a set of attributes that people have or achieve that relates to the ability to perform physical activity (9)

- cardiorespiratory endurance

- muscular endurance

- muscular strength 

- power

- flexibility

- agility

- balance

- reaction time

- body composition

Subcomponent of physical fitness (5)

- cardiorespiratory fitness

- muscular endurance

- muscular strength

- flexibility 

- body composition

contributes to one's ability to function in a more skilled and efficient manner (6)

- agility

- balance

- coordination

- power

- reaction time

- speed

Healthy adults 18-64 should participate in moderate activity minimum of 30 min on 5 days/week (150 min/week) or ≥ 20 minutes vigorous activity on 3 days/week (75 min/week), muscular strength on ≥2 days/week

- combinations can be made 

- moderate intensity can be divided ≥10 minute X 3

*additional health benefits are obtained ≥300 min/week moderate or ≥150 mins/week vigorous

Improvement in Cardiovascular and Respiratory Function

- increased VO₂

- decreased minute ventilation at submax intensity

- decreased HR, BP, myocardial O₂ cost at submax 

- increased capillary density, blood lactate threshold, disease signs/symptoms

Reduction in Cardiovascular Disease Factors

- Reduced resting BP, total body fat, insulin needs, platelet adhesiveness/aggregation, triglycerides and inflamation

- Increased HDL-C and glucose tolerance 

Decreased Morbity and Mortality

- Primary prevention (prevent disease occurance)

- Increased activity/fitness → lower CVD, CAD, stroke, T2DM, osteoporosis fractures, colon/breast cancer, metabolic syndrome, and gallbladder disease

- Seondary prevention (after cardiac even to prevent 2nd)

- All-cause mortality reduced in post myocaridal infaction 

Other Benefits

- Decrease anxiety, depression, falls/injury in older adults

- Improved cognititve function, well-being, work/recreational/sport activity, physical function and independent living in elderly

- Effective therapy for many chronic diseases

- Identify those with medical contraindications to PA participation

- Identify those who should have medical/physical evaluation prior to PA/assessments

- Identify those who should have supervised PA program

- Identify those with significant but non-limiting health/medical concerns

- Provide benchmark data

- Provide normative data for screening assessments

- Physical Activity Readiness Questionnaire (PAR-Q): designed to identify clients for whom strenuous PA is not recommended or who would benefit from physician clearance prior to exercise

- AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire: more comprehensive and surveys recognize signs and symptoms suggestive of CVD and other ACSM-established risk factor thresholds

*PAR-Q effective in identifying clients at high risk, but not those with little/no risk

- Health History Questionnaire: establish medical/health risks for both activity asessment and activity participation (family history, history of disease/illness/surgeries, past/present health behavior/habits, current drug/medication use, and history of signs/symptoms of CVD/chronic/metabolic disease)

- Medical Examination: desired by higher risk individuals and guided by law/policies with health care provider

- male ≥45, female ≥55

- family history of CV events (MI, bypass, angioplasty,        sudden cardiac death)

- current smoker, quit within 6 mo., regular exposure

- sedentaty

- Obese: BMI ≥30 kg, waist circumference ≥102 cm male and ≥88 cm female

- Hypertension: ≥140 systolic and ≥90 diastolic on two seperate occasions or on antihypertensive medication

- Dyslipidemia: ≥130 LDL-C, ≤ 40 HDL-C, ≥200 TC, or taking lipid lowering medication

- Prediabetes: FBG between 100-125 mg/dL or a 2-hour oral glucose tolerance test ≥140 mg/dL but <200 mg/dL. FBG of ≥126 mg/dL indicates diabetes → high risk

- Negative Risk Factor: ≥60 mg/dL HDL-C

*If client has any one of these they are High Risk and should be reffered to physician

- Pain/discomfort in chest, neck, jaw, arms: constricting, squeezing, burning, heaviness

- Dyspnea: shortness of breath at rest/mild exertion

- Dizziness or syncope: loss of consciousness, may be normal from reduction in venus return 

- Orthopnea (dyspnea at rest) or paroxysmal nocturnal dyspnea (during sleep) → left ventricular function → relieved by sitting up

- Ankle edema: sign of heart failure 

- Palpitations or tachycaridia

- Intermittent claudation: pain in muscle with inadequate blood supply usually during exercise → CAD

- Known heart murmur: may indicate CVD

- Unusual fatigue or shortness of breath: may signal onset of CPM

*Clients with known CPM are High Risk and must be evaluated by physician prior to exercise testing/training*

Exceptions:

1. well-controlled exercise induced asthma can participate without clearance as long as the are LOW Risk

2. newly diagnosed diabetes clients as long as the are LOW Risk 

*vigorous training should be approached cautiously*

Missing information is an automatic positive risk factor, unless risk factor is prediabetes then it is positive only if:

1. client is ≥45

2. BMI  ≥25 kg/m² and additional risk factor for prediabetes such as family history, hypertension, high waist circumference, or sedentary lifestyle

Risk Classification Medical Exam, Exercise Test, Supervision of Exercise Test Recommendations

- Low risk: asymptomatic, <2 risk factors

- Moderate risk: asymptomatic, ≥2 risk factors, medical exam before vigorous exercise

- High risk: Symptomatic, known CPM disease, medical exam and supervised exercise test before all exercise

- Medical diagnosis

- Previous physical exam findings

- History of symptoms 

- Recent illness, hospitalization, new diagnosis, surgeries

- Orthopedic problems such as arthritis and joint swelling

- Medication use and drug allergies

- Other habits: caffeine, alcohol, tobacco, recreational drugs

- Work history with physical demand emphasis

- Family history of CPM disease

- Normal: <120/80

- Prehypertension: 120-139/80-90

- Stage 1 hypertension: 140-159/90-99, lifestyle modification and antihypertensive drugs indicated 

- Stage 2 hypertension: ≥160/110, lifestyle modification and two drug combination for most

*primary HT: no established pathology (idiopathic), secondary HT: associated with identifiable causes*

- Physical activity

- Weight reduction

- Dietary Approaches to Stop Hypertension (DASH)

- Dietary reduction in sodium 

- Low fat dairy products 

- Moderation of alcohol consumption

LDL

<100            Optimal

100-129        Near/above normal 

130-159        Borderline high

160-189        High

≥190            Very high

TC

<200            Desirable 

200-239        Borderline high

≥240            High

HDL

<40              Low

≥60              High

Triglycerides

<150            Normal

150-199        Borderline high

200-499        High

≥500            Very high

pre-diabetic state of hyperglycemia associated with insulin resistance and increased risk of cardiovascular disease

- 2-hour glucose levels of 140-199 mgdL

pre-diabetes condition in which fasting blood glucose level is consistantly elevated above normal levels and associated with insulin resistance and increased cardiovascular disease 

- fasting glucose levels of 100-125 mgdL

partial impairment of coronary artery blood flow and oxygen

- stable ischemia: result of increased oxygen demand of heart, as seen in exercise

- unstable ischemia: more severe, seen with symptoms at rest during a time of little exertional stress and therefore lower oxygen demand, may be warning sign of heart attack

- verbally explained

- gives opportunity to ask questions 

- indicate withdrawl at any time

- parent signature if minor

- determine acceptable/appropriate process

- protect privacy (HIPPA) 

- indicate purpose if Ex test is not for diagnosis

- obtain IRB approval 

- indicate authorized personal

- indicate emergency procedure

- HR: increases linearly with workload until max is reached, maximal HR decreases with age

- SV: increases with workload up to 40%-60% VO2 then slightly decreases in sedentary but trained it increases

- Q increases during graded intensity until 50%

- Ventilation: increases with intensity until 50-80% VO2max when ventilatory threshold is reached 

- BP: SBP increases with workload, DBP is constant or slightly decreases 

- assessed before exercise

- at each intensity of exercise, HR should reach steady state to move on to next stage and taken two minutes before the end of each stage

- BP should be assessed at the last minute of each stage

- assessed for minimum of 5 minutes after test/exercise or until stable

- estimate of myocaridal oxygen demand (RPP=HR X SBP)

- increased fitness → lower RPP

- direct indication of energy demand put on the heart and energy consumption of the heart

- SBP: first of two or more sounds (phase 1)

- DBP: point before disappearance of sound (phase 2)

- maximum rate of O₂ consumption during incremental exercise

- accepted criterion measurement of CRF

- functional capacity of the heart

- product of maximal Q and a-VO₂ difference

- implies true physiological limit has been reached 

Maximal

- require participant to exercise to volitional fatigue

- may need medical supervision

- offers increased sensitivity in the diagnosis of CVD in asymptomatic individuals 

- better estimate of VO₂

Submaximal

- recommended in stable patients 4-7 days post MI to assess efficacy of medical therapy

- basic aim is to determine HR response to 1 or more work rates to predict VO₂

- Steady state achieved for each work rate

- linear relationship between HR and work rate

- minimal difference between estimated and actual HR

- mechanical efficiency is the same for everyone

- subject is not on medication, ill, consuming high amounts of caffeine, under stress, or in hot environment

- intensity, length, expense, type, personnel needed, equipment/facilities, physician, safety concerns, information needed, accuracy of test, appropriate mode of exercise, participant willingness

- Field test: walking/running for predetermined time or distance, easy to administer to large numbers with little equipment but HR/BP is unmonitored and individual motivation may impact results

- Motor driven treadmills: submax and max testing, can accommodate sedentary to fit individuals but are expensive, make HR/BP hard to measure, and need calibration

- Mechanical cycle ergometers: submax and max testing, lower equipment price, transfer ability, easy to take HR/BP, but is a less familiar load resulting in fatigue or underestimation of VO_2max, and needs calibration

- Step testing: inexpensive, little equipment, little practice, short duration, tests masses, but difficult to measure

- Cooper 12-minute test: cover greatest distance in alloted time

- 1.5-mile test for time: run distance in shortest time 

- Rockport 1-mile Fitness Walking Test: estimates CRF and measures HR upon completion 

- 6-minute walk test: evaluate older adults and clinical patients 

- accurate measure of HR is critical for valid testing, submax uses 70% HRR or 85% age-predicted HR

Cycle ergometer tests

- Astrand-Ryhming: single-stage test lasting 6 min, suggested work rate is based on sex and CRF

- YMCA: 2-4 3-minute stages of continuous exercise, each work rate is performed for at least 3 minutes and maintained for an additional minute if two measured HR vary more than 5 bpm

*errors: inaccurate pedaling and imprecise achievement of steady state HR

Treadmill Tests: stages should be 3+ minutes to ensure steady state

Step Test: CRF based on recovery 

- angina or like symptoms

- ≥ 10 mmHg drop in SBP with increased work rate or below pre-exercise resting measurement

- excessive rise in BP: SBP >250 mmHg or DBP>115 mmHg

- shortness of breath, wheezing, leg cramps, claudation

- poor perfusion: light headed, confusion, nausea, cold/clammy skin

- failure of HR to increase with work load

- noticeable change in heart rhythm or palpitation

- subject requests to stop 

- physical/verbal manifestations of severe fatigue

- equipment failure

- Frequency: ≥ 5d/wk moderate, ≥3+ d/wk vigorous, or combination on ≥3-5 d/wk

- Intensity: moderate or vigorous in general pop., light-moderate in deconditioned

- Time: 30-60 min/day moderate, 20-60  min/day vigorous, or combo but <20 min/day can be beneficial

- Type: regular, purposeful exercise involving major muscle groups in a continuous and rhythmic nature

- Volume: target volume of ≥500 to 1,000 MET/min/wk, increasing pedometer steps by ≥2,000 steps/day to reach ≥7,000 steps/day, and exercising below this can still be beneficial especially in sedentary

- Pattern: exercise may be performed in continuous bout or multiple sessions of ≥10 min accumulating daily recommendation, exercise <10 min bouts may be beneficial in deconditioned

- Progression: gradual progression of volume, frequency, and/or intensity to reach goal/maintain; this may enhance adherence and reduce risk of musculoskeletal injury and risk of CAD

SAID principle: specific adaptations to impose demands

- dependent on type and mode of exercise

- specific exercise elicits specific adaptations

Determining Exercise Intensity:

Heart Rate Reserve Method

- need resting and maximum HR

- HRR = [(HR_max - HR_rest) X % intensity] + HR_rest

Determining Exercise Intensity:

Peak HR Method

- need HR_max through max testing or formula

- Target HR= HR_max X % intensity desired

- EX: 180 (HR_max) X 85% = 153 bpm for targeted HR

Determining Exercise Intensity:

Peak VO₂

- need measured or estimated VO_2max

- Target VO₂= VO_2max X % intensity desired

- EX: client with measured VO_2max of 60 mL·kg^-1·min^-1 with ExRx of 90% max → 60 X 90%= 54 mL·kg^-1·min^-1

Determining Exercise Intensity:

VO₂ Reserve Method (VO₂R)

- need measured/estimated VO_2max and VO_2rest

- VO₂R is the difference between VO_2max and VO_2rest

- Target Vo₂R= [(VO_2max - VO_2rest) X intensity desired] + VO_2rest

- EX: client with VO_2max of 35, VO_2rest of 3.5, and intensity of 60% VO₂R →

[35-3.5) X 60%] + 3.5= Target VO₂R of 22.4 mL·kg^-1·min^-1

Determining Exercise Intensity:

Talk Test Method

- measure of relative intensity

- helps decifer between moderate and vigorous (no more than a few words)

- once comfortable speech is no longer possible, vigor may need to be reduced

Determining Exercise Intensity:

Perceived Exertion Method

- subjecting rate of how hard someone is working

- Borg's RPE Scale: 6-20, 11-16 reccommended

- Borg's Category Ratio Scale (CR-10): 0-10, 5-8 reccommended, 5-6 moderate, 7-8 vigorous 

- Intrinsic: history of injury, body composition, bony alignment abnormalities, strength or flexibility imbalances, joint or ligamentous laxity, predisposing musculoskeletal disease

- Extrinsic: excessive load on body, type/speed of movement, number of repetitions, footwear, surface, training error, excessive distances, fast progression, high intensity, running on hills, poor technique, fatigue, adverse environmental conditions, air quality, darkness, heat/cold/altitude/humidity, wind, and faulty equipment

- rate of dehydration and aerobic performance reduction are directly related

- hyponatremia: lower than normal blood Na+ concentration from drinking too much water

- increased sweat rates may lead to a decrease in SV prompting HR to maintain cardiac output at submax work

- "HR drift" or elevated HR can decrease performance

- heat stress can lead to diminished CNS function and increased muscle glycogen utilization

- increased risk of hypothermia

- HR and Q are similar to thermoneutral environment

- respiratory rate is higher at submax and VO_2max may be slightly lower

- primary barrier is extra work associated with clothing

- barometric pressure causes partial pressure of oxygen (PO₂) to decrease at altitude and decrease ability to provide oxygen to working muscles

- increased ventilation at lower PO₂ 

- initial days of high-altitude: SV decreases and HR increases causing an increase in Q but no change in BP

- altitude can cause sleep disturbances and weight loss

-improve/maintain bone mass

- better cardiometabolic risk profile

- lower risk of all-cause mortality

- fewer cardiovascular disease events

- improve body composition, blood glucose tolerance, and insulin sensitivity

- maintain lean mass contributing to maintenance/increase of BMR

- improve musculotendinous integrity

- carry out ADL's increasing percieved quality of life and self efficacy

- Strength: muscles ability to exert force

- Endurance: muscles ability to continue to perform successive exertions or many repititions

- Power: muscles ability to exert force per unit of time

- identify weakness/imbalances

- baseline data

- program basis

- progressive improvements

- promote long-term exercsie adherance

- Progression

- Regularity

- Overload

- Specificity 

- assessment of maximal muscle tension throughout a ROM set at constant angular velocity

- controls speed of joint rotation

- measures rotational force or torque

- expensive

Progression

- demands placed on the body must be continually and progressively increased over time to achieve long-term gains in muscular fitness

- particularly important after first months of training when threshold for training-induced adaptations are higher

- increase training weight about 5-10% a week and reduce reps by 2-4 a week for beginners 

- 2 plus 2 rule: [2+ reps over assigned goal on 2 consecutive occations

- program variance is important for exercise adherence

- 2-3 nonconsecutive days

- inconsistent results in modest adaptations

- inactivity results in loos of strength/size

- to enhance muscular fitness, the body must exercise at a level beyond that at which it is normall stressed

- manipulated by changing intensity, duration, or frequency

- distinct adaptations that take place as a result of the training program

- specific to muscle actions, velocity of movement, ROM, muscle groups trainined, energy systems involved, and intensity and volume of training

- saggital: left and right

- frontal: front and back

- transverse: upper and lower

Types of Resistance Training: DCER

Dynamic Constant External Resistance

- most common type, enhances performance skills

- weight lifted does not change from lifting (concentric) and lowering (eccentric) 

- limited by the strength of weakest joint agle muscle

- variable resistance machines: force muscle to maximally contract through ROM

- free weights:less expensive, variety of exercises for balance/coordination, 

- machines: limit use to fixed planes of motion, easy to use, isolate muscle group

- involves dynamic muscular actions that are performed at a constant angular limb velocity

- specialized equipment mainly for rehab

- specialized method of conditioning designed to enhance neuromuscular performance

- quick, powerful movements involving rapid stretch of muscle (eccentric) followed by rapid shortening (concentric)

- time between eccentric and concentric is amortization 

- 40+ reps per session is most beneficial volume

- multiple-joint exercises are generally more effective for increasing muscle strength because they involve greater amounts of mass

- machines:both single/multiple joint, train all major muscle groups, usually in correct anatomical plane

- free weight: move freely, require stabalizing muscles, proper use

- body weight:variety, no equipment, cannot adjust weight

- stability/med balls, tubing:elements of balance while targeting selected muscle groups, inexpensive

- choice of exercise

- order of exercise

- resistance used

- training volume

- rest intervals

- rep velocity

- training frequency

- promote muscle balance across joints and between opposing muscle goups

- include multiple joint exercises

- open and closed kinetic (ADL's)

- include multidirectional exercises

- include lumbo-pelvic hip complex to reduce injury

- large muscle groups before small

- multiple-joint before single-joint

- plyometrics before traditional strength exercise

- training sets should be performed to muscle fatigue but not exhaustion

- RM <6 have greatest effect on developing strength

- RM ≥20 greatest effect on developing endurance

- reps between 8-12 (60-80%) commonly used to increase fitness

- length of rest period will influence energy recover and training adaptations

- increase strength: heavier weights and longer rest (2-3 min) 

- increase endurance: lighter weights and shorter rest (<1 min)

- number of exercises, reps, and sets all influence training volume

- recommended to train each muscle group for 2-4 sets to achieve muscular fitness goals

- multiple set training is more effective than single set training for muscle strength enhancement

- cadence at which resistance is performed can affect adaptations because gains in muscular fitness are specific to training velocity

- systematic variation in training program design

- after time adaptations to a stimulus will no longer take place unless stimulus is altered 

- varying variables such as exercise, resistance, sets, and rest periods

Summary of ACSM FITT Principle for Muscular Strength

- frequency: 2-3 nonconsecutive days/week

- intensity: sedentary: 40-50% 1RM, intermediate: 60-70% 1RM, experienced heavier: ≥80% 1RM, experienced lighter: <50% 1Rm

- type: multi-joint for major muscle groups, target agonist/antagonist to avoid imbalances, vary equipment and BW exericises

- reps: 8-12 for strength and 15-20 for endurance

- sets: 2-4 sets for strength and power, 1 set for novices

- rest: 2-3 min between sets, 48h between sessions

- progresstion: gradual resistance, reps, and frequency

- Prescreening/risk classification

- Resting HR/BP, height, weight, BMI, ECG

- Body composition: waist circumference, skinfold

- CRF: submax or maximal on cycle ergometer or treadmill

- Muscular strength: 1-RM-multiple-RM (bench/leg press)

- Muscular endurance: push-up and curl up test

- Flexibility: sit-and-reach

Flexibility

- defined as ROM of a joint or group of joints

- static: full ROM of joint because of external forces

- dynamic: full ROM of joint achieved by voluntary use of skeletal muscles in combination with external forces 

Factors Affecting Flexibility

- muscle properties: viscoelastic properties

- physical activity and exercise: greater ROM of affected joints by moving joints through fuller ROM during exericise

- anatomical structure: influenced by structure and sturctures surrounding it (joint capsule, muscle, tendons, skin)

- age and gender: reduction in collagen with age, women have greater ROM 

- static: slow and constant motion held in final position or point of mild discomfort for 15-30 sec, does not increase muscle temperature and blood flow redistribution

- ballistic: rapid and bouncing movements resulting momentum used to exten affected joing through full ROM, no longer advocated 

- proprioceptive neuromuscular facilitation (PNF): collection of stretching techniques combining passive stretch with isometric and concentric muscle actions designed to use the autogenic and reciprocal inhibition responses of the Golgi Tendon Organ's (GTO's)

- dynamic flexibility: slow and controlled, sport-specific movements that are designed to increase core temperature and enhance activity-related flexibility and balance 

- muscle spindles: collection of 3-10 intrafusal, specialized muscle fibers that are innervated by gamma motor neurons and provide information about the rate of change in muscle length

- GTOs: located in musculotendinous junction and respond to changes in amount and rate of muscle tension 

- goniometers: measures joint's ROM in degrees, stabilization and movement arms 

- sit-and-reach test: common LB and hip joint assessment

- functional movement screenings: assess individuals for potential weakness and imbalances in strength , flexibility, and motor control 

- structured around same health-related fitness components: progressive overload, specificity, individual differences, and reversability

- assessment determines FITT program

- ≥2-3 sessions/week for 3-4 weeks

- 2-4 reps/exercise holding stretch 10-30 secs (30-60 older adults) accumulating 60 sec of stretch

- PNF: 3-6 light/mod contraction followed by 10-30 sec static partner stretch 

- conducted when muscle is warm 

- for patients with suspected myocaridal ischemia

- valuable in assessment of viable/ischemic myocardium in patients with known CVD being considered for revascularization procedure

- used in conjunction with GXT to improve diagnostic accuracy in patients with suspected CVD

- uses special detector (gamma camera) to create an image following an injection of radioactive material

- performed in patients at high risk for CAD, severe deconditioning, orthopedic disabilities, etc.

- certain medications are administered to mimic the physiologic effects of exercise

- Dobutamine: gradually increase HR and strength of contractions

- Adenosine: simulates coronary artery circulation during exercise (very accurate to detect CAD)

- special x-ray to create a series of detailed pictures 

- detection of coronary arterey calcified plaque

- used to further define risk prediction

- reflect general health

- identify normal/abnormal physiological responses to EX

- provide info to precisely design ExRx

- provide prognostic insight, especially with multiple CVD risk factors

- anthropometric: non-invasive, quantitative tequniques determining body size by measuring, recording, analyzing specific dimensions of the body

- Height and Weight: in/cm and lb/kg

- Body Mass Index: BMI=Weight (kg)/Height (m²), underweight: <18.5, normal: 18.5-24.9, overweight: 25-29.9, Obese: 30-34.9, Obese II: 35-39.9, Obese III: ≥40

- ≥30 associated with hypertension, dyslipidemia, CHD, mortality

- children/adolescents overweight: BMI in 85th-95th%, obese: >95th%

- Circumference Measures: determine body fat distribution, adroid or central/abdominal obesity is associated with higher risk of cardiometabolic diseases compared to gynoid or hip/thigh obesity

- Waist-Hip Ratio: circ. of waist/circ.of hips, health risk is high when cic. is ≥35 in or 88 cm for women and ≥40 in or 102 cm for men

- body comp: relative proportion of fat and fat-free tissue 

- determining BodyComp helps: identify individuals with high and low levels of body fat that are associated with increased health risks, design appropriate exercise prescriptions, formulate dietary recommendations, assess the progress of a client in response to a weight management program, and estimate weight loss goals

- range of 10-22% for men and 20-32% for women is considered health satisfactory

- used to determine amount of subcutaneous fat, located directly below skin

- based on assumptions: approximately 1/3 of total body fat is located subcutaneously and amount of subcutaneous fat is proportional to body fat

- accuracy is ±3.5% assuming proper technique and regression equation used 

- rapid, non-invasive body composition assessment tool

- electrical current passes through body and related to % of water contained in various tissues (lean has more water is a good conductor and fat has less making it a poor conductor) 

- accuracy is ±2.7%-6.3%

- guidelines: thermoneutral environment, no eating/drinking w/in 4 hr, no EX w/in 12 hr, urinate w/in 30 min, no alcohol consumtion 2d prior, no diuretic med w/in 7d, avoid menstruation, use same BIA analyzer

- Hydrostatic weighing: calculates body density from body volume based on Archimedes principle of water displacement, desity of muscle/bone > fat, ±2.7%

- Air Displacement Plethysmography (ADP): quick, non-invasive, accomodates all people, accuracy similar to HW

- DEXA: very low current A-rays at two energy levels to measure bone mineral content, body fat, and lean soft tissue, 1.7% error, gold standard 

- 5-10% weight reduction results in improved health

- safe/effective weight loss is 1-2 lb/wk

- negative energy balance: energy expenditure exceeds energy intake 

- total energy expenditure (TEE): total number of calories expended each day, reflects amount of energy required to carry out all metabolic processes within the body 

- resting energy expenditure (REE/RMR): 60-70% TEE

thermic effect of food: 10% TEE

physical activity expenditure: 20-30% TEE

- REE predictive equations that include fat-free mass are most accurate

Frequency: ≥5 days/week

Intensity: mod-vig aerobic, initial should be mod (40-60%) and progress to vig (≥60%)

Time: ≥30 min/day progressing to 60 min/day of mod 

Type: aerobic involving large muscle groups and incorperate resistance training and flexibility

- increase fruit/vegetable intake

- consume half of grains as whole grains

- increase intake of fat-free or low-fat milk

- choose variety of seafood consumed

- replace protein foods that are higher in solid fat

- use oils to replace solid fats

- choose foods high in K+, fiber, Ca++, and Vitamin D

- provide clients with strategies to make lifestyle changes

- self-monitoring: food/activity log, monitoring BW

- goal setting: realistic goals for exercise

- stimulus control: modifying environment to enhance successful behavior change (removing risky food, hang exercise calendar)

- problem solving: identify situations that pose problem and develop solution

- supplements and herbal products are not regulated by government in terms of efficacy, safety, dosing, and purity of product

- Pregnancy: increased energy and nutrient needs, additional 300 calories/day, prenatal vitamin, increased need for protein, folic acid, and iron, avoid herbal supplements, avoid self-prescribed diets

- Children: increased Vitamin D 600 UI, Ca for bone health

- Older adults ≥65: increased Vitamin D to 800 UI, Ca intake of 1,200 mg/d post menopausal and men ≥70, Vitamin B12 supplement ≥50

- girls stop growing at 15, boys 17

- increase in height during childhood is due to bone growth

- total bone mass increases until 20 yrs in men

- adult females have 30% less skeletal muscle mass than males

- fat mass increases in both men and women but % increases in women and decreases in men

- young childrens seated HR is 100-110 and HR_max is higher than adults

- respiratory frequency is higher in children and decreases throughout childhood/adolescence

- lung function measures increase as a function of height throughout youth

- faster exercise recovery time than adults

- stroke volume is higher resulting in lower cardiac output

- BP is lower at rest and exercise

- hemoglobin concentration increases with age

- children have greater blood flow and oxygen concentration but also greater oxygen cost during exercise

- children have lower peak VO₂

- increases with age

- accelerated increase in boys during puberty and plateau in girls in proportion to slower increase in fat-free mass and muscle mass

- girls tend to have better flexibility than boys

- have more sweat glands but output is lower than adults resulting in a lower ability to produce sweat

- temperature when sweating starts is higher than adults so children cannot sustain exercise as long as adults when temp exceeds 100°F

- obese children accimatize to heat stress more slowly with a lower core temp threshold

Children and Adolescents: Impact of Chronic Exercise

- physical activity will increase cardiorespiratory and muscular fitness, metabolic health, cardiometabolic profiles, body composition, motor performance, muscular strength/endurance, and mental health

- no evidence that exercise including resistance training, weightlifting, and plyometric training has adverse effects

- resistance training and sports conditioning have been shown to reduce the rate of sports-related injuries

- ≥60 min/day of mod/vig activity with vigorous activity on at least 3 days/week

- muscle and bone strengthening should be included in the 60 min on at least 3 days/week

- if minimum is not met intensity and duration should be adjusted until minimum is met

- bone strengthening exercises result in a physical impact on the skeletal system

- muscle strengthening should include a 5-10 minute warm up and end with a cool down

- 1-3 sets of 8-15 reps or to fatigue on nonconsecutive days

- 1-3 sets of 3-6 reps for power exercise

- progress gradually by 5-10%

- children can be successfull in a structured resistance program training program

- clinical exercise testing should be reserved for those children with clinical indication

- ~12 kg or 26lb of weight is typically gained

- increases in estrogen and aldosterone, contribute to water retention and increased blood volume 

- relaxin is released limiting uterine contractions and increases joint laxity, HFS should caution flexibility

- cardiac output, stroke volume, and HR increase at rest but vascular resistance decreases 

- supine position can exacerbate reduced venous return to the heart 

- resting oxygen uptake increases by 20-30% bc of fetal growth

- caloric need increases by 150 kcal trimesters 1-2 and 300 kcal in the third

- reduce risk of pregnancy related conditions: preeclampsia (pregnancy HT), gestational diabetes, pregnancy related edema in extremities

- improves mood and alleviates some discomfort

- chronic exercisers tend to have smaller (normal weight) babies reducing complications

- frequency: 3-4 day/week to prevent low birth weight

- intensity: moderate for BMI of <25, light for BMI of ≥25, HR ranges for intensity have been developed for low risk

- time: ≥15 min/day gradual increase to max 30 min/day (120 min/week) with 10-15 min warm-up/cool-down (150 min/week), prescreened women with a BMI ≥25 can exercise at light intensity for 25 min/day increasing 2 min/week until 40 min/day 3-4 day/week is achieved

- type: dynamic, rhythmic, large muscle groups

- progression:optimal time to progress is after first trimesterbc discomfort and risk are lowest, progress minimum of 15 min/day 3 day/week to max of 30 min/day 4 day/week

- PARmed-X pregnancy screening tool especially for sedentary/medical conditioned women

- exercise at 40-60% HRR (RPE 12-14)

- pregnancy HR: >20 yr=140-155 bpm, 20-29 yr=135-150 bpm, 30-39 yr=130-145 bpm, ≥40 yr=125-140 bpm

- ingest 16 oz. water prior and 1 cup every 20 min

- terminate exercise and consult physician when: vaginal bleeding, shortness of breath prior to exercise, dizziness, headache, chest pain, muscle weakness, calf pain/swelling, preterm labor, decreased fetal movement, or leaking amniotic fluid

- resistance training moderate level of 12-15 reps

- avoid isometric exercise and Valsalva maneuver

- postpartum exercise may begin 4-6 weeks after vaginal delivery and 8-10 weeks after cesarean section with medical clearance

- gain body weight and fat mass but lose fat-free mass, muscular strength, height, and bone

- very old population loses body weight and cell mass

- decreased body water content, elasticity/pliability of tissue, ROM, neuromuscular function, coordination, reaction time, balance, and agility

- vessels become stiffer and elasticity of cardiac tissue is lost resulting in higher blood pressure and resistance to blood flow

- higher ventilation, BP, oxygen extraction, lower Q and SV, and lactic acid concentrations during submax exercise

- lower exercise capacity

- declining thermoregulation, number/activity of sweat glands resulting in lower ability to benefit from evaporative or radiant cooling

- cannot withstand cold due to reduced ability to divert blood flow toward deeper tissue

- icreases physical function/fitness, prevents falls, improves mental health, and helps achieve healthy weight

- improves management of dementia, anxiety, back pain, cognitive changes, and sleep

- frequency:≥5 day/week mod or≥3 day/week vig

- intensity: moderate intensity: 5-6 RPE or 3-<6 MET, vigorous intensity: 7-8 RPE or ≥6 METS

- time: 30-60 min mod or 10 min bouts, 20-30 min vig

- frequency:≥2-3 non-consecutive day/week

- intensity: 60-70% 1RM or 5-6 RPE mod 7-8 RPE vig

- progressive, 8-10 exercises, ≥1 set 10-15 reps

- frequency:≥2 day/week

- intensity: stretch until point of tightness

- time: 30-60 sec/stretch, 10 min sessions

- type: static

- improves balance, agility, and proprioception to reduce falls

- perfom 2-3 day/week

- recommendations: dynamic movements moving center of gravity, progressively difficult postures, stressing postural muscles, reducing sensory input, and tai chi

Most older adults do not require exercise test prior to a moderate intensity PA program, exercise test should be done for multiple risk factors/moderate risk older adults for vigorous activity

- light (<3 METs) initial workload with small increments

- Naughton Treadmill Test (may need handrails), Cycle Ergometer

- higher rate of ECG false positives may be related to greater frequency of left ventricular hypertrophy (LVH) and presence of conduction disturbances in older adults

- increased prevalence cardiovascular, metabolic, and orthopedic problems may increase likelihood of test termination

- thorough medical history and physical exam to determine contraindications to exercise

- diagnosed CVD or present symptoms can be risk classified and treated accordingly

- no CVD symptoms should be able to perform light intensity (<3 METs) with little risk

- identify functional limitations associated with poorer health status that can be targeted for exercise intervention

- developed and validated as predictors of disability, institutionalization, and death

- before administering: cosider specific population, be aware of ceiling/floor effects, understand scoring predictive capabilities 

- adaptations include decreased rectal temperature, HR, RPE

- increased exercise tolerance, sweating rate, and reduction in sweat salt

- acclimatization results in: improved heat transfer from the body's core to external environment, improved cardiovascular function, more effective sweating, and improved exercise and heat tolerance

- heat cramps: muscle pain/spasm in abdomen, arms, and legs that usually occur in association with strenuous activity, muscle fatigue, and water loss. respond to stretching, hydration, intravenous saline fluid, and dietary sodium chloride

- heat syncope: temporary failure caused by pooling of blood in peripheral veins. occur in unfit, sedentary, nonacclimatized. caused by standing erect too long or cessation of strenuous, prolonged, upright exercise because of maximal cutaneous vessel dilation resulting in declined BP and insufficient O2 delivery to brain. recovery is rapid once laying supine but HR/ BP may take hours until back to normal

- heat exhaustion: most common form of serious heat illness. occurs during exercise/physical activity in the heat when body cannot sustain level of Q needed to support skin blood flow for thermoregulation. intravenous fluid administration or oral fluids will help recovery

- Exertional Heat Stroke: caused by hyperthermia and characterized by elevated body termperature (104°F), CNS dysfunction, multiple organ system failure causing delerium, convulsions, or coma. greatest risk is during high intensity prolonged exercise when ambient wet-bulb globe temp is >28°F. life threatening medical emergency that requires immediate and effective whole body cooling with cold water and water immersion therapy. inadequate physical fitness, excess water adiposity, improper clothing, protective gear, incomplete heat acclimatization, illness, or meds increase risk

- Frostbite: when tissue temperatures fall lower than 0°C or 32°F

- most common on exposed skin and hands and feet

- contact occurs by touching cold objects with bare skin.

- determinants are temp, speed, and wetness

- pain that is primarily localized to lumbar and lumbosacral area that may or may not be associated with leg pain

- clinical guidelines recommend PA for management

- LBP subgroups: LBP associated with serious pathology (cancer/fracture), LBB with specific neurological signs/symptoms, and non-specific LBP

- Subgroup of duration: acute (4-6w), subacute (<3mo), and chronic (≥3mo)

- individuals with chronic LBP have reduced CRF levels, muscular strength/endurance

- exercise testing and Rx should be guided by same considerations as general population if actual/fear of pain/reinjury permits and not associated with other pathology

- can be traumatic, acute, or chronic

- 80% recover within 4-6 weeks regardless of treatment

- recurrency is high

- causes include: disc compression, degenerative changes in lumbar spine, various joint/bone pathologies, and muscle imbalances

- core muscles are very important to spine function/stability

- pain questionnaires and outcome measures are used subjectively to quantify pain and functional impairment

- core stabilization should complement FITT progressing through stages of increasing intensity

- stages: abdominal bracing (deep stabalizing), cocontraction of deep muscles of core while in more challenging positions and movement of extremeties, and maintaining cocontraction of deep stabilizing muscles while performing exercise designed to recruit larger srtabilizers in more functional positions 

Medical Considerations: Altitude Illness

- Acute Mountain Sickness (AMS): common. symptoms: headache, nausea, fatigue, decreased appetite, poor sleep, poor balance, and mild swelling in hands, feet, or face. develops w/in 24h of alt. exposure. recover: limited physical exertion and stopping ascent 24-48h

- High Altitude Cerebral Edema (HACE): uncommon, potentially fatal. occurs in ascent and exacerbation of unresolved AMS

- High Altitude Pulmonary Edema (HAPE): uncommon, potentially fatal. occur in repeated ascent/descent and strenuous exercise during ascent. symtoms: crackles and rales in lungs, blue lips/nail beds

- many develop sore throat and bronchitis resulting in coughing spasms

- early assessment and mobilization

- identification of and education regarding CVD risk factors

- assessment of patients level of readiness for PA

- comprehensive discharge planning

- identify patients with severe cardiovascular, physical, or cognitive impairments that may influence PA performance

- offset deleterious physiologic/psychologic effects of bed rest

- provide additional medical surveillance of patients and their responses to PA

- evaluate/enable patients to safely return to ADL's w/in limits imposed by their CVD

- prepare patient/support system at home/setting to optimize recovery following acute care hospital discharge

- facilitate physican referral and patient entry into outpatient cardiac rehabilitation program

- Acute coronary syndromes: manifestation of coronary artery disease (CAD) as increasing sympoms of angina pectoris, myocardial infarction (MI), or sudden death

- Cardiovascular disease (CVD): diseases that involve the heart and/or blood vessels; includes HT, CAD, PAD; includes but not limited to atherosclerotic arterial disease

- Cerebrovascular disease (stroke): diseases of the blood vessels that supply the brain

- CAD: disease of the arteries of the heart (usually atheroscerotic)

- Myocaridacl ischemia: temporary lack of adequate coronary blood flow relative to myocardial O₂ demands; it is often manifested as angina pectoris

- MI: injury/death of the muscular tissue of the heart

- Peripheral arterial disease (PAD): diseases of arterial blood vessels outside the heart and brain

- depends on size of MI and occurance of complications

- includes self care activities, arm/leg ROM, and postural changes

- progress to walking short/moderate distance (50-500 ft) with minimal/no assistance 3-4 times a day

- medically stable post-MI

- stable angina

- coronary artery bypass graft (CABG) surgery

- percutaneous transluminal coronary angioplasty (PTCA)

- stable heart failure caused by either systolic or diastolic dysfunction (cardiomyopathy)

- heart transplantation

- valvular heart surgery

- peripheral arterial disease (PAD)

- at risk for CAD with diagnoses of diabetes mellitus, dyslipidemia, hypertension, or obestiy

- other patients who may benefit from structured exercise and/or patient education based on physician referral and consensus of the rehabilitation team 

FITT Reccomendations for Inpatient Programs

- frequency: mobilization: 3-4 x/day for first 3 days hospital stay

- intensity: seated/standing resting HR + 20 bpm for MI patients and +30 bmp for patients recoving from heart surgery, upper limit of ≤120 bpm w/ corresponding RPE ≤13

- time: begin with intermittent walking bouts of 3-5 min and progressively increase duration. 2:1 ex/rest ratio

- type: walking

- progression: when continuous exercise duration reaches 10-15 min increase intensity as tolerated w/in reccomended RPE and HR limits

- prognostic assessment

- evaluation of medical therapy or coronary intervention

- physical activity counseling

- DBP ≥110 mmHg

- decrease in SBP >10 mmhg with increasing workload

- significant ventricular/atrial arrhythmias with or w/out associated signs/symptoms

- second or third degree heart block

- sign/symptoms of exercise tolerance including angina, marked dyspnea, and ECG changes successive of ischemia

- unstable angina

- uncontrolled hypertension (>180/110)

- orthostatic BP drop of >20 mmHg with symptoms 

- significant aortic stenosis 

- uncontrolled atrial/ventricular arrhythmias

- uncontrolled sinus tachycardia (>120 bpm)

- uncompensated heart failure 

- third degree AV block without pacemaker

- active pericarditis or myocarditis

- recent embolism

- acute thrombophlebitis

- acute systemic illness or fever

- uncontrolled diabetes mellitus 

- severe orthopedic conditions that would prohibit exercise

- other metabolic conditions, such as acute thyroiditis, hypokalemia, hyperkalemia, or hypovolemia 

- medical/surgical history with most recent CV event, comorbidities, and other pertinent medical history

- physical examination with an emphasis on the cardiopulmonary and musculoskeletal systems

- review of recent CV tests and procedures including 12-lead ECG, coronary angioplasty, echocardiogram, stress test, revascularization, and pacemaker/implantable defibrillator implantation

- current medications including dose, route, and frequency

- CVD risk factors

- HR/BP

- Body weight- symptoms/evidence of hange in clinical status not necessarily related to activity (dizziness, palpitations, irregular pulse)

- symptoms/evidence of exercise intolerance

- change in medications and adherence to the prescribed medication regimen

- consideration of ECG surveillance that may consist of telemetry or hardwire monitoring, "quick look" monitoring using defibrillator paddles, or periodic rhythm strips depending on the risk status of the patient and the need for accurate rhythm detection 

- develop/assist patient to implement a safe and effective formal exercise and lifestyle physical activity program

- provide appropriate supervision/monitoring to detect change in clinical status

- provide ongoing surveillance data to the patient's health care providers in order to enhance medical management

- return the patient to vocational and recreational activities or modify these activities based on the patient's clinical status

- provide patient and spouse/family education to optimize secondary prevention through aggresice lifestyle management and judicious use of cardioprotective medications

- exercise tetsting at baseline is essential for the development of an ExRx in patients who had MI with or w/out revascularization or undergone coronary revascularization alone

- variables to be considered: safety factors including clinical status, risk stratification category, exercise capacity, ischemic/anginal threshold, musculoskeletal limitations, and cognitive/phsychological impairment that might result in nonadherence and/or inability to meet exercise guidelines; assocaited factors including premorbid activity level, vocational and avocational requirements, and personal health/fitness goals 

- frequency: ≥3 day/week, can do multiple short (1-10 min) sessions

- intensity:can be based on exercise test (60-80% VO₂), RPE of 11-16,or at HR beflow ischemic threshold

- time: warm up/ cool down for 5-10 mins each, include static stretching, ROM, and light intensity aerobic activities. goal o f 20-60 min/session but may begin at 5-10 min aerobic activity post CV event with gradual increase of 1-5 min/session or 10-20% increase in time/week

type: aerobic, rhythmic, and using large muscle groups with emphasis on calorie expenditure to maintain healthy body weight or aerobic interval training (AIT) alt. 3-4 min at high intensity (90-95%) and moderate intensity (60-70%) for 40 mins

- progression: no standard form but should consider fitness level, motivation, goals, symptoms, limitations

* should take prescribed meds at recommended time

- low risk cardiac patients may begin with continuous ECG monitoring and decrease to intermittent ECG monitoring after 6 sessions or when deemed appropriate

- moderate risk patients may begin with continuous ECG monitoring and decrease to intermittent ECG monitoring after 12 sessions or when deemed appropriate

- high risk patients may begin with continuous ECG monitoring and decrease to intermittent ECG monitoring after 18 sessions or when deemed appropriate

- not uncommon for patients to begin cardiac rehab before exercise test

- recommendations based on what was accomplished during inpatient, home exercise, and RPE

- should monitor fatigue, dizziness/light headedness, chronotropic incompetance, and signs/symptoms

- cadiac symtoms that are stable or absent

- appropriate HR, BP, and rhythm responses to exercise

- knowledge of proper exercise and awareness of abnormal symptoms

- motivation to continue exercise

- caused by the development of atherosclerotic plaque in systemic arteries that leads to significant stenosis, resulting in reduction of blood flow to regions distal to the area of occlusion

- creates mismatch of O₂ supply and demand causing ischemia to develop in affected areas like calf, leg, buttock

- if severe PAD leads to claudation or pain at rest, intervention may be indicated to avoid gangrene and amputation

- used to determine time of onset of caludation pain pretherapeutic and post-therapeutic intervention, to measure postexercise, ABI, and to diagnose the presence of CVD

- PAD patients are classified as high risk indicating medical supervision of exercise

- medication dose should be noted/repeated in identical pattern for exercise tests

- ankle/brachial artery SBP should be measured bilaterally after 5-10 min post exercise in supine position

- begin treadmill protocol start with slow speed and gradual increments in grade

- monitor claudation pain perception scale and time and distance to maximal pain should be recorded

- patients should recover in supine position for at least 15 mins post exercise test and record time for pain to resolve

- 6-min walk test may be used to assess ambulatory function

- frequency: weight bearing aerobic exercise 3-5 day/week, resistance ≥2 day/week

- intensity: moderate (40-60%) allowing patient to walk until they reach a 3 out of 4 pain score, allow time for ischemic pain to subside before resuming exercise

- time: 30-60 min/day, some may start with 10 min bouts accumulating 30 min/day, many may need to begin program by accumulating 15 min/day and gradually increasing time by 5 min/day biweekly

-type: weight-bearing aerobic exercise, cycling may be used for warm up but not primary exercise

*heart failure patients can use CVD recommendations*

- rate responsive: programmed to increase/decrease HR to match level of PA

- single-chambered: only one lead placed into right atrium or right ventricle

- dual-chambered: two leads, one in RA and one in RV

- cardiac resynchronization therapy: three leads, one in RA, RV, and one in coronary sinus/LV myocardium

- type of pace maker defined by 4-letter code: first letter is chamber (A for atria), second is chamber sensed, third is pacemakers response to chamber sensed event, and fourth is rate response capabilities (inhibited (I), rate responsive (R))

- monitors heart rhythms and delivers shock if life-threatening rhythms are detected 

- mainly used for high rate tachycardia and v-fib

- aim to protect against sudden cardiac death from v-tach/v-fib

- pacemaker modes (HR limits and ICD rhythm) should be obtained prior to exercise

- exercise testing should be used to evaluate HR and rhythm responses prior to exercise program

- if ICD is present, HR_peak during test/exercise should be at least 10 bpm below programmed HR threshold 

- after 24h after device implantation, upper ext. ROM may help avoid joint complications

- to maintain device and incision integrity, 3-4w after implant, rigorous upper ext. activities should be avoided but lower ext. are allowable

- HFS should be aware of: elevated HR_rest, delayed HR response to exercise, and below normal HR_peak

- ExRx: extended warm up and cool down, using 11-16 RPE, and incorperate stretching and ROM

- 1 yr post transplant HR response normalizes and THR may be used based on exercise test 

- improves muscular strength/endurance

- decresases cardiac demands of muscular work for ADLs

- prevents/treats other diseases/conditions: osteoporosis, T2DM, and obesity

- increases ability to perform ADLs

- improves self-confidence

- maintains independence

- slows age and disease related declines in muscular strength/mass

- RPE of 11-14

- frequency: 2-3 day/week with 48h rest 

- intensity: 10-15 reps w/out straining 11-14 RPE

- type: bands, free weights, machine, wall pulley

- progression: increase by 5% if upper limit becomes easy or 2-5 lb upper and 5-10 lb lower per week

- assess work demands (strength/endurance, muscles)

- use exercises that mimic movement patterns

- educate patient about environmental concerns 

- monitor physiologic responses to simulated work if possible 

- stroke: brain injury caused by either vascular ischemia or intracerebral hemorrhage and is a leading cause of disability in US

- VO_2peak is half of age-matched individuals

- inital 3-6 mo postevent focuses on basic mobility function and recovery of ADLs

- 8-23% improvement in VO_2peak after 2-6 mo training 

- type 1: absolute deficiency in blood insulin release because of the desctruction of pancreatic insulin screening beta cells

- type 2: elevated glucose levels typically as a result of increasing insulin resistance

*responds well to exercise therapy and insulin sensitivity/blood glucose monitoring drug therapy*

- CV: decrease coronary inflammation markers (c-reactive protein), stress/damage on arteries, blood platelet adhesiveness, fibrogenen levels, blood viscosity, and clotting; increase new blood vessel growth, vascular regeneration, and ischemic threshold during ADL's

- Metabolic: increased insulin sensitivity, blood lipid profile; decreased fasting blood glucose, triglyceride levles, and CAD risk factors

- Pulmonary: overall benefit is that client can exercise longer at higher intensities

- DM: group of metabolic diseases characterized by an elevated blood glucose concentration (hyperglycemia) as a result of defects in insulin secretion and/or an inability to use insulin 

- T1: autoimmune destruction of insulin producing Beta cells of the pancreas; primary characteristics are absolute insulin deficiency and a high propensity of ketoacidosis

- T2: caused by insulin-resistant skeletal muscle, adipose tissue, and liver combined with insulin secretory defect; characteristics are excess body fat w/ upper body fat dist.

- Prediabetes: elevated blood glucose levels in response to dietary carbohydrates (impaired glucose tolerance IGT), elevated blood glucose in the fasting state (impaired fasting glucose IFG)

- HbA1C: reflects mean blood glucose control over past 2-3 mo with a general goal of <7% (>6.5% may indicate DM)

- light/moderate exercise with low risk: no test neccessary 

- prediabetes with ≥10% risk of CV event who want to start vigorous exercise (>60%): supervised ECG exercise test

- if positive/nonspecific changes in ECG during exercise or ST and T wave changes occur at rest follow up testing may be performed 

FITT: Diabetes Mellitus

- frequency: 3-7 day/week

- intensity: 40-60% or 11-13 RPE, higher intensity may allow better blood glucose control

- time: 150 min/week moderate at ≥10 min bouts; additional benefits achieved ≥300 min/week mod/vig

- type: large muscle groups, rhythmic nature

- progression: increase duration and intensity for further caloric expenditure

*resistance training is the same as health pop.

- hypoglycemia (<70 mgdL) is most serious problem and can occur for 12h post exercise; symptoms: shakiness, weakness, abnormal sweating, nervousness, anxiety, tingling in mouth/fingers, and hunger

- using insulin pumps during exercise may reduce insulin delivery

- hyperglycemia with or w/out keytones are a concern for T1; symptoms: polyuria, fatigue, weakness, increased thirst, and acetone breath; should be treated like heat illness

- if pre-exercise blood glucose is <70 mgdL, carbohydrate snack of 15g should be taken and a reading of >100 mgdL before starting/continuing exercise

- if pre-exercise blood glucose is >250 mgdL with presence of ketones or >300 mgdL w/ or w/out ketones blood glucose should be lowered before initiating exercise

- Dyslipidemia: abnormal blood lipid and lipoprotein concentrations and exists when LDL-C or trglyceride concentrations are elevated or HDL-C is reduced

- major modifiable cause of CVD

- individuals should be screened and risk classified

- use caution because underlying CVD may be present

- standard exercise testing is appropriate but special consideration should be given to the presence of other chronic diseases (met syn, obesity, hypertension)

- healthy weight maintenance should be emphasized and aerobic exercise becomes foundation

- short term goal of 150 min/week and long term goal of 300 min/week expending >2,000 kcal/week

- >250 min/week helps healthy weight loss management

- frequency: ≥5 day/week

- intensity: 40-70% VO₂R or HRR

- time: 30-60 min/day or 50-60 min/day to maintain weight loss

- type: primarily aerobic that involves large muscle groups, involving resistance training and flexibility if comorbidity is not present

- resting SBP ≥140, DBP ≥90, taking antihypertensive meds, or being told by physicain on two seperate occations you have high BP

- leads to increased risk of CVD, PAD, stroke, heart failure, and chronic kidney disease

- risk of CVD doubles with every 20 mmHG increase in SBP and 10 mmHg increase in DBP

- recommended lifestyle changes: smoking cessation, weight management, reduced sodium intake, DASH diet, and PA

- recommendations vary on BP level and presence of other CVD risk factors

- hypertension w/ uncontrolled BP should consult physician prior to exercise, light/mod exercise can take place such as walking w/out consulting physical

- hypertension with high risk should have medical evaluation prior to exercise

- hypertension with high risk or target organ disease (LVH) who plan to exercise mod/vig should have medically supervised symptom limited exercise test

- resting SBP ≥200 and/or DBP ≥110 are relative contraindications to exercise testing

- if exercise test is for non-diagnostic purpose individuals may take prescribed meds

- individuals on Beta blockers will reduce HR response to exercise and maximal capacity

- individuals on diuretics may experience hypokalemia or other electrolyte imbalances, dysrhythmias, or false positive exercise tests

- test should be stopped if SBP >250 and/or DBP >115

*aerobic exercise leads to a 5-7 mmHg reduction in resting BP in individuals with hypertension*

- frequency: aerobic on all/most days, resistance 2-3 d/week

- intensity: moderate aerobic (40-60%) or 11-13 RPE, resistance (60-80%)

- time: 30-60 min/day continuous aerobic or 10 min bouts, 1 set of 8-12 reps for each major muscle group

- type: emphasis on aerobic, machine or free weights for resistance with 8-10 different exercises

- progression: relate to healthy adults with consideration of BP control, changes in meds, adverse affects of meds, presence of other comorbidities; progression should be gradual avoiding large increases

- uncontrolled and/or sever hypertension should only exercise after physician clearance and/or med Rx

- individuals with CVD or other chronic illness should only perform vig exercise is rehab centers under medical supervision

- Beta blockers may predispose to hypoglycemia and reduce submaximal and maximal exercise capacity

- antihypertensive meds such as a-blockers, calcium chanel blockers, and vasodilators may lead to sudden excessive reductions in postexercise BP

- obese and overweight hypertension individuals should focus on increasing caloric expenditure

- BP-lowering effects of exercise are immediate and can lead to post exercise hypotension

- individuals with documented ischemia should exercise below ischemic threshold (≤ 10 bpm)

- avoid valsalva maneuver during exercise

- curvalinear increase in SBP during exercise puts pressure on arterial intima increasing likelihood of dislodging athersclerotic plaque causing skroke or MI

- >180/110 exercise is only engaged after initiating drug therapy

- >250/115 exercise is contraindicated and not engaged until BP is reduced

- during exercise if BP >220/105 exercise is stopped

- characterized my constellation of risk factors that are associated with increased incidence of CVD, DM, and stroke

- typically individuals with met sym are overweight/obese, have elevated triglycerides, hypertension, and elevated plasma glucose

- Diagnosis is made when ≥3 risk factors are present: weight circumference, insulin/glucose resistance, dyslipidemia, and hypertension

- root causes: overweight/obese, physical inactivity, insulin resistance, and genetic factors

- International Diabetes Federation (IDF): define Met Syn as the presence of abdominal adiposity and 2+ risk factors

- NCEP and ATP III treatment guidelines (3 interventions): weight control, PA, treatment of associated CVD risk factors

- IDF primary intervention: moderate restriction in energy intake (5-10% weight reduction/yr), moderate increase in PA, and change in dietary intake

- IDF secondary intervention: pharmacotherapy for associated risk factors

- special considerations should be given for individuals with associated risk factors

- exercise considerations to obese/overweight should be followed for those individuals

- obese/overweight individuals may need low initial work load

- because of the potential presence of elevated BP, strict protocol in measuring BP should be adhered

- FITT is consistent with healthy adults

- individuals will likely present CVD and DM risk factors and special consideration should be given to individual risk factors

- goal of program is to reduce CVD and DM risk factors

- to reduce risk factors associated with CVD and DM, moderate (40-60%) should be used and when appropriate progress to vigorous (≥60%)

- characterized by excess body weight with BMI commonly used as criterion to define these conditions

- overweight: ≥25, obese: ≥30, and morbidly obese: ≥40

- linked to CVD, DM, various forms of cancer, and musculoskeletal problems

- moderate reductions in energy intake with adequate elvels of PA maximize weight loss

- classify risk category as other comorbidities may be present resulting in medical screening or supervised test

- musculoskeletal limitations may require modifications

- low initial work load (2-3 MET) may be needed

- consider cycle ergometer for ease of test administration

- consider exercise equipment weight specification

- standard test termination may not apply

- check appropriate cuff size

- frequency: ≥5 day/week

- intensity: initially mod (40-60%) eventually vig (≥60%)

- time: ≥30 min/day (150 min/week) progress to ≥60 min/day (300 min/week) moderate or ≥10 min bouts 

- type: aerobic primarily using large muscle groups and incorperate resistance training and flexibility

- weight loss maintenance may take more than recommended 150 min/week

- 250 min/week of PA may enhance long-term weight loss

- PA should be performed 5-7 day/week

- the addition of resistance training does not appear to prevent the loss of fat-free mass or the observed reduction in EE but there may be additional health benefits by improving CVD and DM risk factors

- target ≥5-10% reduction in BW over 3-6mo

- enhance communication with health professionals following weight loss

- target eating and exercise behavior for long-term weight loss

- target reducing energy intake by 500-1000 kcal/day, >2,000 kcal/week, and dietary fat to <30% total energy intake

- minimum of ≥150 moderate progress to >250 min

- include resistance as supplemental to aerobic

- incorperate behavioral modifications for maintenance

- variety of procedures performed on obese ≥40 BMI or ≥30 BMI with comorbid risk factors

- can include gastic banding, reducing the size of the stomach, and gastric bypass

- ≥150 min/week is associated with greater postoperative weight loss at the 6-12mo

- ≥250 min/week for preventing weight re-gain

- once cleared for exercise by physician FIIT for healthy adults is applied

- intermittent and non-weight bearing may contribute to initial adherance

- usually grouped into chronic obstructive pulmonary diseases (COPD) and chronic restrictive pulmonary diseases (CRPD)

- COPD diseases: chronic bronchitis, emphysema, and asthma; progressive airflow limitation associated with abnormal inflammatory lung response that limits ability to move air during inhalation/exhalation

- CRPD diseases: interstitial lung disease made up of a small group of diseases that cause inflammation resulting in lung tissue necrosis and decreased lung volume

* cardinal symtom is dyspnea with exertion

- chronic bronchitis: >3mo cough resulting in chronic pulmonary inflammation leading to damage of bronchial lining impeded lung function and air flow obstruction

- emphysema: permanent enlargement of airspaces along with necrosis of alveolar walls causing accumulation of air in lung tissue

- asthma: inflammation and increased smooth muscle constriction in the lungs in response to various stimuli; during episde inflammatory mediators are released causing bronchioal smooth muscle spasm, edema formation, and production of mucous resutling in vascular congestion

- chronic inflammatory disorder of the airways that is characterized by episodes of bronchial hyperresponsiveness, airflow obstruction, and recurring wheeze, dyspnea, chest tightness, and coughing that occur particulartly at night or early morning and are variable and often reversible

- symptoms can be provoked or worsened by exercise resulting in downward cycle of physical inactivity and worsening exercise tolerance

- primary benefits: increase CRF, work capacity, and decreased exertional dyspnea with little/no effect on resting pulmonary function

- exercise training may reduce airway inflammation, severity of asthma, number of days with symptoms, number or ER visits, reduced anxiety/depression, and QOL

- physiologic function testing: cardiopulmonary capacity, pulmonary function (pre/post exercise), and oxyhemoglobin saturation via noninvasive methods

- treadmill or cycle ergometer

- age appropriate standard maximal protocols may be used

- administration of bronchodilator (B-agonist) may help provide optimal assessment of cardio capacity

- assessment of exercise-induced bronchoconstriction should be assessed via vigorous exercise

- evidence of oxyhemoglobin desaturation ≤80% should be used as test termination criteria

- converting borg CR10 scale to dyspnea scale may be beneficial in measuring exertional dyspnea

- 6-minute walk test may be used when asthma is severe or other equipment is not available

*applies to all levels of disease severity*

- frequency: ≥2-3 day/week

- intensity: at ventilatory aerobic threshold or at least 60% VO_2peak measured from exercise test or 80% 6-min walk speed

- time: ≥20-30 min/day

- type: aerobic using large muscle groups, swimming can be asthmogenic and better tolerated

- progression: if ExRx is tolerated well after first month increasing intensity to 70%, time to 40 min/day, and frequency to 5 day/week

*resistance training should follow FITT for healthy adults

- exercise causing symptom exacerbation should be stopped until airway function and symptoms improve

- use of short-term bronchodilators may be beneficial to use before/after exercise

- exercise in cold environments, high intensity and long duration activities should be avoided

*exercise is an effective intervention that lessens the development of functional impairment and disability in all patients with COPD regardless of severity

- assessment of physiologic function includes CRF, pulmonary function, and determination of arterial blood gases or oxyhemoglobin saturation

- modify protocols to functional limitation and dyspnea

- now recommended that GTX be between 5-9 min

- submax exercise testing may be used but age predicted HR_max may not be accurate

- exercise testing mode is usually walking or cycling, arm ergometry may exacerbate dyspnea

- terminate test with severe arterial oxyhemoglobin desaturation ≥80%

* because individuals with COPD are usually older adults, FITT for older adults can be applied

- frequency: 3-5 day/week

- intensity: patients with COPD vigorous (60-80%) and light (30-40%), based on dyspnea range 4-6, higher intensity related to greater health benefits

- moderate/severe COPD may only be able to exercise for  few minutes initially or intermittant exercise leading to sustained higher intensity and duration

type: walking or cycling

*resistence and flexibility is encouraged and should use protocol for healthy adults

- may be beneficial to focus on shoulder girdle for resistance training due to increased dyspnea during upper body ADL's

- patients recieving optimal medical care who still present inspiratory muscle weakness and dyspnea may benefit from inspiratory muscle training: (4-5 day/week, 30% maximal inspiratory pressure, 30 min or 2x15 min, inspiratory resistant training, threshold loading, normocapnic hyperpnea)

- closely monitor and adjust intensity/duration as tolerated, dyspnea supercedes ExRx

- may use dyspnea rating from GXT test for target intensity

- measure of blood oxygenation should be made during initial GXT (should be >90%)

- advanced disease supplemental O₂may help exercise performance

- acute exacerbations of pulmonary disease should limit exercise until symtoms reduce

*risk of OTC is drug interaction

- asprin: CVD patients poses no concern for exercise

- cold and flu: ephedrine increases systemic BP

- diabetics: avoid OTC containing alcohol or sugar bc they are likely to affect blood sugar

- nonsteroidal anti-inflammatory (ibuprofen or naproxen) are used cautiously in diabetic patients bc of potential increase in hypoglycemia

- cough suppressance: can impede productive cough and used cautiously in pulmonary patients, exercise effect negligble

- B-blockers: decrease mortality and risk of second MI

- lower HR and contracibility

- increase exercise capacity by decreasing coronary ischemia

- makes initial exercise intensity determination dificult

- may limit functional capacity

- limits using HR as target intensity

- required more rigorous self-monitoring

- may increase risk of hypoglycemia by blocking symptoms

- used for treating HTN and angina (ACE only HTN)

- increase arterial diameter lessening BP and work by the heart

- CCB's effect is central ACE is more peripheral

- have some effect on HR and contractibility but less than B-blockers posing less concern for exercise

- ACE inhibitors do work in lungs and can produce dry cough

- Nitrates: little effect of HR and contractility

- Statins: associated with muscle soreness when taken with fibric acid and indication that rhabdomyolysis may be occuring →may need to see physician or increase recovery time

- used in CHF for certain persistant arrhythmias

- increases contractility

- slows rate

- mediates arrhythmias

- increases exercise capacity

- can cause ST segment depression at rest or during exercsie

- used to control HTN and edema by triggering kidney to secrete water

- increased water secretion may increase resting and submax HR bc of decreased blood volume or BP

- may effect exercise capacity or thermoregulation

- should check body weight regularly

- used as bronchodilator for short and long-term athma relief

- corticosteroids are for managing asthmatic exacerbations and longer-term treatment but should be used cautiously

- increase hepatic insulin output

- lower insulin resistance

- decrease absorption of carbohydrates

- some may increase VO₂ while others have no effect

- diabetic exerciser needs to monitor blood glucose before, during, and after exercise

- inflammation of a joint

- autoimmune, chronic inflammatory disease slowly and progressively affecting the synovial lining of joints and other connective tissue

- severe joint pain and inflammation

- reduced muscle mass

- decreased muscular strength/endurance and mobility/PA

- associated with increased risk of CVD independent of other risk factors

- assessment includes history, ROM, strength tests, and outcome measures to determine stage and functional status

- dynamic/isometric exercises are effective for improving strength, CRF, and cardiovascular health

- chronic local degenerative joint disease that is more prevalent with age

- deficits in articular cartilage of synovial joints

- bone remolding and overgorwth occurs at joint margins

- common in large weight bearing joints like hips and knees, cervical lumbar spine, distal interphalangeal joints of fingers, and carpometacarpal joint of thumb

- symptoms: pain, joint stiffness, and decreased strength and CRF

- assessment includes history, ROM, strength testing, and CRF

- exercise improves overall function, flexibility, QOL, strength, CRF, prevents disability, and decreases pain

- can include land-based or aquatic-based programs

- can include analgesics, nonsteroidal anti-inflammatory, and disease modifying antirheumatic drugs

- prolonged or excessive use of NSAIDs can cause GI bleeding

- RA-remitting drugs may cause secondary organ disease, including myopathy

- steroids may predispose individuals to stress fractures

- oral corticosteroids may cause skeletal myopathy, trucal obesity, osteoporosis, and GI bleeding

- most arthritis patients tolerate symptom limited exercise tests following the healthy adult guidelines

- high intensity exercise is contraindicated with acute inflammation flare up and test should be postponed

- mode chosen should be least painful, cycle ergometer may be best choice

- allow ample warm up time

- monitor pain levels during test (Borg CR10), stop if pain is too severe

- muscular strength/endurance may be measured via typical protocol but pain may limit muscle contraction

*identify program that minimizes pain while progressing towards greater health benefits

* follows FITT for healthy adults, considering pain, stability, and functional limitations

- frequency:3-5 day/week, 2-3 day/week resistance, daily flexibility and ROM

- intensity: light/mod associated with lower risk of injury/pain using 40-60% HRR or VO₂R or 30-40% for deconditioned; 10-15 reps at 40-60% RM

- time: ≥150 min/week aerobic but 10 min bouts may be beneficial for low pain level

- type: aerobic activities with low joint stress, resistance training should include all major muscle groups while incorperating flexibility/ROM

- progression: gradual and individualized based on pain and symptoms

- avoid strenuous exercise during acute flare up or inflammation but move joints through ful ROM

- adequate warm-up and cool-down (5-10 min)

- significant pain may need interim goals lower than recommended ≥150 min/week

- inform that small discomfort during or immediately after exercise is common but pain gets progressively worse 2+ hours after exercise intensity/duration should be reduced

- advise exercise during time of peak low pain rating

- advise the wear of shoes that meet biomechanical profile

- incorperate exercises to improve neuromotor control, balance, and maintenance of ADLs

- warm water exercise helps relax muscles and reduce pain

- syndrome characterized by chronic widespread nonarticular (soft tissue)musculoskeletal pain

- do not show signs of inflammation or neurological abnormalities and do not develop joint disease/deformities

- primarily diagnosed in women and prevalence increases with age

- signs/symptoms: chronic diffuse pain/tenderness, fatigue, sleep disturbances, morning stiffness, and depression

- pain can appear and subside in different areas of the body

- symptoms may exacerbate with stress, poor sleep, humidity, physical inactivity, or excessive activity

- preliminary diagnostic criteria: determine pain location, symptom severity, symtoms present at same level ofr 3+ mo, and confirming symptoms are not from different disorder

- level of severity is determined by fatigue, waking unrefreshed, or cognitive symtoms

- reduced aerobic capacity, muscle function, ROM, and functional performance

- caused by chronic widespread pain that limits ability to complete ADLs

- treatment: medications for pain, sleep, and mood, education programs, cognitive behavioral therapy, and exercise

- resistance training improves pain, tenderness, depression, and overall well being

- exercise improves flexibility, neuromuscular function, CRF, functional performance, PA levels, self-efficacy, depression, anxiety, and QOL

- Lifestyle PA: 30 min mod activity above regular PA

- can participate in symptom limited exercise test but 6-min walk test is frequently used in this population

- review symptoms prior to test to determine severity and location of pain

- assess previous/current exercise experience to determine symptoms post exercise

- use high levels of motivation for those with depression

- determine level of understanding for cognitive dysfunctioning patients

- protocol should based on symptoms

- order of testing should be considered for adequate rest/recovery

- monitor pain/fatigue levels

- position patient correctly on testing equipment

- consider non-weight bearing test methods for those with pain in lower extremities

- educate patient on post-exercise soreness/fatigue and normal fluctuations in pan/fatigue as a result of condition

- FITT for healthy adult is generally used with these considerations: monitor pain level, give adequate recovery time, prescribe exercise individual can handle bc of symptoms/deconditioning, and begin at loe level and progress slow to avoid symptoms

- symptoms always determine starting point

Aerobic

- frequency: begin 2-3 day/week and progress 3-4 d/wk

- intensity: begin at ≤30% and progress to <60%

- time: begin at 10 min/day accumulating 30 min and progress to 60 min/da6

- type: low impact non-weight bearing initially to minimize pain

Resistance Training

- frequency: 2-3 day/week

- intensity: 50-80% 1RM

- time: 3-5 reps per muscle group for 2-3 sets for strength and 10-20 reps for 2-3 sets for endurance

- type: elastic bands, ankle cuffs/weights, machines

Flexibility

- functional activity recommendation: ADLs that can be performed without specialized equipment (walking, rising from chair, etc.)

- progression: depend on symptoms and should be educated on how to reduce or avoid certain exercises during flare up

- demonstrate exercises to avoid injury

- avoid exercise when excessively fatigued

- lessen exercise when symptoms increase during/after exercise

- avoid free weights during fatigue or flare up

- exercise in climate controlled and avoid humidity

- consider group exercise for social support

- consider complementary therapy (tai chi) to help reduce sympoms

- characterized by low bone mineral density and deterioration of the bone microstucture that increase skeletal fragility and risk of fracture

- postmenopausal women and men ≥50 are at risk

- PA may reduce risk by enhancing peak bone mass achieved during growth and development by slowing rate of bone loss with aging and reducing risk of falls through strength and balance

- diagnosis is based on DEXA scans with a SD of ≤-2.5

- osteopenia describes those at risk for osteoporosis with a SD of -1.0 to -2.5

- normal BMD is +1.0 to -1.0

- Nonmodifiable: female, aging, family history, white/asian, loss of height/kyphosis, small frame, menopause before 45, and previous fracture before low-energy trauma

- Modifiable: physical inactivity, low calcium intake, Vitamin D defficiency/smoker, excessive alcohol/caffeine/soda intake, low strength/physical ability, low body weight, low testosterone in males, impraired vision/hearing, postural hypotension, untable environment, poor footwear, and multiple medications

- primary osteoporosis is age related

- secondary oseoporosis is due to other factors such as drug regimens for other chronic illness or the female athlete triad

- female athlete triad: disordered eating followed by amenorrhea and can result in early onset osteoporosis

- peak bone density is achieved in the 20s and loss begins aroudn 25-30

- in early postmenopausal decade bone loss is more evident in cortical (compact) bone and often signaled by low-energy trauma

- late postmenopausal bone loss is marked by trabecular (spongy) bone which comprises much of the hip and spine

- most bone growth occurs by second decade of life and peak bone velocity is around puberty (13-15)

- goal for healthy aging of bone is to maximize development of peak bone and minimize rate of bone loss

- genetics, nutrition, and PA all effect bone health

- PA prevents osteoporosis by increasing bone-forming osteoblast cell activity and reducing bone-resorbing osteoclast activity for overall osteogenic effect of bone growth or slowing of bone loss

- strain and frequency on bone are imperative for bone growth and minimizing bone loss

- exercise program should consider: current state of bone health, site of adaptation, appropriate degree of strain via force, torque/compression, safety, and compliance

- alternate upper/lower exercises to minimize risk of undue stress on tendons

- strategies to enhance bone health should begin early in life and seek to: maximize bone mass/peak bone mass, reduce age-related falls related to bone loss, prevent falls, avoid other risk factors for osteoporosis/fracture, and reduce pain/disability

Individuals at Risk for Osteoporosis:≥1 risk factor

- frequency: weight bearing aerobic activity 3-5 day/week and resistance training 2-3 day/week

- intensity: aerobic moderate (40-60%) and resistance training moderate 60-80% 1RM 8-12 reps or vigorous 80-90% 1RM 5-6 reps each major muscle group

- time: 30-60 min/day combination weight bearing aerobic and resistance

- type: weight bearing aerobic such as walking, jogging, jumping, and resistance

Individuals with Osteoporosis

- frequency: same as above

- intensity: moderate (40-60%) weight bearing aerobic and moderate (60-80%) 8-12 reps resistance

- time: same as above

- type: weight bearing aerobic activities as tolerated and resistance training

- because there are currently to contraindications to exercise it is recommended to prescribe moderate intensity exercise that does not cause or exacerbate pain

- explosive movement and impact loading should be avoided 

- BMD of the spine may appear normal/increased after osteoporotic compression fractures occure or osteoporosis of the sping but hip BMD may be a more reliable indicator of osteoporosis

- for those at increased risk for falls balance activities should be included 

- because of the immobilization effects of bed rest individuals are encouranged to stay as physically active as they can to preserve musculoskeletal integrity

- bone loading exercises usually increase in parallel with exercise intensity

- characterized by uncontrolled growth and spread of abnormal cells resulting from damage to deoxyribonucleic acid (DNA) by internal factors and environmental exposures

- usually classified according to cell type: carcinomas are epithelial, leukemia is from blood, lymphoma is from the immune system, and sarcomas are from the connective tissue

- 76% of diagnosed cancers are in individuals ≥55 years

- treatment involves surgery, radiation, chemotherapy, hormones, and immunotherapy

- some treatments can damage healthy cells causing side effects and limit exercise ability 

- physical function may be diminished from losses is aerobic capacity, muscle tissue, ROM, and other limitations

- cancer/therapy has the potential to effect health-related components of physical fitness and neuromotor function so understanding how individual was affected by cancer is important prior to ExRx

*standard exercise testing methods are generally applied to cancer patients that have been cleared by a physician

- ideally patients should recieve a comprehensive health fitness assessment prior to starting exercise but no assessment is required to start a light intensity, progressive strength training, and flexibility program in survivors

- be aware of exercise contraindications from comorbid chronic diseases before implementing ExRx

- no evidence that medical supervision required for symptom-limited and maximal exercise testing needs to be different than other populations

- understanding common toxicities associated with treatment including increased risk of fractures, cardiovascular events, and neuropathies related to specific treatment and musculoskeletal morbidities secondary to treatment is important

- 1RM testing is safe among this population

- cancer survivors should avoid inactivity before/after treatment 

- no precise recommendations regaurding FITT but there is ample evidence that exercise is safe during/after treatment

- overall recommendations conclude FITT of healthy adults but individuals will vary and ExRx adjusted accordingly

- frequency: completed treatment goals are to increase PA level to 3-5 day/week, resistance training 2-3 day/week, and flexibility daily (during treatment: daily PA can increase over 1mo)

- intensity: tolerance may be variable. survivors may increase intensity slowly for all PA. HR may be unreliable indicator for those in treatment. if PA is tolerated without adverse effects/symptoms intensity does not differ from healthy populations. resistance training (60-70% 1RM)

- time: short bouts may be useful, survivors may increase duration as tolerated (75 -150 min/week like healthy pop) and resistance should be at least 1 set of 8-12 reps

- type: aerobic should be proloned, rhythmic, large muscle groups; resistance should be weights, machines, weight bearing, flexibility should be stretching or full ROM exercises

- progression: slower may be needed and if progression leads to increased fatigue or adverse symptoms FITT needs to be reduced to tolerable level

- cancer related fatigue is prevelent in patients undergoing chemotherpy and radiation treatment and may prevent/restrict their ability to exercise

- survivors with metastatic disease to bone will require modifications due to increased risk of bone fragility/fracture

- identify when patient is in immune depressed state, exercising at home or medical setting may be needed

- use of antiretroviral therapy (ART) reduces viral load of HIV and significantly increased life expectancy

- ART is associated with metabolic and anthropomorphic health conditions including dyslipidemia, abnormal fat distribution, and insulin resistance

- because of the migration of HIV into predominantly low SES, many are beginning therapy with higher BMI and reduced muscular strength/mass

- treatment options include: PA, dietary counseling, anabolic steroids, growth hormone, and growth factors

- exercise training enhances functional aerobic capacity, cardiorespiratory and muscular endurance, and well-being

- no evidence suggests PA participation will suppress immune function

- increased prevalence of cardiovascular pathophysiology , metabolic disorders, and complex medication routine HIV individuals require physician consultant prior to exercise testing

- test should be postponed in individuals with acute infections

- variability of results with be higher in HIV individuals

- BP and ECG monitoring bc of cardiovascular impairments

- limitations to stress testing: asymptomatic have normal GXT with reduced exercise capacity likely related to sedentary lifestyle; symptomatic have reduced exercise time, VO_2peak, and ventilatory threshold; and HIV individuals have reduced exercise time, VO_2peak,and abnormal nervous/endocrine repsponses

*health benefits are gained through aerobic/resistance training and FITT is consistant with healthy adults

- frequency: aerobic 3-5 day/week, resistance 2-3 day/week

- intensity: aerobic 40-60%, resistance 60% 1RM 8-10 reps

- time: aerobic begin 10 min progress to 30-60 min, resistance 30 min to complete 2-3 sets of 10-12 exercises, flexibility incorperated daily

- type: modality will vary, osteopenia patients should include weight bearing exercise, contact/high risk sports are not recommended due to bleeding

- progression: initiate all exercise at low volume and intensity and progress slowly, long term goals of asymptomatic are consistant with healthy adults

- currently no established contraindications but ExRx should be asjusted according to current health status

- supervised exercise is recommended for symptomatic and diagnosed comorbidities

- should report increased fatigue/RPE, lower gastrointestinal distress, and dyspnea if they occur

- dizziness, swollen joints, and vomiting should stop exericse

- monitoring health fitness benefits and CVD risk factors is critical in ExRx managment

- nonprogressive lesion of the brain ocurring before, at, or soon after birth that interferes with normal brain development

- caused by damage to areas of the brain that control and coordinate muscle tone, reflexes, posture, and movement

- type and severity or dysfunction vary considerably

Spastic (70%)

- characterized by increased muscle tone typically involving flexor muscle groups of upper extremities and extensor msucle groups of lower extremities

- antagonist muscles are usually weak

- spacity is a dynamic condition decreasing with slow stretching, warm external temperature, and good positioning

- quick movements, cold external temperature, fatigue, or emotional stress increases hypertonicity

Athetoid

- characterized by involuntary and/or uncontrolled movement that occurs primarily in extremities

- extraneous movements may increase with effort and emotional stress

- Class 1: severe spasticity and/or athetosis resulting in poor funtional ROM and strength in all extremities of the trunk, depended on power wheelchair or mobility assistance

- Class 8: demonstrate minimal neuromotor involvement and may appear to have near normal function

- severe CP may move in reflex patterns whereas mild involvement may only be hindered by reflexed during extreme effort or emotional stress

- associated conditions (epilepsy) may significantly interfere with exercise testing

- goals of exercise testing: uncover challenges/barriers to regular PA, identify risk factors for secondary health conditions, determine functional capacity, and prescribe appropriate exercise intensity for aerobic/strengthening

- adolescents with CP may show decline in gross motor capacity related to loss of ROM, postural changes, or pain as well as reduced aerobic capacity

- disability related changes in older adults with CP: greater physical fatigue, impaired motion/problematic joint contractures, and loss of mobility impacting overall fitness level

- medical clearance should be given before exercise testing

- functional assessment should measure ROM, strength, flexibility, and balance to choose exercise testing equipment, protocols, and adaptations

- testing should use adaptive equipment (straps, gloves) to ensure safety

- CRF testing is depended on functionality of individual: arm/leg ergometry for atheoid CP, class 1-2 may give minimal effort resuliting in maximal effort, class 3-4 wheelchair ergometry is recommended, and class 5-8 ambulatory may use treadmill testing but care should be taken at final stages when skill may deteriorate

- because of varying severity maximal protocol cannot be generalized and is recommended to test at 2-3 submax levels starting at minimal power

- submax steady state workloads should be comparable to sporting conditions

- moderate/severe CP patients may benefit from Wingate anaerobic test

- athetoid CP should be tested on closed chain

- eccentric training may decrease contraction and improve net torque in muscles exhibiting increased tone

- results may vary daily in individuals bc of muscle tone fluctuations

- FITT principles are consistant with normal population

- ExRx needed to elicit health benefits in individuals with CP is unclear

- because of lack of movement control EE is high even at low power outlet levels

- class 1-2 aerobic exercise should start with frequent short bouts of moderate intensity and progressively increased intensity to 50-85% for 20 mins

- moderately involved CP patients should follow general population FITT

- individuals with CP fatigue easily

- training will be more effective for high muscle tone patients if: several short sessions are conducted, relaxation/stretching is included, and new skills are introduced early in session

- resistance training does not cause adverse effects on muscle tone

- resistance training should target weak muscle groups that oppose hypertonic muscle groups

- dynamic strengthening exercises going through full ROM at slow contraction speeds to avoid stretch reflex activity in opposing muscles are recommended

- hypertonic muscles should be stretched slowly to limit to maintain length

-30 sec stretch improves muscle activation of antagonist muscle group whereas sustained stretching for 30 min is effective in temporarily reducing spasticity in stretched muscle

- general focus for CP children is on inhibiting abnormal relfex activity, nomalizing muscle tone, and develping reactions to increase equilibrium

- focus with CP adolescents and adults is more on functional outcomes and performance

- growth may significantly change hypertonicity in muscles because of inadequate adatations in muscle length

- CP individuals are more susceptible to overuse injuries because of their higher incidence of inactivity and associated conditions

- most common developmental disorder in US 3% of pop

- defined as significant subaverage intelligence (2 SD below avg), having limitations in 2+ adaptive skills (communication, self care, home living, social skills, community use, self-direction, health/safety, functional academics, leisure and work, and level of care required), and evident before 18 years

- 90% cases are classified mild ID

- most common cause is Fetal Alcohol Syndrom followed by DS

- mortality is much higher than general pop

- cardiovascular and pulmonary disorders are the most common medical problems in those with ID except DS

- most frequent causes of morbidity/mortality for individuals with DS are infections, leukemia, and early developmental Alzheimers

- life expectancy for DS has increased to ~60 years

- individuals with ID are perceived to have lower physical fitness and PA and high levels of obesity compared to general pop

- exercise testing appears to be fairly safe in individuals with ID and safety related to CV complications do not differ from general pop

- no evidence for or against safety of exercise testing in individuals with ID

- treadmill testing appear to be valid and reliable

- recommended that individuals with ID receive a full health related physical fitness assessmentincluding CRF, muscle strength/endurance, and body comp

- physician supervision of preparticipation health screening exercise tests is recommended

- familiarize individuals with test procedures

- provide environment where participant feels valued, give simple one-step instructions, and provide safety procedures

- select appropriate test and individualize protocols

CRF field tests are reliable but not valid for individual prediction of aerobic capacity in DS

- standard HR formula (220-age) should never be used but instead population specific formula

- CRF: walking treadmill protocols with individualized speeds, Schwinne Airdyne using both arms, 20-m shuttle, Rockport 1-mi walk

- Muscular Strength/Endurance: 1-RM using machines, isokinetic testing, isometric maximal voluntary contraction

- Anthropometrics and Body Comp: BMI, waist circumference, skinfolds, air plethysmography, DEXA

- Flexibility: sit and reach, joint-specific goniometry

- FITT generally follows general pop guidelines but emphasis on PA and EE

- aerobic exercise training recommendations are consistent with achieving an EE of ≥2,000 kcal/wk but may take several months of participation before this level can be achieved

Aerobic

- frequency: 3-7 day/wk to maximize EE but 3-4 day/wk should include mod/vig intensity

- intensity: 40-80%, RPE may not be appropraite indicator

- time: 30-60 min/day to promote/maintain weight loss but bouts of 10-15 min to accumulate goal may be alt.

- type: walking is primary recommendation with progressionto running with use of intermittent runs, swimming combined with arm/leg ergometry is also effective, bc muscle strength is low it should be of focus

Resistance

- frequency: 2-3 day/wk

- intensity: begin with 12 reps at 15-20 RM for 1-2 wk and progress to 8-12 reps at 75-80% 1RM

- time: 2-3 sets with 1-2 min rest

- type: machines targeting 6-8 major muscle groups with supervision for first 3mo

- most require encouragement during testing and training

- many are on various medications

- many have motor control problems and poor coordination creating balance and gait problems so handrailing use and activities that do not require motor coordination should be used

- most have short attention span so plan accordingly

- most require supervision during testing and training

- careful spotting/supervision during resistance training even with machines

- varied activities are suggested to increase enjoyment

- individualize training program

- low levels of aerobic and muscular strength (<50% age related)

- almost all have low HR_max likely caused by reduced catecholamine response to exercise

- high likelihood of congenital heart disease

- not unusual to have atlantoaxial instability (cervical vert)

- many exhibit skeletal muscle hypotonia (floppy, rag doll) coupled with excessive joint laxity so increasing strength around major joints is a priority

- physical characteristics affecting exercie performance include: short stature, limbs, and digits commonly coupled with malformations of feet and toes, and small mouth/nasal cavities, and large protruding tongue

- diagnosed with CKD if kidney damage is evidenced by microalbuminuria or have glomerular filtration rate <60 mL/min/1.73m^-2 for ≥3 mo

- CKD is divided into five stages based on glomerular filtration rate and presence of kidney damage

- hypertension, DM, and CVD are common among CKD population and with presence of these comorbidities individuals rise from stage 1 to stage 5 CKD

- when individuals progress to stage 5 CKD (glomerular filtration rate of <15 mL/min/1.73m^-2) their treatment options include renal replacement therapy (dialysis) or kidney transplant

- because CVD is the major cause of death diagnostic exercise testing is indicated

- exercise testing is included in the pretransplantation workup for kidney recipients

- testing should be supervised by trained medical personnel with the use of standard test termination criteria/methods

- CKD is associated with low functional capacities but VO_2peak can be increased with training but never reach values of non CKD controls

- reduced functional capacity is thought to be related to many factors such as sedentary lifestyle, cardiac dysfunction, anemia, and musculoskeletal function

- medical clearance from primary physician and nephrologist prior to exercise

- when testing CKD patients in stages 1-4 standard testing procedures should be followed but testing should be performed on non dialysis days and BP monitored

- treadmill and cycle ergometers have been used

- HR may not be reliable so RPE should be monitored

- isotonic trength testing should be done using 3 RM+ bc 1 RM testing is generally contraindicated bc of fear

- muscular strength/endurace can be assessed using isokinetic dynanometers ranging from 60-180°

- because of low functional capacity traditional exercise tests may not always yield the most valuable info

*initially use light-to-moderate intensities and progress slowly

- frequency: aerobic 3-5 d/wk, resistance 2-3 d/wk

- intensity: aerobic moderate (40-60%, 11-13), resistance 70-75% 1 RM

- time: aerobic 20-60 min/day or 3-5 min bouts accumulating 20-60 mins, resistance min 1 set 10-15 reps 8-10 different exercises, flexibility performed daily

- type: walking, cycling, swimming; free weights or machines

- gradually progressed to >volume over time but initial intensity should be light for as little as 10-15 min

- progression is dependent on clinical status

- individuals resistant training should perform 1 set 10 reps at 70% 1RM twice per week ans consider adding secnd set when individual can complete 15 reps easily

- hemodialysis: exercise on non dialysis days and not immediately following, emphasis on RPE

- peritoneal dialysis: may attempt exercise with fluid in abdomen but if discomfort arises fluid should be drained

- kidney transplants: FITT should be reduced during periods of rejection but exercise can continue

- chronic inflammation demyelinating disease of the CNS 

- onset usually occurs between 20-50 years

- initial symtoms: transient neurological deficits including numbness, weakness, double/blurred vision

- believed to be caused by an autoimmune response influenced by a combination of environmental, infectious, and genetic factors

- symptoms include: visual disturbances, weakness, sensory loss, fatigue, pain, coordination deficits, bowel/bladder dysfunction, and cognitive/emotional changes

- recognized disease courses: relapsing remitting: periodic exacerbations followed by full or partial recovery of deficits, primary progressive: continuous disease progression from onset with little/no plateaus/improvements, progressive relapsing: progression from onset with distinct relapses superimposed on the steady progression

- secondary progression: those who have relapsing remitting will eventually (10-25 yrs) develop a slow and steady decline in function

- MS individuals generally have lower maximal aerobic capacity and it continues to decrease with increasing levels of disability 

- 3-6 mo post progressive aerobic training have demonstrated improvements in VO_2peak, functional capacity, lung function, and delayed onset of fatigue

- MS individuals can improve strength and function with progressive resistance training with greater gains in those with mild/less disability

- exercise testing may yeild more accurate results due to worsening fatigue throughout the day 

- avoid testing during acute exacerbation periods

- balance/coordination problems may require leg/arm cycle ergometer

- recumbent stepping ergometer helps distribute work to all extremities, minimizing potential muscle fatigue

- depending on disability continuous/discontinuous 3-5 min stages increasing work rate for each stage from 12-25 W

- be cautious of heat sensitivity in this population

- joint ROM and flexibility assessment is important bc increased tone/spasticity can lead to contracture formation

- isokinetic dynamometry can accurately evaluatie muscle performance and 8-10 RM can evaluate strength

- physical performance tests assessing endurance, strength, gait, and balance may be used

*individuals with minimal disability may use healthy adult FITT 

- frequency: aerobic 3-5 d/wk, resistance 2 d/wk, flexibility 5-7 d/wk 1-2 times a day

- intensity: aerobic 40-70% or 11-14, resistance 60-80% 1RM, flexibility stretch to point of light discomfort

- time: aerobic increase initially to min of 10 min and progress to 20-60 min, resistance 1-2 sets of 8-15 reps and increase rest time when training weak muscles, flexibility hold static stretch 30-60s for 2-4 reps

- increase frewuency and time for stretching spastic muscles

- incorperate functional activities to promote optimal carry over

- use RPE in addition to HR for intensity 

- decrease FITT to tolerance during acute exaerbations

- take medication side effects into consideration with testing

- systemic fatigue improves with increased fitness, important for participant to understand this 

- HR/BP responses may be blunted because of dysautonomia so HR may not be valid indicator of intensity

- some may restrict fluid intake bc of bladder control issues, they should be counseled to increase fluids

- some may have cognitive deficits that may inhibit thier understanding of testing/training instructions

- watch for signs/symptoms of Uhthoff Phenomenon involving transient worsening of neurological symptoms, most commonly visual impairment associated with exercise and elevation of body temp, use cooling strategies and adjust time and intensity

- chronic progressive neurogenerative disorder characterized by symptoms consisting of resting tremor, bradykinesia (inaility to initiate/perform purposeful movement), rigidity, postural instability, and gait abnormalities

- PD is the result of damage to the dopaminergic nigrostriatal pathway resulting in a reduction in the neurotransmitter dopamine

- genetics and environment are thought to be causing with contributing factors including aging, autoimmune responses, and mitochondrail dysfunction

- severity is classified as early disease with minor symptoms of tremor/stiffness, moderate disease with mild/moderate tremor/stiffness, and advanced disease with significant limitations in activity regardless of treatment/medication

- symptoms affect movement and PD patients may have dificulty performing ADLs

- stress and anxiety increase tremors

- postural instability/impaired balance may lead to increase episodes of falling

- generally patients demnstrate sloweed, short-stepped, shuffle walking with decreased leg swing

- drug therpay is the primary intervention

 Levodopa is the single most effective drug available to treat all cardinal features of the disease

- long term use is associated with morot complications including motor fluctuations and dyskinesias in about 50%

- other side effects include nausea, sedation, orthostatic hypotension, and psychiatric symptoms (hallucinations)

- lecodopa is now always combined with carbidopa to precent systemic adverse effects

- deep brain stimulation (DBS): electrical stimulation of the deep brain nuclei is used when medical intervention is inadequate in controlling motor complications

- regular exercise will decrease or delay secondary sequelae affecting musculoskeletal CRF systems, improving gait performance, QOL, aerobic capacity, and reducing disease severity

- most have impaired mobility and problems with gait, balance, and functional ability often accompanied by low levels of physical fitness

- tests on gait, balance, mobility, and ROM are recommended prior to exercise testing

- manual muscle testing, arm curl tests, weight machines, and dynamometers, and chair rise tests may evaluate strength

- 6-min walk test may be used to test CRF, sit to stand chair test for mobility, and 10-m walk test for gait

- decisions regarding testing is influenced by severity of PD or physical limitations, treadmill and cycle ergometers may be used

- very advanced PD and those unable to perform GXT bc of instability, severe stooped posture, and severe deconditioning may beneft from radionuclide stress test

- symptom-limited testing is recommended: dyspnea, abnormal BP response, and appearance deteriorations

- know effect of medications and test during peak medication effect

- DBS signal may interfere with ECG, consult physician

*FITT of healthy adults generally applies with consideration to individual limitations

*bc disease is chronic and progressive ExRx should be prescribed early and continued on regular, longterm basis

*key outcomes are improved gait, balance, and joint mobility

- frequency: aerobic 3 d/wk, resistance 2-3 d/wk

- intensity: aerobic 40-60% or 11-13, resistance 40-50% 1RM progressing to 60-70%

- time: aerobic 30 min, resistance ≥1 set 8-12 reps (10-15 starting)

- type: aerobic cardiorespiratory and neuromotor exercise, resistance emphasis on extensor muscles of trunk/hip and all major muscles of lower extremities to maintain mobility

*flexibility is same as healthy adults with emphasis on spinal and neck mobility

- PA and exercise improved instability and balance

- static, dynamic, and balance training during functional activities should be included

- use safety precautions when using PA that challenge balance

- training programs should use a variety of challenging exercises to improve balance

- orthostatic hypotension, cardiac arrhythmias, sweatng disturbances, HR, and BP should be monitored during exercise

- levodopoa/carbidopa may produce exercise brachycardia and transient peak dose tachycardia and dyskinesia

- outcome of exercise training varies significantly

- cognitive decline and dementia are common neuromotor symptoms and may effect training and progression

- incorperate/emphasize fall prevention/reduction and education

- avoid using multitasking until performing a single task well has been accomplished

- results in partial/complete loss of somatic sensory, and autonomic functions below the lesion level

- lesions in cervical (C) regiod typically result in tetrapalegia (quadrapalegia), whereas lesions in thoracis (T), lumbar (L), and sacral (S) regions lead to parapalegia

- SCI patients are at high risk for the developement of secondary complications: shoulder pain, UTI, skin ulcers, osteopenia, chronic pain, problematic spasticity, depression, CVD, and T2DM

- exercise and PA reduce prevalence of secondary complications and improve QOL

- cruitial to take into account lesion level when testing/ExRx

- L2-S2: lack voluntary control of bladder, bowels, and sexual function but upper extremeties/trunk usually have normal function

- T6-L2: have respiratory and motor control that depends on functional capacity of abdominal muscles (minimal at T6 to maximal at L2)

- T1-T6: can experienceautonomic dysreflexia (uncoordinated, spinally mediated reflex response called mass reflex), poor thermoregulation, and orthostatic hypotension, but arm function is normal; if there is no sympathetic innervationto the heart HR_peak

- C5-C8: are tetrapalegic (quad), those with C8 lesions have voluntary control of shoulder, elbow, and wrist but decreased hand function; those with C5 kesuibs rely on biceps brachii and shoulder muscles for self-care and mobility

- C4 require artificial support for breathing

- initial trunk ROM, wheelchair mobility, transfer ability, and upper/lower extremity involvement assessment 

- voluntary arm ergometry is the norm referenced for CRF assessment

- stationary wheelchair roller system and motor driven treadmill allow for realistic simulation of external conditions (speed/slope)

- incremental exercise starting at 0W increasing 5-10W per stage for tetrapalegia, parapalegia can start at 20-40W increasing 10-25W per stage

- sport specific CRF assessments like Leger and Boucher shuttle test should have incremental test around predetermined angular court

- tetrapalegia may have postexercise hypotension after maximal exercise

- no special considerations for muscular strength assessment with acception of lesion level

- wheelchair joint contractures may develop so sport-specific exercise training should include upper ext. stretching and strengthening to promote balance

*FITT for general population should be applied

- empty bowels, bladder, or bag before exercise

- avoid skin pressure sores and check areas regularly

- decreased CRF may be found in complete SCI above T6

- high lesions may reach peak HR, Q, and VO₂ at lower intensity levels than those with lesions below T5-T6

- during exercise autonomic dysreflexia results in an increased release of catecholamines that increases HR, VO₂, Bp and exercise capacity

- if BP extremely elevates immediate emergency responses is needed (remove stimulus causing increase) if symptoms persist medical attention should be sought

- deconditioned but healthy participants should start at 5-10 min bouts of moderate intensity with 5 min recovery progressing to 3 sessions/wk, 30 min/day, ≥70%

- higher levels of SCI with tetra may benefit from lower body positive pressure (compressive stockings, elastic binder, or electrical stim to leg muscles)

- electrical stim to paralyzed muscles can increase venous return and Q

- strengthening exercises in wheelchair should be complimented with nonwheelchair exercises

- tenodesis: active wrist extensor driven finger flexion allows functional grasp in individuals with tetra who dont have use of hand muscles

- individuals with SCI test to endure higher core temps during endurance exercise but generally have lower sweat rates than controls

- due to increased aging population and prevalence of overweight/obesity 

- Preparticipation Screening: exercise training is fenerally safe for majority of individuals wtih multiple disease/chronic conditions wishing to particpate in light/moderate intensities

- a referral to health care provider prior to exercise is recommended for individuals who fall into high risk categories 

- individuals with multiple CVD risk factors that are not classified as high risk should be encouraged to consult physician prior to vigorous exercise

- exercise stress testing is recommended only for highest risk iindividuals (diagnosed CVD, symptoms suggestive of new/changing CVD, DM and additional CVD risk factors, end-stage renal disease, and specified lung disease)

- info gathers from exercise test may be useful in establishing safe/effective ExRx for low/moderate risk 

- test is not deemed inappropraite for low/moderate risk if the goal is to design effective ExRx

- generally follow FITT for general population 

- challenge is determining specifics of FITT for those that present multiple disease/conditions or CVD risk factors especially when there is variability in dose that can most favorably impace a particular disease, health condition, etc

- evidence supports the role of PA in delaying premature mortality and reducing risks of many chronic diseases/health conditions

- clear evidence for dose-response relationship thus any PA should be encouraged

- begin with FITT and ExRx for single disease/condition that confers greatest risk or is the most limiting in regards to ADLs, QOL, and starting exercise program

- consider client goals 

- begin with FITT most conservative for multiple disease/conditions the client presents with

- know magnitude and time course of response of various health outcomes that can be expected as a result of FITT and ExRx prescibed in order to progress client safely

- frequently monitor signs/symptoms to ensure safety, proper adaptation, and progression

- injury to muscle or tendon

- muscle tendon unit (MTU) serves to generate force either by concentric contraction or to create movement by eccentric contraction to resist a load

- injury can occur at any point along the continuum

- acute pain and dysfunction usually come 1-2 days after injury

- DOMS-related pain may be due to muscle fiber damage and inflammation that accompanies unaccustomed high-intensity eccentric contractions 

- in sports the most common injury is to the muscle ia direct impact that often causes a contusion

- strains can occur in any MTU but most are in calf and thigh

- degree of strain should be assessed to apply appropriate treatment

- injury to ligament (collagenous fibrous structures connecting bone to bone) or tissue connecting to bones

- most common site is ankle inversion

- immediately PRICE in a position of minimal discomfort

- rate of healing progression is dependent on type of tissue and degree of damage

- inflammation phase lasts 2-3+ days to increase blood flow causing edema acting as a brace/immobilizer by inhibiting contractile tissue activity

- repair phase 3-5 days up to 2 mo, varies on tissue and damage, damaged tissue is replaced with scar tissue, should exercise with gradual progression of low-load stress with no/minimal ROM

- remoldeling phase can take up to 2-4 mo, is characterized by weakened, repaired tissue, exercise is to promote hypertrophy and strength

- goal is to reduce pain and inflammation

- all medications are accompanied by risk of toxicity 

- commpnly used medications: NSAIDs (ibuprofen, naproxen) for analgesic and anti-inflammatory properties, Analgesic's (hydrocodone+acetaminophen, acetaminophen, acetaminophen+codeine) for pain control with sedating properties

- adaptations to resistance training increase ligament and tendon strength, and collagen content to enhance integrity of connective tissue

- fiber size, fast twitch fibers, and rate of force production increase with resistance training for increased durability

- preventative strategies to reduce risk of muscle strain: warm up 5-7 mins prior to large muscle group exercise, stretch tight muscles after warm up (15-30 sec), balance regular physical activities/sports wtih resistance training, and avoid exercise when fatigued (increases injury risk)

- pathological change in tendon because of repeated stress/microtrauma

- tendonitis: acute inflammatory tendinopathy

- tendinosis: tendon wtih significant degenerative changes in ansence of inflammatory response (more common as most seek treatment for -itis)

- most common sites include rotator cuff, wrist flexor/extensor, patella, and achilles

- usually result from overload injuries that disrupt MTU

- often present swelling (in acute) and pain, especially with contraction or stretch of involved muscle

- assessment incldes evaluation of strength, extensability, and palpation of involved tendon to determine tenderness

- indivduals should reduce activity of affected muscle to decrease repetative loading of damaged tendon

- most improve with rest, stretching, icing, and analgesics

- may take up to 6 mo to subside

- once symptoms subside strengthen affected area

- frequency: 3-4 d/wk

- intensity: 3-4 sets of 6-15 reps BW w/ progressive loading

- time: completion of exercises or pain level threshold

- type: eccentric until pain free then concentric/plyos

- usually occurs with repeated trauma to medial calcaneal tubercle

- common in athletes that run or weight bearing exercise

- symptoms: pain with first weight-bearing steps then pain subsides with activity and increases after prolonged rest

- barefoot walking may exacerbate pain

- assessment includes palpation along plantar fascia, evaluating extensability of gastrocnemius

- acute stage is best managed with pain control and exercise restriction 

- pain management includes NSAIDs, ice massage, minimizing stress 

- introduce stretching once acute phase ends 

- functional weight-bearing exercises may relive stress by supporting medial longitudinal arch by strengthening extrinsic/intrinsic musculature 

- frequency: 3X daily

- intensity: 10 reps hold 10s

- type: gentle stretch of fascia (flexor/gastroc soleus)

* pain determines intensity/duration

- frequency: idea was that flexibility in time/duration would overcome lack of time barrier but there was no change in adherence (assigned frequency/time combo)

- intensity: more likely to adhere to low intensity program but individuals with exercise experience are far better at high intensity programs

- type: most exercising on their own at home have greater adherence to home based programs compared to structured, supervised programs

- refers to systematic view of a behavior by specifying relationships between variables and predicting specific behaviors and situations

- essential elements: variables that influence particular behavior, relationship between variables, and understanding conditions in which relationships occur or dont occur

- therefore a theory would explain the variables that influence PA, how the variables inteact with one another to influence PA, and conditions under which PA occurs

- hypothetical depiction of behavior or situation

- do not attempt to understand variables underlying behavior but represent what is happening with a behavior

- provide framework for better understanding PA adoption

- help HFS understand why client has stopped PA 

- allow HFS identify which types of clients respond to which types of PA promotion strategies

- used to understand behavior and create PA interventions

- effective for increasing PA in sedentary

- proposes that individuals move through a series of stages during PA adoption: precontemplation, contemplation, preparation, adoption, and maintenance

- processes are thought to receive differential emphaiss during particular stages of change such as increasing knowledge, aware of risks, caring about consequences, comprehending benefits, and increasing healthy opportunities

- behavioral processes of change include substituting alternatives, enlisting social support, rewarding yourself, committing yourself, and reminding yourself 

- TTM intervention allows individuals to increase behavioral strategies, cognitive processes, decisional balance, and self-efficacy

- Precontemplation: not intending to take action within next 6 mo; may be uninformed, unmotivated, or discouraged from previous failed attempts; inactive or not thinking about becoming active

- Contemplation: intending to alter behavior within next 6 mo; may be aware of pros of PA but costs may outweight benefits; inactive and thinking about becoming active 

- Preparation: intending to increase PA in immediate future 30 days; may have plan to change behavior or seeking assistance; doing some PA but not meeting guidlines

- Action: made specific, measureable changes in PA in past 6 mo; doing enough PA for <6 mo

- Maintenance: maintaining PA and working to prevent relapse; making PA a habit at recommended levels for ≥6 mo

- experiential: consciousness raising, dramatic relief, self-reevaluation, social reevaluation, and social liberation

- behavioral: self-liberation, counterconditioning, stimulus control, contingency management, and helping relationships

Precontemplation to Contemplation: processes focus on consciousness raising, environmental reevaluation, dramatic relief; decisional balance: Pro<Con; Self-efficacy: Low

Contemplation to Preparation: processes focus on consiousness raising, environmental reevaluation, self reevaluation, and dramatic relief; decisional balance: Pro>Con, Self-efficacy: increasing

Preparation to Action: processes focus on self-liberation; decisional balance Pros>>Cons; Self-efficacy: high

Action to Maintenance: processes focus on stimulus control, reinforcement management, counterconditioning, and helping relationships; decisional balance: Pros>>Cons; Self-efficacy: high

- comprehensive theoretical framework that has been extensivel employed in understanding, describing, and changing exercise behavior

- based on principle of triadic reciprocation in individual (emotion, personality, cognition, biology), behavior (past and current achievement), and environment (physical, social, and cultural) all to interact to influence future behavior

- central to consept of self-efficacy: ones belief in their capability to successfully complete a course of action 

- task self-efficacy: individuals belief they can actually do the behavior

- barriers self-efficacy: whenther an individual believes they can regularly do behavior in the face of barriers

- outcome expectations: anticipatory results of behavior, if outcomes are valued change is more likely to ocur

- both self-efficacy and positive outcome expectations are necessary for an individual to adopt and maintain behavior

- factors influencing behavior: environment, individual personality/experience, and behavioral factors

- enactive mastery: successful performance of taget behavior, enhances perception of self-efficacy

- vicarious experience: seeing similar individual successfully perform behavior and comparing one's own performance to others

- verbal persuasion: others express faith in individual's capabilities 

- correcting misinterpretations of physiological messages: reducing negative emotional states 

*most successful are vicarious experiences and feedback techniques

- verbal persuasion to reinforce task mastery

- provide exposure to positive vicarious experiences

- explain/reinforce positive physiological states from experience

- encourage various forms of PA

- encourage client recall of successful behavior

- maintain PA lof to help track success

- encourange reasonable, specific PA goals that can be achieved in a short time

- encourage perseverance and praise efforts to achieve goals, not just attainment of goals

- theorizes that an individual's beliefs about whether or not they are susceptible to disease, and their perceptions of the benefits of trying to avoid it, influence their readiness

- used in populations that are motivated to be PA primarily for health

- applied to cardiac rehabilitation and DM prevention/treatment

- four main components: perceived susceptibility/severity and perception of benefits/barriers

- susceptibility + severity= perceived threat

- benefits + barriers= outcome expectation

- threat + experience= liklihood of action

- most powerful determinants are benefits vs barriers

- perceived susceptibility: belief about chances of getting disease/condition → explain risk information

- percieved severity: beliefs about seriousness/ consequences of disease/condition → refer to info, discuss treatment options

- percived benefits: belief about effectiveness to reduce susceptibility/serverity → provide benefit/prevention info

- percieved barriers: belief about direct/indirect costs associated with behavior → discuss FITT, provide low cost PA choices

- cues to action: factors activating change process → help them look for cues, find out what it would take for them to start

- self-efficacy: confidence in ability to perform behavior → assess level of confidence, use SE building techniques

- assist in identifying susceptibility/severity

- educate risk of current behavior (no change)

- assist in identifying benefits of behavior

- prepare clients for barriers and develop plan

- holistic, inclusive approach that can help gain a stonger understanding of exercise behavior and better understanding of intrapersonal (psychological) and interpersonal (influence of exercise environment) factors that influence PA

- this theory is used as a predictor of motivating individuals to engage in PA by explaining behaviors that influence an individual's motivation

- assumption that individuals have three primary psychosocial needs they are trying to satisfy: self-determination or autonomy, demonstraing of competance or mastery, and relatedness of ability to experience meaningful social interactions with others

- motivation exists on a continuum from amotivation to intrinsic motivation

- amotivation is lowest levels of self-determination → no desire to engage in behavior

- intrinsic motivation is highest degree of self-determination → interested in engaging in behavior for satisfaction, challenge, or pleasure

- extrinsic motivation is between amotivation and intrinsic, engage in behavior for external factors → become more attractive, lose weight, stress reduction

- those with highest degree of self-motivation have greater intentions like self-efficacy to overcome barriers and physical self-worth

- intention-based model used to explain PA

- extension of theory of reasoned action and identifies intention as primary influence in behavior determination

- intentions are determined by attitude (+or -), subjective norms (social pressure), and percieved behavioral control (ease or difficulty)

- link between percieved behavioral control and behavior when percieved control reflects actual control of nonvolitional behavior (running in rain)

- TPB predicts exercise intentions and behavior but poor evidence that interventions for increasing PA are effective

- implementation interventions improves exercise behavior outcomes → develop self-efficacy, create supportive environment, and make PA accessible

- behavioral beliefs + evaulation of behavioral outcomes → attitude towards behavior → intention → behavior

- normative beliefs + motivation to comply → subjective norm → intention → behavior

- control beliefs + percieved power → percieved behavioral control → intention → behavior

- comprehensive approach integrating layers of intra- and interpersonal, community/organizational, institutional, environmental, and public policy factors

- considers impact of and connection between individual and environment

- helps identify opportunities to promote PA by recognizing the multiple variables that influence individual decision

- HFS can help promote PA by identifying variety of PA options, discuss potential environmental barriers, and encourage joining training club/group

- systems theory uses microsystem (personal interactions between family, work, etc.), mesosystem (physical settings), and exosystem (larger social influences of economics, policies, etc.)

- intrapersonal: knowledge, attitudes, behavior, beliefs, barriers, motivation, skills, enjoyment, self-efficacy, demographics → focus on changing skills, knowledge, attitudes

- social environment: family, spouse, peers, schools, workplace, access to social support, community norms, cultural background, influence of health professional → education programs, work incentives, social marketing

- physical environment: natural factors (weather), access to equipment, safety, community design, transportation → implement changes to physical environment first

- policy: education, urban planning, health, environmental, workplace → align PA program participation with priorities, emphasize importance of PA education, require workplace support PA

- central component of most theories

- to improve: include experiencing successful completion of tasks (mastery/accomplishment), hearing/seeing others exerperiences and successfull application of strategies (modeling/vicarious experience), social persuasion (tell you can do it), and reduction of stress and physical/emotional arousal

- based on premise that individuals become more committed to what they say to themselves than what they hear from others

- attemps to shift behavioral responsibility to individual and away from external source

- strategies include: eliciting priorities, needs, and values; building rapport; supporting autonomy; resisting temptation to prescribe prematurely; and tailoring counseling to address dimensions necessary for change

- four general prnciples to resolve ambivalence: express empathy, develop discrepancy, rolling with resistance, and supporting self-efficacy

- types of talk: sustain talk is about costs of changing and benefits of not changing where change talk is about benefits of changing and and costs of not changing

- HFS should make observations, not evaluations; express feelings, not thoughts; identify needs, not strategies; and make requests, not demands

- encompass techniqes such as behavioral contracting, goal setting, self-monitoring, and reinforcement which are used to impact constructs of all theories

- often integrated with other theories as techniques for promoting behavior changes

- low complexity but among the most effective at increasing PA

- short term adherence usually involves extrinsi reinforcers such as social, material, activity, and special outings

- intrinsic factors usually help long term adherence

- environments promoting intrinsic motivation focus onproviding positive feedback to increase feeling of competance, acknowledging participant difficulty within program, and enhancing sense of choice and self-initiation to build feelings of autonomy

- must be done as part of an onoing process to be effective

- requires client and HFS to work together to develop, implement, measure, and revise goals to provide direction, enhance persistence, and learn new strategies

- set short and long-term goals to allow measurement and assessment of regular basis

- SMART principle: Specific, measureable, action-oriented (indicate what needs to be done), realistic (achievable), timely, and self-determined

- anything someone does to increase exercise level

- can be provided through, guidance, reliable alliance, reassurance of worth, attachment, social integration, and opportunity for nurturance

- clients are looking for support in times of stress or difficulty

- sharing goals increases odds of success

- any strategies that can be adapted to change negative feelings may improve exercise adherence

- dissociation strategies encourage individuals to block out feelings associated with exertion such as fatigue, sweating and discmfort (better for light/moderate intensities)

- association strateies focus on bodily sensations such as respiration, temperature, and fatigue (better for high intensities)

- key component in determining intrinsic motivation in SDT

- self-ratings of affective valence and ratings of pleasantness can be markers for the transition between aerobic and anaerobic

- ongoing process wn which efforts are made to prevent a return to former behavior, inactive lifestyle

- prevention techniques: goal setting, self-monitoring, rewards, and check-ins

- focuses largely on self-regulation and anticipation with a specific plan of how to deal with decreasing exercise levels

- specific prevention: plan exercise when outside routine, create new exercise goals, and vary routine

- HFS should offer praise after missed class or reach out to absentee

- help maintain motivation

- intrinsic: anything that is fulfilling because of internal pleasure from completing task/goal

- extrinsic: external, things earned in response to completing task (treats, awards, body appearance)

- intrinsic more sustainable over time

- identify other extrinsic rewards when some lose potency and attempt to make exercise more intrinsically rewarding

- intrinsic more effective in initial stages and extrinsic for later stages

- increase self-efficacy of health-related behavior

- help individuals identify ways to initiate and maintain exercise and build self-efficacy

- individual observes behavior then evaluates outcomes through comparisons/standards/goals

- discuss potential barriers and develop adherence plan 

- examples are exercise calendar/contracts and telling people of goals

- goals are inherently valued, futuristic outcomes that are derived from a level of dissatisfaction with present condition or circumstance

- goals increase persistence, knowledge, and skill attainment

- goals should address SMART principle

- explicit goals: reduce ambiguity of task making the achievement of goal more likely

- short term goals may be more beneficial 

- HFS should provide regular feedback and encouragement

- describes process of visualizing oneself engaging in specific behavior en route to achieving desired outcome

- mental rehearsal may strengthen cortical connections in brain that are involved in actual physical performance of targeted task

- imagery effectiveness should increase as more senses are included because of additional brain connections

- internal or external imagery

- visualize to overcome barriers

- types: energy, appearance, technique, etc.

- involves a sender and reciever, sender conveys message and reciever interprets and responds

- nonverbal cues convey emotions, level of engagement, etc.

- active listening is a specific type of listening demonstrating a more complete comprehension of the message by listening with undivided attention and repeating back to the speaker the message that was heard to assure accuracy of interpretation

- HFS should convey messages to inspire and motivate

- convey that client will be accepted regardless of success or failure but clients need to feel challenged as well

- process by which one responds to an environmental demand that is perceived as threatening

- occurs when environmental demand taxes/exceeds one's resources and endangers one's well-being

- elicits response pattern that compensates for external disturbance and restores homeostasis

- inability to cope properly can yield biological/psychological damage/death

- demand or stimulus = stressor

- duration can be acute: fight/flight or major life event or chronic: steady accumulation of minor pertubances

- eustress: good stress that promotes growth, development, and improvement

- distress: bad stress that is negative or damaging

- primary appraisal: one evaluates significance of event and its associated threat/harm, stressors are classified as threatening with future harm or chalenging with expectation of achieving growth, mastery, or profit

- secondary appraisal: one evaluates controllability of stressor and coping resources to alter situation or manage emotional reaction; evaluate resources available, emotional reaction or control over feelings, and ability to deal effectively with resources or coping self-efficacy

- coping with problem management: focused on changing stressful situation, taking an active rle in problem solving and information seeking

- coping with emotional regulation: more passive, altering feelings or thoughts about stressful situation or denying and avoiding situation

- escape-avoidance bahavior has been associated with higher levels of psychological distress and poorer QOL

- steriotypical response pattern of stress

- alarm reaction stage: stressor first recognized by system and fight-or-flight response is initiated

- resistance stage: cascade of metabolic, hormonal, and immune changes is fenerated as a compensatory stress reaction until biomechanical substrates have been depleted

- exhaustion stage: organism has depleted all resources and is no longer able to mount a defense to stressor (may result in death)

- impact of repeated stress exposure can be problematic because individuals who remain in the resistance phase have difficulty withstanding additional challenges

- the ability to chieve stability through change

- model refers to rapid activation of bodily systems to cope with stressor and restore homeostasis as efectively as possible

- all body systems are involved

- if body does not compensate well the repeated stressors accumulate increasing risk of physical ailment development

- if body is unable to stop/shut off stress response then systems can be driven to exhaustion resulting in the breakdown of feedback mechanisms and overexposure to stress hormones (cortisol)

- high levels of stress associated with abnormally enlarged heart and hypertension

- stress increases concentrations of activated platelets and triglycerides, FFA, and lipoproteins in blood

- elevated lipid levels promote quick blood clotting in case of physical trauma but over time promote development and growth of plaques (arthrosclerosis) hardening and narrowing blood vessels increasing BP and likelihood of MI and stoke

- corticosteroids (cortisol) are released in response to stress and high concentrations increase risk of CVD, T2DM, and reduce immune function and cognitive performance

- increased vulnerability of infections and disease

- sympathetic NS activity and release of cortisol suppress immune system and limit number of lymphocytes increasing susceptibility to contract disease

- psychological stress has been correlated with reduction in natural killer (NK) that combats cancerous tumor cells and monitors neoplastic (new/abnormal) growth

- glucocorticoid cascade hypothesis: release of GC's (specifically cortisol) is related to memory impairment and hippocampal atrophy

- chronic stress promotes psychological distress and development of psychological disorders

- chronic stress is a greater predictor of depressive symptoms

- personality can accentuate severity of distress/depression

- burnout: physical, mental, and emotional exhaution brought on by unrelieved work stress

- burnout is associated with cognitive failures in everyday life, increased inhibition errors, and variability in performance on attention tasks

- what people do to alleviate, eliminate, or manage stress geared towards person's appraisal of/concern of discrepancy

- continuous appraisals/reappraisals of shifting person-environment relationship

- problem-focused coping: reduce demands of stressful situation or expand resources such as seeking info, getting advise, or drawing on previous experiences; most often used when people believe personal resources/demands of situation are changeable

- emotion-focused coping: attempts to control/manage emotional response to stressful event such as seeking support, drinking, engaging in activities; used when the believe that curcumstances are fixed and unchangeable

- emotional support: empathy, love, trust

- instrumental support: tangible aid that meets a need

- informational support: advice/info concerning problem

- appraisal support: self-evaluation purposes like constructive feedback

- social suppor is most beneficial when it meets the needs caused by stress

- social support is suggested to enhance well-being/health

- behavioral control: take concrete action to reduce impact

- cognitive control: uses thought processes/strategies to manipulate/modify impact

- decisional control: choose between different courses of action

- informational control: glean knowledge about stressful event and consequences of situation

- repetitive movement of alrge muscle groups and higher rate of O₂ consumption has stress reducing benefits

- acute bouts improve vigor, self-esteem, and alertness

- more physically fit report less depression, anxiety, and tension

- distraction hypothesis: thought process about stress is momentarily reduced

- cognitive dissonance: people create/perceive benefits so as to justify time/effort to exercise

- self-efficacy: those who engage/maintain active lifestyle may see themselves as more in control of their lives and more capable of handling stress

- expectancy theory: exercisers may hold a set of positive expectancies regarding social norms endorsing exercise

- learn to control and target feelings of tension by focusing on certain muscle groups and alt. tightening and contracting focusing on the sensation of relaxation

- yoga has been shown to promote positive emotions and lower inflammatory responses

- Massage therapy

- Hypnosis: influences states of consciousness to change perception

- Meditation: practice of exercising the mind where individual focuses on calming and quieting body while keeping mind alert

- systematic desensitization: attempts to transform a feared object or situation into a pleasant or neutral event; counterconditioning with contact with feared object and a calmin reponse is trained

- desensitization: reduce fears by slowly exposing feared object

- biofeedback: gaining control over bodily process (HR, muscle tension); operant conditioning: attaining voluntary control of bodily responses to stressors

- benzodiazepines: result in sedative and muscle relaxant

- B-blockers: influence PNF and block catecholamines and stress hormones responsible for fight-or-flight response

- both decrease physiological arousal and feelings of anxiety

- usually only prescribed for acute care but progressively more are requiring medications for long-term care

- four categories: constitutional, statutory, case, and administrative

- criminal law: governs conduct of both individuals and groups towards society as a whole; requires that persecutor provide beyond reasonable doubt to find the defendant guilty

- civil law: pertains to personal responsibilities that individual or group must observe when dealing with other individuals or groups; only requires that plaintiff demonstrate that the preponderance of evidence supports his/her claim to find the defendant liable

- wrongful act, whether intentional or accidental, from which an injury, insult, or death occur to another person

- plaintiff: group that is injured or sustains pecuniary damage

- defendant: individual or group responsible for tortuous act

- tort includes intentional misconuct, negligent conduct, and "no fault"

- no fault: ultrahazardous activities and product liability

- failure to exercise degree of care

- for plaintiff to successfully prosecute 4 elements must be well documented

1. legal duty must be established between client/HFS

2. breach of that legal duty: substandard performance or failure to act

3. breach of duty owed was the factual cause of injury/death

4. negligent act or failure to act resulted in well-documented damages/losses: economic/noneconomic

- risk management strategies: adhere to standard of care, use waivers and assumption of risk forms, and purchase liability insurance