Exexcise Prescription, Implementation (and Ongoing Support) Part 2

General Indications for Stopping an Exercise Test           Onset of angina or angina-like symptoms Drop in SBP ≥ 10 mmHg with an increase in work rate or if SBP decreases below the value obtained in the same position prior to testing Excessive rise in BP: systolic pressure >250 mmHg and/or diastolic pressure > 115 mmHg Shortness of breath, wheezing, leg cramps, or claudication Signs of poor perfusion: light-headedness, confusion, ataxia, pallor, cyanosis, nausea, or cold and clammy skin Failure of HR to increase with increased exercise intensity Noticeable changes in heart rhythm by palpation or auscultation Subject requests to stop Physical or verbal manifestations of severe fatigue Failure of the testing equipment 1-RM or Multiple RM Testing Familiarization/Practice Sessions 1. The subject should warm up by completing a number of submaximal repetitions of the specific exercise that will be used to determine the 1-RM 2. Determine the 1-RM (or any multiple of 1-RM) within four trials with rest periods of 3-5 minutes between trials 3. Select an initial weight that is within the subject’s perceived capacity (~50% - 70% of capacity) 4. Resistance is progressively increased by 2.5-20.0 kg (5.5-44.0 lbs) until the subject cannot complete the selected repetitions; all repetitions should be performed at the same speed of movement and ROM to instill consistency between trials 5. The final weight lifted successfully is recorded as the absolute 1-RM or multiple RM Push-up and Curl-up (crunch) Test Procedures for Measurement of Muscular Endurance Push Up 1. “Down” position until the chin touches the mat. The stomach should not touch the mat 2. Maximal number of push-ups performed consecutively without rest is counted as the score 3. The test is stopped when the client strains forcibly or unable to maintain the appropriate technique within two repetitions Curl Up 1. Two strips of masking tape are to be placed on a mat on the floor at a distance of 12 cm apart for subjects < 45 yr, or 8 cm apart for subjects ≥ 45 yr 2. Knees bent at 90° at top position, and spines flexed to 30° at bottom position 3. Metronome of 40 bpm 4. Repetitions continue until subject reaches 75 curl-ups or breaks cadence Absolute and Relative Contraindications to Resistance Training and Testing Absolute           Unstable CHD Decompensated HF Uncontrolled arrhythmias Severe pulmonary hypertension (mean pulmonary arterial pressure >55 mmHg) Severe and symptomatic aortic stenosis Acute myocarditis, endocarditis, or pericarditis Uncontrolled hypertension (>180/110 mmHg) Aortic dissection Marfan syndrome High ntensity RT (80% to 100% of 1-RM) in patients with active proliferative retinopathy or moderate or worse non proliferative diabetic retinopathy Relative       Major risk factors for CHD Diabetes at any age Uncontrolled hypertension (>160/100 mmHg) Low functional capacity (< 4 METs) Musculoskeletal limitations Individuals who have implanted pacemakers or defibrillators Guidelines for Resistance Training in Children and Adolescents               Ensure appropriate training for individual providing training instruction and supervision Provide a safe exercise environment Start training session with a 5- to 10- min dynamic warm-up Initiate training program two to three times per week on non-consecutive days, with light resistance and ensure exercise technique is correct General training session guidelines: one to three sets of 6 – 15 reps with combination of upper and lower body exercise Incorporate exercises specifically focusing on the trunk Training programs should induce symmetrical and balanced muscular development Individualized exercise progression based on goals and skill Graduate increase (~5% - 10%) in training resistance as gains are made Use calisthenics and/or stretching post-resistance training session Be aware of individual needs/concerns during each session Continually alter training program to maintain interest and avoid training plateaus Ensure proper nutrition, hydration, and sleep Instructor and parents should be supportive and encouraging to help maintain interest Sit-and-reach Procedures    26 cm mark, no shoes for sit-and-reach. For YMCA test yardstick perpendicular at 15 inch mark YMCA = heels touching tape 10 to 12 inches apart Both = Hold position for 2 seconds Chapter 7: General Principles of Exercise Prescription (GETP 9th Edition) Components of the Exercise Training Session Warm-up: At least 5-10 minutes of light-to-mod)erate intensity cardiorespiratory and muscular endurance activities Conditioning: At least 20-60 minutes of aerobic, resistance, neuromotor, and/or sport specific activities (exercise bouts of 10 min are acceptable if the individual accumulates at least 20-60 minutes/d of daily aerobic exercise) Cool-down: At least 5-10 minutes of light-to-moderate intensity cardiorespiratory and muscular endurance activities Stretching: At least 10 minutes of stretching exercises performed after the warm-up or cooldown phase Commonly Used Equations for Estimating Maximal Heart Rate Fox: HRmax = 220 – age Astrand: HRmax = 216.6 – (0.84 x age) Tanaka: HRmax = 208 – (0.7 x age) Gellish: HRmax = 207 – (0.7 x age) Gulati: HRmax = 206 – (0.88 x age) Methods for Prescribing Exercise Intensity Using HR, VO2, and METs      HRR Method: VO2R Method: HR Method: VO2 Method: MET Method: Target HR (THR) = [(HRmax - HRrest) x % intensity desired] + HRrest Target VO2R = [(VO2max – VO2rest) x % intensity desired] + VO2rest Target HR = HRmax x % intensity desired Target VO2 = VO2max x % intensity desired Target MET = [(VO2max)/3.5] x % intensity desired Metabolic Calculations for Estimation of Energy Expenditure During Common Physical Activities Walking, Running, Leg & Arm Cycling, and Stepping Equations are provided Work Rate Formula: Resistance (kg) x distance per flywheel (m) (= 6m for cycle ergometer, 2.4m for arm ergometer) x revolutions per minute or pedal frequency per minute MET-min: METs x min x # of times per week Kilocalorie per minute: [(METs x 3.5 x body wt in kg) / 1000] x 5 Key conversions: 1 mph = 26.8 meters/min 1 inch = 2.54 cm 1 kg = 2.2 lbs. FITT Principle for Aerobic (Cardiovascular Endurance) Frequency: ≥ 5 d/wk of moderate exercise, or ≥ 3 d/wk of vigorous exercise, or a combination of moderate and vigorous on ≥3-5 d/wk Intensity: Moderate and/or vigorous intensity is recommended. Light to moderate intensity may be beneficial in deconditioned individuals Time: 30-60 min/d or 20-60 min/d of vigorous exercise. < 20 min/d can be beneficial in deconditioned individuals Type: Purposeful exercise that involves major muscle groups and is continuous and rhythmic in nature Volume: A target volume of ≥ 500 – 1,000 MET-min/week. Increasing pedometer counts by ≥ 2,000 steps/day to reach a daily step count of ≥ 7,000 steps/day. Exercising below these volumes may still be beneficial for individuals’ unable or unwilling o reach this amount of exercise. Pattern: Maybe performed in one continuous session per day or in multiple sessions of ≥ 10 min to accumulate the desired duration and volume of exercise per day. Exercise bouts of < 10 min may yield favorable adaptations in very deconditioned individuals Progression: Gradual progression by adjusting duration, frequency, or intensity until the desired exercise goal is attained (maintenance). FITT Principle for Resistance Exercise Frequency: Each major muscle group should be trained on 2-3 d/wk Intensity: ●60% - 70% 1-RM for novice to intermediate exercisers to improve strength ●≥80% 1-RM for experienced strength trainers to improve strength ●40% - 50% RM for older adults beginning exercise to improve strength ●40% - 50% 1-RM may be beneficial for improving strength in sedentary individuals beginning a resistance training program ●< 50% 1-RM to improve muscular endurance ●20% - 50% 1-RM in older adults to improve power Type: ●Resistance exercises involving each major muscle group are recommended ●Multi-joint exercises affecting more than one muscle group and targeting agonist and antagonist muscle groups are recommended for adults ●Single joint exercises targeting major muscle groups may also be included in a resistance training program, after performing multi-joint exercises for that particular muscle group ●A variety of exercise equipment and/or body weight can be used to perform these exercises Repetitions: ●8-12 repetitions is recommended to improve strength and power in most adults ●10-15 repetitions is effective in middle-aged and older individuals starting exercise ●15-20 repetitions are recommended to improve muscular endurance Sets: ●2-4 sets are recommended for most adults to improve strength and power ●A single set of resistance exercise can be effective especially among older adults and novices ●≤2 sets are effective in improving muscular endurance Pattern: Rest intervals of 2-3 minutes between each set of repetitions are effective. A rest of ≥ 48 h between sessions for any single muscle group is recommended Progression: A gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency is recommended FITT Principle for Flexibility Frequency: 2-3 d/wk with daily being most effective Intensity: Stretch to the point of feeling tightness or slight discomfort Time: Holding a static stretch for 10-30 s is recommended for most adults. For PNF stretching a 3-6 s light-to-moderate contraction (e.g., 20%-75% if maximum voluntary contraction) followed by a 10-30 s assisted stretch is desirable Type: Static, dynamic, ballistic flexibility, and PNF are each effective Volume: A reasonable target it to perform 60 s of total stretching time for each flexibility exercise Pattern: Repetition of each flexibility exercise 2-4 times is recommended. Flexibility exercise is most effective when the muscle is warmed thought light-to-moderate aerobic activity or passively through external methods such as moist heat packs or hot baths Progression: Methods for optimal progression are unknown Chapter 8: Exercise Prescription for Healthy Populations of Pregnancy, Children, and Adolescence (GETP 9th Edition) Physiologic Response to Acute Exercise during Pregnancy           Oxygen Uptake (VO2) Heart Rate (HR) Stroke Volume Cardiac Output Tidal Volume Minute Ventilation (Ve) Ventilatory Equivalent for O2 Ventilatory Equivalent for CO2 Systolic Blood Pressure Diastolic Blood Pressure Increase Increase Increase Increase Increase Increase Increase Increase No change/ decrease No change/decrease Contraindications for Exercise during Pregnancy Absolute          Hemodynamically significant heart disease Restrictive lung disease Incompetent cervix/cerclage Multiple gestation at risk for premature labor Persistent second or third trimester bleeding Placenta Previa after 26 wk of gestation Premature labor during the current pregnancy Ruptured membranes Pre-eclampsia/pregnancy-induced hypertension Relative              Severe anemia Un-elevated maternal cardiac dysrhythmia Chronic bronchitis Poorly controlled Type 1 diabetes mellitus Extreme morbid obesity Extreme underweight History of extremely sedentary lifestyle Intrauterine growth restriction in current pregnancy Poorly controlled hypertension Orthopedic limitations Poorly controlled seizure disorder Poorly controlled hyperthyroidism Heavy smoker FITT Principle for Women who are Pregnant frequency: 3-4 d/wk intensity: moderate for women with a bmi < 25 kg/m2, light intensity for women with a bmi ≥ 25 kg/m2 time: ≥ 15 minutes/day gradually increasing to a maximum of 30 minutes/day of accumulated moderate intensity exercise to total 120 min/wk. with a 10-15 minute warm-up and cool-down this results in approximately 150 min/wk of exercise. women with a pre-pregnancy bmi of ≥ 25 kg/m2 who have been medically pre-screened can exercise at a light intensity starting at 25 min/d adding 2 min/wk until 40 min, 3-4 d/wk is achieved type: dynamic, rhythmic physical activities that use large muscle groups such as walking and cycling progression: the optimal time to progress is after the first trimester (13 wk). gradual progression from a minimum of 15 min/d, 3 d/wk to a maximum of approximately 30 min/d, 4 d/wk Special Considerations for Pregnant Women    During pregnancy metabolic demand increases by ~300 kcal/d Isometric and Valsalva maneuver should be avoided as should supine position after 16 wk of pregnancy Gradual exercise in post-pardum period may begin ~4-6 wk after normal vaginal delivery or about 8-10 wk (w/ medical clearance) after a cesarean section delivery Physiologic Responses to Acute Exercise in Children Compared to Adults            Absolute Oxygen Uptake (VO2 L/min) Relative Oxygen Uptake (VO2 mL/kg/min) Heart Rate Cardiac Output Stroke Volume Systolic Blood Pressure Diastolic Blood Pressure Respiratory Rate Tidal Volume Minute Ventilation (Ve) Respiratory Exchange Ration Lower Higher Higher Lower Lower Lower Lower Higher Lower Lower Lower FITT Recommendations for Children (Aerobic) Frequency: Daily Intensity: Moderate to vigorous and should include vigorous intensity at least 3 d/wk Time: ≥ 60 min/d Type: Running, brisk walking, swimming, dancing, and bicycling FITT Recommendations for Children (Muscle Strengthening) Frequency: ≥ 3 d/wk Time: As part of their 60 min/d or more of exercise Type: Can be unstructured. (e.g., playing on the playground equipment, climbing trees, tug of war). Or structured weight lifting or working with resistance bands FITT Recommendations for Children (Bone Strengthening) Frequency: ≥ 3 d/wk Time: As part of 60 min/d of exercise or more Type: Running, jumping rope, basketball, tennis, resistance training, hopscotch ** 8 – 15 submaximal repetitions of exercise should be performed to the point of moderate fatigue with good mechanical form before the resistance is increased** **Children and adolescence are defined by ACSM as 6-17 years old** Effects of Aging on Selected Physiologic and Health-Related Variables                Resting Heart Rate Maximum Heart Rate Maximum Cardiac Output Resting and Exercise Blood Pressure Absolute and Relative VO2 Max Residual Volume Vital Capacity Reaction Time Muscular Strength Flexibility Bone Mass Fat-Free Body Mass % Body Fat Glucose Tolerance Recovery Time Unchanged Lower Lower Higher Lower Higher Lower Slower Lower Lower Lower Lower Higher Lower Longer Exercise Testing in Older Adults  Initial workload should be light, < 3 METs, with small workload increments of 0.5 – 1.0 METs. Naughton Treadmill Protocol **Older adults are defined by ACSM as ≥ 65 yr old, and individuals 50-64 yr old with clinical conditions** FITT Recommendations for Older Adults (Aerobic Exercise) Frequency: ≥ 5 d/wk for moderate intensity, or ≥ 3 d/wk for vigorous intensity activities. Or a combination of 3-5 d/wk of both Intensity: On a 0-10 scale for physical exertion, 5-6 for moderate intensity and 7-8 for vigorous intensity Time: For moderate intensity accumulate at least 30 up to 60 min/d in bouts of at least 10 min each to total 150 – 300 min/wk moderate intensity exercise. Or at least 20-30 min/d of more vigorous intensity, totaling 75-100 min/wk. Or an equivalent combination of moderate and vigorous intensity physical activity Type: Any modality that does not impose excessive orthopedic stress – walking, aquatic exercise, stationary cycling FITT for Older Adults (Muscle Strengthening/Endurance Exercise) Frequency: ≥ 2 d/wk Intensity: Moderate 60% - 70% 1-RM. Light 40%-50% 1-RM for older adults beginning a resistance program. When 1-rm is not measured, intensity can be prescribed between moderate (5-6) and vigorous (7-8) intensity on a scale of 0-10 Type: Progressive weight-training or weight bearing calisthenics (8-10 exercises involving the major muscle groups; ≥ 1 set of 10-15 repetitions each), stair climbing, and other strengthening activities that use the major muscle group FITT for Older Adults (Flexibility) Frequency: ≥ 2 d/wk Intensity: Stretch to the point of feeling tightness or slight discomfort Time: Hold for stretch of 30-60 s Type: Activities that increase flexibility using slow movements that terminate in sustained stretches. Static rather than ballistic movements Chapter 10: Exercise Prescriptions for Populations with Chronic Diseases and Health Conditions (GETP 9th Edition) FITT for Arthritis Frequency: Aerobic exercise 3-5 d/wk, resistance exercise 2-3 d/wk, flexibility/range of motion (ROM) exercise are essential and should be performed daily if possible Intensity: Moderate, or light depending on condition of patient Time: A goal of ≥ 150 min/wk, bouts of 10 minutes are allowed Type: Low joint stress activities including walking, cycling, and swimming FITT for Diabetes Mellitus (Aerobic, Resistance, and Flexibility) Frequency: 3-7 d/wk Intensity: 40% - < 60% VO2R corresponding to an RPE of 11-13 on a 6-20 scale Time: Type 2 DM patients should engage in a minimum of 150 min/wk of exercise at a moderate intensity or greater Type: Activities using large muscle groups in a rhythmic continuous fashion Progression: Progressively increase duration. Followed by adding higher intensity **Hypoglycemia = blood glucose levels < 70 mg/dL** FITT Principle for Dyslipidemia (Aerobic) Frequency: ≥ 5 d/wk to maximize caloric expenditure Intensity: 40% - 75% VO2R or HRR Time: 30-60 min/d; to promote or maintain weight loss: 50-60 min/d or more Type: Aerobic physical activities that involve the large muscle groups FITT Recommendations for Hypertension (Aerobic & Resistance) Frequency: Aerobic on most, preferably all days of the week; resistance exercise 2-3 d/wk Intensity: Moderate aerobic exercise (40% - < 60% VO2R or HRR; RPE 11-13 on a 6-20 scale), supplemented by resistance training at 60% - 80% 1-RM Time: 30-60 min/d of continuous or intermittent aerobic exercise. Resistance training at 60% 80% 1-RM Type: Walking, jogging, cycling, and swimming. Machine or free weights for resistance training Metabolic Syndrome   Characterized by risk factors associated with increased incidence of CVD, DM, and stroke o Root causes of the metabolic syndrome are overweight/obesity, physical inactivity, insulin resistance, and genetic factors FITT principle is the same for healthy adults regarding aerobic, resistance, and flexibility FITT Recommendations for Individuals with Osteoporosis (Aerobic and Resistance) Frequency: Weight-bearing aerobic activities 3-5 d/wk and resistance exercise 2-3 d/wk Intensity: Moderate intensity (40% - < 60% VO2R or HRR) for weight bearing aerobic activities and moderate intensity (60% - 80% 1-RM, 8-12 repetitions of exercises involving each major muscle group) in terms of bone loading forces, although some individuals may be able to tolerate more intense exercise Time: 30-60 min/d of a combination of weight bearing aerobic and resistance activities Type: Weight-bearing aerobic activities (e.g., stair climbing/descending, walking, other activities, as tolerated) and resistance exercise (e.g., weight lifting) FITT Recommendations for Individuals AT RISK for Osteoporosis ** Same as previous FITT for Osteoporosis with these exceptions** Intensity: Aerobic: Moderate (40% - < 60% VO2R or HRR) to vigorous (≥ 60% VO2R or HRR) intensity. Resistance: moderate (60%-80% 1-RM, 8-12 reps w/ exercises involving each major muscle group). To vigorous (80%-90% 1-RM, 5-6 reps involving each major muscle group) Type: Weight-bearing aerobic activities (e.g., Tennis, stair climbing/descending, walking with intermittent jogging), activities that involve jumping (e.g., volleyball, basketball), and resistance exercise (e.g., weight lifting) FITT Recommendations for Overweight and Obesity Aerobic, Resistance, and Flexibility Frequency: ≥ 5 d/wk to maximize caloric expenditure Intensity: Moderate to vigorous intensity encouraged. Initially begin with moderate and progress to more vigorous Time: A minimum of 30 min/day progressing to 60 min/d of moderate intensity, aerobic activity Type: The primary role of exercise should be aerobic physical activities that involve the large muscle groups. As part of a balanced exercise program, RT & Flexibility should be incorporated (based on healthy people guidelines) Chapter 6: Body Composition and Weight Management (Resources for the Exercise Physiologist) Estimating Desired Body Weight and Percentage Body Fat 1. Estimate percentage body fat (using one of the methods discussed in earlier chapters i.e., skinfold, bod pod, BIA, etc.) 2. Fat Mass = Total body mass x (Percentage body fat/100) 3. Fat-Free Mass = Total body mass – Fat mass 4. Desired weight = Fat-free mass/[1-(Desired percentage body fat/100) Example: BF % = 31%, Total body mass = 213 lbs.; Desired BF % = 25% 1. 31% 2. 213 x (31/100) Fat Mass = 66.03 3. 213 – 66.03 Fat-Free Mass = 146.97 4. 146.97/[1-(25/100) =195.96 lbs or ~196 lbs. Total Energy Expenditure (TEE) o TEE is the total number of calories expended each day and reflects the amount of energy required to carry out all the metabolic processes within the body. o Resting Energy Expenditure (REE) or (RMR): 60%-70% of TEE o Thermic Effect of Food: 10% of TEE o Physical Activity Expenditure: 20%-30% of TEE Physical Activity Level (PAL) Low active: PA = 1.4 < PAL < 1.6 Active: PA = 1.6 < PAL < 1.9 Very active: PA = 1.9 < PAL < 2.5 **TEE = REE x PAL** REE Equation REE (kcal/day) = 66.47 + 13.75(wt in kg) + 5(ht in cm) – 6.8(age in yr) Example: wt = 81.82 ht in cm = 182.9 age in yr = 35 REE = 66.47 + 13.75(81.82) + 5 (182.9) – 6.8(35) =1,869 kcal/day If PAL is 1.5 Example: TEE = REE x PAL TEE = 1,869 x 1.5 TEE = 2,803 kcal **Using the example above, in order to lose 1 lb of weight per week this individual would need to make caloric requirements to reach 2,503 kcal/day** **Any individual should not consume < 1,200 kcal/day as it is likely at this level that they will not meet basic nutrient needs** Key Recommendations of the 2010 Dietary Guidelines Foods to Reduce: High sodium foods such as soup, bread, and frozen meals; drink less sugary drinks such as regular sodas, sports drinks, energy drinks, and fruit drinks Increase Fruit and Vegetable Intake: Fresh, frozen and canned; if using canned vegetables, rinse off liquids stored in since this portion contains sodium Color Your Plate: Eat a variety of vegetables, especially dark green, red, and orange vegetables and beans and peas Consume At Least Half of all Grains as Whole Grains: For example, buckwheat, bulgar, millet, oatmeal, quinoa, rolled oats, brown or wild rice, whole-grain barley, whole rye, and whole wheat. Use nutrition facts level to choose good or excellent sources of fiber. Good sources of fiber are 10%-19% of the daily value per serving; excellence sources of dietary fiber contain 20% or more Increase Intake of Fat-Free (skim) or Low-Fat (1%) Milk: Includes milk products such as milk, yogurt, cheese, or fortified soy beverages Choose a Variety of Protein Foods: Include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds Increase the Amount and Variety of Seafood Consumed: Choose seafood (e.g., salmon, tuna, trout, tilapia, shrimp, crab, and oysters) in place of some meat and poultry twice a week Replace Protein Foods that are Higher in Solid Fats: Replace, for example, friend meats, bacon, sausage, with choices that are lower in solid fats and calories and/or are sources of oils Use Oils to Replace Solid Fats when Possible: Use olive, canola, corn, safflower, or sunflower oil in small amounts rather than solid fats such as butter, stick margarine, shortening, and lard Choose Foods that Provide More Potassium, Dietary Fiber, Calcium, and Vitamin D: These foods include vegetables, fruits, whole grains, and milk and milk products Recommended Macronutrient Proportions by Age Young Children (1-3 Carbohydrate (%) 45-65% Protein (%) 5-20% Fat (%) 30-40% years) Older Children and Adolescence (4-18 years) Adults (≥ 19 years) 45-65% 10-30% 25-35% 45-65% 10-35% 20-35% Behavioral Strategies for Weight Loss Self-Monitoring: Keeping food or PA logs or monitoring body weight on a regular basis Goal Setting: Setting realistic goals for the number of minutes of exercise to complete over the next week or month Stimulus Control: Modifying ones environment to enhance successful behavior change, such as removing risky foods or making an exercise calendar Problem Solving: Identifying situations that pose a problem for overeating, and devising a plan of how to eat healthy Prescription Drugs to Treat CVD, Metabolic, and Pulmonary Disorders Beta-Blockers: Lower HR, and myocardial contractility. Lower coronary ischemia during exercise. This effect makes initial exercise intensity determination difficult, may limit functional capacity, inhibits using HR as an exercise intensity target and requires more rigorous patient selfmonitoring. Beta Blockers may also block symptoms of hypoglycemia and increase the risk of undetected hypoglycemia during and after exercise. CCBs and ACE Inhibitors: Both increase arterial diameter; thereby lessening blood pressure and decreasing the work by the heart. CCBs effect is central, while ACE inhibitors actions are more peripheral. CCBs have some effect on HR and contractility, the extent of this effect is not as much as that of Beta Blockers. Therefore, CCBs and ACE inhibitors pose much less concern regarding exercise responses, but the EP-C must be aware of unusual changes in blood pressure or HR both before and during exercise. ACE Inhibitors do work in the lungs and can produce an irritating dry cough. Nitrates and Cholesterol-Lowering Drugs: Tend to have very little effect on HR and contractility, and thus no direct impact on exercise capacity or the exercise prescription. Digitalis: Increases contractility, slows HR, and mediates arrhythmias. In the CHF patient, digitalis typically increases exercise capacity. Digitalis can also cause ST-segment depression at rest or during exercise. Diuretics: Increased water excretion may result in an increased resting and submaximal HR. Decreased blood volume and decreased blood pressure could have a slight negative impact on exercise capacity and thermoregulation B2-Agonists (Pulmonary): Bronchodilators Oral Medications to Treat Diabetes: Increase hepatic insulin output, lowering insulin resistance, and decreasing absorption of carbohydrates. The diabetic exerciser needs to monitor blood glucose closely before, during and after each exercise session. Domain III: Exercise Counseling and Behavioral Strategies – 15% Chapter 10: Theories of Behavior Change (Resources for the Exercise Physiologist) Difference between a Theory and a Model Theory – Refers to a systematic view of a behavior by specifying relationships between variables and predicting specific behaviors and situations ↘Related to physical activity, a theory would explain the variables that influence physical activity, how these variables interact with one another to influence physical activity, and the conditions under which physical activity occurs. Model – Defined as a hypothetical depiction of a behavior or situation. ↘Models do not attempt to understand the variables underlying a particular behavior, but rather represent what is happening with a particular behavior. Transtheoretical Model of Change (TTM) Pre-contemplation – Individuals in this stage are not intending to take action within the next 6 months. May be because they are uniformed about the health effects of a sedentary lifestyle, uninformed about the consequences, not motivated to make changes, or have made several failed attempts at physical activity adoption and is now discouraged or debilitated. ↘Application: Stage 1: Inactive and not thinking about becoming more active These individuals do not currently engage in physical activity and do not plan on doing so in the near future Contemplation – Individuals in this stage are intending to alter behavior within the next 6 months. They may be becoming more aware of the pros of engaging in physical activity; however, the costs associated with physical activity may still outweigh the benefits ↘Application: Stage 2: Inactive and thinking about becoming active These individuals are thinking about adopting physical activity and are planning to become more physically active within a reasonable time frame Preparation – Individuals in this stage are intending to increase their physical activity in the immediate future. These individuals may have a specific plan to change behavior and may be seeking out resources for assistance. ↘Application: Stage 3: Doing some physical activity These individuals are currently doing physical activity, but are not meeting the standards and guidelines identified by the ACSM