PT153: Therapeutic Exercises 2

AEROBIC EXERCISES

Kristofferson G. Mendoza, PTRP Department of Physical Therapy College of Allied Medical Professions University of the Philippines Manila

Learning Objectives
At the end of the session, students should be able to Determine the components of an aerobic exercise program Apply principles of a conditioning program for patients with
Coronary Artery Disease Stroke and/or history of Hypertension Peripheral Vascular Disease COPD Diabetes Mellitus Well population

Objectives
Determine criteria for initiating an exercise session for different clients / patients. Decide when to terminate an exercise session based on established protocols and guidelines

Background Knowledge
Cardiovascular physiology Exercise physiology Muscle physiology Knowledge of different conditions presenting with impaired aerobic capacity

Endurance
Ability to work for prolonged periods of time and resist fatigue Types
Cardiovascular endurance
Cardiorespiratory fitness, aerobic endurance aerobic power Ability to perform large muscle dynamic exercises More of a general total body endurance

Muscle endurance
Local muscle endurance Ability of a muscle group to perform repeated contractions over a period of time without fatigue

INTENSITY DURATION FREQUENCY MODE

Determinants of an Aerobic Exercise Program

Intensity
Overload principle
Stress on an organism is greater than the one regularly encountered during daily life Exercise must be above the training stimulus threshold for adaptation to occur
stimulus that elicits a training or conditioning response

Specificity principle
Adaptations in metabolic and physiologic systems depending on the imposed demand

Intensity
Quantifying intensity
Heart Rate VO2 Max Rating of Perceived Exertion

Intensity
Heart Rate
Maximum Heart Rate = 220 - age

Karvonens Formula
Target Heart Rate = RHR + (MHR - RHR) (60-80%)

For UE work
Maximum Heart Rate = 220 age - 11

Intensity
Rating of Perceived Exertion Useful for patients with heart rate suppressors e.g. Beta blockers Original Revised

Rating of Perceived Exertion Original version ( 6-20 )

Intensity

Intensity
Rating of Perceived Exertion Revised version ( 0-10 )

Intensity

Intensity
Exercising at a high intensity elicits a greater improvement of the VO2 max The higher the intensity, the longer the exercise intervals, the faster the training effect Exercising at high intensities increases the risk for CV complications and musculoskeletal injury Maximum oxygen consumption (VO2 Max) BEST measure of exercise intensity

Intensity
Goal Achievement of intensity
60-90% MHR OR 50-85% VO2 Max Beginners: 50-60% VO2 Max Average: 60-70% VO2 Max Fit: 75-85% VO2 Max

Duration
Dependent on Total work performed Intensity Frequency Fitness level HIGH intensity LOW intensity SHORT duration LONG duration

Duration
Poor functional capacity
5 - 10 minutes

Beginners
10 - 20 minutes

Average
15 - 45 minutes

Fit
30 60 minutes

Duration
Moderate to Minimal intensity 20 30 minutes High intensity 10 15 minutes Exercise longer than 45 minutes increases the risk for musculoskeletal complications

Frequency
Dependent on the health and age of the individual LOW intensity HIGH intensity HIGH frequency LOW frequency

Frequency
POOR
Daily

Beginner
Every other day

Optimal frequency
3-4 times a week 2 times a week does not generally evoke CV changes for well population Increase in frequency beyond optimal range, increases risk for musculoskeletal complications 30-45 mins 3x a week protects against CV disorders

Frequency
3 5 sessions / week Greater than 5 METS Daily or multiple daily sessions Less than 5 METS

Mode
Large muscles Rhythmic Long duration Lower extremity versus Upper extremity exercise

Mode
Lower Extremity
Larger muscle mass Higher VO2 max HR increases linearly as a

Upper extremity
Smaller muscle mass Lower VO2 max than LE

function of increased workload / VO2 max HR plateaus just before maximal VO2 max Systolic BP increases Diastolic BP remains the same

exercise HR higher Stroke volume lower Systolic AND Diastolic BP higher

Warm-up Aerobic exercise period Cool-down

EXERCISE PROGRAM

Warm-up
Muscle temperature Nerve conduction velocity Vasodilation Adaptation of respiratory centers Venous return

Warm-up
Components
Graduated low intensity warm-up (5-10 minutes) of total body movement
HR increase 20bpm

Flexibility exercises

Warm-up
Should NOT cause fatigue Decreases
Risk for ECG changes (arrythmias) Musculoskeletal disorder

Aerobic exercise
Continuous Interval Circuit Circuit-interval

Continuous
Submaximal and sustained Achievement of the steady state Duration: 20 60 minutes Intensity: 60 85% VO2 Max Most effective in increasing endurance for healthy individuals

Continuous
Two types: Intermediate Slow Distance
20-60 minutes continuous exercise Most commonly used for managing weight

Long Slow Distance

Longer than 60 minutes for athletic training Provided after 6 months of successful ISD

Interval
Designed to improve strength and power more than endurance Incorporates recovery after continual exercise Useful for beginners work - rest - work

Interval
Exercise period is followed by rest interval
Rest relief (Passive recovery) Work relief (Active recovery)

Work recovery ratio

1:1 to 1:5

1 : 1.5 work interval allows the succeeding exercise interval to begin before recovery is complete

Interval
Aerobic Interval Training For patients with poor CV fitness 2-15 minutes at 50-80% functional capacity Anaerobic Interval Training For patients with high CV fitness 30 sec 4 minutes at 85-100% functional capacity Usually results in greater lactic acid concentrations

Circuit
Series of exercise activities Several exercise modes Improves both strength and endurance

Circuit interval
Stresses both aerobic and anerobic systems Delays the need for glycolysis and lactic acid production

Cool-down
Prevents
Pooling of blood Post-exercise syncope Ischemia, arrythmias, and other complications

Increases oxidation of metabolic waste

Cool-down
Length of cool-down phase proportional to intensity and length of the conditioning phase Typical 30-40 aerobic exercise period
Warrants a 5-10 minute cool-down phase

Coronary Artery Disease Stroke and/or history of Hypertension Peripheral Vascular Disease COPD Diabetes Mellitus Well population

AEROBIC CONDITIONING PROGRAM DESIGN

Coronary Artery Disease

In-patient phase Out-patient phase Maintenance phase

In patient phase
3 - 5 days Objectives
Initiate early return to independence Prevent deleterious effect of bed rest Help allay anxiety and depression Promote risk factor modification

In patient phase
Role of PT
Sit- to- stand 1-3 days post-op Orthostatic challenge to the CV system 3-5 days post-op Low-level exercise program (1-3 METS)

In patient phase
Exercise recommendations Intensity
2-3 METS progressing to 3-5 METS by d/c RPE < 13 (6-20) Post-MI: HR <120 bpm or RHR + 20 bpm To tolerance, if asymptomatic

In patient phase
Exercise recommendations Duration
Begin with intermittent bouts lasting 3-5 minutes, as tolerated Rest periods can be slow walk or complete rest Attempt 2:1 exercise/rest ratio

Frequency
Early mobilization: 3-4 times / day (days 1-3) Later mobilization: 2 times/day (beginning on day 4) with increased duration

In patient phase
Exercise recommendations Mode
ADLs Selected arm and leg exercises Early supervised ambulation

Out-patient phase
Initiated 6-8 weeks upon discharge Objectives
Improve functional capacity Promote early return to normal activity Promote positive lifestyle changes

9 METS functional capacity: suggested exit point Weaned from continuous monitoring to selfmonitoring

Out-patient phase
Exercise recommendations Intensity: 40-60% MHR Duration: Initial 10-15 minutes, Target 30-60 minutes Frequency: 3 4 times / week Mode: Continuous / Circuit interval
Walking, treadmill, cycle ergometer

Maintenance phase
3 - 6 months post-cardiac patient Objectives
Maintenance of function Compliance with exercise program Risk factor modification

Entry-level criteria
Functional capacity of 5 METS Clinically stable angina Medically controlled arrhythmias during exercise

Maintenance phase
Exercise recommendations Intensity
40-75% MHR

Duration
45 minutes to tolerance / session

Frequency
3 5 days / week

Mode:
Continuous / Interval

Coronary artery disease

Mode of exercise Patient preference Skill required for proper performance Potential for carryover at home Availability of exercise equipment

Stroke and Hypertension

Avoid valsalva maneuver Avoid isometric component Circuit training (weight training + endurance) RPE when patient is taking anti-HTN Instruct patients to move slowly

Stroke and Hypertension

Exercise recommmendations Intensity: 40-70% VO2 Max / 40-65% MHR Duration: Gradual warm-ups and cool-down / 30-60 minute/session (aerobic training) Frequency: 3-7 days/week Mode: Large muscle group aerobic exercise, walking, swimming

Stroke and Hypertension

Special considerations NO exercise if resting systolic BP > 200 mmHg or diastolic BP > 110 mmHg Risk of heat intolerance for patients taking beta blockers and diuretics Anti-HTN may provoke syncope post-exercise: good cool-down Individuals with BP > or equal 160/100 should add endurance exercise after initiating pharmacologic therapy

Peripheral Vascular Disease (PVD)

Relieve claudication Improve walking capacity and qol Ensourage daily exercise with frequent rest periods Low impact, NWB activities (swimming, cycling) Add WB exercise as condition improves Avoid exercising in COLD air or water Interval training is appropriate FEET care

Peripheral Vascular Disease (PVD)

Grade I II III IV Subjective Grading for PVD
Definite discomfort or pain but only at initial level Moderate discomfort from which patients attention CAN be diverted by conversation Intense pain CANNOT be diverted Excruciating and unbearable pain

Peripheral Vascular Disease (PVD)

Exercise recommmendation Intensity: Grade II III on the claudiaction pain Frequency: 3-5 days / week Duration: initial: 35 minutes of intermittent walking; increased 5 minutes each session until 50 minutes of intermittent walking can be completed
Goal: 35-50 minutes of continuous walking

Mode: non-impact aerobic exercise

COPD
Keep the exercise intensity low and gradually increase over time Reduce intensity if symptoms occur Mind the environment Use of supplemental oxygen / bronchodilators Breathing exercises Walking strongly recommended

COPD
Exercise recommendations Intensity: low intensity, adjust according to patients response Duration: maximal limits tolerated by the symptoms Frequency: 3 5 times / week; if reduced functional capacity , daily Mode: walking, staionary cycling progress with upper body resistive exercises

Diabetes Mellitus
Exercise improves glucose control and circulation Reduces cardiovascular risk Assists in weight control Reduces stress Patients should undergo exercise testing prior to initiation of an exercise program

Diabetes Mellitus
Exercise recommendations Intensity: 50 80% HR Reserve Duration: 20 60 minutes Frequency: 3 4 /week Mode: walking, treadmill, stationary cycle

Diabetes Mellitus
Considerations Monitor glucose levels prior to and following exercise
Should exercise with glucose level between 100 200 mg /dl Have carbohydrate snack readily available during exercise

Do not exercise when

Fasting glucose > 250mg/dl + ketosis Use caution when glucose > 300 mg/dl

Maintain hydration during exercise session

Diabetes Mellitus
Do not exercise alone Avoid exercising body part injected by insulin Do not exercise patients with poorly controlled complications Do not exercise in extreme environmental temperatures Late-onset hypoglycemia can occur up to 48 hours following exercise especially when beginning or modifying program

Diabetes Mellitus
Ingest 20 30 grams of additional carbohydrates if pre-exercise glucose is <100 mg/dl Avoid valsalva and jarring/pounding activities Monitor for signs of autonomic neuropathy (hypoglycemia / hyperglycemia) Proper feet care Limit WB activities for patients with peripheral neuropathy

Well Population
Mode Season

Well Population
Mode Long Slow Distance training Pace / Tempo Interval Repetition Fartlek

Long Slow Distance

Intensity
Achievement of 70% VO2max (80% MHR)

Duration
Training distance > race distance Lasts from 30 minutes 2 hours

Frequency
1-2 per week

Conversation exercise

Long Slow Distance

Benefits: Increase CV and thermoregulatory function Mitochondria Oxidative capacity Fat utilization and lactate clearance

Long Slow Distance

Disadvantages Not specific with lower intensity sports Does not stimulate neurologic pattern

Pace / Tempo
Intensity: At the lactate threshold or slightly above the race pace Duration: 20 -30 minutes Frequency: 1 -2 / week Threshold training

Pace / Tempo
Benefits Develops race pace Enhance body to sustain exercise Increases running economy Increases lactate threshold

Interval
Intensity: Close to the VO2 Max Duration: 3 5 minutes; Work/Rest ratio 1:1 Frequency: 1 2 / week Benefit
Increase VO2 max

Not to be performed if unfit

Repetition
Intensity: Greater than VO2 Max Duration: 30 90 seconds; Work/Rest ratio 1:5 Frequency: Once a week High reliance on anaerobic metabolism Benefits
Increases running speed High capacity for anaerobic metabolism Beneficial for final kick / push

Fartlek
Intensity: Varies between LSD and pace Duration: 20 60 minutes Frequency: Once a week Benefits
Challenges all the system Increases VO2 max Reduce boredom Increases lactate threshold Increases running conomy

Sports Season
Season
Off-season (Base training) Preseason In season (Competition) Postseason (active rest )

Objective
Develop sound conditioning base Improve factors important to aerobic endurance and performance Maintain factors

Freq
5-6

Duration
Long

Intensity
Low-mod

6-7

Long-mod Short Race distance Short

Mod-high Low-training High-racing Low

5-6

Recovery

3-5

References
Rothstein, J.M., Roy, S.H., & Wolf, S.L. (2005). The rehabilitation specialists handbook. Philadelphia: F.A. Davis. Whaley, M.H., Brubaker, P.H., & Otto, R.M. (2005). ACSMs guidelines for exercise testing and prescription. Philadelphia: Lippincott Williams & Wilkins. Kisner, C., & Colby, L.A. (2007). Therapeutic exercise: Foundations and techniques. Philadelphia: F.A. Davis. Seigelman, R.P., & O Sullivan, S.B. (2006). National physical therapy examination review and study guide. Philadelphia: International Education Resources. Encabo, Michelle. 2008. Powerpoint presentation on Aerobic Exercise. UP-CAMP Basco, Mmark David. 2009. Lecture Notes on Aerobic Exercise. UPCAMP

THANK YOU
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