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Clinical Exercise Physiology


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Title: Clinical Exercise Physiology

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.

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

  • 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

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
  • 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
  • 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
  • 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

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
  • For example The same GXT test would not be
    performed on a young adult as would be performed
    on a 70 year old person.

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  • 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
  • Exercise and Clinical settings HR is determined
    through readings obtained from the ECG recordings
    and directly off the digital display of the

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-pres
    sure 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
  • 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

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
  • 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
  • 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

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
  • 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
  • Can interfere with exercise performance.

  • 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

Type II Diabetes (noninsulin-dependent diabetes
  • 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 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
  • Develops from a combination of genetic and
    environmental factors.

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Rheumatologic Diseases
  • Encompass disorders of the musculoskeletal
  • Often chronic and often leads to disability
  • Clinical exercise physiologists can play a role
    in minimizing disability through appropriate
    evaluation and exercise prescription.

  • 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

Orthopedic and Neuromuscular Diseases and
  • 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
  • The heart beats faster at rest, typically from
    100-110 bpm and responds more slowly to exercise.

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