Other Clinical Conditions Influencing
Exercise Prescription
Cardiac Wellness
Institute of Calgary
Updated May 2010
Material to be Covered
ACSM’s Resource Manual for Guidelines for
Exercise Testing and Prescription (6th ed.)
Chapters 7, 8, 23, 24, 36, 37, 38
ACSM’s Guidelines for Exercise Testing and
Prescription (8th ed.)
Chapter 10
Diabetes Mellitus
ACSM’s Resource Manual for Guidelines for
Exercise Testing and Prescription (6th Edition) Chapters 8, 24, 37
ACSM’s Guidelines for Exercise Testing and
Prescription (8th Edition) - Chapter 10
Diabetes Mellitus
 Complex
metabolic disorder
 Characterized
by:
– Abnormal glucose metabolism defects in insulin
release, action, or both
– Secondary microvascular degeneration
Diabetes Mellitus
 IDDM
(Type I):
– Caused by an acute or gradual loss of insulin-
producing beta cells in the pancreas
– Maintain high levels of plasma glucose
– Subject to ketoacidosis
–  loss of water and sugar through urine

Secondary thirst, weight loss and increased
appetite
Diabetes Mellitus
 NIDDM
(Type II)
– Decreased sensitivity of peripheral receptors
especially in SM and liver
– Decreased plasma glucose
– Plasma insulin usually increases
Diabetes Mellitus
Characteristics
Type I
Type II
Age of onset
< 20
> 40
Frequency
0.5%
4-5%
Family Hx
Probable
Frequent
Symptoms
Thirst, polyuria,
weight loss, 
appetite
Mild or frequently
none
Obesity
+
++
Serum insulin
Low to zero
High (initially)
Insulin Tx
Always
20-30%
Diagnostic Criteria for
Diabetes

Symptoms of diabetes plus casual plasma
glucose concentration of ≥200 mg/dL
(11.1mmol/L)

Fasting plasma glucose of ≥126 mg/dL (7.0
mmol/L) (fasting is defined as no caloric intake
for at least 8 hours)

2 hour plasma glucose ≥200 mg/dL-1 during
oral glucose tolerance test (OGTT)
Complications
 Wide-ranging
Complications
– Hypo or hyperglycemia
– Retinopathy
– Hypertension and CAD
– Autonomic neuropathy
– Peripheral neuropathy
– Nephropathy
Treatment
 IDDM
– Subcutaneous injections of insulin (SA and LA)
– Dietary regulation
– Exercise daily
 NIDDM
– Weight loss
– Oral hypoglycemics
– Possibly insulin
Benefits of Exercise
 Improved
insulin sensitivity
 Decreased
risk of CV disease:
– Improved blood lipids
–  caloric expenditure (improve BMI)
– BP in those with hypertension

Increased fitness
− Aerobic, strength and endurance, flexibility

Improved psychological well being
Benefits of Exercise
 NIDDM
– Reduced blood glucose and HgA1c levels
– Improved glucose tolerance
– Improved insulin response to oral glucose
 IDDM
– Improvement in insulin sensitivity may be transient
Response to Exercise
 Acute
exercise results in  glucose use
 glucose production necessary to
maintain normal levels
 Therefore
 Compromised
in the diabetic state
Screening Procedures
 History
and Physical Exam
 Diabetes
Evaluation
 Cardiovascular
Exam
– Often includes clinical exercise testing
Clinical Exercise Testing
Other Considerations
– change to standard protocols or arm
ergometry
 Modality
 Hypertensive
 Presence
response
of silent ischemia
 Postural
hypotension or blunted HR response
 Glucose
monitoring and adjust insulin
 Sub-max
exercise to determine training intensity
Exercise Prescription:
 Frequency
– 3-7 d/wk
– Low – mod intensity if 7 days/week (IDDM)
 Intensity
– Target Heart Rate or MET level

50 -80% Karvonen method or VO2 max RPE/talk
test

12-16 on a 6-20 scale
FITT Intensity
Other Considerations
 THR
always 10bpm below:
– 1mm horizontal or downsloping ST segment
depression
– Anginal symptoms or other CV insufficiency
– SBP 240mmHg, plateau SBP or SBP
– DBP 110mmHg
FITT Intensity
Other Considerations
 THR
always 10bpm below:
–  frequency ventricular dysrhythmias
– Other significant ECG disturbances
– Radionuclide evidence LV dysfunction
– Mod/sev wall motion abnormal with exercise
– Other signs/symptoms of intolerance
Exercise Prescription
 Time
– 20-60 minutes/session
– 5-10 min WU and CD
 Type
– Aerobic: may require non-wt bearing
– Resistance: may be contraindicated, if not as per
guidelines for cardiac patients
Prescription Guidelines: RT
1
set, 10-15 reps, 8-10 exercises
 2-3
days/week
 RPE
11-14
pressure product (RPP) during RT 
exceed RPP during aerobic exercise training
 Rate
 Avoid
Valsalva, tight grip
 Exhale
on exertion
Exercise Prescription
Other Considerations
 Encourage
to wear medical alert ID
 Encourage
to exercise with a partner
 Ensure
adequate hydration
 Reinforce
 Exercise
 May
proper footwear
with caution in temperature extremes
need to limit isometric exercise
Precautions for Avoiding
Hypoglycemic Events
 Aware
of signs and symptoms
– Diaphoresis
– Weakness
– Pallor
– Lightheadedness
– Tremor
– Tachycardia
– Palpitations
– Visual disturbance
– Mental confusion
– Fatigue
– Headache
– Memory loss
– Seizure or coma
Precautions for Avoiding
Hypoglycemic Events
 Measure
blood glucose before, during and after
exercise
– < 100mg/dL (5.5 mmol/L) eat CHO snack
– Delay exercise if >300 mg/dL or > 240 mg/dL with
postive ketones
 Adjust
−
insulin dosages associated with exercise
Avoid exercise during periods of peak insulin activity
 Insulin
should not be injected into an exercising
muscle
late in the evening  risk of nocturnal
hypoglycemia
 Exercise
Precautions for Avoiding
Hyperglycemic Events
 Aware
of signs and symptoms of hyperglycemia:
– Dehydration
– Vomiting
– Hypotension and reflex
– Abdominal pain
tachycardia
– Frequent urination
– Impaired consciousness
– Hyperventilation
– Odor of acetone
on breath
– Nausea
 Measure
blood glucose and ketones before,
during and after exercise
−
Postpone exercise if blood glucose >300mg/dL (~16.5mmol/L)or
240 mg/dL (~ 13 mmol/L) with ketones
Hypertension
ACSM’s Resource Manual for Guidelines for Exercise
Testing and Prescription (6th Edition) - Chapters 38
ACSM’s Guidelines for Exercise Testing and
Prescription (8th Edition) - Chapter 10
Hypertension
 Prevalence:
 BP
15-20% in western civilization
is determined by Cardiac Output and Total
Peripheral Resistance
Classification of Hypertension
 Essential
(Primary) hypertension:
– No single cause
 Secondary
hypertension:
– Hypertension secondary to other disorders of
the renal, endocrine, and nervous systems
Associated Complications
 Primary
risk factor for cardiovascular disease
– Changes extent and presence of calcium
 End-organ
damage
– LVH
– Arteriosclerosis in retina
– Renal failure
Lifestyle Modifications for
Hypertension
 Weight
 Limit
Loss
alcohol intake
 Increase
 Reduce
aerobic physical activity
sodium intake
 Maintain
adequate intake of dietary potassium
Lifestyle Modifications for
Hypertension Continued
 Maintain
adequate intake of dietary calcium and
magnesium for general health
 Stop
smoking
 Reduce
intake of dietary saturated fat and
cholesterol for overall cardiovascular health
Benefits of Exercise
 Reduce
BP
– Reduced Cardiac Output
– Reduced Total Peripheral Resistance
– Changes in body composition
 Improve
risk factor profile
Response to Exercise
 Gradually
increase SBP
– Response > in those with hypertension
– Should increase > 10mmgHg and not decrease
 Decrease
 Typical
or no change DBP
range 180-210/60-85
 Exaggerated
response (>230/100) may predict
future hypertension and/or CAD
Screening Procedures
 To
diagnose should have three separate
readings
 If
high risk would require CV Exam often
includes clinical exercise testing
Clinical Exercise Testing
Other Considerations
 Standard
methods and protocols
 Medications
 ECG
taken at normal time
may show LVH
 Possible
dysrhythmias due to diuretic treatment
 Observe
for exaggerated pressure response
– SBP > 260 mmHg
– DBP 115 mmHg
Exercise Prescription
 Frequency
– Most, preferably all days of the week
 Intensity
– Target Heart Rate or MET level

40-<60% heart rate reserve (HRR) or VO2 max

Aim for 700 – 2000 kcal/week
Exercise Prescription
 Time
– 30-60 minutes/session; intermittent: minimum of 10-
minute bouts accumulated to 30-60 minutes
– 5-10 min WU and CD
 Type
– Aerobic
– Resistance: may be contraindicated, if not as per
guidelines for cardiac patients

Need to monitor BP with isometric activity
Exercise Prescription
Other Considerations
 Do
not exercise if resting BP:
– SBP > 200 mmHg or
– DBP > 110 mmHg
 Some
antihypertensives may cause post
exercise hypotension therefore adequate CD
important
may cause a ↓ in K+ which may result
in arrhythmias
 Diuretics
 Avoid
Valsalva maneuvers during RT
Peripheral Arterial Disease
(PAD)
ACSM’s Resource Manual for Guidelines for Exercise
Testing and Prescription (6th Edition) - Chapters 38
ACSM’s Guidelines for Exercise Testing and
Prescription (8th Edition) - Chapter 10
Peripheral Arterial Disease
(PAD)
 Common
manifestation of atherosclerosis
 Prevalence:
 Have
10% in age 60+
similar risk factor profile as CV disease
Peripheral Arterial Disease
(PAD)
 Acute:
– Muscle blood flow supply/demand mismatch
 Chronic:
–
Deconditioning
–
Impaired oxidative metabolism
–
Lack of blood flow limits ability to do ADLs
Diagnosis of PAD
 Symptoms
– Claudication
– Intermittent muscular pain relieved with rest
 Based
on history and physical exam
– Risk factors
– Hemodynamic assessment

Auscultation of femoral arteries

ABI

Arteriography
Ankle/Brachial Index
 Resting
 Used
SBP in ankle and arm by Doppler
to measure the severity of PAD
 Abnormal
ABI: <0.9 at rest or 20% ↓ after
exercise
 Severity
not correlated to treadmill performance
Associated Complications
 Detrimental
effects on functional status
– < 1-3 blocks
– VO2 max typically 10-16 ml/kg/min
 Prevents
ability to do ADLs
 Ischemic
ulceration
 Gangrene
and tissue loss
Treatment
 Medical
management is marginally effective
– Trental ( blood viscosity), Cilostazol
 Lifestyle
Modification to reduce risk factors
(hypertension, smoking, and diabetes)
 Surgery
or angioplasty
Benefits of Exercise
 Improved
 15-30%
functional tolerance
 in oxygen consumption
 Improved
walking ability
–  speed and duration
– Delayed onset of claudication (improvements of 106-
177% of pain free walking)
– Improved perception of physical functioning
 Increased
level of habitual exercise
Benefits of Exercise
 Improved
functional tolerance may result from:
–  peripheral blood flow
– improved muscle metabolism
– walking efficiency
 Improved
functional tolerance may result from:
−
 peripheral blood flow
−
Improved muscle metabolism
−
Walking efficiency
Response to Exercise
 With
onset of activity there is a mismatch of local
muscle blood flow supply/demand
 Results
activity
in localized ischemic pain that limits
Screening Procedures
 CV
screening should be done to assess the
presence or extent of CAD
– History and physical exam
– Includes clinical exercise testing
Clinical Exercise Testing Other
Considerations
 Protocols
should be adapted
– Discontinuous to achieve VO2 max
– Consider arm ergometry
– Slower speed and less rapidly changing grade
 Use
scale for subjective ratings of pain
 Record
time of pain onset and point of maximal
pain
 Assess
with functional status questionnaires
Subjective Grading Scale
for PVD Pain
 Grade
1 - Definite discomfort or pain, but only of
initial or modest levels (established, but minimal)
 Grade
2 - Moderate discomfort or pain from
which the patient’s attention can be diverted, for
example by conversation
 Grade
3 - Intense pain (short of grade 4) from
which the patient’s attention cannot be diverted
 Grade
4 - Excruciating and unbearable pain
Exercise Prescription
 Frequency
– Weight-bearing aerobic exercise 3-5 d/wk
 Intensity
– Target Heart Rate or MET level

Moderate intensity (40- <60% HRR or VO2 max

A pain score of 3/4. Individuals should have time to
allow ischemic pain to subside before resuming
exercise.
Exercise Prescription
 Time
– 30-60 minutes/session (can start with 10-minute
bouts and exercise intermittently to accumulate 30-60
minutes)
– 5-10 min WU and CD
 Type
– Aerobic:

Weight bearing exercise preferred; Non-weight
bearing may be used for WU and CD
 Non-weight bearing activity is encouraged
– Resistance:
 As per guidelines for cardiac patients
Exercise Prescription
 Progression
– Start with work load that brings on
claudication pain at a level of ¾ on PVD pain
scale
–  work load when duration > 10 minutes
– Start with 35 mins, which may be intermittent
– Progress to 50 mins, 3-5 days/wk
Exercise Prescription
Other Considerations
A
cold environment may aggravate the
symptoms of claudication; therefore a longer
warm-up may be required
 Beta
blockers may  time to claudication
 Improved
tolerance may unmask CV ischemia
Pulmonary Disease
ACSM’s Resource Manual for Guidelines for
Exercise Testing and Prescription (6th Edition) Chapters 7, 23, 36
ACSM’s Guidelines for Exercise Testing and
Prescription (8th Edition) - Chapter 10
Pulmonary Disease
 Diseases
of the respiratory tract are classified
as:
– Obstructive Disease
– Restrictive Disease
– Vascular Disease
Chronic Obstructive Airway
Disease (COPD)
 Results
from non-uniform narrowing in the
airways secondary to inflammation
 resistance and results in uneven
distribution of minute ventilation (VE)
 Narrowing
 Characterized
by:
– Expiratory flow obstruction
– Dyspnea at rest and with exertion
– Reversible airway hyperactivity
COPD disorders
 Chronic
Bronchitis:
– Inflammatory disorder of the small airways in the
–
–
–
–
–
lungs
Characterized by coughing, wheezing and sputum
production
 arterial O2 saturation and CO2 levels due to
hypoventilation
Flow rates can be improved with bronchodilators
Considered a “blue bloater” due to stocky habitus with
central and peripheral cyanosis
Eventually can lead to right heart failure
COPD disorders
 Emphysema:
– Gradual destruction of lung tissue as well as airway
inflammation
– Abnormal enlargement of the airspaces by
destruction of the alveolar walls
– Loss of lung elasticity and elastic recoil pressure
– Unresponsive to bronchodilators

Pursed lips breathing
– Usually not cyanotic and little sputum production
– High VE
– “Pink puffer” due to significant dyspnea and barrel-
chest with marked lung hyperinflation
COPD Disorders
 Asthma:
– Characterized by increased airway reactivity to
various stimuli
– Airways respond with  mucous and constriction
– Results in non-productive cough and wheezing
– Symptoms controlled by inhaled and oral
bronchodilators
Diagnosis
 Pulmonary
Function Testing
– Spirometry

Airway patency and air volume in/out of lungs
 Forced vital capacity (FVC), forced expiratory
volume in 1 second (FEV1.0) and FEV1/FVC
– Lung volume
 Total lung capacity (TLC), residual volume (RV)
– Diffusing capacity
 Rate at which gases diffuse from the lung (alveoli)
to the blood in the pulmonary capillaries
Diagnosis
 Cardiopulmonary
Exercise Testing (CPX)
– Maximal exercise tolerance
– Ventilatory limitations
– Pulmonary gas exchange
– CV responses to exercise
Treatment
 Medical
management
 Discontinuation
 Exercise
of smoking
Benefits of Exercise
 Psychological
benefits
– Mastering something difficult
– Social interaction
– Distraction
 Improved
functional tolerance
– Perceived exercise tolerance increases
– Exercise endurance improves
– Improvement in ability to do ADLs
– Avoid downward spiral of deconditioning
Response to Exercise
 Tissues
 VO2 and CO2 production
 Cardiac
Output and VE  to meet the demands
 Typically
exercise capacity is not limited by the
pulmonary system as O2 transport capacity >
that of the heart
Physiological Limiting
Factors in COPD
 Impaired
lung mechanics
 Inefficient
pulmonary gas exchange
 Pulmonary
 Abnormal
vascular insufficiency
skeletal muscle metabolism
Screening Procedures
 History
and Physical Exam
 Pulmonary
Evaluation
 Cardiovascular
Exam
– Often includes CPX
Clinical Exercise Testing
Other Considerations
 CPX
for specific exercise prescription and
pre/post evaluation
 Cycle
ergometry is often used
 Monitor
arterial oxygen saturation (SaO2)
– <90% may require supplemental O2 during exercise
 Use
scale for subjective ratings of dyspnea
 Keep
in mind absolute and relative
contraindications
Dyspnea Scale
Nothing
0
Severe
5
Very, very slight
0.5
Very slight
1
Slight
2
8
Moderate
3
9
Somewhat severe
4
6
Very severe
Very, very severe
7
10
Dyspnea Scale
+1 Light, barely noticeable
+2 Moderate, bothersome
+3 Moderately severe, very uncomfortable
+4 Most severe or intense dyspnea ever
experienced
Exercise Prescription
 Frequency
– 3-5 d/wk
 Intensity
– No consensus as to the optimal exercise intensity
– MET level (or THR)

60-80% peak work rates
– Maximal limits as tolerated by symptoms
– 3-5 on Dyspnea Scale
– Talk test/RPE
Exercise Prescription
 Time:
May need to start with intermittent
exercise until patient is able to sustain higher
intensities and durations of activity
– 30-50 minutes/session
– 5-10 min WU and CD
 Type
– Aerobic:

Activities involving large muscle groups
 Arm ergometry
– Resistance:
 As per guidelines in Chapter 7 – Guidelines for
Exercise Testing and Prescription
Exercise Prescription
Other Considerations
 Maintain
 Use
SaO2 at > 88%
pursed-lips breathing
 Carry
bronchodilators if prescribed
 Exercise
indoors during times of inclement
weather or if environmental irritants exist
Alternative Modes of Exercise
Training

Continuous positive airway pressure

Upper body resistance training

Ventilatory muscle training
Guidelines for Inspiratory
Muscle Training
1. Frequency---Minimum of 4 to 5 d·wk-1
2. Intensity---30% of maximal inspiratory pressure
(PImax) measured at functional residual capacity
3. Duration---Two 15-minute sessions or one 30minute session per day. If this cannot be
achieved, the intensity should be reduced