Exercise Prescription for the Certified

Cardiac Rehab Professional

Erik Ostrowski, MS, ACSM-RCEP, CCRPSouthern 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 assessment2. Nutritional management3. Weight management4. Blood lipid management5. Blood pressure management6. Diabetes management7. Tobacco Cessation8. Pyschosocial Management9. Physical Activity Counseling10. 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

Frequency # of days per week

Intensity (difficulty) %HRmax, %HRR, %VO2max,

%VO2R, METs, RPE Time (duration)

minutes per session Type (mode)

Continuous, rhythmic activities that involve large muscle groups

F – Frequency I – Intensity T – Time T - Type

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 groupsEquipment Examples:

Practical 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

EXERCISE

EXERCISE

EXERCISE

EXERCISE EXERCISE

EXERCISE EXERCISE

Time (Duration) How many minutes should a patient with

CVD exercise during a given session? 20-60 minutes May 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 VO2RModerate (medium): 40-60% HRR or VO2RVigorous (high): 60-80% HRR or VO2RNear 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 in beats-per-min (bpm)Heart Rate Reserve (HRR)

The difference between maximal and resting HR values

Expressed in beats-per-min (bpm)Also called “Maximal Heart Rate Reserve (MHRR)”

Heart Rate Reserve (HRR) MethodKarvonen Formula: ((HRmax – HRrest) x %) + HRrest

Also referred to as the Karvonen Method1. Find HRmax

Directly measure using a maximal cardiopulmonary stress test Estimate through equation (220-age)

2. 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

bpm2. Find HRrest via pulse oximeter: 74 bpm3. Pick desired ACSM Intensity Level: 50% = 0.504. 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) MethodFormula: ((VO2max – VO2rest) x %) + VO2rest

1. Find VO2max Directly measure using a maximal cardiopulmonary

stress test2. 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 ml/kg/min

2. Constant VO2rest = 3.5 ml/kg/min

3. Pick desired ACSM Intensity Level: 50% = 0.504. Plug into Karvonen Formula

((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 = 3.3/1.0 (speed/incline) Airdyne = 58 watts Arm 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 DataExample: Larry walked 1260 ft. during his 6MWT without any complaints. How can we determine a starting exercise intensity with just this information?1. Convert 6MWT speed to miles-per-hour

1,260 6min/ft x 10 6min/hr. = 12,600 ft/hr 12,600 ft/hr ÷ 5,280 ft/mi = 2.386 mph Treadmill setting = 2.4 mph / 0.0 incline

2. Convert treadmill setting to METs using the metabolic equation See ACSM’s Guidelines for Exercise Testing and Prescription (9th ed.) or

use computer system software if available 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 intensity equivalents:

Light: 30-40% HRR/VO2R = RPE ~8-11 Moderate: 40-60% HRR/VO2R = RPE

~12-14 Vigorous: 60-80% HRR/VO2R = RPE ~15-

17

Progression Starting exercise goal:

Attain 30-40 minutes of continuous exercise at a low-moderate 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 (this includes home exercise!) 150-300 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 BodyChestBack

ShouldersBicepsTriceps

Mid/Lower Body

AbdomenGluteals

QuadricepsHamstrings

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 HealthcareHerrin Hospital