

LOL parti iz and number and HDL subspecies (espacialy in young

individuals with a strong famiy history of premature CVD and in those
individuals vthout vadtional CVD risk factor)

«+ Chostodograp, hear toro is present or suspocted

+ Comprahenshe blood mit panel and complet tod count as
indicated by history and physical examination (so Tabo 3.

PATIENTS WITH PULMONARY DISEASE
Chest odootoph

«+ Pulmonary function tosis ee Tobe 3.3

+ Carbon monoxidodituin capacity

+ Other specialized pulmonary studios (.9, oximetry or blood gas analysis)
‘ho LOL onary apna Goss

1. Patents shoud be seated quity fr atest § min na chair wih back
support atar than on an examination table) with the fat on the foe
and their rms supported at heart level. Paints should retain rom
smoking cigares ar ingesting caffine or at last 30 min precoding the

2, Measuring supine and standing valves may be inicatod under speci
Sreumstances,

3. Wap cult firmly around upper am at hart el algn ut with
bac ater,

4. The appropriate ouf size must bo sed to ensure accurate maasuroman.
The bladder within th cu should encre at last 00% ofthe upper am.
Many adits quite a large adult cult

$. Paco stthoscope chost poco below tho ante space ove the
bachal aer, Bel and daptragm sido of dest piece appear equally

lacio in assessing BP (15

ui init cut pressure to 20 mm Hg above fist Kootot sound

Souy clase pressure at rate equal t 2-5 mm Hg 5".

8. SBP is the point at which he fist of two r more Kerotkot sounds
is heard phase 1, and DBP is no point bafore tho disappearance of
Korotot sounds phase 8

9. Atleast two measurements shoud be made Iminimum oft min apor

and the average should be take.

10. BP shoud be measured in both arms during te fist examination. Higher
pressure should bo used when theo is consistent interarm difference.
Provide to patients, verbally and in wing, tei spectic BP numbers and

BP goals

Produ fr Assessment

require two or more anuhypertensive medications to achieve the goal BP (ie.
<140/90 mm Hg or <13080 mm Hg for patients with diabetes mellitus or
chronic kidney disease) (23).

UPIDS AND LIPOPROTEINS

‘The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of
igh Blood Cholesterol in Adults (Add Treatment Panel I or ATP I) outlines
the National Cholesterol Education Program’ (NCEP) recommendations for
cholesterol testing and management (se Table 32) (27) ATP I and subsequent
updates by the National Heart, Lung, and Blood Institute (NHLBD, American

“ EU) >=:
sification and Management of Blood Pressure for Adults!

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ATP Il Cassation of LDL Total, and HDL Ch

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Heart Association (ANA), and American College of Cardiology (ACC) identify
loves lpoprotein (LDL) cholestrol asthe primary target for cholestrol-
lowering therapy (12.2427). This designation is based on a wide variety of
evidence indicating elevated LDL cholesterol is à powerful rik factor for CVD,
and lowering of LDL cholesterol results in a striking reduction inthe incidence
of CVD. Table 32 summarizes the ATP If classifications of LDL, total, and high

density ipoprotein (HDL) cholesterol and triglycerides

According to ATP I, a low HDL cholestrol, defined as <40 mg + dl, is
strongly and inversely associated with CVD risk, Clinical trial provide sug
gestive evidence that raising HDL cholestrol reduces CVD tisk, However, the
mechanism explaining the role of low serum HDL cholesterol in acceler
the CVD process remains unclear. Moreover, it remains uncer
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 th
[ATP I does not identify a specific HDL cholesterol goal level to achieve wit
therapy. Rather, ATP HI encourages nondrug and drug th
HDL cholesterol and are part of the management of other li
tisk factors,

There is growing evidence ofa strong association between elevated wiglyc
rides and CVD risk. Recent studies suggest some species oftrihyceride-ich
Iipoprotein, notably small very low-density lipoproteins (VLDLS) and inter
mediatedensiy lipoproteins (IDLS), promote atherosclerosis and predispose 10
(CVD. Because VLDL and IDL appear to have atherogenic potential similar to that
Of LDL cholesterol, ATP IN recommends non-HDL cholesterol (ic, VLDL plus
LDL cholesterol) as a secondary target of therapy or individuals with elevated
twglycerides(rglyeeides =200 mg dL).

The metabolic syndrome is characterized by a constellation of metabolic
risk factors in one individual. Abdominal obesity atherogenic dyslipidemia
(e, elevated triglycerides, small LDL cholesterol particles, and reduced HDL
cholesterol), elevated BP insulin resistance, prothrombotic state (be, increased
tisk fr thrombus formation), and proinflammatory state (ie, clevated 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 overweighvobesiy, physical inactivity, insulin
resistance, and genetic factors, Because the metabolic syndrome has emerged
as an important contributor to CVD, ATP I places emphasis on the metabolic
syndrome asa risk enhancer However, ATP I recognized that there are no well:
established criteria for diagnosing the metabolic syndrome, Table 3.3 lis dir
ent profesional organizations proposed metabolic syndrome creia including

1 recommendations put forth by ATP II (27).

ATP I designates hypertension, eigarete smoking, dlabetes mellitus, over
weight and obesity, physical inactiviy, and an atherogenic dit as modifiable
nonlipid risk factors, whereas age, male gender, and family history of premature
VD are nonmodifible nonlipid risk factors for CVD. Triglyeerides, lipoprotin
remnants, ipoprotein(), small LDL particles, HDL subspecies, apolipoproteins B

4 GUOEUNES FoR u. Stratus) === |

stabole Syndrome Criteria: NCEP/ATP IDE and WHO

Site __ NEEDATP wre mo
Body Weight Vi eur Re Wastionip der
Free

Van Sirene SRE 09m

Wine EEE EEE TI

Pl ELLE SCAN C2

Rance” pocos doses

Score o a.

Dyslpidamia Specie veowenter

FO Vence Men 4009 sa, Men Hg de
Women: <img et Wan 260 mg: aL" Women. 239 mg eL

Tee 210 ma». mp ae 10mg. dL

Beated = EO 0 =m FO of 289 mm Raa Aninpeonace mes
Blo ‘resent ot even done" a BP =
Free grosa paris or 250 mg

Other We Na Dry bumsen

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and AL, and the total choleterolto-HDL cholesterol rato are designated by
ATP In as emerging lipid risk factors. Thrombogenic and hemostatie fctors,
Inflammatory markers (eg, high sensitivity C-reactive protein), impaired fasting
glucose, and homocysteine are designated by ATP IT as emerging nonlipid risk
factors. Nevertheless, recent studies suggest that homacysteine-lowering therapy
doesnot result in a reduction in CVD risk.

The guiding principle of ATP IN and subsequent updates by the NHLBI,
AHA, and ACC is thatthe intensity of LDL-Iowering therapy should be adjusted
10 the individuals absolute risk for CVD (68,12.13,2427). The ATP IN trat
ment guidelines and subsequent updates by the NHLBI, ANA, and ACC are
summarized in ACSM Resource Manual for Guidelines for Exercise Testing and
Prescription, Seventh Edition (26).

Multiple analyses of blood profiles are commonly evaluated in clinical exercise
programs, Such profiles may provide useful information about an individuals
‘overall health status and bility to exercise and may help to explain certain ECC
anormales, Because of varied methods of assaying blood samples, some cx

on is advised when comparing blood chemisries from diferent 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 ofthese medications act in the ivr 10 lower
blood cholesterol and in the kidneys to lower BP (sce Appendix A). One should
pay particular attention to liver function tests such as alanine transaminase
(ALT) aspartate transaminase (AST), and bilirubin aswell as to renal (kidney)
function tests such as creatinine, glomerular filtration rate, blood urea nitrogen
(BUN), and BUN/ereatinine ratio in patents on such medications. Indication of
volume depletion and potassium abnormalities can be seen inthe sodium and
potassium measurements.

BLOOD PROFILE ANALYSES

PULMONARY FUNCTION

Pulmonary function testing with spiromeiry is recommended for all smokers
>45 yr and in any individual presenting with dyspnea (Le, shortness of breath),
chromie cough, wheezing, or excessive mucus production (9). Spiromety is a
simple and noninvasive ts that can be performed easily: Indications for sp
romeuy are listed in Table 3.5. When performing spirometry, standards for the
performance of the test should be fllowed (16).

Although many measurements can be made rom a spitometrc test, the most
commonly used include the forced vital capacity (PVC), forced expiratory vo
lume in one second (FEY, ), FEV, (FV ratio, and peak expiratory flow (PEP)
Results from these measurements Can help to ideal the presence of restictive
or obstructive respiratory abnormalities, sometimes before symptoms or signs
of disease are present. The FEV, /FVC is diminished with obstructive airway
diseases (eg, asthma, chronic bronchitis, emphysema, chronic obstrctive pal:
‘monary disease [COPDI) but remains normal with restrictive disorders (eg.
Lyphoscoliosi, neuromuscular disease, pulmonary bros, other serial
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 spiromety
documents an obstructive defet. A diferent approach for claslying the sever:
ity of obstructive and restrictive defects is that ofthe American Thoracic Society
(ATS) and European Respiratory Society (ERS) Task Force on Sandardization of
Lung Function Testing as presented in Table 3.5 (20). This ATSERS Task Force
prefers 10 use the largest available vial capacity (VC), whether itis obtained on

5 GUDELNESFOR| u. Stratus) === |

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Inspiration (IVC), slow expiration (SVC), or forced expiration (FV). An ob-
structive defect s defined by a reduced FEV, JFVC ratio below the Ah perce
tile ofthe predicted value, The use ofthe fh percentile of the predicted value
as the lower limi of normal doesnot lead o an overestimation o the presence
of an obstructive defect in older individual, which is more likely when a fixed
value for FEV, JEVC or a FEV, /FVC of 0.7 ls used asthe dividing line between
normal and abnormal (17) A ‘restrictive defect is characterized by a reduction
in he total lung capacity (TLC), as measured ona lung volume study below the
filth percentile of the predicted value, and a normal FEV, JVC (17).

The spitometsc classification of lung disease is useful in predicting health
status, use of health resources, and morality Abnormal spirometry can alo be
indi
Be used to identify patients in which interventions such as smoking cessation
and use of pharmacologic agents would be most beneficial. piromeri testing is
also valuable in idemifying patients with chronic disease (ie, COPD and heart
failure) that have diminished pulmonary function that may benefit from an in
spiratory muscle raining program (6,19).

The determination of the maximal voluntary ventilation (MV) should also
be obtained during routine spirometi testing (16,20). MVV can be used 10
estimate breathing reserve during maximal exercise. The MVV should ideally be
‘measured rather than estimated by multiplying the FEV by a constant value as
is often done in practice (20).

CONTRAINDICATIONS TO EXERCISE TESTING

For certain individuals, the risks o exercise testing outweigh the potential bene.
fits, For these patients, its important to carefully asses risk versus benefit when
deciding whether the exeris test should be performed. Box 35 outlines both
absolute and relative contraimdications to excris testing (10), Performing the
preexeris evaluation with careful review of prior medial history as described
call in Chapter 3, helps identify potential contraindications and increases the
Safer of the exerce test, Patents swith 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 contrindi
‘ations might not apply in certain specific clinical situations such as soon ater
cute myocardial infarction, revacculartzation procedure, or bypass surgery or 10
determine the need for or benefi of drug therapy. Finally, conditions exist that
preclude reliable diagnostic ECG information from exerise testing (eg, left
bundle-branch block, digais therapy). The exercise est may sl provide useful
information regarding exercise capacity, subjective symptomatology, pulmonary
function, dysshythmias, and hemodynamics. In these conditions, additional
evaluative techniques such as ventilatory expired gas analysis, echocardiography,
‘or clear imaging can be added to the exercise testo improve sensitivity, spec
fic and diagnostic capabilites

|

ABSOLUTE
A recent significant change in Ih esting olecuocardogram (ECG)
suggesting signifiant ischemia, recent myocardial infarction within 2 or
‘other acute cardiac event
À + Unstable angina
Uncontrd cade dyschythmiae causing symptoms or hemadynamic
(compromise
Symptomatic severe sortie stonosis
Uncontroled symptomatic heart fire
‘Acute pulmonary embolus or pulmonary infection
‘cute nyocaras or pericaditi
Suspected or known dissecting aneurysm
‘Acute systomi infection, accompanied by fever, body aches, o swollen
mon glands

RELATIVE?

+ Let main coronary stenosis

+ Moderato stenotic valvular heart disease

+ Elecvoyte abnormalities (o.., hypokalemia or hypomagnesamia)

+ Severe arterial hypertension a. systole blood pressure SBP of >200
mm Hg andor a sto BP |DBP] of >110 mm Ha at rest

“Techydyathythmia or brachen
+ Hyperone eariomyopaty and other forms of outlow wact obstruction
+ Nouomotor, musculoskeletal, o rheumatoid disorders tht are exacerbated
by excise

+ High degre atioventiclr block

+ Vonvicuar anourysm

+ Uncontroed metabote disease (eg. diabetes, thyrotoxicosis. or
myxedema)

+ Chronic infectious disease (09. HV)

+ Mental or physical impairmant acing o inbilty to exercise adoquately

[Emergency departments may perform a symptom-limited exercise test on pa:
tient who present with chest pain (Le 8-12 h after initial evaluation) and meet
the indications outlined in Tale 3.6 3,25). This practice (a) appears to be safe
in appropriately screened patients; (b) may improve diagnostic accuracy; and
(© may reduce cost of car. Generally these patients include those who are no

= GUDEUNEs FoR! u. Stratus) === |

ications and Contraindica
Rogatemans bare eur ECG wstng hat shou be constan te emergency
peta song
FES exe eneymes a nina shou be ma!
ECG atthe une peser. and pecar 1210 ECS tons no sgntcan cane
1 Absence erent ECG anormales ht woes sate auront lo
+ Fom admasen!o mo tv rest am abl om te second ant ol cs ezymes
patent eompomat,lnsenng Dos! pon syto, pratt types atom
+ Hate dbname ast pra ete fears testing
Contranacaton to ecran ECO tas in th emergency datent sting
Nw or ang ECG stores an o ost og
fray toto een
Worsening peor me chst pin symptoms fom admission tothe tev of
teresa sig
+ ERS nat imminent conn giorgio

longer symptomatic and who have unremarkable ECGs and no change in serial
cardiac enzymes. Exercise testing in this setting shouldbe performed only as part
‘ofa carefully constructed patient management protocol, whats now commonly
refered toas 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
califimess 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 he informed consent process 10 ensure that the participant
knows and understands the purposes and risks associated with the tes or exe
‘se program in heaviness or clinical settings. The consent form should be
verbaly 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 specifi questions fom the
participant on the form along with the responses provided. The consent form
‘must indicate the participant is free 0 withdraw from the procedure at any time.
IW the participant is a minor, a Tegal guardian or parent must sign the consent
form, I is advisable to check with authoritative bodies (eg, hospital risk man
agement, institutional review board, cl legal counsel) to determine what is
appropriate for an acceptable informed consent process. Also, al reasonable ef
forts must be made to protect the privacy of the patient’ health information (eg.
‘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 Figue 3.1. No sample form should be adopted fora specific test

Infomad Consent or an Exercise Test

1. Purpose and Explanation ofthe Test

your fnes fv! We may so te test at any Emo boss f Sita uno
argus your hewt te, escrearaogrm, "bos psn, o symptoms yay ay
‘ootons is import for yout else tn you may sp when You wan boca
lens of aque or ny ater corn.

‘hore existo pest of eran changes orcuing ding the test These ince
‘eel ica pesto orto epi’ fsa ov boat yen: a to

Ietanes, aot aac sta, of dou Every ot wel te mate to mean ese
‘sty gun of relay natos ego yous not a nessa by
‘ale to doa va unis oe

Inma yor posses ata you Das tats gos expences of has
‘aad sync ag. nenas of bea wth wie sey Pa presse,
{gina neues feces. nao. vm ec. and as) min yea eft
opi sey ys melts pong epg oe e,

‘re response kr ay cos your medal story a weas ator tha may
Bu doo toto ou we ao expects trop radar Unsung pong:
Sn rn acento in pos, ose tale edo 1 eg sta.

4. BoneteTo Be Expected
‘romans add ron th rise test may seno dogo of you nose
1 Bag ne ect os: modi, nl wast ype op Se
tas you man own ik

5. Inguiies
‘Rey aun abou tho mesure udn oeuvre ts oth sete of owe
{est ane god youre any conn e quests pane tok Tr rer
Sanos

‘infomation at 3 banc ding eri testa wl be tata pages a
1906 not to be fomased evened a ay inva cat yout aay Py
Clon vino your rta consort Nana o can cis may bo Ue fo
HS andy a Soon purpose wah your FW o pricy ene.

here rr to ur engage nan ero testo determino my erie
‘net an staf oca Pest My pumas fpr ts bern teste
star tn at am Jun 1 lp me at oy pont 1120 che

noe 00 em, nd undrstunt mo st pcs tutora ana nant
ras an decorate Kc Paro ris a scat nd hava nd opor a
kon Va avo bn enero toy Sisi, emir 10 regalo no Lt

Dae E
Dae E
EJ ERE

HFIGURE 22, Sunpe of normed consent om or promos uc ts

Py EU) === |

or program unless approved by local legal counsel and/or the appropriate inst
tutional reiew board
the exercise test s for purposes other than diagnosis or Ex R, (ie for

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 exerce test for research purposes

Because most consent forms include the statement “emergency procedures
and equipment ar available,” the program must ensure available personnel are
<pproprisely trained and authorized to carry out emergency procedures that use
such equipment. Wetten emergency policies and procedures should be in place,
and emergency drills should be practiced at lest once every 3 mo or more often
when there i a change in staff (18). See Appendk B for more information on
emergency management,

PARTICIPANT INSTRUCTIONS

Explicit instructions for participants before exercise testing increase test vay
and data accuracy: Whenever possible, ten instructions along witha deserip-
tion of the preexerise 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 exeris testing procedures
are consistent beiween/among assessments (5). The following points should be
considered for inclusion in such preliminary instructions however, specific in
structions vary with tes ype and purpose

+ A a minimum, participants should refrain from ingesting food, alcohol, or
caffeine or using tobacco products within 3h 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

ing shoes. Women should bring a loose tin
buttons down the front, and should avoid restrictive undergarments.

+ Ifthe evaluation ison an outpatient basés, participants shouldbe made aware
that the exercise test may be fatiguing, and they may wish to have someone
company them tothe assessment to drive home afterward,

+ Ae exercise tests 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 B-blocking
agents may be asked to taper their medication over a 2 to 4d period to
‘minimize hyperadrenergie withdrawal responses (ee Appendix A).

+ I he exercise testis for functional or Ex R, purposes, patients should
continue their medication regimen on their usual schedule so thatthe exer
¿ise responses will be consistent with responses expected during exercise
training,

‘+ Participants should bring alist oftheir medications including dosage and fe
quency of administration tothe assessment and should report the lst actual
dase taken. As an alternative, participants may wish to bring their medica
tions with them for the exercise testing staf 10 recon.

+ Drink ample fads over the 24-h period preceding the exercise test 1
normal hydration before testing.

THE BOTTOM LINE

The ACSM Exercise Testing Summary Statements are the following:

+The preexercise evaluation i vital o ens
nite.

+ Regardless of whether or not an exercise testis indicated prior to stating a
physical activity program, identifying known CVD risk factors (see Tale 22)
is important for patient management

+ Exercise testing information can be used to counsel an individual regarding
the risk for developing CVD, tayloring the Messe intervention program
(Le, exerie, dit, and weight los) to potentially ameliorate CVD risk fa
tors, and when appropriate, refer to the appropriate health care professional
for addtional assessment

+ In those individuals who require exercise testing, absolute and relative
contraindications must be considered before initiating the assessment
(ee Box 39)

ng exercise training can e safely

+ Individuals undergoing an exercise test should receive detailed instructions
regarding the procedure and complete an informed consent document

American Cee of Sports Melkine ere Medien:
National ert Lang, and lod tt Heth norman fr Proteina
À ca oc dopo

sil Aci Gales or American 28)

$8 GUDELNESFOR| u. Stratus) === |

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1. Abert KG, Ze 2, Din, dosis and ken of dates metas nds com.
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pp Bands MME Dani Sl Dicta psc 0 pen and coges: à

‘Se sme foe Nn han Sane tp, NG re

[ra en le MA el Acs anal ep dient

Si nen hc Amen a Actas Comicon Eso aa,

Caen AECI

46. Meant Fl Wicks Er MA Gass Xp Nour dci sima.
dnd te mui ing pte janie hoon pans lo plc wi
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9. Fan Gh PL. ist AS tal tie pny ring ah aetna con
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10 Gio Rama Che Kat Commie onthe rage pains wh ern
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Health-Related Physical Fitness Testing
and Interpretation

is the numerous health
Fits that result rom regular participation in physical activity and structure
exercise programs including enhancement of actoble capacity (Le,
respiratory füness [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 witha lower
prevalence of chronic disease and health conditions and their rik Factors (29)
Measures of health-related physical fitness and CRF are closely aed 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 rehabiltative programs
should be the promotion of health; therefore, exercise programs should focus
on enhancement of the healthrclated components of physical fitness including
‘CRE Accordingly, the focus ofthis chapter is on the health-related components
‘of physical füness rather than the skllrelatd components for the general
population (40)

PURPOSES OF HEALTH-RELATED PHYSICAL FITNESS TESTING

Measurement of physical fitness common and appropriate practice in preven
re and rehailtatve exercise programs, The purposes of healfiiness testing.
such exercise programs include the follow

+ Educating participants about their present Hess status relative to
"heard standards and age and sex matched noems

+ Providing data that are helpful in development of individus
prescriptions (Ex 1 addres all healftness components

+ Collecting baseline and follow-up data that allow evaluation of progress by
exercise program participants

+ Motivating participants by establishing reasonable and atainable heathy
fines goals (see Chapter 11).

CHAPTER 4 Heat Reed Mu) ===. |

BASIC PRINCIPLES AND GUIDELINES

‘The information obtained from health-telated physical fitness testing, in con
bination with the individuals health and medical information, is used by the
Icalvfiumess and clinical exercise professional to enable an individual o achieve
specific heahlvfuness goal. An sal health-related physical fitness ts is rl
able, valid, relatively inexpensive, and easy 10 administer The test should yield
rests that are indicative of the current state of physical fitness, reflect postive
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 o prior to arava atthe
testing fact (see Chapter 3). Certain steps shouldbe 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
a the Physical Acıviy Readiness Questionnaire (PAR-Q) (See Figure 21) (89)
for the American Heart Assocation (AMA American Collegeof Spons Medicine
(ACSM ealtvFitness Facility Preparticipation Screening Questionnaire (see
Figure 22) 3.102), À listing of preliminary testing instructions for all cents can
be found in Chapter 3 under “Participant Instructions.” These instructions may
be modified to meet specii needs and citeumstances,

TEST ORGANIZATION

‘The following should be accomplished before the elienvpatient arrives atthe

+ Assure all forms, score sheets, tables, graphs, and other testing documents
are organized in the clients or patients fle and available for the tests
Administration

+ Calibrate all equipment (eg. metronome, cycle ergometer, treadmill, sphyg-
‘momanometer, skinfold calipers) atleast monthly, or more frequently based
on use; cenain equipment such as ventilatory expied gas analysis systems
should be calbrated prior o each test according to manufacturers specifica
tions; and documen equipment calibration i a designated folder.

+ Organize equipment so hat tests an follow in sequence without stesing the
same muscle group repeatedly

+ Provide an informed consent form and allow ime forthe individual under
going assessment to have all questions adequately addressed (ste Figure 3.1)

+ Maintain room temperature between 68° F and 72° F (20° Cand 22° C) and
Hamid of less than 60% with adequate flow.

When multiple tests are to be administered, the organization of the tsting
session can be very important, depending on what physical fitness components

Guoeunes FoR! u. ratio) =|

ae tobe evaluated. Resting measurements such as heat rate (HR), blood pressure
(BP), height, weight, and body composition shouldbe obtained first. Research has
not established an optimal testing order for multiple health-related components
of Tunes (Le, candiorespiratory [CR] endurance, muscular fitness, body compo-
sition, and Mexibiliy), but sufficient time should be allowed for HR and BP 10
return to hasline between tests conducted serially Because certain medications,
such as B-blockers which lower IR, will affect some physical fitness test results,
Ace 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 entiation should be controlled as
much as possible. To minimize subject anxiety, the test procedures should be
explained adequately and the tet environment should be quiet and private, The
won should be equipped vih a comfortable eat and/or examination table to be
sed for resting BP and HR and/or elecuocardiogaphi (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 initiating the process.

BODY COMPOSITION

is well established that excess body at, particularly when located cent
around the abdomen, is associated with hypertension, metabolic syndrome,
Type 2 diabetes mellitus, stroke, cardiovascular disease (CVD), and dyslipidemia
(85). Approximately two-thirds of American adults are classified as overweight
(body mass index [BMI] =25 kg + m’), and about 33% ofthese are classified
as obese (BMI 2:30 kg m 3). Although the prevalence of obesity has steadily

‘over the last tree decades, rent data indicate a plateau i obesity trends,
particularly in women (23,38) Perhaps more uoubling are the statistics relat
ing 10 children that indicate (a) approximately 32% of children aged 2-19 yr
ae overweight or obese; and (b) over the past Ihre decades, the percentage of

ren aged 6-11 yr who are considered obese has increased from approx
rately 4% to more than 17% (95). Moreover, 2006 data indicate race and sex
difrences in overwcighobesiy with Black and Hispanic women continuing
to have the highest prevalence (93). The troubling data on overweighvOobes
prevalence among he adult and pediatric populations and its health implications
have precipitated an increased awareness in the value of lenuilying and teating
individuals with excess body weight (26,334,105).

‘Basic body composition can be expressed as the relative percentage of body
mass that is ft and fatlree tissue using a two-compartment model. Body
composition can be estimated sith Iborstory and field techniques that vary
in terms of complet, cost, and accuracy (34,65). Diferen assessment tech
niques ae briefly reviewed in this section, but details associated with obtaining

CHAPTER 4 Heat Reed … LO

measurements and calculating estimates of body fa fora of these techniques ae
beyond the scope of the Guidelines. For more detailed information, see ACSMS
Resource Manual for Guidelines for Exercise Testing and Prescription, Seventh
Edition (101) and elsewhere (48, 51,60), Before collecting data for body compost
ton assessment, the technician must be tained, experienced in he techniques,
and already have demonstrated reliability in his or er measurements, indepen:
dent ofthe technique being used. Experience can be acerucd under the direct
supervision ofa 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 i cal:
lated by dividing body weight in kilograms by height in meters squared (kg m
For most individals,obesity-telated health problems increase beyond a BMI of
25. kg = m 2. The Expert Panel on the dentication, Evaluation, and Treatment
(of Overweight and Obesity in Adults (35) defines a BMI of 25.0-20.9 kg + m ? as
‘overweight and BME of =30.0 kgs mas obese, BMI ls to distinguish between
body fat, muscle mass, or bone, Nevertheless, an increase risk of hypertension,
sleep apnea, Type 2 diabetes mellitus, certain cancers, CVD, and mortality ae
associated with a BMI 230.0 kg + m! (Table 4.1) (86). Interestingly, ter ls
‘compelling evidence to indicate patients diagnosed with congestive heart failure
(CHE) actually have improved survival when BMI is =30.0 kg: m à a pheno-
menon known asthe “obesity paradox" (79), for reasons that are not clear (4).
Compared o individuals classified as obese, the ink between a BMI inthe over“
weight range (25.0-29.9 kg m 3) and higher moral risk s less clear. However,
ABMI of 250-299 kg m + similar to a BM =300 kg m more convincingly
linked to am increased isk for other health isues such as Type 2 diabetes well
dssipidemi, hypenension, and cenain cancers (68). A BMI of <183 kg « m à

Classification of Disease Risk Based on Body Mass Index (EMI)
and Waist Circumference

‘ase a Fave Homa

eat
Econ Memo Mamen om

Ta Era = =

CETTE 250-298 ena cm

n ETC [rn Ter

r 35099 Ven ‘ery

i FT Eutemey han Estoy

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mm GUDELNESFOR| u. Stratus) === |

also increases morality risk and is responsible or he lower porion ofthe J-shaped
curve when ploting ik on the y-axis and BMI on the x-axis (39). The use of spe
(ie BMI values to predict percent body fat and heath risk can be found in Tale
42 G1). Because ofthe relatively lange standard error of estimating percent body at
from BMI (23% BD G4), other methods of body composition assessment shoul
be used to estimate percent ody fat during a physical ness assessment,

Circumferences

‘The pattern of body fat distribution is recognized as an important indicator of
cal and prognosis (28:90). Android obesity that is characterized by more fat
on the trunk (Le, abdominal fat) increases the risk of hypertension, metabolic
syndrome, Type 2 diabetes mellitus, dysipidemia, CVD, and premature death
compared with individuals who demonstrate gynoid or gynecoid obesity (Le,
fat distributed in the hip and thigh) (85). Moreover, among individuals with
increased abdominal ft, higher levels in the visceral compartment confer a
higher risk for development of the metabolic syndrome compared to a similar
distribution of ft within the subcutaneous compartment (40).

Circumference (or gh) measurements may be used to provide a general re.
resentation of body composition, and equations are available for both sexes and a
range of age groups (103,104). The accuracy may be within 24.0% ofthe acta
body composition if the subject posseses similar characteristics tothe original
‘alidation population and the git messurements are precise, A cloth ape measure
with a spring-loaded handle (e y, Gulick tape measure) reduces skin compresion
and improves consistency of measurement, Duplicate measurements are recom
‘mended a each ste and should be obtained in a rotational instead of a consect
tive onder (Le, take measurements of all ses being assessed and then repeat the
sequence). The average of the two measures is used provided they do not dife by
‘more than 5 mm, Box 4.1 contains a description of the common measurement sts.

The waisto-hip ratio (WHR) isthe circumference ofthe waist (above the
lac crest) divided by the ircumferene ofthe hips (see Box 4.1 for butockv/hips

MA cio |
EN Be

Abdomen: With the subject standing upight and rloxed, a horizontal
mossure taken atthe height ofthe lac crest, usualy atthe
level of the umbilicus

A withthe subject standing erect and ams hanging fre at
tha sides with hands facing the thigh, a horizontal measure
‘midway between the acromion and cecanon processes.

Butocka/ips: With ve subject standing erect and feet together a horizontal
measure is taken atthe maximal croumference of buttocks.

‘This measure i used forthe hip measure in a waisvip

Cat: With ie subject standing rect eet apart ~20 cm,
horizontal messur taken atthe leve of the maximum
‘ercumference between the knee andthe ankle, perpendicular
to the long xs.

Forearm: With the subject standin, arms hanging downward but
sight away tom the vunk and palms facing anterior.
a measure & taken perpondewar tothe long axis at ho
maximal ircuméerenco.

Hipshigh: With the subject standing, logs slighty apart (-10 em). o
horizontal messur 5 taken atthe maximal cicumferonc of
the proximal thigh, ust below the gltea ol

MieThigh the subject standing and one foot on a bench o the
noo is lxod at 90 dogroos, a measure is taken micuay
Between the inguinal cease andthe proximal border ofthe
patela, perpendicular to the long axis.

Wat: ‘withthe subject standing. ams at he sides, ft together,
and abdomen relaxed, a horizontal messur taken atthe
‘narrowest part ofthe torso abono tho umbilcus and below
tho iphoi process) Tho National Obesity Tsk Foco NOTF)
suggest obtaining a horizontal measure recy above
tho ic erst as a method to enhance standardization,
Unfortunately, eurent orme re nt preciatod on the
NOTE suggested sit.

“ EU) >=:
FREE stondardzed Description ot
{Continued

À Procedures
+ Al mossurements should be made with Nexo yet inelastic apo

‘+ Tho ape should bo placed on ho sin surface without compressing the
subcutaneous adipose tissue.

+ Ifa Gui springioadod handle is used, the handle should bo extended to
the same marking with each ia.

+ Tate dupicate measures at each sito and ceest# dupicato mossurements
0 not within 8 mm.

‘Rotate tough measurement sts o low timo or skin to gain normal

measure) and has traditionally been used as a simple method for assessing body
fat distribution and identifying individuals with higher and more detimental
amounts of abdominal fat (3455). Health risk increases as WHR increase, and
the standard for risk vary with age and sex. For example, heath isk is very high
for young men when WIR is >0.95 and for young women when WHR is >086.
For individuals aged 60-69 yr, the WHR cutoff values are >1.03 for men and
20.90 for women forthe same high-risk classification as young adults (51),
The waist circumference may also be used as an indicator of heath risk
because abdominal obesity isthe primary Issue (20,28). The Expert Panel on the
Identficaon, Evaluation, and Treatment of Ovenweight and Obesity in Adults
provides a classification of disease risk based on both BM and waist circule
rence as shown in Table 4.1 (33). Previous research has demonstrated that the
sais circumference thresholds shown in Tale 4.1 effectively identify individuals
at increased health risk across the different BMI categories (56). Furthermore,
à newer risk stratification scheme for adults based on waist circumference has
been proposed (see Table 43) (14). Several methods for waist circumference
measurement involving different anatomical sites are available. Evidence ind
cates tha all curently available waist ircumferenee measurement techniques

inAdute
Kor EME) an
tor oss so Dames
ra Para 1. mo 055-170
Tr Er SET

CHAPTER 4 Heat Reed Mu) ===. |

are equally reliable and effective in identifying individuals at increased health
risk (86,108)

[Measurement of Waist Circumference
Measurement of waist circumference immediately ahove the ae crest as
proposed by National Institutes of Health guidelines, may be the pref
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 7 = 070-090) with body composition determined by hydrodenstomety
(48), The principle behind skinfold measurements thatthe amount ofsubeuane-
ous fs proportional o the total amount of hod fat eis assumed that close 10
‘one-third ofthe tou fais located subcutancousy The exact proportion of subcuta
‘cous oto fat ares with sex, age nd rae (94), Therefore, repression equations
‘sed to convert sum of skinfolds to percent body ft should consider these variables
for greatest accuracy. Bax 42 presents astandarized description of skinfold sites
and procedures Refer 10 ACSMS Resource Manual or Guidelines or Exercise Tsing
and Prescription, Seventh Edtin (101) for ational descriptions of skinfold sts.
Skinfold assessment of body composition is very dependent on the expenise of
the technician, so proper taining (te, knowledge of anatomical landmarks) and
ample practice of the technique Is necessary to obtain accurate measurements. The
accuracy of predicting percent body fat fom skinfolds is approximately 233%,
assuming appropriate techniques and equations have been used (31).

Factors that may contribute to measurement error within skinfold assesses
include poor technique and/or an inexperienced evaluator, an extremely obese
or extremely Jean subject, and an improperly calibrated caliper (i.e, tension
should be set at ~12 g + mm >) (49). Various regression equations have been
developed to predict body densty or percent body fat from skinfold measure.
‘ments. For example, Bow 4.3 lists generalized equations that allow calculation of
body density without a loss in prediction accuraey fora wide range of individuals
9,54). Other equations have been published that are sex, age, race, fat, and
spor specific (50). Ata minimum, simple anthropometric measurements should
Be included in dhehealıh assessment of ll individuals

Anthropometric Measurements
Although limited in the ability to provide highly precise estimates of
percent body fa, anthropometric measurements (Le, BMI, WHR, waist
«icumference, and skinfolds) provide valuable information on general
cal and risk suatiication. As such, inclusion ofthese easily obtainable
variables during a comprehensive healh/imes assessment is beneficial,

ES ae

SKINFOLD SITE
‘Abdominal Vertical fold: 2 em to the rght side ofthe umbiicus

Ticops Vera fl on the postrior mine of ho upper am.
haifa between the acomion and olecranon processes,
‘wth the arm hei Koay to the sido ol tho body

Biceps erica fold on the anterior aspect ofthe arm over the bay
‘ofthe bicops muscle, 1 om above the oval used o mark ho
tices site

CChesyector Dingen fl on-ha ho distance between he anterior
‘lary line andthe po (mon, or one-third of the distance
baton the antrir ana In and the ippo (woman)

Medial caf Verical fot: atthe maximum cecumferenco of tho caf on
the midline ofits mei! border

Nidosilary Vertical oon the midair ine tthe lve ofthe xphoid
process ofthe storrum. An altomato method is a horizontal
fold taken at te love ofthe xphoi/storal bordo inthe
mir ine

Subscapler Diagonal fold at a 4deqree angle; 1-2 em below the inferior
ange of the scapula

Supraiac Diagonal fli in with tho natural ange o ne iar crest
‘akon in th anterior axilary Ino immoditoh superior tothe
dc rest

Thigh ‘erica fold on the anterior mine ofthe thigh, midi
between the proximal border ofthe patella and the inguinal
ease m)

Procedures

‘All measurements should be made onthe ight side ofthe body with the
subject standing upright

+ Calar shouldbe plaad ect on tho skin surface, 1 em away trom the
thumb and finger, perpendicular to tho skinfld, and halfway botwoon the
¿stand the base ofthe fold

+ Padh shouldbe maintained whl roading the cakpor

+ Wait 1-2 ot longer before reading calper

+ Toke dptcate measures at each ito and rotes if duplicate measurements
0 not tin 1-2 mm

‘+ Rotate trough measurement sites or alow me for skin 10 rain normal
texture and thickness

cos nn, EE

MEN
+ Seven Site Formula (hast, midauilry, icops, subscapular, abdomen,
supe, thigh)
Body donsity = 1.112 — 0.00043498 um of soven skinfolds)

+ 0,00000056 (sum of seven site!
= 000028826 ago) [SEE 0.008 or 3.5% fo)

+ Three-Sie Formula (ches, abdomen, thigh)
Body density = 110898 ~ 00008287 sum of tes skinfolds)
+ 0.000001 (sum of woo site? 0.00025% aed
[SEE 0.008 or ~3.4% fo)

+ Three-Sie Formula (chet trceps,subscapalr)
Body donsity = 11125025 ~ 0.0013125 (sum of threo skinfolds)
+ 0.000085 (sum of tee skinfolds? — 0.000284 age)
ISEE 0.008 o -3.6% fa)

WOMEN
+ Seven-Site Formula (hast, mil, ticeps,subcapuar abdomen,
supe, tight
Body donsity= 1.097 - 0.00046971 (sum of sevn since)
+ 0.00000056 (sum of seven skinfolds? = 0.00012828
(ope) [SEE 0008 or 38% a

+ Thvoe-Site Formula (cops, supra, thigh)
Body donsity= 1089421 — 0 0006629 sum of Uvoo skinfolds)
+ 0.0000023 sum of tee sols” ~ 00001392 (age)
[SEE 0.009 or ~3.9% fa)

+ Three-Site Formula (vicops,supralic, abdominal
Body density = 1069733 - 0.0008245 (sum ove skinfolds).
+ 00000025 sum of tee skinfolds? = 0.000097 lago
[SEE 0.009 or ~3.9% fat)

a o aah

|

DENSITOMETRY

Body composition can be estimated from a measurement of whole-body density
sing the ratio of body mas to body volume. Densitometry has been used asa
reference or criterion standard for assessing body composition for many years
The limiting factor in the measurement of body density i the accuracy of the

7 EU) >=:

body volume measurement because body mass is measured simply as body
weight. Body volume can be measured by hydodenstometry (underwater)
‘weighing and by plethysmogeaphy

Hydrodensitometry (Underwater) Weighing

‘This technique of measuring body com
ciple that states when a body is immersed in wate, is buoyed by a counterfore
‘xa 1 the weight of the water displaced. This Toss of weight in water allows
for calculation of body volume, Bone and muscle tissue ate denser than water,
whereas ft tissue s less dense. Therefore, an individual with more fat-free mass
(ETA) for the same total body mass weighs more in water and has a higher
body density and lower percentage of body fa. Although hydrostatic weighing
{sa standard method for measuring body volume and hence, body composition,
At requires special equipment, the accurate measurement of residual volume

populaion-specific formulas, and significant cooperation by the subject (44)

Fora more detailed explanation of the technique, see ACSMS Resource Manual for
Guidelines fr 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 plthysmograph that measures body
volume by changes in pressure in closed chamber. This technology is now well
established and generally reduces the anxiety associated with the technique of
Inydrodensitometry(31,44,70). For amore detailed explanation ofthe technique,
see ACSMS Resource Manual for Guidelines or 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
‘ofthe 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)

42

= 450

Each method assumes a slight different density of fat mass (FM) and FFM
Several population specific, two-component model conversion formulas are also
available (see Table 4.4). Currently thee to six component model conversion
formulas are avaiable and are increasingly more precise in calculating percent
bodyfat compared to two-component models (3451).

CHAPTER 4 Heat Reed o Sr

ion of Body Density to

= sar

CZ
1602
1800,
1648

USE
am on - am
(86/05 = 439
or [DO 487
81/00 = am
57700-4582
an Du 828
87/09 = ea
(495/00 = 450
at ¡Das
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j Sage
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or

(619/08.

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1496/00 = 481

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LS

ws

nd 87700 = ass

‘21/00 = 478
97/08 = a2
(603 700-4
1695/00) = 480
CODE
97/00 = 452
496/00 = 451

Resistance vines

Erdrnce vied

[asser

i
AS
H
i
E

masa 533/00- 491
nase 526/00 508
‘has (60/00 - 532

best ET

Soins era oy 16:73 Men 67700 410

Alemoepcandngo 1679 Waren _W70/0n 422

era
SE paco ay body sy. NA nom be a pps

n EU) === |

OTHERTECHNIQUES:

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 heaviness testing because of cost and the need for highly tained
personnel (48). Rather, bioelectrical impedance analysis (BIA) and near-infrared
feractance are used as assessment techniques in routine healthvfiines testing

xy of BIA is similar to skinfols, as long as stringent
protocol adherence (eg, assurance of normal hydration status) is followed,
and the equations programmed into the analyzer are valid and accurate for the
populations being tested (3047). shouldbe 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). Nearinfraed interactance
requires addtional research to substantiate the validity and accuracy for body
composition assessment (58,73). Detaled explanations of these techniques
are found in ACSMS Resource Manual for Guidelines for Exerise Testing and
Prescription, Seventh Edition (101)

BODY COMPOSITION NORMS

There are no universally accepted noms for body composition; however,
Tables 45 and 46, which are based on selected populations, provide percentile
values for percent body ft in men and women, respectively À consensus opinion
for an exact percent body la value associated with optimal health risk has yet 10
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 ths range although age and race, in addition to sex, impact what
‘may be construc as a heathy percent body fat (41).

CARDIORESPIRATORY FITNESS

CRE ls related 10 the ability w perform lange muscle, dynamic, moderate
‘vigorous intensity exercise for prolonged periods of time. Performance of exer
¿ise at this level of physical exertion depends on the integrated physiologic and
Functional state of the rspirtor cardiovascular, and musculoskeletal systems,
RF i considered a health-related component of physica unes because (a) low
levels of CRF have been associated with a markedly increased is 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 () high levels of CRF
fre associated with higher levels of habitual physical activity, which in turn are
associated with many health benefits (1011,6398,107), As such, the assessment
of CRF isan important par of any primary or secondary prevention and rcha
batatve programs.

CHAPTER 4 Heat Reed fay Sr

mn ws a =

on Se E

+ ee #

EE — ES
RE. =
E

‘THE CONCEPT OF MAXIMAL OXYGEN UPTAKE

Maximal oxygen uptake (VO) is accepted as the criterion measure of CRE
This variables typealy expressed clinical in relative (mL » kg? + min") as
‘opposed to absolute (ml min + terms, allowing for meaningfl comparisons
betweenamong individual with differing body weight, VO, she product of
the maximal cardiac output Q(L blood > min ') and arterial-venous oxygen di
ference (mL O, + L blood). Significant variation in VO, across populations
and fitness levels results primarily fom differences in Qin individuals without
pulmonary disease; therefore, VO. closely related o he functional capacity
‘ofthe heart. The designation of VO), implies an individuals tre physiologie
limit has been reached and a plateau In VO, may be observed between the final
wo work rates ofa progressive exercise ts. This plateau is rarely observed in
Individuals with CVD or pulmonary disease. Therefore, peak VO, is commonly
used o describe CRF in these and other populations with chronic diseases and
health conditions ©)

Open circult spirometry is used to measure VO, In this procedure, the
subject breathes through a low-resstance valve with her or his nose occluded

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(or through a nonlatex mask) while pulmonary ventilation and expired factions
of oxygen (0) and carbon dioxide (CO,) are measured, Modern automated
systems provide ease of use and a detailed printout of test results that save time
and effon (27). However, system calibration is still essential to obain accurate
resul (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 VO. generally is
reserved fr esearch or clinical settings

‘When direct measurement of VO, I not fesble a varity of submaximal
and maximal exrise tests an be used to estimate VO, These tests have been
validated by examining (a) the correlation between direcly measured VO,
and the VO estimated from physiologic responses to submaximal exer
(eg. IR ata specified power output): or(b) the correlation between directly mea
sured VO, and test performance (eg, time to run Lor 15 má [1.6072 kml)
for time 10 volitional fatigue using a standard graded exercise test protocol
should be noted that ther i the potential fr a significant overestimation of

CHAPTER 4 Heat Reed o Sr

dicey measured VO, by these types of indirect measurement techniques.
Overestimation is more likely to occur when (a) the exercise protocol chosen for
testing 5 100 aggressive fora given individual (ie, Bruce rendmill protocol in
patients with CHF); or (9) when teadmil testing is employed and the individual
"heavy relies on handrail support (5). Every efor should therefore be taken 10
choose the appropriate exercise protocol given an individuals characteristics and
‘minimize handrail use during testing on a treadmill (76.

MAXIMAL VERSUS SUBMAXIMAL EXERCISE TESTING

‘The decison to use maximal or submaximal exercise test depends largely on the
seasons forthe test, risk level ofthe clienypatien, and availability of appropriate
equipment and personnel, VO, can be estimated using conventional exercise
test protocols by considering tet duration ata 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 tothe point of volitional fatigue,
which might ental the need for medical supervision as detailed in Chapter 2 and
or emergency equipment (see Appendix B). However, maximal exercise testing
offer increased sensitivity inthe diagnosis of CVD in asymptomatic individuals
and provides a etter estimate of VO, (ce “Indications and Purposes" section
in Chapter 3). In addition, the use of open circuit spirometry during maximal
xeric testing may allow for the accurate assessment of anaerobicientlatory
threshold and direct measurement of VO / VO pay

Practitioners commonly rely on submaximal Gxerise tests to assess CRF
because maximal exerise testing is not always feasible in the healviness
setting. Submaximal exercise testing is also recommended in stable patients
+7 d posemyocardial infarction (MI) to assess efficacy of medical therapy
prior to hospital discharge among other clinical indices (43). In the heathy
fines setting, the basic alm of submaximal exercise testing is to determine
the HR response to one or more submaximal work rates and use the results to
predict VO... Although the primary purpose of the tes has traditionally been
to predict VO), from the HR workload relationship, As important to obtain
additional indices of the clients response to exercise. The practioner should
‘we the various submaximal measures of HR, BR, workload, rating of pereived
exertion (RPE), and other subjective indices as valuable information regarding
ones functional response to exercise. This information can be used to eval
ate submaximal exercise responses overtime in a controlled environment and
appropriate determine the Ex R,

‘The most accurate estimate of VO, is achieved from the HR response 10
suhmaximal exercise tests fall ofthe following assumptions are achieved:

‘+ Asteady state HR i obtained for each exercise work rte
+ A linear relationship exists between HR and work rte

+ The diference between actual and predicted maximal HR is minimal.

+ Mechanical efficiency (Le VO, ata given work rate) isthe same for everyone.

1 EU) === |

+ The subject is not on medications, using high quantities of caffeine, under
large amount of tes, il, or ina high temperature environment all of which
may alter HR.

MODES OF TESTING

Commonly used modes for exercise resting include weadmils, cycle ergometes,
steps, and field tests. The mode of exerese 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 24 and Table 2.3)

There are advantages and disadvantages of cach exercise testing mode:

+ Field tests consis of walking or running in a predetermined time or distance
Ge, 12-min and 1.5-mi [24 km] walk/run tests, and the 1-mi and 6-min
walk es). The advantages of id ests ae they are easy to administer to large
‘numbers of individuals at one time and lle equipment (eg, stopwatch) s
needed, The disadvantages are some tess can be maximal or some individ
als, particulary in individuals with low aerobic fitness, and potentially be
‘unmonitored for BP and HR. An individuals level of motivation and pacing
ality 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,
VO an he estimated from the test resus,

+ Motorsdriven treadmills can be used for submaximal and maximal testing
and are often employed for diagnostic testing in the United States (3). They
provide a familiar form of exercise and, ifthe correct protocol is chosen (Ic,
aggressive vs. conservative adjustments in workload), can accommodate the
least physically ito the test individual across the continu of walking 10
running speeds. Nevertheless, a practice session might be necessary in some
‘ses to pert habituation and reduce anxiey On the other hand, trcadmill
usually are expensive, not easily transportable, and potemialy make some
measurements (e, BR ECG) more dificult, particularly while an indivi
is running, Tcadmill must be calibrated 10 ensure the accuracy ofthe test
(76) In addition, holding on wo the support rails) should be discouraged 10
ensure accuracy of metabolic work output, particularly when VO, is estimated
as opposed to directly measured. Extensive handrail use often leds 10 signif
ant overestimation of VO, 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, trnsportabilis; and greater eae
in obtaining BP and ECG (i appropriate) measurements. Cycle ergometers
also provide a non-weightbearing test modality in which work rates are
casily adjusted in small increments. The main disadvantage is eyeing isa less
familiar mode of exercise to individuals in the United States, often resulting

CHAPTER 4 Heat Reed o Sr

inlimiing localized muscle fatigue and an underestimation of VO, . The cycle
ergometer must be calibrated, and the subject must maintain the proper pedal
rate because most tess seguire HR to be measured at specific work rates (76)
Electronic cycle ergometers can deliver the same work rate across a range
of pedal rates (Le, revolutions + min”, pm), but calibration might require
Special equipment not available in some laboratories, Some electronic fitness
‘cles cannot be calibrated and should not be usd for testing

+ Step testing is an inexpensive modality for predicting CRF by measuring
the HR response to stepping at a fixed rate andor a fixed step height or by
‘measuring postexercise recovery HR. Step tests require litle or no equipment,
steps are easily transporabl, stepping skill requires litle practice, the test
usually of short duration, and stepping i advantageous for mass testing
(22,72, Postexercise (recovery) HR decreases with improved CRE and test
resus 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 equiv:
lents (METS), which may exceed the maximal capacity ofthe participant (6)
Therefore, the protocol chosen must be appropriate for the physical fitness
level ofthe client. In addition, inadequate compliance to the step cadence and
excessive fatigue in the lead mb may diminish the value ofa step test. Most
tests do not monitor HR and BP while stepping because of the difculty of
measuring HR and BP

Field Tests

Two of the most widely used walk/nun (based on subject preference) test for
assessing CRF are the Cooper 12-min test and the 15-mi (2.4 km) test for time.
The objective ofthe 12-min testi to cover the greatest distance inthe alloted
me period and forthe 1.5-mi (24 km) test to run the distance inthe shortest
period of time, VO, can he estimated from the equations in Chapter 7.

The Rockport One Mile Fitness Walking Tests another well-recognized field
test for estimating CRE In ths test, an individual walks 1 mi (1.6 km) as fast as
possible, preferably on a tack 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 kim) walk, but this may overestimate the VO... compared to when
"IR is measured during the walk. VO, is estimated from’ regression equation
found in Chapter 7 based on weight, age, sex, walk time, and HR (62)

addition 0 independently prediting morbidity and mortality (21,97), the
G-min walk test has been used t0 evaluate CRF in older adults and some clin
¿al patient populations (eg, individuals with CHF or pulmonary disease. The
American Thoracic Society has published guidelines on 6-min walk test proce:
dures and interpreation (8). Even though the test s considered submaximal
it may result in ncar-maximal performance for those with lowe physical fitness
levels or disease (57) Clients and patients completing less than 300 m (~984 1)
during the 6-min walk demonstrate a poorer short-ierm survival compared to

7 GUOEUNES FoR! u. Stratus) === |

those surpassing this threshold (16). Several multivariate equations are aval
able to predict VO, yy from the 6-min walk; however, the following equation
requires minimal clita information (16):

+ VO, = VO, mL + kg! + min"! = (0.02 X distance [ml) = @.191 x

age yal) - (007 x weight Ul) + (0.09 X hai lem + (026 x RPP
De 10%) +245

Where m = distance in meters: yr = year: kg = kilogram; cm
RPP = rate pressure product (HR X systolic BP [SBP] in mom Hg)

+ For theaforementioned equation: R?= 0.65and SEE = 2.68 (R = coefficient
of determination; SEE = standard error of estimate)

Submaximal Exercise Tests

Singl-stage and multistage submaximal exercise tests are avaiable to estimate
VO), from simple HR measurements. Accurate measurement of HR is critica
for valid testing, Although HR obtained by palpation is commonly used, the
accuracy ofthis method depends on the experience and technique ofthe eralu-
ator Its recommended that an ECG, HR monitor, or a stethoscope be used 10
determine HR, The use ofa elavely inexpensive HR monitor can reduce a sg
nificant source of error in he test. The submaximal HR response sexily altered
bya number of environmental (eg, heat, humidity, see Chapter 8) dietary (eg.
caffeine, time since lst mea), and behavioral (eg. ancy. 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 individuals fitness program.
In addition, the test mode (eg. cycle, weadmill, step) should be consistent with
the primary exercise modality used by the participant to address specificity of
vrsiing issues, Standardized procedures or submaximal testing ae presented in
Box 44. Although thee are no specific submaximal protocols for treadmill test
{ng several stages rom any of the treadmill protocols Found in Chapter 5 can be
used to ases submaximal exercise responses. Prexercise test instructions are
presented in Chapter 3

Oyelo Ergometer Tests

‘The Astrandyhming cycle ergometer test sa single-stage test sing 6 min
Or the population studied, these wscarchers observed at 30% VO a. the
average HR was 128 and 138 heat min or men and women, respectively Ha
‘woman was working a VO, of 131: min and her IR vas 13 eats min,
then her VO,. was estimate toe 3.0 + min“ The suggested work rate is
based on sex and am individuals fines tats as follows

men, unconditioned: 300 or 600 kg m + min”! (50 or 100 W)
men. conditioned: 600 oF 900 kg + m min”! (100 or 130 W)
women, unconditioned: 300 oF 450 kg m min? (30 oF 75 W)

women, conditioned: 450 or 600 kg m + min”! (75 or 100 W)

CHAPTER 4 Heat Reed |, ETES
= General Procedures fr Sub
EX: se vs"

1. Obtain esting HR and BP immediately pro o exercise in Ihe exerce

postu.

“The cient should be femilarized with the egometer using a eye

ergometer. propery positon the ont on the ergometer Ve. upright

posture, -25-degres bend the knee at maximal eg extension, and

hands in proper position on handlbasl (81-8)

3. Tho exercise test should begin with a 2-3 min worm to acquaint the
ont withthe eye ergemeter and prepare him or her forthe exercise
intensity in the fst stage ofthe test.

4. A specific protocol should consist of 2-07 Jmin stages wth appropriate
increments in work rat,

5. HR should be mentored at last two times during each stage, near
the end ofthe second and thd minutes ofeach stage. I HR is
10 boats min, steady stato HR Vo, two HAS within 5 boats + min)
‘ould be reached bole the workload is increased

6. BP should bo monitored in he last minute of each stage and repeated
(void) in tho vent of a hypotensive or ypenensive response

7. RPE (using either the Borg category or ategor-atio scale [ses Table 4.70
and aciional rating seals should be monitored near the end ofthe ast
minute of och stage

8. Clents appearance end symptoms should be monitored and recorded
regula

9. The test should be terminated ven th subject reaches 70% heat ato
reserve 85% of age-rodeted HR, fais 1o conform tothe exercise
test protocol, experiences adverso Sons ar symptoms, requests to stp,
ar experiences an emergency stuaton.

10. An approprate coo!-downitecovery period shouldbe initated consisting
of ether
28, continued exorcise at a work ate equivalent 10 that ofthe first stage

ofthe exercise test protocol or lower or
ba passive cookdown i the subject experiance signs of discomfort or
an emergoney situation occur

11. Al physilogic observations (e.. HR, BR signs and symptoms) shoul! bo
continued fo at last 5 min of recovery unless abnormal responses occu
which woud warrant a longer posttest survilance period. Coninue low
love exercise until HR and BP stabi, but not necessary unt thy
reach prooxrise levels

Be is pene Hat HA ma ar a, FO tl pacas en

$0 GUDELNESFOR| u. Stratus) === |

‘Tho Borg Rating of Porcivod Exertion Scale

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The pedal rate is set at 30 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 VO), rom a nomo-
gram (sce Figure 4.1). This value must then be adjusted for age because HR...
decreses with age by multiplying the VO, value by the following correction
factors (6):

In contrast 0 the Astrand-Ryhming cycle ergometer single-stage test, Martz
eval. (71) measured HR a a series of submaximal work rates and extrapolated
the response to the subjects age-prediced HR... This multistage method is a
wellknown assessment technique to estimate VO, and the YMCA testis a
good example (111). The YMCA protocol uses two 1 four 3-min stages of con
‘Unous exercise (see Figure 42). The ts designed to ras the steady state HR
ofthe subject to between 110 beats + min and 70% heart rate reserve (HR)
(or 85% of the age predicted HR) for at last rwo consecutive stages. Is im
portant to remember that two consecutive HR measurements must be obtained
thin this HR range to predict VO

Inthe YMCA protocol, cach work rate is performed fr at last 3 min, and HR
is recorded during the final 15-30 sof the second and third minutes. The work

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Y Seti tet work rate a 150 kgmimin (0.5 Kg at 50 rpm)

2 Nine HA in the tr minute of hostage is:
£80, sot the 2nd sage a 750 karin (2.5 kg at 50 rom)
80-60, st mo 2nd stag at 600 kamimin (2.049 a 80m)
90-100, st the Zn stage at 450 kamımın (1.59 st 80m)
100, sotto 2nd stage at 300 karin (1.0 hg 80 Bm)

3 Set mo and An (required) according tothe work rates in
tho columns Below the Sr as

1 FIGURE 42. YUCA cy agomety pate, Resistance seins sown here prop |
Ja orgomata vin yal of mer (I

rate should be maintained for an additional minute ifthe wo HRs vary by more
an 3 beats min *. The test administrator should recognize the eror associated
predicted HR, and monitor the subject throughout the test Lo ensure
maximal, 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 s then extrapolated tothe age-predicted HR... (e. 220 = age), and
perpendicular line is dropped othe x-axis to estimate ike work rate that would
have been achieved if the individual had worked to maximum (sce Figure 43).
The two lines noted as +1 standard deviation (SD) in Figure 4.3 show
what the estimated VO,,., would be ifthe subjects true HR. were 168 or
192 beats» min, rather than 180 beats» min". Part of the eror involved in
estimating VO from submaximal HR responses occurs because the formula
=220 = age" has an SD of 12 beats» min- and can provide only an estimate of
IR, 106). In addition, errors can be attributed to inaccurate pedaling cadence
(voakload) and imprecise achievement of steady state HR. Table 48 provides
normative values for estimated VO, from work rate on the YMCA submax
cycle ergometer test with specific reference to ae and sex (111), VO a, can alo
be estimated from the work rate using the formula in Chapter 7 (see able 7.9)
This equation is valid to estimate VO, at submaximal steady state workloads

Heart rate (beats-min*)

150 900 450 600 780 900 1050 1200
Work rate (kg-m-min-1)

{ys go og 6419 VO). was estate by extapaatng te rt at IR

‘Bat woud ve boon ached ot HR wes determined by oping in fom tat HR
‘us tote aus VO. asumated ug te fm n Chapter and expessed in = mn"
Joct's vue MA, was +1 standard dovaton (SO) from the 180 beats» min” von.

(Geom 30010 1,200 kg + m + min“) (49.0 W to 196.1 W); therefore, caution must
be used if extrapolating to workloads outside of this range

Treadmill Tests

The primary exercise modality for submaximal exercise testing traditional has
been the cycle ergometer, although treadmills are used in many settings, The
same endpoint (70% HRR or 85% of age-predicted HR...) is used, and the stages
ofthe test should be 3 min or longer to ensure a steady state HR response at
cach stage. The HR values are extraplated to age-predicted HR... and VO,
is estimated using the formula in Chapter 7 fom the highest speed and/or grade
that would have been achieved ifthe individual had worked to maximum. Most
common treadmill protocols presented in Chapter 5 can be used, but the dura
tion ofeach stage should be atleast 3 min.

GUIDELINES FOR EXERCISE TEST

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CHAPTER 4 Heat Reed fay Sr

‘Stop Tests

Step tests are also used to estimate VO, Astrand and Ryhming (7) used a single
step height of 33 cm (13 in) for women and 40 em (15.7 in) for men ata rate 0122 3
Steps» min These tests require VO, of about 258 and 29.5 mL kg!» min
respective: HRis measured as described forthe eyelets, amd VO, estimated
from the nomogram (See Figure 4.1). In contest, Mart et al. (71) sed a single
step height of 12 in (30.3 cm) and our step ates to systematically increase the
work ae. steady sate HR ls measured foreach step rat, and a line formed from
these HR values ae extrapolated o age-predicted HR, The maximal work ae is
determined as described for the YMCA cyele est. VO. 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 Tes has demonstrated that
Such est performed on large scale and at low cost (09)

Instead of estimating VO. frm HR responses o several submaximal work
rates, a wide variety of step teats have been developed to categorize CRF based on
an individual recovery HR following a standardized step test. The 3-Minute YMCA,
Ste Testis a good example of such atest. This test uses a 12 (303 cm) bench,
with a stepping mate of 24 steps = min estimated VO, of 258 mL.» kg! min)
‘Mer stepping s completed, the subject immediately sis down and HR i counted
for 1 min. Counting must tart within 5 sat the end of exercise. HR values are used
Lo obtain a qualitative rating of fitness from published normative tables (111)

CARDIORESPIRATORYTEST SEQUENCE AND MEASURES:

A minimum of HR, BR and subjective symptoms (Le, RPE, dyspnea, and angina)
should be measured during exercise tests. Alter the iil screening process,
Selected baseline measurements should be obtained prior to the start of the
exercices, Taking a resting ECG prior to exercise testing requires that tained
personnel are available to interpret the ECG and provide medical guidance

An ECG isnot considered necessary when diagnostic testing i not heing done

The sequence of messures is sed in Table 52,

THR 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 he second and third
fingers (Le. index and middle fingers) most typically over the radial artery,
located near the thumb side ofthe wrist. The pulse i typically counted for 15,
and then multiplied by 4, to determine the HR for | min, For the auscultation
‘method, the bell of the stethoscope should be placed tothe et 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 subjects torso is relatively
stable. HR telemetry monitors with chest electrodes or radio telemetry have
proven tobe accurate and reliable, provided there is no outside electrical interfer
fence (e, emissions from the display consoles of computerized exercise equip»
ment) (06). Many electronic cycles and treadmills have embedded HR telemetry
‘monitoring into the equipment

$6 GUDELNESFOR| u. Stratus) === |

BP should be measured at heart level with the subjects arm relaxed and not
grasping a handrail (treadmill) or handlehur (cycle ergometer, To help ensure
accurate readings, the use of an appropriate-sized BP culls important, The rub-
her bladderof the BP œuf should enciel atleast 80% of the subjects upper arm
he subjets arm is lage, a normal size adult cul willbe too smal, thus resul
ting in an erroneous elevated reading: whereas ithe cuff is too large forthe sub-
ets arm, the resultant reading wil he erroneously low. BP measurements should
be taken witha recently calibrated aneroid sphygmomanometr. Systolic (SBP)
and diastolic (DBP) BP measurements can be used as indicators for stopping
an exeris test (se next section of Chapter +). To obtain accurate BP measures
during exercise, follow the guidelines in Chapter 3 (ee Bax 34) for resting BP;
however, BP wil be obtained in he exercise position. fan automated BP system
is used during exercise testing, calibration checks with manual BP measurements
must be routinely performed to confirm accuracy ofthe automated readings (76)

RPE can be a valuable indicator for monitoring an individuals exercise ole
ance, Although RPES correa with exercise HRs and work rte, lage intrin
dividual variability in RPE with healthy individuals as well as patient populations
‘mandates caution inthe universal application of RPE seals (109). Borgs RPE
scale was developed to allow the exerisr to subjectively rate her or his feelings
during exercise, taking ito account personal physical fitness level and general a
tigue levels (77). Ratings can be influenced by psychological factors, mood states,
environmental conditions (13), exercise modes, and age reducing its utility (09)
Currently wo RPE scales are widely used: (a) the orginal Borg or category scale,
which rates exercise intensity from 6 10 20 (sce Tale 4.7); and () the category
ratio sale of 0-10. Both RPE scales are appropriate subjective tools (1343).

During exercise testing, the RPE can be used a an indication of impending
fatigue. Most apparently, healthy subjects wach ‚hir subjective limit of aigue
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 (7)

The development of dyspnea and/or angina during exercise is also important
10 subjectively quant In particular exercise limited by dyspnea as opposed
10 other subjective symptoms appears to indicate an increased risk for future
adverse events (2,12) Four level scales for perceived dyspnea and angina during
exeris ate available through the current AHA sciemii statements on recon
‘mendations or clinical exercise laboratories (76).

‘TESTTERMINATION CRITERIA,

Graded exercise test (GNT) whether maximal or submaximal, isa safe procedure
‘when subject sercening and testing guidlines as outlined in Chapter Zar adhered
to. Occasional; for safety reasons, the test may have tobe terminated prior othe
subjet reaching a measured VO, NO, volitional fige, ora predetermined
endpoint (Le, 50%-70% HRR or 70-85% age-predicted HR). Because of the

individual variation in HR... the upper limit of 85% of an estimated HR, may

CHAPTER 4 Heat Reed … ETES
Ea I mi suce

+ Onset of angie or anginsäke symptoms

+ Dropin SBP of =10 mm Hg with an increase in work ato oi SBP
‘decreases below te value obtained nthe same poston pio 1 testing

+ Excossiv so in BP: systoli pressure >250 mm Hg andor dastoie
pressure >115 mm Hg

+ Shores of brath, hooting, log ramps,or claudio
Sins o pooeporluin:Ightheadodress, contusion, ata, pall,

‘cyanosis, nausea, or cold and cama sin

Falure of HR to increase wih increased exercise intensity

Nvieable change in hart rhythm by palpation or auscultation

Subject quests to stop

Physical or vorbl manfestaions of severo fatigue

Faure ofthe testing equipment

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 exeris 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 49 provides normative values for VO, in mi kg» min) estimated
from weadmill speed and grade with specific reference 10 age and sex. Research
suggests VO, below the 20th percentile or age and sex, hat often indicative
of asedentary 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 ava
able regression equations, research indicates prediction formulas derived from a
Veterans Affitscohor (Predicted METS = 18 ~ 0.15*age) and the St James Take
ean project (Predicted METS = 14.7 ~ 0.13*age) may provide somewhat beter
prognostic information in men and women, respectively (61).

Although percent predicted aerobic capacity appears 10 be prognostic
(Ge. lower percent predicted = worse prognosis) an individual age has signif
icant influence on predictive characteristics im men and women. Specifically in
younger individuals (40-60 ye), percent predicted aerobic capacity may have
tw decrease below 60%-70% before indicating poor prognosis, ater which the

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Age 2029 ge 30-39
A | Gotetestam wav, nan Emme À
x ‘une! (mg (mie) te) (ine) etage time à
RB superior — 210 605 200 829 3000 583 198 so ©
ES 2805 555 186 97 77.03 EN 182 oR
90 2700 380 181 934 2525 517 175 joo.
85 Excellent — 2530 518 175 1000 24:13, 500 170 1024 E
80 25:00 511 173 10:09 23:06 48.3 166 10:46 Es
75 7513 485 166 1043 2210 a 162 mo À
Mg 2290 475 163 1059 21:30 460 15 m2 à
65 2200 468 161 m0 2100 453 157 na À
El 21:10 456 158 129 20:09 441 154 11:54 El
55 21:40 48 156 mar 20.00 239 153 1:58 Él
mr je 20.00 439 153 158 1900 424 10 aa 3
45 1908 426 150 1220 1807 a2 6260
40 1830 au 147 1238 17:49 407 14 1258
25 1600 0 vas ee | uw En ME à
D x 177 399 147 1815 1628 387 139 taa E
25 1638 20 140 1336 1546 378 1% uw À
20 1656 380 137 14.00 15:00 367 12 ua 3
15 15:00 367 133 14:34 14:02 352 129 15:13 CI
ane er a7 128 1530 1300 338 125 1557
1138 318 120 1794 m3 312 18025
1 800 265 105 2058 800 265 105 2058

2328 n= 12,730

Total = 15,058

Experienced writers

1% plaglarism free

Ae Age 50-59
AT TN

* (une) (ofa) "im ima (tne) tag) me tame)
D superior — 2230 561 187 910 2700 540 181 sa $
95 2690 525 17 951 22 490 1m 107 8
9 24:00 49.6 169 10:28 22:00 468 161 11:10 bé
857 Excelent 2300 282 165 1048 2020 406 156 ma E
+0 2145 An 160 ns 1937 483 152 aos
75 2042 us 156 mao 1895 ae 1a nm 3
D a 2001 199 153 158 1800 a0 15 es |
us 50% 30 a 151 12.0 1708 397 ia wz À
oo 1900 224 140 1224 1629 20 140 m 3
E 1800 210 145 1238 1600 EN 17a
50 Fai 1722 40.1 143 13:12 15:18 371 134 14:23 ES
45 J 17:00 395 141 13:24 15:00. 367 133 14:34 2
20 1614 EN 138 1250 1412 355 10505
35 1538 378 136 an 13 En a u À
30 py 1500 267 133 ren 1800 En CT
2 1430 259 131 ase 1221 28 19 1% À
20 1345 ue 128 1524 mas 320 10 um à
15 1200 98 125 1558 100 308 ue
very poor 1200 323 121 1646 1000 24 ug #7 à

1001 En 18 1848 8:15 269 1062038 8

1 290 251 101 22 525 28 oss _%m 3
PET n= 1087 E

Total = 28,781 8

(continued)

Experienced writers

Power for Met @

Fitness Categories for Maxi

1% plaglarism free

Hoe 60-69 707-78
A A rr À
* une) img "mien" te) une) igen) "mie me à
Boom 2500 Su 173 70.08 74:00 85 m nm À
95 718 457 159 11:26 2000 439 159 us À
El 19:10 27 150 1220 17.00 395 1a BA À
85 Excellent 1801 410 145 1253 16:00 381 137 13:58 E
a vor 26 ai 19328 1500 367 12 130 E
75 1609 383 138 1382 1201 352 19 mu À
DZ gi 1520 E] 135 1:16 13:05 339 126 1554 à
6 1500 367 133 1430 1222 331 123 we À
60 14:15 356 130 15:04 1203 324 121 16:43 El
55 13:47 349 128 1523 11:29 316 119 1712 a
5 gy 102 Er 125 1656 1100 309 17 mae 3
45 1230 230 123 1621 1026 30. 116 ene
20 1200 323 121 1646 10:00 204 us 1828
E 1130 En ie sv En ea À
De 1087 208 ur va 900 20 109 199 E
25 1004 205 18 1833 a 269 1062036 $
20 930 297 in 18:10 724 257 18 aia?
15 8:30 273 107 20:19 6:40 24.6 1.00 22:52 @
D error — a 256 103 2151 531 230 0% 240
5 557 236 097 2408 400 208 08 2758
1 216 197 085 2047 2:15 182 08 346

2971 near

Total n = 3,888

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LE Age 30-39
Brent MOV, Meme Mme | Bale Mao, “Min un Me ©

* (une) (mg) "im im (tne) tag) men À
D superior TE 545 183 930 2537 520 176 os |
95 2400 496 169 1028 2226 ara 18 næ à
9 22:00 46.8 161 11:10 21:00 453 157 1:33 bé
857 Excelent 2100 453 157 mas 2000 439 15 se E
20 2001 as 153 158 1990 224 1 HA à
75 1800 24 149 224 1802 210 1 ase
D a 1808 a 146 1251 vo EN ea À
BE Bon a0 145 1258 16.18 En 18 ear
oo 17.00 295 at 1924 1649 a2 136 woe
E 16:17 385 138 1348 15:10 369 m ae
50 Fair 15:50 378 137 14:04 15:00 367 133 14:34 ES
as 1500 367 139 en 1200 352 19 3
20 1436 EN 132 1450 1320 Pr > ww. |
35 1400 357 129 1514 1300 En ise
30 as a 126 1548 1208 za 1e à
2 1230 E] 123 1621 147 320 10 ws É
20 1200 23 121 1648 100 209 inv à
15 mo 309 i 1738 1000 24 mw 5
1 y geor 1904 295 18 1833 290 280 TE 5
849 276 108 2008 738 259 19 za 8

1 600 237 097 7358 527 229 0% um 3
1200 aaa? E

Total = 5587 5

(continued)

16

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Fitness Categories for Maxi

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Ross 7 50-58
A A er À
* une) img "mien" te) ee) tinge) tats) me 8
Boom 2500 Sur 173 1005 Fat 31 m mE
95 2100 453 187 1133 1601 410 15 a
El 1820 = 151 a 1630 388 1391340
85 Excellent 18:02 410 145 1253 15:16 370 134 14:24 E
a 1702 En ai 1328 15.00, 367 12 Er
75 1622 386 139 1345 1402 352 or À
DZ gi 16:00 381 137 1358 13:20 342 127 1 à
6 1501 27 138 1430 1240 32 124 im À
60 1430 359 131 14:53 1213 326 122 16:35 El
55 1401 352 129 1513 1200 323 121 16:46 a
5 gy 1822 245 127 1534 na EN 0 mS
45 1200 me 12 1658 1100 309 117 mae >
20 1216 28 122 1631 10:19 299 114 1618
E 1200 23 iar a ACT En es À
De 1.0 au ne 1720 920 287 1m wog
25 1022 202 115 1805 200 280 109 we $
20 1000 294 1 1897 8:10 268 1% mu à
15 9:07 282 1.10 19:35 730 258 103 21:38 CI
0 Verypoor — 898 206 105 2052 640 246 100 2252
5 700 251 10 2222 533 20 0% 246
1 500 222 093 2549 331 201 09 2908

n= 3923
Total n = 9831

Expori

‘Age 60-69 Age 70-79
‘Balke Teadmi MaxVO, 12MinRun 15 Run | Balke Teedmil MaxVO, 12Min Pan 154i Run
% (timo) (ksi) (rile) (timo) ine) CU) mis) (ine)
Superior — 1200 224 129 1224 19-00 224 149, 1224
95 15:46 378 136 14:05 1521 372 135 19:21
90 130 359 131 14:53 1206 325 122 16:40,
85 Excellent 19:17 342 126 1545 1200. 323 121 16.46
80 1215 327 122 16:33 1047 306 116 1751
75 1200 223 121 1646 1016 298 114 1821
D q 1109 EN 118 17:30 1001 294 118 1837
65 eae 11:00. 309 17 17:38 1000 294 118 1837
60 10:10 297 114 1827 9.06 281 110 1936
55 10:00 294 113 1837 200 280 109 19:43
CRE 935 288 112 1904 Bas 276 108 2002
45 " 207 282 110 19:35 805 267 105 2052
40 833 273 107 20.16 735 259 103 2131
35 804 266 105 2052 707 253 102 2207
DI por 732 259 103 2136 64a 247 100 2246
25 70 251 101 2221 623 22 099 2320
20 639 246 100 2252 555 235 097 24:06
15 612 239 098 2337 500 22 093 25:49
10 532 230 095 24:48 420 215 os 2651
sever 4:45 218 092 26:19 312 196 086 2000
1 307 195 086 3012 17 168 078 36:13
131 = 155
Total n = 1,286

‘Adapted with permission from Physical Fness Assessments and Norms for Adult and Law Enforcement The Cooper Insttute, Dalles, Texas. 2009

Formore information: wow coopennattte 9

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26

A EU) === |

increase in mortality risk becomes rather steep. In older individuals (>60 yO),
there appears o be a more linear relationship between percent predicted aer.
bic capacity and moral risk across the range of potential values as opposed
toa single threshold In a comparison ofthe physical fitness status of any one
Individual to published norms, the accuracy of the classification is dependent
on the simiariies between the populations and methodology (eg, estimated vs,
measured VO, maximal vs submaximal.

Although Stibmaximal exercise testing is not as precise as maximal exercise
testing, lt provides a general reflection of an individuals physica fitness ata
lower cost, potently reduced risk for adverse events, and requires les time
and effort on the part ofthe subject. Some ofthe assumptions inherent in a sub
‘maximal test are more easily met (eg. steady state HR can be verified), whereas
others (eg, estimated HR...) introduce unknown errors into the prediction of
VO, ... When an individual is given repeated submaximal exercise tests over a
period of weeks or months and the HR response toa fixed work rate decreases
ver time, iis likely thatthe individuals CRF has improved, independent of
the accuracy of the VO, prediction, Despite differences in test accuracy and
methodology virtually al evaluations can establish a baseline and be used to
track relative progres,

MUSCULAR STRENGTH AND MUSCULAR ENDURANCE

Muscular strength and endurance ar health-related fitness components that may
improve or maintain the following (110)

+ Bone mass, which is related 0 osteoporosis

‘Glucose tolerance, which is peminent in both the prediabetic and diabetic state

+ Musculotendinous integrity, which is related toa lower risk of injury includ
ing low back pain.

+ The ability o Cary out he activities of daly living. which is related o per
ceived quality of life and slF-fficacy among other indicators of mental health.

+ The FFM and resting metabolic rate, which are elated to weight management,

The ACSM has melded the terms muscular strength, endurance, and power
ino a category termed “muscular fess” and included it as an integral portion
of total health-related fitness in the postion stand on the quantity and quality
of exercise for developing and maintaining fitness (42). Muscular strength refers
10 the muscles ability to exert force, muscular endurance isthe muscles ably
continue to perform successive exertions or many repetitions, and muscular power
is the muscle ability o exert force per uni of time (i, rate) (29). Traditionally
tests allowing few (<3) repetitions ofa task prior to reaching momentary mus
cular fatigue have been considered strength measures, whereas those in which
‘numerous repetitions (> 12) ae performed prior to momentary muscular tique
were considered measures of muscular endurance. However, the performance of
2 maximal petition range (ie, 4, 6,07 8 repetitions ata given resistance) also
an be used to assess strength

CHAPTER 4 Heat Reed … ETES

RATIONALE

Physical füness tests of muscular strength and muscular endurance before com:
mencing exercise training or as par of a heallhmes screening evaluation can
provide valuable information on a clients baseline physical fitness level, For
example, muscular ness 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 fess assessments can lso serve as a basis
for designing individualized exercise training programs. An equally useful app
‘ation of physical ames testing is to show a clients progressive improvements
over time as a result of the training program, and thas 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 (RON). Results of any one test ae specific othe procedures used, and
fo single test exits for evaluating total body muscular endurance or strength.
Individuals should participate in familiarization/practice sessions with test equip
ment and adhere 1 a specific protocol including a predetermined repetition dura
¡on and ROM in order to obtain a reliable score that can be used to track true
hystologic adaptations overtime, Moreover, warm-up consisting o 5-10 min of
Tight tensity, aerobie exercise (4, treadmill or cycle ergometer), state ste
ing, and several light intensity repetiions ofthe speciic testing exercise should
precede muscular fess testing, These warm-up activities increase muscle tem
perature and localized blood flow and promotes appropriate cardiovascular re
sponses to exercise À summary of standardized conditions include the following

Swit posture.
Consistent repetition duration (movement speed).
Full ROM.

Use of spotters (when necessary).

Equipment familiaizato

Warm-up.

Change in muscular fitness over time can be based on the absolute value of
the external load or resistance (eg, newton, kilograms [kg or pounds [Il
but when comparisons are made between individuals, the values should be
expressed as relative values (pee kilogram of body weight [kg > kg). In both
cases, caution must be used inthe interpretation ofthe 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 (eg. fe
‘weight vs machine weight) may differ In addition, the biomcchanics fora given
resistance exercise may difer significantly when using equipment from different
‘manufactures, farther impacting geeralizailiy,

% GUDEUNES FoR! u. Stratus) === |

MUSCULAR STRENGTH

Although muscular strength refers to the extemal force (properly expressed in
resetons, although kilograms and pounds are commonly used as well) that can
be generated by a specific muscle or muscle group, it commonly expressed
terms of resistance met or overcome. Strength can be asessed either stat
ally (Le, no overt muscular movement at a given joint oF group of joints) or
‘dynamically (Le, movement ofan external load or body par in which the muscle
changes length). Static or bometrie strength can be measured conveniently using
à variety of devices including cable tensiometers and handgrip dynamometers
Im certain instances, measures of static strength are specific 1 the muscle group
and joint angle involved in testing; therefor, their wily in describing overall
‘muscular strength may be limited, Peak force development in such tess is com
‘monly referred o asthe maximum voluntary contraction (MVC)

Traditional; the one repetition maximum (RM), the greatest resistance that
can be moved through the fll ROM in a controlled manner with good posture,
as been the standard fr dynamic strength assessment. With appropriate testing
familiarization, L-RM isa reliable indicator of muscle strength (6784). A multiple
RM, such as 4- or 8-RM, can be used asa measure of muscular strength, For exam
ple, fone were taining with 6-108-RM, the performance ofa 6-RM to momentary
‘muscular fatigue would provide an index of strength changes over ime, indepen:
dent of the tue RM, Reynolds e al (01) have demonstrated multiple repettion
tess inthe 4- to RM range provide a reasonably accurate estimate of 1-RM.

In addition, a conservative approach to assessing maximal muscle strength
should be considered inpatients at high risk for or with known CVD, pulmonary.
and metaboie diseases and health conditions. For these groups, assessment of 10-
10 15-RM that approximates training recommendations may be prudent (110)
Valid measures of general upper body strength include the 1-RM values for bench
pres or shoulder press. Corresponding indices of lower body strength include
TERM values for the leg press or leg extension. Norms based on resistance lifted
divided by body mas forthe bench pres and leg press are provided sn Tables 4.10
and 4.11, respectively The following represents the basic steps In 1-RM (or any
‘multiple RM) testing following familirization practice sessions (69)

1. The subject should warm up by completing a number of submaximal ret

ons ofthe specific exercise that willbe used o 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.

cet an initial weight that is within the subjects perceived capa

308-708 of capaci,

4. Resistance is progressively increased by 25-200 kg (53-440 1) untl the
subject cannot complete the selected repetition(s); all repetitions should be
performed atthe same speed of movement and ROM 10 instill consistency
between trials.

5. The final weight lied successfully is recorded as the absolute 1
multiple RM

CHAPTER 4 Heat Reed o LO ——. |

for Upper Body Strength for Men and

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igor Men and
Women by Age (Continued)

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28 Categories for Log Strength by Ago and Sex!

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CHAPTER 4 Heat Reed … ETES

Isokintic testing involves the assessment of maximal muscle tension
throughout a ROM set at a constant angular velocity (eg, 60 angles + 5°)
Equipment that allows contol of the speed of joint rotation (degrees + 5°) as
well asthe ability to test movement around various joints (e knee, hip, sho

der, elbow) is avaiable 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 f a muscle group to execute repeated muscle
actions over a period of time sulficint to cause muscular fatigue or to maintain
à specific percentage of the RM for a prolonged period of time. Ifthe total
number of repetiions at a given amount of resistance is measured, the resul is
termed absolute muscular endurance Ifthe number of repetitions performed ata
percentage ofthe 1-RM (eg. 70%) is used pretesting and postesting, the result is
med relative muscular endurance. Simple field tests such asacurl.up (crunch)
test (1945) or the maximum numberof push-ups that ean be performed without
rest (19) may be used to evaluate the endurance ofthe abdominal muscle groups
and upper body muscles, respectively. Procedures for conducting the push-up
and cur-up (crunch) muscular endurance estare given in Bax 4.6, and physical
fines 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 repeitons or the duration of static muscle action before
fatigue. For example, the YMCA bench press test involves performing standard
‘eed petitions at arate of 30 Ni or rep min". Menare tested using a363-kg
(80 1) barbell and women using a 139-k (35 I) harbll Subjects are scored
by the number of successful repetitions completed (111). The YMCA testis an
excellent example of a est hat attempts to contol for repetition duration and
posture alignment, this possessing high reliability, Normative data forthe 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-
ential ove the next several decades as described in Chapter 8, As individual
are living longer, i is becoming ineteasingly more important 10 find ways 10
extend active and independent fe expectancy. Assesing muscular strength
and endurance, neuromotor fitness and other aspects of health-related physical
fimess among older aduls can ad in detecing physical limitations and yield
importan information used to design exercise programs that improve muscular
fines before serious functional limitations or injuries occu. The Senior Fitness
Test (SFT) was developed in response 10 a need for improved healthfitness

10 cuveunesron u. =|
PROF 2:20 aná ur Crunch Test
ft rc

| PUSHLUP:

1. Tho pushp testis admiisered with men starting inthe standard “dower
positon hands poining forward and under the shouder beck straight
head up. using the 1008 as the pivotal point and women athe modes
“knoe pustrup" postion lags together, lower eg in contact with mat with
“nidos pantarflexod, back straight hands shouder with apart head up,
Using the knees a the pivotal pot.

2, The dienupatent must ais the body by sraightning the elbows and
requ to tho “down” position, unt the cin tosches the mat. The stomach
should not touch the mat

3. For both men and women, he subject's back must be svaight at ll mes
and the subject must push u 10 a straight arm poston.

4, Tho maximal umber of pushups performed consecutively without rest 5
counted a the score

5. Tho ostis stopped whon the cont sans forciy or unable to maintain
the appropriate technique within two petitions

CURLUP (CRUNCH

1. Two stips of masking tape ae tobe placed on a maton ho Foor at
a distance of 12 cm apor (or contspationts <5 1 or 8 om apart
ior eiontsipationts 245 y.

2. Subjects re tien a supine postion across tho tape, knees bent a 90°
with fet on the flor and arms extended to thei sides, such hat Ho
fingertips touch the nearest tip. This the bottom positon To reach the
top positon, subjects are 1 flex tho spines to 20°, reaching thor hands
forward nd their fingers touch tho second sip of tape.

3. A motronome sto be set at AD beats min“ At the fist beep, the subject,
begins the curp, reaching the top position atthe second been, roturing
to the starting pasion atthe ti, top posiion atthe fu, et

4, Repostions are couned each time the subject reaches the bottom positon.
“Tho tests concluded either when the subject reaches 75 curs, or the
‘cadence is broken,

5. Every subject willbe alowed several practic opottons prior 1 the start
ofthe test

‘tina gn nc tn eg tn en
Pn pene a sv cn to Dolo Sc lo

CHAPTER 4 Heat Reed … ETES

Sex ew
er =
=
Fair +
= =

assessment tools for older individuals (92). The test was designed 10 assess the
key physiologic parameters (strength, endurance, agility, balance) needed o
perform common everyday physical activities that are often difficult to perform
in later years. One aspect of the SFT isthe 30 chair stand test. This test, and
‘thers ofthe SFT, meets scientific standards for rliabity and valid. simple
and easy to administer in the “fea” setting, and has accompanying performance
noms 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
fess tests such as the LRM, Tuo specific tests included inthe SFT — the 30-5
chair stand and single-arm curl — can be used by the health/itness and clini

cal exercise professionals to safely and effectively assess muscular strength and
endurance in most older adults.

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a E CI N

Coronary Prone Clients

Moderate intensity resistance training performed 2-3 d= wh" iseletive for im
proving muscular finess, preventing and managing a variety of chronic medical
conditions, modiying CVD risk factors, and enhancing psychosocial well-being
for individual with and without CVD. Consequently, authoritative professional
cal 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 STsegment changes on the ECG,
abmormal hemodynamics, and complex ventricular dyshyuhmias suggests mod
trate intensity (eg, performance of 10-15 repetitions) resistance testing and
tesining can be performed saely by patients with CVD deemed “low risk” (eg.
individuals without resting or exercise induced evidence of myocardial ischemia,
severe le ventricular dsfunetion, or complex ventricular dyshydhmias, and
with normal or near normal CRF [see Chapter 2). Moreover, despite concerns
that resistance exercise clits abnormal cardiovascular “pressor responses” in
patients with CVD and/or controlled hypertension, studies have found strength
testing and resistance training in these patients eii HR and BP responses that
appear to fall within clinically acceptable limits (110). Resistance taining in
‘moderste-o-high risk patients with CVD may be deemed appropriate follow
ing a thorough clinical assessment by an experienced health cae professional.
Furthermore, moderate-t-high risk patients with CVD who do participate ina
resistance ining program should be closely monitored (110). Absolute and rela
tive contraindications to resistance testing and training ae provided in Bas 47

CHAPTER 4 Heat Reed o re
soxar Absolute and Relative Conraindi
and Testing

ABSOLUTE
‘Unstable CHO
Decompensated HF
Uncoattod arhythnias
‘Severe pulmonary hypotension (mean pulmonary aa presse >88 men Hg)
Severe and symptomatic arti stonosis
Acute myocaris, endocarditis, or poricarstis
{Uncontoleë hypertension (180/110 mm Hg)
Bone dissection
Morten syndrome
High intensity RT (80% to 100% of AM) in paint with active protferative
‘etinopathy or moderate or worse nonrolferatve dabei retinopathy

RELATIVE (SHOULD CONSULT A PHYSICIAN BEFORE PARTICIPATION)
‘Major sk factors for CHO
Diabetes at any age
"ncontroled hypertension 160/100 mm Hg)
Low functional eapacty (<a METS)

India who have implanted pacemakers or defiilators

Children and Adolescents

Along with CRE 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 a sprinting and jumping, and enhancing selfconfidence and self
estcem. 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 recrction programs, and youth sport centers, Use of resistance

sos EU) >=:

training equipment commonly available in unes facilities is also appropri
ate for the assessment of muscle strength and endurance. When properly
‘xlministered, different muscular fitness measures can be used to assess a
childs 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
Ihealtvfitness and clinical exercise professionals should demonstrate proper
performance of each kil, provide an opportunity for each child to practice a
few repetitions of each skill, and offer guidance and instruction when neces-
sary. In addition, tis important and usually required to obtain informed con:
sent rom the parent or legal guardian prior o 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).

| + Ensuro appropriate training for indus! prosicing taining instruction
and supervision

+ Provide a sate excise environment

+ Start warning session with a5 10 10min dynamic warm-up

+ nite traning program two 0 Ihr times por wook on noneonsecutie
days, wäh ight resistance, and ensue exe technique is corect

+ General wainng session guidlines: on to Ie sets of 6-15 repetitions
With combination of upper and ower body oxercso

+ Incoporato exercises specifically focusing on trunk
Training program should induce symmetrical and balanced museular

evelopment

Individuaized exercise progression based on goals and ski

Gradual increase (~5%-10% in waning resistance as gains ae made

Use calstnencs andor stretching postesistance taining session

Be aware of individual needs/eancoms during each session

Consider use of an indduatzed exercise log

Continual ltr waning program to maintain interest and avoid training

pataus.

Ensure proper nutriion, yan, and sleep

+ Insuuctor and parents should be supportive and encouraging to help
maintain interest

CHAPTER 4 Heat Reed fay Sr

FLEXIBILITY

Flexbi is the ability to move a joint through its complete ROM. I is impor:
tant in athletic performance (eg, ballet, gymnastics) and inthe ability to cary
out activities of daily living, Consequently, maintaining exil of all joints
Faciittes movement; in contrast, when an activity moves the structure ofa joint
beyond its full ROM, tissue damage can occur

Flexibility depends on a number of specie variables inchuding distensibility of
the join capsule, adequate warm-up, and musck viscosiy In addition, complemce
(Ge. tightness) of various other issues suchas igmentsand tendons aci te ROM
Js as muscular strength and endurance i specific tothe muses involved, exi
À joim specifi; therfore, no single Neviily test can be used o evaluate total ody
kei Laboratory tests usually quant leit in tems of ROM expressed in
degres. Common devices fr ths purpose include goniometer, elecuogoniometes,
the Leighton Nexometer, inclnometrs, and tape measures Comprehensive ns
tions are available forthe evaluation of flexibly of mos anatomic joints (2480).
Visual estimates of ROM can be useful in ness sreening but are inacurate relative
to directly measured ROM, These estimates can include neck and trunk flexibility,
ip esi; lower extremity eit, shoulder Nexis and postural sessment.

A more precise measurement of joint ROM can be assessed at most anatomie
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 415

Range of Motion of Select Single Joint Movomonts in Degreos

Fern Bm Ennion Er
orzo! ion a Horacio. ws
Foren. FO rer
30-50 An
20.45 tamis a
TON Eons. =o
1520 Ponto =a

10 Everson 19-20

106 EU) === |

provides normative ROM values for select anatomic joins. Additional infor
‘mation can be found in the ACSMS Resource Manual for Guidlines for Exercise
Testing and Prescription, Seventh Edition (101)

The sitand:-each ts has been used commonly to assess low back and ham
string fexbity: however, its relationship to predict the incidence of low back
pain i limited (54). The si-and-teach testis suggested to bea etter measure of
hamstring flexibility than low back flexibility (53). The relative importance of
hamstring flxiily to activites of daily living and spots performance, here
fore, supports the inclusion of the sitande-reach test for health-related fitness
testing unl aeriterion measure evaluation of low back Mesibiity is available
Although limb and torso length disparity may impact sicand-reach scoring
modified testing that establishes an Individual zero point for each participan
as not enhanced the predictive index for low back flexibility or low back pain
(73274)

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 Tow back pain; however, this hypothesis remains to be sub
stantated (88). Methods for administering the stvand-reach test are presented in
Box 4.9, Normative data fr two si-and-teach tests are presented in Tables 4.16

Qu.

À Prost GiontsPatents should pero a short warm-up pr o tis test
| end include some suetches (0.9. modiied hurdler’ svete) Is also

À recommended that the particpant retrain om fast, ey movements,

which may increase the possibilty of an injury. Tho participants shoes should
be removed,

À 1. For to Canadian Tunk Forward Fin tos, the cont sits without shoes
‘and the soles ofthe feet la against the lexometer(sitandeach box) at

tho 26 em mark. Iner edges of tho sales ar lacod within 2 om of tho
‘measuring scale. For the YMCA sitandveac ost a yardstick is pacod on
the flor and tape 8 pacnd across a right ange tothe 16 in mark. Tho
celenvpationt st wih the yardstick botwoon the lags, with logs extended
{a sight anges 10 the taped in on the floor. Heels of the feet should touch
the edge of th taped ine and be about 10 to 12 i apart. (Note the 20r0
point at the fotbox interface and use the appropriate norms.)

2. The diontpatient shoul slow reach forward with both hands as far
as possible, holding this positon apprcximatly 2s, Be suo that the
paricipont keeps the hands pall and does not lad with one hand
Fingertips can bo overlapped and shouldbe in contact with the measuring
Potion or yardstick ofthe sitandeach box

L.

<< EI
A

3. The scoros the most distan pont lem or a) reached with the ing
“The best ol wo vial should be recorded, To asis wit the best
‘attempt, th cienupaion should exhale and drop th heed between
the arms whon reaching. Testers shoud ensure that the knoos ofthe
participant stay ostendod; however, tho participant's knaos should not be
prossed down, Tho cionpationt should bathe normaly during the ost
and should no hold hais breath at aay time. Norms fe the Canadian
test ro presented in Table 4.16. Not that these norms use a sitand-

reach box in which the "zero" point is set atthe 26 cm mark fa box is
usedin which te zero point is sot at 23 cm (e.g. Fitnessgram), subtract
3 em rom each value inthis table, The norms for the YMCA test re
presented in Table 4.17.

td wah puma no)

A COMPREHENSIVE HEALTH FITNESS EVALUATION

A comprehensive healivGness assessment includes the following:

+ Prescrening/ris classification
+ Resting HR, BP height, weight, BM and ECG (if appropriate).
+ Body composition,

+ Waist circumference,

+ Skintold assessment

Bester Ba m nm mn
Vere eee eee ee
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ee

08 EU) === |

ach Test Im) by Ag

iness Categories

E 2 2 m 2 Am 20 V À
CO BER
E

TA
M e 8 v ev

see 6 a
‘rage

M one ae BD u om om
20 _ Weinen HI EE
do mee 9 mé w 6 9 4 +

Na wn pao to) 200 DY CA A Ww USA, Org Att ns.

+ Canliorespiratoy fines.

+ Submasimal or maximal vest ypically on a cycle ergometer or te adel

+ Muscular strength

+ 1-10 muliple-RM upper body (bench pres) and lower body leg press),
+ Muscular endurance.

+ Curtup test

+ Pash-up test,

+ Specific motion using appropriate equipment wo fatigue (Le, bench pres)
+ Flexibility

+ Sieandereach test or goniomeric measures of isolated anatomic joints

Additional evaluations may be administered; however the components of
à healthvfaness evaluation listed cari representa comprehensive assessment
that can be performed within 1 d. The data accrued from the evaluation should
be interpreted by a competent healthfitnessor clinical exercise professional and
conveyed wo the cien patient, This information i central tothe development of
à ciemt/patients short and long-term goals as well as forming the basis for the
initial Ex R, and subsequent evaluations to monitor progress.

THE BOTTOM LINE

The ACSM Health-Related Fitness Testingand Interpretation Summary Statements

+ Healtuness assessments provide a wealth of information regarding an in
dividuals health and functional status. A comprehensive assessment includes
an evaluation of body composition, CRE muscle strengihvendurance, and
Aesibiy:

CHAPTER 4 Heat Reed |, Sr

+ Each component of the assessment can be performed through several ap
proaches to accommodate availability of equipment, the facility training of
personnel, and healbvitness stats ofthe individual undergoing testing

+ Adherence to the recommendations for the heullvfuness assessments pro:
‘ied in Chapter 4 allows for an individualized and safe approach

+ When available, results from each component ofthe cabines assessment
should be compared to normative dats provided in Chapter 4

ASM crée Media
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nea ties onthe Linn, aban and Treatment f Oven and
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REFERENCES

1.208 Papa cy Gdns fr Americans [mel Rocke (MD Ofice of Diem
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evra Cage pre Mine oan Stand, Amen Amocaton Recomendatoro
ice sois adios md me plo sis i Med
Aia Re O e ay pedos md com a ar cos ws ly
Fons Ree) Wie Ae at Aue o Fnac nl and noch
1. ad FO. Ri A na or clio fee cac (pal ine) Io

pal De

Ce ee oe
Pye ee and lc moray pun dy l heathy day men PU
Lines

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sos moray À presen dy bsy men and warn JANA 1092010712910

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1 bay GA tho the you th he bt st A Ja Na 00605070

15 baud mde Anden Kyo L Denatomeie mala oD) compotion ron of
‘srr ani simpre dm NY Aad EE 90,

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‘yen wp and sara! psu han bx le Ch III 92538

ur. Cale Low Bac Ran Stone. hed is GTA an D A

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En 16 Ra AE an ler Ayo Suda one Mama

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Agra CAEL SE ta & Pen Pegs Heth el Ari Caco,

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Gar Is

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‘= ric long em moral ip nth COPD, Chat CO PA

22, cin Yong A) Duchame ME eal Annan Clee of pride oso sand:
pren cu er dren, Mal St pr Fae. 2 DIES

23, puc belen JW nn Rel Gm Mean Wey Pal) Chana ot
condon a seen men wat ray comes A Col 199434) 216-2

24 kn Murase As nef Mica ale gl.
Ale (40) Lipps Wlan € Wien 200.027

25. Cal Cacao dh eon Elan nd Tet of Occ an Ob in A
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Standard graded exercise tests (GXT) are used clinically to assess a patients
abi to tolerate increasing intensities of acrobi exercise. Electocandiographic
(ECG), hemodynamic, and symptomatic responses are monitored during
the GXT for manifestations of myocardial ischemia, hemodynamiceletrcal
instal or other exerton-rlated signs or symptoms, Ventilatory expired gas
analysis may also be performed during the GNT, particulary in patients with
congestive heart lure (CHE), suspectedicon imitations,
and/or unexplained dyspnea upon exerion

INDICATIONS AND PURPOSES

The exercise test may be sed for diagnostic (Le, inti abnormal physiologie
responses), prognostic (Le, ent adverse events), and therapeutic (Le, gauge
impact of a given intervention) purposes as well as for physical activity coun
seling and to design an exercise prescription (Ex R,) (see Chapters 7 and 9)
However, the recommendations for conducting the ÓXT as part of the prepar
ticipation health screening for purposes of initiating or maintaining an exercise
program (see Chapter 2), especially program of vigorous intensity; may der
From those regarding the use ofthe GXT to gain information for clinical decision
‘making and management that may inclu an exercise program.

DIAGNOSTIC EXERCISE TESTING

Determining appropriateness for diagnostic exercise testing to assess for angio-
sraphically significant cardiovascular disease (CVD) is inluenced by age, sex, and
Spmptomatolay as outlined in Table 5.1. Asymptomatic men and women have a
‘very low (<5% probability) tolow (<10% probability) Ikelihood of angiographi-
cally significan CVD across the third to the sixth decade of lf. 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 havea high (90% probability) likelihood of angio-
graphially significant CVD from the fourth to the sixth decade of lie whereas
‘women have an intermediate (10%-90% probability likelihood from the fourth
10 the ith decade and high likelihood in the sixth decade onward

hood of Atherosclerotic Cardin:

[CE Are un
Momen _iermadiie Lan. eric
Gem Men ho introdate memes
Mn Mo Inermeaste __ Meme
Women Han Inermedste —— intros
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Is widely believed the diagnostic GXT has the greatest use in patients with
an intermediate pretesprobabily of angiographically significant CVD, The
reason for this belie isthe dramatic impact the exercise response has on posttest
probability of disease. This concept is illustrated in Figur 3.1. From this graph,
tis clear that a positive GNT (Le, STsegmen depression suggestive of CVD)
improves the probability of angiographically significant CVD tothe greatest evel
in he subject with intermediate pretest likelihood (Le hid bar fom let prob
ability increases from ~10% pretest 10 >60% posts,

The same exercise testing procedures and concepts are also used when more
advanced diagnostic techniques are employed such as nuclear perfusion sean
hing. Asymptomatic individuals generally represent those with a low likelihood
(Le, <10%) of significant CVD. Therefore, diagnostic GNT. in asymptomatic
individuals generally is not indicated but may be useful to ensure a normal physi
‘ogc response (Le, hemodynamics, ECG, and symptomatology) when muluple
(CVD risk factor ae present (25) (See Table 22), indicating at least a moderate
risk of experiencing a serious cardiovascular event within 5 yr (72). Among
symplomatic men, STsegment depression, faite o reach 85% ofthe predicted
‘maximal heat rate (HR), and a diminished exercise capacity during peak or
symptom-limited tread 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 220%) (13). À diagnostic
GNT may be indicated in selected individuals that ate about to start a vigorous
mens. exercise program (See Chapter 2), or those involved in occupations in
Which acute cardiovascular events may affect public safety.

In general, patents with a high probability of disease (eg, ypleal angina,
Prior coronary revascularization, myocardial infarction (MI) ac tested to assess
residual myocardial ischemia, threatening ventricular arthythmias, and progno-
sis rather than for diagnostic purposes. Exercise eletrocadiography for diag-
nostic purposes i less accurate in women largely because of «greater number
of als positive responses. Although differences in test accuracy between men

me EU) === |

(st

E 45 yo Romont HOP Torok DM.

Posttest Probability of CAD (%)
45 yo. sympa o lk Factors

Pretest (Clinical)
Probability of CAD (%)

1 FIGURE 5: nos of poso or ego STsepantespose ding OKT on he postent
prob a page gent CID m jot ih hen protest probate
ED ea ane une gent win pormasion rom E,

and women may approximate 10% on average, ihe standard GNT is considered
the initial diagnostic evaluation of choice, regardless of sex (23). À truly postive
exercise test requires a hemodynamically significant coronary lesion (eg, >75%
stenosis) (3), yet neatly 90% of acute MIS ocur atthe site of previously nonob-
structive atherosclerotic plaque(s) 36)

The use of maximal or sign/symptomlimited GXT has expanded greatly 10
help guide decisions regarding medical management and surgical therapy in a

broad spectrum of patients. For example, immediate exercise testing of selected
low-risk patients (ie, no hemodynamic abnormalities and arthythmias, near
normal/normal ECG, and negative inital biomarkers for cardiac injury) pre
Seating to the emengency department with signdsymptoms of acute coronary
syndrome is becoming increasingly recognized as a valuable tool in making
decisions regarding which patients require additonal diagnostic studies before
hospital discharge (4,5 43.46,71). The use of exercise testing inthis capacity has
been found tobe safe and reduces both length of hospital stay and cos, Patients
iniiall screened to be at low risk subsequcntly demonstrate a preserved exercise
capacity (Le, 27 metabolic equivalents [METS]) and no hemodynamicrECG
abnormalities during testing have a low likelihood of acute coronary syndrome
and subsequent events (4) In patients with chroni conditions such as CHF and
pulmonary hypertension, exerise testing may also prove valuable in guiding
reatment decisions as several variables obtained rom this assessment respond
favorably to numerous pharmacologic and surgical interventions (68,27).

EXERCISE TESTING FOR DISEASE SEVERITY AND PROGNOSIS

Exercise testing is useful forthe evaluation of disease severity among individuals
with known or suspected CVD. The magnitude of tchemia caused by a coronary
lesion generally is (a) direct proportional to the degree of ST-segment depres
sion, the number of ECG leads involved, and the duration of SEscgmen depres:
Sion in recovery; and (b) versely proportional othe ST slope, de ate pressure
product (RPP) (Le, eam rate [HR] X systolic blood pressure [SBP]) at which the
ST-segment depression occurs, and the HR,,,, SBP, and METs achieved

The exercise testing response is likewise important gauge of disease severity
in patients seth chronic conditions such as CHF, pulmonary hypertension, and
chronic obstructive pulmonary disease (COPD) (9). A progressively diminished
aerobic capacity is universally refective of increasing disease severity in these
‘onic conditions, Data exclusively obtained from ventltoy expired gas anal
sis and reflective of abnormaliis in ventilation perfusion matching (Le, minute
entltionfarhon dioxide production [VE/VCO,] slope, and para pressure of
endeidl carbon doxide [PEECO,]) alko provide insight int disease seventy espe:
«ia among patients with CHE pulmonary hypertension, and COPD. The prognos-
ti value of exercise testing appears to be consistent i ll individuals regardless of
their health sas when there is a progressively diminishing aerobic capacity that is
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 cenain populations such as heat ale. Several numeric
Indices of prognosis have been proposed and are discussed in Chapter 6 (11,47)

EXERCISETESTING AFTER MYOCARDIAL INFARCTION

Exercise testing alter MI canbe performed before o soon after hospital dicharge
for prognostic assessment, Ex R,. and evaluation of medical therapy or intr
ventions including coronary revascularization (25). Submaximal exercise tests

ne EU) >=:

are curently recommended before hospital discharge at 4-6 d after acute MI.
Submaximal exercise testing provides sufcient data to assess the elfeciveness
‘of current pharmacologic management cz, hemodynamic response to physical
exetion on antihypertensive medication) (se Appendix A) as well as activities of
‘aly living and carly ambulatory exercise therapy recommendations. Symptom
limited GX are considered safe and appropriate early alter discharge (~14-21 d)
for Ex R, and physical activity counseling and farther assessment of pharmacologic
‘management efficacy (25), Patients who have not undergone coronary revascular-
{zation and are unable to undergo exercise testing appear o havea poor prognosis
Other indicators of adverse prognosis in the post MI patent include ischemic
ST-segment depression ata low level of exercise (particularly if accompanied by
reduced let ventricular systolic funcio), functional pacity of <5 MET, and a
hypotensive SBP response to exercise (se Box 6.1)

FUNCTIONAL EXERCISE TESTING

Exercise testing is useful to determine functional capacity This information can be
valuable for physical activity counseling, Ex, disability assessment, and to help
estimate prognosis. Exeris testing may also provide valuable information as part
‘ofa return to work evaluation fhe patient’ occupation requires aerobic activi.

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 forage using one of
Several established nomograms with 100% considered normal (sce Figure 52)
(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 (NO) are alo available for men and women (39)
When using a particular regression equation for estimating percentage of normal
exercise capacity achieved, [actors such as population speciiciy exercise mode,
and whether exercise capacity was measured diec or estimated should be con
sidered, Laly recent investigations have found that percent predicted aerobic
‘capacity is prognostc in patients with CVD and CHE (7.39).

Data supporting the prognostic ability of aerobic capaciy in apparently healthy,
high-risk individual for the development of CVD, and known CVD cohons are
convincing (9). Kodama etal. 42) performed a meta-analysis that collectively
included 33 studies totaing more than 100,000 subjects and 6,000 all cause
‘mortality and 4.000 cardiovascular events, They found estimated aerobic capaci
{rom tweadmill speed and grade or ergometer workload was a consistent prog:
most marker in apparently healthy men and women, Each 1 MET increase in
aerobic capacity reflected a 13% decrease in all-cause morality and 15% decrease
in cardiovascular events (42) Myers etal (55) examined a large cohor of >3,000
‘men with variable CVD risk factors with and without confirmed disease and found
aerobic capacity was a superior predictor of morality when compared to tobacco
‘se, hypertension, clvated lipids, and diabetes mellitus. Subjects with CVD and

Exercise Capacity
(0% of Normal in Role Mon)

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a
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so

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1 GURE 52, Nomograms of percan roms! mures capacity man vit spect coanry
‘omen, MEI, meat sunset printed wih Damon Ham 5 and Loin

an exercise capacity 54.9 METS had a relative risk of death 4.1 times greater
compared to those with an exercise capacity =10.7 METs over a mean follow-up
(6.2 yt For every 1 MET increase in exercise capacity there vas a 12% improve
‘ment in survival Similarly, findings from the National Exercise and Heart Disease
Project among post-MI patient demonstrated that every 1 MET increase alter the

m EU) >=:

Exercise Capacity

(cof Normal a Heat Men)
20- o
25: bo
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e ©.

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8

exercise tmining program conferred an approximate 10% reduction in morality
from any cause over 19 yr of follow-up, regandless of study group assignment (21)

Kavanagh cal (37,38) investigate two large cohorts of men and women with
confirmed CVD who were refered to cardiac rehabilitation and found directly
measured peak oxygen uptake (VO) during a progressive ele ergometer est

Exercise Capacity
(0% of Nomalin Hey Women)

15
a qu
a: 13
7 i
70:

qe
©.

s
$.
4.
4.
5

to exhaustion at program entry was a powerful predictor of cardiovascular and all:
‘use mortal. The cf points above which there was a marked survival benefit

© 13 ml kein"? 0.7 METS) in womenand 15 ml + kg: min * (43 MET)
inmen. For each Imi. kg- min increase in aerobic capacity, there wasa 9% and
10% reduction in cardiac mortality in men

1d women, respectively

se EU) === |

In patients dignos with CHE the prognostic bil VO, supported
by 20 yr of esearch (8), ONei et al. (59) found a VO, < 10 kg min?
À indice of particular poor prognosis, à Ivesiold supported by other
inventions (9) In fact. the We of VO) at hs thresholds cosiered a Key
acexpable indication for han wanspan candidacy (25)

crabe capacity a valuable prognostic marker in patients with inter
long discas and pulmonary neral hypenension as well Two groups of ive

nor have found VO, 10 e a significan pedir of mortality in patients
with COPD 02,60) Similar to patents with CHE Higa et al. 02) found a
NO ys <10 mL > hg min "tobe indcatve ofa pantculary por Prognose
in hor with COPD. A small ivesgation by Miki et al. 50) indicated
NO, may alo be prognostic patients with pulmonary ross Several sal
tnvdlgationslkewise indicate VO, is prognostic in patients with pulmonary
arterial hypertension (6, Moreover Shah ta (69) found aerobic capac est
rated from treadmill time was a significant predictor of mortality in a cohort of
03 pates with pulmonary ater kyperenson. Additional research is needed
to soii the prognesi use of aerobic capacity inpatients with inertial and
vascular pulmonary dise and conditions

“The presurgkal ssesment of aerobic capac ging increased recognition
as an impor near of por outcome. Loewen etal. (45) found patents with
spose lung cancer are at significant greater il for surg complications and
poor outcome poxprocedire i VO, fal lower than 16-15 mi. kg» min
respectively Recent guidlines put fry the American Collegeof Cho Physcians
{ACCP suppor the use of eure tng wih entr expired gs ans
to ases presi and postsungial akin patents eth Jung cancer (19). This
cn recommends patents witha VO, <10 mL» gin! be consi
fre a high ok for posa complets and monada; redes of ether
«Sarco such a pulmonary funcion. Adina. patents wih a VO y
<15 ml kg: min in combination witha forced expiratory volume in one second
(FEN, ) and difsen egy that & <A0% predicted should ab he considered
igh ik fr complications and poor outcome. In ler patents undenping ste
Bass surgery McCullough eta. (48) reported a WO), <158 ml" hg" min
signif a higher sk fr postu compliions. LS; Older etal (61) fund
NO, ata ventory threshold of <11 0 ml. kg > min saint predictor
cardiopulmonary morality in patents underginginradblomial ungen; Given
the rowing body of evidence, i appears presnical assessment of aerobic cacy
to quirk or postsungial compheatons may be advantageous

EXERCISE TEST MODALITIES.

‘The weadmil is the most common exercise testing mode used in the United
States, Treadmills in clinical exercise laboratories should be electronically driven,
allow fora wide range ofspeed (1-8 mph or 1.61-12:8 km +) and grade (0%-
20%), and be able to suppor a body weight of at Teast 350 Ib (159.1 kg). The
Acad should have handel for balance and stability; but given the negative

impact ight gripping of the handrails can have on both the accuracy of estimated
exerise capacity (he, estimated VO with handrail gripping is greater than
measured VO,,.,) andthe quality of the ECG recording, handrail use should be
discouraged oF minimized tothe lowest eve possible when maintaining balance
{sa concern. An emergency stop button shouldbe readily visible and avallabl to
both the subject undergoing testing and supervising staff (52).

Cle ergometers are the most common exercise testing modes used in many

European countries. Cyeleergometry i less expensive and requires les space
an adil testing and isa wae alternative to read esting in individuals
with obesity and those who have onhopedic, peripheral vascular, and/or neuro-
logic limitations. The cycle ergometer must include handlebars and an adjust
abl seat allowing or the knee 10 he 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 canbe maintained over wide range of pedal rates, Because ther is ess
movement ofthe patients arms and thorax during cycling, is caser to obtain
beter quality ECG recordings and blood pressure (BP) measurements Hower
stationary cycling is an un amilir method of exercise for many and is highly de:
pendent on patent motivation. Thus, he test may end prematutey (Le, because
of localized leg fatigue) before a cardiopulmonary endpoint has been achieved.
Lower values for VO AD, ., during cycle ergometer testing (vs. trem et
ine) can rang from 3% to 25%, depending on the participants habia activity
physical conditioning, eg strength, and familiarity with eyeing (30.54.67)

Arm ergomety is an alternative method of exercise testing for patients who
‘cannot perform leg exercise. Because a smaller muscle mass is used during arm
emometr VO”, NO y. during arm exercise is generally 20%-30% lower than
that obtained during adm testing (24). Although this test has diagnostic
use (14), it has been lagely replaced by the nonexereise pharmacologic stress
techniques that are described later in this chapter. Arm ergometer tests can be
used for physical activity counseling and Ex R, for certain disabled populations
(eg. spinal cord injury) and individuals who perform dynamic upper
body work during occupational or leisure time acóvives

Routine calibration procedures should be followed for all exercise testing
modes (ie, treadmill, lower extremis; and upper extremity exgomety). Specie
calibration procedures are usually provided by the manufacturer. À description
‘of general calibration procedures for the treadmill and cycle and arm ergometers
ae 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 boing tested Ce. age, symptomatology). Some ofthe most common ex
excise protocols and the predicted VO, for each stage are strate in Figure 53
The Bruce treadmill test remains one of the most commonly used protocols,

en EU) >=:

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El e | UE
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E us [7 ri 28 | = she]
a A mo [o Li] eet
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al ue [ol A ist
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SIE] voue =
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particulary in cardia stress testing centers (56). However, the Bruce protocol
employs relatively large incremental workload adjustments (Le, 2-3 MER per
stage) every 3 min. Consequently, changes in physiologie responses tend to be
less uniform, and exercise capacity may be markedly overestimated when iis
predicted from exerise time of workload, which is particularly rue with hand:
rail se

Recent evidence indices ischemic thresholds are observed at similar RPP
when comparing the Bruce protocol to a more conservative treadmill protocol
(57). However, does appear the RPP corresponding wo an ischemic threshold is
significantly diferent fora given patient with CVD when performing an exercise
test ona ucadmill compared 10 a cycle ergometer (57,58). Specifically, the RFP
corresponding to an ischemic uhreshold and maximal STsegment depresion
is significantly lower during eyeleergometry compared to weadmill testing. In
general, protocols with larger incremental workload adjustments such as the
Bruce or Elend ae better suited for screening younger and/or physically active
individuals; whereas protocols with smaller increments suchas the Naughton or
Batke-Ware (ke, <1 MET per stage) are preferable for older or deconditioned
individuals and patents with chronic diseases, If serial esting & 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
gaine in popularity (10). Individualized (53) and standardized ramp ess, such
2 the Ball Sate UniverstyBruce amp (33), 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 later standardized ramp test matches work
rates o equivalent periods on the Bruce protocol while increasing the work rates
in ramp fshion,

‘Advantages of ramp protocol include the following (54):

Avoldance of large and unequal increments in workload
Uniform increase in hemodynamic and physiologic responses

More accurate estimates of exercise capacity and ventilatory threshold
Individualized est protocol (amp eat)

Targeted test duration (applies only to individualized ramp protocols).

Whichever exercise protocols chosen, it should be individualized so that the
mil speed and increments in grade are based on the subjects perceived fune.
nal capacity deal, increments in work rate shouldbe chosen so thatthe total
ime ranges between 8 and 12 min (10), assuming the endpoint i volitional
‘augue. For example, increments of 10-15 W > min (61-92 kg m» min 1) can
be used on the cycle emometer for older individuals, deconditioned individuals,
and patients with CVD or pulmonary disease. Increases in treadmill grade of
1%-3% min with constant belt speeds of 15-25 mph (2-440 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)

for (a) prognostic assessment (b) physical activity counseling and Ex Rand (©)
evaluation of medical therapy (25), Moreover, submaximal exercise testing may
be prefered in healuviness setings, particularly during the assessment of in
viduals deemed w be at greater risk of candivascular events, These tests are gen.
¿rally terminated at a predetermined level such as an HR of 120 beats. min,
70% of heart rate reserve (HRR), 85% of age predicted HR... or 5 METS, but
these termination criteria may vary based on the patient and clinical judgment
(10) Established teadmil or engometry exercise testing protocols that are more
conservative in nature (Le, ramp) are typieally appropriate for submaximal
vesting,

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 ona 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
(Le, patients with vascular, orthopedic, and neurologic comorbidities). Peak
MER obtained during arm ergometry appear to be predictive of adverse events
in patients unable to perform treadmill testing 34), Work rates ate adjusted
by altering the cranking rates andor resistance against the Mywhcel. Work rate
Increments of 3-10 W (306-61.2 kg > m+ min *) every 2-3 min ata cadence
of 60-75 revolutions + min * (rpm) are common recommendations (32). Arm
‘exgometry is best performed in he seated position with the fulenum ofthe handle
adjusted o shoulder height, SBP taken bythe standard cul method immediately
after arm erank ergomery are likely 0 underestimate "true SBP responses (33)
Brachial SBP during arm ergomeury can also be approximated using a Doppler
stethoscope atthe dorsalis pedis ater:

TESTING FOR RETURN TO WORK

‘The decision w return to work after cardiac events a complex one with ~25%
of these patents failing 10 resume work (29). National and cultural customs,
local economic conditions, numerous nonmedical variable, employer stereo:
types, and worker attitudes may govern failure to return 10 work. To counteract
these deterrents, job modifications should be explored and implemented 10
Faciltate the resumption of gainful employe
Work assessment and counseling ae useful in optimising return to work de:
sons. 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 o (a ascertain
job aerobic requirements and potential cardiac demands, () establish tentative
ime lines for work evaluation and return to work; (c) individualize rchailita
on according to job demands; and (d) determine special work-related needs

se EU) === |

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 patients ability 1 safely
return to work (25) because (a) the patients responses can help assess prog:
nosis; and (b) measured or estimated MET capacity can be compared 10 the
estimated aerobic requirements of the patients job to assess expected relative
work energy demands (2). For most patients, physical demands are considered
appropriate if the 8 henergy expenditure work requirement averages =30% peak
MER achieved on the GXT and peak job demands (eg. 5-45 min) are within
guidelines preserbed for a home exercise program (e, 580% MET). Most
Contemporary job tasks require only very light to light aerobic requirements
Ge, <3 MER) (70).

À GXT ts commonly the only functional assessment required to determine
return to work status, However, some patients may benefit from futher func:
tional testing if job demands differ substantially from those evaluated with the

T, especially patients with (a) borderline physical work capacity in ration
ship to the anticipated job demands; (1) concomitant let ventricular dysfunc
on; andor (c) concerns about resuming a physically demanding occupation.
Job tasks that may evoke disproportionate myocardial demands compared to a
GGXT include those requiring static muscular contraction work combined with
temperate stress and intermittent heavy work (70)

Tess simulating the ask(s) in question can be administered when insufficient
information is available to determine patients ability to resume work within a
reasonable degree of safety. For patients a ic for seriosarthythmias 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 o evaluate types of work not evaluated with a GXT (70). For example,
à weight camping test that simulates occupational tasks can be used to evaluate
tolerance forlight-to-heavy static work combined with ight dynamic work,

MEASUREMENTS DURING EXERCISE TESTING

Common variables assessed during clinical exercise testing include BR: ECG
changes, subjective ratings, and signs and symptoms. Ventilatory expired gas
analysis responses may be included inthe exercise test, particulary in certain
groups such as patients with CHF and individuals being assessed for unex-
plained exertional dyspnea. Last; antral blood gas analysis can also be per
formed during an advanced exercise test assessment

HEART RATE AND BLOOD PRESSURE

THR and BP should be measured before, during, and after the GXT. Table 52
indicates the recommended frequency and sequence ofthese measures. À stan

dardized procedure should be adopted for cach laboratory so that baseline mes:
sures can be assesed more accurately when repeat testing is performed.

Dom Eee

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Several devices have been developed to automate BP measurements during
exercise and demonstrate reasonable accuracy (52). These devices also typically
allow for auditory confirmation ofthe 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 sill 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 arc also possible absolute and
relative indications for test termination (se Box 52) (23).

+

Insoouate sphygmamanometer
Improper uf ize

‘Auster acuity of techiian

Rate of inflaton or deflation of œuf pressure
Experience of tenican

Reaction ime of chin

Faulty equipment

Improper stethoscope placement or pressure

Background noise

‘lowing patent to hold tracmi and o ox elbow

Contin physiologic abnormaliies (e. damaged racial artery, subelavin
steal syndrome, atesovenous fst)

Box

ELECTROCARDIOGRAPHIC MONITORING

A high quality ECG is of paramount importance for an appropriately conducted
GNT (see Appendix ©). Proper skin preparation lower the resistance at the skin
electrode interface, and thereby improves the signal to noise ratio. The general
areas for electrode placement shouldbe shaved, if necessa and cleanse 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 electrodos
placed according to standardized anatomic landmarks (23). Although 12 lads
are simultaneously recorded and readily avaiable for assessment, three leads —
representing the inferior, anterior, and lateral cardiac distribution — ae typically
‘monitored in realtime, with 12-ead ECGs printed atthe end ofeach 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-ead resting ECG, use of torso leads should be
noted on the ECG,

Signal processing techniques have made i possible to average ECG wave:
forms and atenuate or eliminate clectriealsmererence or artifact. Although this
technology continues to evolve, computer driven ECG interpretation should be
considered a compliment rather than a replacement to manual interpretation.
Morcover, 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. Somati ratings of perceived exertion (RPE) (see

Chapters 4, 7, and 10) and/or speciic symptoms (eg. degree of chest pain,

A En

ABSOLUTE INDICATIONS

+ Drop in systole BP of = 10 mm Hg with an increase in work rate, ori
systole BP docreases below the valo obtained in the same positon prior

10 testing when accompanied by ner evidence o ischemia

Moderataly severe angina (defined as 3 on standard ca)

Increasing nervous system symptoms (eg. ana, dones, or near syncope)

Sign of pooeporluion cyanosis or palos

Technical ificuties monitoring the ECG or SBP

Subjects desire to stop

Sustained ventricular tachycardia

ST ovation (+10 mm) in lads without diagnstic O waves (thor than,

ravi)

RELATIVE INDICATIONS.

+ Dropin syst BP of =10 mm Hg with anineroas in work ato, oi
stoi BP below the value obtained inte same positon prior to testing

+ ST or ORS changes suchas excessive ST depression (>2 mm horizontal or
dowsloping SEsegment depression or marked xi shit

Arthas othr than sustained ventricular year, including
mafocal PVCs, tiles of PVCs, supraventricular tachycardia, hear block
‘or bradyarhythmies

+ Fatigue, shortness of breath, wheezing, lg cramps, or causation

+ Development of bundle-branch Bock or trou conduction delay
that cannot be distinguished from vonwiuar taciycarda

+ Increasing chest pain

‘Hypertensive response (SBP of >250 mm Hg andor a DBP of >115 mm Hal

burning discomfort, dyspnea light-headedness, leg discomforupain) should
be assessed routinely during clinical exerise tests. Patients are asked to pro
vide subjective estimates during the last 15 s of each exercise stage (or every
2 min during ramp prowocols) either verbally or manually. For example, the
individual can provide a number verbally or point toa numberifa mouthpiece
or face mask prechides oral communication. The exercise technician should
restate the number to confirm the correct rating. Ether the 6-20 category scale
(Gee Chapter 4 or the 0-10 eategory-raio 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.

12 EU) === |

i 2 3 4
sway ee
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Angina Sse

+ +

i 2 3 4
solos semen magia Biken
Sain Roe es JS
LS ee oar
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élan Selo

ss

1 2 3 4
under Moden, tay mom, oso
== ne Sm Se
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FIGURE SA. Freut sed sos fr assesing na patent val ong th, cis
on mas, an sos (tar

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 evel of angina, laudication
andor dyspnea can be found in Figure 34. In general, ratings of =3 on the an
fina scale or a degree of chest discomfort that would cause the patient to stop

nal daily activities are reasons to terminate the exercise tet (see Box 32)
Interesting: patients with CVD reporting dyspnea as a primary actor Imiting
exercise may have a worse prognosis compared to those reporting alternate sub
jective symptoms (Le, exercise limited by leg fatigue or angina) (1,18).

GAS EXCHANGE AND VENTILATORY RESPONSES

Currently, the combination of standard GXT procedures and ventilatory expired
xs analysis (Le, caniopulmonary exercise testing) i the clinical standard for
Patents with CHE being assessed for transplantation candidacy’ and individuals
with unexplained exertional dyspnea (25). The analysis of ventilatory expired
xs overcomes the potential inaccuracies associated with estimating VO, from
work rate (Le, treadmill speed and grade). The direct measurement of VO, is
more reliable and reproducible than estimated values from treadmill or cycle
ergometer work rates. VO, 1 Uhe most accurate measurement of functional
‘capacity and ia useful index of overall cardiopulmonary health (12).

The measurement of VO,, VCO,, and the subsequent calculation of the re
spiratory exchange ratio (RER) can als be used to ases the level of physical
exertion during the GXT with greater precision than that obtained from age-pre-
dicted HR, The assessment of VE ako should be made whenever gas exchange
responses are obtained. In fac, the combined assessment of VE and VCO,, com
‘monly expressed asthe VEANCO, slope and termed ventilatory eficincy, provides
robust prognostic information in patients with CHF (12) Because hear and lung
diseases frequently lead to ventilatory and/or as exchange abnormalities during
exerce, an integrated analysis ofthese measures can be useful for differentia
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. Last collection of gas ex
change and ventilatory responses are increasingly being used in clinical tals 10
bjecively asses the response to specific interventions (10).

ARTERIAL BLOOD GAS ASSESSMENT DURING EXERCISE

In patents who present with unexplained exertional dyspnea, pulmonary disease
should be considered as a potential underlying cause. Is important to quantify
gs partial pressures im these patents because oxygen desaturation may occur
during exertion, Although measurement of the partial pressure of oxygen in ate
sal blood (P,O,) and partial pressure of carbon dioxide in ater blood (P,CO,)
have been the standard in the past, the availability of pulse oximetry and the
estimation of arterial oxygen saturation (SPO, has replaced the need o routiely
draw arterial blood in most patients. In patients with pulmonary disease, mea
surements of oxygen saturation in arterial blood (Sa0,) correlate reasonably well
with SpO, (+2%-3% accuracy rates), provided SpO, remains >85%. A decrease
of >9% in SpO, during exercise testing is considered an abnormal response sug
sitive of exerce induced hypoxemia, Invasive assessment o areal blood gases
‘still required a precise measurement clinically warraned (12)

INDICATIONS FOR EXERCISE TEST TERMINATION

The absolute and relative indications for termination ofan 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 (Le, active vs passive recovery), mon
itoring should continue for at least 6 min after exercise or until ECG changes
return to basclne and significant signs and symptoms resolve (23). STsegment
changes that occur only during the postexereise period are currently recognized
10 bean important diagnostic par ofthe test (68). HR and BP should also return
to ncar baseline levels before discontinuation of monitoring, In addition, the

En EU) >=:

IR recovery from exercise is an impo
recorded (see Chapter 6) (2544),

nt prognostic marker that should be

IMAGING MODALITIES USED IN CONJUNCTION WITH
EXERCISE TESTING

Cardiac imaging modalities are being increasingly used in conjunction with GXT
to more aceurately 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:
tuacilty va hypokinetc (Le, decreased), dyskinetic (Le, impaired), orakinetic
(e, absen) wall motion in the affected segments. Exercise echocardiography is
highly indicated in patients with suspected myocardial ischemia with an intr
mediate pretest probabiliy for CVD and/or an uninterpetable ECG,

Exercise echocardiography isals valuable in he assessment fable scheme
‘myocardium in patients with known CVD that are being considered fora revascu:
larization procedure. Patients with known or suspected CVD and a normal exer
‘se cchocardiography response appear to have alow risk for adverse events (49)
In patients with valvular disease, exercise echocardiography is highly indicated
for the assessment of (a) equivocal aor stenosis; (b) evidence of low cardiac
Output; (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. ln patients with suspected pulmonary
hypertension, exercise echocardiography wit sue Doppler imaging may also be
advantageous, although the evidence in support of tis 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 ae several different imaging protocols using technetium (Te)-59m
or thallous (thallium) chloride-201. Comparison of the west and stress images
permits the identification of fixed and reversible perfusion abnormalities as well
2 thie differentiation,

Te-99m permis higher dosing with es radiation exposure than thallium and
results in improved images that are sharper and have less aifac nd attenuation.
Consequently, Te i the pelered imaging agent when performing woneographic

images ofthe ha sing single-photon emision computed tomography (SPECT)
SPECT imagesare obtained witha gamma camera tht oa 80 degrees mund
the patient sopping a press angles o record the imag Cardiac ages then te
(play in hes fom tne ire ans 1 allo vistazo of the har in
thee dimensions Thus maple myocardal segments canbe viewed individ
aly without the overap of segments ha occur wih planar maging Person
defects tht ae present during execs hut not sn sx suggest myc
Schema Person def that ae present ding exceso and pert a mat
Suggest previous Ml or cr, The exten and ibn of cher myocardium
can be Wei ns manne. Exerc nla SPECT imaging bas a sat
Ce. percentage o individuals wth postive ts who havea gen dee) of 87%
and pes (Le, percentage of individuals wth neg fest who do nou have
agen dese) of 73 for detecting CVD wth 250% coronary senos (4,

Cartas radbonuclide imaging à highly led or pas, with an
intermediate prees (se Tale 31) probably for CVD andr uninerpreable
ECG a vel sin toos puis witha high press probably inespecive of
CG Imerprenbiliz This procedure s alo highly valuable in de ascent
of viabefacheme myocardium in patents with chemie cadomyopathy and
severe et enticlardysunction who re being considered [or a veu
don procedure. Patent wth known or suspected CVD and à normal cardiac
radiomucide imaging study apcır o have a Tow rd for averse evens (49)
Convery: patents tha perfusion defect area higher rk for adverse evens
‘egies of angiography findings 20) À cent published por on the ap
progra saca crac dance imaging providats touprchrsne at
dations for this prcedare O1)

IMAGING MODALITIES NOT USED IN CONJUNCTION WITH
EXERCISE TESTING

PHARMACOLOGIC STRESS TESTING

Patents unable to undergo a GXT for reasons such as severe deconditioning,
peripheral vascular disease, orthopedic disabilities, neurologi disease, and/or
‘concomitant illness may be evaluated by pharmacologie stress testing, The two
‘most commonly used pharmacologic tests are dobutamine stress echocardiogrs
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 i infused intravenously with the
dose increased gradually umil 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
imolerable side effects, and a significant increase or decrease in BP Atropine may
be given if an adequate THR is not achieved or other endpoints have not been
reached at peak dobutamine dose. HR, BR ECG, and echocardiographic images

we EU) >=:

are obtained throughout the Infusion of atropine. Echocardiographic images are
obtained similar to exercise echocardiography. A new or worsening wall motion
abnormality constitutes a postive test fr ischemia,

‘Vasodilators such as dipyridamole and adenosine are commonly used o assess
coronary perfusion in conjunction with a nuclear imaging agent. Dipyridamole
and adenesine cause maximal coronary vasodilation in normal epicardial arteries,
but not in stenotic segments. As a result, a coronary steal phenomenon occurs
sth a relatively iereased flow to normal arteries and a relatively decreased flow
to stenoie arteries, Nuclear perfusion imaging under resting conditions is then
compared with imaging obtained alter coronary vasodilation, Interpretation is
similar to hat for exercise nuclear testing, Severe side elects are uncommon, but
Both dipyridamole and adenosine may induce marked bronchospasm, particularly
in patients with asthma or reactive airway disease, Thus, administration ofthese
agents is contraindicated in such patients (41). The bronchospasm can be rated
with theophylline, although ths is ae needed with adenosine because the hal
Iie is very short. Cafeine and other methylxanthines can block the vasodilator
effets of dipyridamole and adenosine, and thus reduce the sensitivity ofthe test,
Therefore, lis recommended that these substances be avoided for at last 24 I
before the stress test. The diagnostic accuracy of pharmacologic nuclear stress
testing is similar o that of exercise nuclear stress testing (41).

‘COMPUTED TOMOGRAPHY IN THE ASSESSMENT
OF CARDIOVASCULAR DISEASE

Advances in cardiac computed tomography (CT) offer addtional methods for
the clinical assessment of CVD. Although there ae several types of cardiac CT,
electron beam computed tomography (EBCT) has heen available since 1987 and
provides the most robust scientific data, EBCT isa highly sensitive method for
letection of coronary artery calcified plaque (17).

However, es important 10 understand the presence of caeiied plaque docs
‘ot in ill indicate the presence of a flow obstructing coronary lesion; com
versch the absence of coronary calcium does not self indicate the absence of
auheroselertie plague. A coronary calcium score of zero makes the presence of
atherosclerotic plaque including vulnerable plaque highly unlikely: Moreover,
2 score of zero Is associated witha low annual risk (0.1%) ofa 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
rom obsteuctive CVD. Measurement of coronary anery calcium appears 1 im-
prove risk prediction in individuals with an intermediate Framingham risk sore
Ge, 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

risk prediction, However, the measurement of coro
rary artery calcium isnot recommended in individuals with alow (Le, <10%
10 likelihood ofa cardiovascular even) or high (Le, >20% 10 yr likelihood of

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
postexerise ls 0.20%, 004%, and 0.01%, respectively (52). Accordingly
individuals who supervise exerce ts must have the necessary cognitive and
technical skills to safely administer an exercise test. The American College of
Cardiology (ACC), AHA, and ACCR with broad involvement from other pro:
fessional organizaions involved with exeris testing including the American
College of Sports Medicine (ACSM), have outlined the cognitive skills needed 10
competently supervise exercise test (68). These sil are presented in Box 33

+ Knowiodge of appropriate indications fr exercise testing

+ Knowodge of alternative physiologic cardiovascular tests

+ Knowdge of appropriate contandicatos, risks, and risk assossment of
testing

+ Knowledge 10 promply recognize and eat comptons of ects testing

+ Competence in cardiopulmonar resuscitation and svecessul completion
‘ofan American Heart Assocation sponsored couse in advance
‘cardiovascular ite support and renewal on a regular basis

+ Krowodg of various exorcise protocols and indications fr each

+ Knowdge of base cadioaseur and exercise physiology including
homodynamie response 10 execs

+ Knowndg of cardiac arya and the aby to recognae and eat
serious arhythmis (ee Appendix ©)

+ Knowledge of cardiovascular drugs and how they can affect exercise
performance, hemodmemies, and the electrecardogram ses Append: A)

+ Knowodge ofthe affects of age and disease on hemodnam andthe
locrocardiogaptic response to exorcise

| + Knowiadge of princes and dtais of exorcise tsting including propor

lead placement and sin preparation

+ Knowodge of endpoints of exorcisotosing and iicaions to trminate

exercise testing

ss EU) === |

Im most cases, clinical exercise tests can be supervised by properly trained
health care professionals such as exereise physiologists, nurses, and physi:
cian assistants who are working under the supervision of physician (Le, the
physician must be in the immediate vicinity and availble for emergencies for
exercise testing of individuals at igh 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 tained
nonphysician personnel supervising the test and physicians in the immediate
viciniy compared to those conducted with direct physician supervision (32)
In situations in which the patient is deemed 10 be at increased risk for an a
verse event during the GXT, the physician should be immediately available to
‘manage potential emergency situations. Such cases include, but are not limited
16, patients undergoing sympton-limited testing following recent acute events
{acute coronary syndrome or Ml), severe left ventricular dysfunction, severe
valvularstenosis (eg, aortic stenosis), or known complex arhythmias (68) (ee
Chapter 2).

THE BOTTOM LINE

‘The ACSM Clinical Exercise Testing Key Points ate as follows

+ Although a clinical exercise test may not be indicated for most individuals
about to begin an exercise program (see Chapter2), the high value of informa:

on obtained from this procedure isnot debatable

+ Aerobic capacity may be one of the single best prognostic markers in ll ind
Vidal regardless ofheal status.

“+ Standard clinical exercise testing is well accepted for he assessment of indi
‘duals 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 tained nonphysican personnel can
safely perform a clinical exereise test may result in the expanded use of this
valuable procedure in various clinical settings.

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REFERENCES

À Ai Rust Hahah tal ren gica of dsp pies re
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Interpretation of Clinical
Exercise Test Results

‘This chapteraddresses the interpretation and clinical significance of exercise test
results withspecii reference to hemodynamic, eleetrocatdiograpic (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 probly of a patent having CVD cannot be estimated accurately from the
serie ts result and diagnostic characteristics ofthe est alone, lo depends on
{he bkeibood of having disease Before the ests administered, Bay’ theorem states
thatthe posts probably of having diseases determined bythe disease probabl
fy before de test andthe probably that the test wl provide a rue resul (50). The
probability ofa patient having disease before the esis most importan related o
the presence of symptoms (particulary chest pain characteristics), in addition to the
patients age, sex, and the presence of major CVD risk factors (se Table 22),

Exercise testing in individuals with known CVD (Le, prior myocardil in
farcion (MU, angiographically documented coronary stenoses, andlor prior
coronary revasculasizaion) s warranted if here is a recmergence 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
Ge, substenal chest discomfort that may radiate w the back, ja, or arms, and
symptoms provoked by exertion or emotional stress and relieved by rest and/
‘or nitroglycerin) makes the pretest probability so high thatthe test result docs
‘not dramatically change the likelihood of underlying CV. Atypical angina
Ge, ches discomfort that leks one ofthe mentioned characterises of typical
angina) generally indicates an intermediate pretest likelihood of CVD in men
>30 yr and women >50 yr (sce Table 5.1 and Figure 5.1). In fc, the use of
exercise testing to assist inthe diagnosis of CVD may he most beneficia in those
Individuals with an intermediate pretest probability (see Chapter 3).

The use of exercise testing in screening asymptomatic individuals, particu
lar among individuals without diabetes melltus or major CVD risk factors,

omerene fe A

is diagnostically problematic in view of the low to very low pretest likelihood
Of CVD (see Table 5.1). An American Heart Assocation Scientific Statement on
exercise testing in asymptomatic adults concluded that there is currently insul-
cien evidence 10 support exercise testing as a routine screening modal for
atheroscleotle CVD in asymptomatic individuals (3). Given the limited abit of
serie testing o indemf atherosclerotic CVD and predict sk of adverse events
(during exercise, this asesement is not indicated prior to initiation ofan exercise
program in asymptomatic individuals (se Chapter 2). Even so, the use of exercise
testing in asymptomatic individuals may be useful to heaviness and clinical
(serie profesional given its ability o (a) eet general health; (b) dently nor
mal and abnormal physiologic responses to physical exertion; () provide infor
‘matin 10 more precisely design the exercise prescription (Ex R); and (d) provide
prognostic insight, especially among those with multiple CVD nek factors (33)

INTERPRETATION OF RESPONSES TO GRADED EXERCISE TESTING

Before iterpreing clinical exercise test data, ts important to consider the pur
pose of the test (eg, diagnose, prognostic, therapeutic applications, Ex R,) and
the individual clinical characteristics that may influence the exereise test OF its
interpretation (eg, age, sex), Medical conditions illuencing tes inerpreaion it
clude onbopedi imitations, pulmonary disease, obesity, neurologie disorders, and
decondtioning. Medication effects (see Append A) and resting ECG abnormalities
(Gee Appendix C) also must be considered, especially resting ST-segment changes
secondary to conduction defects, left ventricular hypertrophy (LVID, and other
factors that may contribute to spurious SFsegment depresion,

Although total body and myocardial oxygen consumption (MVO)) are d
rectly relate, the relationship between these variables can be altered by exercise
taining, medications, and disease. For example, exercise-induced myocardial
ischemia may cause left ventricular dysfunction, exercise imolerance, and a
Inypotensive blood pressure (BP) response (see Box 5.2). The severity of symp.
tomatic ischemia is inversely related to exercise capacity: however lft ventric
lar ejection fraction docs not correlate well with exercise tolerance (3945).

Responses to exercise tests are useful in evaluating the need fr and elective:
ess of various types of therapeutic interventions, The following variables are
importan 10 quantify accurately when assessing the diagnostic, prognostic, and
therapeutic applications of he test, Each i described in the following sections
and summarized in Box 6.

+ 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 dysthythmias.

‘+ Limiting clinical signs or symptoms.

+ Ventilatory gas exchange responses (eg. VO, minute ventilation (VE)
carbon dioxide production [VCO].

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HEART RATE RESPONSE

Maxima heat ate (HR) may be predicted fom age usingany of several published
equations (212356) (See Chapter 7). Fo the most used equation (20 — age), the
relationship between age and HR, for large sample ofsubjets is wel established:
however interindividual variability high (+12 beats min). Asa resul, there is
a potential for considere eror i the use of methods that extrapolate submaximal
test data to an age-predited HR

lt has yet to be demonstrated alternate equations that claim higher accuracy
and less variability provide clinically superior information compared to use of
‘he 220 ~ age equation (52). Using the 220 — age equation, failure to achieve an
age predicted HR =85% in the presence of maximal or (Le, chronotropic
Incompetence) is an ominous prognostic marker. In addition, flare to achieve

ue EU) === |

an age predicted HR. >80% (Le, cvonotopic incompetence), using the equa
tion (THR. — HR (220 ~ age) — HR...) also an indicator of increased
risk for alverse events (35). A delayed decrease In HR eatly in recovery after a
symptomlimited maximal exercise test (Le, =12 beats * min"! decrease ater
the fist minute in recovery) is also a powerful independent predictor of overall
‘mortality and should therefore be included inthe exercise test assessment (35)
Achievement of age-predictod HR, should not be used as an absolut test
endpoint or as an indication that effort has been maximal because ofits high
intersubjet variability. The clinical indications for stopping an exercise
ae presented in Box 52. Good judgment on the par of the supervising heathy
fines, clinical exercise or health cae professional remains the most important
criterion for terminating an exercise test

BLOOD PRESSURE RESPONSE

‘The normal BP response to dynamic upright exercise consists ofa progressive in
crease in SBP no change or a slight decrease in DBR, and a widening of the pulse
pressure (see Box 6.1). The following ae key points concerning interpretation of
the BP response to progressive dynamic execs

+ Adrop in SBP (210 mm Hg decrease in SBP with an increase in workload), or
failure of SBP 1 increase with increased workload, is considered an abnormal
test response. Exercise-induced decreses in SBP (Le. exertional hypotension)
may occur in patients with CVD, valvular heart disease, crdiomyopathics,
aonie outflow cbstrucion, and serious dysrhythmias. Occasionally, patients
without clinically significant heat disease demonstrate exertional hypoten-
sion caused by antihypertensive therapy, prolonged strenuous exeris, 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 ater
coronary artery bypass gral surgery (CABG). An SBP >250 mm Mg and/or
à DBP >115 mm Hg continue tobe used as termination criteria for exercise
testing Moreover, an excessive BP response to exercise ls predictive of Future
hypertension and CVD (55).

+ The normal postexercise response isa progressive decline in SBP During passive
recovery in an upright posture, SBP may decrease abruptly because of periph
tral pooling (and usually normalizes upon resuming the supinc poston). SBP
remains below protest esting values for several hours afer the tes, an expected
physiologic response termed postevercise hypotension, which occur in most

viduals (51). A lue to detease ora rise in SBP over the frst several min
es of recovery may indicate increased moray risk (26). DBP ako remains
below pretest resting values during the postexercise period in most individuals.

‘+ Im patents on vasodilators, calcium channel blockers, angiotensin-converting
enzyme inhibitors, and a and B-adrenergic blockers, the BP response 10
exercise is variably attenuated and cannot be accurately prediced in the
absence of clinical test data (sce Anpendix A)

omerene MN Sucio) === |

+ Although HR, is comparable for men and women, men generally have
higher SDPs (20 25 mm Hg) during maximal radnill testing. However
the sex difference is mo longer apparent alter 70 yr. The rate presse product
(RPP), or double product (SBP mm Hg X HR beats » min 1), am india
tor of myocardial oxygen demand. Maximal double product values during
exercise testing are typically between 25,000 (10th percentile) and 40.000
(0th percentile) (17). Signs and symptoms of ischemia generally occur at a
reproducible double product

ELECTROCARDIOGRAPH WAVEFORMS

Appendix € provides information to aid in the interpretation of resting and
exercise ECGs, Moreover, a detailed review of ECG analysis is provided inthe
ACSM Resource Manual or Guidelines for Exercise Testing and Prescription, Seventh
Edition (54). 1 should be noted an athletes resting ECG may present with several
benign normal variants including respiratory sinus arrhythmia, sinus bradycar
dia, incomplete right bundle-branch block, erly repolarization, and increased
‘voltage in the precordial leads (24). Additional information is provided here with
‘respect to common exercise-induced changes in ECG variable. The normal ECG
response to exercise includes the folowing

“+ Minor and insignifiant changes in P wave morphology.

‘+ Superimposition ofthe P and T waves of successive beats

+ Increases in septal Q wave amplitud

+ Slight decreases in R wave amplitude

+ Increases in T wave amplitude (although wide variability exists among
lients/patients).

+ Minimal shortening ofthe QRS duration
+ Depression ofthe J point
+ Rateselted shortening of the QT interval.

However, some changes in ECG wave morphology may be indicative of
vnderlyng pathology For example, although QRS duration tends to decrease
slightly with exercise (and increasing HR) n heathy individual, it may increase
in patients with either angina or lft ventricular dysfunction. Exercise-induced
P wave changes are rarely een and are of questionable significance. Many fac:
tors affect R wave amplitude; consequently, such changes during exercise have
0 independent predictive power (#4)

‘SFSegment Displacement

ST segment changes are widely accepted criteria for myocardial ischemia and
injury The interpretation of STsegments may be affected by the resting ECG
configuration (e, bundle-branch blocks, LVID and pharmacologic agents (eg

dirais therapy). There may be J point depression and tll, peaked T waves
av high exercise intensities and during recovery in healthy individuals (49)

se EU) === |

Depression ofthe J point that leads to marked STsegment upslopings caused by
‘competition between normal repolarization and delayed terminal depolarization
forces rather than by ischemia (41), Exercise-induced myocardial schemta may
be manifested by different types of ST-segment changes on the ECG as shown,
in Figure 6.

SFSegment Elevation

+ STscgmentclevation Carly repo
ECG in varios paterns. Recent data suggest that an early repolarization pat
tern in the inferior leds may indicate an increased risk of cardiac moral 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
9). Early repolarization exclusively observed in the anterolateral ll pre.
cordial leads snot thought to be associated with increased risk for sustained
ventricular arshythmia, whereas global early repolarization (Le, limb and
precordial leads) appears to indicate a higher risk (3). ncreasing HR usually
‘causes these elevated STsegments to return to the isoelectric ine.

+ Exercise-induced ST-segment lation in leads with Q waves consistent with a
prior MI may be indicative of wall motion abnormalities, ischemia, or both (10)

risaion) may be seen in the normal resting

Noma
Abnormal

Millimeters

Classic Upsloping

FIGURE 6: Sraegmanı runas ring enc Casi STangman epson cin
Bio cares sa Nonne vansopng ST sega at 10 rm bow te soin
280 ma pan ined pant Soy upsopng STaagmen caresse (cond comp Su
con à oies and aca amas shoud be pas on ee inc

omerene MA Sais) === |

+ Exerciseinduced STsegmentelevation on an otherwise normal ECG (except
in augmented voltage right [VR] or ches lads VI and V2) generally indi
‘ates significant myocardial ichemia and localizes the ischemia o a specific
area of myocardium (48), This response may als be associated with entr
lararshythmias and myocardial injury.

SFSogment Depression

+ STisegmen depression (Le, depresion of the J point and the slope at 80 ms
pas the J point) i the mest common manifestation of exercise-induced myo-
cardial schema,

+ Horizontal or downsloping STsegment depression is more indicative of myo:
cardial ischemia than i upsloping depression.

+ The standard criterion for a positive tests =1.0 mm (0.1 mV) of horizontal
or downsloping ST-segment a the J point extending for 60-80 ms.

+ Slowly upsloping STscgment depression should be considered a borderline
response, and added emphasis should be placed on other clinical and exercise
variables.

+ STsegment depression does not localize ischemia to a specific aca of
myocardium.

+ The more leads with (apparent ischemie ST-segment shifts, the more severe
the disease,

+ Significant ST-segment depression occurring only in recovery likely repre
Sents a true postive response and should be considered an important diag
nostic finding 34),

+ Adjustment of the STsegment relative to the HR may provide additional
diagnostic information. The STAIR index isthe ratio of the maximal ST-
segment change (a) tothe maximal change in HR from rest to peak exercise
(beats min). An STAR index of >1.6 pv » eats» min defined as
anormal. The STAR slope reflects the maximal slope relating the amount
ofthe ST-segment depression (nV) to HR (beats min ') during exercise, An
STAR slope of 224 WV beats min” defined as abnormal 29,30),

SFSogment Normalization or Absence of Chango

+ Ischemia may be manifested by normalization of resting STsegments. ECG
abnormalities a est including T-wave inversion and SEscgment depression
‘may return to normal during anginal symptoms and during exercise in some
patents (36.

Dysthythmias

Exeriseassociated dysrhythmins occur in healthy individuals as well as pa
tiens with CVD. Inereased sympathetic drive and changes in extracellular and
Intracellular electrolytes, pl, and oxygen tension contribute to disturbances in

150 EU) === |

myocardial and conducting tissue automaticity and entry, which are major
mechanisms of dsthythmias.

‘Supraventricular Dysrhythmias

Isolated premature trial contractions (PACS) ae common and require no special
precautions Atrial utter or atrial fibrillation may occur in organe heart disease
or may reflect endocrine, metabolic, or medication effects. Sustained supraven-
tricular tachycardia (SVP) occasionally i induced by exercise and may require
Pharmacologie treatment or clectroconversion if discontinuation of exercise is
Lo abolish the rhythm. Patients who experience paroxysmal atrial tachycardia
may be evaluated by repeating the exercise test alter appropriate treatment

Ventricular Dysrhythmias

Isolated premature ventricular complexes or contractions (PVCS) can occur dur
ng exercise in apparently healthy or asymptomatic individual as well as those
iagnosed with CVD, In some individuals, progressive exercise vo maximal exe.
tion induces PVCS, whereas in others, e reduces their occurrence. The clinical
significance of exercise-induced PVCs remains a matter of debate although there
ae data to suggest the occurrence of ventricular ectopy during exercise warrants
clinical consideration (9). The suppression of PVCs that are present at rest with
exeris testing does not exclude the presence of CVD, and PVCs that increase
in frequency complex, or both do not necessarily signi underlying ischemic
can disease (9,16). Serious forms of ventricular copy include paired or mul
(form PVCs or runs of ventricular tachycardia (=3 PVCs in succession) These
dysthalmias 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 hear disease.

Some data indicate that exerciscánduced PVCs are associated with a higher
‘morality in asymptomatic individuals (27), In a cohort referred for clinical
exercise testing who were fre of heat failure, the occurrence of PVCs during
recovery rather than during exercise was prognosticall significant (14). Another
investigation assessing a large cohon referred for exercise testing (n > 29,000)
defined frequent ventricular ectopy as, “the presence of >7 PVCs per minute,
ventricular bigeminy or uigeminy, ventricular couplets or triples, ventricular
tachycardia, ventricular Nutter, wrsade de points, or ventricular fibrillation”
(20) Frequent ventricular ectopy inthis study during exercise and recovery was
à significant predictor of mortality, although its occurrence in recovery was a
Significantly steonger prognostic marker.

Criteria for terminating exercise tests based on ventricular ctopy include
sustained ventricular tachycardia, multifocal PYCS, and short runs of ventricular
tachycardia. The decision to terminate an exercise test should also be influenced
by simultancous evidence of myocardial ischemia and/or adverse signs or symp
toms (ee Bor 5.2).

omerene MA Sucio) === |

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 STsegmer
changes alone (12). Angina pectoris and ST:segment changes are currently com
sidered independent variables that identify patients at increased risk for subs:
quent coronary events. Moderate-tosevere angina (Le, ang of 3-40m a point
scale) isan absolute indication for exercise test termination (17). Individuals
vndergolng exercise testing forthe assessment of CVD who complain of dyspnea
with physical exertion may have a poorer prognosis compared 10 those who com
plain of other (ie, angina) or no exertional symptoms (2), Lat; termination of
exeris testing secondary to dyspnea as opposed to lower extremity fatigue may
indicate a worse prognosis in patents with heart disease (1).

Inthe 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” efor,
although important for intrpreting test results, can be dificult. Various cierta
ave been used to confirm that a maximal effort has been elicited during graded
exeris testing (GXT), However all ofthe following criteria for maximal ont
an be subjective and therefore possess limitations to varying degrees:

“+ Faire of HR to increase with further increases in exercise intensity.

+ A plateau in NO, (or failure to increase VO, by 150 mL + min) with in
creased workload (58). This criterion has fallen into disfavor because a pla
‘eau is inconsistently seen during GXT and i confused by various definitions
and how data are sampled during exerise (46).

+ -Arespiratony exchange ratio (RER) =1.10 sa minimal vheshold that may be
obtained in most individuals putting forth a maximal effort, although there
‘may be considerable interindividual arab with an RER 21.10 (57)

‘+ Various postexereise venous acti cid concentrations (eg, 8-10 mmol 1-1)
have been used however, there is also significant interindividual varity in.
this response.

+ A tating of perceived exertion (RPE) >17 on the 6-20 scale or >9 on the
0-10 see.

Although al of the aforementioned criteria possess limitations, peak RER is
perhaps the most accurate and objective noninvasive indicator of subject effort
during a GNT (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
‘uses of exercise intolerance. The combination of ths technology with stan

12 EU) === |

dard GXT procedures is typically referred to as caropulmonary exercise testing
(CPx) (8). These responses can be wed o ases clenypatient effort during
an exercise tet, particular when a reduction in maximal exercise pac
À suspecte. Sabmaximal fort fom the clenvpatent on a maximal O
cam interfere wich the interpretation ofthe test result and subsequent paient
‘management. Moreover the us of CPX may be advantageous when srl tes
ing needed fr ether escarh or clinical purposes 10 ensure consisten ont
among assessment (6). Maximal ongen uptake (0, or peak ongen uptake
{NO provides important information about cadlorespirtoy ites and is
à por maker of prognoss.Populaonspeie nomogtams (ee Figure 52)
and/or population norms (ce Tae 49) may be used to compare WO. wilh
the expected value according 10 ag, ex, and physical fitness sas 3847),
Addon the assessment of veto eficency (Le, VENCO, slope and
partial pressure o end-da carbon dioxide (PEXCO, 1 provides robust prog
{andor diagnos information in patents with congestive hear allure (CHF)
and pulmonary hypertension (4,9.

Vertlatoy expued gas responses often are used in clinical settings as an
estimation of the point at which lactate accumulation inthe Mond cur,
Sometimes referred to asthe lactate or anacobie real, Asessment of this
Physiologic phenomenon through ventilatory expired gas apically feed
to 2 ventory trshold (VD. Several diferent methods using ventilatory
expired gas responses exist for the estimation of this pont. These include the
‘etilatory equivalents and Vlope method (6). Whichever approach i wed it
Should be remembered VT provides only an estimation, and the concept of ar
Aerobie threshold during exercise controversial (5). Because exercise beyond
the latte threshold is associated with metabolic acidosis, Byperventation,
anda reduced capacity to perform work, ls estimation fs a useful physiologic
messurement when evaluating interventions in patiens with har and pulmo
tay disease as wells studing the limit of performance in apparently healthy
individuals. However, should be noted that secondary to abnormal ventory
‘sponses ebserved in significant proportion of patents with CHF (Le, exercise
«Scllatoy vention) determination of VT may not be posable (13)

In addition to eaimating when blood lactate values begin 1 cress, mas
snl minute venation (VE. ca be used in conjunction with the maximal
voluntary venation (MVV] o ass determining if there is. ventilatory
Imitation to maximal exercise. A comparison between VE. and MVV can be
sed when evaluating responses to a CPX. MVY can be dietly measured by
2112-13: deep and rapid breathing mancuver or estimated from the equation
fored expiratory volume in 1 KFEV, X 40] (9 MVV is peered [FEV
x AO o ensure precie quamiicaton of ventilatory capaci: The relatonship
Derween VE, and MVY, typical refered to as the ventory reserve, tad
tionally is defined asthe percentage ol the MVV achieved at maximal exrise
(Ge. the VE, VV rato). ln most normal healthy individuals, the VE VV
ratio 0.50 (6. Vales surpassing this threshold ae indicative of reduced
‘entlatry reserve and à possible pulmonary imitation to exercise

omerene fm A

Pulse oximetry should also be assessed when CPX is used to assess possible
pulmonary imitations o exercise. A decrease in pulse oximeter saturation >3%
during exercise also indices a pulmonary limitation. Laly, most currently
available ventiltory expired gas systems also possess capabilities for pulmo:
rary function testing. Obstructive or restrictive paterns on baseline pulmonary
function testing provide insight into the mechanism of limitations to exercise.
Morcover, a =15% decrease in FEV, and/or peak expiratory flo following CPX.
compared to baseline values is indicative of exeris-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 62). The factors
tha determine the predictive outcomes of exercise testing (and other diagnostic
tests) are the sensitivity and specificity ofthe est procedure and prevalence of
VD in the population tested (50). Sensitivity and specificity determine how
effective the test sin making correct dingnoses in individuals with and without
disease, respectively: Disease prevalence is an important determinant of the pre
dictie value of the test, Moreover, non-ECG criteria (eg. duration of exercise
‘or maximal metabolic equivalent [MET] level, hemodynamic responses, sym
toms of angina or dyspnca) should be considered inthe overall interpretation of
exercise test resul

SENSITIVITY

Sensitivity refers to the percentage of patients tested with known CVD who dem
‘onstrate significant STsegment (Le, postive) changes. Exercise ECG sensi

‘Sensitivity, Speciticiy, and Pre
(Graded Exercise Testing

the percentage of patients with CVD who have a

specify = TWITN + FP) = the percentage of patients without CVD who
| have a negative ost

| predictive value (positive test) = TPITP + FP = the percentage of patients
À wth positive ost result who havo CVD

À precio value negative test = TNITN + FN) = the percentage of patients
| wth a negativ test who donot have CVD

ve porte stan neo VOLT on np pw ee tn
(rote orto poste re MC

m AO Sica <= |
Ea-- re Ve
=

+ Falure to reach an ischemic threshold

+ Montoring an insuteiont number ol leads 1 deter ECG changes

+ Faluroo recognize non-EC signs and symptoms that may bo associated
with underying CVD (e. exertional hypotension)

‘Angiography significant CVD compensated by colateral rultion |

+ Muscdoskolta Imtabons to xorisoprecoding cados sbnormaities

+ Technical or abserer onor

for the deweion of CVD usually is based on subsequent angiographically
determined coronary anery stenosis of 270% in atleast one vessel, À true pos
tive (TP) exercise test reveals horizontal or downsloping ST-segment depresion
‘of £10 mm and correctly identifies a paient with CVD. False negative (FN)
test results show no or nondiagnostic ECG changes and fail to identify patients
wth underlying CVD.

Common factors that contribute to EN exercise tests are summarized in
Box 6.3. Test sensitivity is decreased by inadequate myocardial stress, medica
tions hatattenuate cardiac demands to exercise or reduce myocardial ischemia

B-blockers, nitrates, calcium channel blocking agents), and insuficient
lead monitoring, Preexisting ECG changes such as LVH, left bundle-
branch block (LBBB), or the preexeitaion syndrome (Wolf-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
{ecting CVD by applying validated muluivarat scores (hc. pretest risk mark
ers in addition 10 ST-segment changes and other exercise test responses) (7)

SPECIFICITY

‘The specficiy of exercise tests refers o the percentage of patients without CVD.
who demonstrate nonsignificant (te, negative) ST-segment changes. À true neg
ative test correctly idenulis an individual without CVD. Many conditions may
‘use abnormal exercise ECG responses in the absence of signifiant obstructive
VD (see Bor 6.)

Reported values forthe specificity and sensitivity of exercise ECG testing
vary because of diffrence in patent selection, test protocols, ECG criteria fora
positive tes, 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) Sensitwiy, however, is somewhat lower, and specificity s higher when
workup bas (Le, only assessing individuals with a higher likelihood for a given
disease) is removed (19,42)

omerene MA Sua) === |
BRE causes of Abnormal Segment
Obstructive Cardiovascular Dis

Resting repolaizaion abnarmalties eg. lft bundlebranch Blok)
Cardiac hypervophy

Acceloratad conduction dlecs (eg. Walk Parkinson White syndome)
Digitalis

Norischomie eariomyopathy

Hypokalemia

Vasoregultory abnormalities

Mia valve prolapsed

Percadal disorders

Technical or observer enor

Coronary spasm in the absence of significant coronary artery discase
noma

Being a women

PREDICTIVE VALUE

‘The predictive value of exercise testing is a messure of how accurately
result (postive or negative) correctly identifies the presence or absence of CV
in tested patients. For example, the predictive value of a positive testis 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 atained an
adequate level of myocardial stress, generally defined as having achieved =85%
of prediciod HR, during the test, although this ceterion is inherently Mawed
given the large variability in the HR response at maximal exercise (52). Predictive
value cannot be estimated direc rom a tests specifityor sensitivity hecause
depends on the prevalence of disease in the population being tested.

COMPARISON WITH IMAGING STRESSTESTS

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 i superior 10
nuclear imaging in detecting let main or triple vessel CVD (38). Patients with
‘clear imaging studies poste for reversible perfusion defects appear to have a
worse prognosis compared to individuals with a normal study (D). An abnormal
chocardingraphy response during exercise (Le, increased left ventricular filing
pressure) also appears to be indicative ofan increased risk for future adverse
events (25)

150 EU) === |

PROGNOSTIC APPLICATIONS OFTHE EXERCISE TEST

Risk or prognostic evaluation is an important activity in medical practice on
which many patient management decisions are hase. tn patients with CVD,
several clinical factors contribute to patient outcome including a) severity and
stability of symptoms; (D) left ventricular function; (°) angiographic extent and
Seventy of CVD; (d) electrical stability ofthe myocardium: and (e) the presence
fof other comorbid conditions. Unless cardiac catheterization and immedine
coronary revasculaizaion ae indicated, an excres test should be performed in
individuals with known or suspected CVD to asses rik ol future cardiac events
and to assist in subsequent management decisions. As stated in Chapter 5, data
derived from the exercise est are most useful when considered in the context
of othe clinical information. Important prognostic variables hat can be derived
From the exercise test are summarized in Box 6.1.

fom.

I RGURE 62. Duo nomogam usas vo stops 1 estate pognss e agonia
cn a Stangen ston ine, Second, dared degree ol anna is mare on meine
(Serie capaci. Fina, e mark on te schema reading Ines connected 1 the mark on e
rom ne pont et ch soe sects the progress sc AD

omerene MA Sucio) === |

Several multivariate prognostic scores such asthe Veterans Administration
score (43) (validated for the male veteran population) and the Duke nomogram
(69) (vaidated forthe general population including women) (sce Figure 62) can
be helpful when applied appropriate: The Duke nomogram does not appear 10
be valid in patents >75 yr (33). Patients who recently have sulered an acute
MI and received thrombolytic therapy and/or have undergone coronary revasct
larization generally have a low subsequent cardiac event rate, Exercise testing
sll can provide prognostic information in this population, as well as asis in
physical activity counseling and Ex R,

THE BOTTOM LINE

+ Interpreting the results of a clinical exercise test requires a multivariable
approach,

+ The HR, hemodynamic, and ECG response 10 exercise are key objective po

© clinician, In
addition, the subjective symptoms including RPE, angina, and dyspnea are
importan components of exercise test interpretation

+ When ventilatory expired gas is assessed during the clinical exercise test,
a highly accurate determination of acrobic capacity is possible in addition
toa potentially more accurate quantification of exercise effort (i. peak
RER) and assessment of submaximal exercise performance and ventilatory
efficiency

+ Clinical exercise testing assists in the diagnosis of CVD as wel asthe physi-
¿logic mechanisms for abnormal Functional limitations such as unexplained
exertional dyspnea,

+ The diagnostic accuracy of clinical exercise testing depends on the charac:
teristics ofthe patient who is undergoing the assessment and the quality of
the test.

+ Clinical exercise testing data, and in part
valuable prognostic
this procedure.

Online Rese

À Seen omen muets ape
Donner

158 EU) === |

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4, Noma ue Le Mirmo Hane, SD, tiger Wi Whip crs. rc
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4. Nasa} Fehr ST lon dg tense testing Am] Car, 90910906:

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oe i ng eg emp
eee ee
os ee emcee
its
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o
ta
a EE a rd jin co
NH oe o a
in lung
ias
NT

SECTION

DEBORAH RIEBE, PHD, FACSM, ACSM-HFS, Associate Editor

AN INTRODUCTION TO THE PRINCIPLES OF
EXERCISE PRESCRIPTION

“The scieili evidence demonstating the beneficial effect of exercise is indisput
able, and the benefits of exercise far outweigh the risks in most adults (20,38)
(Gee Chapers I and 2). An exerisewaining program ideally is designed to meet
individual health and physical fitness goals The principles of exercise prescrip
tion (Ex R,) presented in this chapter are intended to guide healh/tnes, public
health, clinical exercise, and health care professionals in the development of
an individually tailored Ex R, for the apparently healthy adult whose.
prove physical fines and health and also may apply to adults wi
chronic diseases, disables, or heath conditions, when appropriately screened
(ee Chapters 2, 8-10). Recreational and competitive athletes will benefit from
more advanced traning techniques than are presented inthis chapter. This ei
tion ofthe Guidelines employs the Frequency (how often), Intensity (how hard.
Time (duration or how Tong), and Type (mode or what kind), with the addition of
total Volume (amount) and Progression (advancement) or he FITEVP principle
SÍ Ex R, to be consistent with the American College of Sports Medicine (AC)
recommendations made in its companion evidence-based position stand (20).
‘The FITEVP principles of Ex R, presented inthis chapter are based on the
application ofthe 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 FITEVP principle of Ex R, may not apply because of indi-
dual characterises (eg. heath status, physical ability, age) or athletie and
performance goals. For individuals with clinical conditions and healthy indi
‘duals with special considerations, accommodations should be made tothe Ex
Ras indicated in other related chapters ofthe Guidelines (sce Chapters 8-10)
For most adults, an exercise program including aerobic, resistance, Neil
oy and neuromotor exercise training is indispensable o improve and maintain
physical fimes and health (20). Deals of the FITT-VP principle of the Ex R,
provided later inthis chapter. These Ex R, guidelines present recommended

cusoreR 7 SU) :===- |

targets for exercise derived from the available scientific evidence showing most
individuals wil realize benefit when following he stated quantity and quality of
exerce, However, some individuals will want 1 or need to include only some
ofthe health-related components of physical unes in cir training regimen or
exercise les than suggested by the guidelines presented inthis chapter Even ¡fan
individual cannot meet the recommended targets in this chapter, performing some
exerise 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:
used exercise recommendations including relevant ACSM position stands
(5:17,2025,32) and other professional scientific statements (7,38 31,54)

GENERAL CONSIDERATIONS FOR EXERCISE PRESCRIPTION

A program of regular exercise for most adults should include a variety of exer
(iss Ieyand activities performed as part of daily living (20). The optimal Ex R,
should address the health-related physical fess components of candiorespra
tory (aerobic) fitness (CRF), muscular strength and endurance, flexibility, body
composition, and nevromotorfitnes, Reduction in the time spent in sedentary
acidos (e, television watching, computer us, siting in a car or at à desk)
in addon to regular exercise à important forthe 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 carliometaboli disease biomarkers, and depresion (20,38) Even in physt-
cally active individuals who meet dhe recommended targets or exercise, period
‘of physical inacvity are detrimental to heal (20,34). When periods of physical
‘inactivity are broken up by shor bouts of standing or physical activity (eg, very
short walk around the ofic or home), the adverse elects of physical inact
are reduced (20,34. Therefore, the Ex R, should include a plan to decrease pe
(ds of physical inactivity in addition tan increase in physical activity (20 31,34)

Overuse injuries (Le, tissue damage resulting from repetitive demand over

ime, termed cumulativ trauma disorders) and other musculoskeletal injures are

cof concern o as, To reduce the potential for overuse disorders and injury an
assortment of exercise modalities may be helpful (20). Common components of
the Ex R, seem tobe helpful at least under some circumstances to reduce muscu
loskcletal 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 sof particular concern in middle-aged
and older adults, can be minimized by (a) following the prepaticiation health
Screening and evaluation procedures outlined in Chapters 2 and 3, respectively
(6) beginning a new program of exercise at Iightto-moderate intensity: and
(© employing a gradual progression of the quantity and quality of exercise (20)
Also important o the Ex R ae behavioral factors that may enhance the adoption
and adherence to exercise participation (see Chapter 11)

Bone health sof great imponance to younger and older adults (see Chapters 8
and 10), especially among women. The ACSM recommends loading exercises

m EU) >=:
msn

| Warm: atleast 5-10 min of Hght-1o moderate intensity codcrespratoy
and muscular endurance zes

CUT components of te Exercise
=

Conditioning: a est 20-60 min of aerobic, resistance, neuromotr, and!
or sports activites (exercise bouts of 10 min ao acceptable he individual
accumulates at last 20-60 min =" of cy aerobic exercise)

Cookdown: atest 5-10 min of ighttomodeatentonsy dires péter
and musculr endurance eines

Stretching: at east 10 min of stretching exoriss porormodafor the
warm or eookdoun phase

(e, weight bearing and resistance exercise to maintain bone heath (45.7.2032)
and these types of exercises should be par ofan exercise program, particularly in
Individual at risk for low bone density (..,esteopenia) and osteoporosis

‘An individuals goals, physical bility; physical funess health stats, schedule,
physical and social envionment, and available equipment and facilites should
be considered when designing the FITT-VP principle of Ex R, for a client or
patent. 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, lex and neuromotor exercise training based on a combination
ofthe FITTVP principles of Ex R,. The following sections present specific re
‘ommendations for the Ex Ro improve health and fess.

COMPONENTS OF THE EXERCISE TRAINING SESSION

A single exercise session should include the following phases:

Warm-up.
Conditioning andor sports-related exercise
Cool-down,
stretching.

‘The warm-up phase consists ofa minimum of 5-10 min of ligh-to-moderate
intensity aerobi 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 adjus othe changing physiologic, biomechanical, and bioenergeic demands
placed on it during the conditioning or sports phase of the exercise sesion.
‘Warming up also improves range of motion (ROM) and may reduce the risk of
injury (20) For the purpose of enhancing the performance of caniorespiraory

plaglariem

Methods of Estimating Intensity of Cardiorespiratory and Resistance Exercise

2
p:
ä
Pereeived
HAN or Exertion (Rating 20METs MMETS METS: Young Middle older One E
Ion or "HR VO onGZORPE nn On MU MET (20-00 A, (PSV) Repetition Q
Seale) à 2
Very fight <30 <7 <37 Very light <a <37 <a <2 <24 <20 <16 <30 3
eE So 3
E 7-6 SRE Verylightiotenly 264 WEG Auer 20 46 A0 7 0-0 E
light (RPE 9-11) E
AT E 3106 46-77 40-00 2248 STO
somewhat hard
GPE 2-19) E
Vigorous —60-<90 76-<95 61-<91 Somowhathad 62-<91 G4-<91 68-<92 60-<88 72<102 GOES 48<68 70-<5 E
ro very hard £
Pela 3
Nor =90 EE TT DE E 25 = 5 €
‘maximal to Dir El
maximal El
HR, maximal heart ote; HAR, heart ote reserve; MET metabole equivalent APE, rating ol parodied exertion: VO, manimum axygen consumption VO, A onen uptake E
‘Adapted from 120) 3

so

166 EU) === |

endurance, aerobic exercise, sports, or resistance exercise, specially activities
that are of Tong duration or with many repetitions, a dynamic, cadiorespiraony
endurance exercise warm-up i superior to Mlexbiity exercise (20)

The conditioning phase includes aerobic, resistance, Medhy, and neuro-
motor exercise, and/or spons activites Specific about these modes of exercise
are discussed in subsequent sections of this chapter. The conditioning phase is
followed by a cooldown period involving aerobic and muscular endurance acti
ity of light-to-moderate intensity lasting at lest 5-10 min. The purpose of the
‘cooldown period ito allow for a gradual recovery of heart rate (HR) and blood
pressure (BP) and removal of metabolic end products from the muscles used

ming phase
ing phase is distinct fom 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 (ic, the number of days per week dedicated
to an exercise program) isan importan contributor to healuhflinss benefits
that result from exercise, Aerobic exercise is recommended on 3-5 d + wk!
for most adults, with the frequency varying with the intensity of exercise
(2025,32.3852). Improvements in CRE ae attenuated with exercise Frequencies
23 dk and a plateau in improvement with exeris done >3.d + wk (20)
Vigorous intensity exercise performed > d= wk-? might increase the incidence
of musculoskeletal injury so this amount of vigorous intensity, physical activity
‘snot recommended for most adults (20). However, fa variety of exercise modes
placing diferent impact stresses on the body (eg. running, cycling) or using dif
ferent muscle groups (eg, swimming, running) are included in the exercise pro:
gram, daily vigorous intensity, physical acuity may be recommended for some
Individuals. Aternately a weekly combination of 10 3 d= wk" of moderate
and vigorous intensity exereise can be performed (20,3252)

Hess benefits can occur in some individuals who exercise once or
vice per werk at moderate-to-vigorous intensity, especially with large volumes
of exercise as can occur in the “weekend warrior" patern of exerise (20). In
spite of the possible benefits, exercising 1-2 times» wk? is not recommended
for the most adults because the risk of musculoskeletal injury and adverse car
diovascular events ls higher in individuals who are not physically active on a
regular basis and those who engage in unaccustomed exercise (20).

[AEROBIC EXERCISE FREQUENCY 7900
RECOMMENDATION
saveur

D ci one oder vent

cusoreR 7 _ i :===- |

‘combination of 3-5.d wk of moderate and vigorous intensity exercise
is recommended for most adults o achieve and maintain halles
benefits.

INTENSITY OF EXERCISE

There is a positive dose response of health/fitness benefits that results fom in
creasing exercise intensity 20), The overload principle of training states exercise
belowa minimum intensity, oF threshold, will nt challenge the body suficieny
10 result in changes in physiologic parameters, including increased maximal
oxygen consumption (VO...) (20). However, more recent findings demonsteate
the minimum threshold of tensity for benefit seems 0 vary depending on an
Individuals CRF level and other factors such as age, health status, physiologie
differences, geneic, habitual physical activity and socal and psychological fe:
tors (204647). 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 1-14 metabolic equivalents (METS) seemingly require an exercise intensity of
at least 45% oxygen uptake reserve (VOR) to increase VO, but no threshold
is apparent in individuals with a baseline unes of <11 MTS (20,46). Highly
tained athletes may need to exercise at near maximal” (Le, 95%-100% VO...)

raining intensities to improve VO whereas 70%-80% VO... may provide a
sulfcient stimulus in moderately trained athletes (20 40.

Interval training involves varying the exercise intensity a fixed inervals der
ing à single exercise bout. The duration and intensity ofthe inervals can be
‘aed depending on the goals of the training session and physical fitness level,
fof the client or patient, Interal taining can increase the total volume andr a
rage exercise intensity performed during an exercise session. Improvements in
(CRF and cardiometabolic biomarkers with short-term (=3 mo) interval taining
are similar o or greter than with single intensity exercise in healthy adults and
individual with metabolic, cardiovascular, or pulmonary disease (20). The use
of tera training in adult appears beneficial, but the longer effects andthe
safety of terval taining remain toe evaluated

[AEROBIC EXERCISE INTENSITY Ba -1-12]
RECOMMENDATION

Moderate (eg, 40%<60% heart rate reserve [FRR] or VO,R) 1 vigor
ous (eg, 60%-<90% HRR or VOR) intensity aerobic exercise is recom
tended lor mos adults, and ight (eg, 30% 40% HR or VOD to
Det tcsy mnt exer an be bene in individ who

tre deconditined neral ining may sam fective way to increase

ite toe vous ander mens seis Imeniy performed ung an
eee

168 EU) === |

Methods of Estimating Intensity of Exercise

Ser effective methods for presrbing exercise items result in improve
amené CRF at can be recommended for individual Ex R, (20). Tale 7.1
Shows the approximate classification of exercise intensity commonly used in
practice. One method of determining exercise intensity snot necessarily eu
Jet he intensity derived using another method, because no ties hve com.
pared al ofthe methods of measurement ofexrce intensity smullaneou In
Sion, the relationships among mesure of acual energy expendiue (EE)
and the absolute (Le, VO, and METS) and retire methods to prsenbe exercise
intensity Le, SRR, animal hear ate, and WVO,..) ean vay com
siderably depending on exercise test protocol, exercise mode, Girls mens,
and characteristic ofthe cen or patient resting HR phys fines lee
‘ge, and body composition) as wel a ther Htors 20)

“The HRR or VO,R methods may be preferable or Ex R, because exercise
Intensity can be ündereshmated or overestimated when using. the HR
(Ge, SHR.) or VO, (Le, VO.) methods (2049) However, the advantage
ofthe RE Or VO,R methods wot universally accepted 20-44). Furthermore,
the acuracy of any ofthese methods may be influenced by the method of mes.
Suremen o estimation used (20)

“The formula "220 ~ age” is commonly used to prdic HR, (19). This or
smu simple tous, butt can anderestinae or everest eased MR,
(21,2348 38, Specialized repression equations for smating HR, may be su:
Desir to the equation 01220 ag, a least i some individuals (126438)
[Although these equations are promising, they cannot yt be recommended for
unver application, although they may he applied to populations Similar to
those in which they were derived (20). Tale 72 shows some ofthe more com
monly used equations to estimate HR, For greater accuracy in determining
ere items for the Ex R, using edit measured HR, prefered
to estimated methods; but when not fail, estimation of ner intensity
acceptable

Measured or estimated measures of absolute exercise intensity include
calorie expenditure (kcal = min"), absolute oxygen uptake (ml. min oF
Le min amd METS. These absolute measures an resul in misclasification

Rate
CIC AECE ENE
‘evand@ AR... = 2166 DBZ Menand women se =D
To WR, = 200-107 Kage) Hea non ond women

Genen) HR, = 207= 7 ope) Nan ae women paient

fess raga wh od rg oe
A Reymptomat aioe warn
tae tates war

cusoreR 7 _ i :===- |

of exereis intensity (eg, moderate and vigorous intensity) because they do
ot take into consideration individual factors such as body weight, sex, and

ss level (1.2.27). Measurement error, and consequently miscassieation,
ss reaer when using estimated rather han directly measured absolute EE and
Under fre living compared to laboratory conditions (1,227) For exam
an older individual working at 6 METS may be exercising at a vigorous
‘maximal intensity, whereas a younger individual working atthe same absolute
intensity willbe exercising moderately (27). Therefore, fo individual Ex Ry a
relative measure of intensity (ee, the enengy cos of the activity relative 0 the
individuals maximal capaci, such a % VO, The, VO, mL kg» min",
MRR, and VO,R) is more appropriate, specially for older and decondtioned
individuals 27,32),

À summary of methods for calelating exerise intensity using HR, VO,,
and METE are presented in Box 7.2 Intensity of exerise taining is wally
determined as a range o the calculation using th formulae presented in Boy
72 need o be repeated twice (Ge once forthe lower limit of the desired in
tensity range and once for the upper limi ofthe desired intensity ange). The
presclbd exercise intensity range or an Individual shoul be determined by
{aking various actors into consideran, including age, habitual physical ac
tity level. pia ines level, and hal status Examples asating the
Asc of several methods for prescribing exercise intensity ae found in Figure
7.1. The reader is directe to other ACSM publications (eg, [205] for fr.
ther explanation and examples using these ational methods of presenting
ere intensity).

Boa mete eet

+ HRR method: Target HR (THA) = WHR ga? = HR) 9% intensity
desired) + HR

+ VOJA method Target OR = (Dana = VOX % intensity
sita] + VO ug

+ HR mothod: Target HA = HR,

1% imensiy desired

+ VO, method Target VO," = VO, ne X % intensity dosed
+ MET method: Target MET“ = [NO 18.5 mL» Kg" + min")
% intensity desired

Ce A

mo EU) === |

Heat to Rosen HAR) Mer
HR. Toben me
PR 190 ban mar!
ested Greenery ange 0-20
Fer Toot Han ato THR) = Un = HR.) tons HA

tn
ere
fin Den = base iy = No bat

21 Onermanon oeuvres tony af HAR
Coman eared m deca by vg by 100
SHRR = dared menan x HAR
SHAR = 09 NO bone mn
SSHAR = 0.6 NO ous mn"

8) Osemae AR ange

AR à Hg
Te stamina an iio THR range
o tin pein of TR age
THR = G6 boots «mn + 70 beat min“! = bets «min
‘TH ange 128 Ds mato Gen em

(base ma!

VO, san 110, Method
‘tae ost te
an
ssm gt min
ned rc ent ange SO8-£0%
Ferme 1090110, «MO = Op) À % mai + VO,
ne no
I VO
VOR cont ig Tt amiga
NOIR = 28m stg’? mn
2) Onieranon fours mensay as V0,
Comer nt testy PVO, mia detal by dng by 10
SOA = dened menaty x VOR
Gaine OR
WOR = 08 À 265m ig mn = 3 mL kg mint
SOIR = 08 x 2688 219" mn? = Om kg mat
2) Gnome tgp VO,R nm
(AOR + On
1 tome owe target VO, rng:
Togo, B 3m em à 25m Ag ma =
went ig min"
1 cotrmin ue rg VO, ange:
PDO, among mm à ISLA =
oa mtg’! mn
‘ergot ange: 168 mL kg nt A mg min?
IRFIGURE 71. Caples fh opcion of aout moro fx presents or
‘tensty HR... manera hast ate, HR» rest nu at; MEL metab ent
VO; volme angen cono per uni alma. VO, mona volume of open
toned par un of te. Apts rom 1

cusoreR 7 SM) :===- |

4) Doe MET trat ange pn
MET = 38m cg smn
(ato aner MET wpe
TMEVASmL= kg" ema" x MEG kg mint
LME = 188 mig mar SL kg mae AB METE
ost upper WET get
METAS ML kg in" = x METIDA ML kg mn"
MET = 194 mt hg mn 798 mt kg" ma SS METE
lent ca! acts rem EE vai Da rt ge om
condi à paca actos (1210 byusng metab ces.
{ane om n al 230 erence (2, Ao soe ton ean
pas roo! mortal otra

HR. Meses Or Estat Meca
‘ia cr
À man ro age
Roman THA = HR, deg %
Sn ertmandHR. I muss HR. nt ses
= 220 one
"Ti one HR rae
Tet Dies M
Com dre Ao ena by ving y 100
Deter lowe lt GTR ge:
THR = 178 boat me 070 = 123 boats: min
PR TS beats: mn 1080 = HOES: min
AR range 123 bens mn 10 Ds =a

300, Messed or Estimated Matted
‘A woman 28 ve
Estimated O) 30 mL kg mn
essed, ge 0-00
Fer: VO, deseas %
Determine tet, range
ge D, = Dein % XV,
‘Comer eared testy O; o a deems by sig y 100
Determine let of wget, ane
TO, = 080 x DL lg oma Ig mn“
Determine per of net ge:
O. O60 x 30mL IET em Big ema
Tget\0, ange 15m ig 2m 0 1B mL "Hg" mi"
1)” Determine MET up range pas
AO
Géo louer MET topa:
METAS ML kg rma X METIO mk kg mit
AMET 150 mb sig" ma PAG kgs mae 8 METS
Cart gpa’ MET get
METAS MLS rma" x MET O mL kg min"
KMET = 180 mL ge ma VAS mL sng =m! 51 METS

Figure 7.1. (Conve

m EU) >=:

2 Monty cal cts requir EE wine rt are em
compendio ol pon stats (121 by uam metab ee.
‘tors shown n hbo 734 elenco 2) See he oi eames
of soot meuheiconunens

sng meto kun 2 Table 73 o determina nain seed on «wan
‘otal st
‘on 329 of age
rg
og 70 n 1778 em
NO, 88m hg mnt
ested Fos gage: 25%
Ferrada VO, = 38 +102 x 5000) + (09 x speed ac)
baremo tet,
TND, = ad VO,
TO 2 O80 x Samt D mar = 482 mg mnt
2. Onto venera pora
VO, = 25 +102 send + (DD x spa x % gl
{G2mL sig rem 35+ 02 speed + D9 x pu x 0025)
297202 x spend à 19. speed «0026
387 = 02 x speed + DOZ25% sec
307-0225 onen
194 men pora
‘Spee on tno: 17m eh (67 =n)

sng metabo calas 2) Tab 72) determine % grade ng waking on

‘raat
‘Amon Say of ge whois moderate physical ate
‘ogre eg

og 701 (77Bem)
Destos walıng sped: 25 mm 1,67 m 2m
Desnes MET 8 Mets
Fama: O, = 38, 11 x spo + (18 x speed gee)
"Baten get D
Ha NO, = MET 325 mL «kg sm“
TOO, = 8x 8m kg te i= MEL hg mn
2. Det vad ade:
NO, 25.01 spond (18 spa x 2 race)
SL sig’? ma 2 98 + OT Pme De
(8 67 mes: re
WER X 6 mea) HBX 67m 81 x grade)
V4 267 à 1206 2 # gode
79 2 106% ge
006 = % gado
en

migure 7.1. (Cone

cusoreR 7 ETES

sng mota cations 22 (ao 23 to detamine tage werk at ge m mi)
‘ona ono roo apartar
om 22 rage
Magie 00 66 dia)
Meg D n (778 cm
Desteavo; 181g «mm?
Frs VO, «70 ¥ 18 works mass
Co oo on ae agora:
NO, = 70 + 119% wor ral mess
mag"? mn! 70.4 18 0 ate 19
MO won rer
S504 = 18 wore to
Work sata eme min" = 866

Figure 71. (Corinna

Metabole Calculations forthe Estimation of Energy Expenditure
(VO. {mL kg: min") During Common Physical Activities

Vai Compara
stg Meo
a ese ms
Component Somone
E DTA Eee
ae ERREUR
ES DEAN 09x speed x Moat erste or
eae" PET
ma
E OBA mapa TIRA TET mop — Most eet or
ES Pa poe res of
Pra Re mn
Tapón 5 35 (1 x wom TAO Wost osa or
Es wert oes of 200-
1200 ge mm +
Fre
ES Gx war ww West cometer
oar moss tr oes between
ng
Fran
Spates
‘Sn por pdr ese doi mag, 10% = 0%,
oto ye omg amenant

Bi oe nm ZUR om OD mom 108 en 288g: me
E

(Een an gr Puno ttn he Sate ar rn. Ma
Senet’ ore sand satu non on 3 Non bm pone
sms nig

aces tor a

m EU) >=:

When using VO, or METS to prescribe exercise, healih/iness,publichelih,
clinical exercise, and health cae professionals can identify activities within the
desired VO, of MET range by using. a compendium of physical activities (12) 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 o recommend these for universal
sc at this time, A direct method of Ex R, by plotting the relationship between
HR and VO, may be used when HR and VO, are measured during an exercise
test (see Figure 7.2). This method may be particularly useful when prescebing
exercise in individuals taking medications such as fblockers or who have a
chronic disease o 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 affecüve valence (Le, the pleasantness of
exercise) can be used to modulate or refine the prescribed exercise intensity
(Gee Chapter 11), These include the Bong Rating of Perceived Exetion (RPE)
Seales (12-14,33), OMNI Seales (40,41 55), Talk Test (35), and Feeling Scale
(29. 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)

METHODS or Esrmanne rene Fi EC) ED
Seren metas van ewe o ema Inensty

O e weile part al cnt in
E catecismo
MELO he che qu isc cen ey ot nca
Decale o ec oe Ce Br 2)

EXERCISETIME (DURATION)

Exercise time/duraion is prscribed asa measure of the amount of time physical
activity ls performed (i, time + session”, ‚and wk D. I is recommended
‘that most adults accumulate 30-60 min >? (22130 min = wk") of moderate
imensiy exercise, 20-60 min + d-1 (2275 min » whe") of vigorous intensity
exercise, or a combination of moderate and vigorous intensity exercise per
day to atain the volumes of exercise recommended inthe following discus
sion (20,52), However, les than 20 min of exercise per day can be beneficial
‘specially in previously sedentary individuals 20,52), For weight management,
longer durations of exercise (260-90 min + d ') may be needed, especialy in
individuals who spend lage 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 R, recommendations for promoting and
‘maintaining weight loss.)

cusoreR 7 _ Lo :===- |

180:
mo
160.
150.

Heart rate (beats -min-1)

S 10 16 20 2530 95 4
VOz (mL: kg"! min‘)

1 RGURE 72 Pes ec rt te us loto een pst a

VO, Aine of nt ar ri a Br tps spat MR O,

igs OIE Base ENDS es or LD gr À ni

WERK ono Fr ns nao S0 Oy es Omen ons

A TH anges 15-18 xs

The recommended ümelduraion of physical activity may be performed
continuously (Le, one sesion) or intermittently and can be accumulated over
the course of a day in one or more sessions of physical activity that total a least
10 min» session . Exereisehouts of <10 min muy yield favorable adaptations
in very deconditioned individual, but farther study is needed to confem the
effectiveness of these shorter bouts of exercise (20).

Aenosic exenaisenmeiounamom =F EQ
RECOMMENDATION

Most ls sul acumula 30-0 mind 130 min wh of
ee am (en ed hve
IE con mote amd eme eat
ee pu os ccc. Tin
tad mos emos
io oc us crus fay mans
MA ca terca sn a,

we EU) >=:

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 ral:
{zing heaviness outcomes, particularly with respect o body composition and
weight management. Thus, exerise volume may he used 10 estimate the gross
EE of an individuals Ex R, MET-min = wk and cal wi" can be used to et
mate exercise volume in a tandardized manner Bo 7. shows the definition and
«alculaions for METS, METmin, and Kcal » min! for a wide array of physical
“cities. These variables can also be estimated using previously published tables
(1,2). MET-min and kcal «min can then be used to calculate MET-min «wh
and Kcal + wk that is accumulated as part of an exercise program to evaluate
‘whether the exerise volume is within the ranges described later in this chapter
‘ha wil ely result in healıhfiness benefits

The results of epidemiological studies and randomized clinical wials have
shown there is a dose-response asoclatin between the volume of exercise
and healivfiness outcomes (Le, with greater amounts of physical activity the

MetabolEquivalonte (META): An index of EE. IA MET to rai of he

rato of energy expended during an activay tothe rate of energy exponded at

| rest... (One) MET is the rate of EE wile siting at et... y convention,
[1 MET sequal ol an oxygen uptake of 95 ImL = kg" = min 1381

|
|
|

À MEE min: An index of EE (hat quanti tho tot amount of physica act
performed ina standardized manner across individuals and types of actos
À (89. Calculated as the product ofthe number of MET associated with one
‘or more physical actives and the number of minutes the actos wore
performed Le. METS x min; usually standardized per week o per day asa
messure of exo volume

i

H

|

A |
Bee ee

een |

u |

ee |

|

|

|

|

| Example:

logging at ~7 METE) or 30 min on 3 d wi! for 7049 ma:
| 7 MET x 30 min x 3 times por wook = 630 MEF man «wk?

Im METS x 35 mL» kg! « mer! X 7049) + 1000) x 5 = 8575 keat min"
8575 Kcal» min! x 30 min x 3 times por week = 771.75 keal- wk"!

cusoreR 7 SM) :===- |

heahfiness benefi lso increase) (16,20,52). I is not clear whether or not
there isa minimum or maximum amount of exercise that is needed to attain
heafimess benefits. However, a total EE of =500-1,000 METmin + whe" is
consistently associated wit lower rates of CVD and premature mortality. Thus,
2500-1.000 MET-min > xk is a reasonable target volume for an exercise pro:
gram for most adults (20,52). This volume is approximately equal o (a) 1,000
eal + wk"? of moderate intensity. physical activity (or about 150 min wk");
db) an exercise intensity of 3-59 METs (or individuals weighing —68-01 kg
1--150-200 I); and (c) 10 MEE wk? (2032), should be noted that lower
volumes of exercise (ie, 4 heal hg”! + whe? or 330 heal + whe can resul in
cabines benefits in some individual, especially in individuals who are de
conditioned (16.20.52). Even lower volumes of exercise may also have benefi,
ut evidence slacking to make definitive recommendations (20
Pedometers are effective tools or promoting physical activity and can be
used to approximate exercise volume in steps per day (50). The goal of 10,000
steps dis ofen cited, but it appears hat achieving a pedometer step count of
at east 5400-7900 steps» € can meet recommended exercise targets (20,50)
To achieve step counts of 5400-7,900 steps + done can estimate toal exercise
volume by considering the following (a) walking 100 steps min! provides avery
rough approximation of moderate intensity exereise;(b) walking 1 mile“ yields
about 2,000 steps + Y; nd (c) walking ata moderate intensity for 30 min +
elds about 3,000-4.000 steps + d (10.0.2830). For weight management,
igher step counts may be necessary and a population-based study estimated men
may require 11,000-12.000 steps * d'!, and women 8,000-12,000 steps d'
respectively to maintain a normal weight (20,50) Because of the substamil errors
‘of prediction when using pedometer step counts, sing tes min combined wih
currently recommended time/durations of exercise (e, 100 steps * min "for 30
min + sesion”? and 150 min + wk") is judicious (20)

[AEROBIC EXERCISE VOLUME 1-12]
RECOMMENDATION

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TYPE (MODE)

Rhythmic, aerobic ype 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 74. The principle of

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specificity of training should he kept in mind when selecting he exercise modal
ties o be included in the Ex R, The specificity principle states thatthe physi
logic adaptations to exercise ae specific 1 the type of exercise performed (20)

Tile 74 shows aerobic or cardiorespiratory endurance exercises categorized
by the intensity and sil demands. Type A exercises, recommended forall adults,
require lite skill to perform, and the intensity can easy he modified o accommo.
dut a vide ange of physical fines levels, Type B exercises are ypicall performed,
At a vigorous intensity and are recommended for individuals who are a las of
average physical ines and who have been doing some exercise ona regula basis.
Type € exereises require skill 0 perform, and therefore are best for individuals
who have reasonably developed motor skills and physical fitness to perform the
exereiss safely Type D exercises are recreational sports that can improve physica
fess but which are generally recommended as ancillary physical activities per.
formed in addition o recommended conditioning physical activites, Type D phys
cal activities are recommended only for individuals who posses adequate motor
skills and physical fess to perform the sport; however, many of these sports may
be modified to accommodate individuals of lower skill and physical fines levels,

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RATE OF PROGRESSION

‘The recommended rte of progression in an exercise program depends on the
individuals health stats, physical fitness, training responses, and exercise pro
gram goals, Progression may consist of increasing any ofthe components of the
FITT principle of Ex R, as tolerated by the individual. During the initial phase
ofthe exercise program, increasing exercise timeduration (Le, min sesion )
is recommended. An increase in exercise time/duration per session of 3-10 min
very 1-2 wh over the frst 4-6 wk of an exercise training program i reasonable
for the average adult (20). After the individual has been exeresing regularly for
1 mo, the FIT of exercise is gradually adjusted upward over the next 4-8 mo
= or longer for older adults and very deconditione individuals — to mest the
recommended quantity and quality of exercise presented in the Guidelines. Any
progression in the FITT.VP principle of Ex R, shoul be made graduallyavoding
le increases in any ofthe FITE'VP components to minimize risks of muscular
Sorenes, injury, undue fatigue, and the long-term ik of overtraining. Following
any adjustments in the Ex R, the individual should be monitored for any adverse
¿lic of the increased volume, such as excessive shortness of breath, fatigue,
and muscle soreness and downward adjustments should be made f the exercise
is not well tolerated (20).

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MUSCULAR FITNESS

The health benefits of enhancing muscular fitness (e, the funcional param:
ter of muscle strength, endurance, and power) are well established (520,32)
Higher levels of muscular suength are associated with a significantly better
‘adiometabolic risk actor profile, lower risk of al cause moral, fewer CVD
events, lower risk of developing physical function limitations, and lower risk
for nonfatal disease (20). In addition to greater strength, thee isan impr:
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

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with pre-hypertension 10 Stage 1 hypertension (6,17,20,36) (see Chapter 10)
According resistance taining may be effective for preventing and treating the
“metaboliesyndeome” (20) (see Chapter 10). Important, exerise that promotes
muscle strength and mass ls effectively increases bone mass (i, bone mineral
density and content) and bone strength of he specific bones stressed and may
serve as a valuable measure to prevent, slow, or even revers the loss of hone
mass in individuals with osteoporosis (3,420.52) (see Chapter 10). Because
muscle weakness has been identified as a risk factor for the development of
Osteoathritis, resistance training may reduce he chance of developing this mus-
culoskeetal disorder (20:43) (see Chapter 10). In individuals with osteoarthritis,
resistance training can reduce pain and dsabilty (20,31). Preliminary work ug:
¡ets that resistance taining may prevent and improve depresion and ane
Increase vigor, and reduce fatigue (20)

Each component of muscular fitness improves consequent 10 an appropri
ately designed resistance training regimen and correctly performed resistance
exercises. As the tained muscles strengthen and enlarge (Le. hypertophy) the
resistance must be progressively increased if additional gains ae tobe accrued.

cusoreR 7 SM) :===- |

To optimize the efficacy of resistance taining, the FITT-VP principle of Ex R,
should be tailored to the individuals goals (5,20)

Although muscular power is important for alee events such as the shot
put or javelin throw, muscular strength and endurance are of greater importance
‘na general training regimen focusing on healthiness outcomes or young and
rmidle-aged adults. In addition 1 focusing on muscular strength and endurance,
oder adults (=63 yr) may benefit from power training because this element of
muscle fitness declines most rapidly with aging and insufficient power has been
sociated with a greater risk of accidental falls (11,15)

GOALS FORA HEALTH RELATED resistance F177 EE)
TRAINING PROGRAM

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‘The guidelines described inthis chapter or resistance traning are dedicated 10
improsing heath and most approprit oran overall or general physical ess pro
gram that includes but does not necessarily emphasize muscle development (320).

FREQUENCY OF RESISTANCE EXERCISE

For general muscular fines, particularly among those who are untrained or rec
reatioally trained (4, not engaged in formal training program), an individual
should resistance train each major muscle group (Le the muscle groups of the
ches, shoulders, upper and lower hack, abdomen, hips, and legs) 2-3 d= wh
with a least 48 separating the exercise training sessions or the same muscle
group (320). Depending on the individuals daily schedule, all muscle groups
to be trained may be done so in the same sesion (ie, whole body), or each
session may “spi” the body into selected muscle groups so that only a few of
groups ae trained in any one sesion (5,20). For example, muscle ofthe lower
body may be tained on Mondays and Thursdays and upper body muscles may
be tained on Tuesdays and Friday, This split weight training routine emails
444+ wh "to train each muscle group 2 times + uk 1; however, each session is
of short duration than a whole body session sed to train all muscle groups.
‘The split and whole body methods are effective as long as cach muscle group is

ined 2-3 «wk ?. 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 taining regimen

182 EU) === |

RESISTANCE TRAINING FREQUENCY "7900
RECOMMENDATION

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(TYPES OF RESISTANCE EXERCISES

Many types of resistance training equipment can effectively be used 10 improve

free weights, machines with stacked weights or pneu
resistance bans, Resistance training regimens should
include mulujolnt or compound exereses that affect more than one muscle
group (eg, chest pres, shoulder press, pulldown, dips, lower hack extension,
abdominal crunchícud-up, leg press, Squats). Single joint exercises targeting
major muscle groups such as biceps curls, triceps extensions, quadriceps ex
tensions, leg curls, and cal raises can also be included ina resistance training
program (5.20.

To avoid creating muscle imbalances that may lead to injury opposing muscle
groups (Le, agonists and antagonists), such asthe lower back and abdomen or
the quadriceps and hamstring muscles, should be included in the resistance
training routine (5,20) Example ofthese types of resistance exercises are low
Hack extensions and abdominal crunches 10 target the muscles in the lower
Back and abdomen, and lg presses and leg curls to exercise the quadriceps and
hamstring muscles.

TYPES OF RESISTANCE EXERCISES 9009
Many types of resistance ining equipment can

eve be sr o improve muscular nce, Malo ee al
ing mane Uan one muscle poupand targeting sons amd antagonist mus
cle groups are recommended for all adults. Single joint exercises targeting
majo muscle groups may ao be included ns stance ining pora.

VOLUME OF RESISTANCE EXERCISE (SETS AND REPETITIONS)

Each muscle group should be tained for a total of two to four ses. 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 sts of bench presses or with two
sets of bench presses and two sets of dips (97). reasonable rest interval between
sets is 2-3 min Using different exercises to tran the same muscle group adds

cusoreR 7 _ a :===- |

variety, may prevent long-term mental “salenes,” and may improve adherence
Lo the training program, although evidence that these factors improve adherence
‘slacking 20),

Fou sets per muscle group is more effective than two set; however, even a
single set per exercise will significantly improve muscular strength, particularly
among novices (520,37). By completing one set of two diferent exercises that
affect the same muscle group, the muscle has executed two sets For example,
bench presses and dips afec the pectoralis muscles of the chest so that by
completing one set of exch the muscle group has performed a total of tu sets
Moreover, compound exercises such as the bench press and dips also tain
the triceps muscle group. From a practical standpoint of program adherence,

individual should carefully assess her/is 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
‘option of a resistance training program that will be realistically maintained
cover the long term.

The resistance training intensity and numberof repetitions performed with
cach set are very related, That i, the greater the intensity or resistance,
the fewer the number of repetitions that will need to be completed. To improve
muscular strength, mass, and — 10 some extent — endurance, a resistance ex
(reise that allows an individual to complete 8-12 repetitions per set should be
Selected, This translates toa resistance that ~60%-80% of the individuals one
‘repetition maximum (1-RM) or the greatest amount of weight hited fora single
repetition. For example, fan individuals 1-RM in the shoulder pres is 100 Ib
(453 kg), then, when performing that exercise during the training sessions, he/
she should choose a resistance between 60 and 80 lb (27-36 kg), Han individual
performs multiple sts per exercise, the number of repetitions completed before
fatigue ocurs will be ator close to 12 repetitions withthe first set and will de
cline to about 8 repetitions during the ls et for that exercise. Each set should
be performed to the point of muscle fatigue but not failure because exerting
muscle to the point of file increases the ikelihond of injury or debilitating
residual muscle soreness, particularly among novices (5,20,37)

the objective of the resistance training program is mainly to improve mus
cular endurance rather than strength and mass, a higher numberof repetitions,
perhaps 15-25, shouldbe performed per set along with shorter est intervals and
fewersets (Le, Lor 2 sets per muscle group) (320). This regimen necessitates a
lower intensity of resistance ypically of no more than 50% 1-RM.Simulaiy; oler
and very deconditioned individuals who are more susceptible 10 musculotendi
nous injury should begin a resistance training program conducting more sepet

fons (Le, 10-15) at a moderate intensity of 60%-70% of RM, or an RPE 013-6.
on a 10-point scale (5,2032) assuming the individual asthe capacity ose this
inensiy while maintaining proper Ming technique. Subsequent to a period of
adaptation to resistance taining and improved musculotendinous conditioning,
‘older individuals may choose to follow guidelines for younger adults (ke, higher
imensity with 8-12 repetitions per set) (20) (see Chapter 8)

m EU) >=:

VOLUME oF Resistance exercise sets Fir
AND REPETITIONS) RECOMMENDATION

Adults should tran 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 ftnes, For older adults and very deconditioned
individuals, =1 set of 10-15 repetitions of moderate intensity (Le, 60%
70% LRM), resistance exercise is recommended

RESISTANCE EXERCISE TECHNIQUE

To ensure optimal healthvfitness gains and minimize the chance of injury, each
resistance exercise should be performed with proper technique regardless of
taining statis 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 fal ROM of the joint, and employing proper
breathing techniques (e, exhalation during the concentric phase and inhalation
during the eccentric phase and avoid the Valalva maneuver) (5,20) However,
is not recommended resistance training be composed exclusively of ecenttic or
lengthening contractions conducted at very high intensities (ee, >100% RMD
because ofthe significant chance of injury and severe muscle soreness as well
2 serious complications such as rhabdomyolysis (Le, muscle damage resulting
in excretion of myoglobin imo the urine that may harm kidney function) that
can ensue (3,20). Individual who are naive to resistance raining should receive
instruction on proper technique from a qualified healthtness professional (eg
ACSM Certified Health Fitness Specialist, ACSM Certified Personal Trainer")
on each exercise used during resistance training sessions (5,20)

RESISTANCE EXERCISETECHNIQUE 1512)
RECOMMENDATIONS a 8
Alindilduls should perform resistance training sing comet technique.
Proper resistance exercise techniques emply controll! movement
brought full ROM and involve concentric and eccentric muscle actions,

PROGRESSION/MAINTENANCE

As muscles adapt oa resistance exercise training program, the participant shold
continue 10 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 10 increase the amount
of resistance hited during taining. For example, ian individual is using 100 Ib
(45:3 kg) of resistance for a given exercise, and herhis muscles have adapted 10
the point w which 12 repetitions are easily performed, then the resistance shoul
be increased so that no more than 12 repetitions are completed without significant

cou OE === |

muscle fatigue and difficulty in competing the last repetition ofthat set, Other
‘rays to progressively overload muscles include performing more sets per muscle
roupand increasing the number of wk the muscle groups ae trained (5.20),
On the other hand, if the individual has attained the desired levels of muse
lar strength and mass, and heshe sechs 1 simply maintain that level of muscular
fess iis not necessary to progressively increase the training stimulus. Tati,
increasing the overload by adding resistance, sets, or traning sessions per week
is not required during a maintenance resistance taining program. Muscular
strength may be maintained by training muscle groups a lle as 1 d wh!
as longas the training intensity or the resistance lifted is held constant (520).
The FITEVP principle of Ex R, for resistance raining is summarized in Tale 7.6
Because these guidelines are most appropriate for a general Funes program, a more
rigorous training program must be employed if ones gal is o maximally increase
‘muscular strength and mass, particularly among competitive athletes in sports such
‘football and bodybuilding, 1 the reader is interested in more than heaviness

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160 EU) === |

and general outcomes or instead desires to maximal develop muscular strength
and mass, he/she is refered to the ACSM position stand on progression models in
resistance training for healthy adults fr additional information (520).

PROGRESSION/MAINTENANCE OF "1800
RESISTANCE TRAINING RECOMMENDATION
MA
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ME mme
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FLEXIBILITY EXERCISE (STRETCHING)

Joint ROM or flexibility can be improved across all age groups by engaging in
Rexibiliy exercises (20,32). The ROM around a joint is improved immediately
alter performing flexibility exerise and shows chronic improvement after about
3-4 wk of regular stretching ata frequency of at least 2-3 times + wk"? (20),
Postural stability and balance can also be improved by engaging inflexibility
‘exercises, especial when combined with resistance exercise (20). I is possible
that regular Nesibility exercise may result in a reduction of musculotendinous
injures, prevention of low back pain, or delayed onset of muscle soreness, but
the evidence is far rom 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 inthis chapter enhance the effectiveness of flexibility
exercises. I is mont effective to perform flexibility exercise when the muscle
temperature is increased through warm-up exereses or passively through meth
os such as moist heat packs or ho baths, although this benefit may vary across
muscle tendon units (20)

‘etching exereises may result in an immediate, shortterm decrease in
muscle strength, power, and sports performance performed alter stretching,
vith the negative effect particularly apparent when strength and power is in
portant to performance (20, 29). Before specifi recommendations can be made,
‘more research is needed on the immediate effects of exbily exercises on the
performance of fitnesstelated activites. Nevertheless, ts reasonable based on
the available evidence to recommend when feasible, individuals engaging in a
general fitness program perform flexibility exercise following cadiorespeatory or

‘bance ts = oat — ha sso rapa (2
FLEXBILIY exercise necommenoanon Fi7T EJ EES
TOM Is improved ach and coma Gow
Fg cae Paring excep an os eave when he

cusoreR 7 SM) :===- |

muscles are warm. Flexibility exercises may acutely reduce power and
strength so i is recommended that Neil exercises be performed
alter exercise and sports where strength and power ae important for
performance.

(TYPES OF FLEXIBILITY EXERCISES,

Flexibility exercise should target the major muscle tendon units of the shoulder
salle, chest, neck, trunk, lower back, his, posterior and anterior les, and ankles
(20), Box 7.4 shows the several types ol Nexiiliy exercises hat can improve ROM
Aldhough often considered “contraindicated,” properly performed halte sete

ng may be considered for adults, particularly for individuals engaging in activites
that involve ballistic movement such as bisketall and is equally effective a state
stretching in increasing joint ROM (20). Proprioceptive neuromuscular facilita
tion (PNF) techniques that require a partner to perform and state stretching are
Superior 10 dynamic or slow movement stretching in increasing ROM around a
joint 20). PNF technique typically involve an isometric contraction followed by
“static stretch in the same muscohendon group (Le, contracts),

Ballistic methods or "bouneing” stretches use the momentum ofthe
‘moving body segment to produce the set (57.
Dynamic or slow movement stretching volves a gradual rnsiton tom

one body poston to another, and a progressive increase in reach and ange of
‘motion asthe movements repeated several ties 10)

State stretching insives sow teta à musciehondon group and
holding th position for a peñod af üme ie, 10-305). State stretches con be
acive or passive (0)

Activo stati stretching involves holding the stetched poston sing the
stengt ofthe agonist muscle 3 i common in many forms of yoga 20,
Passive static stretching invvos assuming a poston who hocing amb

‘rotor port ofthe body with or without the assstance 01 a prior device
(such as coste bands o 8 ballet bare) 120)

Propriocoptivo neuromuscular facilitation (PF) methods aho several
Forms bit ypealy involve an somet contraction ofthe solctod muscle)
tendon group flowed by static svetching ofthe same group le, contact
rela) (39.42,

168 EU) === |
FLEXIBILITY TYPE RECOMMENDATION Fi

8
À sr ob exces targeting the mjor

‘muscle tendon units should be performed. A variety of static, dynamic,
and PNE Mexibily exercises can improve ROM around a joint

VOLUME OF FLEXIBILITY EXERCISE (TIME, REPETITIONS,
AND FREQUENCY)

odin a stretch or 10-305 othe point of tightness or slight discomfort enhances
joint ROM, and there seems o be litle addtional benefit resulting from holding
the strength fora longer duration, except for oder individuals (20) In older dus,
stretching for 30-60 may result in greater flexibility gains than shorter duration
stretches (20) (se Chapter 8). For PNF sueches, iis recommended that the in
vidal ofl ages hold a lighto-moderate contraction (be, 20%-75% of maxi
‘mum voluntary contraction) for 346s, followed by an assisted stretch for 10-30 s
(20), Flesbilty exercises should be repeated 2-4 times to accumulate awl of 60
Sof stretching for each flexibility exercise by adjusting timc/duraon and repet

tions according to individual needs (20). The goal of 60 of stretch time can be
atained by, for example, to, 30 stretches or four, 15s stretches (20). Performing
Aexibilty exercises 22-3 à + wk * will improve ROM but stretching exercises are
most effective when performed daily (20). A stetching routine following these
guidelines can be completed by most individuals in 10 min (20). À summary of
the FITTV? principle of Ex R, for flexibiliy exercise is found in Table 77.

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En ROUE sue mat hat pos Sot bt.

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cusoreR 7 _ Lo :===- |

FLEXBILITY VOLUME necomuenoanon Fir EJES

A total of 60 s of lexibiltyexerise per joint i rec-
‘ommended. Holding a single flexibility exercise for 10-30 510 the point
of tightness or sight discomfon i effective, Older adults can benefit from
holding the stretch for 30-60 5. À 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 =2-3 d wk "is
recommended with daily exibility exercise being most effective

NEUROMOTOR EXERCISE

Neuromotor exercise training involves motor skills such as balance, coordination,
xt, and agliy and proprioceptive training and is sometimes called funcional
Jines traning, Other multifaceted physical activities sometimes considered to
he neuromotor exercise involve varying combinations of neuromotor exercise,
resistance exercise, and Mexibiiy exercise and include physical activites such as
‘aij (at ei), qigong. and yoga, For older individuals, he benefits of neuromotor
exercise training are clear, Neuromotorexerese taining results in improvements
in balance, agility, and muscle stength, and reduces the risk of falls and the fear
of falling (720,32) among older adults (see Chapter 8). There ae few studies of
the benefis 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 lack of research on middle age and younger adults, definitive
recommendations for benefit of neuromotor exercise taining cannot be made;
nonetheless, there may be benefit especally for individuals participating in physi
cal activites requiring agility; balance, and other motor skills (20).

The optimal effectivencss ofthe various types of ncuromotor exercise, doses
(Le, FIT), and training regimens are not known for adults of any age (20.32)
Studies that have resulted in improvements have mostly employed traning fe
«quencies of =2-3 d uk with exercise sessions of =20-30 min duration for a
total of =60 min of ncuromotor exercise per week (20,32. There s no available
evidence concerning the numberof repetitions of exercises needed, the inenst
ofthe exercise, or optimal methods for progression. A summary of the FITT-VP
Principle of Ex R, for neuromotor exercise found in Tale 74.

NNEUROMOTOR EXERCISE RECOMMENDATIONS Fir ES

Neuromotor exercises involving balance agility coor-
‘ination, and git are recommended on =2-3 d + wh for older individu:
als and are likely beneficial for younger adults as well The optimal dura
tion or numberof repetitions ofthese exeriss is not known, but neuro-
‘motor exercise routines of = 20-30 min in duration for a otal of 2:60 min
of neuromotor exercise per weck are effective

100 EU) === |

Nouromotor Exercso Evidence-Based Rocommenc

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EXERCISE PROGRAM SUPERVISION

‘The ealvfiness and clinical exercise professional may determine he level of st
person that is optimal for an individual by evaluating information derived from
the prepatcipton heahih screening (see Chapter 2) and the preexeraise evalua
tion (see Chapter 3) that may include health screening, medical evaluation, and/
‘or exeris testing as indicated by the individuals exercise goals and heal stats,
Supervision by an experienced exercise leader can enhance adherence 10 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 aduls intting a new exercise program (20,32)

THE BOTTOM LINE

‘+ An exercise program that includes aerobe, resistance, Hebi, and neuro-
‘motor exercise taining beyond ADL to improve and maintain physical fitness
and healh is essential for healtitness benefits among most adults

+ This edition of the Guideline employs the FITT-VP principle of Ex R, thats,
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 intensit
bic exercise taining 230 min » d 2,25 d wk 21 total =150 min > wh";
vigorous intensity cardiorespiratory exercise training =20 min + d*,
23 d + wk"! to tol 275 min + wk 1; or a combination of moderate and
vigorous intensity exercise to total an EE of =500-1,000 MET-min» wk +

cusoreR 7 SM) :===- |

+ On 2-3 4 + ke! adults should also perform resistance exercise for each of
the major muscle groups and neuromotor exercise involving balance, agil,
gat, and coordination (eg, such as standing on one leg walking or running.
through cones, dance steps).

+A series of flexibility exercises foreach of the major muscle tendon groups

34 wh. is recommended to maintain joint ROM,

+ The exercise program should be modified according w an individuals habita
physical acviy physical function, physical fitness Level, health stats, exer-
¿ise responses, and stated goa

+ Adults, including physally active adults, should concurrent reduce total time
engage in sedentary behaviors and intrspese frequent, show bouts of sanding
and physical activity betwen periods of sedentary activity throughout he da:

2008 rye cy aden for A Amrum (2):
heap ces

ACSWUA Each Malin
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en Catia por ips tnd on rio mode ne

aoa inc om ing sr and Atty ui >

uo Soc ani Canin Sito:
[ema

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REFERENCES

Genese human yal seine M Sports ce ASTRO.
“orth a NE WINE il Compara psa ei anupda loci
dal an MET neni Ml Sá os Esc 200920 Sapp 88504
‘en ag jr Mas een Ci ops nnd ac
LE Cl Spore Matin Amel Calg pro ne posten snd
{penton modas Tune ing fr Beal ads. Med Sei Sports Exc 2004103
«Stan al fpr, Aon Ds An, ad pees

182 EU) === |

Amen Cole e Sons Maine, Coda Za W) Ptr DN, a Amena Cage of
{Ee it nl ol pyc ay orl aaa Mal re

a mg Ber FL Waly SH, Oto RM, Ameria Clg Spor Meli ACM
a rte tng dl cs ae HD ppt Was &

9 Na PO sp Sa of Py Wiking apc Rtn Sean Age Copenhagen
‘Bena Mp 102 14

20 Rest DR) Wat. Thompe Pes) JO. Pedo men phys any and
Be bern US al he Spor Be LO 10

11 eco ae. oJ Mc ove fuer tes no acon sy
‘moral stan in vn ee pepe) Sa Heath Ag HOTTE

da. Bayh Der xeon se Spur Ra oven eS

À ep mn gen Pec econ edo bane and end ee ig,
eee Br Pha Pk os.

14. fy ite Ce The ces lp xr, sand pa in ees heat
‘Seed Mod on go Wo ss a Ra OP

19 Gon al LM, Winters KM Pc A, Schwan Oro nic i sk ad
seca me ang mc e pa e

10. Chad 1. ze C Se Bl SN Els ie des of pyle on ce
nr Snes mu >; cer er hos poned women heed
bla pc admin conoid a JAM 307270) 8-9)

vr Bondy Je ae SN Jat a rl Amen Cog Spr ne Po Sond
Sopra pic aint tin mesi ferme ims and presents o wiht rea
iMate aoa E os OR

in Bren Ameo ol Spars Meier ACS Rene Manor Gales Es
rn Pec he ie Dy Upto Wil & Wlan 3p

1 D ot ic ol aya pra ona Na

20. ner Ce Denn MR, a Ana Cage Soc Mole Pn Sod
‘he gun and uy of eee lr docking and manag cororopi mu
A ayo: pect pme one ed
PRET Doe

21, Gut Gin DR Oban RE M Da A Rs GD, al VE. Longin mode ol
‘erat Berne af aha Suns ae DOT

22, Gaus Duper Amen Clogs Si ke. AC Mei Cats ab
Br Qu ip Vilas & Wim 01h

2. Glas Show Ted RA ick Hh Me ON Amar ME Heat te reponse eee
‘teeing pepo vn, e e Jn Nc e o Ci DR

dy ch jota O Na st bt how e fc the mort af dor xc

Jon ter oh 18911300

25 tem week Pate ca sa aya pate lt u menden
te ala am he Aman Cote loan bn te Amer Hest so ed

26. lbn Wwe e ad chen ia tine wh
tapeo reese ming Speed O NE =

an. wey ET pea say rm, ob and e ena cepa ppl aci
USA yor Ec 301316 Sup SS, dicen 9-3

28. ng oran Bare PEL Pl lp ee pe cy ento:
amd anus Ra QE Sort 20060016855

29. mg Ciganc CH Te ara arme ao ll sra ry penn
ud min Bunt oo OSA ls

0. Mall Moe ater ES alo DC Dyas Sa sr vs pth et on
dureza gy youn Senn Conde DOOR

su ict andere de ca md some va mares
MeN JO 14539 a

32 Ne Rei Wasa aa ct a ac ahi le als co
nor he Ameren Clg Ss einer Amer est ca Ned
Se Be MINES

ie Sica) === |

te rot ie ere per en
tea arc erento
a Sante ate a
RE ne EBENE nya ate
eer een
ne,
ett ari ol meta una ec andrea fr digan sn pesen. Sri
Sear
A co Ja rm gm
Ban an ann cents re
SEE en
en terres ve
ER N ETT
En
so Bea Ea ch dan on cet
En sent
a rte CN
ee
Een ET acm
nen
ER ER np wha
een
eier
em:
Senn
O
Me arene id
Td men
oe Beet an ren se sr ca
pei erg mm er ae
DE he inet tea a
SiS ie
te A ce
en
ee went an each
Rime ate ates naar ree
ra dae
o nay
Recah Cee tah edo e
ie Sos elec ae pce tn
SAO RE LENS
DE
einen
EB econ entra
a
nt
8 Bel os see ve Juno height when combined with haskell cui] Stemgh Cond.
MATE a sna ml dor m

rete Am ol Canto

Exercise Prescription for Healthy
Populations with Special Considerations
and Environmental Considerations

PREGNANCY

“The acute physiologic responses to exercise are generally increased during preg
nancy compared with nompregnancy (121) (see Table 8.1). Healthy, pregnan
women without exereise containdications (2) (See Box 81) are encouraged
to exercise throughout pregnancy. Regular exercise during pregnancy provides
Irallvftmess benefits to the mother and child (2.34). Exercise may also reduce
the risk of developing conditions associated with pregnancy such as pregnancy
juced hypertension and gestational diabetes melltus (34,60). The American
College of Sports Medicine (ACSM) endorses guidelines (76) regarding exercise
in pregnancy and the postparum period se forth by the American College of
Obstetricians and Gynecologists (2,11), the Joint Commince 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 ofexercise during pregnancy and als provide guidance on exercise presi
tion (Ex R,) and contraindications to beginning and continuing exercise during
cgnancy The CSEP Physical Activity Readiness Medical Examination, termed
I PARmed.X for Pregnancy, should be used for dhe heath screening of pregnant
‘women before thee paniipation in exercise programs (88) (see Figure 8.)

EXERCISE TESTING

Maximal exercise testing should not be performed on women who are pregnant
unless medically necessary 21,32) Ia maximal exercise test is warranted, the test
shouldbe performed with physician supervision aftr the woman has been medically
evaluated for contrandications to exercs (see Figure 8.). A woman who was se
etary before pregnancy or who asa medical condition (se Box 1) should recive
‘carance from her physician or midwife before beginning an exercise program

EXERCISE PRESCRIPTION

‘Therecommended Ex, for women who ae pregnant should be modified according
10 the womans symptoms, discomfons, and abilities during pregnancy: I impor
tant to he aware of contraindication for exercising during pregnancy (se Bor),

m

cuore 8 FOTOS

loge Responses to Acute Exercise during Pregnancy,

ce

pared to Nonprognaney (121)
Open ue urge dependen! ese) rose
Gare ott see
Tome see
Mine vena see
rer TNT ease

weno)
Testy camaro io arian corms Tan

VOA CO

oi ba psu ESTERO

Dame boot pese Fo caresse

+ Unevalated matoral cac ysthytmia
+ Chronic ones

+ Poorly convoted Type 1 diabetes meus

+ Extreme mord obesity

+ Exrome undorweight

+ History of extreme sodontary testo

+ Invauterine growth restiction in erent pregnancy
+ Poorly controlled hipertension

+ Orhopodi imitations

+ Pooty control seizure disorder

+ Posty controled hyperthyroidism

+ Heavy smoker

ABSOLUTE
+ Homodmomicaly significant haar disease

+ Rostictve lung disouse

+ Incompetent corviforcage,

+ Mutipl gestation at sk for premature labor
+ Pesistnt second or tid timestr bieedng
+ Placenta rova ater 26 wk of gestation

+ Prematrelbar during ho curent prog
+ Ruptuod membranes

+ Preeclampsialpregnancrindvced hypertension

rtd wn puma oh

150 EU) === |

PARmed-X for PREGNANCY Eine

Ate PREONANCT I a pun fr pst seee
prin na penal Rss tos ar er eee
SSS eee

aoe

1 PGURE 81. Pra! Atty Fonos PAR for egnancy, Rosine wth permission

cuore 8 o Oe

PARmed-X for PREGNANCY iia canon

[© cowrnamoscaTions ro EXERCISE: te completed b your heath care provider

M AGURE 8: (Contec

ENT RECOMMENDANONS FoRWomeN Fit EJES
WHOARE PREGNANT
Be.
FRequanoy: 34d: wc! sc sagas ana quency of
der
min ercer E
fess Ure or dwt") lees tc TO hn a
pt baby) ias viva low rh we gen
en cosita sd erre pices
I ete ow bith cia porn hal pl
IDE Bates a xro tng ls ey peso nu
een we coreo o mos
ee
aa tg recs ern cc
Uv ae mery Ser mcsmmendes br
gray tty mae dee OD as bg
ere
Elm 13270)
BTS den mega rac 30 in:
D est petty exis oe ni er
A ede ots conc bee inc
emmener
Dee em mp soci a ol eran

10 EU) === |

25 kg m? who have
een medially prescreened can exercise ata light intensity start

ingat 25 min adding 2 min + wh"! nil 40 min 3-4 d+ whe"
achieved (77.

‘Type: Dynamic, shythmic physical activities that use large muscle groups
such as walking and cycling

Progression: The optimal time 10 progress i after the frst wimeser

(13 wh) because the discomforts and risks of pregnancy are lowest at that,
time, Gradual progression from a minimum of 13 min d-!, 3d» whe"
(at the appropriate target HR or RPE) to a maximum of approximately
30 min d-!,4d- wk * (atthe appropriate target HR or RPE) (2).

Heart Rate Ranges That Correspond
Exercise for Low-Risk Normal
‘and to Light Intensity Exercise for
Pr

À am <25 kg mi

| Age yr) Fitness Lovet Hoart Rato Range (beats min"
| <0 = 140-185

| 202 Low 129-144
eine 136-160
Fe 145-160
HE Low re

Aie 130-145
Fe 140-156

À Ago ve) Hoar Rato Range (beats «min
202 102-124

HE 11-120

à
=
2

cuore 8 o Oe

‘SPECIAL CONSIDERATIONS

‘+ Women who are pregnant and sedentary or have a medical condition should
gradually increase physical activity levels to meet the recommended levels
tarlier as per prepariipation completion of the PARmed-X for Pregnancy
(68) (see Figure 8.1).

+ Women who are pregnant and severely obese and/or have gestational diabetes
mis or hypertension should consul their physician before beginning a
exercise program and have their Ex R, adjusted to ‚hir medical condition,
symptoms, and physical fess level

+ Women who are pregnant shoul! avoid contact sports and sportive that
may cause Iss of balance or trauma to the mother or feu, Example of sport!
activities o avoid include soccer basketball ce hockey, roller lading horseback.
siding, skiinghnow hoarding, cuba diving, and igorous iensio;mcquet sport,

+ Exercise should be temminated immediately with medical follow-up should any
ofthese signs or symptoms occur: vaginal bleeding, dyspnea before exertion,
‘dizziness, headache, chest pain, muscle weakness, calf pain o swelling, preterm
Labor, decreased feal movement (once detected), and amniotic ui leakage
(2, the case of elf pain and swelling thrombophlebitis shouldbe rule ou.

+ Women who ae pregnant should avoid exerising in the supine position ater
16 of pregnancy to ensure that enous obstruction docs not occur (32).

+ Women who are pregnant should avoid performing the Valsalva maneuver
during exercise

“+ Women who are pregnant should avoid exerising 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
‘uid replacement (8) for ational information,

+ During pregnancy, the metabolic demand increases by ~300 Kcal + a
‘Women should increase calorie intake to meet the calorie costs of pregnancy
and exercise. To avoid excessive weight gain during pregnancy, consult

fe weight gain guidelines based on prepregnancy BML available from

xe of Medicine and the National Research Counei (118).

“+ Women who are pregnant may participate in a strength taining program that
‘incorporates all major muscle groups with a resistance that permits multiple
submaximal repetitions (Le. 12-15 repetitions) o be performed to a point of
‘moderate fatigue Isometric muscle actions and the Valla mancuser should
be avoided as should the supine position ater 16 wk of pregnancy (32)
Kegel exerises and those that strengthen the pelvic oor are recommended
10 decrease the risk of incontinence (73).

+ 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 (73). Decondiioning typically occurs during
the inital postpartum period so women should gradually increase physica
activity levels until prepregnancy physical fitness levels are achieve. Light
to-moderate intensity exercise does not interfere with breastfeeding (75),

zo epee Sao) === |
THE BOTTOM LINE

“+ Women who are pregnant and healthy are encouraged to exercise throughout
pregnancy with the Ex R modified according to symptoms, discomforts,
and abilities. Women who are pregnant should exercise 3-4 d + wh"? for
2215 min d* gradually increasing to a maximum of 30 min + d* for each
exerce session, accumulating a tota ol 150 min + wk! of physical activity
that includes the warm up and cool down. Moderate intensity exercise rec
‘ommended for women with a prepregnancy BMI <25 kg» m’. Light intensity
exercise is recommended for women with prepregnancy EMI of =25 kg - m.

The Aman Congreso On md Coen:
‘The Caan Soy for Exc hilo (led fr Pregnancy)
ee cnt occ

| Mie Say dl Obstet and Gynecol of Canada:

CHILDREN AND ADOLESCENTS

Children and adolescents (defined as individuals 6-17 yr) are more physically
active than their adult counterpans. However, only our youngest children ae 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 all or children and adolescents to engage in at
least 60 min - day" of moderateto-vigorous intensity, pl

include vigorous intensity. physical activity, resistance exercise
ing activity atleast 3 d+ wk (114), In dhe United States, the prevalence of
meting ths guideline was-42% in children aged 6-11 yr and nadolescents 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 cadiometaboli risk fae
tors (63,80). Thus, the benefits of exercise are much greater than the risks.
However, because prepubescent children have immature skeletons, younger
children should mot participate in excessive amounts of vigorous intensity

Most young individuals are healthy, and it is safe for them to start moderate
imensity exercise training without medical sreening. Clinical exercise testing

cuore 8 FOTOS

should be reserved for children in whom there isa specific clinical indication.
Physiologic responses o acute, graded exercise are qualitatively similar to those
seen in adults, However, there are important quantitative differences, many of
Which ae related to the effets of body mass, muscle mass, and height. I a
dition ts notable children have a much lower anacrobic capacity than adults
limiting their ability o perform sustained vigorous intensity exercise (14).

EXERCISE TESTING

Generali the adult guidelines fr standard exercise testing apply to children and
adolescents (see Chapter 3). However, the physiologie responses during exercise
(ler rom those of adults (see Table 82) so thatthe following issues should be
considered (87,121)

‘+ Exercise testing for clinical or heathvfitness purposes is generally not indi
¿ted for children or adolescents unless there 4 à health concern,

+ The exercise esting protocol shouldbe hased on the reason the tests being
performed and the functional capabiliy of the child or adolescent.

+ Children and adolescents should be familiarized withthe text protocol and
procedure before testing to minimize stress and maximize the potential for a
sicersfal test

+ Treadmill and cycle ergometers should be available for testing, Treadmills
tend 10 elicit a higher peak oxygen uptake (VOL) and maximum HR
(OR). Cycle engometers provide les ik for injury but need to be correctly
sized forthe child or adolescent

+ Compared to adults, children and adolescents are mentally and psycho:
logically immature and may require extra motivation and support during the

In addition, heaviness testing may be performed outside of the clinical
seating. In these types of sewings, the Fitnessgram test battery may be used 10

in Children Compared

Asco sagen ua Taser
Pate ongen bte Higher
Hoare ger
Card op Laer
Date oes presse ner
espro to er
Mine warn ner

espro ce at Taner

m EU) >=:

assess the components of helh-relaed fitness in youth (39). The components
‘ofthe Fitnessgram test battery include body composition (Le, BML or skinfold
thicknesses), cadiorespiratony fitness (CRE) (Le, 1-min walk/nun and PACER),
muscular fitness (Le, test and pullupfpush-up tests), and Mex
Ge, sivand-reach tes)

EXERCISE PRESCRIPTION

‘The Ex R, guidelines outlined in this chapter for children and adolescents estab
lish the minimal amount of physical activity needed to achieve the healthfitness
benefits associated with regular physical activity (114). Children and adolescents
should be encouraged to participate in various physical activites that ae enjoy
able and age appropriate.

Fir necommenpanonsroncmonen Fir
AND ADOLESCENTS

fete eects

Pen;
ee
Bee memes
lo NE
mm mrs ae
SES

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E Ne
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nano dou
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‘Type: Muscle strengthening physical activities can be unstructured

(eg. plying on playground equipment, climbing tees, ug-ofwar)
orstructred (eg. ling weights, working with resistance bands)

Bone Strengthening Exercise
Frequency: =3 d + wk!
Time: As part of 60 min + 4 or more of exercise

“Type: Bone strengthening activite include running, jumping rope,
basketball, tennis, resistance training, and hopscotch

‘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)

ight to 15 submaximal repetitions of an exercise should be performed 10.
the point of moderate fatigue with good mechanical form before the ress
tance is increased

+ Because of immature thermoregulatory systems, youth should avoid exercise
in hot humid environments and be properly hydrate. See this chapter and
the ACSM position stands on exerising in the heat (6) and id replacement
(8) for addtional information.

+ Children and adolescents who are overweight or physically inactive may not
be able to achieve 60 min > d-! of moderae-to-vigorous intensity, physical
activity: These individuals should start out with moderate imensty, physical
activity as tolerated and gradually increase the frequency and time of physical
activity to achieve the 60 min goal Vigorous intensity, physical activity
can then be gradually added at least 3d wh

+ Children and adolescents with diseases or disabilities such as asthma, di
betes mellitus, obesity stc Abrasis, and cerebral palsy should have their
Ex R, tailored to their condition, symptoms, and physical fitness level (se
Chapier 10),

+ Efforts should be made to decrease sedentary activities (Le, television wate
ing, suring the Internet, and playing video games) and increase activites that
promote lifelong activity and fitness (Le, walking and cycling

THE BOTTOM LINE

‘+ Most children >10 ye do not meet the rec A physical activity guide-
lines. Children and adolescents should participate in a variety of age appro-
priate physical activites to develop CRF and muscular and bone strength
[Exercise supervisors and leaders should be mindful ofthe external tempera
ture and hydration levels of children who exercise because oftheir immature
thermoregulatory systems.

Onlin

À us: Department of Health and aman Serves. 2008 Pic th Gli or
À Annie 2800) LS Department a eal and aman Serves [lema
Ra ne lerne

|
i

an Commitee apor 2008. Washington (DO) SONS D
pune pg cite

zu GUDEUNES FoR! u. Stratus) === |

OLDER ADULTS

‘The term older adalı (defined as individuals =65 ye and individuals 50-64 ye
with clinically significant conditions or physical limitations that affect movement,
physical fünes, or physical activity) represents a diverse spectrum of ages and
Physiologie capabilities (107), Because physiologic aging doesnot occur uniformly
ss the population, individuals of similar chronological age may differ dramat
cally in their response to exercise. In addition, its dificult o distinguish the e
{ects of aging on physiologie function from the effects of deconditioing or disease.
leal status is often a bete indicator of ability o engage in physical activity than
(hronologicl age. Individual with chronic disease should bein consultation with
a heal care provider who can guide them with ther exerise program.

‘Overwhelming evidence exists that suppons the benefits of physical activity
in (a) slowing physiologie 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 (€) reducing the risks
of physical disability: and (D increasing longevity (7.106). Despite these benefits,
folder adults are the last physically active of all age groups. Although recent
trends indicate a slight improvement in reported physical activity, only about
22% of individuals 265 ye 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).

“Tosafelyadministeran exercise est anddevelopasound Ex, requires knowledge
ofthe effects of aging on physiologic function a rest and during exerce. Table 83
provides a list of age-eatad changes in key physiologic variables. Underying disease
and medicion use may le the expected response to acute exercise

Pestag eae TI
Past saco D esse ner
Posch sd eve rectum ong pia en Lor
Oe Umm and tego

es volume Ber
i copa Lower
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Mores seg Lore,
Fox Toe
Bone mes Lomas
Fate bey mass er
Boy ft age
Gosse trance ewer

eso mo Longer

cuore 8 o A

EXERCISETESTING

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.)
Exercise testing may require subi differences in protocol, methodology, and
dosage. The following list details the special considerations for testing older
adults (107):

+ The inital workload should be light (Le, <3 metabolic equivalents [METS]
and workload increments should be small (Le, 05-10 MET) for those with
low work capacities. The Naughton treadmill protocol i a good example of
sucha protocol (se Figure 53).

À cycle ergometer may be preferable toa treadmill for those with poor bal
ance, poor neuromotor coordination, impaired vision, impaired gat patterns,
weight-bearing limitations, and/or foot problems. However, local muscle
Fatigue may he a facto for premature test termination when using a cycle
ergometer

+ Adding a tcadmill handrail support may be required because of reduced bal
ance, dereased muscular strength, poor neuromotor coordination, and far.
However, handrail support for gait abnormalities will reduce the accuracy of
estimating peak MET capacity based on the exercise duration 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 o the exerise protocol, the inital
stage may need to be extended, the test restarted, or the est repeated. In these
situations also consider an intermittent protocol (see Chapter 3).

+ Exercise-induced dysthythmiae are more frequent in older adults than in
individual in other age groups.

+ Prescribed medications are common and may influence the eecwocardio-
graphic (ECG) and hemodynamic responses to exercise (se Appendix A).

+ The exercise ECG has higher sensitivity (Le, —84%) and lower speciiciy
Ge, —T0%) than in younger age groups (Le, <50% sensitivity and 80%
specificity). The higher rate of false positive outcomes may be related to the
greater frequency of left ventricular hyperrophy (LVA) and the presence of
conduction disturbances among older rather than younger adults (45)

There ar 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
Ukelihood ofan cry test termination. In addition, many older adults exceed the
age-predicted HR, during a maximal exercise test

ze EU) >=:

Exercise Testing for the Oldest Segment of the Population

The oldest segment of the population (=75 yr and individuals with mobility
limitations) most likely has one or more chronic medical conditions. The likeli:
hood of physical imitations also increases with age, The approach described
earlier is not applicable forthe oldest segment of the population and for ind
viduals with mobility Limitations because (a) a prerequisite exercise test may
be perceived as a bare to physical activity promotion; (b) exercise testing
is advocated before imitation of vigorous intensity exercise, but relative few
individuals inthe oldest segment ofthe population are capable or likely o par
ticipate in vigorous intensity exercise especially upon initiation of an exercise
program: (€) the distinction between moderate and vigorous intensity exercise
among older adults i difficult (e.g, a moderate walking pace for one individual
‘may be near the upper mit of capacity for an older, unlit adul with multiple

onic conditions) and (d) there isa pauciy of evidence of increased monly
or cardiovascular event risk during exercise or exerise testing inthis segment
ofthe population. Therefor, the following recommendations are made forthe
aging population:

‘+ Uni of an exercise tet, thorough medical history and physical examina
on should serve to determine cardiac contraindications to exercise
+ Individuals with cardiovascular disease (CVD) symptoms or diagnosed dis
cae can be risk clasiid and treated according Lo standard guidelines (see
Chapter 2)
+ Individuals fee from CVD symptoms and disease should be able o initiate a
light intensity (<3 METS) exercise program without undue risk (46).

Physical Performance Testing

Physical performance testing has lrely replaced exercise stress testing for

assessment of functional status of older adults (30). Some test bateies
Ihave been developed and validated as corcates of underlying fitness domains,
whereas others have been developed and validated as predictors of subsequent
disability: institutionalizaion, and deat. Physical performance testing is appeal
ng in that most performance tests require itl space, equipment, and cost; can
bbe administered by lay or healvfitness personnel with minimal traning: and are
considered extremely safe in healthy and clinical populations (24,96). The most
widely used physical performance tests have iemifid cut points indicative of
functional limitations associated with poorer health status that can be targeted
for an exercise intervention. Some of the most commonly uscd physical per
formance tests are described in Table 84. Before performing these assessments,
(a) carefully consider the specific population for which cach test was developed:
(b) be aware of known floor or ceiling elects; and (c) understand the context
(Ge, the sample, age, health status, and intervention) in which change scores or

es are attribut.

cuore 8 FOTOS

‘Commonly
Mn and spon FE
Sonor Fines en 00

ETES
Seven tems: 39 s ar sand 305 am cars, nal toms
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‘The Senior Fess Test was developed sing a large, healthy community dc
ing sample and has published normative data for men and women 60-94 ye for
Items representing upper and lower body strength, upper and lower body flex

‘bility, cadioespiraory endurance, agi 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, insttuionalizaion,
and death but also has known ceiling effects that limit ts use as an outcome for
‘exercise interventions in generally healthy older adults. change of 3 point in
the SPB is considered a small meaningfl change, whereas a change of 1.0 points
is considered a substantial change (49). Usual gat speed, widely considered the
simplest test of walking ail has comparable predictive validity to the SPPB
(90), but its sensitivity to change with exercise interventions has not been consis

tent, À change in usual gat speed of 0.03 m + =! is considered a small meaning

fal change and a change of 0.10 m «ss considered a substamtial change (49).

ze EU) >=:

EXERCISE PRESCRIPTION

The general principles of Ex R, apply to adults of al ages (see Chapter 7). The
relative adaptations to exercise and the percentage of improvement inthe compo-
‘of physical fitness among older adults are computable with those reported
in younger aus and are important for maintaning health and functional aby
and attenuating many of the physiologie changes that ae associated with aging
(Gee Table 8.3). Low functional capacity, muscle weakness, and deconditioning
are more common in older adults than in any other age group and contribute 10
loss of independence (7). An Ex R, should include aerobic, muscle strengthening!
endurance, and Mexbiltyexereises. Individuals who re frequent Éallrs or have
mobility limitations may also bench from specific neuromotor exercises o improve
balance, agi and proprioceptive training in addition to the other components
of health-related physical ness, However age should not be ahurier to physical
acviy promotion because posite improvements ae atainable at any age.

For Ex R, 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 26 MER. In contras for older adult, activities should be defined
relative to an individuals physical fitness within the context of perceived physi
‘aexertion using a 10-point scale, on which Os considered an flot equivalent
to siting and 10 is considered an all out effort, a moderate intensity, physical
aetiviy Is defined as 5 or 6, anda vigorous intensity, physical city 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
substantial increase in HR or breathing (82).

FITT RECOMMENDATIONS FOR
OLDER ADULTS

‘Aerobie Exercise

To promote and maintain health, oder adult should adhere tothe following.
Ex, or aerobic (cardiorespratory) physical activites. When older adults
‘cannot do these recommended amounts of physical activity because of
chronic conditions, they should be as physically active as their abiliies and
conditions allow:

Frequency: =5 d « wh"! for moderate intensity, physical activities oF
234 wh * for vigorous intensity, physical activites or some combina
tion of moderate and vigorous intensity exercise 3-5 d+ wk

Intensity: On a scale of 10 for level of physical exertion, 3-6 for
moderate intensity and 7-8 for vigorous intensity (82)

soo

cuore 8 o A

‘Time: For moderate intensity physical a
‘oF up 10 60 (for greater benefit) min» din bouts of atleast 10 min each
o total 150-300 min + uk", ora least 20-30 min = d-? of more vigorous
intensity, physical activities to total 75-100 min + uk ' or an equivalent
(combination of moderate and vigorous intensity; physical activity:

Type: Any modality that doesnot impose excessive orthopedic stress
= walking isthe most common typeof activity. Aquatic exercise and
Stationary cycle exercise may be advantageous for those with limited
tolerance for weight-bearing activity.

Muscle Strengthening/Endurance Exercise

Frequency: =2 d + wh!

Intensity: Moderate intensiy (Le, 60%-70% one repetition maximum
[IRM]. Light intensity (Le, 40%50% 1-RM) for older adults beginning
à resistance training program. When 1-RM isnot 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 calsth
(B10 exercises involving the major muscle groups; =1 se of 10-15
repetitions exch), stair climbing, and other strengthening activites that
use the major muscle groups.

Flexibility Exercise
Frequency: =2 d - wk"!

Intensity: Suetch to the point of feeling tightness or slight discomfon.
Time: Hold stretch for 30-605.

Type: Any physical activites that maintain or increase leibilty using
slow movements that terminate in sustained stretches for each major
muscle group using state stretches rather than rapid balls movements,

Neuromotor (Balance) Exercises for Frequent Fallers or Individuals
with Mobility Limitations

There are no specific recommendations or exercises that sncoxporate neuromo:
vor (balance) taining into an Ex R,. However, neuromotor exercise training,
which combines balance, agility, and proprioceptive taining is effective in
reducing and preventing falls if performed 2-3 d + uk ' (7.44). General recom
‘mendations include using the following: (a) progressively dificult postures that
gradually reduce the base of support (€, two-legged stand, semitandem stand,
tandem stand, one-legged stand); (9) dynamic movements that perturb the
center of gravity (eg. tandem walk, circle turns); () stressing postural muscle

zo EU) === |

groups (eg. hecl, toe stands); (d) reducing sensory input (e standing with
eyes closed) and (e) tai chi. Supervision ofthese activities muy be waranted (5),

SPECIAL CONSIDERATIONS

There are numerous considerations hat should be taken into account to maxi
miz the elective development of an exercise program including the following:

+ Intense and duration of physical activity should be light atthe beginning
in particular for older adults who ar highly deconditioncd, functionally lin
ited, or have chronic conditions that afec thei ability to perform physical
tasks,

+ Progression of physical activities should be individualised and tailored 10
tolerance and preference; a conservative approach may be necessary for the
‘most deconditioned and physically limited older aduls.

+ Muscular strength decreases rapilly with age, especially for those >50 yt
Although resistance waining s important across the espa, becomes more
rather than ess important with increasing age (7 4 22).

+ For suength waining involving use of weightlifting machines, nial taining
sessions should be supervised and monitored by personnel who are sensitive
10 the special needs of older adults (se Chapter 7).

+ Inthe carly stages of an exercise program, muscle stengthening/endurance
physical activities may need to precede aerbic raining activities among very
fell individuals. Individuals with sarcopenia, a marker of fay, need 10
increase muscular strength before they are physiologically capable of enge
singin acrobi training.

+ Older adults should gradually exceed the recommended minimum amounts
of physical activity and attempt continued progression if they desire 10 im
prove and/or maintain their physical fitness.

+ I chronie conditions preclude activity at the recommended minimum
amount, older als should perform physical activites 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 cog

Ion. Individuals with significar cognitive paiement can engage in physical
activity but may require indwidualzed assistance

+ Strututed physical activity sessions should end with an appropriate cool-down,
picularly among individuals with CVD. The cooldown should include a
¡gradual reduction of efor and intensity and optimal exibiliy exercises.

+ Incorporation of behavioral strategies such as socal support, elec, the
ability o make healthy choice, and perceived safety all may enfance partit
pation in regular exercise program (see Chapter 11)

+ The healthyitness and clinical exercise professional should also provide
regular feedback, positive reinforcement, and other behavioralprogrammatc
strategies to enhance adherence,

THE BOTTOM LINE

All older adults should be guided in the development ofa personalized Ex R, or

ity plan that meets thee needs and personal preferences, The Ex R,
should include actobic, muscle srengthening and endurance, Nesibity, and
neuromotor exercises, and focus on maintaining and improving functional abi
li tn 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,

Online Rest

comio Scale Phys anciana Performance Maty (28
Epica elu inde ed

‘hort Physical Performance ate (12
AS

LOW BACK PAIN

Low back pain (LBP) is waditionally described as pain thats 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 isa recurrent and uncomfortable inconvenience, whereas
for others, chronie LBP isa major cause of chronic disability and diste. The
mere description ofthe problem of LBP based on spa charactrisus of pain
belles the complexity of the problem and its impact, Best evidence clinical
guidelines now recommend physical activity asa key component of management
cross the spectrum of he condition (427.115).

Most caes of LBP show rapid improvement in pain and symptoms within
the fist month ofsymptom occurrenc (89). Roughly one-half to thre-quarters
of individuals, however, will experience some level of persistent or recurrent
symptoms, with the prevalence of LBP being twice a high for individuals with a
prot history of LBP (57), Furthermore, recurrent episodes end toward increased
Severity and duration, and higher levels of disability including work dist
and higher medica and indemnity costs (117).

ndiiduats with LBP can be subgrouped into one of three general categories:
(a) LBP associated with a potentially serious pathology (ey cancer or facture)

22 EU) >=:

(6) LBP with specific neurological signs and symptoms (eg, radiculopathy or
spinal stenosis); and (0) nonspecific LBP (17) the latte of which accounts for
up 10 90% of cases (57). For the purposes of management, LBP may be fur.
ther subgrouped according 1 the duration of symptoms: (a) acute (the inital
4-6 wk); () subacute (<3 mo); and (c) chronic (23 mo) (27,115). 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 i symptom of another serious pathology (eg. cancer), exercise
testing and Ex R, should be guided by considerations related to the primary
condition, For all other causes, and in the absence of a comorbid condition
(eg. CVD with its associated risk factors), recommendations for exercise testing
and Ex R, are similar as for healthy individuals (See Chapters 2 and 7). Some
considerations, however, must be given to individuals with LBP who are fear
fal of pain and/or reinjury and thus avoid physical activity. as well a to those
individuals who persist in physical activity despite worsening symptoms (54)
Individuals with LBP who are fearful of pain andor reinjuny often misinterpret
any aggravation of symptoms asa worsening of thee spinal condition, and hold
the mistaken belief that pain equates with tissue damage (103) In contrast, those
‘with LBP who peris in physical activity may not allow injured tisues he time
that is needed to heal. Both behaviors are associated with chronic pai,

EXERCISE TESTING

Exercise and physical fitness testing is common in individuals with chronic
LBP with litle to no evidence of contraindication based on LBP alone. 1 LBP is
cute, guidelines generally recommend a gradual return to physical activity As
such, exercise testing should be symptom limited in the fist weeks following
symptom onset (1)

Cardiorespiratory Fitness

Many clientspatients with chronic LBP have reduced CRF levels compared 10
the normal population. Current evidence, however, has filed to find clear
relationship between CRF and pain (116, What is clar, however, that chronic
LBP cannot be fully explained by deconditioning or avoidance of physical act
vity for fear of pain. Despite this, the advice to stay physically active is neatly
‘universal in current clinical practice guidelines for LBP (427,119).

The guidelines for standard CRF testing apply to individual with LBP (see
Chapter 4) with the following considerations:

+ Compared to cycle and upper extremity ergomety treadmill testing produces
the highest VO... in individuals with LBP Actual or anticipated pain may
limit performance (120)

+ Actual or anticipated pain may limi submaximal testing as often as maximal
testing (36 39,109,110), Therefore, the choice of maximal versus submaximal

cuore 8 .’ ——. |

testing in individuals with LBP should be guided by the same considerations
as fr the general population,

Muscular Strength and Endurance

Reduced muscle strength and endurance inthe trunk has been associated with
{BP (1), as have changes in strength and endurance ratios (eg. flexors vs. ex:
tensors) (15). here has also been the suggestion newromotor imbalances may
exist between pared muscles such as he erctor spin in individuals with LBP
(04). 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.
culate are common in individuals with LBP (48), When interpreting these
rests, however, several actos must be kept in mind:

‘+ Assessments using isokinetic dymamometers with buck attachments selector
teed machines, and hack hyperextension benches specifically test the trunk
muscle in individuals with LBP, The rliabiliy o these tests is questionable
because of considerable leaning effect in particular between the first and
second sessions (33,64,92)

+ For individuals with LEP performance is often limited by actual or antic:
pated fear of rinjuy (65)

Flexibility

‘There is no clear relationship between gross spinal flexibility and LBP or associ
sued disability (4) A range of studies have shown associations between measures
of spine flexibility hip exibiliy; and LBP (72). The nature of these associations,
howeve, is ikely complex, and requires farther study: Assessing spine Nesihility
is sul recommended as par of a standard clinical evaluation in LBP (13) and
‘may provide insight into the condition ofthe individual. Furthermore, there ap
pears to be some justification, although based on reaively weak evidence, for
Nesbit testing inthe lower limbs, and in particular the hips of individuals
vith LBP.

In general, ibi testing in individuals with LBP should be guided by the
same considerations as forthe general population (see Chapter 4). I is essential
however, o dently whether the assessment is limited by stretch tolerance of the
target structures or exacesation of LB symptoms

Physical Performance

Physical performance tess afford another indicator of the functional impact of
LBP when added to the traditional impairment-based measures such as muscle
strength and flexibily (105) or they assess the impact of LBP and its associated

a EU) === |

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psychomotor slowing. Such testing is complementary o self-reports of function.
"Examples of such tests mostly include a timed component and ate presented in
Bos 83.

EXERCISE PRESCRIPTION

‘Clinical practice guidelines forthe management of LBP consistently recommend
staying physically active and avoiding bed rest (17) Although it may be best 10
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 (D)

Current evidence doesnot provide any consensus on the typeof exercise that
should be promoted in individuals with LBP or on how to best manage the pro:
gram variables for these individual (17). When recommendations are provided,
they should follow very closely the recommendations forthe general population
(ee Chapter 7) combining resistance, aerobic, and flexibility exercise (1). In
chronic LBR exeris programs that incorporate individual long, supervision
stretching, and strengthening are associated with the best outcomes (27.35). À
complete exercise program based on the exercise preferences of the individual

and healtfitness, clinical exercise, anor health care profesional may be most
appropriate (4). Minimum levels for intensity and volume should be the same as
for healthy population (sce Chapter 7).

‘SPECIAL CONSIDERATIONS

+ Exercises to promote spinal stabilization (71,95) are often recommended
Insel on the suggestion that intervertebral instability may bea cause of cer
tain cases of LBP (86).

+ This approach provides no clear addtional benefit over other approaches
10 the management of nonspeciie 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
‘ith LBP based on the preference ofthe individual and the health fitness,
clinical exercise, and/or health care professional

+ Conan 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 “perpheralizaion” of
symptoms, thats, distal spread of pain into the lower limb with cenain
sustained or repeated movements ofthe lumbar spine (3). In such a situ
ation, exis or activities that aggravate peripheraliation should tempo:
rar be avoided.

‘+ Exercises or movements that result in a “centralization” of symptoms (Le,
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.

+ li and lower limb fexbity should be promoted, although no sreiching
intervention studies have shown elfcay in eating or preventing LBP (35)

+ His generally not recommended to use trunk flexibility asa treatment goal
in LBP (112

THE BOTTOM LINE

LBP isa complex multidimensional phenomenon, Recommendations for exer-
¿ise testing and Es R, are similar to those for healthy individuals when LBP is
‘not associated with another serious pathology (eg. cancer). I may be best 10
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 ac
vity Performance is often limited by actual or anticipated fear of reinjury and/
or pain

216 EU) >=:

| eu rem term i te |

piers NINDS Nil pan hm

ENVIRONMENTAL CONSIDERATIONS

EXERCISE IN HOT ENVIRONMENTS

Muscular contractions produce metabolic heat that is transferred from the ative
‘muscles tothe blood and then 10 the body's core. Subsequent body temperature
elevaions elit heat loss responses of increased skin blood low and increased
Sweat scretion 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 va sweating and dey
heat exchange is governed by biophysical properties dictated by surrounding
temperature, humidity and ait motion, sky and ground radiation, and clothing
(43), However, when the amount of metabolic heat execeds heat loss, hyperher-
‘mia (Le, elevated internal body temperature) may develop. Sweat that drips from
the body or clothing provides no cooling benefit I secreted sweat drips from the
body and is not evaporated, a higher sweating rate willbe needed to achieve the
evaporative cooling requirements (100). Sweat losses vary widely and depend on
he amount and intensity of physical activity and environmental conditions 46)
(Othe factors can ater sweat rates and ultimately Mid needs. For example, heat a+
climatiation results in higher and more sustained sweating aes, wheres aerobic
exercise taining has a modest et on enhancing sweating fate 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 tsk (74). Dehydration can augment core temperature eleva:
tions during exercise intemperate (83) as well as in hot environments (102). The
‘ypical reported core temperature augmentation with dehydration fs an increase
O0. 10 02° € (02° 100.4" F) with cach 1% of dehydration (99), The greater
cat storage with dehydration is associated witha proporionate decrease in heat
loss. Thus, decreased sweating rue (Le, evaporative heat loss) and decreased
cutaneous blood flow (Le, dey heat los) are responsible for greater heat storage
observed during exercise when hypohydrated (79).

Counteracting Dehydration

Dehydration (Le, 3%-5% body mass loss) Ikely does not degade muscular
strength (37) or anaerobic performance (25). Dehydration >2% of body mass
decreases aerobic exercise performance intemperate, warm, and hot environments

cuore 8 .’ ——. |

and as the level of dehydration increases, acrobi exercise performance is reduced
proportionally (61). The critical water deficit (ie, >2% body mas for most ind
‘ils and magnitude of performance decrement are key related o environmc
val temperature, excise task, and the individual unique biological characteristics
(eg. tolerance to dehydration). Acute dehydration impair endurance performance
regardless of whole body hyperthermia or environmental temperature; and endu-
rance capacity (Le, ime o exhaustion) is reduced more in a hot environment than
ina temperate or cold one.

Individuals have varying sweat rates, and as such, fluid necds for
duals performing similar tasks under idemical conditions can be diferent
Determining sweat rate (Lh orq h ') by measuring body weight before and

fer exercise provides Mud replacement guide, Active individuals should drink
test 1 pt of flu foreach pound of body weight lot. Meas can help stimulate
thirst resulting in restoration of fluid balance. Snack breaks during longer train
ing sessions can help replenish uds and be important in replacing sodium and
other eleetolytes. In a fed setting, the additive use of first morning body mass
‘measurements in combination with some measure of fst morning urine con
centration and gross thirst perception can provide a simple and inexpensive way
10 dichotomize euhydraion from gros dehydration (see Figure 82) (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: provide recommendations for hydration prior to, during, and following
exeris or physical activity 8).

1 PGURE 82. W tas fr mea” U stan for “ui” stn fo “mest” When 10 or
"rosal maras ae peon! Gran iy Na he maras present dom.
ens ey ly, Rae an permisos hom 2)

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Overdrinking hypotonic uid is the mechanism that Teads 10 exercises
associated hyponatremia, a state of lower than normal blood sodium concen
tation (play <135 mEq » L-') 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 swcat rate and by consuming sal-containing Muids
or foods when participating in exercise events tha 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 lllnosses.

Heat illnesses range from muscle cramps to ie-threatening hyperthermia and
ae described in Tale 8.5 Dehydration may be citer a direct (Le, heat cramps
and heat exhaustion) (101) or indirect (Le, heatstroke) (22) factor in heat
ines

eat 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 seat sodium are contributing factors, Het cramps respond

cuore 8 FOTOS

A Comparison of the Signs and Symptoms

(Occur in Hot Environmonts (6)

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sea vomtng, parent. sean ve)

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ello rest, prolonged stretching, dictary sodium chloride (Le, 16-14 sp of tale
salt or one toto salt tablets added to 300-500 ml. of fui, buin broth, or
salty snacks) or intravenous normal sane Nui

Heat syncope sa temporary circulatory failure cause by he pooling of blood
in he peripheral veins, particulary ofthe lower extremities. Heat syncope tends
10 occur more often among physically unfit, sedentary, and nonacelimaized
individual. is caused by standing eee for along period; ora the cessation of
strenuous, prolonged, upright exercise because maximal cutaneous vesel dia
tion results in a decline of blood pressure (BP) and insufficient oxygen delivery
10 the brain, Symptoms range from light-headedness to less of consciousness:
however, recovery s rapid once individuals sit or lay supine. Complete recovery
of stable BP and HR may take a few hours, Se the ACSM position stand on heat
illness during exereise for additional information (6).

Heat exhaustion is the most common form of serious heat illness. I occurs
during exercise/physical activity inthe heat when the body cannot sustain the level
of cardiac output (Q) needed to support skin blood flow fo thermoregulation and
Hood low for metabolic requirements of exercise. It is characterized by prominent
Fatigue and progressive weakness without severe hyperthermia, Oral uds are pre
ferred for rehydration in individuals who ate conscious, able to swallow, and not
losing uid (ie, vomiting and diarthea). Intravenous fluid administracion fail
tates recovery in those unable to ingest oral luis or who have severe dehydration.

Exenional heatstroke is caused by hyperthermia and is characterized by
clevated 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

zo EU) >=:

intensity prolonged exercise when the ambient wet-bul globe temperature
(WBGD) exceeds 28° C (82 F). It isa lfethreatening medical emergency that
requires immediate and effective whole body cooling sith cold water and ie
water immersion therapy Inadequate physical fitness, excess adios

clothing, prowective pads, incomplete heat a

tions also increase risk

Exercise Prescription.

Healyitness and clinical exercise professionals may use standards established
by the National nstitte for Occupational Safty and Health to define WBGT lev
els at which the risk of heat injury is increased, but exercise may be performed i
preventive steps are taken (81). These steps include required rest breaks between
exercise periods.

Individuals whose Ex R, specifies a target heart rate (THR) will achieve this
‘THRata lower absolute workload when exercising in a warmhot versus a cooler
environment. For example, in hot or humid weather, an individual will achieve
their THR with a reduced running speed. Reducing ones workload to maintain
the same THR in the heat will help to reduce the risk of heat illness during
acclimatization. As heat acelimaization develops, a progressively higher exercise
intensity vall be required o eii the THR. The fst exercise session inthe heat
may lst as litle as 5-10 min for safety reasons but can be increased gradually

Developing a Personalized Plan

Adult and children who are adequately rested, nourished, hydrated, and acc
mate o heat ae at less isk for exertional heat illnesses, The following factors
should be considered when developing an individuaized plan to minimize the
ect of hyperthermia and dehydration along with the questions in Box 85 (20)

+ Monitor

+ Modify activity in extreme environments: Enable acces to ample fluid pro-
vide longer andor more rest breaks to faite heat dissipation, and shorten
or delay playing times, Perform exercise at times ofthe day when conditions
willbe cooler compared to midday (early morning, Later evening). Children
and older adult should modify activities in conditions of high-ambient tem
peratures accompanied by high humidity (see Bax 86),

+ Consider heat acclimatization status, physical Funes nutrition, sleep depri-
‘ation, and age of participants; iment; timelduration, and time of day for
xeric; alla of fluids; and playing surface heat relction (Le, grass
vs. asphalt. Allow atleast 3 h, and preferably 6h, of recovery and ehydra

on time between exercise sessions.

+ Heat acclimatization: These adaptations include decrased rectal temperature,
IR, and RPE: increased exercise tolerance time; increased sweating rte; and à
reduction in swat salt Acclimatization results in the following: (a) improved

1 environment: Use the WEGT index to determine appropriate

PAPA. que sions to Evaluate Readiness t
Du CR

À Adults should ask he folowing questions to ealute renines to exercise
| in a hot envrenment Correct action should be taken if any questions
‘answered "na"

+ Have | developed a pan o avoid dehydration and hyperthermia?

+ Have | accimatzed by gradual increasing oxercso duration and intensity
foc 10-14 87

+ Do limit intense exercise to tho cooler hous ofthe day cat morning)?

+ Do | avoid lngthy warmup parods on hot. humid days?

+ When taining outdoors, do | know where Huds are asbl, or do cary
water bottes in à belt er abockpack?

+ Do | know my sweat rate and the amount lid {hat I shout ink to
replace body weight 10?

+ Vias my body weight this morning within 1% of my average body weight?

ls my 24 husine volume plant?

+ Is my une color “palo yo“ or “straw colored"?

‘Won hoot and humiday ar high, d educe my expectations, my

x00 paco, ho distance, andor duration of my workout 010007

Do | wear Iooso-ting, porous, Ighiweght doting?

Do | know the signs and symptoms of het exhaustion, exertional

À heatsuoke, heat syncope, and hast camps (see Tobe 8.47

| + Do 'xerise with a partner and provide feedback about ser physical

À appearance?

| + Dol consume adequate satin my dor?

Do | avoid or reduce oxoris in the heat if experience sleep loss,
infoctousinoss, fever, area, veming,carbopydrato depto
some medias, lechal, or drug abuse?

A ts ra So rs TT scenes
Langer prod inte she; ele ng every I m
‘Sop activity ananas ana tos ni
sigas: ent acosan ofa ter alow ong Sauce oes,
dom oar eee

‘Cone

m EU) === |

Heat transfer from the bodys core 10 the external environment (b improved

caiovascularfanction;() more elective sweating: and (d) improved exerce

erformance and heat tolerance, Seasonal aclimatizaion will ocur gradu-

ally during te sping and ealy summer months with sedentary exposure 10

the heat. However, this process an be faciiated with a structure program

of modemte 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 headgeat) as possible o permit heat loss and reduce the risks of
yperhermia especially during the initial days of acclimatization,

+ Education: The taining ol participants, personal trainer, coaches, and com:
‘munity emergency response teams enhances the eduction, recognition (See
Table 83), and treatment of heat-related ines. Such programs should em
phasize the importance of recognizing signs/symptoms of heat intolerance,
being hydrate, fed, rested, and aclimatized to heut. Educating individuals
about dehydration, assessing hydration state, and using a aid replacement
Program can help maintain hydration

Organizational Planning

Wen clients exercise in hoykumid conditions, personnel fitness lits and
organizations should formulate a standardized heat stress management plan that
‘incorporates the following considerations

‘Screening and surveillance of at-risk participants.

+ Environmental assessment (Le, WBGT index) and criteria for modifying oF
canecling exercise.

“+ Heat acclimatization procedures

© Easy access to uid and bathroom facilite.

+ Optimized but not maximized fluid intake tha (a) matches dhe volume of id
consumed 10 he volume of sweat los; and (b) limits hody weight change 10
<2% of body weight

‘+ Awareness ofthe signs and symptoms of heatstroke, heat exhaustion, heat
ramps, and heat syncope (see Tale 8.5)

lementation 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 hfe-threatening
hyperthermia. In addition, dehydration has been associated with an increased
risk or heat exhaustion and i a risk factor for heststroke, Sweat losses vary
widely among individuals and depend on exercise and environmental
conditions, Thus, lid needs willbe highly variable among individuals. The risk,

cuore 8 .’ ——. |

of dehydration and hypembhermia can be minimized by monitoring he environ
ment; modifying activities in hot, humid environments; wearing appropriate
clothing: and knowing he signs and symptoms of heat nes,

eee |
e |
| ria ot fa pt sd cea
een |
ii J

EXERCISE IN COLD ENVIRONMENTS

Individuals eserise and work in many cold weather environments (ic. low
temperature, high wind, low sola radiation, and ran/waer exposure). For the
‘most pat, cold temperatures are nota 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 interac to determine if exercising inthe cold ec addtional
physiologie strain and injury risk beyond that associated with the same exercise
(done under temperate conditions. In most case, exercise in the cold does not
increase cold injury risk. However, there are scenario (Le, immersion, rain, and
low-ambient temperature with wind) where whole body or local thermal ba
ance cannot be maintained during exerese-elated cold stress that contributes
10 hypothermia, frostbite, and diminished exercise capability and performance.
Furthermore, exercise-related cold stress may increase the risk of morbidity and
monaliy in at-risk populations such as those with CVD and asthmatic condi
ons. 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 specifi factors
that increase the isk of developing hypothermia include immersion, rain, wet
clothing, low body ft, older age (Le, =60 y), and hypoglycemia (23)

Medical Considerations: Cold Injuries

Frostbite oceurs when tissue temperatures fall lower than 0° € (32° F) (30.73)
Frostbite is most common in exposed skin (Le, nos, cars, checks, and exposed
wrists) but also occurs in the hands and feet. Contact frostbite may occur by
touching cold objects with hare skin, particularly highly conductive metal or
stone that causes rapid heat loss.

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