KIN 492 Exam 1

clinical exercise physiology

application of the principles of exercise physiology to individuals afflicted with chronic diseases

- a subspecialty of exercise physiology, which also includes applied exercise physiology

- how exercise influences the disease process

what is clinical exercise physiology

-US department of labor

- clinical exercise physiology association

- american college of sports medicine

- american council on exercise

- canadian society of exercise physiology

initial notions

600 BCE - Susruta

- daily exercise, 50% max 500 BCE

- phythagoras: daily exercise

- herodicus: father of sports med

- hippocrates: hippocratic oath

william heberden

-1700s

- angina pectoris

- sawing wood everyday

harvard fatigue lab

1st exercise physiology lab (1920s)

- D.B Dill, PhD

- Sid Robinson: vo2 max in aging; peak in young adulthood, reduces 0.5 ml/kg/min/year; vo2 max strong predictor of health

Kenneth H. Cooper

"father of aerobics"

- emphasis on cardiovascular system

- 12 minutes walk/run test for vo2 max estimates

- basis for 10,000 steps per day

diseases and conditions related to a lack of exercise

60% of American adults are not regularly active and 25% of adults are not active at all

2007 exercise is medicine

mission: to make the scientifically proven benefits of PA the standard in the US health system and worldwide

- lead to policy changes supporting PA

- incorporate exercise physiology subject matter into med school

- assess patient PA at every clinical visit

- counsel patients on meeting PA recommendations with individual prescription

future directions and goals might include

enhanced acceptance of the CEP as an allied health professional, licensure

- widening the types of patients CEP's work with

- continued development of professional organizations for the CEPs

- continued enhancement of the body of knowledge for treating chronic diseases with exercise

physical activity

an bodily movement in produced by skeletal muscles that results in caloric expenditure

- uses energy, and energy utilization enhances weight loss or weight maintenance

- important in the prevention and management of obesity, CHD, and diabetes mellitus

PA recommendations

150 min/week moderate intensity aerobic

OR> 75 min/week vigorous aerobic

AND 2 days/week resistance exercise

light PA

< 3 METs

moderate PA

3-6 METs

vigorous PA

6 METs

what to focus on understanding about PA

-health benefits of PA (addresses PA minimum)

- fitness benefits of PA

health benefits of PA

-reduction in premature mortality

- reduction in CVD risk

- reduction in colon cancer

- reduction in T2DM

- improved mental health

fitness benefits of PA

-cardiorespiratory fitness

- muscle strength and endurance

- muskuloskeletal flexibility

- improved body composition

cardiorespiratory fitness

-ability to perform PA without undue stress/fatigue

- ability of the cardiovascular and pulmonary systems to efficiently transport blood, oxygen to muscles

- enables ADLs with less effort

- more activity generally better

muscular endurance

-ability of skeletal muscle to perform work that is hard or prolonged, respectively

- improves ability to perform ADLs

- very low prevalence in adults (20% meet 2x/week)

muskuloskeletal flexibility

-range of motion in a joint or series of joints

- reduces chance of injury/disability

excess body weight

balance cals in cals out

three primary levels of PA program implementation

-program based, supervised exercise

- exercise counseling, prescription, self monitored

- community based programs

what are some commonly identified determinants PA participation

-self-efficacy

- social support

- PA and environmental factors

Self-efficacy

how well you can perform a task

social support

family, friends, exercise groups, etc

physical and environmental factors

access to resources, safety, etc

environmental factors affect PA behavior

-encouragement: family/friends, community programs, and exercise professional

- barriers: access to resources, inclement weather, unsafe neighborhood, and fitness to participate

classical approach of PA

assess

- prescribe

- counseling

- follow up

- massive attrition due to drop out

cognitive behavioral therapy

-focuses on modifying negative or dysfunctional thoughts to improve adherence to PA

- method for behavior change

health belief model

individual level

- perceived susceptibility

- perceived severity

- perceived benefits

- perceived barriers

- cues to action

- self-efficacy

relapse prevention

individual level

- skills training

- cognitive reframing

- lifestyle rebalancing

theory of planned behavior

individual level

- attitude toward behavior

- outcome expectations

- value of outcome expectations

- subjective norm

- beliefs of others

- motive to comply with others

- perceived behavioral control

social cognitve theory

interpersonal level

- reciprocol determinism

- behavioral capability

- self-efficacy

- outcome expectations

- observational learning

- reinforcement

social support model

interpersonal level

- instrumental support

- informational support

- emotional support

- appraisal support

ecological persepctive

environmental

- intrapersonal

- interpersonal

- institutional

- community

- public policy

transtheoretical model

individual level

- precontemplation

- preparation

- action

- maintenance

lifestyle-based PA promotion

-focuses on home or community-based participation in many forms of activity that include much of a person's daily routine

- lack of time is a common barrier to regular PA

- lifestyle changes including PA incorporated everyday behavior

PACE model

PATIENT-centered ASSESSMENT and COUNSELING for EXERCISE and nutrition

- physicans deliver intervention 3-5 minutes counseling

- patients in PACE group got booster phone calls

- concept relies on the "stages of change" model

- initially used specifically for PA, incorporated nutrition later

- basis for the exercise is medicine solution

implementing behavioral determinants

human behavior such as PA 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 envirionemental barriers and provided insights into how to overcome these barriers

general principles about drugs

-drugs do not confer new functions on organs and tissues; rather they attentuate, accentuate, or replace a response

- multiple effects; desired effect vs unwanted or side effect

Pharmacokinetic

what the body does to the drug; how it is absorbed, distributed, metabolized, and excreted

Bioavailabilty

influenced by route of administration (IV/enteral)

half life

time it takes for one half of the drug concentration to be eliminated from the body

Pharmacodynamic

what the drug does to the body

- primary (planned) vs secondary effect (unwanted or side)

dose-response relationship

relationship between amount of drug and body's response

- maximal response or maximal efficacy is the dose beyond which no further increase yields any further drug response

effective dose

dose that is therapeutically effective in 50% of subjects

lethal dose

dose that is lethal in 50% of subjects

- sometimes toxic dose as in human trials

therapeutic index

a measurement of the relative safety of a drug LD/ED

vitamin C

ED: 1

TD: 20

TI = 20/1 = 20

Coumadin

Ed: 1

TD: 4

TI = 4/1 = 4

mechanisms of action

specific interaction through which a drug elicits a pharmacological effect

characteristics of actions taken by patients can change an agent's physiologic response

-age

- body mass

- gender

- genetics

- conexisting disease

- ambient environment

- EXERCISE

- time of day

- food present in GI tract

Compliance

the extent to which a patient acts in accordance with the prescribed interval and dose of a regimen (adherence)

- missing doses, doubling doses, taking wrong meds

Persistence

the act of continuing a course of treatment for the prescribed duration

- stopping doses, loss of symptoms, unpleasant side effects

graded exercise test

gold standard measurement of cardiorespiratory fitness; based on product of 2 factors:

- cardiac output (amount of blood pumped/min)

- a-vo2 difference (amount of oxygen extracted from the blood)

- fick eq: vo2 (ml/kg/min) = Q (l/min) x (a-vO2diff) (mL/L)

why learn about exercise testing

because the same principles and elements are used in conjunction with many similar and more complex diagnostic and prognostic procedures

- stress electrocardiogram (ECG/EKG)

- cardiopulmonary stress echocardiogram

- exercise stress myocardial perfusion imaging (MPI)

pharmocologic stress with imaging (ECG, echo, or myocardial perfusion)

-b-agonists (dobutamine)

- increase myocardial oxygen consumption

- increase chronotropicity

- rate of contraction

- redistribute blood flow (adenosine, dipyramole)

cost and accessibility (stressing the heart)

GXT with ECG ($450) < stress echo < stress radionuclide (exercise or pharm stress) < computed tomography with aniogram < cardiac catheterization with aniogram

6 elements for graded exercise testing

1. pretest considerations

2. appearance and quantification of Sx

3. test termination criteria

4. rest/exercise/recovery ECG, BP, HR responses

5. assessment of functional capacity

6. interpretation of findings and generation of report

6 pretest considerations

1. testing personnel

2. informed consent

3. general interview and physical examination

4. pre-test likelihood for CHD

5. pretest instructions preparation for ECG

6. selection of exercise protocol and modality

testing personnel

required personnel may vary with patient status

- ACSM risk stratification categories

- low risk, moderate risk, high risk ability to safely conduct test

- select proper protocol and test mode

- identify and respond to clinical s/s

- interpret test responses and findings correctly

- risk of major event or death during test: 1-10 per 10,000 tests

low risk

men < 45 with < 2 CAD risk factors women < 55 with < 2 CAD risk factors

- NO TESTING

moderate risk

men > 44 with 2+ CAD risk factors women > 54 with 2+ risk factors

- YES TEST

high risk

1+ s/s of CAD or pulmonary or metabolic disease prior history of CAD or pulmonary or metabolic disease

- YES TEST

informed consent

a brief explanation of why the test is being done and test procedures

- puts patient at ease, reduced "white coat syndrome"

- explanation of risks

- patient confirmation

- test purpose

- test procedures

- risks

Indications

a reason to use a medical test or intervention; identify a patient's future risk or prognosis

- symptoms

- ECG changes

- extent and magnitude

- time to onset

- time to resolution

- vo2 or functional capacity

- VE/VC02

indications of testing

1. assist diagnosis of CAD - chest pain, ECG

2. establish future risk, or prognosis

3. prescribe accurate safe exercise program

4. determine effectiveness of treatment

Contraindications

a condition or factor that functions as a reason to avoid or terminate specific medical treatments, generally due to risk of harm to patient

- absolute or relative

absolute contraindication

do not start, or immediately discontinue intervention or treatment if a patient presents

relative contraindications

pay close attention for progression towards absolute contraindications

absolute contraindications to testing

-myocardial infarction within prior 2 days or other acute cardiac event

- change in ECG suggesting MI

- unstable angina

- symptomatic, severe aortic stenosis

- decompensated, symptomatic heart failure

relative contraindications of testing

-left main stenosis

- moderate valvular stenotic disease

- severe arterial hypertension

- tachycardia

subject preparation

-wear appropriate clothing for exercise, access to chest

- use medications as directed by primary care physician

- no food, caffeine, etc. for 4 hours prior to testing

selection of protocol and modality

-steady state versus ramp

- maximal versus submaximal

- try to match patient capabilties

- complete test in 7-12 mins

- try to use the same (common) protocol, to allow results to be compared between tests and people

select mode

-treadmill, cycle ergometer, arm ergometer, pharmacologic

- accessibility, familiarity, concerns

- accomodate patient needs

- orthopedic (injury, amputation, paralysis)

- gait and balance

- safety

steady state versus ramp

a ramp Bruce protocol elicited higher maximal values, longer exercise times, and was perceived as easier than the "steady state" protocol

Modality

-cycle ergometer protocols generally give 5-20% lower maximal values

- will depend on familarity

appearance and quantification of symptoms

maintain regular communication between staff and patient

- at the end of each stage assess: rating of perceived exertion and clinical symptoms

normal stopping criteria

- plateau in VO2 (with increasing WL)
- plateau in HR (with increasing WL)
- RER greater than 1.1
- venous blood lactate > 8mM
- RPE > 17 (Borg 6-20 scale)

clinical stopping criteria

-BP > 25/120

- BP drops > 10 with increase in workload

- ST elevation > 1mm - ST depression > 2mm

- serious arrhythmia

- limiting dyspnea or angina (2+ on scales)

- gait

- fatigue

- patient asks to stop

hypertensive response

SBP > 210 mmHG

-2-3x increased future risk for developing hypertension

hypotensive response

SBP < 90 mmHg
- 10 mmHg increase in SBP below prior value with evidence of ischemia
- decrease below resting SBP

abnormal recovery BP response

by 3 min into recovery, systolic BP should have dropped to <90% of peak BP

- [SBP 3 min]/[SBP peak] < 0/9 (e.g. 140/152 = 0.92)

chronotropic incompetence

inability for HR to increase commensurate with increased demands during exercise

- associated with increased CV events

- no beta-blockade taken prior testing: <80% of age predicted

- beta-blockage taken prior to testing: <62% of age predicted

recovery HR

twofold increased future risk for CV events and all-cause mortality if:

- decrease in HR < 12bpm at 1 min

- decrease in HR <22 bpm at 2 min

assessment of functional capacity

-exercise duration

- estimated METs

- peak oxygen uptake declines: healthy, inactive (5% to 10% per decade) OR healthy, active (3% to 6% per decade)

typical chest pain

-heaviness, pressure, squeezing, generalized left to midchest

- radiation to neck, jaw, back, left arm, less commonly the right arm

- worsened with exertion or relieved with rest or nitroglycerin

atypical chest pain

-sharp, stabbing, pricking, tingling

- no radiation

- none clearly present; can happen at any time

noncardiac chest pain

-discomfort clearly attributable to another cause

- no applicable radiation or alleviating factors

ST segment

1. evidence for myocardial ischemia diagnosis

2. time of onset

3. magnitude of change

4. time to resolve

5. call it "positive" or "negative" or "non-diagnostic"

heart rate response

normal: >85% of age predicted, not on beta-blockage.

-chronotropic incompetence: 80% of age predicted, not on beta-blockade); associated with increased future risk for cardiac mortality

normal recovery rate

12 bpm in 1 min, > 22 in 2 min

- associated with increased future risk for cardiac mortality

duke score = time (bruce)

- [5 x (mm ST depression)]
- [4 x (angina score of 0,1, or 2)]

duke score implications

- < -11 = high risk = >3% 1 yr mortality
- -10 to 4 = intermediate risk = >1% to 3% 1 year mortality
- > 4 = low risk = <1% 1yr mortality

angina index

0 - none

1 - typical angina

2 - angina causing test cessation

false positive

-female

- digoxin therapy

- LBBB

- LVH

- cardiomyopathy

false negative

-failure to reach ischemic threshold

- insufficient effort

- monitoring of insufficient leads

common routine method for assessing myocardial ischemia and function

GTX combined with imaging modality

- nuclear myocardial perfusion and echocardiography

exercise echocardiography

-used to assess ischemic heart disease by evaluating left ventricular wall motion during contraction

- evaluated as normal, decreased contraction, absence of contraction, abnormal movement during contraction

Hypokinetic

decreased contraction