Theraex For IKFR

Therapeutic Exercise
Arnengsih Nazir, MD
Terminology
• Physical Activity is defined as any bodily movement produced by the
contraction of skeletal muscles that results in a substantial increase in
caloric requirements over resting energy expenditure
• Exercise is a type of physical activity consisting of planned, structured,
and repetitive bodily movement done to improve and/or maintain
one or more components of physical fitness
• Physical fitness is the ability to carry out daily tasks with vigor and
alertness, without undue fatigue, and with ample energy to enjoy
leisure-time pursuits and meet unforeseen emergencies
ACSM. ACSM’s Guideline for Exercise Testing and Prescription, 10th edition, Philadelphia, ACSM;2018
Component of Physical Fitness
Health-Related Components of Physical Fitness
• Cardiorespiratory endurance: the ability of the

circulatory and respiratory system to supply
oxygen during sustained physical activity
• Body composition: the relative amounts of
muscle, fat, bone, and other vital parts of the
body
• Muscular strength: the ability of muscle to exert
force
• Muscular endurance: the ability of muscle to
continue to perform without fatigue ACSM. ACSM’s Guideline for Exercise Testing
and Prescription, 10th edition, Philadelphia,
• Flexibility: the range of motion available at a joint ACSM;2018
Component of Physical Fitness
Skill-Related Components of Physical Fitness
Agility: the ability to change the position of the body in space with speed
and accuracy
Coordination: the ability to use the senses, such as sight and hearing,
together with body parts in performing tasks smoothly and accurately
Balance: the maintenance of equilibrium while stationary or moving
Power: the ability or rate at which one can perform work
Reaction time: the time elapsed between stimulation and the beginning
of the reaction to it
ACSM. ACSM’s Guideline for Exercise Testing and
Speed: the ability to perform a movement within a short period of time Prescription, 10th edition, Philadelphia,
ACSM;2018
1. Exercise Physiology
Aerobic Exercise
Benefits of Regular Physical Activity and/or Exercise
McArdle, W., Katch, F., & Katch, V. (2010).Exercise physiology: Nutrition, energy and human performance (7th ed.). pp. 461
• Improvement in Cardiovascular and Respiratory Function
• Increased maximal oxygen uptake
• Decreased minute ventilation at a given absolute submaximal intensity
• Decreased myocardial oxygen cost for a given absolute submaximal intensity
• Decreased heart rate and blood pressure at a given submaximal intensity
• Increased capillary density in skeletal muscle
• Increased exercise threshold for the accumulation of lactate in the blood
• Increased exercise threshold for the onset of disease signs or symptoms (e.g.,
angina pectoris, ischemic ST segment depression, claudication)
• Reduction in Cardiovascular Disease Risk Factors
• Reduced resting systolic/diastolic pressure
• Increased serum high-density lipoprotein cholesterol and decreased serum
triglycerides
• Reduced total body fat, reduced intra-abdominal fat
• Reduced insulin needs, improved glucose tolerance
• Reduced blood platelet adhesiveness and aggregation
• Reduced inflammation
• Decreased Morbidity and Mortality
• Primary prevention (i.e., interventions to prevent the initial
occurrence)
• Higher activity and/or fitness levels are associated with lower death rates
from CAD
• Higher activity and/or fitness levels are associated with lower incidence
rates for CVD, CAD, stroke, type 2 diabetes mellitus, metabolic syndrome,
osteoporotic fractures, cancer of the colon and breast, and gallbladder
disease
• Secondary prevention (i.e., interventions after a cardiac
event to prevent another)
• Cardiovascular and all-cause mortality are reduced in patients with
post-myocardial infarction who participate in cardiac rehabilitation
exercise training, especially as a component of multifactorial risk
factor reduction
• Other Benefits
• Decreased anxiety and depression
• Improved cognitive function
• Enhanced physical function and independent living in older
individuals
• Enhanced feelings of well-being
• Enhanced performance of work, recreational, and sport activities
• Reduced risk of falls and injuries from falls in older individuals
• Prevention or mitigation of functional limitations in older adults
• Effective therapy for many chronic diseases in older adults
RISKS ASSOCIATED WITH PHYSICAL ACTIVITY AND EXERCISE
• Participation in exercise is associated with an increased risk

for musculoskeletal injury (MSI) and cardiovascular
complications
• MSI is the most common exercise related complication and is
often associated with exercise intensity, the nature of the
activity, preexisting conditions, and musculoskeletal
anomalies
RISKS ASSOCIATED WITH PHYSICAL ACTIVITY AND EXERCISE
• Adverse cardiovascular events such as sudden cardiac death

(SCD) and acute myocardial infarction (AMI) are usually
associated with vigorous intensity exercise
• SCD and AMI are much less common than MSI but may lead
to long-term morbidity and mortality
PREVENTION OF EXERCISE-RELATED CARDIAC EVENTS
• Health care professionals should know the pathologic conditions

associated with exercise-related events so that physically active
children and adults can be appropriately evaluated
• Physically active individuals should know the nature of cardiac
prodromal symptoms (e.g., excessive, unusual fatigue and pain in the
chest and/or upper back) and seek prompt medical care if such
symptoms develop
• High school and college athletes should undergo pre-participation
screening by qualified professionals.
PREVENTION OF EXERCISE-RELATED CARDIAC EVENTS
• Athletes with known cardiac conditions or a family history should be

evaluated prior to competition using established guidelines
• Health care facilities should ensure their staff is trained in managing
cardiac emergencies and have a specified plan and appropriate
resuscitation equipment
• Physically active individuals should modify their exercise program in
response to variations in their exercise capacity, habitual activity level,
and the environment
Preventing Muscle Strain
• Warm-up before a vigorous activity; 5 to 7 minutes of a large muscle group
activity such as walking, jogging, or cycling should suffice. This should be enough
activity to break a sweat
• Stretch stiff and short muscles after your general warm-up
• Stretch each muscle for 15 to 30 seconds for four repetitions
• Balance your sports or other leisure activities with strengthening exercises
• Avoid fatigue during the activity. Fatigue can increase your risk of injury
• Strengthen underused muscles to prevent overuse to susceptible muscles
Brody LT, Hall CM. Therapeutic exercise: moving toward function. 3rd Edition. Baltimore. Lippincott Williams & Wilkins, a Wolters Kluwer business; 2011
Resistance Exercise
https://www.researchgate.net/figure/Basic-outline-of-the-musculotendinous-and-neural-adaptations-to-resistance-
training_fig1_8405816/download
Physiological Adaptation to Resistance Exercise
Source: Kisner, Carolyn.; Therapeutic exercise : foundations and techniques / Carolyn Kisner, Lynn Allen Colby. — 6th ed
Benefits of Strength Training on the Cardiovascular System
• Decreased heart rate
• Decreased or unchanged systolic blood pressure
• Decreased or unchanged diastolic blood pressure
• Increased or unchanged cardiac output
• Increased or unchanged stroke volume
• Increased or unchanged maximal oxygen consumption
• Decreased or unchanged total cholesterol
THANK YOU
Pre-Participation
Health Screening
and Risk Classification
Arnengsih Nazir, MD
Pre-participation health screening before initiating
physical activity or an exercise program may include:
• Self-guided methods such as the Physical Activity
Readiness Questionnaire (PAR-Q)
• CVD risk factor assessment and classification
• Medical evaluation including a physical examination and
stress test
ACSM. ACSM’s Guideline for Exercise Testing and Prescription, 9th edition, Philadelphia, Wolter Kluwers. Lippincott Williams & Wilkins;2014
• The aim of Pre-Participation Screening are to identify:
• Subjects with underlying cardiorespiratory and metabolic
conditions that may limit or exclude them from exercise programs
• Subjects with cardiovascular risk factors who should undergo
further medical evaluation and exercise testing
• Appropriate level of exercise intensity, supervision, and special
exercise precautions for subjects with chronic medical conditions
• Individuals with special needs that may require modifications to
their exercise program
Tan B., Sien NC, Lim I. EIMS Exercise Prescription Guide, Marshal Cavendish Edition, Singapore;2015
The Screening Process
• A self-guided questionnaire such as physical activity readiness
questionnaire (PAR-Q) is the recommended entry level for screening
• If the subject answers “no” to all 7 questions, he is at low risk for
health complications, and is generally safe to begin exercising without
supervision at any intensity
ACSM. ACSM’s Guideline for Exercise
Testing and Prescription, 10th edition,
Philadelphia, ACSM;2018
http://www.euro.who.int/en/health-topics/disease-prevention/physical-activity/data-and-statistics
CVD Risk Factor
Assessment and Classification
Risk Classification
• The aim of risk classification is to assign subjects undergoing
pre-participation screening into one of the three risk groups:
low, moderate, or high
• Risk classification of all individuals was based on:
• the number of cardiovascular disease (CVD) risk factors
• the presence of signs or symptoms and/or known cardiovascular
(CV), metabolic, and/or pulmonary disease
Risk Classification
• Recommendations for a pre-participation medical examination and
exercise testing were then based on the risk classification and
proposed exercise intensity
Atherosclerotic Cardiovascular Disease (CVD) Risk Factors and Defining Criteria
Signs or symptoms of cardiovascular (cv), metabolic, or
pulmonary disease
• Pain; discomfort (or other anginal equivalent) in the chest, neck, jaw, arms,
or other areas that may result from ischemia
• Shortness of breath at rest or with mild exertion
• Dizziness or syncope
• Orthopnea or paroxysmal nocturnal dyspnea
• Ankle edema
• Palpitations or tachycardia
• Intermittent claudication
• Known heart murmur
• Unusual fatigue or shortness of breath with usual activities
ACSM. ACSM’s Guideline for Exercise Testing
and Prescription, 9th edition, Philadelphia, a
Wolter Kluwers. Lippincott Williams &
Wilkins;2014
ACSM. ACSM’s Guideline for Exercise Testing
and Prescription, 9th edition, Philadelphia,
Wolter Kluwers. Lippincott Williams &
Wilkins;2014
Case Study
CASE STUDY I
• Female, age 21 yr, smokes socially on weekends (10–20 cigarettes). Drinks
alcohol one or two nights a week, usually on weekends
• Height 63 in (160 cm), weight 124 lb (56.4 kg), BMI 22.0 kg m2
• RHR 76 beats min1, resting BP 118/72 mm Hg
• Total cholesterol 178 mg dL1 (4.61 mmol L1), LDL 98 mg dL1 (2.54 mmol
L1), HDL 57 mg dL1 (1.48 mmol L1), FBG unknown
• Currently taking oral contraceptives
• Attends group exercise class two to three times a week. Reports no
symptoms
• Both parents living and in good health
CASE STUDY II
• Man, age 54 yr, nonsmoker. Height 72 in (182.9 cm), weight 168 lb (76.4
kg), BMI 22.8 kg m2
• RHR 64 beats min1, resting BP 124/78 mm Hg
• Total cholesterol 187 mg dL1 (4.84 mmol L1), LDL 103 mg L1 (2.67 mmol
L1), HDL 52 mg dL1 (1.35 mmol L1), FBG 88 mg dL1 (4.84 mmol L1)
• Recreationally competitive runner, runs 4–7 d wk1, completes one to two
marathons and numerous other road races every year
• No medications other than over-the-counter ibuprofen as needed
• Reports no symptoms
• Father died at age 77 yr of a heart attack, mother died at age 81 yr of
cancer
CASE STUDY III
• Man, age 44 yr, nonsmoker. Height 70 in (177.8 cm), weight 216 lb
(98.2 kg), BMI 31.0 kg m2
• RHR 62 beats min1, resting BP 128/84 mm Hg. Total serum
cholesterol 184 mg dL1 (4.77 mmol L1), LDL 106 mg dL1 (2.75
mmol L1), HDL 44 mg dL1 (1.14 mmol L1), FBG unknown
• Walks 2–3 mi two to three times a week
• Father had Type 2 diabetes and died at age 67 yr of a heart attack;
mother living, no CVD
• No medications; reports no symptoms
CASE STUDY IV
• Women, age 36 yr, nonsmoker. Height 64 in (162.6 cm), weight 108
lb (49.1 kg), BMI 18.5 kg m2
• RHR 61 beats min1, resting BP 114/62 mm Hg. Total cholesterol 174
mg dL1 (4.51 mmol L1), blood glucose normal with insulin injections
• Type 1 diabetes diagnosed at age 7 yr
• Teaches dance aerobic classes three times a week, walks
approximately 45 min four times a week
• Reports no symptoms
• Both parents in good health with no history of CVD
Case Study V
• A 22-yr-old woman recent college graduate come to you asking a
prescription of exercise that she want to do
• Since becoming an accountant 6 mo ago, she no longer walks across
campus or plays intramural soccer
• Her body mass index (BMI) is 27, she reports no significant medical
history and no symptoms of any diseases, even when walking up
three flights of stairs to her apartment
• She reports that her father died at the age of 60 due to stroke
• She wants to begin walking on treadmill three times a week
CASE STUDY VI
• A 50-yr-old nonsmoking male reports currently walking 40 min on Monday,
Wednesday, and Friday, something he has done “for years.”
• He reports having what he describes as a “mild heart attack” at 45 yr old,
completed cardiac rehabilitation, and has had no problems since.
• He takes a statin, an angiotensin-converting enzyme (ACE) inhibitor, and aspirin
daily.
• His daily systolic blood pressure ranging from 120-130 mmHg, and his diastolic
blood pressure ranging from 80-85 mmHg
• His latest fasting blood glucose was 90 mg.dL-1, and glucose tolerance test was
120 mg.dL-1
• He wants to joint a “club jantung sehat” and do a brisk walking exercise three
times a week
CASE STUDY VII
• A 35-yr-old business consultant come to you asking about whether
she could joint a club for a long-distance bike ride
• She reports no current symptoms of CV or metabolic disease
and has no medical history except hyperlipidemia, for which she takes
a HMG-CoA reductase inhibitor (statin) daily
• She is no longer participate in the club because she has no time to do
it, however, know she realize that her body weight increased
significantly in recent year
• Her aunt was died due to CABG surgery 2 years ago at the age of 50
• Sometimes she smoke because some of her friends are smokers
Questions
• Please define a risk classification for cardiovascular disease for all
three patients
• Using the algorithm please determine whether the patients need to
undergo medical examinations, exercise testing, and MD supervision
in exercise testing before participating in exercise training
Answer
Screening Algorithm
Screening Algorithm
Case Study
Case Study 1
• A 50-yr-old nonsmoking male was recently invited by colleagues to
participate in a 10-km trail run.
• He reports currently walking 40 min on Monday, Wednesday, and Friday,
something he has done “for years.”
• His goal is to run the entire race without stopping, and he is seeking
training services.
• He reports having what he describes as a “mild heart attack” at 45 yr old,
completed cardiac rehabilitation, and has had no problems since.
• He takes a statin, an angiotensin-converting enzyme (ACE) inhibitor, and
aspirin daily.
• During the last visit with his cardiologist, which took place 2 yr ago, the
cardiologist noted no changes in his medical condition.
CASE STUDY II
• A 22-yr-old recent college graduate is joining a gym.
• Since becoming an accountant 6 mo ago, she no longer walks across
campus or plays intramural soccer and has concerns about her now
sedentary lifestyle.
• Although her body mass index (BMI) is slightly above normal, she reports
no significant medical history and no symptoms of any diseases, even when
walking up three flights of stairs to her apartment.
• She would like to begin playing golf.
CASE STUDY III
• A 45-yr-old former collegiate swimmer turned lifelong triathlete
requests assistance with run training.
• His only significant medical history is a series of overuse injuries to his
shoulders and Achilles tendon.
• In recent weeks, he notes his workouts are unusually difficult and
reports feeling constriction in his chest with exertion, something he
attributes to deficiencies in core strength.
• Upon further questioning, he explains that the chest constriction is
improved with rest and that he often feels dizzy during recovery.
CASE STUDY IV
• A 60-yr-old woman is beginning a professionally led walking program.
• Two years ago, she had a drug-eluting stent placed in her left anterior
descending coronary artery after a routine exercise stress test
revealed significant ST-segment depression.
• She completed a brief cardiac rehabilitation program in the 2 mo
following the procedure but has been inactive since.
• She reports no signs or symptoms and takes a cholesterol-lowering
statin and antiplatelet medications as directed by her cardiologist.
CASE STUDY V
• A 35-yr-old business consultant is in town for 2 wk and seeking a
temporary membership at a fitness club.
• She and her friends have been training for a long-distance charity bike
ride for the past 16 wk; she is unable to travel with her bike and she
does not want to lose her fitness.
• She reports no current symptoms of CV or metabolic disease
and has no medical history except hyperlipidemia, for which she takes
a HMG-CoA reductase inhibitor (statin) daily
Questions
1. Using the above data please identify the following from each cases:
• Current participation in regular exercise
• Known CV, metabolic, or renal disease
• Signs and symptoms suggestive of disease
• Desired intensity
• Medical clearance needed
2. Use the screening algorithm to determine the recommended
intensity of exercise
Answer:
• Exercise professionals working with patients with
known CVD in exercise-based cardiac rehabilitation and
medical fitness settings are advised to use more in-
depth risk stratification procedures
• Risk stratification criteria from the American
Association of Cardiovascular and Pulmonary
Rehabilitation (AACVPR)
LOWEST RISK
All characteristics listed must be present for patients to remain at lowest risk:
Exercise Testing Findings:
• Absence of complex ventricular dysrhythmias during exercise testing and
recovery
• Absence of angina or other significant symptoms (e.g., unusual shortness of
breath, light-headedness, or dizziness, during exercise testing and recovery)
• Presence of normal hemodynamics during exercise testing and recovery
(i.e., appropriate increases and decreases in heart rate and systolic blood
pressure with increasing workloads and recovery)
• Functional capacity ≥7 metabolic equivalents (METs)
LOWEST RISK
Non-exercise Testing Findings

• Resting ejection fraction ≥50%
• Uncomplicated myocardial infarction or revascularization procedure
• Absence of complicated ventricular dysrhythmias at rest
• Absence of congestive heart failure
• Absence of signs or symptoms of post-event/post-procedure myocardial ischemia
• Absence of clinical depression
MODERATE RISK
Any one or combination of these findings places a patient at moderate risk:
Exercise Testing Findings

• Presence of angina or other significant symptoms (e.g., unusual shortness of
breath, light-headedness, or dizziness occurring only at high levels of
exertion [≥7 METs])
• Mild-to-moderate level of silent ischemia during exercise testing or recovery
(ST-segment depression <2 mm from baseline)
• Functional capacity <5 METs

• Rest ejection fraction 40%–49%
HIGHEST RISK
Any one or combination of these findings places a patient at high risk:
Exercise Testing Findings
• Presence of complex ventricular dysrhythmias during exercise testing or
recovery
• Presence of angina or other significant symptoms (e.g., unusual shortness of
breath, light-headedness, dizziness at low levels of exertion [<5 METs] or
during recovery)
• High level of silent ischemia (ST-segment depression ≥2 mm from baseline)
during exercise testing or recovery
• Presence of abnormal hemodynamics with exercise testing (i.e., chronotropic
incompetence or flat or decreasing systolic blood pressure with increasing
workloads) or recovery (i.e., severe post-exercise hypotension)
• Rest ejection fraction <40%
• History of cardiac arrest or sudden death
• Complex dysrhythmias at rest
• Complicated myocardial infarction or revascularization procedure
• Presence of congestive heart failure
• Presence of signs or symptoms of post-event/post-procedure
myocardial ischemia
• Presence of clinical depression
Medical Evaluation
At the time of physician referral or program entry, the following
assessments should be performed:
• Medical and surgical history including the most recent
cardiovascular event, comorbidities, and other pertinent medical
history
• Physical examination with an emphasis on the cardiopulmonary
and musculoskeletal systems
Medical Evaluation
• Review of recent cardiovascular tests and procedures including 12-
lead electrocardiogram (ECG), coronary angiogram, echocardiogram,
stress test (exercise or pharmacological studies), cardiac surgeries or
percutaneous interventions, and pacemaker/implantable defibrillator
implantation
• Current medications including dose, route of administration, and
frequency
• CVD risk factors
• Exercise training is safe and effective for most patients
with cardiac disease; however, all patients should be
stratified based on their risk for occurrence of a
cardiac-related event during exercise training
• Routine assessment of risk for exercise should be performed
before, during, and after each CR session, include the
following:
• HR, Blood pressure (BP)
• Body weight
• Symptoms or evidence of change in clinical status not necessarily related to
activity (e.g., dyspnea at rest, lightheadedness or dizziness, palpitations or
irregular pulse, chest discomfort, sudden weight gain)
• Symptoms and evidence of exercise intolerance
• Change in medications and adherence to the prescribed medication regimen
• ECG and HR surveillance
Signs and Symptoms of Exercise Intolerance
• Angina, typically manifested as chest, left arm, jaw, back or lower neck pain or
pressure
• Unusual or severe shortness of breath
• Abnormal diaphoresis
• Pallor, cyanosis, cold, and clammy skin
• Central nervous system symptoms such as vertigo, ataxia, gait problems, or
confusion
• Leg cramps or intermittent claudication
• Physical or verbal manifestations of severe fatigue or shortness of breath
EXERCISE PRESCRIPTION
Arnengsih Nazir, MD
General Principal of Exercise Prescription
Objective of The Prescription
• Exercise prescription is the process of designing regimen of
physical activity in a systematic and individualized manner
• The art of exercise prescription is the successful integration
of the science of exercise physiology with behavior change
principles that results in long term compliance to a physical
activity regimen
1. Nieman DC. Exercise testing and prescription: A health-related approach. 7th edition. New York. McGraw-Hill; 2011
2. Wilder RP, Jenkins JG, Panchang P, Statuta S. Therapeutic exercise. In: Cifu DX et al. (editors). Braddom’s physical medicine and rehabilitation, 5th
edition. Elsevier, Inc.; 2016
General Principal of Exercise Prescription
• Exercise prescriptions are designed to enhance physical fitness,
promote health by reducing risk factors for chronic disease, and
ensure safety during exercise participation
2. Wilder RP, Jenkins JG, Panchang P, Statuta S. Therapeutic exercise. In: Cifu DX et al. (editors). Braddom’s physical medicine and rehabilitation, 5th
edition. Elsevier, Inc.; 2016
• The optimal exercise prescription for an individual is determined from
an objective evaluation of that individual’s response to exercise
• The exercise prescription should be developed with careful
consideration of the individual’s health status, medications, risk factor
profile, behavioral characteristics, personal goals, and exercise
preferences
2. Wilder RP, Jenkins JG, Panchang P, Statuta S. Therapeutic exercise. In: Cifu DX et al. (editors). Braddom’s physical medicine and
rehabilitation, 5th edition. Elsevier, Inc.; 2016
Components of the Exercise Training Session
1. Warm-up: at least 5–10 min of light-to-moderate intensity
cardiorespiratory and muscular endurance activities
2. Conditioning: at least 20–60 min of aerobic, resistance, neuromotor,
and/or sports activities (exercise bouts of 10 min are acceptable if
the individual accumulates at least 20–60 min ∙ d−1 of daily aerobic
exercise)
3. Cool-down: at least 5–10 min of light-to-moderate intensity
cardiorespiratory and muscular endurance activities
4. Stretching: at least 10 min of stretching exercises performed after
the warm-up or cool-down phase
Warm Up
• The warm-up is a transitional phase that allows the body to
adjust to the changing physiologic, biomechanical, and
bioenergetic demands of the conditioning or sports phase of
the exercise session
• Warming up also improves range of motion (ROM) and may
reduce the risk of injury
Warm Up
• A dynamic, cardiorespiratory endurance exercise warm-up is
superior to static flexibility exercises for the purpose of
enhancing the performance of cardiorespiratory endurance,
aerobic exercise, sports, or resistance exercise, especially
activities that are of long duration or with many repetitions
The Conditioning Phase
• The conditioning phase includes aerobic, resistance,
flexibility, and neuromotor exercise, and/or sports activities
• The conditioning phase is followed by a cool-down period
involving aerobic and muscular endurance activity of light-to-
moderate intensity lasting at least 5–10 min
The Cool-down and Stretching Phase
• The purpose of the cool-down period is to allow for a gradual
recovery of heart rate (HR) and blood pressure (BP) and removal of
metabolic end products from the muscles used during the more
intense exercise conditioning phase
• The stretching phase is distinct from the warm-up and cool-down
phases and may be performed following the warm-up or cool-down,
as warmer muscles improve ROM
Component of Exercise Prescription
(FITT-VP principle of Ex Rx)
• Frequency (how often)
• Intensity (how hard)
• Time (duration or how long)
• Type (mode or what kind)
• Total Volume (amount)
• Progression (advancement)
Aerobic (Cardiorespiratory Endurance Exercise)
AEROBIC EXERCISE FREQUENCY RECOMMENDATION
Moderate intensity aerobic exercise done at least 5 d ∙ wk−1, or vigorous intensity aerobic
exercise done at least 3 d ∙ wk−1, or a weekly combination of 3–5 d ∙ wk−1 of moderate and
vigorous intensity exercise is recommended for most adults to achieve and maintain
health/fitness benefits
AEROBIC EXERCISE INTENSITY RECOMMENDATION
Moderate (e.g., 40%–59% heart rate reserve [HRR] or O2R) to vigorous (e.g.,
60%–89% HRR or O2R) intensity aerobic exercise is recommended for most
adults, and light (e.g., 30%–39% HRR or O2R) to moderate intensity aerobic
exercise can be beneficial in individuals who are deconditioned
Interval training may be an effective way to increase the total volume and/or
average exercise intensity performed during an exercise session and may be
beneficial for adults
Summary of Methods for Prescribing Exercise Intensity Using Heart Rate
(HR), Oxygen Uptake (O2), and Metabolic Equivalents (METs)
1. HRR method: Target HR (THR) = [(HRmax/peak − HRrest ) × % intensity desired] +
Hrrest
2. VO2R method: Target VO2R = [(VO2max/peak − VO2rest) × % intensity desired + Vorest
3. HR method: Target HR = HRmax/peak × % intensity desired
4. VO2 method: Target VO2 = VO2max/peak − % intensity desired
5. MET method: Target MET= [( O2max/peak) / 3.5 mL ∙ kg −1 ∙ min −1] × % intensity
desired
Case Study
Determination Exercise Intensity Using Heart Rate Reserve (HRR) Method
Available test data:

• HRrest: 70 beats min1
• HRmax: 180 beats min1
• Desired exercise intensity range: 50%–60%
Questions:
• Please calculate HRR
• Please determine exercise intensity using %HRR
• Please determine THR range
Case Study
Determination Exercise Intensity Using Maximal Heart Rate (HRmax) Method
Available test data:

• A man 45 yr of age
• Desired exercise intensity: 70%–80%
Question:
• Please determine THR range
AEROBIC EXERCISE TIME (DURATION) RECOMMENDATION
Most adults should accumulate 30–60 min ∙ d−1 (≥150 min ∙ wk−1) of moderate intensity
exercise, 20–60 min ∙ d−1 (≥75 min ∙ wk−1) of vigorous intensity exercise or a combination of
moderate and vigorous intensity exercise daily to attain the recommended targeted volumes
of exercise
This recommended amount of exercise may be accumulated in one continuous exercise

session or in bouts of ≥10 min over the course of a day
Durations of exercise less than recommended can be beneficial in some individuals
AEROBIC EXERCISE TYPE RECOMMENDATION

Rhythmic, aerobic exercise of at least moderate intensity that involves large
muscle groups and requires little skill to perform is recommended for all
adults to improve health and CRF
Other exercise and sports requiring skill to perform or higher levels of fitness
are recommended only for individuals possessing adequate skill and fitness
to perform the activity
Aerobic (Cardiorespiratory Endurance
Exercise)
AEROBIC EXERCISE VOLUME RECOMMENDATION
A target volume of ≥500–1,000 MET-min ∙ wk−1 is recommended for most adults.
This volume is approximately equal to 1,000 kcal ∙ wk−1 of moderate intensity PA,
~150 min ∙ wk−1 of moderate intensity exercise, or pedometer counts of ≥5,400–
7,900 steps ∙ d−1
Because of the substantial errors in prediction when using pedometer step counts,
use steps per day combined with currently recommended time/durations of
exercise.
Lower exercise volumes can have health/fitness benefits for deconditioned

individuals; however, greater volumes may be needed for weight management
Rate of Progression
• The recommended rate of progression in an exercise
program depends on the individual’s health status, physic
fitness, training responses, and exercise program goals
• Progression may consist of increasing any of the components
of the FITT principle of Ex Rx as tolerated by the individual
Rate of Progression
• During the initial phase of the exercise program, applying the
principle of “start low and go slow” is prudent to reduce risks of
adverse cardiovascular events and MSI as well as to enhance
adoption and adherence to exercise
• Initiating exercise at a light-to-moderate intensity in currently inactive
individuals and then increasing exercise time/duration (i.e., minutes
per session) as tolerated is recommended
Rate of Progression
• An increase in exercise time/duration per session of 5–10 min every
1–2 wk over the first 4–6 wk of an exercise training program is
reasonable for the average adult
• After the individual has been exercising regularly for ≥1 mo, the FIT of
exercise is gradually adjusted upward over the next 4-8 mo or longer
for older adults and very deconditioned individuals to meet the
recommended quantity and quality of exercise presented in the
Guidelines
Rate of Progression
• Any progression in the FITT-VP principle of Ex Rx should be made
gradually, avoiding large increases in any of the FITT-VP components
to minimize risks of muscular soreness, injury, undue fatigue, and the
long-term risk of overtraining
• Following any adjustments in the Ex Rx, the individual should be
monitored for any adverse effects of the increased volume, such as
excessive shortness of breath, fatigue, and muscle soreness, and
downward adjustments should be made if the exercise is not well
tolerated
Strategies to Enhance Compliance with
Cardiovascular Endurance Training Programs
• Minimize musculoskeletal injuries by adhering to the principles of
exercise prescription
• Encourage group participation or exercising with a partner
• Emphasize mode variety and enjoyment in the program
• Incorporate behavioral techniques and base prescription on theories
of behavior change
Strategies to Enhance Compliance with
Cardiovascular Endurance Training Programs
• Use periodic testing to document progress
• Give immediate feedback to reinforce behavior change
• Recognize accomplishments
• Invite spouse or significant other involvement and support of the
training program
• Ensure that the exercise leaders are qualified and enthusiastic
RESISTANCE TRAINING PROGRAM
• The goals of a health-related resistance training program should be:
• To make activities of daily living (ADL) (e.g., stair climbing, carrying bags of
groceries) less stressful physiologically
• To effectively manage, attenuate, and even prevent chronic diseases and
health conditions such as osteoporosis, type 2 diabetes mellitus, and obesity
Determinants of Resistance Exercise Program
1. Alignment of segments of the body during exercise
2. Stabilization of proximal or distal joints to prevent substitution
3. Intensity: the exercise load (level of resistance)
4. Volume: the total number of repetitions and sets in an exercise
session
5. Exercise order: the sequence in which muscle groups are exercised
during an exercise session
6. Frequency: the number of exercise sessions per day or per week
7. Rest interval: time allotted for recuperation between sets and sessions of
exercise
8. Duration: total time frame of a resistance training program
9. Mode of exercise: type of muscle contraction, position of the patient,
form (source) of resistance, arc of movement, or the primary energy
system utilized
10. Velocity of exercise
11. Periodization: variation of intensity and volume during specific periods of
resistance training
12. Integration of exercises into functional activities: use of resistance
exercises that approximate or replicate functional demands
Stabilization
• External stabilization can be applied manually by the therapist or sometimes by
the patient with equipment, such as belts and straps, or by a firm support
surface, such as the back of a chair or the surface of a treatment table.
• Internal stabilization is achieved by an isometric contraction of an adjacent
muscle group that does not enter into the movement pattern but holds the body
segment of the proximal attachment of the muscle being strengthened firmly in
place. For example, when performing a bilateral straight leg raise, the abdominals
contract to stabilize the pelvis and lumbar spine as the hip flexors raise the legs.
This form of stabilization is effective only if the fixating muscle group is strong
enough or not fatigued.
Intensity
• The intensity of exercise in a resistance training program is the
amount of resistance (weight) imposed on the contracting muscle
during each repetition of an exercise. The amount of resistance is also
referred to as the exercise load (training load)—that is, the extent to
which the muscle is loaded or how much weight is lifted, lowered, or
held.
Indications for Low-Intensity Versus High-Intensity Exercise
Submaximal Loading Near-Maximal or Maximal Loading
In the early stages of soft tissue healing when injured When the goal of exercise is to increase muscle strength and power
tissues must be protected. and possibly increase muscle size.
After prolonged immobilization when the articular cartilage is not For otherwise healthy adults in the advanced phase of a
able to withstand large compressive forces or when bone rehabilitation program after a musculoskeletal injury in preparation
demineralization may have occurred, increasing the risk of for returning to high-demand occupational or recreational activities.
pathological fracture to evaluate the patient’s response to resistance
exercise, especially after an extended period of inactivity.
When initially learning an exercise to emphasize the In a conditioning program for individuals with no known pathology.
correct form.
For most children or older adults. For individuals training for competitive weight lifting or body building
When the goal of exercise is to improve muscle endurance.

To warm-up and cool-down prior to and after a session of exercise.
During slow-velocity isokinetic training to minimize

compressive forces on joints.
Volume
• In resistance training the volume of exercise is the summation of the total
number of repetitions and sets of a particular exercise during a single exercise
session times the intensity of the exercise. The same combination of repetitions
and sets is not and should not be used for all muscle groups
• There is an inverse relationship between the sets and repetitions of an exercise
and the intensity of the resistance. The higher the intensity (load), the lower the
number of repetitions and sets possible. Conversely, the lower the load, the
greater the number of repetitions and sets possible. Therefore, the exercise load
directly dictates how many repetitions and sets are possible.
Repetitions
• The number of repetitions in a dynamic exercise program refers to the
number of times a particular movement is repeated. More
specifically, it is the number of muscle contractions performed to
move the limb through a series of continuous and complete
excursions against a specific exercise load.
Repetitions
• If the RM designation is used, the number of repetitions at a specific
exercise load is reflected in the designation
• For example, 10 repetitions at a particular exercise load is a 10-RM
• If a 1-RM has been established as a baseline level of dynamic
strength, a percentage of the 1-RM used as the exercise load
influences the number of repetitions a patient is able to perform
before fatiguing
Repetitions
• The “average,” untrained adult, when exercising with a load that is
equivalent to 75% of the 1-RM, is able to complete approximately 10
repetitions before needing to rest
• At 60% intensity about 15 repetitions are possible, and at 90%
intensity only 4 or 5 repetitions are usually possible.
• For practical reasons, after a beginning exercise load is selected, the
target number of repetitions performed for each exercise before a
brief rest is often within a range rather than an exact number of
repetitions.
• For example, a patient might be able to complete between 8 and 10
repetitions against a specified load before resting. This is sometimes
referred to as a RM zone, it gives the patient a goal but builds in some
flexibility.
• The number of repetitions selected depends on the patient’s status
and whether the goal of the exercise is to improve muscle strength or
endurance. No optimal number for strength training or endurance
training has been identified. Training effects (greater strength) have
been reported employing a 2- to 3-RM to a 15-RM.
Sets
• A predetermined number of consecutive repetitions grouped together is known
as a set or bout of exercise.
• After each set of a specified number of repetitions, there is a brief interval of rest.
• For example, during a single exercise session to strengthen a particular muscle
group, a patient might be directed to lift an exercise load 8 to 10 times, rest, and
then lift the load another 8 to 10 times.
• That would be two sets of an 8- to 10-RM.
Sets
• As with repetitions, there is no optimal number of sets per exercise session, but 2 to 4
sets is a common recommendation for adults.
• As few as one set and as many as six sets, however, have yielded positive training effects.
• Single-set exercises at low intensities are most common in the very early phases of a
resistance exercise program or in a maintenance program.
• Multiple-set exercises are used to progress the program and have been shown to be
superior to single-set regimens in advanced training.
ACSM. ACSM’s Guideline for
Exercise Testing and
Prescription, 10th edition,
Philadelphia, ACSM;2018
Common Strength Training Dosages
Flexibility Exercise
• Ballistic methods or “bouncing” stretches use the momentum of the
moving body segment to produce the stretch
• Dynamic or slow movement stretching involves a gradual transition
from one body position to another and a progressive increase in
reach and range of motion as the movement is repeated several times
• Static stretching involves slowly stretching a muscle/tendon group
and holding the position for a period of time (i.e., 10–30 s). Static
stretches can be active or passive
Flexibility Exercise
• Active static stretching involves holding the stretched position using
the strength of the agonist muscle as is common in many forms of
yoga
• Passive static stretching involves assuming a position while holding a
limb or other part of the body with or without the assistance of a
partner or device (such as elastic bands or a ballet barre)
• Proprioceptive neuromuscular facilitation (PNF) methods take
several forms but typically involve an isometric contraction of the
selected muscle/tendon group followed by a static stretching of the
same group (i.e., contract relax)
CASE STUDY I
• Susan is a 47-year-old nurse who consulted to a physiatrist had primary complaint of posterolateral
right (R) thigh pain.
• Past medical history was unremarkable.
• The pain was worse with weight bearing first thing in the morning, got better with limited activity,
but worsened by the end of the day, especially if she had been on her feet quite a bit during the day.
• Secondary complaints included intermittent, dull low back pain, and occasional bouts of sharp pain
in the arch of her R foot.
• She was diagnosed and treated by the physiatrist for iliotibial band fascitis and intermittent plantar
fascitis.
• The short- and long-term goals set for her were aimed at decreasing disability and returning the
patient to a pain-free level of functioning.
• Susan met the goals established with regular treatment and requested that the physiatrist assist her
with establishing a regular physical activity habit
• Since her BMI is high (30) she also wants to decrease her body weight
Questions
• Based on the information provided, does the patient/client require
medical evaluation prior to participating in aerobic exercise?
• How would you screen this patient/client prior to proceeding with an
exercise program?
• How would you approach establishing an exercise prescription for this
patient/client?
Questions
• What exercise test would you utilize with this patient/ client?
• How would you conduct the exercise test?
• How would you create an exercise prescription for the patient/client?
Questions
• What normal cardiovascular changes would you expect during
exercise?
• What physiologic adaptations to the exercise program would you
expect after 6 months?
• What psychologic adaptations to the exercise program would you
expect after 6 months?
Questions
• How would you recommend the patient/client progress the exercise
program
• What education would you provide for the patient/ client?
Answer
Case Study
• Lisa is a 17-year-old high school student who complains of right (R) ankle
pain and swelling.
• She describes injuring herself yesterday during basketball practice.
• Coming down after a rebound attempt, she landed on the foot of another
player, twisting her ankle and falling to the ground.
• Immediately after the injury, she was able to move her ankle and walk off
the court.
• Now Lisa reports difficulty bearing full weight on her R foot and is unable
to walk or run without a significant limp.
• Her team is contending for the state championship in 6 weeks, and Lisa
hopes to play
EXAMINATION
• Pain: 4/10 at rest, constant in nature in non–weight-bearing: 6/10 with weight-
bearing
• Gait: R foot flat, “step to” pattern with use of axillary crutches.
• Active Range of Motion: Plantar flexion/dorsiflexion 20 to 5 degrees; foot
inversion/eversion 3 to 5 degrees with pain end range
• Passive Range of Motion: Plantar flexion/dorsiflexion 40 to 15 degrees; foot
inversion/eversion 3 to 8 degrees with muscle guarding
• Accessory Motion: Subtalar and talocrural distraction hypomobile; subtalar
medial/lateral glide hypomobile with muscle guarding; talonavicular,
cuboid/navicular and cuneiform/navicular all hypomobile
EXAMINATION
• Palpation: Moderate localized swelling in region distal to R lateral malleolus;
marked tenderness and early signs of ecchymosis in same region
• Strength Testing: Anterior tibialis 4/5 (pain elicited); posterior tibialis 5/5;
gastrocnemius/soleus 5/5; peroneus longus 4−/5 (pain elicited)
• Resisted Testing: Dorsiflexors and evertors weak and painful
• Balance: Unable to assess because of patient discomfort in weight bearing
• EVALUATION: Acute, traumatic ligamentous injury to the R ankle.

Although this patient requires comprehensive intervention, only one exercise
related to resistive training is described. This exercise would be used in the late
phase of this patient’s rehabilitation.
• ACTIVITY: Resisted hip abduction and ankle eversion
• PURPOSE: To increase the muscle performance of the ankle evertor and hip
abductor muscles.
• STAGE OF MOTOR CONTROL: Controlled mobility
• MODE: Resistive band
• POSTURE: Standing with one foot on the resistive band and the band around the
other foot. A support should be readily available for balance as needed.
• MOVEMENT: Standing on the uninjured leg, abduct the hip in the frontal plane,
and evert (pronate) the ankle. Maintain good spinal posture throughout the
exercise. Do not hike pelvis. Move only at the hip joint. Avoid moving out of the
frontal plane. Moving toward flexion results in the motion performed by the
flexor abductor group. Return to the start position.
THANK YOU

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Therapeutic Exercise

• Cardiorespiratory endurance: the ability of the

Power: the ability or rate at which one can perform work

• Participation in exercise is associated with an increased risk

• Adverse cardiovascular events such as sudden cardiac death

• Health care professionals should know the pathologic conditions

• Athletes with known cardiac conditions or a family history should be

Non-exercise Testing Findings

Exercise Testing Findings

Non-exercise Testing Findings

Available test data:

Available test data:

This recommended amount of exercise may be accumulated in one continuous exercise

Durations of exercise less than recommended can be beneficial in some individuals

AEROBIC EXERCISE TYPE RECOMMENDATION

Lower exercise volumes can have health/fitness benefits for deconditioned

When the goal of exercise is to improve muscle endurance.

During slow-velocity isokinetic training to minimize

• EVALUATION: Acute, traumatic ligamentous injury to the R ankle.

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