Exexcise Prescription, Implementation (and Ongoing Support)

Domain I: Health and Fitness Assessment & Domain II: Exercise Prescription, Implementation (and Ongoing Support) – 60% Part A a. Tools that provide accurate information 1. Physical Activity Readiness – Questionnaire (PAR-Q) - *Minimum Requirement* AHA/ACSM Health/Fitness Facility Pre-participation Screening Questionnaire 2. CVD Risk Factor assessment and classification by qualified health/fitness, clinical exercise, or health care professionals 3. Medical evaluation including a physical examination and stress test by a qualified health care provider b. The key components included in an informed consent and health/medical history Components of Medical History (Box 3.1)           Medical diagnosis of any prior illness or condition (e.g., cardiovascular disease, hypertension, obesity, etc.) Previous physical examination findings History of symptoms Recent illness, hospitalization, new medical diagnoses, or surgical procedures Orthopedic problems including arthritis, joint swelling, and any condition that would make ambulation (walking/moving) or use of certain test modalities difficult Medication use (including dietary/nutritional supplements) and drug allergies Other habits including caffeine, alcohol, tobacco, or recreational (illicit) drug use Exercise history. Information on readiness for change and habitual level of activity: FITT of exercise Work history with emphasis on current or expected physical demands, noting upper and lower extremity requirements Family History of cardiac, pulmonary, metabolic, stroke or sudden death Components of Informed Consent 1. 2. 3. 4. 5. 6. Purpose and explanation of the test Attendant risks and discomforts Responsibilities of the participant Benefits to be expected Inquiries – Questions about procedures or anything else Use of medical records 7. Freedom of consent c. Limitations of informed consent and health/medical history   PAR-Q can only identify those who are at high risk; it does not differentiate between those who are at low and moderate risk Most forms do not make recommendations based on intensity of the proposed exercise program Part B a. Risk factor thresholds for ACSM risk stratification Positive Risk Factors         Age: Men ≥ 45 yr; Women ≥ 55 yr Family history: Myocardial infarction, coronary revascularization, or sudden death before 55 yr in father or other male 1st-degree relative or before 65yr in mother or other female 1st-degree relative Cigarette smoking: Current cigarette smoker or those who quit within the previous 6 months or exposure to environmental tobacco smoke Sedentary lifestyle: Not participating in at least 30 minutes of moderate intensity physical activity (40% - <60% VO2R) on at least 3 d of the week for at least 3 mo Obesity: Body mass index ≥ 30 kg/m2 or waist girth > 102 cm (40in) for men and > 88 cm (35 in) for women Hypertension: Systolic blood pressure ≥ 140 mmHg and/or Diastolic blood pressure ≥ 90 mmHg confirmed by measurements on at least two separate occasions, or on antihypertensive medication Dyslipidemia: LDL-C ≥ 130 mg/dL or HDL-C < 40 mg/dL or on lipid-lowering medication. If total serum cholesterol is all that is available, use ≥ 200 mg/dL Pre-diabetes: Impaired Fasting Glucose (IFG) = fasting plasma glucose ≥ 100 mg/dL and ≤ 125 mg/dL or Impaired Glucose Tolerance (IGT) ≥ 140 mg/dL and ≤ 199 mg/dL confirmed by measurements on at least two separate occasions Negative Risk Factor  HDL-C: ≥ 60 mg/dL **In the absence of a CVD risk factor, that CVD risk factor should be counted, expect in prediabetes. If pre-diabetes criteria is missing or unknown, pre-diabetes should only be counted for those ≥ 45 yr. If < 45 yr pre-diabetes should only be counted if BMI is ≥ 25 kg/m2 and additional CVD risk factors for pre-diabetes (e.g., family history).** b. The major signs or symptoms suggestive of cardiovascular, pulmonary and metabolic disease          Pain; discomfort (or other angina equivalent) in the chest, neck, jaw, arms, or other areas that may result from ischemia Shortness of breath at rest or with mild exertion Dizzyness or syncope Orthopnea or paroxysmal nocturnal dyspnea Ankle edema Palpitations or tachycardia Intermittent claudication Known heart murmer Unusual fatigue or shortness of breath with usual activities c. ACSM Risk stratification categories and their implication for medical clearance before administration of an exercise test or participation in an exercise program    Low Risk: Asymptomatic with < 2 risk factors. No medical exam required before moderate or vigoSBProus exercise. No exercise stress test required before mod or vig exercise. No MD supervision of exercise test if done for submax or maximal testing Moderate Risk: Asymptomatic with ≥ 2 risk factors. No medical exam required before moderate exercise but is required for vigorous exercise. No exercise stress test required before mod or vig exercise. No MD supervision required before submax or max testing High Risk: Symptomatic, or known cardiovascular, pulmonary, renal, or metabolic disease. Yes for all, moderate and vigorous. d. Risk factors that may be favorably modified by physical activity habits       Smoking Obesity Sedentary lifestyle Pre-diabetes Hyperlipidemia Dyslipidemia e. Blood pressure levels + important info    Normal = SBP of < 120 mmHg and DBP of < 80 mmHg Pre-hypertensive = SBP of 120-139 mmHg and/or DBP of 80-89 mmHg – require healthpromoting lifestyle modifications to prevent the development of hypertension Hypertensive = SBP of ≥ 140 mmHg and/or DBP of ≥ 90 mmHg Important Procedure Details 1. Patients should be seated for 5 min. Patient should refrain from cigarette smoking or ingesting caffeine for at least 30 minutes preceding measurement 2. Wrap cuff around upper arm at heart level; align cuff with brachial artery 3. The bladder within the cuff should encircle at least 80% of the upper arm 4. Inflate cuff pressure to 20 mmHg above first Korotkoff sound 5. Slowly release pressure at rate equal to 2-5 mmHg 6. SBP is the first of two or more Korotkoff sounds is heart (phase 1), and DBP is the point before the disappearance of Korotkoff sounds (phase 5) 7. At least two measurements should be taken (minimum of 1 minute apart) and the average should be taken 8. BP should be measured in both arms during the first examination. Higher pressure should be used when there is consistent inter arm difference f. Recommended plasma cholesterol levels for adults based on national cholesterol education program/ATP guidelines LDL Cholesterol <100 Optimal 100-129 Near optima/above optimal 130-159 Borderline high 160-189 High ≥190 Very high Total Cholesterol <200 Desirable 200-239 Borderline high ≥240 High HDL Cholesterol <40 Low ≥60 High Triglycerides <150 150-199 200-499 ≥500 Normal Borderline high High Very high Chapter 3: Pre-exercise Evaluation (GETP 9th Edition) Contraindications to Exercise Testing Absolute          A recent significant change in the resting EKG suggesting significant ischemia, recent myocardial infarction (within 2 d) or other acute event Unstable angina Uncontrolled cardiac dysrhythmias causing symptoms or hemodynamic compromise Symptomatic severe aortic stenosis Uncontrolled symptomatic heart failure Acute pulmonary embolus or pulmonary infarction Acute myocarditis or pericarditis Suspected or known dissecting aneurysm Acute systemic infection, accompanied by fever, body aches, or swollen lymph glands -Patients with absolute contraindications should not perform exercise tests until such conditions are stabilized or adequately treated. Relative             Left main coronary stenosis Moderate stenotic valvular heart disease Electrolyte abnormalities Severe arterial hypertension at rest (SBP of > 200 mmHg and/or a DBP of > 110 mmHg) Tachydysrhythmia or bradydysrhythmia Hypertrophic cardiomyopathy Neuromotor, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise High-degree AV block Ventricular aneurysm Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, or myxedema)’ Chronic infectious disease (e.g., HIV) Mental or physical impairment leading to inability to exercise adequatel -Patients with relative contraindications may be tested only after careful evaluation of the risk-benefit ratio. Chapter 4: Health-Related Physical Fitness Testing and Interpretation (GETP 9th Edition) Proper Order of Assessments 1. Pre-screening/risk classification 2. Resting HR, BP, height, weight, BMI, and ECG (if appropriate) 3. Body composition a. Waist circumference b. Skinfold assessment 4. Cardiorespiratory fitness a. Submaximal or maximal test typically on a cycle ergometer or treadmill 5. Muscular strength a. 1- to multiple- RM upper body (bench press) and lower body (leg press) 6. Muscular endurance a. Curl-up Test b. Push-up Test c. Specific motion using appropriate equipment to fatigue (i.e., bench press) 7. Flexibility a. Sit-and-reach test or goniometric measures of isolated anatomic joints Circumferences Procedures      All measures should be made with a flexible yet inelastic tape measure The tape should be placed on the skin surface without compressing the subcutaneous adipose tissue If a Gullick spring-loaded handle is used, the handle should be extended to the same marking with each trial Take duplicate measures at each site and retest if duplicate measurements are not within 5 mm Rotate through measurement sites or allow time for skin to regain normal texture Risk Criteria for waist Circumference in Adults Women <70 cm (<28.5 in) Very low 70-89 cm (28.5-35) Low 90-110 (35.5-43) High >110 (>43.5) Very high Men <80 cm (31.5 in) 80-99 cm (31.5-39) 100-120 (39.5-47) >120 (>47) Very low Low High Very high **Health risk is very high for young men when WHR is >0.95 and for young women when WHR is >0.86, individuals ages 60-69 Men = > 1.03, Women = >0.90** Skinfolds Skinfold Site Descriptions Abdominal: Vertical fold; 2 cm to the right side of the umbilicus. Triceps: Vertical fold; on the posterior midline of the upper arm, halfway between the acromion and the olecranon process, with the arm held freely to the side of the body. Biceps: Vertical fold; on the anterior aspect of the arm over the belly of the biceps muscle, 1 cm above the level used to mark the triceps site. Chest/pectoral: Diagonal fold; one-half the distance between the anterior axillary line and the nipple (men), or one-third of the distance between the anterior axillary line and the nipple (women). Medial calf: Vertical fold; at the maximum circumference of the calf on the midline of its medial border. Midaxillary: Vertical fold; on the midaxillary line at the level of the xiphoid process of the sternum. An alternate method is a horizontal fold taken at the level of the xiphoid/sternal border in the midaxillary line. Subscapular: Diagonal fold (45° angle); 1-2 cm below the inferior angle of the scapula. Suprailiac: Diagonal fold; in line with the natural angle of the iliac crest taken in the anterior axillary line immediately superior to the iliac crest. Thigh: Vertical fold; on the anterior midline of the thigh, midway between the proximal border of the patella and the inguinal crease (hip). Procedures       All measurements should be made on the right side of the body with the subject standing upright Caliper should be places directly on the surface of the skin, 1 cm away from the thumb and finger, perpendicular to the skinfold, and halfway between the crest and the base of the fold Pinch should be maintained while reading the caliper Wait 1-2 seconds (not longer) before reading caliper Take duplicate measures at each site and retest if duplicate measurements are not within 1-2 mm Rotate through measurement sites or allow time for skin to regain normal texture or thickness Body Density to Body Fat % 495 % Fat = Body Density −450 Pros and Cons to Modes of Testing Field tests Pros: Easy to administer to large numbers of individuals at one time and little equipment needed Cons: Some test1s can be maximal for some individuals, and potentially be unmonitored for HR and BP. These all-out run tests may be inappropriate for sedentary individuals or individuals at increased risk for cardiovascular and/or musculoskeletal complications Motor-driven teadmills Pros: Can accommodate the least fit to the fittest individuals across the continuum of walking o running speeds Cons: Expensive, not easily transportable, and can make some measurements (e.g., BP & EKG) more difficult Cycle ergometers Pros: Lower equipment expense, transportability, easier to obtain BP and EKG Cons: Cycling is a less familiar mode of exercise, often resulting in localized muscle fatigue and an underestimation of VO2 Step testing Pros: Inexpensive modality to predict CRF, requires little equipment, easily transportable, short test, mass testing. Cons: Special precautions may be needed for those who have balance problems or are extremely deconditioned Procedures for Submaximal Testing of Cardiorespiratory Fitness 1. Obtain resting HR and BP immediately prior to exercise in the exercise posture 2. The client should be familiarized with the ergometer. If using a cycle ergometer properly position the client on the ergometer (i.e., upright posture, ~25° bend in the knee at maximal leg extension, and hands in proper position on handle bars) 3. The exercise test should begin with a 2-3 min warm-up to acquaint the client with the cycle ergometer and prepare him or her for the exercise intensity for the first stage 4. A specific protocol should consist of 2- or 3- min stages with appropriate increments in work rate 5. HR should be monitored at least two times during each stage, near the end of the second and third minutes of each stage. If HR is > 110 bpm, steady state HR (i.e., two HRs within 5 bpm) should be reached before the workload is increased 6. BP should be monitored in the last minute of each stage and repeated in the event of a hypertensive or hypotensive response 7. RPE and additional rating scales should be monitored near the end of the last minute of each stage 8. Clients appearance and symptoms should be monitored and recorded regularly 9. The test should be terminated when the subject reaches 70% HR reserve (85% of agepredicted HRmax), fails to conform to the exercise protocol, experiences adverse signs or symptoms, requests to stop, or experiences an emergency situation. 10. A appropriate cool-down/recovery period should be initiated consisting of either: a. Continued exercise at a work rate equivalent to that of the first stage or lower b. A passive cool-down if the subject experiences signs of discomfort or an emergency situation occurs 11. All physiologic observations (e.g., HR, BP, and signs and symptoms) should be continued for at least 5 min of recovery unless abnormal responses occur, which would warrant a longer post-test surveillance period. Continue low-level exercise until HR and BP stabilize, but not necessarily until they reach pre-exercise levels YMCA Cycle Ergometry Protocol