ACSM Guideline for Exercise Testing and Prescription

physical activity (definition)

Any bodily movement produced by the contraction of skeletal muscles that results in a substantial increase in caloric requirements over resting energy expenditure

exercise (definition)

A type of physical activity consisting of planned, structured, and repetitive bodily movement done to improve and/or maintain one or more components of physical fitness

physical fitness (definition)

ability to carry out daily tasks with vigor and alertness, without undue fatigue, and with ample energy to enjoy leisure-time pursuits and meet unforeseen emergencies

Light, moderate, and vigorous activity (defined in METs)

Light: 2.0-2.9 METs

Moderate: 3.0-5.9 METs

Vigorous: >6.0 METs

(see examples on pg. 3)

health-related physical fitness components (5)

Cardiorespiratory endurance

body composition

muscular strength

muscular endurance

flexibility

Skill-Related Physical Fitness Components (6)

agility

coordination

balance

power

reaction time

speed

ACSM-AHA general guidelines for U.S. adult PA

-30 minutes of moderate PA per day on every day of the week (minimum of 5 days/week; 150min/week; additional benefits at 300min/week) OR vigorous activity for 20 minutes (minimum of 3 days/week; 75min/week; additional benefits at 150min/week) OR combo

-muscular strength/endurance training involving all major muscle groups for a minimum of 2 days per week with 48 hours in between each bout

% of global physically inactive adults

31.1%

muscular fitness enhancement benefits

-body composition

-blood glucose levels

-insulin sensitivity

-blood pressure (in hypertensive; more effective than aerobic training)

-reduce pain and disability in osteoporosis

-reduce pain in LBP

-mental health

-treatment of T2DM

-blood lipid profiles (in overweight/obese)

benefits of regular PA/exercise

Many lol (see pg. 9; Box 1.4)

most common anatomical sites for musculoskeletal injury

lower extremities, specifically knees, foot, ankle

highest risk for cardiovascular events (disease)

coronary artery disease

exercise testing is poor predictor of acute cardiac events in a symptomatic individuals

random fact

goals of preparticipation health screening

-identify individuals who should receive medical clearance before initiating exercise program or increasing frequency/intensity/volume

-identify individuals with diseases who could benefit from exercise program

-identify individuals with medical conditions that may require exclusion from exercise programs until they are better controlled

major signs and symptoms of cardiovascular, metabolic, and renal diseases (9)

-pain/discomfort in chest (angina), neck, jaw, arms [myocardial ischemia]

-dyspnea (difficulty breathing, shortness of breath) at rest or mild exertion [cardiopulmonary disorders: left ventricular dysfunction, COPD]

-dizziness or syncope (loss of consciousness due to drop in BP) [reduction in venous return to heart]

-orthopnea (lack of breathing when supine) or paroxysmal nocturnal dyspnea (lack of breathing) [left ventricular dysfunction]

-ankle edema (most evident at night) [unilateral: venous thrombosis, lymphatic blockage] [bilateral: heart failure, venous insufficiency]

-palpitation (unpleasant awareness of forceful/rapid beating of heart) or tachycardia (HB >100/min) [anxiety states and high cardiac output states]

-intermittent claudication (pain in lower extremities with inadequate blood supply {atherosclerosis} brought by exercise) [CAD, diabetes]

-heart murmur [valvular or other CVD]

-unusual fatigue or shortness of breath with usual activities

difference between PAR-Q and PAR-Q+

PAR-Q+ developed to reduce barriers for exercise and false positive screenings. Used for self-guided exercise participation or supplemental tool for health professionals

ACSM preparticipation screening algorithm

-Classify as current exerciser or not; classify identifying known CV, metabolic, renal diseases or signs and symptoms (for this, hypertension is CVD risk factor, not disease); identifying desired exercise intensity

(See on pg. 33-34; figure 2.2)

-results in one of six categories to view if medical clearance is needed [risk stratification] (see on pg. 37-39)

Risk stratification for patients with CVD (low, moderate, high)

(pg. 40-41, box 2.2)

preexercise evaluation components (4)

medical history

risk factor assessment

physical exam

laboratory tests

informed consent for an exercise test components (8)

-purpose and explanation of test

-attendant risks and discomforts

-responsibilities of participant

-benefits to be expected

-inquiries

-use of medical records

-freedom of consent

-signature

(pg. 46)

medical history components

-medical diagnoses and history of procedures

-previous physical exam results

-laboratory findings

-history of symptoms

-recent illness, hospitalization, etc.

-orthopedic problems

-medication use and drug allergies

-other habits (caffeine, drug, alcohol, tobacco)

-exercise history

-work history (emphasis on physical demands)

-family history of cardiac, pulmonary, metabolic disease, stroke, or sudden death

CVD risk factors

-Age (males>45, females>55)

-Family history (health issues in father <55 or mother <65)

-cigarette smoking (current smoker or quite within previous 6 months or exposure)

-physical inactivity (<30mon of moderate intensity PA for 3 days/week for past 3months)

-obesity (BMI >30, waist girth of 40in in males, 35 in for females)

-hypertension (SBP >140mmHg or DBP >90mmHg or on antihypertensive med)

-dyslipidemia (LDL >130mg/dL or HDL <40mg/dL or on lipid lowering med or total serum cholesterol >200mg/dL)

-diabetes (fasting plasma glucose >126 mg/dL or HbA1C >6.5%)

------------------------------------------------

HDL (>60mg/dL)

preparticipation physical exam components

-body weight

-apical (apex of heart) pulse rate/rhythm

-Resting BP

-auscultation of lungs

-palpation of cardiac apical impulse

-palpation and auscultation of carotid, abdominal, and femoral arteries

-evaluation of abdomen for bowel sounds, tenderness, etc.

-palpation and inspection of lower extremity edema

-follow-up exam for concerns

-neurological testing (reflexes, cognition)

-inspection of skin (particularly of lower extremities of DM patients)

recommended laboratory tests for all individuals, and individuals with signs/symptoms of CVD

All:

-fasting serum total cholesterol, LDL, HDL, triglycerides, fasting plasma glucose

CVD:

-carotid ultrasound, chest radiograph, blood chemistry/blood count

data used to develop risk calculator was derived from cohorts of non-hispanic whites and african americans in the US. Suggests limitations to other populations.

random fact

blood pressure assessment

-average of two or more readings, measured in both arms with highest pressure used

-sit quietly for 5+ min with feet on floor, refrain from smoking/caffeine for 30 mins

-bladder within cuff should encircle at least 80% of upper arm

-stethoscope chest piece placed below anticubital space over brachial artery. (both Bell and diaphragm side work)

-inflate cuff pressure to 20mmHg higher than first Korotkoff sound

-release pressure 2-3mmHg/second

-1 minute in between readings

classification of BP (normal, prehypertension, stage 1 hyper tension, stage 2 hypertension)

normal: <120 and <80

prehypertension: 120-139 or 80-89

Stage 1: 140-159 or 90-99

Stage 2: >160 or >100

optimal levels of total cholesterol, LDL, HDL, triglycerides (in mg/dL)

total: <100

LDL: <200

HDL: >60

Triglycerides: <150

abnormal spirometry results can indicate increased risk for (3)

lunge cancer, heart attack, stroke

comprehensive health fitness evaluation components (7)

-informed consent

-preexercise evaluation (ex. PAR-Q+)

-resting measurements (HR, BP, height, weight, BMI)

-CRF measurements

-muscular fitness measurements

-flexibility measurements

Measuring HR

-rest for 5 mins

-30 or 60 seconds for BPM using pulse palpation (radial artery), stethoscope (left of sternum just about nipple), or HR monitor

% of US adults that are overweight or obese

68.5% (~two-thirds)

% of US children/adolescents that are overweight or obese

31.8% (~one-third)

BMI (Quetelet index) formula

(Bodyweight [in Kg])/(height [in m]^2)

BMI categories

Underweight = <18.5

Normal weight = 18.5-24.9

Overweight = 25-29.9

Obesity = BMI of 30 or greater

BMI standard of error to predict body fat %

+-5% fat (large error)

android obesity [compared to gynoid] linked to increased risk of

hypertension

metabolic syndrome

T2DM

dyslipidemia

CVD

premature death

increased visceral fat (thoracic/abdominal cavity) [compared to subcutaneous] linked to increased risk of

metabolic syndrome

Circumference measurements standard of error for predicting body fat %

2.5%-4.0%

circumference measuring guidelines

-use Gulick tape measure

-go through each measurement then repeat

-average of the two used (if within 5mm)

[derived from caucasian subjects]

(see the sites on pg. 72, box 4.1)

Risk Criteria for Waist Circumference in Adults

Very low: men <31.5in, women <27.5in

Low: men 80-89in, women 70-89in

High: men 100-120in, women 90-110in

Very high: men >120in, women >110in

skinfold measurement % of error to predict body fat %

3.5%

skinfold measurement procedure

-made on right side of body, standing

-caliper 1 cm away from thumb and finger

-read caliper after 1-2 sec

-duplicate measure at each site and retest if not within 1-2mm

-allow skin to regain normal texture and thickness between measurements

(see sites on pg.75, box 4.2)

Densitometry and formula

measurement of whole body density using ratio of body mass to body volume

ex. hydrodensitometry (fat floats, bones and muscle sink. body mass-FFM=)

ex. plethysmography (air displacement in closed air chamber)

[(4.95/Db)-4.50]*100

body fat percentage for optimal health

men: 10%-22%

women: 20%-32%

cardiorespiratory fitness (definition)

ability to perform large muscle, dynamic, moderate-to-vigorous intensity exercise for prolonged periods of time

criterion measure of CRF

VO2max (product of maximal cardiac output and arterial-venous oxygen difference; related to functional capacity of heart)

-VO2peak used when plateau of VO2 doesnt occur and is used to describe CRF in special populations

VO2 max measured using

open circuit spirometry (measures expired fractions of oxygen and CO2)

HR can estimate VO2max in submaximal test if:

-steady state HR obtained for each work rate

-linear relationship between HR and work rate

-difference between actual and predicted max HR is minimal

-subject not on any HR-altering medications

-subject not using caffeine, ill or high temperature that could alter HR response

the minimum measurements taken throughout the exercise test (3)

HR (10 or 15 sec readings when palpating), BP, and RPE

types of RPE scales (2)

-Borg (category) scale: 6 to 20

-category-ratio scale: 1-10

modes of exercise testing (4)

-field tests: walking or running predetermined time or distance. Advantages are easy to administer, little equipment needed. Disadvantages are it can be near-maximal for some, which can lead to heightened risk.

-motor-driven treadmills: (primary in U.S.) submaximal or maximal testing. Advantages are it is familiar form of exercise, and can accommodate every individuals by altering speed. Disadvantages are expense of treadmill unit, not easily transportable, make some measurements difficult, and need to be calibrated periodically.

-mechanically braked cycle ergometers: (primary in Europe) submaximal or maximal. Advantages are lower equipment expense, transportability, non-weight bearing, and more ease of measurements. Disadvantage is that it is less familiar form of exercise leading to local muscle fatigue and underestimation of VO2max.

-Step testing: stepping at a fixed rate and/or fixed step height or by measuring postexercise recovery HR. Advantages are little to no equipment, inexpensive, short duration testing, useful for mass testing. Disadvantages are tough for low balance individuals and requires 7-9 METs, low compliance to step rhythm or time can lead to error.

field test examples (4)

-Cooper 12 minute test: cover greatest distance in allotted time period

-1.5 mile test: cover distance in shortest period of time

-Rockport one-mile fitness test: walk 1 mile as fast as possible and HR obtained in final minute or 10 seconds after completion

-6 minute walk test (MOST COMMON)

(see formulas for VO2max on pg.86)

Cycle ergometer tests examples (2)

-Astrand-Ryhming cycle ergometer test: single-stage, 6 minutes, pedal rate at 50 rpm, with goal to obtain HR values between 125 and 170bpm when measured during 5th and 6th minute of work. Average of the two used to predict VO2max.

-YMCA protocol: two to four 3-min stages, pedal rate of 50rpm. Stage one to pedal against .5kg of resistance, stage two is based on steady-state HR during last minute of stage one, as well as for stages three and four

Treadmill tests examples (5)

-ramp

-modified bruce 3 min stages

-bruce 3 min stages (most widely used in U.S.)

-naughton 2 min stages

-modified naughton (CHF) 2 min stages

(see pg. 121 for details)

step tests examples (

-Astrand-Ryhming step test: single step (men 40cm, women 33cm) at 22.5steps/min (lead leg) for 5 mins

-3 min YMCA step test: 12inch bench with 24steps/min, immediately after completion HR is counted for 1 minute

-multiple stage step tests

(Recovery HR measured to limit error when stepping)

(See formulas on pg.92)

VO2max classifications by age and sex

see table on pg. 93

muscular strength and endurance benefits

-bone mass

-muscle mass

-glucose intolerance

-musculotendinous integrity

-ADLs, self efficacy and QoL

-FFM and RMR

muscular strength (definition)

muscle's ability to exert maximal force on one occasion (measured in >4 reps)

muscular endurance (definition)

muscle's ability to continue to perform successive exertions or reps against a submaximal load (measured in >11 reps)

muscular power (definition)

muscle's ability to exert force per unit of time (i.e. rate)

warmup for muscle function tests guidelines

5-10 minute light intensity aerobic exercise, dynamic stretching, and several light intensity reps of the testing exercise

(increases muscular temp and localized blood flow)

muscle function test conditions

-aerobic warm up (5-10 min, light intensity)

-equipment familiarization

-strict posture

-consistent rep duration (movement speed)

-Full ROM

-Use of spotters (when necessary)

hand dynamometer procedure

-hanging at level of thigh, squeeze (dont hold breath), repeat twice each hand, score is the highest reading on each side for each hand added together

upper body strength tests (2)

bench press

shoulder press

lower body strength tests (2)

leg press

leg extension

1-RM and multiple rep max testing procedure for muscular strength

-movement familiarization

-warm up by completing # of submaximal reps

-determine within 4 trials with rest periods of 3-5min

-select initial weight ~50-70% capacity

-resistance increased by 5-10% for upper body and 10-20% for lower body

-record final weight lifted successfully

muscular endurance test examples

-push up (start in down position, women do knee push-up, chin touches mat [stomach should not] with back straight, come up to straight arm position. Test stopped when two consecutive reps are strict form (categories on table 4.11 on pg. 102)

-CURL UP TEST HAS NOT INCLUDED ANYMORE (not sensitive enough to grade performance and can cause LBP)

flexibility (definition)

ability to move a joint through its complete ROM

(factors include distensibility of joint capsule, warm-up, and muscle viscosity)

visual estimates of ROM (6)

neck

trunk

hip

lower extremity

shoulder

postural assessment

ROM of select single joint movements in degrees

see table 4.12 on pg. 103

sit-and-reach test procedure

measures hamstring flexibility more so than LB flexibility

-zero mark at 26 cm

-edges of soles 6in apart

-hold for 2seconds

(see classifications on table 4.13 on pg. 105)

clinical exercise test (purpose)

to observe physiological responses to increasing or sustained metabolic demand

(also called graded exercise test [GXT] or exercise tolerance test [ETT], continues until a sign or symptom linked-maximal level of exertion

(called a cardiopulmonary exercise test [CPX] when analysis of expired gases is a part)

most common diagnostic indication is the assessment of symptoms suggestive of _______

ischemic heart disease

clinical exercise testing categories (3)

diagnosis

prognosis

physiological response to exercise

administers of exercise testing

transitioned from physicians to nonphysican allied health professionals (ex. clinical exercise physiologist, nurse, physical therapist, PA) in order to limit staffing costs and improve utilization of physician's time

experience needed to administer exercise testing

perform at least 50 with supervision, but 200 is also recommended. Maintenance of competency is recommended between 25 and 50 per year

(other skills listed in box 5.3, on pg. 119)

variables monitored during clinical exercise testing (

-HR

-ECG (regularly through test and 6 min after test)

-cardiac rhythm

-BP

-RPE

-clinical signs and symptoms of Myocardial ischemia, inadequate blood perfusion, inadequate gas diffusion, and limitations in pulmonary ventilation

most accurate measure of exercise capacity and useful index of overall cardiopulmonary health

VO2 (direct measurement)

pulse oximetry

-provides noninvasive, indirect measure of arterial oxygen saturation (SpO2). Can be used on fingertip, earlobe, or forehead

-Oxygen desaturation may be cause of exertional dyspnea

-decrease in >5% during exercise is an abnormal response suggestive of exercise-induced hypoxia

-SpO2 <80% with signs and symptoms of hypoxia is indication to stop test

indications for terminating a symptom-limited maximal exercise test

see box 5.4 on pg. 125

cooldown

-continuation of low-intensiy active recovery during postexercise

-without can led to excessive drop in venous return resulting in profound hypotension during recovery and ischemia secondary to decreased perfusion pressure into myocardium.

rate of serious complications (morbidity/mortality) occur in exercise tests ______tests out of 10,000 tests

34 events every 10,000 tests

normal HR response with increased workloads

rate of ~10 bpm per 1 MET (HRmax decreases with age and is attenuated in patuents on Beta-adrengenic blockers)

failure of HR to decrease by atleast 12 beats in the first minute or 22 beats for the second minute of active postexercise recovery

=increased morbidity/mortality in patients with ischemic heart disease (inability of parasympathetic NS to assert vagal control of HR, predisposing to ventricular dysrhythmias)

normal SBP response to exercise

rate of ~10mmHg per 1 MET (greater among men, increases with age, attenuated in patients on vasodilators, calcium channel blockers, angiotensin-converting enzyme inhibitors, and alpha and beta-adrenagic blockers)

SBP of >250mmHg is indication to stop test, and >210 in men and >190 in women is exaggerated response

fun fact and is predictive of future resting hypertension.

blunted response=limited ability to augment cardiac output

no change or slight decrease in DBP when exercise testing, abnormal response:

abnormal response >90mmHg or increase in >10mmHg. >115mmHg=stop test

rate-pressure product (double product) formula

HR*SBP

RPP is surrogate for myocardial oxygen uptake

normal range= 25,000-40,000mmHg*beats/min

criteria to confirm maximal effort elicited during clinical exercise test (5)

-plateau of VO2 with increased workload

-failure of HR to increase with increased workload

-Postexercise venous lactate concentration of >8mmol/L

-RPE at peak exercise of >17 (Borg) or >7

-Peak RER >1.10 (most accurate and objective noninvasive indicator of subject effort)

sensitivity (definition in regards to clinical exercise testing)

-ability to positively identify patents who truly have ischemic heart disease

-test's sensitivity is decreased by inadequate myocardial stress, medications that attenuate cardiac demand or reduce myocardial ischemia, and insufficient ECG lead monitoring

-(see confusing explanation in box 5.8 on pg. 136)

specificity (definition in regards to clinical exercise testing)

ability to correctly identify patients who do not have ischemic heart disease (see confusing explanation in box 5.8 on pg. 136)

most widely accepted and used for its prognosis scores

Duke Treadmill Score or related Duke Treadmill Nomogram (which considers magnitude of ST-segment depression, and presence and severity of angina pectoris; related to annual and 5-yr survival rates and allows categorization into low, moderate, and high risk subgroups)

echocardiography (definition)

allows evaluation of wall motion, wall thickness, and valve function of heart

What does FIIT-VP principle stand for?

Frequency (how often)

Intensity (how hard)

Time (duration or how long)

Type (mode or what kind)

Volume (amount)

Progression (advancement)

Exercise program training (4)

aerobic training

resistance training

flexibility training

neuromotor exercise training

Exercise training components

-Warm-Up: 5-10min of light-to-moderate intensity cardiorespiratory and muscular endurance

-Conditioning: 20-60min of aerobic, resistance, neuromotor, and/or sports activities

-Cool-down: 5-10min of light-to-moderate intensity cardiorespiratory and muscular endurance

-Stretching: 10min

estimation of intensity of exercise

HRmax%, VO2max%, RPE, METs values listed on Tale 6.1 on pg. 146

formula for predicted HRmax

220-age=HRmax

absolute (don't take consideration to body weight, sex, fitness level) measures of exercise intensity include... (3)

-caloric expenditure (kcal/min)

-absolute oxygen uptake (mL/min or L/min)

-METs