Advanced Aerobic Exercise

Cardiorespiratory Fitness (CRF)

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

Function/physical fitness

result of muscular strength and endurance, flexibility, ROM and cardiopulmonary endurance required to attend to personal, household and daily living needs

CRF is a health-related component of physical fitness (strong predictor of mortality)

Function/physical fitness i inversely correlated to functional decline

Why does Aerobic Capacity matter?

training specifics for Aerobic capacity

Submaximal, rhythmic, dynamic, systematic, planned movement of large muscle groups

purpose: to improve cardiovascular and pulmonary systems function at rest, during exertion, and during muscle metabolism

Patient population

Anyone with heart, lungs, and muscles that need that O2 to function

CHF

• dyspnea, fatigue, and peripheral edema

• decreased exercise tolerance due to dyspnea, fatigue or both

• fluid retention in the LE, abdomen or both

Deconditioning/bedrest

• decreased mm mass and strength

• decreased cardiovascular function, blood, plasma, and heart volume

• decreased orthostatic tolerance and exercise tolerance

• decreased bone mineral density

Cardiovascular Specific Physiologic changes

At rest: decreased RHR and BP, increased blood volume Hgb

During exercise: Increased SV, oxygen extraction by mm, increased VO2 max, decreased myocardial oxygen consumption for any given exercise intensity

Respiratory Specific Physiologic changes

At rest: increased lung volume and diffusion capacities

During exercise: decreased air ventilated at the same O2 consumption rate, increased maximal minute ventilation and ventilatory efficiency

Metabolic Specific Physiologic changes

at rest: increased capillary density and mm size, increased mitochondrial number and size myoglobin concentration

During exercise: glycogen sparing, decreased blood lactate levels, decreased reliance on PC and ATP (more oxidation)

Aerobic Exercise: FITT Principle

Frequency, Intensity, Time, type

FITT: Frequency

3-5 days per week

FITT: intensity

moderate (40-59% HR reserve)

Vigorous (60-89% HR reserve)

FITT: Time

Moderate (>/= 150 per week, 30-60 minutes per day)

Vigorous (>/=75 minutes per week, 20-60 minutes per day)

2:1 combination (moderate: vigorous)

Bouts of <10 minutes associated with favorable health outcomes for the deconditioned population

FITT: Type

Continuous training

Intermittent training (targeting major muscle groups)

Interval training (high intensity <> intermittent recovery)

Circuit or circuit interval training

Aerobic Intensity: monitoring

Vitals (HR, BP, O2 Sat., % of HR Reserve, VO2Max, HR Max, normal vs abnormal response to exercise)

Other objective measures (Modified Rate of Perceived Exertion (mRPE), Modified Borg Dyspnea Scale, the Talk Test and the Counting Talk Test)

Moderate intensity

40-59% of HRR

62-76% of HRMax

46-63% VO2Max

Fairly light to somewhat hard on mRPE Scale

Vigorous intensity

60-89% of HRR

77-95% of HRMax

64-90% VO2Max

Somewhat hard to very hard on mRPE scale

Modified Rate of Perceived Exertion (mRPE)

widely used and reliable indicator to monitor and guide exercise intensity through subjective rating of exertion

• original Borg scale (6-20 scale) relates to HR

• Modified RPE scale (0-10 scale)

• no current research indicated one v. the other

moderate Target Range: 3-4 “somewhat hard”

Modified Borg Dyspnea Scale

scale that asks you to rate the difficulty of your breathing

0 = where your breathing is causing you no difficulty at all

10 = where your breathing difficulty is maximal

Moderate Target Range: 3-4 “somewhat hard”

mRPE numbers

0 - Rest

1- Really Easy

2 - Easy

3 - Moderate

4 - Sort of hard

5 - hard

7 - really hard

9 - really, really, hard

10 - maximal, just lime my hardest race

The Counting Talk Test

(CTTactivty/CTTrest) x 100% = %CTT

CTTrest

CTTactivity

%CCT

The CCT is a simple method for recommending aerobic exercise intensities that are adequate to achieve the current ACSM recommendations for moderate to vigorous physical activity intensity without stopping exercise

CTTrest

how high as you can count after a maximal breath at usual talking pace before needing another breath at rest

CTTactivity

how high as you can count after a maximal breath at usual talking pace before needing another breath during activity

%CTT

corresponds to moderate to vigorous exercise, with concurrent validity to heart rate reserve (HRR) and RPE

Maximal vs submaximal testing

serve as a basis for ex. prescription

PT can perform max. ex test, however results may be limited by pt’s overall functional status due to multi-system impairments (may only reach VO2 peak, not max)

Submaximal test can predict VO2max to assess functional limitation or assess outcomes of interventions

Submaximal tests can be performative measurements of everyday tasks — self-paced walking test, TUG, 6 MWT

The Astrand-Rhyming Nomagram 16

nomograms assist with gender predictions of aerobic capacity (absolute VO2max) during submaximal work (adjusted by age)

Progresion and regression: “start low and go slow”

low to moderate intensity recommended for currently inactive individuals

reduces cardiovascular event and injury risk

increases likelihood of pt adherence

Progression and Regression: gradually increase time —> frequency—> intensity

increases 5-10 minutes every 1-2 weeks

Progression and Regression: Reversibility Principle

only 2 weeks of detraining causes significant reductions in work capacity

Specific considerations: Pediatrics

“screen time” related to decreased levels of fitness and other comorbidities (limit to 2 hrs a day)

Specific considerations: LBP

fear-avoidance behavior can decrease cardiorespiratory fitness, so early walking program can gradually improve overall physical activity while improving attitude and pain threshold; downhill walking may exacerbate LBP so treadmill or cycling with lumbar spine flexed can help

Specific considerations: Older adults

consider comorbidities and balance deficits; may benefit from seated cycling or acquatics, treadmill handrail support, combine with cognitive and physical tasks! age-predicted HR max equation is unreliable

Specific considerations: Osteoporosis

choose weightbearing modes

Specific considerations: Pregnancy

“talk test” intensity (can talk but not sing) mRPE 5-6/10, 20-30 minutes most days of the week, avoid heat stress

Specific considerations: Heart failure

exercise regimens should always include aerobic exercise to increase level of work tolerated at decrease HR with decreased perceived effort, dyspnea, and fatigue (“talk test” if A-fib)

Specific considerations: Peripheral Artery Disease

walking should be main modality (specificity)

• intermittent claudication = mismatched oxygen supply and demand

• work to moderate pain (3 out of 4 on claudication pain scale)

• or 50-80% maximum walking speed with seated rests

• Resume only when pain is completely alleviated

Specific considerations: CVA

consider individual functional abilities (decreased function capacity is common), and mobility and address with salient tasks to improve motivation

Specific considerations: COPD

can achieve significant improvement in aerobic conditioning with lower intensity training, dyspnea (SOB with exertion), monitor O2 saturation

Specific considerations: Diabetes

cardiorespiratory fitness = strongest independent predictor of mortality in those with T2DM

research: Resistance exercise decreases HbA1C vs Aerobic exercise increases cardiorespiratory fitness

Resistance exercise performed before aerobic training may decrease postexercise hypoglycemia

Specific considerations: Fibromyalgia

start low and go slow, low impact, aquatic benefits

Specific considerations: HTN

chronic aerobic exercise decreases SBP at sub-maximal workloads, decrease left ventricular pathological hypertrophy, maintain moderate intensity

Specific considerations: MS

avoid overheating, cycling is safer than treadmill for those with balance and coordination deficits

Specific considerations: Alzheimer’s Disease

increase cardiorespiratory fitness is related to less brain atrophy in early disease process, consider leisure activities, known patterns, safe setting with caregiver buy-in

Specific considerations: Parkinson’s disease

consider balance, abnormal BP responses, Rocky Steady Boxing, dancing, salience

Effect of high intensity interval training on diabetic obese women with polyneuropathy: a randomized controlled clinical trial

Conclusion: HIIT is more effective at pain reduction and glucose tolerance in diabetic obese women compared to traditional moderate aerobic intensity training

Medication considerations: Supplemental O2

improves oxygen delivery, monitor oxygen saturation

Medication considerations: Beta blockers

blunt HR response to exercise

use RPE or mRPE

Medication considerations: Antihypertensives

may lead to sudden excessive reductions in post-exercise BP —> gradually terminate exercise with cool-down and monitoring

Medication considerations: Diuretics

increased risk of electrolyte imbalance, weakness, fatigue, OH

Medication considerations: Vasodilators

traget tissue vasculature, risk of postural hypotension and weakness

Medication considerations: Sodium and calcium channel blocker

treats arrhythmias, risk dizziness

Medication considerations: nitrates

reduces cardiac preload and afterload — risk of headache, dizziness, OH

Medication considerations: Statins

risk of liver problems, myalgia, paresthesias, myositis, fatigue, and weakness

Documenting Skilled Care

Vitals and intensity mgmt: Angina, HR, RR, Rests required, recovery time, mRPE, O2...

Address musculoskeletal or neuromuscular factors ("_ cues required to _")

Functional Outcome Measures and GOAL SETTING

• Example: "Improve aerobic capacity as evidenced by [FOM score] to meet age and gender matched norms in order to resume [insert functional activity the patient wants to get back to here] in _ days"

Patient Education and GOAL SETTING

• Vitals management

• Breathing recovery

• Pacing / Energy conservation techniques

• Self-monitoring (Modified RPE, HR, counting talk test)