Exam 1

Clinical Exercise Physiology

Focus: Interplay of exercise and chronic disease

Job Duties

Analyze a patients medical records to assess risk and determine best exercise regimen

Perform fitness and stress tests

measure blood pressure, oxygen usage, heart rhythm, and other key health indicators

Develop exercise programs to improved patients health

CEP knowledge base

Anatomy

Physiology

Chemistry (orgo and biochem)

Psychology

Undergrad or grad in relevant major

Done a clinical internship

Primary work setting

Hospitals

Outpatient clinic

Physician offices

Universities

Cardiac rehab most common

Professional Organizations

CEPA (ACSM Affiliate)

Clinical Exercise Physiology Association

Scope of Practice

Varies by organization

Clinical Exercise Physiology Association (CEPA) Define CEP as "an individual who holds a master's degree in an exercise science-related field and/or is licensed or holds a clinical

exercise certification (such as ACSM-CEP)"

American College of Sports Medicine (ACSM)

American Council on Exercise (ACE)

Canadian Society for Exercise Physiology (CSEP)

CEP Licensure and Certifications

ACSM Certified CEP

Louisiana: requires a state license for the practicing CEP

Efforts toward licensure are ongoing

Professional Recognition, Reimbursement and legal issues

-Recognition of the profession as an allied health professional

-Reimbursement possibility for services rendered from CEP

-Legal considerations

Example: What potential liabilities may exercise physiologists face when their delivery of service results in harm, injury, or death attributable to alleged negligence or malpractice?

Licensure Considerations

Differences across licensure:

What are services may exercise physiologists lawfully provide given the absence or lack of licensure?

Statewide differences:

What practices performed by CEP may be prohibited as a matter of law because state statues regarding unauthorized practice of medicine?

Crossover:

What practices performed by exercise physiologists may be prohibited because they are in the scope practice of other licensed health care professionals and thus prohibited by current law?

The Future

Coalition for Registration of Exercise Professionals (CREP)

Widening the types of patients the CEP might work with

Development of state licensure across the U.S.

Continued enhancement of the body of knowledge for treating chronic disease with exercise and the role of the CEP might play in the process

What is promotion

Use of behavioral strategies in assessing and counselling individuals about their physical activity behavior characters

Behavioral strategies are intended to be used in the context of supportive social and physical environments

Participation in Regular Phsyical Activity

Human behavior such as physical activity is shaped by its surroundings.

Understand the environment in which a client lives

Understand the physical and social contexts in which a client lives

Address environmental barriers and provide insights into how to overcome these barriers

Two commonly identified determinants of physical activity participation.

Self-eficacy

-Persons confidence to exercise under a number of circumstances

-Positively associated with greater participation in physical activity

Social Support

-Consistently shown to be positively associated with greater levels of physical activity participation

Participation in Regular physical activity 2

Physical environment can also present barriers

-Lack of bicycle trails and walking paths away from vehicular traffic

-inclement weather

-Unsafe neighborhood

Lifestyle based physical activity promotion

Most prominent barrier is time

-Less focus on planned physical activity (aka exercise)

-More focus on physical activity as part of a person's daily routine

-Taking the stairs instead of the elevator

--Parking further away from the store or work

--Why is a lifestyle-based focus relevant?

Lack of time is a common barrier to regular physical activity

--Promote lifestyle changes whereby physical activity can be enjoyed throughout the day as part of one's lifestyle

Health belief Model

Perceived seriousness

- How severe is the disease if I were to contract it?

Perceived susceptibility

-How likely is it that I will contract this disease?

Perceived benefits of change

=Personal opinion of the value or usefulness of a new behavior to decrease risk of acquiring disease

Perceived barriers to change (most predictive construct of behavior change!

=Personal opinion of obstacles in the way of adopting a new behavior

Benefits have to outweigh barriers in order for change to occur

Transtheoretical (AKA stages of Changes)

Not Cyclical

1. Precontemplation

-No awerrness/intention of behavior change

2/ Contemplation

-Aware of needed behavior change, planning for change but have not committed

3. Preparation

-Begin planning to make behavior change and are committed to following through

4. Action

-Have implemented intended behavior modifications in an effort to change behavior

5. Maintenance

-Maintaining behavior change and trying to prevent termination of behavior change

6. Termination

-Failure to maintain intended behavior change

Ecological Perspective

Premise: Most effective interventions occur on multiple levels

Incorporation of intrapersonal and environmental detriments across 5 levels

1. Intrapersonal :psychological and Biological variables of the person

2. Interpersonal: Social groups

3. Institutional: organizations (health care facilities, schools, companies)

4. Community: networks within a defined are

5. Public polcy: laws at local, state and national level

Educating on the benefits of physical activity

Focus on designed outcomes

-Why was patient referred?

-What is your ExRx geared towards?

Focus on understanding

-Health benefits of physical activity

-Fitness benefits of physical activity

General Interview

Reason for referral

establish baseline

confidential

BE AS DETAILED AS POSSIBLE

Topics of interview

-Reason for referral

-Demographic information

-History of Present illness

-Current medications/Allergies

-Past medical history

-Family history

-Social history

Demographics

Age

-independent predictor of survival in almost every cardiopulmonary condition

Sex and ethnicity

-Differences in onset of disease

HPI

Record and convey information that led to referral

-Chief complaint and manifestations

-Symptoms

-Objective (medical record) vs subjective (patient

OPWRSTA

Onset

Provocation and palliation

Quality

Region and radiation

Severity

Timing

Associated signs and symptoms

Meds and Allergies

What to include for current meds

-Medication name: generic vs brand

-Dosage: be sure to indicate correct units

-Admin routs: enteral vs parental

-Time: when to take medicine

Allergies

-Name

-Reaction

Drug purpose: do not confer new functions; rather they attenuate, accentuate or replace

Desired effect vs side effect

Medical recoonciliation: Compare the medications that they say with patient records

Consideration Exercise and Drug absorption

Meds effect circulation

Shunting blood away may effect

-Liver: main organ responsible for drug metabolism

-Kidneys: main organ for drug elimination

-GI tract: drug absorption

Medical History

Past medical Problems

Focus on those that may have potential to influence ability to exercise test or train:

Musculoskeletal

-Low back pain, gout, joint issues

Neurologic

-Cerebrovascular disease, stroke, dementia

Respiratory

-Asthma, Obstructive lung disease

Family History

Restrict to first-degree relatives - Parents siblings and offspring

Identify relevant hertiable disorders

Cancers, adult diabetes, familial hypercholesterolemia, coronary heart disease after age 55 in men and 65 in women

Social history

Social

Drugs, alchohol, tobacco

Nutrition patterns and habits

Sleep habits and snoring

Leisure activities

Prior and current exercise habits

Other ideas for interview

Marital status

Transportation

Occupation

Examination General State

Abnormal findings

Patient complaints

General observation

-Does patient appear confortable or distressed

-anxious?

-Healthy or frail

-Well nourished or undernourshied

Exma: BP, HR, and RR

HR

Tachy (>100)

Brady (<40)

Unexplained SOB or labored breath

Tachypnea >20 Bradypnea <8

BP

normal (less then 120 and 80)

Elevated (120-29 and less than 80)

Stage 1 (130-139 or 80-89)

Stage 2 (140 or higher or 90 or higher)

Hypertensive crisis (>180 and/or higher than 120)

Exam Body Fatness

Height, weight, BMI

Circumferences (WHR)

Skinfolds (RIght side)

BIA (BIOelectrical Impedance analysis fat more resistance)

Underwater weighing

Bod pod

Dexa

BMI Calc

Under <18.5

Normal 18.5-24.9

Over (25-29.9

Obese 30-34.9

Obese 2 34-39.9

Obeese 3 (40)

WHR

WOmen

Excellent <0.75

Good .75-.79

Average .8-.86

At risk >0.86

Men

Excellent <0.85

Good .85-0.89

Average .90-.95

At risk >0.95

Exam Pulm

Listen to front and back chest sounds

Exam C/V

Cardiac pulse can be palpated

Pulse in wrist and feet

Skin temp/moisture

-should be warm/dry

-Coold/clammy = poor perfusion

Periph edema

-Swelling CHF

Musculoskeletal system

Gait

Normal, antalgic, hemiplegic, shuffling, weide and so on

Joints

redness, warmnth, swelling, tenderness

Low back pain, red flags:

Radiating pain or numbness present., New onset

Exam Funcitonal Fitness and Balance

Functional Fitness Tests

6 min walk

Time up and go TUG

Short physical performance battery

Balance and potential risk for falls

Berg balance scale

General Uses of GXT (graded exercise testing)

Diagnostic (identify abnormal responses)

Prognostic (identify future, given the presence of disease)

Therapeutic (identify impact of intervention)

Who needs GXT prior to exercise program?

No = low risk

- Fewer than two CV risk factors

Yes = moderate risk

-Two or more CV risk factors

Yes= high risk

- One or more signs or symptoms of CV or pulmonary or metabolic disease

-Prior history of CV or pulmonary or metabolic disease

Elements of GXT

Pretest considerations

appearance and quantification of symptoms

test termination

Resting, exercise and recovery ECG abnormalities

Assessment of functional capacity

Interpretation of findings and generation of final summary report

Pretest consideration

testing personnel

informed consent

general interview and physical examination

pretest likelihood for CHD

Pretest instructions and subject preparation for ECG

Selection of exercise protocol and modality

Testing personael

Exercise technicians

test supervision and safety

-Physician present?

Initial interpretation of test data

-who needs to review

Final interpretation of test data (physician)

Informed Consent

Reason for test (why is test being done)

Test procedures (what to expect)

Explanation of risks (what could happen)

Patient explains or verbalizes all of these back to test supervisor

General interview and exam

Must make sure no changes have occured in the clinical status

Review medical record prior to testing

Determine indications vs contraindications

Indications (aka reasons for test)

Assess symptoms to assist in the diagnosis of coronary heart disease or other medical condition

Identify a patient 's future risk or prognosis

-functional capacity

Evaluate pacemaker, heart rate, or blood pressure response to exertion

Evaluate for return-to-work guidlines and disability determination

Determine effectiveness of an intervention

Absolute Contraindications

Myocardial infarction (MI) within prior 2d or other acute cardiac event

Change in ECG suggesting MI or other acute event

Unstable angina

Symptomatic severe aortic stenosis

uncontrolled symptomatic heart failure

Acute myocarditis or pericarditis

Acute infection

Relative Contraindications

Left main coronary stenosis

Severe arterial hypertension at rest (systoolic >200 mmHg or diastolic >110mmHG)

Tachycardia at rest or marked bradycardia

Uncontrolled metabolic disease or electrolyte abnormality

Subject preparation

Pretest instruction

Clothing & shoes

-comfortable workout wear

-Appropriate shoes (no high heels, no sandals)

Continue medications? Timing of medications?

-Reason Test (diagnostic, prognostic, exercise program)

Food and Water

Substances to avoid

-ETOH

-Cigarettes

-Marijuana

-Other recreational drugs

Subject Preparation(continued)

Skin preparation for ECG

-Eliminate oils and hair

Electrode placement

-Use standard lead placement

or

-Alter site for pacer implant or ICD implant

Selection of Protocol and modality

Select Protocol

-Steady state versus ramp? Maximal versus submaximal?

-Try to match work rate increments (in estimated METs) to patient capabilities (walk a flight of stairs)

-Test duration: 8 to 12

-Use a common protocol

- Use protocol appropriate for repeat testing

Selection of Protocol and Modality

Select Mode ( treadmill, bike, arm ergometer, other)

Quantified, incremental, graded work

Athletes: specificity of testing and training

Occupational Concerns

Accommodate patient needs

-orthopedic

-Body habitus

-Gait and balance

Elements for graded Exercise Testing

Pretest considerations

Appearance and quantification of symptoms

Test termination

Resting, exercise, and recovery ECG abnormalities

Assessment of functional capacity

Interpretation of findings and generation of final summary repoort

Appearance and Quantification of Symptoms

Maintain regular Communication between staff and patient

-use thumbs up/down

Rating of perceived Exertion (RPE)

Use of handrails required

Accommodate other common languages through translation

Test Termination

Submaximal GXt

-reaches predetermined MET level

Symptom limited

-Terminated becasue of onset of symptoms

Resting, Excercise, and Recovery ECG Abnormailites

Resting Abnormalities

-Left bundle branch block

-Right bundle branch block

-Pre-excitation syndrome (premature heart contraction)

-Nonspecific ST-T wave changes with 1mm depression

Resting, Excercise, and Recovery ECG Abnormailites 2

Abnormalities during the ECG

-St-segment depression (presence of subendocardial ischemia)

-ST-segment elevation (stop test immediately)

-T-wave changes (concern when tied to ST-segment channges)

-Arrhythmia

Assessment of functional Capacity

Exercise duration

Estimated METs

VO2max

Declines by

Healthy, inactive: 5% to 10% per decade

Healthy, active: 3% to 6% per decade

Interpretation of GXT 1-3

Angina status

-Typiccal angina, atypical/noncardiac

-time to onset, test limiting, time to resolution, therapies needed to help resolve

ECG findings (ICHEMIA)

-ST segment depression for ischemia diagnosis

-Time of onset, magnitude oof change and time to resolve

ECG findings (arrythmia

-State findings

Interpretation 3-6

Functional Capacity

-Peak MET level and compare to normative data

-Reason for stopping test

HR response

-Before, during, and after exercise

BP response

Before, during, and after exercise

What if patient cannot exercise

STRESS EKG with imaging (paried with dobutamine)

-EKG plus echocardiogram (stress echo)

--allows for assessment of wall motion abnormalities

EKG with radionuclide imaging (nuclear stress test)

-Allows for assessment of distribution of blood flow

Conlusion GXT

The GXT is a useful, and often the first, diagnostic tool to assess the presence of significant CAD with or without nuclear perfusion or echocardiography imaging

Data from the test can be used not only to help diagnose the presence of CAD but alsoo to determine prognosis and help design an exercise training program

Presciption

ExRx does not require approoval of a physicician

The purpoose is to provide a valid and safe exercise guide for a patient to improve health and physical

Goal setting in ExRx

Common exercise goals include

-Improving appearance

-improving quality of life

-Managing weight

-Preparing for competition

-Improving general health

-Reducing the burden of a chronic disease or condition

Principles of ExRx

Specificity of training

-train for specific adaptations you want to see

Progressive overload

-Relationship between magnitude of stimulus or volume of exercise and benefits gained

Reversibility

-Loss of previously acquired exercise training adaptations because of inactivity

FITT principle for cardiorespiratory endurance

F= freqency

I = intensity of excercise

-VO2, heart rate, caloric, watts

T= time or duration

T= type or mode of exercise

Questions to ask

Specificity

-What are your specific goals when performing exercise?

-Do you want to exercise more

-Do you want to be able to do more ADL?

-Do you want too perform something you currently cannot? if soo what

Mode

-What types of exercise or activity do you like best and least

-Do you already have any exercise equipment at home

Frequency

-How many days/weel do you have time for exercise?

Questions to ask 2

Intensity

-Are your primary goals related to your health oor to improvement of your fitness level

-Do you have any musculoskeletal problems that would limit how hard you are able to exercise

Time

-How much time per day do you have to perform exercise?

-What is the best time of day fo ryou to exercise

-Can you get up early or take a lunch break for exercise?

Exercise training sequence

4-5 min warm up

Aerobic session and/or

resistance sesioon

Stati stretching

General Recommendations for CR endurance

Dynamic, large muscle activities

-Walking, jogging, running, swimming, cycling, rowing, dancing

Movements to mimic ADL

Gen Rec Resistance Training

Full Rom

Breathing

-Out during lifiting and in during recovery

Proper form

-Do noot arch the back

Control

-Minimize momentum

-Maintain coontrol during eccentric phase

Gen Rec Flex

Static (recommended)

Stretch of muscles surrounding a joint that is immobale

Ballistic (NOT RECCOMMENDED)

-A method of rapidly moving a muscle to stretch and relax quickly for several repetitions

Proprioceptive neuromusclar facilitation

-A muscle is isometrically contracted, relaxed and then stretched

How much EX is reccommended

ACSM rec

3-5 session

20-60 min per session

Intensity 40-89% HRR or VO2max

Moderate intensity: 40-59% HRR

Vigorous intensity: 60-89% HRR

deconditioned modified recs

At least 2 sessions a week

Minimum 10 min.session

Intensity of 40% HRR if tolerated

Exercise Prescription (what we need to know)

NO TWO clinical patients are exaclty alike

Start program that is doable and progress

At absolute minimum, prooogram should include

Cardiorespiratory

-10 mins per boout ooofo exercise

-2-3 days a week

Resistance training

-2-3 days per week

Flexibility and balance

-As often as possible