Diabetes Treatments

Exercise Guidelines for Patients with Diabetes Mellitus REF-5 Type 2 diabetes mellitus is the most common form accounting for 90% to 95% of …

How to Write an
Exercise Prescription

MAJ Robert L Gauer, MD
LTC Francis G OConnor, MD, FACSM

Department of Family Medicine
Uniformed Services University of the Health Sciences

How to Write an Exercise
Prescription

MAJ Robert L Gauer, MD
LTC Francis G OConnor, MD, FACSM

Department of Family Medicine
Uniformed Services University
of the Health Sciences

Contents

Section Page

Introduction 1
Epidemiology of Inactivity 3
Reasons for Inactivity 5
Role of the Health Care Provider 7
Benefits of Exercise 9
I All-Cause Mortality 9
II Atherosclerotic Vascular Disease 9
III Cancer 10
IV Diabetes Mellitus 10
V Hypertension
11
VI Osteoporosis 11
VII Dyslipidemia 12
VIII Obesity 12
IX Mental Health 13
X Economic Benefits 13
Risks of Physical Activity 15
I Exercise Related Sudden Death 15
II Musculoskeletal 19
III Miscellaneous Risks 20
Current Recommendations 21
I Evolution of Physical Activity Recommendations 21
II Current Recommendations 22
A ACSM recommendations 22
B CDC/ACSM recommendations 23
C AHA Scientific Statement 24
D AMA Guidelines for Adolescent Preventive Services
24
E Department of Health and Human Services 25
F United States Preventive Services Task Force 25
III Summary of Recent Physical Activity Recommendations
25
Exercise Prescription 27
I Approach to Recommending Exercise 27
II Pre-exercise evaluation 31
III Graded Exercise Testing 33
IV Writing the Exercise Prescription 37
A
Activity Selection 37
B Frequency 40
C Duration 40
D Intensity 41
E The Exercise Session 44
Section Page

F Rate of Progression 45
G Muscle Conditioning 47
Special Populations 49
I Cardiovascular Disease 49
General Principles of Exercise Prescription in Secondary
Prevention 53
A Prescription in the Absence of Ischemia or Significant
Arrhythmias 53
B Prescription in the Presence of Ischemia or Arrhythmias
54
C Summary 55
II Diabetes Mellitus 57
A Exercise in Type 1 Diabetes Mellitus 57
B Exercise in Type 2 Diabetes Mellitus 59
C Complications 60
III Osteoarthritis 61
IV Pregnancy 63
V Asthma 67
VI Pulmonary Disease 71
VII Obesity 75
VIII Exercise in the Elderly 79
IX Army Personnel 85
Conclusion 87
Glossary 89

Appendices

A -
Exercise Assessment Form A-1
B - National Cholesterol Education Program: Expert Panel
Guidelines for Diagnosis and Treatment of
High Cholesterol B-1
C - Effects of Medications on Heart Rate, Blood
Pressure, and Exercise Capacity C-1
D - Cardiovascular Prescription Form D-1
E - BEGINNERS PROGRAM TRAINING LOG E-1
F - Intermediate program training log F-1
G - body mass index table g-1

Resources/References

Individual Guidelines for Cardiovascular Exercise REF-3
Exercise Guidelines for Patients with Diabetes Mellitus REF-5
Exercise Guidelines for Pregnancy and Post-partum REF-7
Weight Training Guidelines for Healthy Adults and Low-Risk Cardiac
Patients REF-9

Resources/References continued Page

Aquatic Exercise Workout REF-11
Training for the Army Physical Fitness Test APFT REF-13
Getting Out of Your Chair REF-15
How to Start a Walking Program REF-17
Exercising in Cold Weather REF-19
Sensible Shoes REF-21
Fitness injury prevention REF-23
Conditioning
Exercises REF-25
Bend and Stretch REF-27
National Organizations REF-29
Bibliography REF-31

Figures

1 Exercise Assessment and Prescription Flow Chart 28
2 Cardiovascular Risk Assessment 35
3 Management of Exercise Induced Asthma 70

Tables

table 1 Proportion of Adults Reporting No Leisure-Time Activity
Within The Last Month, 1991 Behavioral Risk Factor
Surveillance System 4
table 2 Barriers and Motivators Associated with Physical
Activity 5
table 3 Physical Activity and the Reduced Risk of
Specific Cancers 10
table 4 Pretest Probability of Coronary Artery Disease by Age,
Gender, and Symptoms 17
table 5 Categories of Activity by Musculoskeletal Impact 19
table 6 Examples of Common Physical Activities for Healthy US
Adults by Intensity of Effort Required 24
table 7 How to Approach Roadblocks 29
table 8 Model for Physical Activity Recommendations 30
table 9 Pre-exercise Evaluation History 31
table 10 Contraindications to Exercise
32
table 11 Indications for Exercise Stress Testing 33
table 12 Components of an Exercise Prescription 37
table 13 Activity Selection Guide 38
table 14 Energy Expenditures for Various Activities 39
table 15 Borg Scale for Rating Perceived Exertion 43

TABLES continued Page

table 16 Classification of physical activity intensity, based on
activity lasting up to 60 minutes 44
table 17 Prognostic Factors for Patients with Coronary
Artery Disease 49
table 18 New York Heart Association Functional
Classification FOR CONGESTIVE HEART FAILURE
50
table 19 Prevention of Hypoglycemia or Hyperglycemia 59
table 20 Exercise and the stress across selected joints 62
table 21 Exercise Guidelines for Pregnancy and the Postpartum
Period 64
table 22 Factors that Suggest Exercise-Induced Asthma 68
TABLE 23 Components of the COPD Exercise Prescription 72
TABLE 24 Classification of overweight and obesity by BMI and
associated disease risk 75
TABLE 25 Functional Changes Associated with
Age 80
TABLE 26 General Guidelines for the Exercise Prescription in
Chronically Ill Patients 82

INTRODUCTION

All parts of the body if used in moderation and exercised in
labors to which each is accustomed, become thereby healthy and
well developed, and age slowly; but if unused and left idle,
they become liable to disease, defective in growth, and age
quickly
Hippocrates

Regular physical activity has been regarded as an important component of a
healthy lifestyle and has been proven to increase longevity and the overall
quality of life1 Recently, this stand has been reinforced by scientific
data linking physical activity to a wide array of physical and mental
health benefits2,3 Despite this evidence and the apparent heightened
public awareness, millions of Americans continue to practice sedentary
lifestyles In order to effect change, it is very important that health
care providers HCPs include exercise counseling as a part of routine
health maintenance HCPs in this paper refers to physicians,
physicians
assistants, nurse practitioners and those directly involved in primary
health care HCPs need to emphasize the benefits of exercise and encourage
all children and adults to engage in at least 20 to 60 minutes of formal
physical activity at a minimum of 3 days per week Most patients can begin
a formal exercise prescription program after consultation with a HCP
Selected high-risk patients, specifically those with pre-existing coronary
artery disease CAD, may require further evaluation prior to initiation of
exercise Specific instruction should be given to the patient as to type,
frequency, intensity and duration of exercise This is most readily
achieved through a written exercise prescription program The products of
an effective exercise program are disease prevention, healthy living and a
general sense of well being

This monograph is designed to assist HCPs in appropriately prescribing
exercise to their patients This document will review specific benefits of
exercise, risks associated with exercise, current recommendations on
exercise, cardiovascular risk assessments, assessing an individuals desire
to become physical fit, and guidelines for writing an
exercise
prescription Information is provided on exercise precautions for
individuals with specific health issues such as heart disease, diabetes
mellitus, lung disease and pregnancy Included are convenient references
that are available to patients in the form of handouts The intent of this
paper is to instill confidence in prescribing exercise to a broad patient
population, thus mastering the art of exercise prescription

EPIDEMIOLOGY OF INACTIVITY

The 1991 National Health Interview Survey-Health Promotion/Disease
Prevention reported that 22 of adults engage in light to moderate physical
activity for at least 30 minutes per day, 54 are somewhat active, but do
not meet the current recommendations, while 24 are completely sedentary
reporting no physical activity over the past month4

Patterns of physical activity vary with demographic characteristics Table
1 Women reported higher amounts of inactivity than did men Variations
in race/ethnicity were significant as well, demonstrating that African
Americans and other ethnic minority populations are less active than white
Americans5 The prevalence of inactivity, in general, increases with age
There does,
however, appear to be a slight increase in physical activity in
adults over 65 years of age, but overall, physical activity declines with
advancing age6 Individuals with a college education are almost twice as
likely to be active compared to individuals with a high school level
education

As with education, socioeconomic patterns are similar Individuals with an
annual income of less than 15,000 per year are twice as likely to be
sedentary compared to adults who makes in excess of 50,000 per year
Differences in education and socioeconomic status account for most, if not
all of the differences in leisure-time physical activity associated with
race and ethnicity7 Among youths, 60 of males and 47 of females
reported participating in vigorous activity of three or more times per
week8

Assessing population attributable risk is one way to demonstrate the impact
of inactivity on society Based on 1992 estimates, 35 of the deaths from
CAD are attributed to physical inactivity Accordingly, an estimated
168,000 of the 480,000 CAD deaths would not have occurred if everyone were
optimally active9 Based on Healthy People 2000 objectives, if 30 of the
population were to engage in regular
exercise, defined as 30 minutes of
light to moderate exercise, preferably daily, approximately 24,000 deaths
from CAD per year would be averted9

Table 1
Proportion of Adults Reporting No Leisure-Time Activity Within The Last
Month, 1991
Behavioral Risk Factor Surveillance System
Demographic Group Sedentary, 95 CI
Sex
Male 2789 2718-2860
Female 3148 3085-3211
Race
White 2775 2724-2826
Nonwhite 3752 3627-3877
Age, years
18-34 2377 2301-2453
35-54 2950 2870-3030
55 3800 3710-3890
Annual income,
14,999 4014 3906-4122
15,000-24,999 3200 3090-3310
25,000-50,000 2543 2463-2623
50,000 1864 1760-1968
Education
Some high school 4806 4675-4937
High school/tech school graduate 3357 3279-3435
Some college/college graduate 2016 1955-2077
A population-based random-digit-dial-telephone survey with 87,433
respondents aged 18 years and older from 47 states
and the District of
Columbia Data are weighted, and point estimates and confidence intervals
CIs are calculated using the SESUDAAN procedure to adjust for the
complex sampling frame7

Additionally, it has been estimated that 250,000 deaths per year in the
United States, approximately 12 of the total mortality, are associated
with a sedentary lifestyle4 The benefit of exercise has been demonstrated
in both primary no evidence of disease and secondary diagnosed disease
prevention strategies Children, young adults and otherwise healthy
individuals that engage in regular exercise can see their risk of acquired
disease decline Those with existing health conditions may see improvement
in their disease process Physical activity, whether it be primary or
secondary prevention, has the potential to benefit all Americans
REASONS FOR INACTIVITY

Regular exercise is regarded as an important component of disease
prevention and health enhancement A large and growing body of clinical,
scientific and epidemiologic evidence supports the concept of exercise and
longevity10 Despite this overwhelming evidence, literally millions of US
adults and children
remain sedentary The pattern is such that only 25
percent of American adults and children engage in sustained physical
activity In order to promote physical activity, it becomes important to
understand why people are sedentary

There are numerous behavioral, physiological and psychological variables
related to initiating and maintaining physical activity11-13 A lack of
time appears to be the most common reason cited as a barrier to exercise
while injury is a common reason for stopping regular activity14 As HCPs
it is our responsibility to tactfully approach a patient and encourage
initiating/maintaining an appropriate exercise program Table 2 lists
other barriers and motivators of physical activity

Table 2

Barriers and Motivators Associated with Physical Activity
Motivators Barriers
Feeling better/more energy No time/too busy
Promote health Exercise will not help me
Prevent heart attacks Lack of confidence
Lower Blood Pressure Facilities not convenient
Look better Too costly
Lose weight Exercise not
interesting/painful
Personal accomplishment Embarrassed of appearance
Contact with friends Poor environment
Increase strength Increased fatigue
Sleep better Do not make me feel better
Adapted from Will PM, Demko TM, George DL Prescribing exercise for
Health: A Simple Framework for Primary Care Am Fam Physician 1996; 53:
579-585

HCPs should practice physical activity recommendations not only to benefit
their own health, but to make more credible their own endorsement of an
active lifestyle If HCPs are to effect change in patient behavior, they
must set the example and adhere to the advice given to patients

ROLE OF THE HEALTH CARE PROVIDER

Most HCPs are aware of the benefits of exercise, however, few within their
practice recommend exercise during patient office visits In one study,
only 47 of primary care physicians surveyed included a careful exercise
history as part of their initial examination The same study noted that
just 13 of patients reported that their physician give them advice
concerning benefits of exercise15 Some constraints cited are: lack of
time, a belief
that intervention will not be successful, lack of reward,
inadequate reimbursement and most significantly a lack of adequate training
in physical activity counseling4

HCPs should routinely counsel patients concerning physical activity HCPs
can be effective proponents of physical activity because patients respect
their advice and as a result are more likely to change their own
behaviors16 With the large number of HCPs and the frequency of office
visits, if providers are modestly effective in exercise counseling, it
would result in a substantial increase in public awareness A national
health objective for the year 2000 is to increase to at least 50 the
number of HCPs who appropriately assess and counsel their patients
concerning exercise17 Achievement of this goal has the potential to
considerably improve the national morbidity and mortality

HCPs are more likely to counsel patients about exercise if three conditions
are met: 1 low-level screening technology to judge the appropriateness
of intervention, 2 recommendations can be delivered easily within the
context of a patients visit, and 3 they can easily monitor the patients
adherence to prescribed recommendations18 This
paper demonstrates a user
friendly and efficient algorithm that meet the above conditions

Likewise, HCPs who have received minimal training in exercise prescription
or are unfamiliar in exercise standards are less likely to recommend
exercise programs to their patients This paper is designed to improve
counseling skills, define the current exercise guidelines and provide a
template of the exercise prescription The objective is to encourage HCPs
to confidently write appropriate exercise programs for their patient
population
There are several studies attempting to improve the physical activity
counseling skills of HCPs The results suggest small but positive effects
on patients, with 7 to 10 of sedentary persons starting to be physically
active19 Two such studies are the PACE Physician-based Assessment and
Counseling for Exercise and INSURE Industrywide Network for Social,
Urban, and Rural Efforts projects The PACE project was developed by the
Centers for Disease Control and Prevention CDC and was designed to
provide specific counseling protocols matched to the patients level of
activity and readiness to change20 Evidence suggests that the PACE
program is practical and
effective in increasing physical activity among
patients counseled in the primary care setting21 Likewise, the INSURE
project proved that medical education seminars combined with reimbursement
for prevention counseling heightened physician awareness and increased the
percentage of patients who subsequently started exercising

Several professional health organizations such as the American Heart
Association AHA, the Academy of Pediatrics, the American Medical
Association AMA, the Presidents Council on Physical Fitness and Sports
PCPFS, and the US Preventive Services Task Force USPSTF all recommend
including physical activity counseling as part of routine clinical
preventive services for adults and young people
BENEFITS OF EXERCISE

Healthy individuals and patients with existing medical conditions can
improve their exercise performance with training, thereby decreasing
morbidity and improving overall quality of life In recent years,
significant information has been obtained concerning the risk of a
sedentary lifestyle and the benefits of regular exercise

I All-Cause Mortality

Attributable risk estimates for all-cause mortality indicate that
low
physical fitness is an important risk factor in men and women Higher
levels of physical fitness appear to delay all-cause mortality
primarily due to lowered rates of cardiovascular disease and cancer22

II Atherosclerotic Vascular Disease

Cardiovascular disease mortality rates are significantly lower among
active than inactive individuals It has been estimated that as many
as 250,000 deaths per year in the United States are attributable to the
lack of physical activity4,23 These statistics are true in all age
groups, and are independent of other risk factors such as smoking,
hypertension, obesity, family history of heart disease, or
hyperlipidemia Inactive individuals are two times more likely to
develop coronary artery disease than active individuals24 Postulated
mechanisms appear to be multifactorial, but include enhanced lipid
profile, decreased blood pressure, weight reduction, increased insulin
sensitivity and increased fibrinolytic activity

Exercise in early adulthood confers protection from cerebrovascular
events in later life Decreasing atherogenesis by altering dependent

risk factors such as lipids and blood pressure appear to be the most
important mechanisms Of those who have suffered a stroke, physical
activity appears to hasten recovery of neurological deficits

III Cancer

Cancer is the second leading cause of death, after heart disease, in
the United States The two most avoidable causes of cancer are tobacco
use and alcohol consumption Physical inactivity appears to be the
other significant modifiable risk factor Moderate exercise appears to
enhance the function of the monocyte-macrophage system and natural
killer cells, therefore it is plausible for exercise in moderate
amounts to reduce cancer risk Table 325

Table 3

Physical Activity and the Reduced Risk of Specific Cancers
Cancer Type Potential Mechanism Potential Risk Decrease
Most cancer types Enhanced immune system Unknown

Colon cancer Shortened intestinal transit time 12 - 20
Decreased body fat
Breast cancer Hormone level changes 24Study of women
45
Decreased body fat
Prostate
cancer Hormone level changes Unknown
Adapted from Presidents Council on Physical Fitness and Sports Physical
Activity and Cancer Series 2, No 2, June 1995 Washington DC: US
Department of Health and Human Services

Epidemiological data suggest that exercise decreases the risk of
certain types of cancer, particularly colon and breast cancer26 It is
known that physical activity alters levels of reproductive hormones and
investigators have hypothesized that active individuals should
experience decreased incidence of hormonal dependent cancers such as
prostate, cervical, ovarian and uterine, however current data do not
consistently support this hypothesis27

IV Diabetes Mellitus

Diabetes Mellitus is categorized as either type 1 formerly referred
to insulin dependant diabetes mellitus or type 2 formerly referred to
non-insulin dependant diabetes mellitus Type 2 diabetes mellitus is
the most common form accounting for 90 to 95 of all diabetes
patients Of those with type 2 diabetes, 60 to 90 of individuals
were obese at the time of diagnosis Physical activity has been shown
to decrease the
risk of developing non-insulin dependent

diabetes mellitus28 Mechanisms that are responsible for this are
weight reduction, increased insulin sensitivity, and improved glucose
metabolism Exercise also prevents or delays the complications of
diabetes, specifically, peripheral and coronary atherosclerotic
vascular disease

Most type 2 diabetics have hyperinsulinism and the most recent
literature suggests that elevated insulin levels are associated in the
pathogenesis of atherosclerotic vascular disease Diabetics who engage
in an exercise program can lead healthier lives and alter potential
complications

V Hypertension

Recent data indicate that over 50 million people in the United States
have hypertension Physical activity is a non-pharmacological
treatment that has been shown over time to have a positive effect Two
large studies indicated that physically active individuals had 40 to
60 lower mortality rates than did otherwise comparable unfit and
sedentary hypertensives29 Cohort studies suggest that inactive
individuals have a 35 to 53 greater risk of developing hypertension

than those who exercise This effect seems to be independent of other
risk factors for hypertension3,30 The average reduction in systolic
blood pressure was 105 mm Hg from an initial systolic blood pressure
of 154 mm Hg and 86 mm Hg reduction in diastolic pressure from an
initial value of 98 mm Hg29 Proposed mechanisms include a reduction
in cardiac output, peripheral vascular resistance and sympathetic
nervous system activity

VI Osteoporosis

Osteoporosis affects over 20 million postmenopausal American women
and an unspecified number of men over 8010 The result of this process
is musculoskeletal weakness, disability, height loss and most
significantly, bone fractures of the hip and spine Two hundred fifty
thousand hip fractures occur annually costing over 10 billion dollars
in medical expenditures31

The development of osteoporosis is related to three factors: 1 a
deficient level of peak bone mass at physical maturity, 2 failure to
maintain this peak bone mass during the third and fourth decades of
life, and 3 the bone loss that begins during the fourth and fifth
decade of life Physical
activity may positively affect all three of
these factors In postmenopausal women, greater gain in bone density
accrues when physical activity and estrogen replacement therapy occur
simultaneously32 A proper exercise regimen that includes weight
bearing will slow the progression of bone loss and provide improved
muscle strength and balance, thereby reducing the overall risk of
osteoporosis and its complications33,34

VII Dyslipidemia

Physical activity positively enhances the lipid levels in the serum
Those who exercise regularly have been found to have 20 to 30 higher
high density lipoprotein HDL levels than those of their sedentary
counterparts35 HDL is a lipid scavenger that protects against
atherosclerosis by removing cholesterol from the serum Exercise also
reduces levels of triglycerides and very-low-density lipoproteins35
There appears to be less consistency comparing the effects of low
density lipoproteins and exercise

VIII Obesity

It is commonly believed that physically active people are less likely
to gain weight over the course of their lives and are thus more likely
to have
a lower prevalence of obesity than inactive individuals
Obesity plays a central role in the development of diabetes mellitus,
and confers an increased risk for hypertension, osteoarthritis, certain
cancers, coronary artery disease and all-cause mortality36-40 Daily
life long exercise with dietary management has been shown to be the
best predictor of long-term success in achieving and maintaining
optimal weight

IX Mental Health

Exercise appears to be medicine in the area of mental health
Depression is the most common mental disorder affecting over 10 million
Americans The estimated lifetime prevalence of major depression is
about 5 for men and 10 for women41 Psychiatrists have observed that
physical activity in patients with depression has both psychological
and physiological benefits42-43 Several studies conducted among
college students demonstrated that regular exercise can reduce anxiety
and depression44-47 The mechanism by which these positive effects are
achieved are unknown, but the most likely mechanism involves
improvement in the function of biogenic amine neurotransmitters48

Exercise in patients with depression is most beneficial when combined
with psychotherapy and/or medication

X Economic Benefits

The most widely used measure of the economic benefit of physical
activity programs is the benefit/cost ratio The benefit is expressed
as the amount of dollars saved from lower medical costs, less
absenteeism and reduced disability expense The cost in the equation
represents the dollar amount required to operate physical activity
programs The literature reports benefit/cost ratio ranging from 076
to 343 with the majority reporting a positive benefit/cost ratio49
Some of these studies were conducted on comprehensive health promotion
programs which included physical activity, weight control, nutritional
education and stress management50 The conclusions of these studies
indicates that physical activity is economically beneficial to
communities, corporations and public health

RISKS OF PHYSICAL ACTIVITY

I Exercise Related Sudden Death

The most significant risk associated with regular exercise is a
sudden death event Among children and young
adults, cardiac deaths
are caused by abnormalities such as hypertrophic cardiomyopathy,
Marfans syndrome, myocarditis and anomalous coronary artery anatomy
Among healthy older adults over 35 years of age, acquired
atherosclerotic coronary artery disease is the most common cause of
exercise- related sudden death ERSD51

Data from numerous studies show that 80 of sudden death among
competitive athletes 35 years and older were associated with coronary
artery disease52 The annual incidence of ERSD among previously
healthy middle-aged men is only 6 to7 per 100,000 exercisers53 A
study of male runners between 30 and 64 years of age in Rhode Island
reported approximately 1 death per 396,000 hours, or 1 per 7,620
joggers per year51,54 Sudden death among marathon runners who undergo
vigorous training and competition is extremely low accounting for 1 to
2 annual deaths in a population of 18,000 to 25,000 runners55 The
risk of myocardial infarction is transiently increased 2 to 6 fold
during exercise, however, regular exercise is associated with an
overall decrease in all-cause mortality30 Figures for
exercise-
related deaths among women are not available, but research suggests
that women are relatively protected from sudden cardiac deaths

As one can see, the risk of ERSD is extremely small Physicians need
to reassure their patients concerning the risk of sudden death and
physical activity As stated previously, the physiologic and
psychological benefits of exercise vastly outweigh the risks56

The rarity of cardiovascular complications during exercise limits the
utility of any strategy designed to reduce the incidence of such
events When comparing etiology of ERSD among different age groups, it
is important to define What, if any, is the best screening tool in
identifying at risk-patients For individuals below the age of 35,
congenital heart disease is the most common pathology for sudden death
In those who are 35 years and older, CAD is the most common cause of
sudden death

The most common cause of ERSD among young athletes is hypertrophic
cardiomyopathy accounting for 24 to 48 of all cases52,57 The most
accurate test to screen for this disease is with two-dimensional and M-

mode echocardiography The use of echocardiography as a screening tool
is limited by the low prevalence of hypertrophic cardiomyopathy and
cost of the test In an attempt to investigate screening strategies
for the prevention of ERSD in young athletes, Epstein and Maron
concluded 200,000 asymptomatic athletes would need to be screened to
identify one athlete who would die as a result of athletic
participation58 The current consensus in the literature and the
sports medicine community is that routine echocardiograms are not
recommended Screening for ERSD is best accomplished inquiring about a
family history, obtaining a targeted history that identifies exercise-
related symptoms and a thorough physical paying particular attention to
the cardiovascular system59

The cardiac exam should include the following: precordial
auscultations in both supine and standing positions to identify heart
murmurs consistent with dynamic left ventricular outflow obstruction;
assessment of femoral arteries to exclude coarctation of the aorta;
recognition of the physical stigmata of Marfans syndrome; and brachial

blood pressure measurements in the seated position Any abnormalities
with the above exam should warrant further investigation prior to
exercise clearance

The risk of CAD increases with age such that by age 35 it is the
primary cause of sudden death Exercise stress testing is the primary
screening tool that provides a controlled environment for observing the
effects of increased myocardial demand for oxygen It is widely used
as a first-choice diagnostic modality, a role in which it functions as
a gatekeeper to more expensive and invasive procedures It serves as
the cornerstone on which the exercise prescription is based and is the
primary method of assessing training efficacy Exercise testing is
generally a safe procedure which can be performed by primary care
physician in an office setting The risk of myocardial infarction and
death have been reported to occur at a rate of 1 per 2,500 tests61
The goal of screening is to identify individuals who have subclinical
CAD Identifying this population prior to exercise clearance may
prevent a catastrophic myocardial event during periods of increased

cardiac stress60

Sound clinical judgment should be utilized in deciding which patients
require exercise testing prior to engaging in a regular exercise
program The most predictive parameters of CAD are description of
chest pain, gender, age, and concurrent medical conditions Table 4
summarizes the pretest probability of CAD based on these parameters
This information is helpful for determining the potential utility of
exercise testing for a given patient Diagnostic testing is most
valuable in patients with an intermediate pretest probability or
higher

Table 4
Pretest Probability of Coronary Artery Disease by Age, Gender, and
Symptoms
Typical/Definite Atypical/Probable Nonanginal
Age Gender Angina Pectoris Angina Pectoris Chest Pain Asymptomatic
30 - 39 Men Intermediate Intermediate Low Very low
Women Intermediate Very low Very low Very low
40 -49 Men High Intermediate Intermediate Low
Women Intermediate Low Very low Very low
50 - 59 Men High Intermediate Intermediate Low
Women Intermediate
Intermediate Low Very low
60 - 69 Men High Intermediate Intermediate Low
Women High Intermediate Intermediate Low
High indicates 90; intermediate, 10 - 90; low, 10; and very low 5
No data exists for patients 30 or 69 years of age, but it can be assumed
that prevalence of coronary artery disease increases with age In a few
cases, patients with ages at the extremes of the decades listed may have
probabilities slightly outside the high or low range
Reproduced from ACC/AHA Guidelines for Exercise Testing Circulation 1997;
96: 345-354

Another factor that must be considered in diagnostic exercise testing
is the range of specificitys and sensitivitys observed In a meta-
analysis of 58 consecutively published reports involving 11,691
patients, it was shown that mean sensitivity and specificity rates were
67 and 72, respectively61 This translates into a small, but
significant number of false-positive and negative results False
negative results are most disturbing as it gives false assurance of
cardiac function to both the HCP and patient

Particularly difficult to detect is the evidence of fixed
stenoses
with collateral blood flow and low-grade stenoses These abnormalities
may not produce sufficient impairment of blood flow to affect the
electrocardiogram Some studies indicate that low-grade stenoses are
unstable and are a source of spontaneous thrombosis leading to
myocardial infarction and sudden death These lesions do not have the
benefit of collateral blood flow As a result exercise stress testing
would not be beneficial in detecting these types of lesions false-
negative result

False-positive results in exercise stress testing, although initially
alarming, are generally not as critical Patients must undergo further
invasive testing to verify absence of CAD These patients usually
suffer undue anxiety with the potential of adverse consequences related
to work and insurance coverage Other causes for false-positive
results include resting repolarization abnormalities, nonischemic
cardiomyopathy, coronary spasms, electrolyte abnormalities, medications
and middle-aged female gender

As one can see, there are limitations and pretest considerations for
exercise stress
testing Both the American College of Sports Medicine
ACSM and American College of Cardiology ACC do not recommend
screening in healthy, asymptomatic individuals unless they are at
moderate risk for suffering a cardiac event Moderate risk is defined
as: evidence of cardiac risk factors, men over 40 engaging in vigorous
intensity exercise and women over 50 engaging in vigorous intensity
exercise

The most important key to prevent sudden death among exercisers in
this age group is to educate patients of specific warning signs
Symptoms may manifest as angina, nausea, abdominal discomfort,
dizziness or fatigue In a case review of 28 marathon runners who died
suddenly or had a myocardial infarction, 20 experienced premonitory
symptoms56 Despite some limitations in screening for ERSD, education
and exercise stress testing in certain populations is the most
effective way to prevent sudden death related to exercise

II Musculoskeletal

The most common problems associated with physical activity are
musculoskeletal injuries, which can occur from excessive amounts of
activity or suddenly beginning
an activity for which the body is not
conditioned These may present as muscle fatigue, joint/ligament
damage or overuse injuries The most common site of injury is the
lower extremity involving the knee, ankle and foot

Studies of injuries during exercise show that the two most important
factors in determining the risk of injuries are age, and the impact
nature of activity62 Additionally, the incidence of injury increases
as the duration and frequency of exercise intensifies The incidence
of orthopedic injuries more than doubles when comparing 45 minute
exercise sessions versus 30 minute sessions, yet improvement in VO2max
is minimal63 Table 5 lists several popular forms of activity
classified by musculoskeletal impact With appropriate conditioning
and gradual increase in duration and intensity, most injuries can be
avoided Injuries, when they do occur, are short-term and gradual
return to exercise is the rule64

Table 5
Categories of Activity by Musculoskeletal Impact
High Impact Low Impact
Jogging/running
Walking/hiking
Basketball Cycling
Volleyball Stationary cycling
Hopping/jumping Swimming
Rope skipping Rowing
Aerobic dancing Cross-country skiing
Downhill skiing
Derived from Pollock ML, Wilmore JH, eds Exercise in Health and disease:
Evaluation and Prescription for Prevention and Rehabilitation 2nd Ed
Philadelphia, PA: WB Saunders Co 1990

III Miscellaneous Risks

Other adverse effects of physical activity include metabolic and
hematologic disorders Metabolic disorders are rare, but include
hyperthermia in warmer weather, hypoglycemia in diabetics, electrolyte
imbalances, and dehydration Hematologic manifestations, likewise
rare, include hemoglobinuria, hematuria and rhabdomyolysis Generally,
these occur in athletes engaged in vigorous activity Lastly, cyclist,
runners and walkers often face risks when traveling on roadways such as
motor vehicle collisions, falls on uneven surfaces, and attacks by
animals

Current Recommendations

I Evolution of Physical
Activity Recommendations

Recommendations for physical activity based on clinical and
scientific data did not surface until the 1960s Expert panels and
committees operating under health and fitness organizations began to
recommend specific physical activity programs to promote physical
health such as the Presidents Council on Physical Fitness of 1965;
American Heart Association AHA in 1972, 1975; and American College of
Sports Medicine ACSM in 1975 In 1978 the ACSM published a position
statement titled The Recommended Quantity and Quality of Exercise for
Developing and Maintaining Fitness in Healthy Adults This statement
outlined the exercise that healthy adults would need to develop and
maintain cardiorespiratory fitness and healthy body composition

Between 1978 and 1990, most exercise recommendations made to the
general public were based on this 1978 position statement In large,
these recommendations addressed only cardiorespiratory fitness and body
composition Over time, interest developed in health benefits of
moderate exercise and alternative physical activity regimens

In 1990,
the ACSM updated its position statement by adding muscular
strength and development as a major objective The 1990
recommendations also recognized that activities of moderate intensity
may have health benefits independent of improving cardiorespiratory
fitness65 An important distinction was made between physical activity
as it relates to health versus fitness The quantity and quality of
exercise needed to attain health-related benefits differed from what
was recommended for cardiorespiratory fitness Lower levels of
physical activity were needed to attain health benefits, yet these
levels were insufficient to improve VO2 max, thus no significant
improvement in cardiorespiratory fitness66,67 As a result of these
findings, the CDC and ACSM jointly published guidelines to reflect the
health benefits of lower intensity exercise

In 1998, the ACSM published updated guidelines These guidelines
detail health benefits at lower intensity exercises, however, the focus
still remains on improving cardiorespiratory fitness
Listed below are current recommendations by various organizations
beginning with
the most recognized authority in physical activity, the
ACSM The recommendations issued in this report are derived from the
ACSM guidelines

II Current Recommendations

A The American College of Sports Medicine Position Stand68 1998

The ACSM has recently published the newest guidelines for the
recommended quantity and quality of exercise for developing and
maintaining cardiorespiratory and muscular fitness and flexibility
in healthy adults This report is divided into cardiorespiratory
endurance and body composition, which contains the frequency of
training, intensity of training, duration of training, and mode of
activity The muscular strength and endurance, body composition,
and flexibility section addresses resistance training and
flexibility training Each of these components will be discussed
separately

1 Frequency of training - the recommendation is 3 to 5 days per
week The VO2max has been shown to increase with frequency
of training and tends to plateau when frequency exceeds 3
times per week The
additional improvement in VO2max which
occurs with training more than 5 days per week is minimal and
the incidence of injury increases disproportionately

2 Intensity/Duration - intensity recommendations are defined as
65 to 90 of maximum heart rate or 50 to 85 of maximum
oxygen uptake or maximum heart rate reserve Duration should
be 20 to 60 minutes of continuous aerobic activity
Intensity and duration are closely related with the total
amount of work performed Improvement in fitness will be
similar for activities performed at a lower intensity-longer
duration compared to higher intensity-shorter duration if the
total energy expenditure is equal A realistic goal should
be to expend 700 to 2,000 kilocalories per week
3 Mode of activity - any activity that utilizes large muscle
groups in a continuous and rhythmic nature such as walking,
running, cycling, swimming, skating and various endurance
game activities

4 Resistance training - training of
moderate intensity
sufficient to develop and maintain fat-free weight FFW
One set of 8 to 12 exercises that condition the major muscle
groups 2 to 3 days of the week Persons under 50 years of
age should complete 8 to 12 repetitions of each exercise and
persons over 50 years and older, 10 to 15 repetitions or
until volitional fatigue, whichever occurs first

5 Flexibility training - major muscle/tendon groups should be
developed using static, ballistic, or modified proprioceptive
neuromuscular fasciculation PNF techniques Static
stretches should be held for 10 to 30 seconds whereas PNF
techniques should include a 6 second contraction followed by
10 to 30 seconds assisted stretch At least 4 repetitions
per muscle group should be completed 2 to 3 times per week

B Recommendation from the Centers for Disease Control and
Prevention and the American College of Sports Medicine 19954

The recommendation is to participate in 30 minutes or more of
moderate-intensity
physical activity on most, preferably all days
of the week This recommendation emphasizes the benefits of
moderate-intensity physical activity that can be accumulated in
relatively short bouts Adults who engage in moderate-intensity
physical activity, that expends a minimum of 200 calories can
expect many of the known health benefits Table 6 provides
several examples of common physical activities and their
respective intensities Accumulation of physical activity in
intermittent, short bouts is considered an appropriate approach in
achieving the activity goal Evidence suggests that the amount of
activity is more important than the specific manner in which the
activity is performed69,70 The frequency of activity should be
most days, if not all days of the week Additionally, this
recommendation also emphasizes muscular strength and flexibility
as a means to improve balance, strength and coordination, which in
turn may prevent injuries and falls

Table 6
Examples of Common Physical Activities for
Healthy US Adults by Intensity
of Effort Required
Light Moderate Heavy/Vigorous
Walking, slowly Walking, briskly Walking, briskly uphill
Cycling, stationary Cycling, pleasure Cycling, fast
Swimming, slow treading Swimming, moderate Swimming, fast treading
Calisthenics, stretching Calisthenics, general Calisthenics, aerobic
dance
Racket sports leisure Racket sports competitive
Golf, power cart Golf, pulling/carrying clubs
Bowling
Fishing, sitting Fishing, standing/casting Fishing in stream
Boating, power Canoeing, leisure Canoeing, rapid 4 mph
Home care, sweeping/vacuuming Home care, general cleaning Moving
furniture
Mowing lawn, riding mower Mowing, power mower Mowing, hand mower
Home repair, carpentry Home repair, painting
Data from Ainsworth et al, Leon, and McArdle71-73

C The American Heart Association/Scientific Statement 199619

The recommended frequency of training is 3 to 4 times per week
Intensity should be greater than 50 of VO2max Duration is
recommended between 30 to 60 minutes Mode of activity is
designed for endurance training Resistance training was not

addressed in this report

D American Medical Association Guidelines for Adolescent
Preventive Services 199419

The recommendations were specifically designed to address physical
inactivity in the pediatric population These recommendations are
similar to the ACSM Frequency should be greater than 3 times per
week Intensity should be moderate with 20 to 30 minutes of
endurance type activity Resistance training was not addressed in
this report
E Department of Health and Human Service DHHS-Healthy People
2,000 19958

The risk reduction objective is to have at least 30 of the
population age six and older to engage in regular, preferably
daily, light to moderate physical activity of 30 minutes in
duration Resistance training was not addressed

F United States Preventive Services Task Force 199619

The objective of this recommendation was for primary prevention in
clinical practice Endurance, strength and flexibility is
encouraged at moderate intensity for 30 minutes preferably most
days of the week

G Several
other organizations such as the Presidents Council on
Physical Fitness; National Heart, Lung, and Blood Institute;
United States Department of Health and Human Services; American
Association for Cardiovascular and Pulmonary Rehabilitation and
Young Mens Christian Association YMCA recommendations are
largely based on the CDC/ACSM guidelines

III Summary of Recent Physical Activity Recommendations

The traditional, structured approach originally described by the ACSM
and other organizations involved specific recommendations regarding
type, frequency, intensity and duration of activity such as fast
walking, running, cycling, swimming or aerobic activity As a way to
bridge the gap for sedentary individuals, physical activity
recommendations have adopted a lifestyle approach to increasing
activity4

This method involves common activities such as brisk walking,
climbing stairs, yard work and engaging in active recreational
pursuits Either approach can be beneficial for sedentary individuals
Individual interests and goals should be used to determine which is
more
appropriate The most recent recommendations cited agree on
several points:19
A All people over the age of 2 years should engage in at least 20
to 60 minutes of endurance-type physical activity of moderate
intensity on most-preferable all-days of the week Intermittent
bouts of physical activity, as short as 8 to 10 minutes, totaling
20 to 60 minutes a day will provide beneficial health and fitness
effects

B Additional health and functional benefits of physical activity
can be achieved by adding more time in moderate-intensity
activity, or by substituting more vigorous activity

C Persons with symptomatic CAD, diabetes, or other chronic health
problems who would like to increase their physical activity should
be evaluated by a HCP and provided an exercise program appropriate
for their clinical status

D Previously inactive men over age 40, women over age 50, and
people at high risk for CAD should first consult a physician
before embarking on a program of moderate physical activity to
which they are
unaccustomed

E Strength-developing activities resistance training should be
performed at a minimum of two times per week At least 8 to 10
strength-developing exercises that use the major muscle groups of
the arm, legs, trunk and shoulders should be performed at each
session, with one or two sets of 8 to 12 repetitions of each
exercise or until volitional fatigue occurs

Exercise Prescription

I Approach to Recommending Exercise

One of the most challenging aspects of medicine is how HCPs approach
a sedentary patient and attempt to recommend and prescribe an exercise
program Clearly, not all patients are willing to accept a providers
advice to start exercising Others may desire to exercise, yet lack
the knowledge or motivation In an attempt to take a non-threatening,
unbiased approach to this subject, this paper has designed a useful
algorithm that demonstrates the approach to exercise assessment and
exercise prescription Figure 1 This algorithm represents a
modification of the assessment utilized by the PACE Program

Utilizing a
single counseling session to implement an exercise
prescription is difficult We recommend two separate office visits or
two consecutive appointment slots Prior to the initial assessment,
patients are asked to complete the Exercise Assessment form located in
Appendix A This form serves several purposes First, it identifies
an individuals physical activity status Secondly, this form will
assess cardiovascular risk and potential necessity for pre-exercise
testing Thirdly, the form will determine the patients performance
goals The first counseling session should entail a review of the
assessment form, a focused history and physical examination, and a
discussion of the individuals performance goals The second session
is utilized to review the individualized exercise prescription

The exercise assessment form identifies three levels of physical
activity: precontemplator, contemplator and active individuals The
precontemplator does not exercise nor intends to start in the near
future The contemplator either has considered starting an exercise
program or is doing so infrequently and the active
individual is near
or achieves physical activity standards Although PACE scores will
vary with practices, approximately 10 1 out of 10 patient visits are
precontemplators, 50 5 out of 10 patient visits are contemplators
and 40 4 out of 10 patient visits are actives desirable levels
The reporting bias by patients tendency of patients to report doing
more intense or frequent activity than they are actually doing can
influence the actual numbers when assessing levels of physical
activity

Figure 1
Exercise Assessment and Prescription
Flow Chart

Follow-up

High Risk

Yes

No

Counseling strategies will differ based on the patients stage of
readiness Precontemplators have no desire to exercise, therefore,
counseling should be aimed at identifying potential personal benefits
of an active lifestyle This patient may present roadblocks to justify
their inactivity
Below are some common roadblocks encountered by HCPs
Table 7 The goal is to encourage the individual into the
contemplator category When confronted by a precontemplator,
distribute the Getting Out of Your Chair handout, located in the
Resources/Reference section and schedule a follow-up appointment

Table 7

How to Approach Roadblocks
Roadblock: How to get past it:
I do not have time Were only talking about three 30
minute sessions each week Can
you do without three television shows a week?

I am usually too tired to exercise Regular activity will improve
your energy level Try and see for
yourself

The weather is too bad There are many activities you can
do in your home, in any weather

Exercise is boring Listening to music during your
activity keeps your mind occupied
Walking, biking, or running can take you past
lots of interesting scenery

I do not enjoy exercise Do not exercise Start a hobby
or an
enjoyable activity that gets
you moving

I get sore when I exercise Slight muscle soreness after
physical activity is common when you
are just starting It should go away in 2 to 3
days You can avoid this by building up
gradually and stretching after each activity
Reproduced from Patrick K, Sallis JF, Long B, Calfas KJ, et al A new tool
for encouraging activity: Project PACE
Phys Sportmed 1994; 22: 45-55

Contemplators are patients who do little or no regular physical
activity, yet are interested in becoming more active These
individuals are ready for change, but may require additional knowledge,
skill, or encouragement Counseling goals should be directed at
reinforcing benefits of exercise, addressing barriers and changing
patient behavior Contracting and setting realistic goals is an
effective counseling method designed to increase activity in this
group

Actives are patients already participating in physical activity at
various levels of intensity This group should be praised for their

self-motivation and encouraged to continue an active lifestyle
Benefits of exercise, pitfalls in their current exercise program, and
short-term goals should be reviewed and established

When an individual has decided to incorporate physical activity
within their lifestyle, a personal goals analysis should briefly be
performed HCPs will be more successful in recommending physical
activity if they know the patients desires Recommendations for
activity will depend on the specific health, fitness and performance
goals of the individual A recommended model is outlined below
Table 8:

Table 8
Model for Physical Activity Recommendations
Individuals goals based on current level of fitness
Recommendations

1 Sedentary Individual
Flexibility Initiate conditioning
exercises/stretching
Health benefits Initiate low to moderate
intensity leisure exercise Table 6
Physical fitness Initiate moderate intensity
exercise aerobic fitness

2 Moderately Active Individual
Flexibility
Continue conditioning
exercises/stretching
Health benefits Continue low to moderate
intensity exercise
Physical fitness Continue moderate intensity
exercise aerobic fitness
Muscle strength and endurance Initiate/continue weight
training program

3 Vigorously Active Individual
Flexibility Continue conditioning
exercises/stretching
Health benefits Goal already achieved
Physical fitness Continue vigorous intensity
exercise aerobic fitness
Muscle strength and endurance Continue weight training
program
Elite performance Competitive organized
sports league

II Pre-exercise Evaluation

The initial evaluation should be incorporated into the routine
history and physical examination Specific issues that should be
addressed are listed in Table 9 The physical examination should
include, but not be limited to, cardiovascular, pulmonary,
musculoskeletal and peripheral vascular assessment
Laboratory
screening generally is not indicated, however, if someone appears to be
at risk for CAD it is not unreasonable to obtain a lipid profile
Remaining laboratory analysis should be dictated by clinical judgment

Table 9

Pre-exercise Evaluation History

Current and past exercise habits mode, frequency, intensity, duration
Current motivation and barriers to exercise
Preferred forms of physical activity
Beliefs about benefits and risks of exercise
Risk factors for heart disease hypertension, diabetes mellitus,
hyperlipidemia,
smoking, family history of heart disease before 55 years of age
Physical limitations precluding certain activities
Exercise-induced symptoms
Concurrent disease cardiac, pulmonary, musculoskeletal, vascular,
psychiatric, etc
Social support for exercise participation
Time and scheduling considerations
Medication profile
Reproduced from Jones TF, Eaton CB Exercise Prescription Am Fam
Physician 1995; 52: 543-550

A medication history prescribed and over-the-counter is very
important and should likewise be obtained Certain medications
interfere with heart rate, blood pressure and
exercise capacity and may
potentially cause cardiovascular or respiratory insult Appendix C
lists some common medications and their specific effects

There is a small subset of patients in which the risk of exercise will
exceed the benefit Table 10 lists the absolute and relative
contraindications to exercise HCPs should carefully review the
contraindications and discuss viable options with the patient In
these circumstances, it is advisable to have a cardiologist and/or
exercise physiologist involved in the decision-making process

Table 10

Contraindications to Exercise
Absolute Contraindications
Recent acute myocardial infarction
Unstable angina
Ventricular tachycardia and other dangerous dysrhythmias
Dissecting aortic aneurysm
Acute congestive heart failure
Severe aortic stenosis
Active or suspected myocarditis or pericarditis
Thrombophlebitis or intracardiac thrombi
Recent systemic or pulmonary embolus
Acute infection

Relative Contraindications
Untreated or uncontrolled severe hypertension
Moderate aortic stenosis
Severe subaortic stenosis
Supraventricular dysrhythmias
Ventricular
aneurysm
Frequent or complex ventricular ectopy
Cardiomyopathy
Uncontrolled metabolic disease diabetes, thyroid disease, etc or
electrolyte abnormality
Chronic or recurrent infectious disease malaria, hepatitis, etc
Neuromuscular, musculoskeletal or rheumatoid diseases that are exacerbated
by exercise
Complicated pregnancy
Adapted from British Columbia Ministry of Health and the Department of
National Health and Welfare PAR-Q validation report In: Canadian
standardized test of fitness CSTF operations manual 3rd ed Ottawa,
Ontario: Fitness Canada, Fitness and Amateur Sport Canada, 1986 and
American College of Sports Medicine Guidelines for exercise testing and
prescription 4th ed Philadelphia: Lea Fegiger, 1991; 59

III Graded Exercise Testing GXT

The American College of Cardiology ACC and the American Heart
Association AHA Task Force in July 1997 updated the latest practice
guidelines for exercise testing61 The report stated that prior to
initiating a fitness program, those who would benefit from a GXT for
risk stratification are those with a history of cardiac disease,
patients on antihypertensives, and
sedentary middle-aged men older than
40 to 50 years In asymptomatic individuals without known cardiac
disease, the risk of suffering a major cardiac event during activity is
small and there is no data to justify or criticize exercise testing74
Table 11 lists indications for exercise stress testing
Contraindications to exercise stress testing are similar to those for
exercise as listed in Table 10 The ACSM and ACC/AHA guidelines are
similar and both discourage screening in asymptomatic adults unless
they are at increased risk

Table 11

Indications for Exercise Stress Testing
1 Evaluation of patients with suspected coronary artery disease
Typical angina pectoris
Atypical angina pectoris

2 Evaluation of patients with known coronary artery disease
After myocardial infarction
After intervention

3 Screening of healthy, asymptomatic patients
Persons in high-risk occupations eg, pilots, firefighters, law
enforcement officers, mass transit operators
Men over age 40 and women over age 50 who are sedentary and plan to start
vigorous exercise
Persons with multiple cardiac risk factors
or concurrent chronic diseases

4 Evaluation of exercise capacity in patients with valvular heart disease
except severe aortic stenosis

5 Patients with cardiac rhythm disorders
Evaluation of exercise-induced arrhythmia and response to treatment
Evaluation of rate-adaptive pacemaker setting
Adapted from Gibbons RJ, Balady GJ, Beasley JW, et al ACC/AHA Guidelines
for Exercise Testing A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines J
Am Coll Cardiol 1997; 30: 260-311

In summary, certain situations may require clinical judgment,
however, the parameters for pre-exercise stress testing for the most
part are straightforward Figure 2 demonstrates an useful algorithm
for evaluating the need for GXT before a patient begins a formal
exercise program

Figure 2

Cardiovascular Risk Assessment

No
Yes

No

Yes

No

IV Writing the
Exercise Prescription
It has been shown that if HCPs take the time to write an exercise
prescription, patients are more likely to comply with the doctors
orders A pharmacological prescription has the drug, dose, route and
frequency, likewise an exercise prescription provides the patient
instructions regarding exercise goals The following sections present
important components of the exercise prescription and is summarized in
Table 12 The cardiovascular exercise prescription form is located in
Appendix D A patient handout on general guidelines for cardiovascular
exercise may be found in the resource and reference section at the back
of the book

Table 12

Components of an Exercise Prescription
Activity Selection
Duration
Frequency
Intensity
Progression
Resistance Training
Flexibility Training

A Activity Selection
The choice of physical activity should be based on the
individuals fitness level and interest The most effective
exercises for aerobic training employ large-muscle groups that are
maintained
in continuous and rhythmic motion Examples include
walking, jogging, running, cycling, swimming, rope skipping,
rowing and stair climbing The most popular activity is walking
This activity requires no specialized equipment or facility
Activity selection will also depend on availability of specialized
facilities such as gymnasiums, pools and fitness centers Table
13 lists several activities with their respective benefits Most
of these activities, if done at or below moderate intensity, will
provide health benefits, but not necessarily cardiorespiratory
benefit For example, while leisure walking will promote health
benefits, the lower intensity, may not increase cardiorespiratory
fitness

Table 13

Activity Selection Guide

Purpose Muscular Muscular Cardiorespiratory
Flexibility Body Composition Speed/ Coordination
Strength Endurance Endurance
Agility
Aerobics X X X
X X
Bicycling
X X
X
Calisthenics X X X
X X
Golf X

Skiing X X X X
X X
Jogging/Running X X
X
Racquet Sports X X X
X X
Stair Climbing X X

Stretching X

Swimming X X X
X X
Walking Fast X

Weight Training X X
X X

Cardiovascular goals can be established by modifying frequency,
duration and intensity Other training options, which can be used
for conditioning of sedentary adults, include calisthenics, arm
exercises and weight training The latter is particularly
important, since traditional aerobic conditioning regimens often
fail to accommodate participants who have an interest in improving
muscular
strength and endurance The levels of energy
expenditures for activities vary and are listed in Table
1461,75,76
Table 14

Energy Expenditures for Various Activities

Activity METs Kilocalories per
hour

Aerobic dancing 6 to 9 440 to 660
Bowling 2 to 4 150 to 300
Calisthenics 3 to 8 220 to 600
Canoeing leisure 3 to 6 220 to 440
Cycling 10 mph 3 to 6 220 to 440
Cycling 10 mph 6 to 8 440 to 600
Dancing 3 to 7 220 to 510
Desk Work 15 to 25 110 to 180
Fishing sitting 15 to 3 110 to 220
Fishing standing/casting 3 to 6 220 to 440
Football touch 6 to 10 440 to 740
Golf walking 2 to 3 150 to 220
Handball 8 to 12 600 to 880
Hiking
cross-country 3 to 7 220 to 510
Lawn mowing 3 to 8 220 to 600
Running at 5 mph 87 640
Running at 6 mph 102 750
Running at 10 mph 163 1,200
Sexual intercourse 2 to 5 150 to 370
Shoveling 4 to 7 300 to 510
Shuffleboard 2 to 3 150 to 220
Skating ice/roller 5 to 8 370 to 600
Skiing cross-country 6 to 12 440 to 880
Skiing downhill 5 to 8 370 to 600
Soccer 5 to 12 370 to 880
Softball 3 to 6 220 to 440
Stair climbing 4 to 8 300 to 600
Swimming moderate 4 to 6 300 to 440
Swimming fast treading 6 to 8 440 to 600
Tennis 4 to 9 300 to 660
Volleyball 3 to 6 220 to 440
Walking at 2 mph 2
150
Walking at 4 mph 45 330
Walking 4 mph and uphill 6 440
mph miles per hour
- 1 MET resting metabolic rate, 35 mL of O2 per kg per minute

- The kilocalories expended during a particular activity are based
on a person weighing 70 kg 154 lb One kilocalorie approximately
200 mL of O2 consumed24,61,75,76

Another consideration when selecting activities is to assess the
patients pre-existing medical conditions It would be
impractical to recommend jogging to a patient with severe
osteoarthritis For obese, elderly or arthritic individuals, it
may be more practical to offer
low-impact exercises designed to decrease injuries and increase
compliance Examples of low-impact activities are cycling,
golfing, walking and swimming Each exercise prescription should
give specific guidance as to what activity will benefit the
patient most

B Frequency

The optimal training frequency appears to be 3 to 4 sessions per
week The amount of improvement in VO2max tends
to plateau when
frequency of training is greater than three times per week,
whereas the incidence of overall injuries increases
significantly77

Although improvement in cardiorespiratory fitness can occur in
deconditioned individuals exercising only 1 to 2 times per week,
such regimens evoke little weight loss, stamina or endurance For
conditioned individuals, training less than 2 days per week will
result in minimal improvement in cardiorespiratory fitness

C Duration

The duration of exercise required for cardiorespiratory fitness
and improvement in VO2max varies inversely with the intensity
The greater the intensity, the shorter the duration of exercise
necessary to achieve improvement in cardiorespiratory fitness
Exercise programs of low intensity but long duration can yield
results similar to those of higher intensity and shorter duration
Current recommendations are to engage in 20 to 60 minutes of
aerobic exercise excluding warm-up and cool-down As with
frequency, duration of exercise in excess of
45 minutes is
associated with increasing incidence of orthopedic injury To
avoid acute injury, gradually increase frequency, duration, and
intensity of activity over a period of several weeks to months

D Intensity

The final and most difficult aspect of the exercise prescription
to write is intensity The intensity should be specifically
tailored to the patients performance goals The optimal
intensity for aerobic exercise training occurs between 50 to 85
of the functional aerobic capacity VO2max Deconditioned
patients should start at 40 to 50 of their VO2max78 VO2max
represents the amount of oxygen transported and used in cellular
metabolism during maximal exercise

Exercise intensity can be prescribed by several methods, the most
popular of which are utilization of the target heart rate;
calculated VO2max; or category-ratio scales for rating of
perceived exertion79 In most cases it is not feasible to
directly measure oxygen uptake in patients Studies show that
heart rate and oxygen uptake are
linearly related during peak
exercise63 Thus heart rate monitoring has become widely accepted
as an indicator of exercise intensity

The recommended target heart rate THR should be 65 to 90 of
maximum heart rate MHR This heart rate range is for
improvement/maintenance of VO2max Health-related benefits may be
seen at lower heart rate ranges This method of calculating THR
has come under some scrutiny because the variability of age-
predicted heart rate maximums Furthermore, recent data suggest
the use of the 220 minus the patients age formula significantly
underestimates the MHR, especially in the elderly population80

The alternate method to calculate THR employs the use of heart
rate reserve HRR - the Karvonen equation First, calculate the
MHR Women subtract their age from 220 and men subtract one-half
their age from 205 The second step is to determine the resting
heart rate RHR Third, calculate the HRR The HRR is MHR minus
RHR Lastly, the THR is the product of training intensity TI,
generally 60 to 80,
multiplied by the HRR then adding the RHR

[THR MHR - RHR x TI RHR]
For example, what is the THR for a 40 year old male with a RHR of
60 who is to exercise between 70 and 80 TI? His MHR is 205
minus 40 divided by 2, which equates to 185 beats per minute
BPM Thus his HRR is 185 MHR minus 60 RHR which is 125 BPM
Seventy percent TI equals 07 TI multiplied by 125 HRR plus
60 RHR This figure calculates to 1475 BPM Eighty percent TI
when calculated using the same formula yields 160 BPM Thus this
individual would have a THR ranging from 148 to 160 BPM

When a THR is calculated, the patient should be taught to monitor
their heart rate at various stages of exercise The easiest pulse
to press is the carotid artery Caution patients, specifically
older individuals not to palpate hard when counting their pulse
In order to calculate beats per minute a patient counts their
pulse for 15 seconds and then multiplies this figure by 4
Alternatively, the radial artery can be utilized Commercial
heart rate
monitors are available for interested patients

Intensity can also be judged as a rating of perceived exertion
RPE, which can be equated to desirable heart rate during
individual activities The original scale introduced by Borg in
the early 1960s is a 15 grade category scale ranging from 6 to
20, with a verbal description at every odd number that is an
important adjunct to heart rate monitoring during training The
RPE scale provides valuable information related to the amount of
strain or fatigue the patient is experiencing during exercise
The original scale was validated in a young population to
represent the actual heart rate at a given level of work
Unfortunately, heart rate maximums decline with age and therefore
actual heart rates and RPE do not match Despite these findings,
the linear relationship between heart rate and work intensity
remains for individuals at all ages76 The following rating of
perceived exertion values should be followed:81

less than 12 - light, 40 to 60 of maximal
12 to 13
- somewhat hard moderate, 60 to 75 of maximal
14 to 16 - hard heavy, 75 to 90 of maximal

The RPE can be a very powerful tool, particularly in populations
who are uncomfortable in measuring pulse, those with arrhythmias
eg, atrial fibrillation, atrial flutter, and patients on drugs
that slow the heart rate eg, beta-blockers, certain calcium
channel blockers The RPE can be performed safely, efficiently
and accurately without interfering aerobic activity Table 15
summarizes the Borg scale79,81

Table 15

Borg Scale for Rating Perceived Exertion
15-Grade Scale 10-Grade Scale
6 0 Nothing
7 Very, very light 05 Very, very weak just
noticeable
8 1 Very weak
9 Very light 2 Weak light
10 3 Moderate
11 Fairly light 4 Somewhat strong
12 5 Strong heavy
13 Somewhat hard 6
14
7 Very strong
15 Hard 8
16 9
17 Very Hard 10 Very, very strong almost
maximum
18
19 Very, very hard Maximum
20
The rating of perceived exertion scales The original scale 6-20 on the
left and the newer 10-point category scale with ratio properties on the
right From Borg GA Psychological bases of perceived exertion Med Sci
Sport Exerc 1982; 14: 377-387

Exercise intensities have been reclassified based on realistic
time periods for training, an individuals relative exercise
intensity and relative intensity by age Table 16 demonstrates
the relationship between VO2max, ratings of perceived exertion,
maximum heart rate and METS Table 14 depicts various activities
with their respective METS and caloric expenditures The ACSM has
also established that lower intensity exercises provide health
benefits without significantly improving cardiovascular fitness
Table 16
Classification of physical activity
intensity, based on activity lasting up
to 60 minutes
Strength-
type
Endurance-type activity exercise
Absolute intensity METs
Relative
Relative intensity in healthy adults age in years
intensity
Maximal
VO2max Maximal Middle- Very
voluntary
heart rate heart Young aged Old old contraction
Intensity reserve rate RPE 20-39 40-64 65-79
80 RPE

Very light 25 30 9 30 25 20 125 10
30

Light 25-44 30-49 9-10 30-47 25-44 20-35
126-22 10-11 30-49

Moderate 45-59 50-69 11-12 48-71 45-59 36-47
23-295 12-13 50-69

Hard 60-84 70-89 13-16 72-101
60-84 48-67
30-425 14-16 70-84

Very hard 85 90 16 102 85 68 425 17-19
85

Maximal 100 100 20 120 100 80 50 20
100

Table provided courtesy of Haskell and Pollock
Based on 8-12 repetitions for persons under age 50 years and 10-15
repetitions for persons aged 50 years and older
Borg rating of Relative Perceived Exertion 6-20 scale Borg 1982
Maximal values are mean values achieved during maximal exercise by healthy
adults Absolute intensity METs values are approximate mean values for
men Mean values for women are approximately 1-2 METs lower than those for
men
Reproduced from The recommended quantity and quality of exercise for
developing and maintaining cardiorespiratory and muscular fitness, and
flexibility in healthy adults Med Sci Sports Exerc 1998; 30: 975-991

E The Exercise Session

A typical exercise session includes a warm-up period, a
cardiorespiratory phase, and a cool-down period Warm-up should
last five to ten minutes
and is designed to prepare the body for
transition from rest to the cardiorespiratory phase A
preliminary warm-up serves to stretch muscles, increase
flexibility and gradually increases heart rate and circulation
An appropriate warm-up will decrease the incidence of both
orthopedic injury and the potential for adverse ischemic
responses Thus warm-up has musculoskeletal and cardiovascular
preventive value An ideal warm-up for the endurance phase of
training should be the same activity only at a lower intensity

The cardiorespiratory phase of exercise should last 20 to 60
minutes at the individuals predetermined heart rate range or
rating of perceived exertion This phase serves to stimulate
oxygen transport and maximize caloric expenditure There appears
to be little additional cardiovascular benefit beyond 30 minutes
of the endurance phase82 Longer exercise sessions are also
associated with a disproportionate incidence of musculoskeletal
injuries63 Improvement in VO2max increases linearly with
increasing
intensity of exercise to a peak of 80 VO2max with
little additional cardiorespiratory benefit thereafter

The cool-down period follows the cardiorespiratory phase and
should last 5 to 10 minutes The cool-down period again may be
the same exercise only at a much lower intensity Exercises of a
muscle-stretching or muscle lengthening nature are likewise
encouraged Specific muscle groups should include extensor muscle
of the back, lower leg and upper extremity These activities will
gradually decrease the heart rate and blood pressure to near
resting values

F Rate of Progression

The providers first goal should be to engage the patient in a
regular exercise program at an acceptable minimum frequency
Thereafter, emphasis is placed first on increasing frequency,
second on increasing duration, and lastly, on increasing
intensity It is best to maximize the preceding variable prior to
increasing subsequent variables

The rates of progression can be separated into 3 phases: initial
conditioning phase;
improvement conditioning phase; and
maintenance conditioning phase The benefits derived from each of
these phases will depend on the patients age, current level of
fitness, intensity of their physical activity program and
individual goals In general, the benefits of physical activity
represent a dose-response curve

The initial conditioning phase lasts approximately 4 to 6 weeks
During this phase, training effects should be appreciated These
are a decrease in resting heart rate, more rapid recovery of
resting heart rate following physical activity, and the ability to
increase duration and intensity without increasing fatigue

The improvement conditioning phase lasts approximately 4 to 6
months Patients can be progressed to reach target heart rates or
desired duration of physical activity It is best to first
increase the duration of activity to the desired length and then
increase the intensity The patient will continue to enhance
cardiorespiratory fitness resulting in improved endurance and
resistance to
early fatigue

Most patients enter the maintenance conditioning phase after 6
months of regular exercise Individuals will have obtained the
desired level of cardiorespiratory fitness and do not need to
increase their duration or intensity of exercise Emphasis may be
refocused from an exercise program involving primarily fitness
activities to one which includes a more diverse array of enjoyable
activities Patients should be advised that different forms of
exercise or activities of similar intensity can be employed to
maintain interest in exercise

The use of a structured exercise program can facilitate patients
through the phases of conditioning Three fitness levels are
assigned: beginner, intermediate and advanced The patients
should be assigned to one of these levels based on their level of
fitness Prior to initiating an exercise program, stress the
importance of maintaining a training log This log provides the
patient with a record of their progress Located in Appendix E
and F are two sample logs, one
for beginners and one for
intermediate athletes Patients who are at an advanced level of
fitness generally have an existing structured program Each level
of fitness has 3 distinct phases designed to steadily increase
cardiovascular fitness These training logs are excellent
resources for training and preparation for local races

G Muscle Conditioning

A comprehensive exercise prescription should contain instructions
on muscular endurance and muscular strengthening Muscular
endurance is best developed by utilizing lighter weights with
greater number of repetitions, while muscular strengthening, which
uses heavier weights with fewer repetitions Muscle conditioning
can be accomplished best by means of static isometric or dynamic
isotonic or isokinetic exercises Resistance training for the
average individual should be performed at rhythmical, slow to
moderate speed through a full range of motion utilizing the major
muscle groups

In resistance training, 8 to 10 repetitions of each exercise
should be
performed or until volitional fatigue if prior to
minimum number of repetitions Different muscle groups should be
used and exercises performed 2 to 3 times per week Small hand-
held weights or wrist/ankle weights can be utilized as a means of
resistance training Most gymnasiums are staffed by weight
trainers who can assist patients develop a weight training
program The resource and reference section at the end of this
book contains specific weight training guidelines to help patients
get started
Special Populations

I Cardiovascular Disease

Cardiovascular disease is the leading cause of mortality in the
United States, accounting for almost 50 of all deaths More than 15
million Americans sustain myocardial infarction each year; of these
600,000 will die10,83 Exercise training has become beneficial in the
treatment of patients with coronary artery disease CAD Substantial
evidence demonstrates improved survival in patients with CAD84,85 The
general principles of an exercise prescription apply to CAD patients as
they do to
healthy persons However, the physiological limitations
imposed by CAD require certain precautions according to the patients
health and clinical status

CAD is a chronic disorder characterized by a number of clinically
defined phases spanning many years to decades These phases include:
asymptomatic, stable angina, progressive angina, unstable angina and
myocardial infarction In patients who have CAD or individuals
suspected of having CAD, the most important management step is to risk
stratify the patient The main objective for risk stratification is to
determine the likelihood of subsequent myocardial infarction, cardiac
arrest, or heart failure in the future Specific prognostic factors are
listed in Table 17 Using the available data, the physician must
formulate a diagnosis and select initial management strategies
Strategies may include non-invasive testing eg, EKG, Echocardiogram,
GXT, referral to a cardiologist eg, cardiac catheterization or
performance of a therapeutic trial

Table 17

Prognostic Factors for Patients with Coronary Artery Disease
Left
ventricular function/damage
Severity of CAD
Coronary plaque event
Electrical stability
General health
Factors predisposing to disease progression
Smoking
Hyperlipidemia
Diabetes mellitus
Hypertension
Other genetic/metabolic factors
Adapted from ACC/AHA Guidelines for Exercise Testing J Am Coll Cardiol
1997; 30: 260-311
Prior to prescribing an exercise program, patients with CAD must have
some form of cardiac stress testing documented Multiple forms of
stress testing are available and include the traditional graded
exercise stress test, myocardial perfusion imaging eg,
thallium/adenosine, stress echocardiography, and exercise radionuclide
cardiac angiography Clinical condition, extent of disease, co-morbid
factors, and availability will dictate the optimal testing strategy

Upon completion of risk stratification, patients can be classified
based on their functional characteristics 61 The American Heart
Association, subsequently utilizes this classification system to make
recommendations concerning activity, supervision, and the need for

monitoring

Table 18

New York Heart Association Functional Classification for Congestive Heart
Failure

Class Functional Status
I Patients with cardiac disease but without resulting limitations of
physical activity Ordinary physical activity does not cause
undue fatigue, palpitations, dyspnea, or anginal pain

II Patients with cardiac disease resulting in slight limitation of
physical activity They are comfortable at rest Ordinary
physical activity results in fatigue, palpitations, dyspnea, or
anginal pain

III Patients with cardiac disease resulting in marked limitation of
physical activity They are comfortable at rest Less than
ordinary physical activity causes fatigue, palpitations,
dyspnea, or anginal pain

IV Patients with cardiac disease resulting in inability to carry on any
physical activity without discomfort Symptoms of cardiac
insufficiency or anginal syndrome may be present at rest
Criteria Committee New York Heart Association Inc: Diseases of
the
Heart and Blood Vessels Nomenclature and
Criteria for Diagnosis, 6th Ed Boston Little Brown and Co, 1964, pg
114

Class A: Apparently healthy

There is no evidence of increased cardiovascular risk for
exercise This classification included 1 individuals under age
40 years who have no symptoms of or known presence of heart
disease or major coronary risk factors and 2 individuals of any
age without known heart disease or major risk factors and who have
a normal exercise test

Activity Guidelines: No restrictions other than basic
guidelines
ECG and blood pressure monitoring: Not required
Supervision required: None
Class B: Presence of known, stable cardiovascular disease with
low risk for vigorous exercise but slightly greater than for
apparently healthy individuals

Moderate activity is not believed to be associated with
increased risk in this group This classification includes
individuals with 1 CAD Myocardial infarction, coronary artery
bypass
surgery, percutaneous transluminal coronary angioplasty,
angina pectoris, abnormal exercise test, and abnormal coronary
angiography whose condition is stable and who have the clinical
characteristics outlined below; 2 valvular heart disease; 3
congenital heart disease; 4 cardiomyopathy; 5 exercise test
abnormalities that do not meet the criteria outlined in class C
below

Class B clinical characteristics: 1 New York Heart
Association NYHA class 1 or 2 Table 18; 2 exercise
capacity over 6 METs; 3 no evidence of heart failure; 4
free of ischemia or angina at rest or on the exercise test at
or below 6 METs; 5 appropriate rise in systolic blood
pressure during exercise; 6 no sequential ectopic ventricular
contractions; and 7 ability to satisfactorily self-monitor
intensity of activity

Activity Guidelines: Activity should be individualized with
exercise prescription by qualified personnel trained in basic
CPR or with electronic monitoring at home

ECG and blood
pressure monitoring: Only during the early
prescription phase of training, usually 6 to 12 sessions

Supervision required: Medical supervision during prescription
sessions and nonmedical supervision for other exercise sessions
until the individual understands how to monitor his or her
activity

Class C: Those at moderate to high risk for cardiac complications
during exercise and/or unable to self-regulate activity or to
understand recommended activity level

This classification includes individuals with 1 CAD with the
clinical characteristics outlined below; 2 cardiomyopathy; 3
valvular heart disease; 4 exercise test abnormalities not
directly related to ischemia; 5 previous episode of ventricular
fibrillation or cardiac arrest that did not occur in the presence
of an acute ischemic event or cardiac procedure; 6 complex
ventricular arrhythmias that are uncontrolled at mild to moderate
work intensities with medication; 7 three-vessel disease or left
main disease; and 8 low ejection fraction
less than 30

Class C clinical characteristics: 1 Two or more MIs; 2
NYHA class 3 or greater Table 18; 3 exercise capacity less
than 6 METs; 4 ischemic horizontal or downsloping ST
depression or 4 mm or more or angina during exercise; 6 a
medical problem that the physician believes may be life-
threatening; 7 previous episode of primary cardiac arrest;
and 8 ventricular tachycardia at a workload of less than 6
METs

Activity Guidelines: Activity should be individualized with
exercise prescription by qualified personnel

ECG and blood pressure monitoring: Continuous during exercise
sessions until safety is established, usually in 6 to 12
session or more

Supervision: Medical supervision during all exercise sessions
until safety is established

Class D: Unstable disease with activity restriction

This classification includes individuals with 1 unstable
ischemia; 2 heart failure that is not compensated; 3
uncontrolled arrhythmias; 4 severe
and symptomatic aortic
stenosis; and 5 other conditions that could be aggravated by
exercise

Activity Guidelines: No activity is recommended for
conditioning purposes Attention should be directed to
treating the subject and restoring him or her to class C or
higher Daily activities must be prescribed based on
individual assessment by the subjects personal physician

The exercise prescription will vary with the clinical state of
each patients CAD status Certain cardiovascular end points must
be considered when designating an appropriate and safe level for
exercise Cardiac stress testing is the tool by which
cardiovascular end points can be determined Results of the
exercise test will determine the recommended quantity of exercise
to be prescribed Substantial data exists on the benefits of
physical activity in secondary prevention of cardiovascular
disease7,62,84

General Principles of Exercise Prescription in Secondary Prevention

A Prescription in the Absence of Ischemia or
Significant
Arrhythmias Low Risk84

Exercise intensity should approximate 50 to 80 of maximal oxygen
consumption, determined by an exercise stress test deconditioned
individuals may begin at lower levels If a patient is awaiting
a GXT and desires to exercise, the MHR should not exceed 20 BPM
over the RHR Upon successful stratification and brief
supervision, the long-term-goal for physical activity in low-risk
CAD patients is to attain cardiovascular training zone of 50 to
75 TI

If a patient intends to walk, activity can be prescribed as the
treadmill step rate at the desired heart rate The step rate is
the number of steps achieved in 15 seconds while walking at the
desired speed on the treadmill Step rate can be easily counted
since it requires less skill than monitoring heart rate

Educate patients on the use of ratings of perceived exertion The
goal to achieve is a RPE of 12 to 13, perceived as somewhat hard
or moderate intensity This rating approximates to 60 to 75 of
MHR

After safe activity
levels have been established, duration is
increased in 5-minute increments each week As patients become
conditioned, resistance training can be incorporated into the
exercise prescription

B Prescription in the Presence of Ischemia or Arrhythmias
Moderate to High Risk84

An exercise stress test and medical supervision are essential for
this type of prescription Exercise testing is utilized to firmly
establish a safe cardiovascular training zone A standard
exercise test is performed and the conditioning work intensity is
derived from the heart rate associated with the abnormality If
the exercise test continues to a high level of effort, the heart
rate at 50 to 60 of maximum can be used if it falls at least 10
BPM below the abnormal level Otherwise, the recommended peak
training heart rate is 10 BPM less than that associated with the
abnormality

It is preferred that these individuals have supervised cardiac
rehabilitation and reevaluation to restratify them to a lower
risk category Supervision achieves
several goals to include
introducing patients to physical activity, motivating anxious
patients and observing for possible complications such as angina,
heart failure and arrhythmias Current recommendations are to
repeat yearly GXT as a means to reassess cardiovascular risk

C Summary

Most individuals in secondary prevention can be restratified as
low risk and can implement their exercise prescription at home or
in a community program The intensity may be less than
individuals exercising for primary prevention, however the
benefits associated for overall health will be equal Interval
exercise stress testing is recommended and coronary risk factor
modification should be addressed and treated aggressively85 It
is encouraged that HCPs coordinate with the patients cardiologist
when initiating an exercise program

II Diabetes Mellitus

Diabetes Mellitus is a chronic disease characterized by poor
regulation of serum glucose The two major forms include type 1
Insulin dependent and type 2 non-insulin dependent diabetes

mellitus Type 1 diabetes is an autoimmune disorder in which there is
a relative or absolute lack of insulin Insulin replacement is the
standard treatment Type 2 diabetes, the more common form, is a result
of decreased insulin sensitivity and increased insulin production
Oral sulfonylureas, biguanides, insulin, and some newer formulations
are standard treatment options

Patients with diabetes mellitus can benefit from a regular exercise
program HCPs will be faced with the challenge of recommending
physical activity to this sub-population of patients Adjustments in
caloric intake and insulin may be required in certain situations
Unanticipated complications such as post-exercise hypo-and/or
hyperglycemia must be addressed and a strategic plan must be formulated
to deal with such issues Prior to any exercise prescription it is
imperative the patient has full knowledge of their disease process, to
include adequate blood glucose control

Patients with diabetes mellitus are 2 to 3 times at higher risk for
heart disease than nondiabetics For individuals with diabetes, 35
years and older, who
have had diabetes in excess of 25 years, an
exercise stress test is recommended prior to engaging in an exercise
program

A Exercise in Type 1 Diabetes Mellitus

It is not the scope of this paper to review glucose metabolism
during exercise, however, it is important to understand the
metabolism of glucose in the diabetic patient Changes in glucose
metabolism in the insulin dependent diabetic are dependent on
several factors: amount of insulin administration, prior
metabolic control, presence or absence of autonomic dysfunction,
and caloric intake

An individual who has demonstrated good glucose control may engage
in 30 to 45 minutes of sustained aerobic exercise without any
complications Skyler and associates recommend blood sugars in
the range of 60 to 130 mg/dl before meals, 140 to 180 mg/dl 1 hour
after meals, and 120 to 150 mg/dl 2 hours after meals as being
well controlled86 Hypoglycemia can occur during exercise, if
insulin is taken 1 to 2 hours before exercise Unlike non-
diabetics, type 1 diabetics are
unable to adjust their serum
insulin levels during exercise As the exercise intensifies the
need for insulin decreases as counter-regulatory hormones
increase After exercise the sustained insulin level in the
diabetic enhances peripheral glucose uptake and inhibits
gluconeogenesis and glycogenolysis thereby inducing
hypoglycemia87 Signs and symptoms of hypoglycemia include vision
changes, fatigue, excessive hunger, increased heart rate,
headache, sweating and tremor

Hyperglycemia may occur in exercising diabetics who are
underreplaced with insulin prior to initiating exercise In this
scenario, substrate production lipolysis, gluconeogenesis, and
glycogenolysis is unchecked because of the lack of opposition of
the counterregulatory hormones This results in an exaggeration
of the pre-existing hyperglycemia and may predispose to the
development of ketoacidosis A therapeutic serum insulin range
exists for each individual

For the non-athletic patient who in not engaged in a vigorous or
prolonged
training program, adjustment of insulin is rarely
required If intensive training is anticipated, the insulin dose
may need to be reduced 20 to 50 Another alternative is to
decrease the insulin that would normally peak during the required
training period88 The preferred site for insulin injection is
the abdomen Patients should avoid injecting the extremities as
increased blood flow to these areas during exercise accelerates
insulin absorption, potentially inducing a hypoglycemic event
Table 19 provides useful guidance for insulin dependent diabetics

Table 19

Prevention of Hypoglycemia or Hyperglycemia

Before Exercise
Estimate intensity, duration, and energy expenditure of exercise
Eat a meal 1-3 hours before exercise
Insulin:
Administer insulin more than 1 hour before exercise
Administer insulin in abdomen and avoid extremity injections
Decrease insulin that has peak activity coinciding with
exercise period may not be required
Assess metabolic control:
If blood glucose 100 mg/dL,
take supplemental pre-
exercise snack
If blood glucose 250 mg/dL or serum ketones are
positive, delay exercise

During Exercise
Supplement calories with carbohydrate feedings 30-40 grams for adults,
15-25 grams for children
every 30 minutes during extended, strenuous exercise
Replace fluid losses adequately
Monitor blood glucose during exercise of long duration

After Exercise
Monitor blood glucose, especially if exercise is not consistent
Increase calorie intake for 12-24 hours after activity, according to
intensity and duration of exercise
Reduce insulin, which peaks in the evening or night, according to
intensity and duration of exercise may not be required
Adapted from Horton ES Role and management of exercise in diabetes
mellitus Diab Care 1988; 11: 201-211

B Exercise in Type 2 Diabetes Mellitus

Exercise is a significant factor in controlling hyperglycemic
events Exercise improves peripheral insulin sensitivity,
enhances insulin binding, and promotes weight reduction These
effects are lost if exercise is discontinued for more than 3 days
Type 2
diabetics do not suffer hypoglycemia as a result of
maintenance of endogenous insulin Individuals on sulfonylureas
however, may be at increased risk of hypoglycemia during exercise
It is recommended that a small snack be consumed prior to
exercise to decrease this incidence
C Complications

Patients with diabetes mellitus do incur additional risks not
shared by non-diabetics Autonomic neuropathy blunted heart rate
response and orthostatic hypotension, macrovascular disease foot
ulcer, stasis changes and angina, and microvascular disease
retinal hemorrhage and increased proteinuria appear to occur at
increased frequency Individuals with known complications should
choose exercise activities that will not aggravate their disease
For example a patient with peripheral neuropathy should be
encouraged to ride a bicycle rather than running The benefits of
exercise still outweighs the risk, however, the patient must
understand the effects of a particular exercise program on their
disease process Diet and medication
adjustments may be required
to ensure safe participation in a physical activity program A
handout for exercise in the diabetic patient may be found in the
resource and reference section

III Osteoarthritis

Osteoarthritis OA is the most common form of joint disease in
humans It is characterized by progressive degeneration of the
articular cartilage and bony hypertrophy of mobile joints Risk
factors associated with OA are trauma, repetitive stress, obesity, age,
gender, race, developmental defects, metabolic/endocrine disorders and
prior inflammatory joint disease89 Obesity in particular is a
significant risk factor A weight loss of 5 kilograms may be
associated with a 50 reduction in developing symptomatic knee OA90
In patients with OA who are already symptomatic, weight reduction may
decrease the severity of joint pain91

Osteoarthritis is uncommon before the age of 40, but by age 65, 80
of individuals have OA92 Exercise has been controversial in the
treatment of OA Until recently, exercise was not recommended for fear
that vigorous motion to an arthritic joint could
further damage peri-
articular tissue and worsen pain It is now known that prolonged
inactivity exacerbates pain and stiffness, results in loss of mobility,
and eventually causes weakness and functional disability Furthermore,
weight bearing on articular joints has been shown to stimulate
proteoglycan synthesis thereby maintaining integrity of the articular
surface93 Recent studies have demonstrated the safety and efficacy of
exercise for patients with arthritis94

In persons over 65, 12 report limitations in physical activity
secondary to pain from arthritis95 The most common and disabling
joint is the knee, followed by the hip Osteoarthritis can result in
decreased muscle strength in the peri-articular muscles, decreased
flexibility, weight gain, and diminished aerobic capacity96 Recent
studies have shown that patients with osteoarthritis are able to
tolerate weight bearing exercises such as walking Goals of an
exercise program in patients with osteoarthritis include maintaining
joint motion, increasing strength and endurance of peri-articular
muscles, increasing aerobic capacity,
assisting in weight loss and
improving activities of daily living Specific regimens to achieve
these goals are range of motion training, strengthening exercises and
aerobic conditioning

In considering an exercise prescription for patients with arthritis,
certain factors must be taken into account Strengthening exercises
and range of motion training are an integral component to physical
activity, particularly of the knee joints Maximizing use of lower
extremity joints will enable individuals to participate in aerobic
activity Prior to exercising, it is recommended to take an anti-
inflammatory agent, which may reduce pain and inflammation

Acute inflammation is an indication to postpone exercise that
involves repetitive use of that joint The affected joint should be
protected through the use of splints Once the acute phase has
resolved, initial rehabilitation should emphasize improving range of
motion and strength Alternatively, recommend different forms of
exercise that vary weight bearing A stationary bicycle is a good
alternative for walking on days when knees are sore and a walk may
be a
better choice of exercise than swimming on days when hands, wrists, and
shoulders are painful Aquatic exercises and newer strength machines
have recently become popular, as these exercises place less stress on
joints see handout on aquatic exercise in the resource and reference
section Various strength and exercise machines are available for
both home use or located at health clubs Below are comparisons of
different exercises and the stress across the particular joint Table
20 Each patient must be educated for self-management, so he or she
may adjust their exercise routine for changes in disease activity
Table 20

Exercise and the stress across selected joints

Hip Knee Ankle Shoulder Spine
Bicycling —
Arm-cranking — — —
Rowing — — —
Cross-country skiing
Climbing
Water running — — —

degree of increased impact — no significant impact
potentially significant
Reproduced from Barry HC, Eathorne SW Exercise and aging Med Clin North
Am 1994; 78: 357-376

IV Pregnancy

Women who are pregnant or plan to become pregnant are encouraged to
maintain an active recreational lifestyle Assuming, there are no
obstetrical or medical complications, they may engage in a moderate
level of physical activity throughout pregnancy Limitations to
activity generally will be defined by the physiologic changes
associated with pregnancy

Several physiologic changes occur during pregnancy Cardiovascular
changes include increased cardiac output/blood volume and decreases in
systemic vascular resistance Care must be taken after the first
trimester to avoid long periods in the supine position In this
position, the enlarging uterus compresses against the inferior vena
cava decreasing venous return to the heart Increased work of
breathing during pregnancy results in decreased performance during
aerobic exercise The effects of exercise on the fetus appear to be
minimal Investigators
concluded that submaximal maternal exercise
does not appear to adversely effect fetal heart rate97,98

Recommendations for exercise during pregnancy are listed in Table 21,
with accompanying handout in the resource and reference section These
are specifically designed for women without obstetrical or medical
complications Appropriate aerobic activities include walking,
swimming, bicycling, low-impact aerobics classes and water exercises
Activities to be avoided are those that entail risk of abdominal trauma
or that are performed in extreme environmental conditions High impact
activities, such as running, may increase the likelihood of
musculoskeletal injury due to increased laxity of connective tissue
Many women find these activities increasingly uncomfortable as
gestation progresses

Contraindications to physical activity are hypertension associated
with pregnancy, pre-term rupture of membranes, pre-term labor with
prior or current pregnancy, incompetent cervix/cerclage, persistent
second or third trimester bleeding and interuterine growth retardation
Additional medical complications
should be carefully reviewed to
determine if an exercise program is appropriate99

Table 21

Exercise Guidelines for Pregnancy and the Postpartum Period
There are no data in humans to indicate that pregnant women should limit
exercise intensity and lower target heart rates because of potential
adverse effects For women who do not have any additional risk factors for
adverse maternal or perinatal outcomes, the following recommendations may
be made:

1 During pregnancy, women can continue to exercise and derive health
benefits even from mild to moderate exercise routines Regular exercise
at least 3 times per week is preferable to intermittent activity
2 Women should avoid exercise in the supine position after the first
trimester Such a position is associated with decreased cardiac output
in most pregnant women; because the remaining cardiac output is
preferentially distributed away from splanchnic beds including the
uterus during vigorous exercise, such regimens are best avoided during
pregnancy Prolonged periods of motionless standing should also be
avoided
3
Women should be aware of the decreased oxygen available for aerobic
exercise during pregnancy They should be encouraged to modify the
intensity of their exercise according to maternal symptoms Pregnant
women should stop exercising when fatigued and not exercise to
exhaustion Weight-bearing exercises may under some circumstances be
continued at intensities similar to those before pregnancy throughout
pregnancy Non-weight-bearing exercises, such as cycling or swimming,
minimize the risk of injury and facilitate the continuation of exercise
during pregnancy
4 Morphologic changes in pregnancy should serve as a relative
contraindication to types of exercise in which loss of balance could be
detrimental to maternal or fetal well-being, especially in the third
trimester Further, any type of exercise involving the potential for
even mild abdominal trauma should be avoided
5 Pregnancy requires an additional 300 kcal/day to maintain metabolic
homeostasis Thus, women who exercise during pregnancy should be
particularly careful to ensure an adequate diet
6 Pregnant
women who exercise in the first trimester should augment heat
dissipation by ensuring adequate hydration, appropriate clothing, and
optimal environmental surroundings during exercise Avoid body
temperatures above 1004 degrees Fahrenheit hot tubs, saunas, prolonged
exercise in heat and humidity
7 Many of the physiologic and morphologic changes of pregnancy persist 4
to 6 weeks postpartum Thus, pre-pregnancy exercise routines should be
resumed gradually based on a womans physical capability Acceptable
guidelines are to resume activity 1 week after vaginal delivery and 6 to
10 weeks following a cesarean-section
8 Strenuous exercise should not exceed 15 minutes and may require
adjusting as the pregnancy advances

The following conditions should be considered contraindications to exercise
during pregnancy:
-Pregnancy-induced hypertension
-Pre-term rupture of membranes
-Pre-term labor during the prior or current pregnancy or both
-Incompetent cervix/cerclage
-Persistent second or third trimester bleeding
-Intrauterine growth retardation
From American College of Obstetricians and
Gynecologist: Exercise During
Pregnancy and the Postpartum Period Technical Bulletin No 189
Washington, DC, ACOG, 1994

Most studies have shown that exercise during pregnancy has no adverse
effect on the outcome of labor Exercise during late pregnancy has
been demonstrated to decrease labor time, incidence of arrested labor,
and cesarean section rates100 In those women who vigorously exercise,
birth weight is reduced by approximately 320 grams101 Head and axial
growth remains unchanged In summary, there are no published data
suggesting increased morbidity associated with exercise and pregnancy,
for mother or fetus

V Asthma

Asthma is an obstructive disorder of the airways characterized by
airway inflammation and hyperreactivity Airway obstruction occurs as
a result of bronchoconstriction, airway edema, smooth muscle
hypertrophy and mucus plug formation102 Asthma associated with
exercise is extremely common Ninety percent of people who have asthma
experience exercise-induced asthma EIA or exercise-induced
bronchospasm EIB during the course of their disease103 In random

testing of athletes, approximately 10 have exercise-induced asthma and
12 to 15 of the general population suffers from this disease104,105
When controlled, it places no physical limitations on an individuals
performance During the 1984 Summer Olympic games, 41 of 67 athletes
known to have EIA won medals

EIA is a clinical syndrome characterized by chest tightness,
shortness of breath, coughing, wheezing, fatigue and prolonged recovery
times from exercise These symptoms are associated with a transient
increase in airway resistance usually occurring during or shortly after
exercise Various stimuli have been identified that contribute to
attacks of EIA Conditions such as cold temperatures, low humidity,
pollutants eg, allergens, dust, irritants, respiratory infections,
fatigue, emotional stress and overtraining may increase the occurrence
of EIA

Most patients diagnosed with EIA give a classic history, however,
many are unaware they have the condition The symptoms are often
perceived as normal for vigorous exercise or a result of being labeled
as out of shape106 Factors in a patients
history that suggest
presence of EIA are listed in Table 22
Table 22

Factors that Suggest Exercise-Induced Asthma
1 Coughing, wheezing, dyspnea, or chest discomfort occurring during
or shortly after exercise
2 Symptoms that vary by season, temperature, or intensity of
activity
3 Complains of decreased, limited exercise tolerance
4 Complains of being out of shape
5 Minimal problems with swimming or warm, humid weather
6 Complains of frequent colds

The diagnoses of EIA may be strongly suggested by history107 In
mild cases, the diagnosis may be confirmed by a therapeutic trial of
medication Pulmonary function testing before and after exercise is
essential in diagnosing EIA FEV1 forced expiratory volume in 1
second and FEV1/FVC forced vital capacity values below 80 of
predicted value indicate obstructive airway disease Occasionally,
when the history is unclear, a methacholine challenge test may be
useful Testing can help avoid overuse of unnecessary medications when
the patients breathing problems may be due to another etiology Once
the
diagnosis is established, treatment options include non-
pharmacologic and pharmacologic therapies Figure 3

Non-pharmacologic interventions may be helpful in the management of
EIA Individuals should choose activities they enjoy, as some sports
are more conducive to asthmatics Sports that involve skill and
coordination more than endurance eg, golf, baseball, or are
conducted in warm humid environments eg, swimming may be better
tolerated by the patient with EIA

Patients should improve physical conditioning and avoid known
precipitants such as cold/dry conditions Incorporating warm-up
activities and breathing through the nose filters and warms the air
have also been effective in preventing asthma attacks Prolonged
submaximal warm-up activities have been shown to induce an EIA
refractory period Athletes are generally advised to perform a series
of short sprints 10 to 12 or warm-up for 10 minutes or less with
vigorous exercise one hour before an event to induce this refractory
period

Pharmacologic interventions include beta agonists, cromolyn sulfate,
corticosteroids, oral
theophylline and ipratropium bromide The drugs
of choice are the beta-agonists These drugs are used for preventive
measure and rescue therapy Short-acting beta-agonist are effective in
80 to 95 of patients108 The guidelines are to inhale a beta-agonist
15 minutes before exercise If symptoms develop during exercise, on-
demand beta-agonist therapy should be repeated

Cromolyn sodium is the second most commonly used medication used for
treatment of EIA It is an anti-inflammatory agent shown to be
effective in 70 to 85 of patients A distinct advantage of this drug
is its low incidence of side effects Cromolyn is most effective when
given 10 to 45 minutes prior to exercise Cromolyn is not a
bronchodilator and should never be used for rescue therapy The other
medications mentioned can be utilized in select patients or used in
combination with beta-agonist or cromolyn sulfate

EIA is common and should be recognized by HCPs Education and
prevention appear to be important factors in managing EIA
Fortunately, there are many non-pharmacologic and pharmacologic
therapies available to control
EIA As a result, patients are able to
perform at or near maximal activity levels
Figure 3
Management of Exercise Induced Asthma

Symptoms persist

Symptoms

persist

Symptoms

persist

PF - Peak flows; FEV1 - Forced Expiratory Volume in 1 second

Adapted from Expert Panel Report Guidelines for the diagnosis and
management of asthma National Heart, Lung, and Blood Institute of Health
publication 91-3042: 121 August 1991
VI Pulmonary Disease

An estimated 15 to 25 million Americans suffer from chronic
obstructive pulmonary disease COPD - including chronic bronchitis and
emphysema109 It is a leading cause of mortality and is responsible
for 200,000 deaths yearly Despite trends in reduced tobacco
consumption, mortality rates for COPD continue to rise primarily due to
previous tobacco use in todays older population110 In patients with
COPD, disability is primarily a result of progressive deconditioning
As the disease progresses, limited ventilatory capacity makes exertion
unpleasant and leads to an increasingly sedentary lifestyle
Shortness
of breath breathlessness and exercise intolerance are the most
incapacitating symptoms patients develop A counter-measure to
progressive functional decline in patients with COPD is exercise
training

Irreversible destruction of lung parenchyma is the hallmark of COPD
Significant ventilation-perfusion mismatch occurs, impairing maximal
gas exchange Additionally, the work of breathing is increased
secondary to increased airway resistance and hyperinflation

It has clearly been demonstrated that exercise is beneficial for
patients who have COPD Structured exercise protocols and less
demanding protocols alike produced significant improvement in exercise
tolerance, decreased minute ventilation and improved dyspnea111
Although exercise may not lengthen life expectancy, it has been shown
to improve the quality of life and therefore should be an integral
adjunctive treatment for all pulmonary patients The components of the
COPD exercise prescription are presented below Table 23
Table 23

Components of the COPD Exercise Prescription
Evaluation
-Assess
cardiac risk
-Assess exercise capacity using a treadmill Naughton protocol or
stationary cycle, starting at a low workload and increasing
extremely slowly, and monitoring desaturation with a pulse oximeter
-Determine appropriate exercise levels to prevent arrhythmias or
hypoxia in cardiac-impaired patients
-Determine the amount of supplemental oxygen needed during exercise
-Determine need for bronchodilators during exercise
-Assess side effects of beta-agonist inhalers or aminophylline
derivatives during exercise

Supervised Exercise
-Direct patient to a supervised rehabilitation program if disease is
significant
-Set a goal of eventually graduating to independent exercise many
patients do this in about 6 weeks

Independent Exercise
-Suggesting an appropriate training mode: stationary cycling,
bicycling, treadmill walking, outdoor walking, stair climbing, or
arm ergometry
-Set a goal of 60 to 80 of maximum heart rate for 20 to 30 minutes,
3 days a week build on individual ability
-Expect a 70 to 80 increase over initial work capacity within
6
weeks
-Provide active encouragement and reassurance especially at first
to overcome anxiety associated with dyspnea

Exercise Aids
-Oxygen supplementation
-Bronchodilators
-Mucolytics
-Corticosteroids inhaled or oral
-Monitoring
Reproduced from Mink BD Exercise and Chronic Obstructive Pulmonary
Disease Phys Sportsmed 1997; 25: 43-52

Prescribing exercise in the COPD patient requires a significant
amount of planning and encouragement Initially, they may benefit from
formal cardiac risk stratification and supervised rehabilitation
programs The exercise prescription should proceed gradually since
most individuals are extremely limited in the amount of exercise
tolerated secondary to deconditioning or dyspnea Extremity
conditioning exercises is a key component to the exercise prescription
Those with severe COPD may initially only be able to perform extremity
conditioning exercises Exercise conditioning has been shown to
improve maximal oxygen uptake, strength and endurance Increased
muscle mass and a better vascular system will help improve peripheral
extraction of
oxygen, which will lead to better physical activity
Evaluate the patients need for bronchodilator therapy, mucolytics or
supplemental oxygen during exercise Physicians will find

that frequent follow-up, encouragement and reassurance are integral to
the success of the rehabilitation process Progress in exercise
tolerance may be minimal in this population, however diligent
participation can reduce respiratory symptoms, reverse anxiety and
depression, and increase the ability to perform activities of daily
living

VII Obesity

Obesity is a common and serious health problem in the United States
The number of overweight and obese persons is increasing among American
men and women Approximately 33 of Americans are overweight Recent
data suggests that Americans are moving away from, rather than toward
the goals set forth by Healthy People 2000 initiative112
Additionally, 50 of American women and 25 of American men attempt to
lose weight, amounting to an annual expenditure of 30 billion dollars
on weight loss treatments113

Obesity is an excess of body fat defined as greater than 20
above
ideal body weight and overweight implies excess body weight greater
than 10 above ideal body weight114 These two terms in clinical
practice are often used interchangeably A more precise analysis of
obesity is the use of body mass index BMI BMI is based on weight
and height in metric measurements and can be calculated using the
following equation: [BMI Weight KG/Height2 M]
A BMI of 25 and above is considered overweight A convenient Body
Mass Index Table is provided in Appendix G Table 24 classifies
obesity, waist circumference and disease risk by BMI

Table 24

Classification of overweight and obesity by BMI and associated disease
risk
Disease Risk
Relative to Normal Weight and Waist Circumference

Obesity Men 40 in 102 cm 40 in 102 cm
BMI Class Women 35 in 88 cm 35 in 88 cm
Underweight 185 —- —-

Normal 185 - 249 —- —-

Overweight 250 - 299 Increased High

Obesity 300 - 349 I High Very High

350 - 399 II
Very High Very High

Extreme Obesity 400 III Extremely High Extremely High
Disease risk for type 2 diabetes mellitus, hypertension, and
cardiovascular disease
Increased waist circumference can also be a marker for increased risk,
even in persons of normal weight
Adapted from National Heart, Lung, and Blood Institute Clinical
Guidelines on the Identification, Evaluation, and Treatment of overweight
and Obesity in Adults: The Evidence Report Bethesda, MD: National
Institutes of Health 1998
Excess weight is independently associated with an increased mortality
rate115 It is associated with other risks for excess mortality,
specifically hypertension, hyperlipidemia and diabetes mellitus116
CAD is more prevalent in obese persons than non-obese persons Male
obese individuals are more likely to die of colorectal and prostatic
cancers, whereas obese women have a greater risk of endometrial,
cervical, ovarian, and breast cancers Obesity is also associated with
a variety of other medical disorders including degenerative joint
disease, diseases of the digestive tract cholelithiasis, reflux
esophagitis, thromboembolic
disorders, heart failure, respiratory
impairment and skin disorders117 Approximately 280,000 deaths each
year are attributable to overnutrition, making it second only to
smoking as a cause of death119

Unfortunately, obesity is one of the most difficult and frustrating
disorders to successfully manage The clinician and patient must
understand that obesity is a chronic medical condition that rarely is
cured A caloric deficit of 3,500 kilocalories is necessary to lose 1
pound of adipose tissue Most experts recommend a loss of no more than
1 to 2 pounds per week

Exercise, specifically aerobic training, is a key aspect to
successful weight loss A weight loss program must incorporate
physical activity to increase caloric expenditure while intake is
reduced in order to obtain the necessary caloric deficit The amount
of energy expended during most aerobic exercise for typical periods
200 to 300 kilocalories per session, five times a week is modest,
approximately 500 to 1,000 kilocalories consumed per week This will
probably have little effect on short-term weight loss

The long-term
impact of exercise for successful maintenance of weight
loss is more clearly established The cumulative effect of increased
energy expenditure will cause long-term weight loss and maintenance of
weight If one expends 500 to 1,000 kilocalories per week for 52
weeks, approximately 7 to 15 pounds could be lost each year

When establishing a weight-reduction program, exercise is an
important component in aiding and sustaining weight loss The
mechanism for weight-reduction is through increased total energy
expenditure, preservation of lean body mass, and changes in metabolism
The most recent ACSM guidelines suggest exercise programs conducted 3
times per week that expend 250 to 300 kilocalories per exercise
session This generally will require at least 30 to 45 minutes of
exercise per session in an individual of average fitness Expending
200 kilocalories per session also results in weight reduction if the
exercise is conducted at least 4 times per week When structuring a
weight-reduction program it is helpful to consider the guidelines
suggested by the ACSM74

1 Caloric intake should not be
less than 1,200 kilocarlories/day
for normal adults
2 Include foods acceptable to the dieter
3 Provide a negative caloric balance that results in a gradual
weight loss
4 The endurance exercise program should occur most days of the
week for 20 to 60 minutes at an exercise intensity at least
65 maximum heart rate
5 Include behavior modification techniques
6 Insure that the suggested eating and physical activity habits
can be continued for life

Obesity must be conceptualized as a chronic illness, and the process
of weight reduction and maintenance of loss requires lifelong care
The ability to lose fat and maintain a desirable body weight is not
easy but can be attained through a firm commitment to a healthy
lifestyle that incorporates physical activity

VIII Exercise in the Elderly

Evaluation of the 1990 census reveals that the average annual growth
rate for the population over 65 years of age was twice that of the
total population In 1989, there were 25 million persons over age 65
in the United States, and it is
expected that this figure will increase
to almost 39 million in 2010 and more than 65 million by 2030 20 of
the population119 The fastest growing segment of the population is
the group older than age 85 years, which has increased 24 during the
past 10 years Two-thirds of the population over 65 rate their health
as good to excellent and 75 have no difficulties performing activities
of daily living ADLs The secret to a long healthy life is a
combination of inherited genetics, good fortune and living a healthy
lifestyle For the most part, the first two factors cannot be
modified, however, the third lies in the hands of the individual

Physical inactivity as stated previously is a risk factor for many
medical conditions Some of the physiologic changes seen in the
elderly due to aging may in fact be more appropriately attributed to
sedentary lifestyles Functional changes associated with inactivity
are reduced aerobic fitness, loss of postural reflexes, loss of muscle
mass and calcium extraction Rather than attributing much of the
functional decline seen among the elderly, perhaps a more complex
model
should be considered As people age there is a tendency toward a
sedentary lifestyle This results in deconditioning, fatigue and
weakness When the body is attacked by disease, disability or injury,
one may see a greater tendency toward inactivity and further physical
decline As an individual continues to physically decline, there is a
deterioration in the sense of wellness, resulting in poor self-esteem,
anxiety, and depression Individuals often lack motivation during this
phase and a further reduction in physical activity ensues resulting in
an irreversible cycle

When discussing physical activity in the elderly, it is important to
understand the physiologic changes associated with age Lipsitz and
Goldberger have described normal physiologic functions as the result of
complex interactions of multiple control mechanisms that allow for the
demands of daily existence119 Aging is marked by the progressive loss
of these control mechanisms This results in a loss of the normal
dynamic range of physiologic function and a reduced capacity to adapt
Table 25 summarizes some of the functional
changes attributed to aging
Table 25

Functional Changes Associated with Age
Cardiovascular
Decreased cardiac output 20-30 decline by age 65
Elevated systolic and diastolic blood pressure 10-40 mm Hg
Decreased maximum heart rate 10 beats/min/decade
Reduced hemoglobin, hematocrit and red cell mass

Respiratory
Decrease vital capacity 40-50 decline by age 70

Musculoskeletal
Loss of muscle strength and mass 20 decline by age 65
Osteoporosis 1 loss per year after 35, 2-
3 per year after menopause
Decreased elasticity and synovial fluid viscosity
Height loss Age 65-74, 15 loss; 85-94, 30
loss on average

Central Nervous System
Reduced number of neurons
Impaired motor response
Decreased brain mass
Adapted from Barry HC, Eathorne SW Exercise and Aging Med Clin N Am,
1994; 2: 357-376

The elderly can be stratified into 2 categories The apparently
healthy and chronically ill population The apparently healthy
individuals
are those who have no significant limitations on physical
activity and require no assistance performing functions beyond the
activities of daily living Prescribing exercise for this group poses
no special consideration outside the aforementioned functional changes
associated with aging Prior to embarking on an exercise program, the
patients current level of fitness should be assessed It may be
necessary to administer a graded exercise test to fully evaluate stress
tolerance

The chronically ill elderly have increased medical conditions ranging
from arthritis, cardiovascular disease, dementia and depression They
tend to heavily use the health care system, require more frequent
hospitalizations and require more care within the home Falls are the
leading cause of fatal injury within this population120 Muscle
weakness and impaired gait and balance are the most significant risk
factors

Prescribing exercise in chronically ill patients can be very
challenging Standard exercise programs may be exhausting, painful or
literally impractical due to their physical limitations These

individuals often lack motivation and knowledge, thus show little
interest in exercise

It is the HCPs responsibility to educate patients in long-term
medical benefits of exercise despite obvious medical limitations The
goal is to begin and maintain a low-intensity program that minimizes
the risk and maximizes the benefits of adjuvant therapy121 There are
many existing senior physical activity classes available through local
YMCAs, Arthritis Foundations, community schools, or churches that can
be beneficial to patients who are motivated to exercise Generally
speaking, the ill elderly are unlikely to initially participate in an
aerobic program of moderate intensity Physical activity with an
emphasis on flexibility and strength may provide more benefit in
improving the functional capacity in this group General guidelines
for exercise prescribing in chronically ill patients are listed below
Table 26
Table 26

General Guidelines for the Exercise Prescription in Chronically Ill
Patients
Evaluation
-Discuss benefits of exercise with patients increased functional

capacity, increased strength and endurance, and improved medical
status
-Review on-going medical conditions, medications and potential
physical limitations
-Assess the need for formal exercise testing Not all chronically
ill patients require exercise testing since most patients are rarely
fit enough to undergo the intensity of testing required to produce
an adequate rate-pressure-product
-Educate patients on warning symptoms and risk of exercise based on
their medical condition
-Assess the need for exercise aids

Component of Training
-Exercise daily if not fatigued
-Adequate warm-up for minimum of 3 minutes
-Initiate exercise at a target heart rate of no more than 20 beats
per minute over resting heart rate, or at normal walking pace if
intensity effort improves, it may then be reasonable to consider
exercise stress testing
-Mode of activity should include walking or equivalent aerobic
activity will be based on physical limitations to include
resistance training and stretching exercises as tolerated
-Accumulate 20 to 30 minutes of exercise daily in
one or several
sessions
-Progression should be gradual

Injury Prevention
-Include warm-up and cool-down periods
-Low intensity activity
-Adequate hydration
-Appropriate clothing and footwear
-Encourage safer modes of aerobic activity walking-with or without
walker, stationary bicycle
-Inform patient on injury prevention proper biomechanics
-Consider home health visit to assess hazards in the home

Compliance
-Set realistic goals
-Reassess every 1-2 months initially then every 3 months thereafter
-Praise compliance and instill motivation
Adapted from Lampman RM Exercise prescription for chronically ill
patients Am Fam Physician 1997; 55: 2185-2192

An area that will require clinical judgment is the use of stress
testing in chronically ill patients In general, these individuals are
rarely fit enough to undergo the rigors of stress testing The level
of intensity required for stress testing usually exceeds the patients
exercise capability As a result, exercise stress testing is often
impractical and not cost-effective121 If a patients medical history
is known and
current medical conditions are stable, it is not
unreasonable to initiate an exercise prescription of low-intensity
without stress testing If a patient has been exercising without
difficulty for several months and desires to increase their intensity,
it may be appropriate to consider stress testing122
Improved quality of life should be the ultimate goal in recommending
an exercise routine Enjoyment and socialization are key components to
a successful program Compliance with an exercise program increases as
the activity is shared with others The social interaction provides
mental and intellectual stimulation that enables individuals to remain
motivated in fulfilling exercise requirements

Another key element for the elderly patient is limited financial
resources The majority of older patients are on fixed income and have
minimal financial reserve for recreational expenses Patients with
specific rehabilitation requirements may be eligible for Medicare
reimbursement for therapeutic exercise programs By large, those
individuals who are still ambulatory, walking is the single most
important
form of physical activity

Safety is of primary importance for all exercising individuals, but
the elderly present some unique challenges They are at increased risk
for falls due to decreased sensory abilities eg, proprioception,
sight, hearing, balance, muscle weakness and gait disturbances
Exercise should be performed on even surfaces with adequate footwear
and appropriate lighting

The elderly are also more susceptible to cold injuries because of
decreased ability to perceive ambient air temperatures This may be
related to loss of subcutaneous fat, peripheral vascular disease,
vasoconstriction, autonomic dysfunction or effects of certain
medications Patient education on appropriate dress such as layered
clothing is recommended

An exercise program should initially focus on improving flexibility
For some patients, especially those with severe medical limitations,
this may be the entire focus of the exercise program For those who
are more ambulatory, exercise intensity should be advanced slowly to
allow for physiological adaptation

The elderly patient has much to gain by
participating in a program of
total physical activity in an enjoyable atmosphere with others who have
similar interests Through exercise, the older individual will feel
healthier and younger Functional state, mobility, cardiovascular
fitness and outlook are bound to improve Aging not only means
degeneration, but also adaptation Regular exercise and training are
an essential component in slowing premature aging

IX Army Personnel

The United States Army has always maintained high standards regarding
physical fitness The logo fit to fight attests to this standard
All soldiers who are not on profile are required to take the Army
Physical Fitness Test APFT two times a year For some, these two
days can induce a significant amount of anxiety Failing this test can
result in unfavorable action, loss of promotion and eventual removal
from the Army

For many, the performance requirements have become more difficult
with the new APFT standards123 More will be required of soldiers to
pass this test Additionally, many units are setting higher standards
and goals for their soldiers physical
readiness The ability to
improve ones score will require consistent physical fitness sessions
and the desire to go the extra mile The rewards for doing well on the
APFT include not only health and fitness benefits but also better
evaluation reports and early promotions

The question that is so often asked is How can I improve my APFT
score? While this question sounds simplistic it bears further
investigation Telling a soldier to train harder or longer is
inadequate Improper training and lack of formal instruction can
result in inefficient training and/or injury

Three components represent the APFT; sit-up event, push-up event and
the two-mile run Each event has a maximum of 100 possible points
Minimum passing score per event is 60 points All three events must be
performed to standard 60 points to score a pass on the APFT124

To perform well individuals must first analyze strengths and
weaknesses for each component of the APFT One must develop an
effective training program to allow proper conditioning It is
important to emphasize that planning for the APFT requires TIME It is

unrealistic to train two weeks before the APFT and expect maximum
performance

In order to improve a particular event, physical training must focus
on specific muscle groups Push-ups are designed to assess upper body
strength Sit-ups assess abdominal muscles and hip flexors Lastly,
the two-mile run assesses cardiovascular fitness and endurance A
sample training schedule is outlined in the reference/resource section
Following these simple guidelines will improve APFT scores

Most importantly, individuals must plan ahead when preparing for the
APFT Two to three months should be reserved to prepare for the APFT
Three weeks before the test, soldiers should train at the testing site
at least once per week and self-administer a diagnostic APFT Two days
before the APFT, soldiers should be instructed to avoid muscle overuse
- stop training and relax On test day, individuals should eat a light
meal prior to testing and conduct a thorough warm-up session During
the push-up and sit-up events, soldiers should be instructed to
maintain a steady pace to avoid muscle fatigue When approaching
muscle
fatigue, pausing for several seconds in the authorized rest
position should be encouraged, with a subsequent return to complete
more repetitions During the run, soldiers are encouraged to maintain
a steady pace to prevent fading at the end When running, individuals
should plan to increase their pace during the final quarter-mile

The secret to performing well lies in hard work, motivation, mental
toughness and determination Encourage soldiers to set goals to
perform well on the APFT See handout Training for the APFT in the
resource and reference section for improvement program The rewards
are improved physical fitness, heightened unit morale and improved
performance evaluations
Conclusion

As one can see, exercise and physical activity can have a tremendous impact
on health and cardiorespiratory fitness As referenced by numerous
organizations, exercise should become a lifestyle of every American,
regardless of their health status It remains the responsibility of the
health care provider to offer exercise to all their patients

As HCPs become more comfortable prescribing exercise and
reimbursement for
preventive services improve, the conscience of the American public will be
heightened Effective counseling and motivation will enable the objectives
set forth by Healthy People 2000 become a reality This paper has been
specifically designed to assist health care providers in prescribing
appropriate exercise A user friendly and efficient approach has been
utilized to assist provider to assess an individuals desire to exercise
through the use of a questionnaire The exercise assessment form can be
distributed and completed in the patient waiting area and given to the HCP
during the patient encounter If an individual chooses to exercise,
several handouts are provided in the resource and reference section to
assist patients in pursuing safe and fun exercise Evidence based medicine
has clearly demonstrated that fit individuals live better and healthier
lives Few medical prescriptions can make a similar claim

Glossary

Aerobic training - training that improves the efficiency of the aerobic
energy-producing systems and that can improve cardiorespiratory fitness19

Anaerobic training - training that improves the efficiency of the
anaerobic
energy-producing systems and that can increase muscular strength and
tolerance for acid-base imbalances during high-intensity effort19

Body composition - a health-related component of physical fitness that
relates to the relative amounts of muscle, fat, bone, and other vital parts
of the body19

Body Mass Index BMI - an index utilized to measure the degree of body
fat Defined as weight in kilograms divided by the square of height in
meters

Endurance - the bodys ability to withstand and endure stress under
conditions of increased physical activity

Exercise - a planned, structured and repetitive body movement designed to
improve physical fitness19

Exercise prescription - the ability to recommend a particular quantity of
physical activity required to achieve specific therapeutic goals such as
health benefits or improved cardiorespiratory fitness

Flexibility training - a health related component of physical fitness that
relates to improving range of motion of a particular joint

Graded Exercise Test GXT - a clinical assessment tool used to determine
cardiorespiratory fitness, exercise capacity and diagnose coronary artery
disease It is a test that provides clinical,
hemodynamic and
electrocardiographic information in a noninvasive, safe, controlled manner
Health - a state of optimal physical, mental and social well-being and not
merely the absence of disease19

Intensity - a measure of cardiovascular conditioning that can be measured
utilizing maximum heart rates or ratings of perceived exertion

Isometric exercise - muscle contraction against a resistance so there is no
effective joint movement Resistance can be adjusted by changing the force
of the muscle being contracted85

Isostatic exercise - muscle contractions against a fixed speed of movement
in which the resistance not only varies but accommodates though the range
of motion according to the input ability of the musculoskeletal lever
system85

Isotonic exercise - muscle contractions performed against a constant
resistance with a concentric shortening contraction and eccentric
lengthening contraction phase Resistance can be applied with ankle
weights, free weights, elastic bands or the individuals body weight85

Kilocalorie - amount of heat energy required to raise the temperature of
one kilogram of water one degree Celsius Used to indicate the value of
food in production of heat and
energy

Physical activity - bodily movement produced by the contraction of skeletal
muscle that increases energy expenditure above basal levels19

Physical fitness - set of attributes that people have or achieve that
relates to the ability to perform physical activity The components of
physical fitness include cardiorespiratory endurance, skeletal muscle
endurance, speed, flexibility and body composition19

Relative perceived exertion RPE - a persons subjective assessment of how
hard he or she is working the Borg scale is a numerical scale for rating
perceived exertion

Resistance training - training designed to increase strength, power and
muscle endurance

Sedentary - performing minimal physical activity or exercise

Sensitivity - the percentage of times a test correctly identifies
individuals with the disease

Specificity - the percentage of times a test correctly identifies
individuals without the disease

Strength training - the use of resistance to increase ones ability to
exert or resist force

Exercise-Related Sudden death - an instantaneous fatal cardiorespiratory
event occurring during or immediately following exercise

VO2max - reflects the maximal ability of the body
to take in, transport and
use oxygen It is the gold standard to measure cardiorespiratory fitness
Commonly measured or estimated utilizing treadmill or cycle ergometer
exercise testing63
Appendices

Appendix A

Exercise Assessment Form

Primary Care Sports Medicine

Uniformed Services University

NAME:______________________________ DATE:____/____/____
SSN: ______________________________ AGE:________________

PACE SCORE

Project PACE Physician-based Assessment and Counseling for Exercise
is designed to encourage patients to engage in appropriate levels of
physical activity The PACE score will assist your doctor in
determining your current physical fitness habits and interests
Choose the number that best describes your current level of physical
activity or your interest in physical activity Do not include
activities that you do as part of your occupation Examples of
vigorous and moderate exercise activities are shown
below

Vigorous exercise includes activities like jogging, running, fast
cycling, aerobics classes, swimming laps, and racquet sports Any
activity that makes you work as hard as jogging and lasts 20 minutes
at a time should be counted These types of activities usually
increase your heart rate, and make you sweat, and get you out of
breath Do not count weight lifting
Moderate exercise includes activities like brisk walking, gardening,
slow cycling, dancing, doubles tennis, or hard work around the house
Any activity that makes you work hard as brisk walking and that lasts
at least 30 minutes at a time should be counted

Current Physical Activity Status

Circle One

Number Only
1 I do not exercise or walk regularly now, and I do not intend to
start in the near future
2 I do not exercise or walk regularly, but I have been thinking of
starting
3 I am trying to start to exercise or walk or During the last
month I have started to exercise or walk on occasion or on
weekends only
4 I have exercised or walked
infrequently or on weekends only for
over one month
5 I am doing vigorous or moderate exercise, less than 3 times per
week or moderate exercise less than 2 hours per week
6 I have been doing moderate exercise, 3 or more times per week or
more than 2 hours per week for the last 1 to 6 months
7 I have been doing moderate exercise, 3 or more times per week or
more than 2 hours per week for 7 months or more
8 I have been doing vigorous exercises, 3 to 5 times per week for 1
to 6 months
9 I have been doing vigorous exercises, 3 to 5 times per week for 7
to 12 months
10 I have been doing vigorous exercises, 3 to 5 times per week for 7
to 12 months
11 I do vigorous exercises 6 or more times per week

CARDIOVASCULAR RISK ASSESSMENT

1 Do you have diagnosed cardiovascular disease? Circle all that
apply
Hypertension
Angina and or a history of myocardial infarction
heart attack
History of a cerebrovascular event stroke

2 Do you have any of the following? Circle all that apply

Hyperlipidemia
Smoking history
Diabetes mellitus
Family history of heart disease

3 Do you have any of the following symptoms? Circle all that
apply
Chest pain brought on by activity
Unaccustomed shortness of breath brought on by mild
exertion
Dizziness or syncope passing out
Extra heart beats or racing heart

PERFORMANCE GOALS

Circle One
Number Only
1 Im not interested in discussing an exercise program at this time
2 Im interested in activities for the sedentary individual
3 Im interested in moderate activities to improve my health and
fitness
4 Im interested in pursuing vigorous activities
5 Im interested in beginning a weight training program

PHYSICIAN ASSESSMENT

1 PACE Score________
Precontemplator Score 1
Contemplator Score 2 - 5
Active Score 6 - 11

2 Cardiovascular Assessment: Figure 2
High Risk
Low Risk

3 Performance Goals:

Moderate
Vigorous

4 Exercise Stress Test
Requirement:____________________________________

5 Patient Handout Issued:____________________________________________

6 Schedule Follow-up Appointment:____________________________________

PHYSICIAN:_______________________
Appendix B

The National Cholesterol Education Program NCEP Expert Panel Guidelines
for Diagnosis and Treatment of High Blood Cholesterol

Treatment Decisions Based on LDL Cholesterol Level
Patient Category Initiation Level LDL Goal
Dietary Therapy

Without CHD and fewer than 2 risk factors 160 mg/dl
160 mg/dl
Without CHD and with 2 or more risk factors 130 mg/dl
130 mg/dl
With CHD 100 mg/dl 100 mg/dl
Drug Therapy

Without CHD and fewer than 2 risk factors 190 mg/dl
160 mg/dl
Without CHD and with 2 or more risk factors 160 mg/dl
130 mg/dl
With CHD 130 mg/dl 100 mg/dl
LDL indicates low-density lipoproteins and CHD indicates coronary
heart
disease

CHD Risk Factors
Positive Negative

Age, years HDL Cholesterol 60 mg/dl
Men45
Women55
Premature menopause without HRT
Family history of premature CHD
Diabetes mellitus
Tobacco Use
Hypertension
Blood Pressure 140/90 or taking
antihypertensive medications
HDL Cholesterol 35 mg/dl
HRT indicates hormone replacement therapy and HDL indicates high-density
lipoproteins

Summary of the Second Report of the National Cholesterol Education Program
NCEP Expert Panel on Detection, Evaluation, and, Treatment of High Blood
Cholesterol in Adults JAMA 1993; 269: 3015-3023

Appendix C

Effects of Medication on Heart Rate, Blood

Pressure, and Exercise Capacity

Courtesy from Project PACE Physician Manual

|Medications |Heart Rate |Blood Pressure |Exercise Capacity |
| |Rest |Exercis|RestR | |
| | |e |ExerciseE | |
|Beta blockers | | | | in patients with |
|including
| | | |angina; |
|labetolol | | | | or in patients w/o|
| | | | |angina |
|Nitrates | | | | in patients with |
| | | | |angina; |
| | | | | in patients w/o |
| | | | |angina; |
| | | | | or in patients |
| | | | |with CHF |
|Calcium channel | | | | in patients with |
|blockers | | | |angina |
|Nifedipine | | | | in patients w/o |
|Dilitiazem | | | |angina |
|Verapamil | | | | |
|Diuretics | | | or | except possibly in |
| | | | |patients with CHF |
|Vasodilators | or
| or | | except or in |
|Nonadrenergic | | | |patients with CHF |
|vasodilators | or | or | | |
|Adrenergic | | | | |
|blockers | | | | |
|Antiadrenergic | | | | |
|agents without | | | | |
|blockade of | | | | |
|peripheral | | | | |
|receptors | | | | |
|Bronchodilators | | | | |
|Methylxanthines | or | or | |Bronchodilators |
|Sympathomimetic | or | or | or |exercise capacity in |
|agents | | | |patients with limited |
|Cromolyn Sodium | | | |bronchospasm |
|Corticosteroids | | | | |
| |Clofibrate may provoke
arrhythmias, angina in patients |
|Hyperlipidemic |with prior myocardial infarction; |
|agents |Dextrothyroxine may HR and BP at rest and during |
| |exercise, provoke arrhythmias, and worsen myocardial |
| |ischemia and angina; Nicotinic acid may BP; Probucol |
| |may cause QT interval prolongation; All other |
| |hyperlipidemic agents have no effect on HR and BP |
|Nicotine | or | or | | except or in|
| | | | |patients with |
| | | | |angina |
|Antihistamines | | | | |
|Cold medicine |Effects similar to those described in| |
|with |Sympathomimetic agents, | |
|Sympathomimetic |Although magnitude is usually | |
|agents |diminished | |
|Thyroid | | | | unless angina |
|medication | |
| |worsens |
|Levothyroxine | | | | |
|only | | | | |
|Alcohol | | |Chronic use may | |
| | | |BP | |
|Hypoglycemic | | | | |
|agents | | | | |
|Insulin and oral | | | | |
|agents | | | | |

Appendix D

Cardiovascular Exercise Prescription

NAME:___________________________ DATE:____/____/____

SSN:______________________________ AGE:______

I Mode of Activity: Running Aerobics Rowing
Walking Cycling Swimming
Racquet Sports _____________

II Duration: 20 minutes 40 minutes ____ minutes

III Frequency: _____ times per week

IV
Intensity: low moderate vigorous

Low Intensity Exercise: 20 - 40 VO2 max or heart rate reserve HRR

Moderate Intensity Exercise: 40 - 60 VO2 max or HRR Borg 13 60
HRR
Vigorous Intensity Exercise: 60 VO2 max or HRR Borg 16 80 HRR

A Estimate your own maximal heart rate Max HR Women use 220 minus
age 220-age, men
use 205 minus one-half their age 205 - age
MAX HR: ____ - ____ ____ BPM
B Determine your resting heart rate RHR ____BPM
C Heart Rate Reserve HRR MAX HR - RHR
HRR: ____ - ____ ____BPM
D Training Intensities TI HRR x TI RHR
Lower limit TI: ____ x ____ ____ ____ BPM
Upper limit TI: ____ x ____ ____ ____ BPM
E Cardiovascular Training Zone: Exercise to maintain heart rate
between _____ and _____BPM

Borg Relative Perceived Exertion Scale

6
7 Very, very light
8
9 Very light LOW INTENSITY
10
11 Fairly light
12
13 Somewhat hard
14 MODERATE INTENSITY
15 Hard
16
17 Very hard

18 VIGOROUS INTENSITY
19 Very, very hard
20

V Progression

Initial Conditioning Phase
Duration - 4 to 6 weeks
Goal is to increase frequency

Improvement Conditioning Phase
Duration - 4 to 6 months
Goal is to increase duration and intensity

Maintenance Conditioning Phase
Occurs after 6 months of regular exercise
Goal is to maintain cardiorespiratoy fitness

VI Special Considerations

Coronary heart disease
__________________________________________________________________
Diabetes Mellitus
__________________________________________________________________
Osteoarthritis
__________________________________________________________________
Pregnancy
__________________________________________________________________
Asthma
__________________________________________________________________
Pulmonary Disease
__________________________________________________________________
Obesity
__________________________________________________________________
Elderly/Chronically
Ill
__________________________________________________________________
Military Personnel
__________________________________________________________________
Other
__________________________________________________________________

VII Follow-up Appointment:
_____________________________________________

Physician:
______________________________________

Appendix E

Beginners Program

Phase 1

| |Day |Training Effort |Duration |Comments |
| |Sunday |Rest | | |
| |Monday |65 - 75 |20 - 30 | |
| | | |minutes | |
| |Tuesday |Rest | | |
|Week 1 |Wednesday|65 - 75 |20 - 30 | |
| | | |minutes | |
| |Thursday |Rest | | |
| |Friday
|65 - 75 |20 - 30 | |
| | | |minutes | |
| |Saturday |Rest | | |
| |Sunday |Rest | | |
| |Monday |65 - 75 |20 - 30 | |
| | | |minutes | |
| |Tuesday |Rest | | |
|Week 2 |Wednesday|65 - 75 |20 - 30 | |
| | | |minutes | |
| |Thursday |Rest | | |
| |Friday |65 - 75 |20 - 30 | |
| | | |minutes | |
| |Saturday |Rest | | |
| |Sunday |Rest | | |
| |Monday |65 - 75 |20 - 30 | |
| | | |minutes | |
| |Tuesday
|Rest | | |
|Week 3 |Wednesday|65 - 75 |20 - 30 | |
| | | |minutes | |
| |Thursday |Rest | | |
| |Friday |65 - 75 |20 - 30 | |
| | | |minutes | |
| |Saturday |Rest | | |

Beginners Program

Phase 2

| |Day |Training Effort |Duration |Comments |
| |Sunday |Rest | | |
| |Monday |65 - 75 |25 - 40 | |
| | | |minutes | |
| |Tuesday |Rest | | |
|Week 4 |Wednesday| 10/20/10 |25 - 40 | |
| | | |minutes | |
| | |65 - 75/75 - 80/65 | |
|
| | |- 75 | | |
| |Thursday |Rest | | |
| |Friday |65 - 75 |25 - 40 | |
| | | |minutes | |
| |Saturday |Rest | | |
| |Sunday |Rest | | |
| |Monday |65 - 75 |25 - 40 | |
| | | |minutes | |
| |Tuesday |Rest | | |
|Week 5 |Wednesday| 10/20/10 |25 - 40 | |
| | | |minutes | |
| | |65 - 75/75 - 80/65 | | |
| | |- 75 | | |
| |Thursday |Rest | | |
| |Friday |65 - 75 |25 - 40 | |
| | | |minutes | |
|
|Saturday |Rest | | |
| |Sunday |Establish benchmark | |Distance covered: |
| | |this | | |
| | |week: 30 minutes at | | |
| | |75 | | |
| |Monday |65 - 75 |25 - 40 | |
| | | |minutes | |
| |Tuesday |Rest | | |
|Week 6 |Wednesday| 10/20/10 |25 - 40 | |
| | | |minutes | |
| | |65 - 75/75 - 80/65 | | |
| | |- 75 | | |
| |Thursday |Rest | | |
| |Friday |65 - 75 |25 - 40 | |
| | | |minutes | |
| |Saturday |Rest | | |
|
|Sunday |Rest | | |
| |Monday |65 - 75 |25 - 40 | |
| | | |minutes | |
| |Tuesday |Rest | | |
|Week 7 |Wednesday| 10/20/10 |25 - 40 | |
| | | |minutes | |
| | |65 - 75/75 - 80/65 | | |
| | |- 75 | | |
| |Thursday |Rest | | |
| |Friday |65 - 75 |25 - 40 | |
| | | |minutes | |
| |Saturday |Rest | | |

Beginners Program

Phase 3

| |Day |Training Effort |Duration |Comments | | |
| |Sunday |Rest | |Enter race for 12th | | |
| | |
| |week | | |
| |Monday |65 - 75 |40 minutes | | | |
| |Tuesday |Rest | | | | |
| |Wednesday| 10/20/10 |40 minutes | | | |
|Week 8 | |65 - 75/75 - 80/65 | | | | |
| | |- 75 | | | | |
| |Thursday |Rest | | | | |
| |Friday |65 - 75 |40 minutes | | | |
| |Saturday |10/20/10 |40 minutes | | | |
| | |65 - 75/85/65 - 75| | | | |
| |Sunday |Rest | | | | |
| |Monday |65 - 75 |40 minutes | | | |
| |Tuesday |Rest | | | | |
| |Wednesday| 10/20/10 |40 minutes | |
| |
|Week 9 | |65 - 75/75 - 80/65 | | | | |
| | |- 75 | | | | |
| |Thursday |Rest | | | | |
| |Friday |65 - 75 |40 minutes | | | |
| |Saturday |10/20/10 |40 minutes | | | |
| | |65 - 75/75 - 80/65 | | | | |
| | |- 75 | | | | |
| |Sunday |Rest | | | | |
| |Monday |60 |40 minutes | | | |
| |Tuesday |Rest | | | | |
|Week 10|Wednesday|75 |40 minutes | | | |
| |Thursday |Rest | | | | |
| |Friday |60 |40 minutes | | | |
| |Saturday |75
|40 minutes | | | |
| |Sunday |Rest | | | | |
| |Monday |65 - 75 |40 minutes | | | |
| |Tuesday |Rest | | | | |
| |Wednesday|10/20/10 |40 minutes | | | |
|Week 11| |65 - 75/75 - 80/65 | | | | |
| | |- 75 | | | | |
| |Thursday |Rest | | | | |
| |Friday |65 - 75 |40 minutes | | | |
| |Saturday |10/20/10 |40 minutes | | | |
| | |65 - 75/75 - 80/65 | | | | |
| | |- 75 | | | | |
| |Sunday |Rest | | | | |
| |Monday |65 - 75 |40 minutes |
| | |
| |Tuesday |Rest | | | | |
|Week 12|Wednesday|10/20/10 |40 minutes | | | |
| | |65 - 75/75 - 80/65 | | | | |
| | |- 75 | | | | |
| |Thursday |Rest | | | | |
| |Friday |65 - 75 |40 minutes | | | |
| |Saturday |Race | | | | |

Appendix F

Intermediate Program

Phase 1

| |Day |Training Effort |Duration |Comments |
| |Sunday |Rest | | |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest | | |
|Week 1 |Wednesday|75 |40 minutes | |
| |Thursday |Rest
| | |
| |Friday |10/20/10 |40 minutes | |
| | |75/85/75 | | |
| |Saturday |75 |40 minutes | |
| |Sunday |Rest | | |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest | | |
|Week 2 |Wednesday|75 |40 minutes | |
| |Thursday |Rest | | |
| |Friday |10/20/10 |40 minutes | |
| | |75/85/75 | | |
| |Saturday |75 |40 minutes | |
| |Sunday |Rest | | |
| |Monday |65 |40 minutes | |
| |Tuesday |Rest | | |
|Week 3 |Wednesday|65 |40 minutes | |
| |Thursday |Rest |
| |
| |Friday |80 |40 minutes | |
| |Saturday |65 | | |
| |Sunday |Rest | | |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest | | |
|Week 4 |Wednesday|75 |40 minutes | |
| |Thursday |Rest | | |
| |Friday |10/20/10 |40 minutes | |
| | |75/85/75 | | |
| |Saturday |75 |40 minutes | |
| |Sunday |Rest | | |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest | | |
|Week 5 |Wednesday|75 |40 minutes | |
| |Thursday |Rest | | |
| |Friday |10/20/10 |40 minutes |
|
| | |75/85/75 | | |
| |Saturday |75 |40 minutes | |

Intermediate Program

Phase 2

| |Day |Training Effort |Duration |Comments |
| |Sunday |Rest | |Enter race for 9th |
| | | | |week |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest | | |
|Week 6 |Wednesday|10/20/10 |40 minutes | |
| | |75/85/75 | | |
| |Thursday |Rest | | |
| |Friday |75 |40 minutes | |
| |Saturday |70 - 75 |50 minutes | |
| |Sunday |Rest | | |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest |
| |
|Week 7 |Wednesday|10/20/10 |40 minutes | |
| | |75/85/75 | | |
| |Thursday |Rest | | |
| |Friday |75 |40 minutes | |
| |Saturday |70 - 75 |50 minutes | |
| |Sunday |Rest | | |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest | | |
|Week 8 |Wednesday|10/20/10 |40 minutes | |
| | |75/85/75 | | |
| |Thursday |Rest | | |
| |Friday |75 |40 minutes | |
| |Saturday |70 - 75 |50 minutes | |
| |Sunday |Rest | | |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest | |
|
|Week 9 |Wednesday|10/20/10 |40 minutes | |
| | |75/85/75 | | |
| |Thursday |Rest | | |
| |Friday |75 |40 minutes | |
| |Saturday |Race | | |
| |Sunday |Benchmark for this | |Distance covered: |
| | |week: | | |
| | |30 minutes at 75 | | |
| |Monday |75 |40 minutes | |
| |Tuesday |Rest | | |
|Week 10|Wednesday|10/20/10 |40 minutes | |
| | |75/85/75 | | |
| |Thursday |Rest | | |
| |Friday |75 |40 minutes | |
| |Saturday |75 |50 minutes | |

Intermediate Program

Phase 3

| |Day |Training Effort |Duration |Comments |
| |Sunday |75 |45 minutes | |
| |Monday |10/20/10 |40 minutes | |
| | |75/85/75 | | |
|Week 11|Tuesday |Rest | | |
| |Wednesday|75 |45 minutes | |
| |Thursday |75 |50 minutes | |
| |Friday |75 |45 minutes | |
| |Saturday |Rest | | |
| |Sunday |75 |45 minutes | |
| |Monday |10/20/10 |40 - 45 | |
| | | |minutes | |
| | |75/85/75 | | |
|Week 12|Tuesday |Rest | | |
| |Wednesday|75 |45 minutes | |
| |Thursday |75 |55 minutes |
|
| |Friday |75 |45 minutes | |
| |Saturday |Rest | | |
| |Sunday |75 |45 minutes | |
| |Monday |10/20/10 |40 - 45 | |
| | | |minutes | |
| | |75/85/75 | | |
|Week 13|Tuesday |Rest | | |
| |Wednesday|75 |45 minutes | |
| |Thursday |75 |55 minutes | |
| |Friday |75 |45 minutes | |
| |Saturday |Rest | | |
| |Sunday |75 |45 minutes | |
| |Monday |10/20/10 |40 - 45 | |
| | | |minutes | |
| | |75/85/75 | | |
|Week 14|Tuesday |Rest | | |
|
|Wednesday|75 |45 minutes | |
| |Thursday |75 |55 minutes | |
| |Friday |75 |45 minutes | |
| |Saturday |Rest | | |
| |Sunday |75 |45 minutes | |
| |Monday |10/20/10 |40 - 45 | |
| | | |minutes | |
| | |75/85/75 | | |
| |Tuesday |Rest | | |
|Week 15|Wednesday|75 |45 minutes | |
| |Thursday |75 |55 minutes | |
| |Friday |75 |45 minutes | |
| |Saturday |Rest | | |

Appendix G

Body Mass Index Table

Calculations of body mass index BMI is recommended as a means of
assessing body fat Persons with a BMI of 185 to 249 are considered
to
be of normal weight Those with a BMI of 250 to 299 are overweight
Patients with a BMI of 300 to 349 or 350 to 399 are in obesity class I
or II, respectively; and those with a BMI of 40 and over are considered
extremely obese obesity class III

|BMI |19 |20 |21 |22 |23 |24 |25 |26 |27 |28 |29 |30 |31 |32 |33 |34 |35 |36 |
|Heigh| | | | | | |Body Weight Pounds | | | | | | |
|t | | | | | | | | | | | | | |
|inch| | | | | | | | | | | | | |
|es | | | | | | | | | | | | | |
|58 |91 |96 |100|105|110|115|119|124|129|134|138|143|148|153|158|162|167|172|
|59 |94 |99 |104|109|114|119|124|128|133|138|143|148|153|158|163|168|173|178|
|60 |97 |102|107|112|118|123|128|133|138|143|148|153|158|163|168|174|179|184|
|61 |100|106|111|116|122|127|132|137|143|148|153|158|164|169|174|180|185|190|
|62 |104|109|115|120|126|131|136|142|147|153|158|164|169|175|180|186|191|196|
|63 |107|113|118|124|130|135|141|146|152|158|163|169|175|180|186|191|197|203|
|64
|110|116|122|128|134|140|145|151|157|163|169|174|180|186|192|197|204|209|
|65 |114|120|126|132|138|144|150|156|162|168|174|180|186|192|198|204|210|216|
|66 |118|124|130|136|142|148|155|161|167|173|179|186|192|198|204|210|216|223|
|67 |121|127|134|140|146|153|159|166|172|178|185|191|198|204|211|217|223|230|
|68 |125|131|138|144|151|158|164|171|177|184|190|197|203|210|216|223|230|236|
|69 |128|135|142|149|155|162|169|176|182|189|196|203|209|216|223|230|236|243|
|70 |132|139|146|153|160|167|174|181|188|195|202|209|216|222|229|236|243|250|
|71 |136|143|150|157|165|172|179|186|193|200|208|215|222|229|236|243|250|257|
|72 |140|147|154|162|169|177|184|191|199|206|213|221|228|235|242|250|258|265|
|73 |144|151|159|166|174|182|189|197|204|212|219|227|235|242|250|257|265|272|
|74 |148|155|163|171|179|186|194|202|210|218|225|233|241|249|256|264|272|280|
|75 |152|160|168|176|184|192|200|208|216|224|232|240|248|256|264|272|279|287|
|76 |156|164|172|180|189|197|205|213|221|230|238|246|254|263|271|279|287|295|
| |
|BMI |37 |38 |39 |40 |41 |42 |43 |44 |45 |46 |47 |48 |49 |50 |51 |52 |53 |54 |
|58
|177|181|186|191|196|201|205|210|215|220|224|229|234|239|244|248|253|258|
|59 |183|188|193|198|203|208|212|217|222|227|232|237|242|247|252|257|262|267|
|60 |189|194|199|204|209|215|220|225|230|235|240|245|250|255|261|266|271|276|
|61 |195|201|206|211|217|222|227|232|238|243|248|254|259|264|269|275|280|285|
|62 |202|207|213|218|224|229|235|240|246|251|256|262|267|273|278|284|289|295|
|63 |208|214|220|225|231|237|242|248|254|259|265|270|278|282|287|293|299|304|
|64 |215|221|227|232|238|244|250|256|262|267|273|279|285|291|296|302|308|314|
|65 |222|228|234|240|246|252|258|264|270|276|282|288|294|300|306|312|318|324|
|66 |229|235|241|247|253|260|266|272|278|284|291|297|303|309|315|322|328|334|
|67 |236|242|249|255|261|268|274|280|287|293|299|306|312|319|325|331|338|344|
|68 |243|249|256|262|269|276|282|289|295|302|308|315|322|328|335|341|348|354|
|69 |250|257|263|270|277|284|291|297|304|311|318|324|331|338|345|351|358|365|
|70 |257|264|271|278|285|292|299|306|313|320|327|334|341|348|355|362|369|376|
|71 |265|272|279|286|293|301|308|315|322|329|338|343|351|358|365|372|379|386|
|72 |272|279|287|294|302|309|316|324|331|338|346|353|361|368|375|383|390|397|
|73
|280|288|295|302|310|318|325|333|340|348|355|363|371|378|386|393|401|408|
|74 |287|295|303|311|319|326|334|342|350|358|365|373|381|389|396|404|412|420|
|75 |295|303|311|319|327|335|343|351|359|367|375|383|391|399|407|415|423|431|
|76 |304|312|320|328|336|344|353|361|369|377|385|394|402|410|418|426|435|443|

National Heart, Lung, and Blood Institute Clinical Guidelines on the
Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults: The Evidence Report Bethesda, MD: National Institutes of
Health; 1998

RESOURCES/REFERENCES
Individual Guidelines for
Cardiovascular Exercise

1 Exercise only when feeling well It is advisable to postpone exercise
for 2 days after signs
and symptoms of a cold or flu including fever have been absent

2 Do not exercise vigorously soon after eating It is best to wait 2
hours or more before resuming activity During exercise, the demand for
blood may exceed the ability of the circulation to supply both the bowel
and the muscles, resulting in cramps, nausea or faintness

3 Adjust exercise to weather
Exercise should be adjusted to
environmental conditions During hot weather conditions it may be
necessary to lower work intensity A good rule of thumb is to work-out
at the usual rating of perceived exertion, 12 to 16, which may be of
lower intensity due to environmental conditions If acclimatizing to new
conditions allow 12 to 14 days to accommodate to higher temperatures
Exercise is best tolerated in low humidity weather and a breeze present
Be alert for heat injuries and drink adequate fluid to maintain
hydration

4 Slow down for hills When ascending hills, decrease speed to avoid
overexertion A useful tool is to maintain the same rating of perceived
exertion as in a usual workout

5 Wear proper clothing and shoes Dress in loose-fitting, comfortable
clothes made of porous material appropriate for the weather In direct
sunlight, wear light-colored clothing and a cap Wear shoes specifically
designed for the type of activity being performed

6 Understand personal limitations When under the guidance of a
physicians care, ask if there are limitations Activities should never
exceed set ratings of perceived exertion or target heart
rates

7 Select appropriate exercises Cardiovascular aerobic exercises should
be a major component of activities For a well-rounded program,
flexibility and strengthening exercises should be included

8 Be alert for symptoms If any symptoms occur during exercise, contact a
physician immediately Specific symptoms are:

A Discomfort in the upper body such as burning, aching, tightness or
sensation of fullness

B Faintness accompanying exercise Brief light-headedness may follow
unusually vigorous exercise This condition does not usually indicate
heart disease and may be managed by exercising at a lower intensity
If fainting spells or feelings or faintness develop during exercise,
discontinue the activity until after evaluation by a physician

C Shortness of breath during exercise During exercise the rate and
depth of breathing should increase but should not be uncomfortable
Breathing should not be so difficult that an ordinary conversation is
an effort, wheezing develops, or more than 5 minutes are required for
recovery
D Discomfort in bones and joints either during or after exercise Mild
muscle
soreness may develop when beginning exercise, however, if joint
and back pain develop, consult a physician

9 Watch for the following signs of overexertion:

A Inability to finish Training sessions should be completed with
reserve

B Inability to converse during exercise

C Faintness or nausea after exercise A feeling of faintness after
exercise may occur if the activity has been stopped too abruptly
Decrease the intensity of the workout and prolong the cool-down
period

D Chronic fatigue During the remainder of the day after exercise, an
individual should feel stimulated, not tired If fatigue persist
during the day, intensity and/or duration of the workout should be
decreased

E Sleeplessness If unable to sleep well despite feelings of fatigue,
the amount of activity should be decreased until symptoms subside A
proper training program should make it easier, not more difficult, to
have good nights rest

F Aches and pains in the joints Mild muscle soreness may accompany
exercise, however joint should not hurt or feel stiff Check exercise
procedure, particularly,
stretching and warm-up exercises, to ensure
correct technique If symptoms persist, check with a physician before
continuing

10 Start slowly and progress gradually Intensity and duration may be
increased every 4 to 6 weeks

Adapted from American Heart Association Exercise Standards: A statement
for Healthcare Professionals Circulation 1995; 91: 580-615
Exercise Guidelines for Patients with Diabetes Mellitus

1 Exercise only when feeling well It is advisable to postpone exercise
for 2 days after signs and symptoms of a cold or flu including fever
have been absent

2 Generally, it is best to exercise with a friend who is aware of your
diabetes

3 Become familiar with specific blood glucose patterns in connection with
different activities Exercise should be started after a stable
relationship has been established between food intake and insulin and/or
medications

4 Know the symptoms of too much and too little glucose in your blood
Low blood glucose - lightheadedness, rapid heart beat, sweating
High blood glucose - frequent urination, vision difficulty, increase
appetite and thirst, weight loss

5 Before
Exercise
Estimate intensity, duration, and energy expenditure of exercise
30 to 45 minutes of exercise is safe when diabetes is under good
control
Good control is defined as blood sugar between 90 to 140 mg/dl
Eat a meal 1 to 3 hours before exercise
Insulin:
-Administer insulin more than one hour before exercise
-Administer insulin in abdomen and avoid extremity injection
-Decrease insulin that has peak activity coinciding with
exercise period may not be required during short workouts
Monitor blood glucose:
-If blood glucose 100 mg/dl, take supplemental pre-exercise
snack
-If blood glucose 250 mg/dl or urine ketones positive, delay
exercise

6 During Exercise
Supplemental calories with carbohydrate feeding hard candies, candy
bars, or juice every 30 minutes during extended, strenuous
exercise
Drink plenty of fluid
Monitor blood glucose intermittently when engaging in prolonged
exercise

7 After Exercise
Monitor blood glucose, especially if exercise is not consistent
Increase caloric intake for 12 to 24 hours after
exercise
Be aware of post-exercise symptoms of too much/little blood glucose
Reduce insulin, which peaks in the evening or night of exercise may
not be required during short workouts

8 You are advised to wear shoes and socks at all times to avoid trauma to
the feet Inspect your feet on a regular basis for blister, corns,
bunions or any other abnormalities

9 If you have diabetic retinopathy, avoid activities such as contact
sports, heavy weight training or inverted hanging to minimize the risk of
eye complications

10 Consult your physician if any symptoms develop during/after exercise
Notify your physician when changing your exercise routine
Exercise Guidelines for Pregnancy
and the Postpartum Period

1 In the absence of obstetric or medical complications, it is safe for you
to engage in moderate levels of physical activity Your physician will
review your medical health and previous pregnancies prior to recommending
exercise

2 Exercise only when feeling well It is advisable to delay exercise when
recovering from an illness or when experiencing episodes or

lightheadedness, nausea, or vomiting

3 The frequency and duration of exercise should be similar to your pre-
pregnancy state As your pregnancy progresses you may find it more
difficult to maintain previous fitness levels and should adjust your
routine according to your abilities The recommendation is to exercise
20 to 60 minutes at a minimum of 3 days per week Strenuous exercise
should not exceed 15 minutes

4 Acceptable aerobic activities are walking, light jogging, swimming,
stationary bicycles, low-impact aerobics, low intensity racquet sports,
and water exercises

5 Avoid high impact activities such as running, contact sports, or
competitive racquet sports Activities that may cause abdominal trauma
such as horse back riding and diving are not recommended Do not engage
in activities in which loss of balance could be detrimental to you or
your baby

6 Avoid exercises that require prolonged time on your back, specifically,
after your first trimester The weight of your growing baby compresses
the large vessels in you abdomen preventing blood return to the heart
As result you may
feel faint or lightheaded

7 Maintain an appropriate diet Pregnancy requires an additional 300
calories per day When exercising this requirement will be higher

8 When exercising ensure adequate hydration, appropriate clothing, and
optimal environmental conditions Particularly, avoid activities such as
hot tubs, saunas, or prolonged exercise that may elevate your body
temperature

9 Stop exercising and contact your physician if you develop chest pain,
extreme shortness of breath, abdominal pain/cramping/contractions or
vaginal bleeding

10 Acceptable guidelines are to resume exercise 1 week after vaginal
delivery and 6 to 10 weeks following a cesarean-section Pre-pregnancy
exercise routines should be resumed gradually, based on your physical
capabilities

11 Conditions in which exercise is not recommended are: pregnancy induced
hypertension, pre-term rupture of membrane, history of pre-term labor,
persistent vaginal bleeding and fetal growth delay

Weight Training Guidelines for Healthy Adults
and Low-Risk Cardiac Patients

1 To prevent soreness and injury,
initially choose a weight that will
allow the performance of 10 to 15 repetitions comfortably, corresponding
to approximately 50 to 60 of the maximal weight load that can be lifted
in one repetition Adults with major coronary risk factors and low-
risk cardiac patients should select an initial weight load that can be
lifted for 12 to 15 repetitions

2 Perform one set of 8 to 12 exercises that condition major muscle groups
2 to 3 times per week Individuals under 50 years if age should complete
8 to 12 repetitions of each exercise and persons 50 years and older, 10
to 15 repetitions or until your muscles are fatigued

3 Dont strain Ratings of perceived exertion should not exceed fairly
light to somewhat hard during lifting

4 Avoid breath-holding Breath in when lowering the weight and breath out
when lifting the weight overhead

5 Increase weight loads by 5 to 10 pounds when 10 to 15 repetitions can be
comfortably accomplished; for high-risk adults and cardiac patients,
weight may be added when 12 to 15 repetitions can be managed easily

6 Raise the weight to a count of two and lower the weight gradually to a

count of four Work the muscle through its whole range of motion

7 Exercise large-muscle groups before small-muscle groups Include
devices for both the upper and lower body

8 Rest 60 to 90 seconds between exercises Avoid sustained handgripping
when possible because this may evoke excessive blood pressure response to
lifting

9 Allow 48 hours of muscle recovery following a session of muscle
failure/overload

10 Stop exercise in the event of warning signs or symptoms, especially
dizziness, abnormal heart rhythm, unusual shortness of breath, or chest
pain

11 Weight lift with a partner when possible This serves to motivate and
encourage each other and spot for one another when utilizing free
weights

Arbitrarily defined as individuals with good left ventricular function
ejection fraction 50 and reasonable cardiorespiratory fitness eg,
completion of Stage III, full Bruce protocol without ischemic ST segment
depression, significant blood pressure abnormalities, or serious
ventricular arrhythmias or symptoms
Aquatic Exercise Workout

1 Aquatic exercise is an effective mode
of physical activity designed to
attain and maintain physical fitness through exercise in water It can
improve muscular endurance Cardiorespiratory fitness, flexibility,
coordination, and muscular strength

2 Due to its low impact to the body, an aquatic exercise program is ideal
for individuals who are overweight, those who suffer arthritis, or those
who have muscle weakness If one is able to exercise, it is recommended
they incorporate other activity modalities, such as walking, jogging, or
cycling to achieve fitness goals

3 Advantages Disadvantages
Less joint stress Access to swimming pool
Enjoyable Intimidating for the non-swimmer
Improved flexibility Less effective in increasing
strength
Improved coordination Financial requirement

4 Below is a sample program and several different exercises one may
incorporate during a fitness session

A Warm-up - 5 to 7 minutes of stretching that can be done on the deck or
in the water

B Conditioning phase - 30 to 45 minutes

1 Side leg raise - in shoulder
deep water with either side of the
body at arms length to wall of pool, raise outside leg sideward
and upward from the hip then return Perform 15 to 30 seconds with
each leg
2 Rear leg lift - in shoulder deep water with hands on pool edge and
chest to wall, raise one leg back and up then return Perform 10
to 20 seconds with each leg
3 Leg over - in shoulder deep water with back facing pool and arms
back reaching the pool edge raise one leg in front of body and
return Perform 15 to 30 seconds with each leg
4 Stride hop - in waist deep water with hands on hip and feet
together, jump, moving left forward and right leg backward Repeat
and alternate legs Perform 2 to 4 minutes
5 Running - Duration 10 to 20 minutes
6 Additional exercises are shown on the following page Exercise
routine need not be limited to the above exercises Lap swimming
is also an effective mode of cardiorespiratory and health related
benefit activity Tailor the program according to individual
preference

C Cool-down - 5 to 7 minutes to
bring body back to pre-exercise state

Training for the Army Physical Fitness Test APFT

Improving APFT scores require dedicated training sessions and hard work
Soldiers are looking for ways to improve test scores now that the Army has
announced new standards By targeting training, soldiers can expect to
improve performance in all three events

Push-ups and Sit-ups

The best way to improve push-up and sit-up scores is to perform circuit
training and timed sets utilizing proper form and technique as outlined in
Field Manual FM 21-20 These exercises should be performed at a minimum
of three times per week Below is an example of a circuit training
session

Push-up and Sit-up Circuits

Push-up Improvement Sit-up Improvement Combined Push-up
and Sit-up
Exercise Time Rest Exercise Time Rest Exercise
Set1 Set2
Regular PU 1:15 2:00 Sit-up 1:15 2:00 Regular PU 1:00 0:45
Close PU 1:00 1:45 Crunch 1:00 1:45 Sit-up 1:00
0:45
Wide PU 1:00 1:45 Flutter Kick 1:00 1:45 Wide PU 1:00 0:30
Regular PU 0:45 1:30 Sit-up 1:00 1:30 Flutter Kick
1:00
0:30
Close PU 0:45 1:15 Abd Crunch 1:00 1:15 Close PU 0:45 0:30
Wide PU 0:30 —– Supine Bicycle 1:00 —– Abd Crunch 0:45 0:30
Elevated PU 0:45 0:30
Supine Bicycle 0:45 0:30
Rest 2 minutes then complete
Set2

Two-mile Run

The best way to improve the two-mile run is to increase your pace This is
best accomplished by running faster when you train, not for longer period
at your normal pace Running faster can be achieved through interval
training and sprints Interval training on a quarter-mile track is
probably the best way to improve the two-mile run time Fartlek training
set time or distance at various speeds is also helpful Running should
be performed at least 3 times per week with a minimum of one day of fast
running An example for a running training schedule is outlined below

Day 1 2 - 3 mile run at normal pace
Day 2 Interval training 400 meter/440 yard sprint 8 times with 2 - 5
minute rest period
Day 3 Rest
Day 4 3 - 4 mile run at slightly slower to normal pace
Day 5 Rest
Day 6 Fartlek
training or Sprints 5 - 6 consecutive 100 meters
sprints/2 - 3 sets
Day 7 Rest

Adapted from Palmer C Training for the APFT Soldiers February 1998: 8
Getting Out of Your Chair

On your PACE Assessment you said that you are not very interested in
physical activity Have you thought very much about what you can get out
of being active?
Physical Activity can help you feel better
Physical Activity can help you look better
Physical Activity can help you be healthier

What would be the two most important benefits of physical activity for you?
Be specific

1
__________________________________________________________________________
____
2
__________________________________________________________________________
_____

Do you know you can get most of the benefits of physical activity just by
walking on a regular basis? You do not have to jog or go to aerobic
classes to be an exerciser

Many things can interfere with physical activity Here are some of the
reasons people give for not being physically active Check the ones that
apply most to you

_____
Exercise is hard work _____ I do not enjoy exercise
_____ I am usually too tired for exercise _____ I hate to
fail, so I will not start
_____ I do not have anyone to exercise with _____ I do not
have a safe place to exercise
_____ The weather is too bad _____ Exercise is boring
_____ There is no convenient place _____ I do not
have the time
_____ I am too overweight _____ I am too old

What are the two main things that keep you from wanting to be physically
active?

1
__________________________________________________________________________
____

2
__________________________________________________________________________
____

The good news is you can do something about the reasons you are not
physically active If you think of them as roadblocks between you and
physical activity, you can figure out how to get around them You can
change the roadblock itself I will get up earlier in the morning to make
time for physical activity You can also change your attitude about the
roadblock I really can find some time to exercise

How can you get around your two main
roadblocks? Look at the ideas on the
back of this sheet

1
__________________________________________________________________________
____

2
__________________________________________________________________________
____

THE FIRST STEP IN BEING PHYSICALLY ACTIVE IS GETTING OUT OF YOUR CHAIR

Based on your health status, your doctor recommends you do the following to
improve your health:
_____ You appear to be able to do either moderate or vigorous
physical activities
_____ You can benefit greatly by starting a program of regular
walking or other moderate activity
If you want to do activities as hard as jogging, you need to
have an exercise tolerance test
_____ Before you increase your physical activity, you need to have an
exercise tolerance test
Call this office for an appointment or referral Providers
Signature __________________________
Your physician strongly encourages you to:
think about the benefits you can get from physical activity and
think about how you can avoid some of the roadblocks between you
and physical activity

Most people can improve their health a great
deal by taking a walk for
30 minutes 3 - 4 times every week If you want information on how to
start doing more physical activity, ask your doctor

Benefits of Physical Activity
IMPROVE YOUR HEALTH
Reduce your risk of heart disease
Reduce your risk of some cancer
Reduce your risk of diabetes
Strengthen your bones

INCREASE YOUR ENERGY

MAINTAIN OR LOSE WEIGHT

IMPROVE YOUR MOOD AND SELF-ESTEEM FEEL BETTER ABOUT YOURSELF

HOW TO GET PAST ROADBLOCKS

ROADBLOCK: HOW TO GET PAST IT:
_____ Exercise is hard work Pick an activity that you enjoy and that is
easy for you No pain, no gain is a myth

_____ I do not have time Were only talking about three 30 minute
sessions each week Can you do without three
TV shows each week?

_____ I do not enjoy exercise Do not exercise Start a hobby
or way of playing that gets you moving

_____ I am usually too tired to exercise Tell yourself, This activity

will give me more energy See if it doesnt
happen

_____ I do not have a safe place to exercise If your neighborhood is not
safe, you can walk at work, walk in a group, or
walk in the morning

_____ I do not have anyone to exercise with me Maybe you have not
asked A neighbor, family member or co-worker
may be a willing partner Or you can choose an
activity that you enjoy doing by yourself

_____ There is no convenient place Pick an activity you can do near
your home or work Walk around your
neighborhood or do aerobics with a TV show at
home

_____ I am afraid of being injured Walking is very safe, and it is an
excellent activity to improve your health

_____ The weather is too bad There are many activities you can do in your
home, in any weather

_____ Exercise is boring Listening to music during your
activity keeps
your mind occupied Walking, biking, or
running can take you past lots of interesting
scenery

_____ I am too overweight You can benefit from physical activity
regardless of your weight Pick an activity
that you are comfortable with, like walking

_____ I am too old Its never too late to start If you are ill,
it is important to talk to your doctor about
physical activity

National Organizations

1 American College of Sports Medicine ACSM
401 West Michigan Street
Indianapolis, IN 46206-1440
327 637-9200
Fax 317 634-7817

2 American Heart Association AHA
7320 Greenville Avenue
Dallas, TX 75231
800 233-1230

3 YMCA
YMCA Program
Store
Box 5077
Champaigne, IL 61820
217 351-5077
800 872-9622

4 American Alliance for Health, Physical Education, Recreation, and Dance
AAHRERD
AAHPERD Publications
PO Box 704
Waldorf, MD 20604
800 321-0789
Fax 703 476-9527

5 Presidents Council on Physical Fitness
450 5th Street, NW, Suite 7103
Washington, DC 20001
202 272-3424

6 National Institute of Healths Publications
Health Promotion Resource Center
Stanford Center for Research in Disease Prevention
1000 Welch Road
Palo Alto, CA 94304-1885
415 723-0003

7 National Heart, Lung and Blood Institute
National Heart, Lung and Blood Institute Information Center
4733 Bethesda Avenue, Suite 530
Bethesda, MD 20814
301 951-3260
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———————–
Patient completes Exercise Assessment Form
Appendix A

Precontemplator
Score 1

Contemplator
Score 2 - 5

Active
Score 6 - 11

Distribute Getting out of your Chair Handout Ref Section

Personal Goals Analysis
History and Physical Examination

Cardiovascular Risk Assessment
See Figure 2, Page 35

Diagnostic
GXT

Special Population:
Diabetes Mellitus
Osteoporosis
COPD
Asthma
Coronary Artery Disease
Pregnancy/Postpartum
Obesity
Elderly/Chronically Ill
Military Personnel

Complete Individual Exercise Prescription
Appendix C

Periodic Follow-up

Review Special Consideration and Limitation within each Special Population
Group

History and Physical Examination
Appendix A
Exercise Assessment Form

Does the Patient have diagnosed disease?

Does patient have symptoms of Cardiovascular Disease?

Does patient have more than 1 major risk factor?

Consider GXT and/or cardiology referral

Moderate activity is safe; vigorous activity should have GXT

Diagnosed
Disease:
Cardiac excluding controlled hypertension
Pulmonary Disease
Metabolic Disease

Risk Factors:
Family history
Tobacco use
Hypertension
Hyperlipidemia
Diabetes Mellitus

Men under 40 years
Women under 50 years

Men over 40 years
Women over 50 years

Moderate or vigorous activity is safe

Moderate activity is safe; vigorous activity requires GXT

Symptoms of Cardiovascular Disease
1 Pain, discomfort or anginal equivalent in the chest, jaw, arms, or
other areas that may be ischemic
2 Shortness of breath SOB at rest or with mild exertion
3 Dizziness or syncope
4 Orthopnea or paroxysmal nocturnal dyspnea
5 Ankle edema
6 Palpitations or unexplained tachycardia
7 Intermittent claudication
8 Known heart murmur
9 Unusual fatigue or SOB with usual activities

Symptoms:
Cough Chest congestion
Wheezing Chest constriction
Dyspnea Decreased endurance

PF or FEV1: 10 to 20 with exercise

All therapy must include education about prevention and proper use of
medication for control of symptoms

Premedicate:
Beta-agonist
2 puffs 15 minutes prior to exercise
Cromolyn sodium
2 puffs 10 to 45 minutes prior to
exercise

Treatment for symptom relief:
Beta-agonist, 2 to 4 puffs rescue treatment only

Future exercise pre-treatment:
Beta-agonist - 2 to 4 puffs
Cromolyn sodium - 2 to 4 puffs
Beta-agonist/cromolyn sodium - 2 puffs each
Long acting beta-agonist - 2 puffs q 12 hours

Consider:
Theophylline
Inhaled corticosteroid
Long acting beta-agonist
Inhaled anticholinergic

Refer to pulmonology

OUTCOME:
Controlled symptoms

Exercise

Tolerance for activity of choice

Yes

Source:unitedmedicalnetwork.com