Continuous exercise at a high relative work load results in a slow rise in VO2 during exercise, probably due to rising body temperature and increasing blood catecholamines

As the exercise intensity increases, blood lactate levels increase; the lactate “inflection” point represents a point of increasing reliance on anaerobic metabolism

1 MET = 3.5 ml/kg/min VO2  = 1.5 kcal/min Energy Expenditure

Average maximal HR (BPM)  =  220  –  Age  (years)

Intrisic Factor: Frank-Sterling Relationship

SV increases progressively until a work-load of 40 to 50% of VO2 max is attained

After this only small increases in SV occur with increasing oxygen demand

Thus during exercise, SV increases to approximately twice its resting value

neural control (sympathetic nervous system)

local factors (pH, pCO2, and lactic acid concentration)

SBP increases in proportion to exercise intensity

Q Increases

TPR reduces

VO2 max  =  max Q   x   max (a – v  O2 diff)

below 50% VO2 max, the relationship between ventilation and workload is linear

at higher intensities, the relationship is curvilinear

At VANT: the upper end of the exercise intensity range usually applied in “aerobic” training programs

Above VANT: rapid accumulation of lactic acid in muscle and blood may preclude prolonged activity 

7.Reduced levels of some hormones like epinephrine, increased sensitivity of other hormones like insulin 

Exercise training can increase the VO2 max by increasing both the max Q and max (a – v O2) difference

Alsong with improvements in respiration, central circulation and cardiac function, peripheral circulation or skeletal muscle metabolism 

Reduced resting, exercise and intrinsic heart rate and increased stroke volume

Reduces circulating catecholamines

Higher levels of physical fitness appear to delay all cause mortality primarily due to lower rates of cardiovascular disease and cancer

Any activity that uses large muscle groups for a prolonged period and is aerobic in nature.

plotting the relationship between the heart rate and the functional capacity (METS or VO2) and the instensity of exercise is 60-85% of the functional capacity

OR

Using a specified percentage of the maximal heart rate; This method underestimates the target heart rate for a given MET level by approximately 15%.

 MHR  x  percentage  =  THR

b. [ Percentage (MHR – RHR) ]  +  RHR =  THR

15-60 min

Usually 30min

What is the association between the extent of arterial disease and work capacity or VO2 max?

  1. Diminished SV

  2. A more rapid increase in HR

  3. An earlier widening of the a – v O2 difference

  4. A subnormal rise in SBP, with the possibility of no increase or even a drop in DBP

It occurs at a relatively constant threshold of myocardial work for an individual patient;

this threshold is best defined noninvasively by the HR x SBP (rate-pressure product, RPP)

static contraction of even small muscle mass in normal individuals produces a significant rise in HR, Q and BP with minimal or no change in SV or TPR, significant rise in LVEDP,  a small increase in LV stroke work 

the left ventricle has scant physiologic capacity to increase its output during static exercise and a sustained muscular contraction that may produce myocardial ischemia, LV failure, or complex ventricular arrhythmias

systemic BP rises normally with static exercise due to an increase in peripheral arterial tone 

True of False

from decreases in HR with some systemic drop in BP

The site of effect is the muscle in training

What HR should be used for stable cardiac patientsduring testing?

aerobic exercise should be encouraged to maintain physical conditioning, provided there is good BP control.

Weight lifting, strenuous isometric exercises and exhausting aerobic exercises must be avoided

  1. Cardiovascular exam

  2. Diabetic complications

  3. Blood glucose regulation

  4. Patient education and awareness

  1. HDLs increase

  2. Triglycerides decrease

  1. Myocardial infarction

  2. Arrhythmias, sudden death

1.  Vitreous hemorrhage

2.  Retinal detachment

1.  Increased proteinuria

1.Be prepared to reduce the overall insulin or oral medication requirement

2.  Estimate the number of calories that will be expended per session. Increase or decrease the intake of food to match the extent that the exercise will deviate from the normal amount.

3.  Try to exercise at about the same time of day to facilitate planning

4. Plot the time of peak blood sugar lowering effect of each type of insulin. If planning to exercise at about the same time, plan to take a light snack 20 to 30 minutes prior to exercise.

5.  Do not exercise if ketones are present in the urine or if the blood sugar is above 300 mg/dl.

6.  If you feel hypoglycemic, irritable, or nervous prior to exercise, check the blood sugar.

7. If planning an unusually large amount of physical activity, be prepared to eat additional food or to reduce the insulin dose. If choosing to increase caloric intake, light snacking every 30 to 60 minutes will help to avoid hypoglycemic reactions.  

8. Alter the injection site for insulin if subsequent exercise would cause the insulin level in the blood to rise too quickly. Avoid:

• arms and shoulder injections sites if weight training or swimming will be done
• thigh injection sites if running, cycling, playing basketball, or doing aerobic dance.  

How do you test Pulmonary Patients who are disabled?

1) VO2 max

  a. Highest value is observed in 1st decade of life

  b. Linear decline continues throughout life

  c. 1 % decline / year between 20 and 70 years

  d. Exercise affects the rate of decline

  e. 5% decline per decade in master athletes and a 9% decline per decade in healthy, untrained individuals

2) Cardiac output –   decline of app 1% / year

3)  Stroke volume –   decline of app 0.7% / year

4)  Maximal heart rate – decline

5)  Peripheral resistance – increases

6)  Blood pressure - increases

1.  Structural changes in lungs and thorax limit ventilatory excursions

2.  Tidal volume and respiratory rate – unchanged

3.  Forced expiratory volume and vital capacity – decreases

4.  Residual volume and anatomic dead space - increases

1.     Increased contribution to body weight of adipose tissue

lMen gain weight up to age 55 and women gain weight for an additional 20 yrs before a decline in weight begins; increase in both the absolute and relative amounts of body fat

2.  Reduction in lean muscle mass

·    Decrease in total number of muscle fibers, especially type II, fast twitch fibers

3.  Loss of bone mass

 1. During the 30 to 40 yrs after age 40, the total loss in skeletal mass may be 30 to 50% of that at an earlier age

2. Rate of bone loss occurs faster in women than men

3. Although the architecture of bone does not change substantially, there is a dramatic decrease in its mineralization

1.  Lean body mass

·        Reversal in age-associated muscle fiber atrophy

·        Increase in the activity of aerobic muscle enzymes

·        Increase in muscle strength

2.  Bones and Joints

·        Improvement in bone mineralization

           •     Improvement in range of motion and flexibility

1.  Glucose tolerance – improves

2.  Insulin sensitivity – improves

3.  Serum triglycerides – reduced

4.  HDL cholesterol – increases

5.  Apolipoprotein A-I - increases

1.  Anxiety – reduced

2.  Psychological tension – reduced

3.  Body image – improved

4.  Mood and attitudes - improved

Orthopedic problems are usually minor in nature but can become major problems if ignored

About 55 to 60% of the total caloric intake should be from carbohydrates to ensure repletion of glycogen stores as an energy source and to protect lean body mass

The caloric consumption must be equivalent to the total energy expenditure

1. Allow time for heat acclimatization (10 to 14 days).

2. Exercise during the cooler parts of the day.

3. Limit or defer exercise if WBGT is in the high risk zone.

4. Plan to drink before, during and after exercise in the heat (400-500 ml before and 300 ml every 20 min during the activity);Don’t judge your need for water by thirst alone;Water is the best fluid;Avoid alcoholic beverages, since alcohol impairs sweating

5. Modulate training intensity (by heart rate monitoring).

6. Monitor daily weight closely. Acute losses are due to water loss. If losses are greater than 3% of weight, they need to be replaced by drinking before the next training session.

7. Salt replacement is essential. Adequate electrolyte replacement is provided by liberal salting of food and a balanced diet. 

8. Wear as little clothing as possible. Clothing should be loose and porous, to allow air to circulate over the skin and permit evaporation of sweat. Never use rubberized sweat suits. White clothing and a visor or hat are suggested

thermoregulatory mechanisms fail to cope with the competing loads:

           (1) external heat load

(2) heat produced metabolically so that core body temperature rises

True or False 

People who habitually function in cold temperatures develop the ability to burn more calories per unit of exercise than the unhabituated person

An amount greater than 12 mcg/ml in the urine is considered doping.

To reach this limit one would have to consume 6-8 cups of coffee in one sitting and be tested within 2-3 hrs

Metaproterenol, Alupent , Salbutamol,  Albuterol, Ventolin, Proventil,  Terbutaline, Brethaire

They increase protein synthesis which will, with training, create an increase in lean muscle mass, resulting in an increase in strength and endurance

They have both anabolic and androgenic effects 

Alkylation in the C-17 alpha position

(Hepatotoxic) 

Esterification in the C-17 beta position

They are not subject to first pass effect and rarely are implicated in hepatotoxicity 

How can steroids maximizes anabolic stimulation and minimizes side effects from high-dose steroid consumption?

simultaneous use of different anabolic steroid preparations with the expectation of saturating multiple androgen receptor populations

 utilize drug-specific side effects 

cycle different steroids over a 6 to 12 week period. 

A 65 year old male patient who develops angina at exercise levels less than ordinary activity (i.e. 2-4 mets), would be classified at what class according to the New York  Heart Classification?

A 55 year old sedentary male wants to begin an exercise program. What is the common etiology for exercise induced sudden death for this type of patient?