Clinical Exercise

Physiology
Chapter 11

Definition, Description, Focus

Clinical Exercise Physiology-Involves the application of exercise

science to prevent and delay the onset of chronic disease in

healthy participants or provide therapeutic or functional benefits
to patients with underlying pathologies.
Clinical Exercise physiologists are healthcare professionals who

use fundamental principles of exercise physiology in clinical

settings to minimize the risk of chronic diseases associated with
physical inactivity and to treat those already afflicted.
Services may be provided in several medical settings such as:

hospitals, rehabilitation centers, and outpatient clinics.

Continued
Services are also

offered in community,
corporate,
commercial,
university fitness and
wellness centers,
nursing homes, and
senior citizen
centers.

Scope

The scope of practice ranges from apparently healthy individuals with

no known medical problems to patients with documented
cardiovascular, pulmonary, metabolic, rheumatoid, orthopedic, and/or
neuromuscular diseases and conditions.

Scope continued

Clinical exercise physiologists are responsible for: Exercise testing and

evaluation and supervision of safe and effective exercise programs in a
healthcare setting .

A knowledge of normal physiological responses to acute and chronic

exercise is essential before attempting to prevent, manage, or
rehabilitate disease.

Exercise Therapy may be altered by specific treatments such as drugs

and medications, surgical procedures, radiation therapy, orthopedic
bracing, casting, or splinting; dialysis, and diet therapy.

Scope continued

For example heart rate and blood pressure responses to exercise can
be reduced significantly by a drug called Beta Adrenergic Blocking
Agent which is commonly used to manage angina or hypertension.

Exercise itself can produce effects requiring alterations in other

therapies the patient is receiving.
For example: It is often necessary for insulin dosages to be reduced in
patients with Type I Diabetes because exercise changes the
pharmacokinetics of subcutaneously injected drugs.

Clinical exercise Physiologists should have a solid background in basic

exercise physiology combined with more advanced training, including
pathophysiology of chronic diseases, pharmacology of drugs and
medicines, medical terminology, medical record keeping and charting,
ECG interpretation, exercise testing, business management and
marketing, and nutrition and diet therapy.

Clinical Testing and Evaluation

Principles
An important tool in clinical settings to clear individuals for safe
participation in physical activity and also as a basis for exercise
prescription.
Two broad classifications of exercise testing:
1. Diagnostic Testing- performed to see how sick someone is
2. Functional Capacity Testing- performed to see how well
someone is
In other words the diagnostic test is performed to uncover
underlying disease while the functional test is performed to
determine the capacity for exercise.

Exercise Tests
Exercise tests, weather for diagnostic or functional purposes,

are usually incremental in nature and as such are referred to as

a graded exercise test (GXT).
Graded-means that the exercise is progressed in a stepwise
fashion from light to maximum levels.
A number of Exercise Protocols are usually performed on the
treadmill or cycle ergometer are available to the examiner,
depending on the purpose of the test and the population being
tested.
For example: The same GXT test would not be performed on a
young adult as would be performed on a 70 year old person.

Screening
Is extremely important in determining an individuals suitability

for an exercise program.

Exercise may not be safe for everyone especially people with
pre-existing medical conditions, such as coronary artery
disease.
For a limited number of individual, exercise TESTING alone
could be harmful to them and should not be done for medical
reasons.

Physical Examination

Many patients require a physicians

referral before they can undergo
exercise testing or enter into an
exercise program.
The ACSM has developed
guidelines to aid the healthcare
professional in determining the
safety of exercise for individuals.
These guidelines suggest that it is
unnecessary for men under the age
of 40 and women under the age of
50 who have no symptoms of heart
disease and are apparently healthy,
and have fewer than two risk factors
for Coronary Artery Disease to have
a medical evaluation by a physician
before starting an exercise program.
Exercise programs conducted in
non-medical settings require a
physicians referral for anyone over
the age of 35.

Health History

The purpose is to a) Identify and exclude individuals with medical

contraindications to exercise, b) identify individuals with clinically significant
disease conditions who should be referred to a medically supervised exercise
program, c) identify individuals with symptoms and risk factors for a disease who
should receive further medical evaluation before starting an exercise program, d)
identify individuals with special needs for safe exercise participation.

Physiologic Measurements
Heart Rate
Blood Pressure
Blood Glucose
Serum cholesterol
Resting ECG (before diagnostic test)
Abnormalities in any of these measurements may indicate

underlying health problems such as heart disease,

hypertension, or diabetes, which may warrant further medical
evaluation before proceeding with the actual test. (Often
expected in diagnostic testing)

Heart Rate
Resting HR usually measured for at least 60 secs. after the

individual has been sitting for 5 mins.

Methods: chest auscultation w/ sensitive stethoscope or radial
pulse or carotid artery palpitation.
Exercise and Clinical settings HR is determined through
readings obtained from the ECG recordings and directly off the
digital display of the oscilloscope.

Blood Pressure

Arterial blood pressure is a function of the arterial blood flow each

minute (cardiac output) and the resistance offered by the vasculature to
that flow.
When the heart contracts and pushes blood, the vessels do not allow all
the blood to instantly flow to all areas of the body as fast as it is being
ejected from the heart.This creates pressure which can be recorded.
The highest pressure recorded during a heart beat occurs during the
contraction aka the systole of the left ventricle and is called the
systolic blood pressure. provides estimate of work by heart and the
pressure exerted on the walls.
During relaxation phase of the heart-diastole-pressure decreases.
This decrease in pressure is called Diastolic blood pressure which
gives and indirect indication of total peripheral resistance or the ease
with which blood flows through the arteries to the capillaries.
BP-is the product of cardiac output and peripheral resistance.

Blood Pressure Cont

Hypertension-resting BP that is chronically elevated.
Normal BP is approx. 120/180 mm Hg for males and 110/170

mm Hg for females.
Exercise will result in an increase in cardiac output causing and
increase in BP.
Systolic BP can increase approx. 200 mm Hg in health, fit men
and women.
Systolic BP multiplied by the heart rate is called Double
Product (also referred to as the rate pressure product) which
provides an estimate of the myocardial (heart tissue) oxygen
demand.

Rating of Perceived Exertion

(RPE)
It is important during GXT to
determine the participants
psychological perception of the
intensity of the exercise.
Psychologist Borg developed
the original scale.
The numerical scale 6-20
closely related to HR from
resting to maximum when
multiplied by 10 (60-200 bpm)
A new scale has been
developed that measures from
1-10.

Electrocardiogram (ECG)

ECG is important for diagnosing

problems associated with
abnormal cardiac electrical
conductivity and rhythm,
insufficient supply of oxygen to
the myocardium, and presence
of damage to the myocardium.

ECG Cont

The outer surface of the heart cells is positive and the inner surface is negative.
This electrical condition of the cell is referred to as being polarized. Immediately
before contraction the cell receives a jolt of electrical activity, which causes a
complete reversal of the cells polarity, meaning the positive charge is now on the
inside of the cell. This process is called depolarization, which produces action
potential.

Submaximum GXT
Gives an estimate of ones maximum fitness level.
Done by evaluating ones cardio respiratory response to a sub maximal exercise.
Gives an estimate of ones VO2 Max.
Less expensive to perform and safer for the participant.
VO2max Can be estimated from equations that either calculate V02max from the last work

achieved on the GXT, from the oxygen requirement for horizontal and graded walking on a
treadmill, or from a subjects HR response to a series of submaximum work rates.
Test is usually taken to a workload that elicits 70-85% of the age predicted maximum HR.
See youtube video

Maximum GXT
Is used for many reasons, ranging from measurement of

VO2max in the world-class athletes to the diagnosis of

abnormal cardiorespiratory function in cardiac patients.
This test is taken until complete exhaustion or until the point at
which abnormal physiologic responses occur.
Abnormal signs and symptoms may include blood pressure and
ECG changes as well as chest pain-angina pectoris, shortness
of breath-dyspnea, or lightheadedness.
Maximum GXT are important because many abnormalities dont
occur until the workload is at a high intensity.
See youtube video

Special Populations and Clinical

Exercise Physiology Practice
Major disease states served by clinical

exercise physiologists
Cardiovascular Disease
Pulmonary Disorders
Metabolic Disorders
Inflammatory Disorders
Orthopedic Disorders
Neurovascular Diseases and Conditions

Cardiovascular Disease
Leading cause of death in

the U.S.
For individuals that survive,
a program that emphasizes
both physical and
psychosocial rehabilitation is
important.
People who have the
atherosclerosis
susceptibility gene are
50% more likely to have
CHD.

Cardiovascular Disease Cont..

Atherosclerosis-normally involves

injury to the endothelial wall on the

artery.
Lipids accumulate between the junction
of the inner and middle linings of the
artery, resulting in obstruction of blood
flow.

Pulmonary Disorders
Commonly separated into 3 Groups:
Obstructive (asthma, chronic bronchitis, and

emphysema)
Restrictive (Pulmonary fibrosis, chest wall deformity, and
neuromuscular weakness)
Disordered Control of Breathing (sleep apnea and
obesity hypoventilation)
Hypoxemia-Deficiency of oxygen in arterial blood

Metabolic Disorders
Any defect in the metabolic processes

that allows for fuels to be properly stored

in the body, delivered to active muscles,
and oxidized for energy.
Can interfere with exercise performance.

Diabetes
Diabetes Mellitus-is a serious health problem in the U.S.

resulting in significant morbidity and mortality in approx. 16

million Americans.
Caused by inadequate secretion of the pancreatic hormone
insulin, by problems related to inadequate action on insulin, or
by a combination of both defective insulin action and impaired
insulin secretion.

Type I Diabetes (Insulin

dependant mellitus)

Occurs primarily as the result of a defect in which the immune system mistakenly
turns on its own body and destroys the insulin producing B-Cells .
After the autoimmune destruction of the B-cells, little or no endogenous insulin is
produced, and the body is unable to move glucose through the blood stream into
body cells to be used for energy or to be stored as glycogen.
Symptoms include frequent urination, unusual thirst, weight loss, blurred vision,
extreme fatigue, and increased susceptibility to infection.

Type II Diabetes (noninsulindependent diabetes mellitus

Occurs as a result of insulin resistance and account for

90-95% of all diabetes cases.

Insulin resistance is strongly associated with physical
inactivity.
Strong genetic predisposition for developing type II
diabetes.
See youtube video

Obesity

Obesity is the excess accumulation

of body fat, and is an important
health problem in the U.S.
Obesity is associated with and
increased frequency of atherogenic
risk factors including: Hypertension,
Hyperinsulinemia, type II diabetes,
and reduced HDL, it also is
associated with osteoarthritis and
various types of cancer.
You are obese is your body mass
index is 30.0-39.9 and morbidly
obese if your BMI exceeds 40.0.
Develops from a combination of
genetic and environmental factors.

What is wrong with this

picture???

How much does this represent

the children of this generation?

Rheumatologic Diseases
Encompass disorders of the

musculoskeletal system.
Often chronic and often leads to
disability
Clinical exercise physiologists can play a
role in minimizing disability through
appropriate evaluation and exercise
prescription.

Osteoarthritis
Most common type of arthrisis
Characterized by local deterioration of

cartilage, leading to joint space loss and

new bone formation.
Typically affects weight-bearing joints,
specially the knees and hips.
Risk factors include advanced age,
obesity, genetic factors, trauma, and
repetitive use.

Rheumatoid Athritis
Present in only 1% of the
population.
A systematic autoimmune
disease of unknown cause
whose major features are
redness, swelling, warmth, and
significant stiffness of the joints.
Pre-disposing factors include
age, female sex, lower
socioeconomic status, and
genetics.
Has been reported to have
increased mortality rates, and
patients with severe forms of
this disease may die 10 to 15
years earlier than expected.

Orthopedic and Neuromuscular

Diseases and Conditions
These range from relatively rare

diseases affecting the central nervous

system and the muscle cells, to the
widespread occurrence of pain affecting
to neck and back.

Lower Back Pain

Is the most frequent
musculoskeletal complaint for
all people at all ages.
Acute lower back pain is
typically, first treated with a mild
analgesic, such as
acetaminophen, along with a
warm shower.
Other treatments include better
posture and exercise to
strengthen and relieve the
stress from the back.

Muscular Dystrophy
Most common muscular disease in

children.
It is a collection of hereditary conditions
that lead to biochemical and structural
changes within the muscle cell.
Results in the muscle wasting with and
incremental disease in muscle strength,
leading to disability, deformity, and often
death.

Duchene MD
Most common and destructive MD.
Caused by a sex-linked recessive

genetic defect and affects young boys at

a rate of 1 out of every 3,500 live births.
Usually appears between the ages of 2-6
yrs. Old
No cure for MD, although exercise
therapy maybe useful in maintaining
mobility.

Multiple Sclerosis
Most common neurological disease in early to middle

adulthood.
Twice as common in women.
Disease of the central nervous system characterized by loss of
myelin sheath.
Suffer from reduced lifespan, bust most will survive at least 25
years from diagnosis.
Important to work closely with members of a healthcare team,,
as the disease progresses, to plan appropriate levels of activity
and to adapt exercise performance and exercise equipment to
allow patients with MS to maintain their highest level of
functional ability.

Advances in Clinical Exercise

Physiology
Important breakthrough in basic research have

led to meaningful applications in the treatment

of chronic disease.
Physical activity is now considered to be a
critical role therapies that at one time wouldnt
have been imagined.

Heart Transplantation
Approx. 2,800 heart

transplants are performed

each year.
Established treatment for
advanced heart disease
1 year survival rates are
now over 80%
Exercise appears to have a
critical role in post-transplant
therapy.

Heart Transplant Cont

Although advances are being made

there is currently no way to establish

nervous system connections between
the patient and the new heart.
The heart beats faster at rest, typically
from 100-110 bpm and responds more
slowly to exercise.