Some important key terms:

Physical activity
“Any bodily movement produced by the
contraction of skeletal muscles that result in
substantial increase over resting energy
expenditure.”

EXERCISE is planned and structured physical

activity designed to improve or maintain physical
fitness.
 Physical fitness is the ability to perform physical
work. Performing physical work requires cardio
respiratory functioning, muscular strength and
endurance, and musculoskeletal flexibility

 O2 consumption influences by age, gender,

hereditary, inactivity and disease.
 Maximum O2 consumption VO2 is the measure
of the body’s capacity to use oxygen.
 It is the maximum amount of oxygen consumed per
minute when the individual has reached maximum
effort.
 It is usually expressed relative to body weight, as
milliliters of oxygen per kilogram of body weight
per minute (mL/kg per minute).
 Dependent upon
 Transport of oxygen
 Oxygen binding capacity of blood
 Cardiac function
 oxygen extraction capabilities
 Muscular oxidative potential.
 Endurance is the ability to work for
prolonged periods of time the ability to
resist fatigue.
 Muscular endurance refers to the
ability of an isolated muscle group to
performs repeated contractions
 cardiovascular endurance is the
ability to perform large muscles
dynamic exercise (such as walking
swimming, and/or biking) for long
periods of time.
 Aerobic exercise training or conditioning
augmentation of energy utilization of muscles
by means of an exercise program.
 The improvement of the muscle’s ability to
use energy is a direct result of
 increased levels of oxidative enzymes in the
muscles, increased mitochondrial density and
size,
 increased muscle fiber capillary supply.
 Adaptation relates that cardiovascular system and muscles use
adapt to training stimulus over time with significant changes
measured in as less as 10-12 weeks.
 Adaptation results in increased efficiency of the
cardiovascular system and active muscles.
 Depends on the
 stimulus threshold(the stimulus that elicits a training
response).
 organism’s ability to change
 The person with a low level of fitness has more potential to
improve than the one who has a high level of fitness.
 The higher the fitness level of individual the greater the
intensity of the exercise needed to elicit a significant
change.
 Myocardial oxygen consumption is the measure of oxygen
consumed by the myocardial muscles.
 the need for oxygen is determined by
 Heart rate
 Systemic blood pressure
 Myocardial contractility
 Afterload
 Balance b/w myocardial oxygen demand and supply is
maintained in healthy individual during max. exercise.
 Greater demand for oxygen results in myocardial ischemia.
 Deconditioning occurs with prolonged bed rest and frequently
seen in pt’s with prolonged acute illness or long term chronic
conditions.
 These effects are also seen, although possibly to a lesser
degree, in the individual who has spent a period of time on
bed rest without any accompanying disease process and in the
individual who is sedentary because of lifestyle and increasing
age
Deconditioning Effects Associated with Bed
Rest

↓ Muscle mass
↓ Strength
↓ Cardiovascular function
↓ Total blood volume
↓ Plasma volume
↓ Heart volume
↓ Exercise tolerance
↓bone mineral density
Energy systems, Energy
expenditure and Efficiency
 Energy system are metabolic systems involving series of
biochemical reactions resulting in the formation of
 ATP, carbondioxide and water.
 Cell uses the energy produced from the conversion of ATP into
ADP and phosphate to perform physical activity. Muscle cells
use this energy for actin-myosin cross-bridge formation when
contracting
 There are THREE energy systems:
 Phosphagen or ATP-PC system
 Anerobic glycolytic system
 Aerobic system
Phosphagen of ATP-PC system
 Phosphocreatine and ATP are stored in the muscle cell.
 Phosphocreatine is the chemical fuel source.
 No oxygen is required (anaerobic).
 When muscle is rested, the supply of ATP-PC is replenished.
 The maximum capacity of the system is small (0.7 mol ATP).
 The maximum power of the system is great (3.7 mol ATP/min).
 The system provides energy for Short, quick bursts of
 Activity.
 It is the major source of energy during the first 30 seconds of
intense exercise.
 Anaerobic glycolytic system:
 Glycogen (glucose) is the fuel source (glycolysis).
 No oxygen is required (anaerobic).
 ATP is resynthesized in the muscle cell.
 Lactic acid is produced (by-product of anaerobic
glycolysis).
 The maximum capacity of the system is intermediate
(1.2 mol ATP).
 The maximum power of the system is intermediate
(1.6 mol ATP/min).
 The systems provide energy for activity of moderate
intensity and short-duration.
 It is the major source of energy from the 30th to
90th second of exercise.
Aerobic system
 Glycogen, fats, and proteins are fuel sources and are utilized relative
to their availability and the intensity of the exercise.
 Oxygen is required (aerobic)
 ATP is resynthesized in the mitochondria of the muscle cell. The
ability to metabolize oxygen and other substrates is related to the
number and concentration of the mitochondria and cells.
 The maximum capacity of the system is great (90.0 mol ATP).
 The maximum power of the system is small (1.0 mol ATP/min).
 The system predominates over the other energy systems after
the second minute of exercise.
 Functional implications
 Intense activity lasting for 2-3 mins repeated after 4
mins of rest enhances anaerobic power. ATP is supplied
by the phosphagen as well as glycolytic system.
 Activities with large muscles, which is less then
maximum in intensity for3-5mins repeated after rest or
mild exercise of similar duration, develops aerobic
power and endurance .ATP is supplied by glycolytic
anerobic, aerobic and phosphagen system.
 Activity of sub maximum intensity lasting 20-30 mins
develops endurance supplied by aerobic system.
Energy expenditure
 expressed in kilocalories,
 Exercises depending on energy cost are
 Heavey
 Moderate
 Light
 Quantification of energy expenditure
 Units used to quantify energy are
 kilocalorie is the amount of heat necessary to raise 1 kilogram
(kg) of water 1°C.
 A kilocalorie (kcal) can be expressed in oxygen equivalents.
Five kilocalories equal approximately 1 liter of oxygen
consumed (5 kilocalorie =1 litre O2)
 MET is oxygen consumed per kg of body weight per min. it is
equal to 3.5 mL/kg/min
Efficiency
 Efficiency is usually expressed as a percentage,
 Work output equals force times distance (W = F × D).
 It can be expressed in power units or work per unit of time (P
= w/t).
Percent efficiency = useful work output/energy expended ×
100

 On a treadmill, work equals the weight of the subject times

the vertical distance the subject is raised walking up the incline
of the treadmill.
 On a bicycle ergometer, work equals the distance (which is
the circumference of the flywheel times the number of
revolutions) times the bicycle resistance.
Cardiovascular Response to
Exercise
Exercise Pressor Response
 Sympathetic nervous system (SNS) response Stimulates the small
myelinated and unmyelinated fibers in skeletal muscle.
 Degree of response equals the involved muscle mass and intensity of
exercise
 The SNS response includes
 generalized peripheral vasoconstriction
 ↑ myocardial contractility,
 ↑ heart rate
 Resulting in ↑ and redistribution of the cardiac
output.
 Cardiac effects
 ↑ heart rate.
 ↓ vagal stimuli
 ↑ cardiac myofibers force development
 Peripheral effects
 Net reduction in total peripheral resistance.
 Increased cardiac output
Testing as a Basis for Exercise
Programs
 Regardless of the type of testing, the level of performance is
based on the sub maximum or maximum oxygen uptake (VO2
max) or the symptom-limited oxygen uptake.
 Fitness Testing of Healthy Subjects

 Field tests for determining cardiovascular fitness include the

 time to run 1.5 miles or distance run in 12 minutes.
 use is limited to young persons or middle-aged individuals
carefully screened and have been jogging or running for some
time
 1-mile walk test
 6-minute walk test
 step tests
Suitable for individual not physically active
 Multistage testing can provide a direct measurement of VO2
max by analyzing samples of expired air.
 Testing is usually completed in four to six treadmill stages,
which progressively increase in speed and or grade. Each stage
is 3 to 6 minutes long.
 Electrocardiographic (ECG) monitoring is performed during the
testing
Stress Testing for Convalescing
Individuals and Individuals at Risk
 Individuals undergoing stress testing should be monitored by ECG and
observed at rest, during exercise and during recovery .
Principles of Stress Testing
The principles of stress testing include the following
 Changing the workload by increasing the speed and/or grade
of the treadmill or the resistance on the bicycle ergometer
 An initial workload that is low in terms of the individual’s
anticipated aerobic threshold
 Maintaining each workload for 1 minute or longer
 Terminating the test at the onset of symptoms or a definable
abnormality of the ECG
 When available, measuring the individual’s maximum oxygen
consumption
 Purpose of Stress Testing
The stress test:
 Helps establish a diagnosis of overt or latent heart
disease.
 Evaluates cardiovascular functional capacity as a
means of clearing individuals for strenuous work or
exercise programs.
 Assists in the selection and evaluation of appropriate
modes of treatment for heart disease.
 Is used clinically to evaluate patients with chest
sensations or a history of chest pain to find
probability of coronary disease.
 It can also evaluate the functional capacity of patients
with chronic disease
 Preparation for Stress Testing
 All individuals who are taking a stress test should:
 Have had a physical examination.
 Be monitored by ECG and closely observed at rest,
during exercise, and during recovery.
 Sign a consent form.
Precautions for Stress Testing and Exercise Program

Monitor the pulse to assess abnormal increases in heart rate.

■ Blood pressure increases with exercise approximately 7 to 10
millimeters (mm) of mercury (Hg) per MET of physical activity.
■ Systolic pressure should not exceed 220 to 240 mm Hg.
■ Diastolic pressure should not exceed 120 mm Hg.
■ Rate and depth of respiration increase with exercise.
■ Respiration should not be labored.
■ The individual should have no perception of shortness of
breath.
■ The increase in blood flow while exercising, which regulates
core temperature and meets the demands of the working
muscles, results in changes in the skin of the cheeks, nose, and
earlobes. They become pink, moist, and warm to the touch.
Termination of Stress Testing
 Progressive angina.
 A significant drop in systolic pressure in response to
an increasing workload.
 Light headedness, confusion, pallor, cyanosis, nausea,
or peripheral circulatory insufficiency.
 Abnormal ECG responses
 Excessive rise in blood pressure.
 Subject wishes to stop.
Multistage Testing
 Each of 4-6 stages last for 1-6 mins.
 Differences in protocol involves
 number of stages,
 magnitude of the exercise (intensity),
 equipment used (bicycle,treadmill)
 duration of stages
 Endpoints
 position of body,
 muscle groups exercised
 types of effort
 Protocols
 Bruce protocols
 Tread mill speed and grade are changed every 3mins.
 Speed increases from 1.7mph-5.0mph
 Initial grade of 10% increases upto 18% during 5 stages.
Introduction(DETERMINANTS OF
AN EXERCISE PROGRAM)

Elicitation of the cardiovascular response is

dependent on three critical elements of exercise:
 Intensity
 Duration and
 Frequency.
Frequency

 Optimal frequency-3,4 times

per week.
 A frequency of two times a
week does not generally evoke
cardiovascular changes,
although older individuals and
convalescing patients may
benefit from a program of
that frequency
Intensity

 Determination of the
appropriate intensity of
exercise to use is based on
 the overload principle
 the specificity principle.
 Determining the maximum heart rate
and the exercise heart rate for
training programs provides the basis
for the initial intensity of the
exercise.
 When the individual is young and
healthy, the maximum heart rate can
be determined directly from a
maximum performance multistage
test, or, less accurately, calculated
as 220-age.
Methods to Determine Maximum
Heart Rate and Exercise Heart
Rate
1. Determine Maximum Heart Rate
(HR)
• From multistage test (for young and
healthy)
• HR achieved in predetermined sub
maximum test
• 220 minus age (less accurate)
2. Determine Exercise Heart Rate
• Percentage of maximum heart rate (dependent
on level of fitness)
• Karvonen’s formula (heart rate reserve)
(HRR) which is the difference between the
resting heart rate (HRrest) and the maximum
heart rate (HRmax).
(HRmax -HRrest)
 The exercise heart rate is determined as
a percentage (usually 60% to 70%) of
the heart rate reserve plus the resting
heart rate

 Exercise heart rate HRR(60–70%) +

HRrest
Individuals at risk

 Max.Heart rate and exercise heart rate

used for the exercise prescription for
individuals at risk for coronary artery
disease.
 Individuals with coronary artery disease
or other chronic disease, and individuals
who are elderly are ideally identified
based on their performance on the stress
test.
 Time(Duration)

 When intensity is below the heart rate

threshold, a 45 min continuous
exercise period provide the
appropriate overload.
 With high-intensity ex,10-15min
exercise periods are adequate.
 Three 5min daily periods are effective
in deconditioned pt.
Exercise Program

There are three components

of exercise program:
1-Warm up period
2-Aerobic exercise period
3-Cool down period
Warm-up Period
Physiological responses :
● Increase in muscle temperature. The higher
temperature increases the efficiency of muscular
contraction
● Increase need for oxygen to meet energy demands
for muscle. Extraction from hemoglobin is greater at
higher muscle temperatures.
● Dilatation of constricted capillaries increases in the
circulation, augmenting oxygen delivery to the active
muscles
● Increase in venous return. This occurs as blood
flow is shifted centrally from the periphery.
 Purposes:
● Warm up prevents or decreases the susceptibility of
MSK system to injury.
● It also prevents the occurrence of ischemic ECG
changes and arrhythmias.
Guidelines:
 Warm up should be sufficient to increase muscle
and core temperature without causing fatigue or
reducing energy stores
Characteristics of the period include:
● 10 minute period of total body movement exercises
such as calisthenics and walking slowly
● Attaining a heart rate that is within 20 beats/min of
target heart rate
Aerobic Exercise Period
It is the conditioning part of exercise
program
● Four methods of training are:
1- Continuous training
2- Interval training
3- Circuit training
4- Circuit interval training
1-Continuous Training:
● Sub maximum energy requirement sustained
throughout the training period
 Stress is placed primarily on the slow-twitch fibers
● Activity can be prolonged for 20-60 minutes
● Continuous training is most effective way to improve
endurance for healthy individuals
2-Interval Training:
In healthy individual,interval training tends to
improve strength and power more than
endurance.
 ● Relief interval is either a rest relief(passive
recovery) or a work relief(active recovery) &
duration ranges from few seconds-minutes ,
Work recovery involves continuing the
exercise but at a reduced level from the work .
3-Circuit training:
 Circuit training employs a series of exercise
activities. At the end of the last activity, the
individual starts from the beginning and again
moves through the series
The series of activities is repeated several times.
● Several exercise modes can be used involving
large and small muscle groups and a mix of static
or dynamic effort.
 ● Use of circuit training can improve strength
and endurance. stressing both the aerobic and anaerobic
systems.
 4-Circuit-interval training
● Circuit and interval training is effective
because of interaction of aerobic and
anaerobic production of ATP.
Cool-Down Period
Cool down period is similar to warm-up
period---it last 5 to 10 minutes and consist of
total body move. and static stretching.
Purposes:
 ●Prevent pooling of blood in the extremities by continuing to use the
muscles to maintain venous return
 ●Prevent fainting by increasing the return of blood to the heart and brain as
cardiac output and venous return decreases.
General guidelines for aerobic
training program
 Establish the target HR and max HR.
 Warm up gradually for 5 to 10 min, including stretching and
repetitive motions at slow speeds, gradually increasing the
effort.
 Increase the pace of activity so the target HR can be
maintained for 20 to 30 min.
 Cool down for 5to 10 min with slow, total body repetitive
motion and stretching activities.
 The aerobic activity should be under taken 3 to 5 times per
week.
 To avoid injuries from stress, use appropriate equipment.
Avoid running, jogging or aerobic dancing on hard surfaces.