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• Planned, purposeful, and progressive exercise is important

FITT-VP

• FITT-VP stands for Frequency, Intensity, Time, Type, Volume, Progression

Vitals/Outcomes During Exercise

• Measurable vitals/outcomes: heart rate, heart rate recovery, BP response, Peak BP, SpO2, RPE, dyspnea, pain, and METs (workload)

Exercise Frequency

• Recommended exercise frequency: at least 3 days/week, spread across 3-5 days/week for cardiovascular endurance

Exercise Intensity

• Moderate intensity exercise is recommended at 40-59% HRR
• Vigorous intensity exercise is recommended at 60-89% HRR

Exercise Time

• Moderate intensity duration should be around 30-60 minutes/day or greater than or equal to 150 minutes per week
• Vigorous intensity duration should be around 20-60 minutes/day or greater than or equal to 75 minutes per week, or combine moderate and vigorous activities daily

Exercise Type

• Aerobic exercise performed continuously or intermittently involving major muscle groups is recommended for most adults

Exercise Volume

• Recommended exercise volume is greater than or equal to 500-1000 METs/week
• This translates to greater than or equal to 7000 steps/day

Exercise Progression

• A gradual increase in exercise volume through adjustments to duration, frequency, or intensity is reasonable
• Start low and go slow when progressing

Formulas for Heart Rate Max

• Tanaka formula for healthy men and women: 208 - (0.7 x age)
• Gellish formula for men and women with a broad range of fitness levels: 207 - (0.7 x age)

Heart Rate Ranges for Exercise Intensity

• Light intensity exercise: 57-63
• Moderate intensity exercise: 64-76
• Vigorous intensity exercise: 77-95

RPE Ranges for Exercise Intensity

• Light intensity exercise: 9-11 (very light to fairly light)
• Moderate intensity exercise: 12-13 (fairly light to somewhat hard)
• Vigorous intensity exercise: 14-17 (somewhat hard to very hard)

MET Equivalents for Exercise Intensity

• Light intensity exercise: 2-3.9
• Moderate intensity exercise: 4-5.9
• Vigorous intensity exercise: 6-8.4

MET Definition

• MET is a metabolic equivalent, measuring physical activity as the amount of oxygen used by the body per kg of bodyweight per minute
• 1 MET is equivalent to sitting at rest
• Exercise equates to physical activity that is structured, planned, and repetitive to meet final objectives

Physical Activity

• Physical activity is defined as any bodily movement produced by skeletal muscles resulting in energy expenditure

Physical Fitness

• Physical fitness is defined as attributes/characteristics related to the ability to perform physical activity with vigor and alertness

Physical Function

• Physical function is defined as the ability to perform activities of daily living, improved by physical fitness, and indicates independence and lack of disability

Monitoring During Exercise

• Monitor the cardiovascular system before, during, and after exercise intervention

Absolute Indications to Stop an Exercise Test

• ST elevation without preexisting Q waves (due to prior MI)
• Drop in SBP >10 mmHg despite increased workload
• Moderate to severe angina
• CNS symptoms (ataxia, dizziness, near syncope)
• Signs of poor perfusion
• Sustained ventricular tachycardia or arrhythmia
• Technical difficulties monitoring ECG or SBP
• Subject requests to stop

Warm-Up and Cool-Down

• Warm-up and cool-down are important for the cardiovascular system

Heart Rate During Exercise

• As intensity increases, HR should increase linearly

Diastolic Blood Pressure During Exercise

• During exercise, DBP should drop or stay the same

Risk Stratification

• The first thing to determine when risk stratifying is if the patient regularly exercises

Chest Pain

• Musculoskeletal pain in chest is normal and represents not angina

Angina

• Angina at vigorous intensity is not normal

• The greater the level of exertion, the greater the risk of experiencing a cardiovascular event

Major Signs and Symptoms of Diseases

• Angina or pain/discomfort in chest
• Shortness of breath (SOB) with mild exertion
• Dizziness or syncope
• Orthopnea (SOB when lying down) or paroxysmal nocturnal dyspnea (dyspnea after the onset of sleep)
• Ankle edema
• Palpitations or tachycardia
• Intermittent claudication
• Known heart murmur
• Unusual fatigue or SOB with usual activities

Cardiovascular Incident

• Patients experiencing signs and symptoms of cardiometabolic diseases during exercise are at higher risk of experiencing a serious cardiovascular event while exercising

Risk Factors for CVD

• Age
• Family history
• Current smoker or quit within the last 6 months
• Not meeting minimum threshold of 500-1000 METs or 75-150 minutes of moderate to vigorous activity a week
• BMI/waist circumference
• Blood pressure
• Lipids
• Blood glucose

Age Risk Factor

• Men 45 and older and women 55 and older

Family History Risk Factor

• Sudden death before 55 in father or male first-degree relative or sudden death before 65 in mother or female first-degree relative

BMI/Waist Circumference Risk Factor

• BMI >= 30 kg or waist girth >= 40" in men and >= 38" in women

Blood Pressure Risk Factor

• SBP >= 130 and/or DBP >= 80 mmHg based on the average of two readings on two occasions

Lipid Risk Factor

• Low-density lipoprotein cholesterol (LDL-C) >= 130mg OR high-density lipoprotein cholesterol (HDL-C) <40 in men and <50 in women OR non-HDL-C <130 or on lipid-lowering medication; if total serum is available, use >= 200

Blood Glucose Risk Factor

• Fasting plasma glucose >= 100 or 2 h plasma glucose values in oral glucose tolerance test >= 140 or HbA1C >= 5.7% (having diabetes is a risk factor for CVD)

Negative Risk Factor

• HDL-C >= 60
• True: Light intensity exercise is nearly always possible regardless of risk factors
• The magnitude of the training response depends on duration, intensity and frequency

Insufficient Training

• Insufficient training stimulus and/or too much recovery can lead to lack of progress or detraining

Overtraining

• Too great a training overload with insufficient recovery can lead to overtraining (or injury)

Stages of General Adaptation Syndrome

• Alarm reaction, resistance, and exhaustion

General Adaptation Syndrome

• The way the body responds and adapts to positive or negative stress

Specificity

• Similarities between training stimulus and performance outcome, includes biomechanical, bioenergetic, and information demands

Progressive Overload

• Progressive increases in training stimulus across the training period: increasing frequency, intensity, volume, time, or movement complexity independently or in combination

Variation

• Sequenced manipulations of exercises and training stimuli

Periodization

• Physiological adaptation, changing exercise selection, volume, or intensity at specified times during training

Motor Learning

• Structured or unstructured variation in the multiplicity of actions or tasks specific to the activity of interest during deliberate practice

Individuality

• Precise responses and adaptation to stimuli vary across individuals (some people do not respond or respond only to certain exercise training)

Reversibility

• The more trained/active, the more resilient and able to maintain exercise

Exercise Modification

• It is almost always necessary to modify an exercise prescription for desired outcome, so False

Walking Speeds for Ambulation

• The speed a patient needs to walk to be considered a community ambulator is 0.8 - 1.2 m/sec
• The speed a patient needs to walk to be considered a household ambulator is 0.4 m/sec
• The speed a patient needs to walk to be able to safely cross the street is 1.2 m/sec

Physical activity

• A patient reporting walking their dog 2 miles 5 days a week for 30-25 minutes is considered physical activity and/or physical fitness
  • This is considered exercise because it is structured and repetitive
  • It is considered physical activity because it is a leisure activity and it increasing energy expenditure

Consideration for patients

• A patient reporting walking their dog 2 miles 5 days a week for 30-35 minutes with a 6% grade for ~1 mile and the patient does not get SOB (shortness of breath) would reasonably be considered physically fit; Yes

Physiologic Change

• The key ingredient to causing a physiologic change with exercise is to overload system/structure trained

Specific Performance

• The key ingredient for improving sport specific performance is specificity

Training Variation

• A Training program, including intervals on Monday, longer distance on Wednesday, and high RPM on Fridays, is an example of variation
• As a patient improves in fitness for their exercise prescription:
• Maximal MET level of exercise will increase
• Heart Rate at rest will decrease
• Cardiac output at rest will stay the same
• As a patient improves in fitness:
• MET level of exercise bout will increase
• % of max HR will be the same and VO2 will be greater
• RPE and Heart rate reflect the same concept/physiologic measure
• %VO2 and METS reflect the same concept/physiologic measure (workload)
• It's True, METS depends on the condition of the patient and the level of workload
• Any duration and MET load adding to 500 MET is acceptable
• Example is 30 minutes of exercise 3 times a week, so a 6 MET is the recommended intensity

Mobilizers vs Stabilizers

• Mobilizers generate torque, concentric power, and shock absorption
• Stabilizers maintain tension to control joint alignment, minimal length change - isometric, continuous activity with movement, and possess high kinematic input

Spinal Stabilizer vs. Mobilizer

• Spinal mobilizer muscles are superficial, cross multiple segments, and cause compressive loading
• Spinal stabilizer muscles are deep, attach to each vertebral segment, and control segmental motion

Mobilizer Muscles

• Rectus abdominus, external/internal obliques, QL, erector spinae, and iliopsoas are mobilizer muscles in the lumbar spine
• The SCM, scalenes, levator, upper trap, and erector spinae are mobilizer muscles in the cervical spine

The Stabilizer Muscles

• The transversus abdominis, multifidus, and QL are stabilizer muscles in the lumbar spine
• Rectus capitis anterior and lateralis, longus colli consist of stabilizer muscles in the cervical spine

Stability Impairment

• Stability impairment can result from joint hypermobility, muscle weakness, impaired postural control, or impaired endurance
• Instability is excessive joint movement w/o muscular control
• Hypermobility: Excessive movement around a joint
• Hyper-mobility of segments or muscle imbalance may as-sociated w/ lower back pain and cervical pain
• Actively train "core" to provide support in positions (endurance and stabilization is emphasized)

Guidelines for Spinal Stabilization

• Kinesthetic awareness fist

• Activation - isometric holding

• Extremity motions - progressive limb loading (dynamic)

• Increase endurance and strength (30-60 sec to 3 mins)

• Use manual resistance (alternation isometrics and rhythmic)

• Develop transition and stabilization

• Perturbations training

• Using BP cuff to activated deep flexors - set to 20mmHg and increase in increments of 2 mmHg up to 30mmHg

• Resistance with BP cuff

Posture During Stabilization

• Attain Posture
• Maintain (patient controls motion in the bases of support)
• Sustain: Position against force or movement

Concepts of PNF

• Mobility
• Stability
• Controlled
• Skill
• PNF: Proprioceptive neuromuscular facilitation
• PNF Uses stimuli to augment (external, motor, tactile proprioceptive, visual auditory) response
• PNF Provides altered or inefficient patterns of motion or posture
• A Diagonal of Movement innate path where maximal response of the trunk and extremities can be facilitated (trunk and extremity)

PNF Indications

• Impaired mobility,
• Impaired muscle performance
• Impaired endurance
• Impaired Balance
• Impaired posture
• Pain
• Body positioning/ mechanic
• verbal and visual cuing
• Manual contract
• Approximation of timing for emphatic
• Manual contact is always on the muscle contraction

PNF Techniques

• Quick stretch enhances muscle firing Techniques for stability include:
• Alternating isometric or rhythmic stabilization
• Reversals of antagonies (slow or dynamic)

Goals of Isometric Holds

• Improve strength

• Improve balance

• Improve Stability

• Increase active ROM and passive rom following technique

• Decrease pain

• Initiate isometric resistance is in a predictable pattern; don't release until the rotation is constricted

Goals of Rhythmic

• Improve balance and stability

• Improve Strength

• Integrate new posture or ROM is is incorporated

• To Initiate rhythmic stabilization is resistance from proximal to distal with unpredictable rotations/ patterns Goal of Reversals of antagonist

• improve balance and coordination of anagonist

• improve endurance of antagonistics patterns

• PNF is manual therapy for exercise

• functional activities