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• The ACSM risk algorithm should be applied to identify risks of adverse exercise events
• First determine if the individual participates in regular exercise
• Note any known signs and symptoms of CVD

Medical Clearance

• Medical clearance must be obtained if needed
• If clearance is needed, determine the intensity of exercise appropriate for the person

CVD Risk Factors

• Age: Men ≥ 45 years; Women ≥ 55 years
• Family history of:
  • Myocardial infarction
  • Coronary revascularization
  • Sudden death before 55 years of age in father or other first-degree male relative
  • Sudden death before 65 years of age in mother or other first-degree female relative
• Cigarette smoking: Current smoker or those who quit within the previous six months; exposure to environmental tobacco smoke
• Physical inactivity: Not meeting the minimum of 500-1000 METS-min of moderate to vigorous physical activity or 75-150 min-wk of moderate to vigorous intensity of physical activity
• Obesity: Body mass index ≥30 kg/m2 or waist girth >40 inches for men or >35 inches for women
• Blood pressure: SBP > 130mm Hg and/or DBP >80 mm Hg
• Dyslipidemia: LDL cholesterol ≥ 130mg/dL; HDL cholesterol <40mg/dL; currently on lipid-lowering medication
• Blood glucose: Fasting plasma glucose ≥100 mg/dL; diabetic or takes medicine to control blood sugar; HbA1C >5.7%
• High HDL Cholesterol: ≥60 mg/dL

Exercise Benefits

• Cardiovascular health:
  • Improved heart health
  • Reduced risk of CVD
  • Enhanced vascular health
• Musculoskeletal health:
  • Increased muscle strength and endurance
  • Improved bone and joint health
• Metabolic health:
  • Weight management
  • Improved insulin sensitivity
  • Better cholesterol levels
• Mental and Emotional wellbeing:
  • Improved mood and reduced stress
  • Reduced symptoms of depression
  • Improved cognitive function
• Enhanced immune function
• Improved sleep quality
• Enhanced Functional Capacity:
  • Improved flexibility and balance
  • Better physical performance
• Decreased Morbidity and Mortality

Exercise Program Red Flags

• Recognize symptoms and signs that would jeopardize a person's safety in an exercise program
• Identify what S&S would prevent starting and stopping exercises

Absolute Contraindications

• Recent significant change in resting electrocardiogram suggesting significant ischemia
• Recent myocardial infarction (within 2 d), or other acute cardiac 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

Relative Contraindications

• Left main coronary stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities (i.e., hypokalemia, hypomagnesemia)
• Severe arterial hypertension (i.e., systolic blood pressure of >200 mm Hg and/or a diastolic blood pressure of >110 mm Hg) at rest
• Tachydysrhythmia or bradydysrhythmia
• Hypertrophic cardiomyopathy and other forms of outflow tract obstruction
• Neuromotor, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise
• High-degree atrioventricular block
• Ventricular aneurysm
• Uncontrolled metabolic disease (e.g., diabetes, thyrotoxicosis, myxedema)
• Chronic infectious disease (e.g., HIV)
• Mental or physical impairment leading to inability to exercise adequately

Measuring Exercise Intensity

Target Heart Rate Zone Method

• HRmax = 220 - age
• Target HR = (HRmax - Resting HR) × % intensity + Resting HR
• Moderate Intensity: Aim for 50% to 70% of HRmax
• Vigorous Intensity: Aim for 70% to 85% of HRmax

Rating of Perceived Exertion Method

• Borg Rating of Perceived Exertion (RPE) Scale: 6-20
• 6 = No exertion at all
• 20 = Maximal exertion
• Moderate intensity: aim for an RPE of 12-14
• Vigorous intensity: aim for an RPE of 15-17

Talk Test Method

• At moderate intensity, the person should be able to talk, but not sing comfortably during exercise
• At vigorous intensity, a conversation should be difficult due to heavy breathing

Metabolic Equivalents (METs) Method

• Use energy expenditure values to determine intensity
• Metabolic Equivalents (METs) Values of Common Physical Activities:
  • Light (1.6-2.9 METs)
    • Walking slowly around home
    • Making the bed/washing the dishes
    • Arts/crafts, playing cards, Fishing
  • Moderate (3.0–5.9 METs)
    • Walking at very brisk pace
    • Walking 3.0 mi/hour
    • Cleaning, heavy — washing windows, car, clean garage
    • Basketball shooting around
  • Vigorous (≥6.0 METs)
    • Walking at very, very brisk pace (4.5 mi/hour)
    • Carrying heavy loads, such as bricks
    • Tennis singles

Definitions of exercise, physical activity, physical fitness

• Exercise: Planned, purposeful, and progressive; also structured, repetitive, with a final or intermediate objective
• Physical activity: Any bodily movement produced by skeletal muscles that results in energy expenditure
• Physical fitness: Attributes/characteristics that relate to the ability to perform physical activity with vigor and alertness
• Physical function: Ability to perform activities of daily living, improved by physical fitness, predictor of independence and disability
• Exercise is physical activity, but physical activity is not exercise
  • Exercise is a subset of physical activity; physical activity includes any movement of the body that requires energy expenditure. Exercise refers to structured, planned, and repetitive physical activity that is specifically performed to improve or maintain physical fitness

Aerobic Exercise Response

• During exercise:
  • Systolic BP (SBP) increases during exercise as the heart pumps more blood supply to meet the demand of working muscles
    • Diastolic BP (DBP) typically remains unchanged or decreasing slightly, depending on the intensity of the exercise
    • Systolic BP increases in a linear fashion with exercise intensity, while diastolic BP usually remains relatively stable
  • HR increases linearly with exercise intensity
    • Increases by approximately 10 bpm per MET of exercise
  • Recovery HR: After exercise, HR should return to resting levels relatively quickly

Cardiovascular System Response to Aerobic Training Program

• Resting HR decreases
• Submaximal HR decreases
• Maximal HR shows no significant change
• Stroke Volume increases
• Cardiac Output increases
  • Due to higher stroke volume and maintained HR
• Blood Pressure
  • Systolic BP increases during exercise, while diastolic BP remains stable or slightly decreases at rest
• Blood Volume increases
  • Due to enhanced plasma volume and red blood cell mass
• Capillary Density increases
  • In muscle tissue for better oxygen delivery
• VO2 Max increases
  • Reflecting improved aerobic capacity
• Arterial-Venous Oxygen Difference increases
  • Allowing muscles to extract more oxygen.

Optimal Loading for Physiologic Adaptations

• Overload Principle
  • The body must be exposed to a workload that exceeds its usual capacity so that the body can adapt
  • Increased demand forces the body to make physiological adjustments
  • Apply the principle effectively by gradually increasing the intensity, volume, or frequency of exercise to ensure continuous improvement
• Progressive overload
  • Involves gradually increasing the intensity, duration, or frequency of exercise to allow the body to adapt over time
    • For example, increasing the weight in resistance training or the duration of aerobic activity ensures that the body continues to adapt and improve
• Specificity Principle
  • Adaptations are specific to the type of exercise performed
    • For example, if you want to improve endurance, you need to perform exercises that specifically target aerobic capacity, like running or cycling
    • This principle emphasizes the importance of aligning your training program with your goals (e.g., strength, endurance, flexibility)
• Periodization involves structuring a training program in cycles of varying intensity and volume to prevent plateaus and reduce the risk of overtraining
• Apply the concept of specificity (SAID principles) to an exercise prescription

FITT Components

• F = Frequency (how often)
• I = Intensity (how hard)
• T = Time (duration or repetitions)
• T = Type (muscle or mode of exercise)
• V = Volume (overall expenditure)
• P = Progression (how to continue to overload)
• Apply the concept of MET/mins for overall weekly exercise volume

METs and Health

• EE quantifies amount of PA
  • The product is the number of METS associated with an activity and the number of minutes it was performed
  • Usually measured per week or per day as a measure of exercise volume
  • Total EE of greater than or equal to 500-1000 mets-min/week is consistently associated with lower rates of CVD and premature mortality

VO2 / MET Relationship

• VO2 and METs
  • Paired Relationship
    • Relationship: 1 MET = 3.5 ml/kg/min of VO2
    • METs simplify the expression of VO2 in terms of the body's energy expenditure relative to rest.
  • %VO2 and METs reflect the same concept/physiologic measure (workload)
• RPE and HR
  • Paired Relationship
    • RPE and HR are closely linked because, as the intensity of exercise increases, both the HR and the perceived exertion (RPE) also increase in a linear manner
    • The most common scale is the Borg Scale, which ranges from 6 to 20, with higher numbers corresponding to greater perceived effort
• Scale
  • Moderate intensity (RPE of 12-14) usually corresponds to 50-70% of maximum heart rate
  • Vigorous Exercise: RPE 15-17 is typically associated with 70-85% of HRmax.

Workload and Training

• Recognize changes in workload (MET) capacity with training and the changes in %VO2Max capability and the subsequent cardiovascular response with change in RPE and HR at set MET load
• Understand purpose and use of basic aerobic field tests and the methods of monitoring workload tolerance

Field Tests

• Conducted outside of the lab to predict Cardiorespiratory fitness by measuring HR response
  • Running, walking, or step tests can be timed/counted and used to estimate VO2 max following protocol and equations from specific tests

Methods of Workload Tolerance Monitoring

• Talk test
• RPE
• HR monitoring if possible
• A rapid increase in HR is used a tolerance moderator
• Identify signs/symptoms:
  • Fatigue
  • Dizziness
  • Excessive sweating
  • Chest pain

Spinal Stabilization

• Know Characteristics of superficial/global spinal muscle and deep/segmental spinal muscles (cervical and lumbar)
• Global Muscle:
  • Superficial (further from the axis)
  • Crosses multiple vertebral segments
  • Produces larger movements and power through the spine
• Deep segmental muscles:
  • Deep (closer to the axis of motion)
  • Attaches to each vertebral segment
  • Stabilizing individual vertebrae and segments of the spine
  • Greater percentage of Type 1 muscle fibers

Core Muscles

• Know Muscles that comprise the deep/segmental core muscles (cervical and lumbar)
• Global
  • Lumbar region: Rectus abdominis, Obliques, QL, erector spinae and ilio psoas
  • Cervical region: SCM, scalene, levator scapulae, Upper traps, and erector spinae
    • Contract 2nd
• Deep
  • Lumbar region: Transversus abdominis, multifidus, deep QL and deep rotators
  • Cervical region: Rectus capitis anterior and lateralis and longus colli
    • Contract First

Deep Core Activation

• Know Methods of activation of the deep core muscles
  • (stabilizers) engaging TA, multifidus, QL, rectus capitis anterior/lateralis, and the longus colli
  • Patients with unilateral back pain often show decreased activation/atrophy in painful side when compared to unimpaired side
  • Drawing in maneuver in thoracic trunk
  • Deep cervical muscles are active with axial extension with mild lordosis
• Progression and regression of limb loading for core stabilization exercises
  • If given one exercise be able to select an exercise that is training/emphasizing the same muscle group but is easier or harder than the original exercise
• Recognize how various positions alter the difficulty for stabilization exercises