Transcript Exercise Prescription for the CCRP

Exercise Prescription for
the Certified Cardiac
Rehab Professional
Erik Ostrowski, MS, ACSM-RCEP, CCRP
Southern Illinois Healthcare
Herrin Hospital
Today

Exercise prescription (Ex Rx) as it relates to the
CCRP exam
 Certified
Cardiac Rehab Professional
 Specific
Ex Rx recommendations for pulmonary patients
have been omitted
 Most
Ex Rx concepts for cardiac patients remain
interchangeable with other chronic disease conditions
CCRP Exam Categories

10 Categories
1.
Patient assessment
2.
Nutritional management
3.
Weight management
4.
Blood lipid management
5.
Blood pressure management
6.
Diabetes management
7.
Tobacco Cessation
8.
Pyschosocial Management
9.
Physical Activity Counseling
10.
Exercise Training
CCRP Exam Blueprint

Exercise Training
 Design
and modify an aerobic
exercise training program
 (10.11,
10.12, 10.13)
 Understand
and consider
various physiologic measures
for use in an Ex Rx
 HR,
HRR, VO2, VO2R and METs
 (10.6)
 Design

and modify a resistance training program
(10.15)
Components of the Ex Rx

FITT Principle



There are four primary
variables that need to
be considered when
designing a basic Ex Rx
F – Frequency




T – Time

T - Type
%HRmax, %HRR, %VO2max,
%VO2R, METs, RPE
Time (duration)


# of days per week
Intensity (difficulty)

I – Intensity

Frequency
minutes per session
Type (mode)

Continuous, rhythmic
activities that involve large
muscle groups
Components of the Ex Rx

What are we missing???

Progression

Volume

FITT Principle becomes
the FITT-VP Principle

F – Frequency

I – Intensity

T – Time

T – Type

V – Volume

P – Progression
Type (Mode)

What types of exercises are appropriate for
patients with CVD?
 Continuous,
rhythmic activities that involve large
muscle groups
Practical Examples:
Equipment Examples:
Frequency

How many times per week
should a patient with CVD
exercise?
 3-5
days/wk
 Up
to 7 days/wk is safe and
effective
 Cardiopulmonary benefits occur (and can be maintained)
with as little as 2 days/wk (intensity/duration dependent)
 Will
depend on an individual’s current fitness level and goals
Time (Duration)

How many minutes should a patient with CVD
exercise during a given session?
 20-60
 May
minutes
be accumulated in shorter intervals
of at least 10 minutes per interval
 In extremely deconditioned individuals, shorter intervals
are acceptable with a goal to attain 10 minutes of
continuous exercise before resting
Intensity

How intense should exercise be for a CVD patient?
 “ACSM
Guidelines indicate that a minimal intensity
threshold lies between 30-40% of the patient’s HRR or
VO2R, with the upper range at approximately 80% HRR
or VO2R”

ACSM Intensity Level Guidelines:
 Light
(low): < 40% HRR or VO2R
 Moderate
 Vigorous
 Near
(medium): 40-60% HRR or VO2R
(high): 60-80% HRR or VO2R
Maximal (very high): 80-90% HRR or VO2R
Intensity

What about an upper limit to exercise intensity levels
for patients with CVD?
 Up
to 80% HRR or VO2R is safe during continuous exercise
 Up
to 90-95% peak HR for short bouts during HIIT
 In
other words, don’t be afraid to allow your patients to
continue exercising past their age-predicted or estimated
values if they are NOT asymptomatic!
Physiological Measures

Heart Rate Maximum (HRmax)
 An
individual’s maximum achievable
heart rate
 Expressed
Heart
The
Rate Reserve (HRR)
difference between maximal and resting HR values
Expressed
Also
in beats-per-min (bpm)
in beats-per-min (bpm)
called “Maximal Heart Rate Reserve (MHRR)”
Heart Rate Reserve (HRR) Method
Karvonen Formula: ((HRmax – HRrest) x %) + HRrest

1.
2.
Also referred to as the Karvonen Method
Find HRmax

Directly measure using a maximal cardiopulmonary stress test

Estimate through equation (220-age)
Find HRrest

Directly measure via palpation (or pulse oximeter) at rest
3.
Pick the desired ACSM intensity level (%)
4.
Input numbers into Karvonen Formula

HRmax, HRrest, and the desired ACSM intensity level
HRR Example

What HR (bpm) would a 60 year-old male need to
maintain in order to be exercising at 50% of his HRR?
1.
Find HRmax using 220-age equation: 220 - 60 = 160 bpm
2.
Find HRrest via pulse oximeter: 74 bpm
3.
Pick desired ACSM Intensity Level: 50% = 0.50
4.
Plug into Karvonen Formula
((HRmax – HRrest) x %) + HRrest
((160 – 74) x 0.50) + 74 = 117 bpm
Remember: To find an intensity range (i.e., 50-80%) you
must perform this equation twice!
Physiological Measures



Maximal Volume of O2 Consumption (VO2max)

The maximal amount of O2 the body can take in and utilize

Usually expressed in ml/kg/min

Adults with CVD are more likely to have a max capacity of 15-30
ml/kg/min
Volume of O2 Consumption Reserve (VO2R)

The difference between maximal and resting O2 consumption values

Usually expressed in ml/kg/min
Metabolic Equivalent (METs)

An expression of O2 utilization in the body

MET = ml/kg/min ÷ 3.5

Adults with CVD are more likely to have a max capacity of 5-10 METs
VO2 Reserve (VO2R) Method
Formula: ((VO2max – VO2rest) x %) + VO2rest
1.
Find VO2max

2.
Directly measure using a maximal cardiopulmonary stress test
Find VO2rest

3.5 ml/kg/min for everyone! (1 MET)
3.
Pick the desired ACSM intensity level (%)
4.
Input numbers into formula

VO2max, VO2rest, and the desired ACSM intensity level
VO2R Example

What VO2 ml/kg/min would a 200 lb., 50 year-old female
need to maintain in order to be exercising at 50% of her VO2R?
1.
Find VO2max using a maximal CP stress test = Ex. 24.5
2.
Constant VO2rest = 3.5
3.
Pick desired ACSM Intensity Level: 50% = 0.50
4.
Plug into Karvonen Formula
ml/kg/min
ml/kg/min
((VO2max – VO2rest) x %) + VO2rest
((24.5 – 3.5) x 0.50) + 3.5 = 14
ml/kg/min
Remember: To find an intensity range (i.e., 50-70%) you must
perform this equation twice!
VO2R Example Continued…

So what now?

Convert to METs
 14

ml/kg/min 3.5 = 4.0 METs
Use metabolic equations to determine equipment settings
 Treadmill
 Airdyne
 Arm

= 3.3/1.0
(speed/incline)
= 58 watts
Ergometer = 41 watts
 Recumbent
Bike = 41 watts
 Recumbent
Stepper (NuStep) = 125 watts
For a helpful calculator visit: http://www.fidel.com/mets/
Intensity – Other Considerations

Peak exercise HR should generally be set at least 10 bpm below
the HR associated with any of the below criteria:

ICD firing threshold

Onset of angina

Plateau or decrease in systolic BP

> or = 250 SBP

> or = 115 DBP

> or = 1mm ST-segment depression

Increased frequency of ventricular dysrhythmias

Other significant ECG disturbances (2nd or 3rd degree AV block)

Other signs/symptoms of exercise tolerance
Prescribing Exercise Intensity w/o
Exercise Test Data

How do we prescribe exercise intensity w/o an exercise
stress test?
 Use
RPE
 Use
HR and/or MET levels derived from the 6MWT as a target
intensity early on
 If
you use HR, remember 220-age with caution because it is
just an estimate and HR is genetically extremely variable!
 Remember:
220-age is invalid if a patient is taking beta blockers!
Prescribing Exercise Intensity w/o
Exercise Test Data
Example: Larry walked 1260 ft. during his 6MWT without any complaints.
How can we determine a starting exercise intensity with just this
information?
1.
2.
Convert 6MWT speed to miles-per-hour

1,260

12,600

Treadmill setting = 2.4
6min/ft
ft/hr
x 10
6min/hr.
÷ 5,280
ft/mi
= 12,600
= 2.386
mph
/ 0.0
ft/hr
mph
incline
Convert treadmill setting to METs using the metabolic equation

See ACSM’s Guidelines for Exercise Testing and Prescription
computer system software if available
(9th ed.) or
use

Larry’s treadmill setting = 2.8 METs

Set all equipment workload settings to 2.8 METs

Titrate equipment individually every 3 minutes until an RPE of 11-13 is reached
RPE

Rating of Perceived Exertion (RPE)
 Subjective
scale of exercise intensity
 6–20 (traditional);
1–10
(modified)
 Valuable
when exercise stress test data
is unavailable
 Relative
 Light:
intensity equivalents:
30-40% HRR/VO2R = RPE ~8-11
 Moderate:
 Vigorous:
40-60% HRR/VO2R = RPE ~12-14
60-80% HRR/VO2R = RPE ~15-17
Progression

Starting exercise goal:
 Attain
30-40 minutes of continuous exercise at a lowmoderate intensity (RPE 11-13) per session

Progression goals:
 Gradually
titrate upward the frequency, intensity and
duration of exercise until the patient achieves:
 5-7
sessions per week
 150-300

(this includes home exercise!)
mins per week
 50-60
mins per session
 12-16
RPE
(somewhat hard - hard)
Gradually increase exercise VOLUME
Volume


What is exercise volume?

Exercise Volume = Duration x Intensity x Frequency

Expressed as MET-min-wk or kcal/wk
Why is understanding exercise volume important?

Standardized measurement being used in research

Excellent way to track exercise progression


Recommend 5-10% increase in exercise volume per week

Strive for 500-1000 MET-min-wk
Exercise volume impact on atherosclerotic lesion progression:

<1000 kcal/wk = Likely progression

1000-1500 kcal/wk = Little/No progression

>2200 kcal/wk = Possible regression
Resistance Training


One exercise for each major muscle group (8-10 in total)
Upper Body
Mid/Lower Body
Chest
Abdomen
Back
Gluteals
Shoulders
Quadriceps
Biceps
Hamstrings
Triceps
Calves
1-2 Sets

8-12 Reps

2-3 mins
Rest/Sets

48-72 hrs
Rest/Sessions
Resistance Training Do’s & Don’ts


Do

Wait to use with PTCA/PCI/MI patients for 2-3 weeks post procedure

Wait to use with CABG/Valve/Surgery patients for 4-5 weeks post procedure

Safe for HF patients

Avoid excessive isometric contractions

Utilize proper breathing technique (avoid Valsalva)

Start light and progress gradually
Don’t utilize resistance exercise in patients with:

Uncontrolled arrhythmias

Symptomatic HF

Severe valvular disease

Large aortic aneurysms

Uncontrolled HTN (resting SBP >160, resting DBP >105)
Take Home Points


If you use HR, remember 220-age with caution because it is just an
estimate and HR is genetically extremely variable

It’s safe to allow patients to exceed the HR ranges you set for them so long
as they are asymptomatic

220-age is invalid if a patient is taking beta blockers
Even if you do not plan to take the CCRP exam, this material is the
foundation for how and why to prescribe exercise for patients with CVD


It meets all AACVPR and ACSM guidelines
Most patients enrolled in cardiac rehab (2-3x/wk) achieve < 1000
kcal/wk or 500-1000 MET/min/wk of energy expenditure

This is NOT enough exercise to reduce CVD risk

All programs should emphasize the need to exercise at home
References

AACVPR CCRP Study Guide

ACSM’s Guidelines for Exercise Testing and Prescription (9th ed.)

Clinical Exercise Physiology (3rd ed.)

Brawner, C. (2010). Prescribing Exercise in Cardiac Rehabilitation
without an Exercise Test. ACSM Certified News, 20, 7-13.

Brawner, C., et al. (2004). Predicting maximum heart rate among
patients with coronary heart disease receiving β-adrenergic blockade
therapy. American Heart Journal, 148, 910-914.

Keteyian, S. et al. (2012). Predicting maximal HR in heart failure
patients on β-blockade therapy. Medicine and Science in Sports and
Exercise, 44, 371-376.

http://www.fedel.com/mets/
Thank You!
Erik Ostrowski, MS, ACSM-RCEP, CCRP
Southern Illinois Healthcare
Herrin Hospital