Essential exercise physiology

•Chapter 18 Clinical Aspects of Exercise Physiology 637 BOX 18.1 CLOSE UP How to Recognize Vital Signs Proper handling of potentially critical situations requires SKIN COLOR recognition of the following nine vital signs: For lightly pigmented individuals, skin color can be a 1. Heart (pulse) rate good indicator of health. Three skin colors are commonly 2. Breathing rate identified in medical emergencies 3. Blood pressure 4. Body temperature 1. Red: Heat stroke, high blood pressure, or carbon 5. Skin color monoxide poisoning 6. Pupils of the eye 7. State of consciousness 2. White (pale, ashen, or white): Insufficien 8. Body movements circulation, shock, fright, hemorrhage, heat exhaus- 9. Pain or abnormal nerve response tion, or insulin shock HEART (PULSE) RATE 3. Blue: Circulating blood is poorly oxygenated, indicat- ing an airway obstruction or respiratory insufficienc A normal pulse rate for adults ranges between 60 and 80 b иminϪ1 and 80 to 100 b иminϪ1 for children. Any Assessing dark-skinned individuals is complicated. long-term alteration from normal may indicate the pres- They normally have pink coloration of the nail beds and ence of a pathologic condition. For example, a rapid but inside the lips, mouth, and tongue. Changes in these weak pulse could indicate shock, diabetic coma, or heat areas strongly indicate a medical emergency. exhaustion. A rapid and strong pulse may indicate heat- stroke or severe fright, and a strong but abnormally slow PUPILS OF THE EYE pulse could indicate a stroke. The pupils are extremely sensitive to situations affecting the BREATHING RATE nervous system. Most persons have pupils of regular out- line and equal size. A constricted pupil can indicate a cen- The normal breathing rate approximates 12 breaths/min tral nervous system (CNS) response to a depressant drug. If in adults and 20 to 25 breaths/min in children. Breathing one or both pupils are dilated, the individual may have sus- can be shallow, irregular, or gasping. Frothy blood from tained a head injury; may be experiencing shock, heat the mouth indicates a chest (lung) injury. Look, listen, stroke, or hemorrhage; or may have ingested a stimulant and feel: look to ascertain whether the chest is rising or drug. The pupils’ response to light should also be noted. If falling; listen for air passing in and out of the mouth, one or both pupils fail to accommodate to light, there may nose, or both; and feel how the chest is moving. be brain injury or alcohol or drug poisoning. Pupil response is more critical in evaluation than pupil size. BLOOD PRESSURE STATE OF CONSCIOUSNESS N ormal systolic blood pressure for 15- to 20-year-old young men ranges from 115 to 120 mm Hg, and diastolic Normally, individuals are alert, aware of their environ- pressure ranges from 75 to 80 mm Hg. Blood pressure for ment, and respond quickly to vocal stimulation. Head young women is usually 8 to 10 mm Hg lower for both injury, heat stroke, and diabetic coma can vary an indi- systolic and diastolic pressures. Between the ages of 15 vidual’s level of conscious awareness. and 20 years, a systolic pressure of 135 mm Hg and above may be excessive, and a pressure of 110 mm Hg or lower BODY MOVEMENTS may be considered too low. Diastolic pressure should not exceed 60 mm Hg for young women and 85 mm Hg for Inability to move a body part can indicate a serious CNS young men. A dramatically lowered blood pressure can injury. Inability to move one side of the body can result indicate hemorrhage, shock, heart attack, or internal from a head injury or cerebrovascular accident. Paralysis organ injury. of the upper limb can indicate a spinal injury; inability to move the lower extremities could mean an injury below BODY TEMPERATURE the neck; and pressure on the spinal cord could lead to limited use of the limbs. N ormal resting body temperature averages 98.6 ЊF PAIN OR ABNORMAL NERVE RESPONSE (37ЊC). Temperature can be measured under the tongue, Numbness or tingling in a limb with or without move- in the armpit, or in the rectum. Changes in body temper- ment can indicate nerve or cold damage. Blocking of a main artery can produce severe pain, loss of sensation, or ature can also be palpated. Hot, dry skin indicates disease, lack of a limb pulse. A complete lack of pain or of aware- ness of serious but obvious injury can be caused by infection, or heat overexposure. Cool, clammy skin indi- shock, hysteria, drug usage, or spinal cord injury. Gener- alized or localized pain in an injured region probably cates trauma, shock, or heat exhaustion. Cool, dry skin indicates no spinal cord injury. can indicate overexposure to cold.

•638 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits Six Categories for ECG Table 18.5 Interpretation 1. Measurements • Heart rate (atrial and ventricular) Figure 18.3 Still picture of an echocardiogram that shows • PR interval (0.12–0.20 s) the right and left ventricles, right and left atria, and mitral and 2. Rhythm diagnosis • QRS duration (0.03–0.10 s) tricuspid valves. 3. Conduction diagnosis • QT interval (HR dependent) 4. Waveform description • Frontal plane QRS axis (–30º to Noninvasive Physiologic Screening and Assessment 5. ECG diagnosis ϩ90º) 6. Comparison with Noninvasive physiologic tests identify specific cardiovas • P wave (atrial enlargement) cular/cardiac dysfunction with minimal patient discomfort previous ECG • QRS complex (ventricular and risk. hypertrophy, infarction) Echocardiography Echocardiography uses pulses • S-T segment (elevated or of reflected ultrasound to evaluate heart function and mor depressed) phology; it identifies the heart’s structural components an • T wave (flattened or inverted measures distances within the myocardial chambers. This • U wave (prominent or inverted) allows estimation of various chamber sizes (volumes) in • Within normal limits addition to blood vessel dimensions and thickness of vari- • Borderline abnormal ous myocardial components. The echocardiogram has sur- • Abnormal passed the ECG in recognizing chamber enlargement, myocardial hypertrophy, and other structural abnormali- ECG ϭ electrocardiographic. ties. Echocardiograms can diagnose heart murmurs, evalu- From Fardy, P., Yanowitz, F.G.: Cardiac Rehabilitation, Adult Fitness and ate valvular lesions, and determine the extent of congenital Exercise Testing. Baltimore, MD: Williams & Wilkins, 1996. heart diseases and cardiomyopathies. • Blood lipid and lipoproteins: Routine laboratory Figure 18.3 presents a typical still echocardiographic testing for CHD risk includes analysis of the blood image showing the left and right atrium and left and lipid and lipoprotein profiles. Individuals with hear right ventricle, the tricuspid valves and the mitral valves. disease often have elevated cholesterol and LDL The echocardiogram provides the ability to measure dif- cholesterol. ferent parameters of size and function of the heart’s chambers for diagnostic purposes. The advent of new • Serum enzymes: Alterations in serum enzymes can diagnose or rule out an acute MI. When myocardial cell death (necrosis) or prolonged lack of blood flo (ischemia) occur, enzymes from the damaged mus- cle leak into the blood because of the plasma mem- brane’s increased permeability. This leakage in- creases serum levels of three enzymes: (1) creatine phosphokinase (CPK), which reflects either skeleta or cardiac muscle necrosis depending on one of three isoenzymes that form; (2) lactate dehydroge- nase (LDH), which also fractionates into different isoenzyme markers, one of which increases during an MI; and (3) serum glutamic oxaloacetic transam- inase (SGOT), which elevates during an MI. Table 18.6 Normal and Abnormal ECG Changes Commonly Observed During Exercise NORMAL ECG CHANGES IN ABNORMAL ECG CHANGES WITH CHD HEALTHY INDIVIDUALS 1. Slight increase in P wave amplitude 1. Appearance of bundle branch block at a critical HR 2. Shortening of PR interval 2. Recurrent or multifocal PVCs during exercise and recovery 3. Shift to the right of QRS axis 3. Ventricular tachycardia 4. S-T segment depression Ͻ1.0 mm 4. Appearance of bradyarrhythmias and tachyarrhythmias 5. Decreased T wave amplitude 5. S-T segment depression/elevation of Ͼ1.0 mm 0.08 s after J point 6. Single or rare PVC during exercise and recovery 6. Exercise bradycardia 7. Single or rare PVC or PAC 7. Submaximal exercise tachycardia 8. Increase in frequency or severity of any known arrhythmia PVC - , premature ventricular contraction; PAC - , premature atrial contraction.

•Chapter 18 Clinical Aspects of Exercise Physiology 639 three-dimensional echocardiogram has enhanced echocardiography as a valu- uestions & Notes Qable diagnotic tool (depts.washington.edu/cvrtc/ocarinas.html). Graded Exercise Stress Test A graded exercise stress test (GXT) Give a typical heart rate for sinus tachycardia. describes the systematic use of exercise for two purposes: 1. Observe cardiac rhythm abnormalities during exercise Give a typical heart rate for sinus 2. Assess overall physiologic adjustments to increased metabolic demands bradycardia. The most common modes for exercise stress testing include multistage bicy- List 5 vital signs. cle and treadmill tests. The test, “graded” for exercise intensity, includes sub- 1. maximal exercise levels of 3 to 5 minutes in duration, each level progressing up 2. to self-imposed fatigue or a specific target heart rate. The graded nature of test 3. ing allows detection of ischemic manifestations and rhythm disorders with 4. small increments in exercise intensity. The GXT provides a reliable, quantita- 5. tive index of the person’s level of functional impairment.For most screening pur- poses, the test does not require maximal effort; instead, the person exercises to at least 85% of age-predicted maximum heart rate. Laboratory-based GXTs remain preferable to field tests (walking or running tests) because of closer control ove the test environment and exercise intensity. A resting ECG precedes the GXT to establish whether the person can engage safely in subsequent graded exercise. The resting ECG also provides an impor- tant baseline measure for subsequent comparisons. Why Stress Test? Stress testing For Your Information serves six important roles in an over- all CHD evaluation: MAJOR SIGNS AND SYMPTOMS OF CARDIOPULMONARY DISEASE 1. Detect heart disease: An Individuals with undiagnosed cardiopulmonary diseases exhibit specific signs and exercise ECG can diagnose symptoms during rest and exercise: overt heart disease and screen • Pain or discomfort (or other angina equivalent) in the chest, neck, or arms for possible “silent” coronary • Shortness of breath at rest or with mild exertion disease in seemingly healthy • Dizziness or syncope (feeling of lightheadedness or faintness) individuals. Between 25% and • Dyspnea (shortness of breath or labored breathing) on rising from a supine posi- 40% of people with confirme CHD have normal resting tion or at night during sleep ECGs. ECG analysis during • Palpitations or tachycardia (unexplained increased heart rate) during rest or mild exercise uncovers about 80% of these abnormalities. exercise • Ankle edema (swelling) 2. Reproduce and assess exer- • Intermittent claudication (ischemic pain described as an aching, weakness, tight- cise-related chest symptoms: Individuals older than age ness, or cramping sensation during physical activity) in the calf of the leg 40 years often experience • Known heart murmur angina symptoms with physi- • Unusual fatigue accompanied by moderate to extreme dyspnea during usual cal exertion. ECG analysis during graded exercise activities provides a more objective and valid diagnosis of exercise- For Your Information induced chest discomfort. CHRONIC FATIGUE SYNDROME AND EXERCISE 3. Screen candidates for preventive and rehabilitative Chronic fatigue syndrome (CFS) involves continual and severe fatigue. Its exercise programs: Stress test prevalence has been estimated at between 1 and 4 million Americans. The cause(s) results help design an of CFS remains unknown but may represent a common end point from multiple exercise program within the causes that include infectious agents (similar to Epstein-Barr virus), immunologic person’s functional capacity variables (perhaps inappropriate production of cytokines such as interleukin-1), and health status. Repeated hypothalamic–pituitary–adrenal (HPA) axis stimulation leading to increased testing evaluates training release of cortisol and other hormones that influence the immune system and other progress and safely modifie body systems, diabetes, neurally mediated hypotension, substance abuse, and possi- the initial exercise ble nutritional deficiencies. Modest regular exercise to avoid deconditioning is prescription. important for all CFS patients (www.ncpad.org ).

•640 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits 4. Detect abnormal blood pressure responses: Exer- tion. This consent must include a written statement that the cise hypertension often signifies underlying cardio person has had an opportunity to ask questions about the vascular complications. procedures with sufficient information clearly provided s consent occurs from a knowledgeable (informed) perspec- 5. Monitor responses to various therapeutic tive. A minor requires prior legal consent from a legal interventions designed to improve cardiovascular guardian or parent. Individuals need assurance that test health and function: Periodic stress testing results remain confidential. Minors must clearly under objectifies the degree of benefit derived fro stand that they may terminate the exercise testing or train- pharmacologic, surgical, or dietary treatment ing program at any time and for any reason. Table 18.8 of heart disease. presents a sample informed consent statement. 6. Quantify functional aerobic capacity and evaluate Contraindications to Stress Testing Certain condi- its degree of deviation from established standards: tions preclude administering a stress test ( absolute con- Metabolic measu.rements du. ring the GXT allow deter- traindications) and other conditions require the GXT be mination of the VO2max or VO2peak. administered under more closely monitored conditions (relative contraindications). Who Should Be Stress Tested? Table 18.7 shows a classification system by age and health status for screenin Absolute Contraindications to Stress Testing Under and supervisory procedures for both stress testing and par- no circumstances should a stress test be administered with- ticipation in a regular exercise program. These guidelines out direct medical supervision if any of the following 12 apply for healthy individuals and those at higher risk. conditions exist: Healthy young adult.s can begin moderate intensity exer- cise at 40% to 60% V O2max without an exercise stress test 1. Resting ECG suggestive of acute cardiac disease or medical examination. Men older than age 40 years and 2. Recent complicated MI women older than age 50 years should have a medical 3. Unstable angina pectoris examination that includes a stress test before starting an 4. Uncontrolled ventricular arrhythmia exercise program. A GXT that precedes exercise training 5. Uncontrolled atrial arrhythmia that compromises takes on added importance for high-risk individuals of any age. This pertains to people with two or more major CHD risk cardiac function factors or symptoms suggestive of cardiopulmonary or meta- 6. Third-degree atrioventricular heart block without a bolic disease. pacemaker Informed Consent “Informed volunteers” must be the 7. Acute congestive heart failure participants in all exercise testing and training. Informed 8. Severe aortic stenosis consent raises awareness about potential risks of participa- 9. Active or suspected myocarditis or pericarditis 10. Recent systemic or pulmonary embolism Recommendations for Medical Examination, Graded Exercise Stress Testing (GXT), and Table 18.7 Physician Supervision of GXT Before Participation in an Exercise Program RISK CATEGORY MEDICAL EXAMINATION AND GXT M.D. SUPERVISION Low risk Moderate exercise; not necessary Moderate exercise; not necessary Men Ͻ45 years Vigorous exercise, not necessary Vigorous exercise; not necessary Women Ͻ55 years; asymptomatic Moderate exercise; not necessary Moderate exercise; not necessary with Յ1 risk factora,b Vigorous exercise; recommended Vigorous exercise; recommended Moderate risk Moderate exercise; recommended Moderate exercise; recommended Men 45 years Vigorous exercise; recommended Vigorous exercise; recommended Women 55 years, with 2 risk factorsa,b High risk Individuals with 1 sign/symptom of cardiovascular or pulmonary diseasec or known cardiovascular (cardiac, peripheral vascular, or cerebrovascular), pulmonary (obstructive pulmonary disease, asthma, cystic fibrosis), or metabolic (diabetes, thyroid disorder, renal or liver) disease aRisk factors: family history of heart disease, cigarette smoking, hypertension, hypercholesterolemia, impaired fasting glucose, obesity, and sedentary lifestyle. bHDL Ͼ 60 mgиdLϪ1 (subtract 1 risk factor from the sum of other risk factors because high HDL decreases CHD risk). cSigns and symptoms of cardiovascular and pulmonary disease: pain, discomfort in chest, neck, jaw, left arm; shortness of breath at rest or with mild exertion; dizziness or syncope; orthopnea or paroxysmal nocturnal dyspnea; ankle edema; tachycardia; intermittent claudication; heart murmur; and unusual fatigue or shortness of breath with mild activity.

•Chapter 18 Clinical Aspects of Exercise Physiology 641 Example of Informed Consent for a Graded Exercise Questions & Notes Table 18.8 Stress Test List 3 common laboratory-based screening Name ____________________________________________ tests for CHD. 1. Explanation of the Exercise Test 1. You will perform an exercise test on a cycle ergometer or a motor-driven treadmill. The exercise intensity begins at a level you can easily accomplish and will advance 2. in stages of difficulty depending on your fitness level. We may stop the test at a time because of signs of fatigue, or you may stop the test when you wish because of 3. fatigue or discomfort that you feel, particularly at the higher exercise levels. Define the term ischemia. 2. Risks and Discomforts The possibility exists that certain abnormal changes can occur during the test. Name 2 common noninvasive physiologic These include abnormal blood pressure, fainting, disorder of heart beat, and in rare CHD screening tests. instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by evaluating preliminary information related to your health and fitness 1. and by observations during testing. Emergency equipment and available trained personnel can deal with unusual situations that may arise. 2. 3. Responsibilities of the Participant List 2 purposes for administering a GXT. Information you possess about your health status or previous experiences of 1. unusual feelings with physical effort may affect the safety and value of your exercise test and you should report this information now. Your prompt reporting 2. of how you feel during the exercise test also is important. You are responsible for fully disclosing such information when requested to do so by the testing staff. List 4 absolute contraindications to stress testing. 4. Expected Benefits From the Tes The results obtained from the exercise test may assist in diagnosing your illness, or 1. evaluating what type of physical activities you might do with low risk. 2. 5. Inquires We encourage you to ask any questions about the procedures used in the exercise 3. test or in the estimation of your functional capacity. If you have doubts or questions, please ask us for further explanations. 6. Freedom of Consent Your permission to perform this exercise test is voluntary. You are free to deny consent or stop the test at any point. I have read this form and understand the test procedures. I voluntarily consent to participate in this test. Date: Signature of Patient: Signature of Witness: _________________________________________________ Questions: Responses: Signature of Physician or Delegate: 11. Acute infections 12. Acute emotional distress Relative Contraindications to Stress Testing Administer a GXT with cau- 4. tion and with medical personnel in close proximity to the test area if any of the following 10 conditions exist: List 4 relative contraindications to stress testing. 1. Resting diastolic blood pressure above 115 mm Hg or systolic blood pressure above 200 mm Hg 1. 2. Moderate valvular disease 2. 3. Electrolyte abnormalities 4. Frequent or complex ventricular ectopic beats 3. 5. Ventricular aneurysm 6. Uncontrolled metabolic disease (diabetes, thyrotoxicosis) 4. 7. Chronic infectious disease (hepatitis, mononucleosis, AIDS) 8. Neuromuscular or musculoskeletal disorders 9. Pregnancy (complicated or in the last trimester) 10. Psychological distress or apprehension about taking the test Maximal Versus Submaximal Stress Testing A maximal GXT (GXT max) r.epresents th. e most common noninvasive method to screen for CHD and determine VO2max or VO2peak. Individuals exercise until they decide to stop or develop

•642 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits Criteria for Stopping a GXT in 9. Testing environment (type and appearance of test- Table 18.9 Apparently Healthy Adults ing room, physical appearance and behavior of test personnel) 1. Onset of angina or angina-like symptoms 2. Ventricular tachycardia Stress Test Protocols Test duration, initial exercise 3. Significant decrease in systolic blood pressure of 20 mm Hg intensity level, and increments of intensity between stages 4. Failure of systolic blood pressure or heart rate to increase for GXT protocols dictate the test to administer. In a national survey of 1400 exercise stress test centers, 71% with an increase in exercise load used treadmills, 17% used bicycle ergometers, and only 5. Lightheadedness, confusion, ataxia, pallor, cyanosis, 12% used step tests. No statistics exist for arm-crank or swim stress tests. nausea, or signs of severe peripheral circulatory insufficienc Treadmill Tests Treadmill tests accommodate individuals 6. Early onset horizontal or downsloping S-T segment depression or elevation (Ͼ4 mm) through a broad spectrum of fitness using the “natural” activ 7. Increasing ventricular ectopy, multiform PVCs 8. Excessive increase in blood pressure: systolicϾ260 mm Hg; ities of walking and running. (See Chapter 7, page 225, for a diastolic Ͼ115 mm Hg 9. Increase in heart rate Ͻ25 bиminϪ1 of predicted normal discussion of different treadmill protocols.) Table 18.10 value (in the absence of ␤-blockade medication) 10. Sustained supraventricular tachycardia presents some of th. e more common exercise test protocols 11. Subject requests to stop test for whatever reason and the predicted VO2 (mL и kgϪ1 и minϪ1) for each exercise 12. Equipment failure level for each test. PVC ϭ premature ventricular contraction. From ACSM’s Guidelines for Exercise Testing and Prescription, 7th ed. Each protocol has advantages and disadvantages. The Baltimore: Lippincott Williams & Wilkins, 2006. Bruce test, one of the more common protocols, uses large abnormal symptoms that signal test termination ( Table 18.9). The term symptom limited describes such stress increments every 3 minutes, resulting in less uniform tests. responses compared with tests with smaller increments GXTmax normally progress through several stages (mul- tistage): the duration, starting point, and increments (e.g., Bruce test) and is better suited for screening of between stages vary with the person (e.g., young active, healthy sedentary, and questionable health status). .Advan- younger and or physically active invidiuals. Protocols with tages of a GXTmax include direct determination of VO2max and maximal cardiovascular responses, screening for smaller increments, such as Naughton test or the modifie abnormal ECG patterns not revealed during rest or low- intensity exercise, and establishing more precise exercise Balke test, are preferable for older or deconditioned indi- training levels. Disadvantages include the considerable stress placed on the person; although GXTmax exhibits low viduals and patients with chronic diseases. The ramp test is risk, the discomfort of being pushed to maximum without prior physical conditioning may deter some persons from an attractive alternative approcah to incremental exercise participating in a subsequent fitness program. For mos healthy people, about the same physiologic information testing in which the work rate increases in a constant and can be obtained from a submaximal test (80%–90% HRmax [maximal safe heart rate]) as from a test requiring all-out continuous manner. effort. All stress tests begin at a relatively low level, with 2- to The criteria for stopping a test distinguish one GXT pro- tocol from another; otherwise, any of the protocols are 3-minute increments in exercise intensity. A warm-up effective. In all instances, an abnormal response should ter- minate the test. should be used either separately or incorporated into the Nine important factors influence physiologic response initial phase of the test. The total test duration should last to submaximal or maximal exercise: at least 8 to 12 minutes. A test longer than 20 minutes pro- 1. Ambient temperature and relative humidity 2. Subject’s sleep state (number of sleep hours prior to vides no additional useful ECG or physiologic data but can testing) establish more precise end points for estimating perform- 3. Emotional state 4. Medication ance capacity. 5. Time of day 6. Caffeine intake Bicycle Ergometer Tests Bicycle ergometers have dis- 7. Time since last meal tinct advantages over other exercise devices. In contrast to 8. Time since last exercise treadmills, power output easily calculated and regulated on the ergometer remains independent of body mass. Most ergometers are portable, safe, and relatively inexpensive. Electrically braked and weight-loaded, friction-type devices represent the two most common cycle ergometers. For electrically braked ergometers, preselected power out- put remains fixed within a range of pedaling frequencies Power output with weight-loaded ergometers relates directly to frictional resistance and pedaling rate. The same general guidelines for treadmill testing apply to the bicycle ergometer and arm-crank ergometer. Power out- put on a bicycle ergometer is expressed in kg-m иminϪ1 or watts (1 W ϭ 6.12 kg-m иminϪ1). Bicycle ergometer tests generally use 2- to 4-minute stages of graded exercise. Initial resistance ranges between 0 and 30 W; power output gener- ally increases 15 to 30 W per stage. Pedaling at 50 or 60 rev- olutions per minute (rpm) represents the typical rpm for weight-loaded ergometers.

•Chapter 18 Clinical Aspects of Exercise Physiology 643 Table 18.10 Modified Treadmill Protocols for Different Populations TREADMILL TREADMILL % TIME (mL иOk2gCϪO1 иSTminϪ1) STAGE MPH GRADE (min) METs 14.0–17.5 Bruce Test (Normally Used for Young Active Adults) 24.5–28.0 4–5 31.5–35.0 7 1 1.7 10 3 45.5–49.0 9.5 3 59.5–63.0 13.5 2 2.5 12 3 70.0–73.5 17 3 20.5 3 3.4 14 3 8.75 3 12.25 2.5 4 4.2 16 15.75 3.5 2 19.25 4.5 5 5.0 18 2 22.75 5.5 2 26.26 6.5 6 5.5 20 2 29.75 7.5 2 33.25 8.5 Modified Balke Test (Normally Used for Normal Sedentary Adults 2 36.75 9.5 2 40.25 10.5 12 0 2 43.75 11.5 2 47.25 12.5 23 0 2 13.5 2 3.5 33 2.5 2 7.0 1 12.25 2 43 5 3 15.75 3.5 3 19.25 4.5 53 7.5 3 22.75 5.5 3 26.26 6.5 63 10 3 29.75 7.5 3 33.25 8.5 73 12.5 3 36.75 9.5 3 40.25 10.5 83 15 3 43.75 11.5 3 47.25 12.5 93 17.5 3 13.5 3 10 3 20 3 11 3 22.5 12 3 25 Modified Naughton Test (Normally Used for Very Sedentary Adults 11 0 2 1.5 0 32 3.5 42 7 52 10.5 63 7.5 73 10 83 12.5 93 15 10 3 17.5 11 3 20 12 3 22.5 13 3 25 MET ϭ metabolic equivalent; MPH ϭ miles per hour. Adapted from Figure 5.3 in Thompson, W.R., et al.: ACSM’s Guidelines for Exercise Testing and Prescription, 8th ed. Baltimore: Lippincott Williams & Wilkins, 2010:114–115. Arm-Crank Ergometer Tests Stress For Your Information testing uses arm cranking ( Fig. 18.4) as the exercise stressor when formulating the FIBROMYALGIA AND EXERCISE prescription for upper-body exercise. Arm-crank exer.cise generally produces up Fibromyalgia (FM) represents a complex condition experienced by 3.4% to 30% lower V O2max values and a 10 to of women and 0.5% of men in the United States. FM causes persistent pain 15 b и minϪ1 lower maximum heart rate in muscles, ligaments, tendons, and joints. Other symptoms include compared with treadmill or bicycle exer- disturbed sleep and headaches. Symptoms can worsen with anxiety, cold cise. Unfortunately, arm-crank exercise environments, depression, hormonal changes, physical overexertion, and interferes with conventional blood pres- increased stress. FM can exist by itself but usually accompanies rheumatoid sure measurement during exercise. Blood arthritis, hypothyroidism, and chronic fatigue syndrome. pressure, heart rate, and oxygen uptake values remain higher during submaximal Individuals with FM benefit from tailored exercise programs that con- arm cranking compared with the same dition muscles and decrease symptoms by countering the effects of power output in leg exercise. Protocols prolonged deconditioning. Primary exercises combine slow stretching, developed for leg cycling tests can evalu- light resistance exercise for all major muscle groups, and low-intensity ate the response to upper-body exercise aerobic activity. Low-impact walking, stair climbing, or swimming is par- with a lower starting frictional resistance ticularly well suited for FM patients. Avoid exercises that include high- and incremental power outputs adjusted impact or high-loading, jogging, aerobic dancing, weight training, racquet accordingly. sports, basketball, or other activities that involve repetitive jumping (www.ncpad.org/ ).

•644 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits Figure 18.4 Examples of 2 arm-crank ergometers for testing physiologic and metabolic responses to upper-body exercise. Safety of Stress Testing The yearly death rate from • True-positive: Test results correctly diagnose heart disease stress testing ranges between 2% and 12% for men with (test is successful). clinical evidence of heart disease. Such broad variation in expected mortality directly relates to the number and • False-negative: Normal test results but heart disease is pres- severity of diseased coronary arteries. ent (test is unsuccessful; heart disease is undiagnosed). In approximately 170,000 submaximal and maximal • True-negative: Test results are normal; no heart disease is stress tests, only 16 high-risk but apparently healthy present (test is successful). patients experienced coronary episodes. This represents about 1 person per 10,000 or approximately 0.01% of the • False-positive: Test results are abnormal but the person does total group. In more than 9000 stress tests, no cardiovas- not have heart disease (test is unsuccessful; healthy person cular episodes occurred for subjects with increased heart diagnosed with heart disease). disease risk. In other reports, the risk of coronary episodes for healthy, middle-aged adults during a maximum stress False-negative results occur 25% of the time, and false- test equaled about 1 in 3000. In most middle-aged individ- positives 15%. False-negative and false-positive test uals, test risk generally increases about 6 to 12 times higher results have dramatic ramifications, particularly a false than for young adults. For patients with documented CHD negative result when an individual’s heart disease goes (including previous MI or episodes of angina), the risk of undiagnosed. Whenever a stress test indicates the pres- cardiovascular incident in stress testing increases 30 to ence of heart disease, subsequent thallium imaging or 60 times above normal. Based on total risk analyses, many angiocardiography (see p. 648) must confirm the diagno experts believe that a lower “overall risk” exists for those sis. Despite these limitations, the predictive value of an who take a GXT and then initiate a regular exercise pro- abnormal stress test result exceeds the predictive value of gram than for those who refrain from testing and remain a normal test result. sedentary. Exercise-Induced Indicators Stress Test Outcomes The clinical value of a stress test of Coronary Heart Disease depends on how well it detects heart disease or its degree of sensitivity. Sensitivity of a stress test refers to the percent- The prognostic value of exercise testing in asymptomatic age of people with actual disease who have an abnormal test individuals comes from exercise-induced observations of result (true-positive test result ). Four possible outcomes ECG ischemia and other abnormalities and fitness-relate from a graded exercise stress test include: variables obtained during the GXT.

•Chapter 18 Clinical Aspects of Exercise Physiology 645 Upsloping S-T Horizontal S-T Downsloping S-T Questions & Notes segment depression segment depression segment depression List 3 factors that influence a person’ physiologic response to submaximal or maximal exercise. 1. 2. Figure 18.5 Three types of S-T segment depression: upsloping, horizontal, and 3. downsloping. Exercise-Induced Electrocardiographic Indicators Describe the Bruce GXT protocol. of Coronary Heart Disease Describe the Balke GXT protocol. Angina Pectoris Approximately 30% of initial manifestations of CHD during Give the units of measurement for power exercise are revealed from chest-related pain, termed angina pectoris. This con- on a bicycle ergometer. dition indicates insufficiency of coronary blood flow, where oxygen supp momentarily reaches critically low levels. Myocardial ischemia (insufficien Define PVC oxygen supply caused by coronary atherosclerosis) stimulates sensory nerves in the walls of coronary arteries and myocardium. (Refer to Fig. 18.3 for loca- tions of angina pain.) After resting a few minutes the pain usually subsides without permanent damage to the heart muscle. Electrocardiographic Disorders Alterations in the heart’s normal pattern of electrical activity rarely present until the heart’s metabolic and blood flo requirements increase above rest. The most common ECG abnormalities during exercise indicate myocardial ischemia from coronary artery obstruction. This obstruction generally relates to more than 50% diameter reduction from occlu- sion. A significantly obstructed coronary artery can still maintain adequat blood flow at rest but cannot deliver sufficient blood (and oxygen) to me increased myocardial needs with exercise. Ischemia does not always produce angina pectoris; its diagnosis most readily occurs through depressions of the S-T segment of the ECG.Figure 18.5 shows three types ofS-T segment depres- sions: upsloping, horizontal, and downsloping. Alterations in cardiac rhythm (arrhythmia) with exercise frequently appear as PVCs (Fig. 18.6). In this case, the ventricles demonstrate disorganized elec- trical activity. The ECG shows this as an “extra” ventricular beat (QRS com- plex) that occurs without a P wave normally preceding it. Exercise PVCs generally herald the presence of severe ischemic atherosclerotic heart disease, often involving two or more major coronary vessels. Individuals who experi- ence frequent PVCs have a high risk of sudden death from ventricular fibrillation an electrical instability when ventricles fail to contract synchronously. This PVC PVC PVC PVC Figure 18.6 Electrocardiographic tracing illustrating premature ventricular contractions (PVCs).

•646 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits BOX 18.2 CLOSE UP Determining Heart Rate From an Electrocardiographic Tracing The ECG depicts the pattern of electrical activity across STANDARD ELECTROCARDIOGRAPH the myocardium recorded by an electrocardiograph. As the wave of depolarization travels throughout the TRACING heart, electrical currents spread through the highly con- ductive body fluids for monitoring by electrodes place Figure 1 shows a standard ECG tracing with time on the skin’s surface. Standard markings on the ECG recorded on the horizontal axis. The paper normally paper allow time interval and voltage measurements dur- moves at 25 mm per second. A repeating grid marks the ing ECG propagation. ECG paper; major grid lines occur 5 mm apart (at 25 mm иsϪ1 paper speed, 5 mm ϭ 0.20 s), minor grid R P-R S-T segment segment Voltage, (mV) T Isoelectric 10mm=1mV P line P-R QS interval QRS interval Q-T interval 0 0.2 0.4 0.6 0.8 Time, (s) Sinoatrial Common A-V node bundle (HIS) Atrioventricular node Left bundle branch Purkinje fibers Right bundle branch Figure 1 Normal electrocardiographic tracing.

•Chapter 18 Clinical Aspects of Exercise Physiology 647 lines occur 1 mm apart (at 25 mm · s Ϫ1 paper speed, Method 2 1 mm ϭ 0.04 s). The graph’s vertical axis indicates elec- This method begins with an R wave that falls on a thick trical voltage. The standard calibration factor equals 0.1 blue line of the tracing (Fig. 2B). Moving to the right, the mV (millivolt) per mm of vertical deflection next six thick lines represent heart rates of 300, 150, 100, 75, 60, and 50 mmиsϪ1 (these numbers need to be mem- DETERMINING HEART RATE orized). If the next R wave (after the first one falling o Three methods determine heart rate from the standard the thick line) falls on either the first through sixth sub ECG tracing. sequent thick lines, the corresponding number (300 to 50) indicates heart rate in mm иsϪ1. Interpolation Method 1 becomes necessary if the next R wave falls between two Figure 2A shows the standard R-R method . The R-R thick lines. In this instance, the first R wave falls betwee interval indicates the time between successive R waves. points 60 and 75 at 70 mmиsϪ1. An approximate heart rate in beats per minute (bиminϪ1) can be determined by dividing 1500 Method 3 (60 s ϫ 25 mmиsϪ1) by the number of mm between adja- This method ( Fig. 2C), often used with irregular heart cent R waves. In the example, heart rate equals rates, counts the number of complete R-R intervals in a 125 bиminϪ1 because 12 mm occurs between two suc- 6-s ECG strip multiplied by 10. In this example, six com- cessive R waves. plete R-to-R intervals occur in 6 s; this equals a heart rate of 60 bиminϪ1 (6 ϫ 10 ϭ 60). A 12 mm between R waves HR = 1500 mm • min-1 = 125 b • min−1 12 mm • b-1 B Start 300 150 100 75 60 50 HR = 70 b • min−1 3-second mark C 6 cardiac cycles in 6 s x 10 = 60 b • min−1 Figure 2 Three methods for determining heart rate from electrocardiographic tracings.

•648 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits disrupts myocardial function, causing cardiac output to de- into the right or left side of the heart. Sensors on crease dramatically. the catheter tip accurately measure pressure gra- dients at various locations within the heart’s Exercise-Induced Nonelectrocardiographic chambers or large vessels and also assess the Indicators of Coronary Heart Disease Two heart’s electrical patterns to determine coronary artery blockage. The oxygen content of arterial useful nonelectrocardiographic indicators of possible CHD and mixed-venous blood comes from blood sam- include blood pressure and heart rate response to exercise. pled from the ventricles or atria. Cardiac catheter- ization takes place under local anesthesia, Hypertensive or Hypotensive Response During a graded depending on the point of catheter entry into the exercise test, a normal, progressive transition in systolic arm or leg. The patient remains awake during the blood pressure occurs from about 120 mm Hg at rest to procedure, and test results usually become avail- 160 to 190 mm Hg during peak exercise. Diastolic blood able on the day of testing. pressure generally changes less than 10 mm Hg. A hyper- 3. Coronary angiography provides an intracardiac tensive response in strenuous exercise can elevate systolic radiograph after a radiopaque contrast medium blood pressure to 250 mm Hg or higher, and diastolic enters the coronary blood vessels, and its passage blood pressure can approach 150 mm Hg. Abnormal blood viewed during a cardiac cycle. This technique accu- pressure responses to exercise often provide an important rately assesses the extent of atherosclerosis and clue to cardiovascular disease. serves as the criterion “gold standard” for viewing coronary blood flow. It also creates a baseline fo Failure of blood pressure to increase with graded exer- other test comparisons and validations. Angiogra- cise called a hypotensive response indicates cardiovascular phy does not show how readily blood flows withi malfunction. For example, diminished cardiac reserve may local portions of the myocardium (not a measure of exist if systolic blood pressure does not increase by at least capillary blood flow) and cannot be used durin 20 or 30 mm Hg during graded exercise. exercise. Heart Rate Response An abnormally rapid heart rate Functional Classification (tachycardia) early in submaximal exercise often foretells cardiac problems. Likewise, abnormally low exercise heart of Heart Disease rate (bradycardia) usually reflects sinus node malfunctio (sick sinus node syndrome). An inability of the heart rate Table 18.11 shows a system for classifying the func- to increase during exercise, especially when accompanied tional and therapeutic characteristics of various stages by extreme fatigue, indicates cardiac strain and underlying of heart disease. Substantial individual differences exist heart disease. in symptoms, functional capacities, and appropriate rehabilitation requirements. Whenever patients under- In asymptomatic women, heart rate recovery provides a take rehabilitation, their classification should include more sensitive predictor of cardiovascular disease and all- available medical screening information and a recent cause mortality than S-T segment depression. Because GXT. nearly two-thirds of women who die suddenly from car- diovascular disease have no previous symptoms, the Exercise Prescription for Cardiac Patients important potential role of treadmill testing this popula- tion should be recognized. Heart rate and oxygen uptake obtained during the GXT form the basis for an individualized exercise prescription. Many Invasive Physiologic Tests people who start exercising do not recognize their limita- tions and exercise above a prudent level. Even group exer- Invasive physiologic tests provide diagnostic information cise programs that require medical clearance may not be unavailable through noninvasive procedures. This infor- appropriate because all members often exercise at about mation includes the extent, severity, and location of coro- the same work level (walk, jog, or swim at a similar pace) nary atherosclerosis, degree of ventricular dysfunction, without much attention paid to individual differences in and specific cardiac abnormalities. The three most com fitness status mon invasive physiologic tests are: Figure 18.7 illustrates a practical approach for func- 1. Radionucleotide studies include two types: (1) thal- tional translation of treadmill or cycle ergometer exercise lium imaging, which evaluates areas of myocardial test responses to an exercise prescription. Heart rate ( A) blood flow and tissue perfusion to differentiat during the Bruce test is plotted as a function of time. LineB between a true- and a false-positive S-T segment depicts a mathematical line of “best fit” drawn through depression (by ECG evaluation), and (2) ventricu- the data points. A target zone for heart rate equals 60% to lography, an imaging procedure that provides 75% of maximum heart rate (167 b иminϪ1; shaded portion information about left ventricular functional represented as C). The individualized prescription includes dynamics. pace (14.0–15.4 min per mile, D) or METs (3.9 to 5.9, E). The acceptable range of exercise intensity in area C, based 2. Cardiac catheterization involves threading a small-diameter, flexible tube (catheter), guided b x-ray, directly into an arm or leg vein or artery

Table 18.11 Functional Capacity and Therapeutic Classifications of Heart Disease Functional Capacity Classificatio Class I No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. Class II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. Class III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Class IV Unable to carry on any physical activity without discomfort. Symptoms of cardiac insufficiency or angina may b present even at rest. If any physical activity is undertaken, discomfort increases. Therapeutic Classificatio Class A Physical activity need not be restricted. Class B Ordinary physical activity need not be restricted, but unusually severe or competitive efforts should be avoided. Class C Ordinary physical activity should be moderately restricted, and more strenuous efforts should be discontinued. Class D Ordinary physical activity should be markedly restricted. Class E Patient should be at complete rest and confined to bed or a chair Exercise Prescription—Untrained Individuals Bruce Treadmill GXT / Level Ground Ambulation 200 Name: Heart rate (b . min–1) 175 A B 150 C Target Heart Rate 125 100 00 3 6 9 12 15 18 GXT Time (min) D Pace Walk Walk-Jog Jog (min per mile) 15 10 E METs 3.5 4 56 7 8 9 10 11 12 Softball Bicycling Basketball Touch Football Soccer Bowling Canoeing Alpine Skiing Golf Aerobics Handball/Raquetball Rope Skipping Max HR: 167 Rest HR: 78 Volleyball Nordic Skiing Target HR: 131 to 145 Tennis/Badminton % Max HR: 60% to 75% Swimming Pace: 14.0 to 15.4 min/mile Skating METS: 4.1 to 5.9 Freq: Duration: Waterskiing Figure 18.7 Exercise prescription based on functional translation algorithm for level ground ambulation. (Courtesy of Dr. C. Foster, Professor, Department of Exercise and Sport Science; Director, Department of Exercise and Sport Science, University of Wisconsni -La Crosse.) 649

•650 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits BOX 18.3 CLOSE UP The Revised rPAR-Q to Assess Readiness for Physical Activity REFERENCE Canadian Society for Exercise Physiology: Par-Q and You. Gloucester, Ontario, Canada: Canadian Society for Exercise Physiology, 1994.

•Chapter 18 Clinical Aspects of Exercise Physiology 651 on heart rate response during the graded exercise test, includes the following Questions & Notes recreational activities: bicycling, canoeing, alpine skiing, aerobics, volleyball, tennis and badminton, swimming, skating, and waterskiing. This quantitative List 2 common noninvasive physiologic method of assigning exercise improves exercise prescription specificity and pre tests for CHD. cision for previously sedentary, healthy individuals and patients with diagnosed cardiovascular diseases. 1. Guidelines Any exercise prescription should begin with 5 to 10 minutes of 2. light stretching and range of motion (ROM) activities followed by several min- List 2 variables used to formulate an exer- utes of light to moderate rhythmic “warm-up” movements. The aerobic condi- cise Rx for cardiac patients. tioning phase should progress in duration so individuals eventually perform 30 to 45 minutes of continuous activity at the prescribed intensity followed by 5 to 1. 15 minutes of low-intensity walking or other rhythmic “cool-down” activities. 2. Most cardiac rehabilitation patients easily tolerate exercising 3 days per week with no more than a 2-day lapse between exercise sessions. For elderly patients or those with poor functional capacity ( Ͻ5 METs), low-intensity exercise should be performed daily or twice daily. As a patient’s functional capacity improves, exercise intensity and duration can increase progressively with little fear of complications. The most recent GXT serves as the basis for updating the exercise prescription. Three other important components of cardiac rehabilitation include (1) patient education, (2) appropriate pharmacologic intervention, and (3) fam- ily support counseling. A trained social worker often coordinates these aspects of the rehabilitative process. Beneficial Effects of Resistance Exercis Resistance exercise helps restore List 2 nonelectrocardiographic indicators and maintain muscular strength, preserve fat-free body mass (FFM), improve of CHD. psychological status and quality of life, and increase glucose tolerance and insulin sensitivity. Combining resistance training and aerobic training yields 1. more pronounced physiologic adaptations (improved aerobic capacity, muscle strength, and lean body mass) in patients with CAD than aerobic training alone. 2. The following six conditions preclude cardiac patients from participating in resistance training: Under what conditions would you use the PAR-Q questionance? 1. Unstable angina 2. Uncontrolled arrhythmias 3. Left ventricular outflow obstruction (e.g., hypertrophic cardiomyopath with obstruction) 4. Recent history of CHF without follow-up and treatment 5. Severe valvular disease, hypertension (systolic blood pressureϾ160 mm Hg or diastolic blood pressure Ͼ105 mm Hg) 6. Poor left ventricular function and exercise capacity below 5 METs with anginal symptoms or ischemic S-T segment depression Resistance Training Prescription Cardiac patients should exercise List 2 benefits of including resistance exer cise as part of the exercise Rx for patients with light resistance (range of 30%–50% of 1-RM) because of exaggerated blood with CAD. pressure responses with straining-type exercise. In the absence of contraindica- tions, elastic bands, light (1–5 lb) cuff and hand weights, light free weights, and 1. wall pulleys can be applied at entrance to an outpatient program. Low-level resistance training should not be started until 2 to 3 weeks after MI. Barbells or 2. weight machines should be introduced after 4 to 6 weeks of convalescence. Most cardiac patients begin ROM exercises using relatively light weights for the lower and upper extremities. In accordance with recommendations of the American Heart Association (AHA; www.americanheart.org), they should per- form one set of 10 to 15 repetitions to moderate fatigue using 8 to 10 different exercises (e.g., chest press, shoulder press, triceps extension, biceps curl, lat pull-down, lower back extension, abdominal crunch or curl-up, quadriceps extension or leg press, leg curl, calf raise). Exercises performed 2 to 3 days a week produce favorable adaptations. The rating of perceived exertion (RPE)

•652 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits should range from 11 to 14 on the Borg scale (“fairly light” mately affects the lung’s mechanical function and compro- to “somewhat hard”). To minimize dramatic blood pressure mises alveolar gas exchange. In the United States, COPD fluctuations during lifting, patients should be warned t ranks as the fourth leading cause of death and the second avoid straining, performing the Valsalva maneuver, and leading cause of morbidity; its economic burden averages gripping weight handles or bars tightly. about $43 billion annually. The natural history of COPD spans 20 to 50 years and closely links to chronic cigarette For heart transplant patients, a carefully supervised smoking. total body resistance training program 3 days weekly for 6 months increases functional strength and muscle mass to COPD is usually diagnosed from changes in pulmonary counter the generally debilitating effects of immunosup- function, most notably a decrease in expiratory flow rate an pressive medication. increase in residual lung volume. Classic symptoms include spontaneous spasms of bronchial smooth muscle that pro- PULMONARY DISEASES duce chronic coughing, inflammation and thickening o the mucosal lining of the bronchi and bronchioles, AND DISORDERS increased mucus production, wheezing, and dyspnea upon physical exertion. Table 18.13 summarizes the differ- The exercise physiologist’s involvement in treating patients ences among major COPD conditions. with pulmonary disease focuses on improving ventilation, decreasing the work of breathing, and increasing the overall In all forms of COPD, the airways narrow to obstruct level of functional capacity. The exercise physiologist applies airflow. Airway narrowing hinders alveolar ventilation b clinical information from the patient’s personal history, phys- trapping air in the bronchi and alveoli; in essence, COPD ical examination, pertinent laboratory data, and imaging increases physiologic dead space. Obstruction principally studies. Disorders of the cardiovascular system usually increases resistance to airflow during expiration, impair impair pulmonary function. Conversely, cardiovascular com- normal alveolar gas exchange, diminishes exercise capac- plications often occur after the onset of pulmonary disease. ity, and reduces ventilatory capacity. Restrictive (reduced lung volume dimensions) and The following brief discussion centers on three major obstructive (impeded air flow) lung diseases represent tw COPD diseases: chronic bronchitis, emphysema, and cystic common classifications for pulmonary dysfunction. Sev fibrosis. Chapter 11 discussed the obstructive condition eral pulmonary disorders combine both restrictive and of asthma and exercise-induced bronchospasm. obstructive impairments. Chronic Bronchitis Acute bronchitis refers to self- Restrictive Lung Dysfunction limiting and short-duration inflammation of the trache Restrictive lung dysfunction (RLD) , characterized by and bronchi. In contrast, chronic bronchitis mostly abnormal reduction in pulmonary ventilation, includes occurs with long-term exposure to nonspecific irritants diminished lung expansion and decreased tidal volume. Increases in mucus secretion accompany prolonged respi- The chest and lung tissues in RLD tend to stiffen and offer ratory tract inflammation. Over time, the swollen mucou considerable resistance to expansion under normal pul- membranes and thick sputum obstruct airways, causing monary pressure differentials. This represents a reduction wheezing and persistent coughing. Partial or complete air- in lung compliance, that is, the change in lung volume per way blockage from mucus secretion causes insufficien unit change in intra-alveolar pressure. Decreased pul- arterial oxygen saturation and edema, which produces monary compliance increases the energy cost of ventilation the characteristic look of the “blue bloater” ( Fig. 18.8). even at rest. Eventually, RLD progresses to a point where Chronic bronchitis develops slowly and worsens over considerable decreases occur in all lung volumes and time. Patients usually have been long-term smokers. capacities. Functional exercise capacity remains low, and fatigue occurs readily with only moderate effort. If left untreated, Table 18.12 lists major RLDs along with causes, signs the disease can lead to death. and symptoms, and treatments. Other known causes of RLD include rheumatoid arthritis, immunologic impair- Emphysema Abnormal, permanent enlargement of air ment, massive obesity, diabetes mellitus, trauma from impact injuries, penetrating wounds, burns and other spaces distal to the terminal bronchi characterizes emphy- inhalation injuries, radiation trauma, poisoning, and com- sema. This disease often develops from chronic bronchitis plications from drug therapy (including negative reactions and occurs frequently in long-term cigarette smokers. to antibiotics and anti-inflammatory drugs) Symptoms include extreme dyspnea, abnormally increased arterial carbon dioxide tension (hypercapnia), persistent Chronic Obstructive Pulmonary Disease cough, cyanosis, and digital clubbing (evidence of chronic hypoxemia; Fig. 18.9). Patients frequently appear thin; Chronic obstructive pulmonary disease (COPD) , also they lean forward with their arms braced on their knees to termed chronic airflow limitation (CAL), includes respira- support their shoulders and chest for easier breathing. The tory diseases that produce airflow obstruction. This ulti effects of trapped air and alveolar distention change the size and shape of the chest, causing the characteristic emphy- semic “barrel chest” appearance (Fig. 18.10).

•Chapter 18 Clinical Aspects of Exercise Physiology 653 Table 18.12 Major Restrictive Lung Diseases and Their Causes, Signs and Symptoms, and Treatment CAUSES/TYPE ETIOLOGY SIGNS AND SYMPTOMS TREATMENT I. Maturational Premature birth (hypoplasia- Asymptomatic; pulmonary No specific treatmen a. Abnormal fetal lung reduced lung tissue) insufficienc development Treat mother prior to birth b. Respiratory distress Insufficient maturation of lung c respiration rate; T lung (corticosteroids); syndrome (hyaline due to premature birth volumes; T PaO2; acidemia; hyperalimentation; membrane disease) rapid and labored respiration continuous positive airway c. Aging Aging and cumulative effects of pressure pollution, noxious gas, No specific treatment II. Pulmonary inhaled drug use, and c residual volume; T vital increase physical activity a. Idiopathic pulmonary cigarette smoking capacity; repetitive periodic fibrosi (IPF) apnea Corticosteriods; maintain b. Coal workers’ Unknown orign (perhaps viral adequate nutrition and pneumoconiosis or genetic) T lung volumes; pulmonary ventilation hypertension; dyspnea; cough; c. Asbestosis Repeated inhalation of coal dust weight loss, fatigue Nonreversible, no known over 10–12 y cure d. Pneumonia T TLC, VC, FRC; T lung Chronic exposure to asbestos compliance; dyspnea; Nonreversible, no known e. Adult respiratory T PaO2; pulmonary cure distress syndrome Inflammatory process caused b hypertension; cough various bacteria, microbes, Drug therapy (antibiotic) f. Bronchogenic carcinoma viruses T lung volumes; abnormal x-ray; g. Pleural effusions T PaO2; dyspnea on exertion; Intubation and mechanical Acute lung injury (fat emboli, shortness of breath ventilation III. Cardiovascular drowning, drug induced, a. Pulmonary edema shock, blood transfusion, T lung volumes; abnormal x-ray; Surgery; radiation; pneumonia) tachypneic dyspnea; high fever, chemotherapy b. Pulmonary emboli chills, cough; pleuritic pain Tobacco use Specific drainag Abnormal lung function tests; Accumulation of fluid withi PaO2 Ͻ 60 mm Hg; extreme Drug therapy; diuretics; pleural space; heart failure; dyspnea; cyanotic; headache; supplemental O2 cirrhosis anxiety Heparin therapy; mechanical c pulmonary capillary Variable depending on type and ventilation hydrostatic pressure location of growth secondary to left ventricular failure Shortness of breath; pleuritic chest pain; T PaO2 Complications of venous thrombosis c respiration rate; T lung volumes; T PaO2; arrhythmias; feeling of suffocation, shortness of breath, cyanotic, cough T lung volumes, T PaO2; tachycardia; acute dyspnea, shortness of breath; syncope Differences Among Major Chronic Obstructive Table 18.13 Pulmonary Diseases NAME AREA AFFECTED RESULT Bronchitis Membrane lining Inflammation of bronchial linin Bronchiectasis bronchial tubes Emphysema Bronchial dilation with Asthma Bronchial tubes (bronchi or inflammatio air passages) Breakdown of alveolar walls; air Air spaces beyond terminal spaces enlarged bronchioles (aleveoli) Bronchioles obstructed by muscle Bronchioles (small airways) spasm; swelling of mucosa; thick secretions Cystic fibrosi Bronchioles Bronchioles become obstructed and obliterated; plugs of mucus cling to airway walls leading to bronchitis, atelectasis, pneumonia, or pulmonary abscess

•654 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits Terminal bronchiole Mucous lining Damaged alveoli Normal alveoli Dorsal Prominent kyphosis anterior chest Increased anterior- posterior chest diameter Figure 18.8 Individuals with chronic bronchitis usually Figure 18.10 Emphysema traps air in the lungs, making develop cyanosis and pulmonary edema with the characteristic exhalation difficult. With time, changes in the patient’s physica appearance known as “blue bloater.” The effects of chronic features include a “barrel chest” appearance. bronchitis displayed in the inset illustrate misshapen or large alveolar sacs with reduced surface for oxygen and carbon diox- ide exchange. Exercise cannot “cure” emphysema, but it does enhance white newborn infants in the United States (1 in 15,000 cardiovascular fitness and strengthen the respiratory mus African Americans and 1 in 32,000 Asian Americans). The culature. Regular exercise also improves patients’ psycho- disease, inherited as a recessive trait because both parents logical state. are carriers, has no current cure and remains fatal. Cystic Fibrosis The term cystic fibrosis (C ; Pulmonary system involvement represents the most com- mon and severe manifestation of CF. Airway obstruction www.cff.org) originated from observing cysts and scar tis- leads to a chronic state of hyperinflation. Over time, RL sue on the pancreas of autopsied patients. These, however, superimposes on the obstructive disorder, leading to chronic are not primary characteristics of the disease (although the hypoxia, hypercapnia, and acidosis. Pneumothorax and pul- term cystic fibrosis remains in use). Table 18.14 lists clini- monary hypertension eventually follow and cause death. cal signs and symptoms of CF. This disease, characterized by thickened secretions of all exocrine glands (e.g., pancre- Treatment of CF includes antibiotics, enzyme supple- atic, pulmonic, and gastrointestinal), eventually obstructs ments, nutritional intervention, and frequent secretion pulmonary airflow. The most common inherited geneti removal. Regular physical activity can provide beneficia disease in whites, CF affects approximately 1 in about 3500 Clinical Signs and Symptoms of A Table 18.14 Cystic Fibrosis and Related B Pulmonary Involvement Figure 18.9 Normal digit configuration A) and example of Early stages • Persistent cough and wheezing digital clubbing (B), indicating chronic tissue hypoxia, a • Recurrent pneumonia common physical symptom of emphysema. • Excessive appetite but poor weight gain • Salty skin or sweat • Bulky, foul-smelling stools (undigested lipids) Latter stages (with • Tachypnea (rapid breathing) significant • Sustained chronic cough with mucus pulmonary involvement) production on vomiting • Barrel chest • Cyanosis and digital clubbing • Exertional dyspnea with decreased exercise capacity • Pneumothorax • Right heart failure secondary to pulmonary hypertension

•Chapter 18 Clinical Aspects of Exercise Physiology 655 outcomes. Twenty minutes of aerobic exercise replaces one session of secretion uestions & Notes Qremoval in some children. Increased minute ventilation with aerobic exercise helps clear excessive secretions from the airways. Improved physical fitnes List 3 symptoms of cystic fibrosis. may also play a role in delaying the severe effects of CF. 1. Pulmonary Assessments 2. Chest and lung imaging provide the most common pulmonary assessment tech- 3. niques. These include conventional radiography and computed tomography (CT) scanning to (1) screen for abnormalities, (2) provide a baseline for subse- List 3 goals for pulmonary rehabilitation. quent assessments, and (3) monitor disease progression. Magnetic resonance 1. imaging (MRI) plays a limited role because the density of large portions of the lungs cannot generate clear magnetic signals. Static and dynamic tests of lung 2. function, pulmonary diffusing capacity, and flow–volume loops also provid important diagnostic information. 3. Pulmonary Rehabilitation and Exercise Prescription List 3 components of a pulmonary rehabili- tation program. Pulmonary rehabilitation receives considerably less attention than rehabilitative programs for cardiovascular and musculoskeletal diseases. Perhaps deemphasis 1. results from rehabilitation’s failure to markedly improve pulmonary function or reverse the natural progression of these debilitating and often deadly diseases. 2. Pulmonary rehabilitation can have marked, positive effects on exercise capacity, respiratory muscle function, psychological status, quality of life variables (e.g., 3. self-esteem and self-efficacy), frequency of hospitalization, and disease progres sion. Nine major goals for pulmonary rehabilitation include the following: For Your Information 1. Improve health status EIGHT FACTORS PREDISPOSING TO 2. Improve respiratory symptoms (shortness of breath and cough) CHRONIC OBSTRUCTIVE 3. Recognize early signs requiring medical intervention PULMONARY DISEASE 4. Decrease the frequency and severity of respiratory problems 1. Chronic cigarette smoking 5. Obtain maximal arterial oxygen saturation 2. Air pollution 6. Improve daily functional capacity through enhanced muscular strength, 3. Occupational exposure to joint flexibility, and cardiorespiratory enduranc irritating dusts or gases 7. Improve strength and power of the ventilatory musculature 4. Heredity 8. Improve body composition 5. Infection 9. Improve nutritional status 6. Allergies 7. Aging Pulmonary rehabilitation programs include the following five components 8. Drugs 1. General care 2. Pulmonary respiratory care 3. Exercise and functional training 4. Education 5. Psychosocial management The exercise and functional training aspects of rehabilitation are particularly important to individuals with end-stage disease because the effects of weakness, fatigue, and severe dyspnea profoundly limit physical activity. Physiologic mon- itoring during exercise rehabilitation should assess heart rate, blood pressure, respiratory rate, arterial oxygen saturation by pulse oximetry (indicates arterial oxygen desaturation), and dyspnea. Dyspnea monitoring involves a perceived dyspnea “Likert-type” scale (Fig. 18.11), similar to psychometric scales for RPE. Extreme shortness of breath, fatigue, palpitations, chest discomfort, or a decrease of 3% to 5% on pulse oximetry indicates the need to terminate the exercise test. The pretraining GXT and spirometric analyses govern the exercise prescrip- tion. Exercise stress test interpretation includes the following: 1. Whether the test terminated for cardiovascular or ventilatory end points

•656 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits DYSPNEA SCALE vide helpful guidelines for formulating an exercise pre- scription. Brief bouts of interval exercise often benefit thi +1 Mild difficulty, noticeable to the population. Patients should exercise a minimum of once patient but not the observer daily because of the relatively low initial training prescrip- tion. Even small gains in exercise tolerance improve an +2 Mild difficulty, noticeable to the individual’s functional capacity and quality of life indices. observer For all patients with pulmonary disease, regular exer- +3 Moderate difficulty, patient can cise contributes to improved respiratory muscle function. continue Two approaches achieve this goal: +4 Severe difficulty, patient cannot 1. Resistance training of the ventilatory muscles by continue use of a continuous positive airway pressure (CPAP) device improves their strength and power. Figure 18.11 Dyspnea scale. Grading of subjective ratings Overload takes place in a manner similar to of dyspnea intensity during exercise testing occurs on a scale of progressive resistance exercise for other skeletal 1 to 4. Dyspnea usually accompanies poor exercise capacity and muscles. impaired ability to increase systolic blood pressure during graded exercise testing. 2. Increases in endurance performance capacity of res- piratory muscles through a general program of reg- ular and progressive aerobic exercise training. NEUROMUSCULAR DISEASES AND DISORDERS 2. Difference between pre- and postexercise Neuromuscular diseases represent conditions affecting the pulmonary function (e.g., a decrease of 10% in brain in specific ways. Progressive nerve degeneration o forced expiratory volume in 1 second [FEV1.0] indi- trauma to specific brain neurons result in impairment tha cates the need for bronchodilator therapy before ranges from simple to complex. More Americans are hospi- exercise) talized with neurologic and mental disorders than any other major disease group, including heart disease and cancer!The 3. Need for supplemental oxygen from arterial oxygen economic costs of brain dysfunction are enormous, but desaturation during exercise with a decrease in they pale in comparison with the staggering emotional toll PaO2 of Ͼ20 mm Hg or a PaO2 of Ͻ55 mm Hg on victims and families. The exercise prescription for a patient with mild pul- Stroke monary disease (shortness of breath with intense exercise) mirrors that for a healthy individual. For patients with Stroke, sometimes called acute cerebrovascular attack, moderate disease (shortness of breath with normal daily refers to a potentially fatal reduction in oxygen supply to activities or clinical symptoms of RLD or COPD), exercise part of the brain from restricted blood supply (ischemia) training can proceed as follows: or bleeding (hemorrhage). The resulting brain injury affects multiple systems depending on the injury site and 1. An intensity no greater than 75% of ventilatory the amount of damage sustained. Effects include motor reserve and sensory impairment and language, perception, and affective and cognitive dysfunction. Strokes can cause 2. The middle of the calculated training heart rate severe limitations in mobility and cognition or can be mild range (50% to 70% of age-predicted HRmax) with only short-term, nonpermanent consequences. 3. The point where the patient becomes noticeably Clinical Features Clinical features of stroke depend dyspneic between 40% to 85% of maximum MET level on a GXT. on the location and severity of the injury. Signs of a hem- orrhagic stroke include altered levels of consciousness, Under these circumstances, exercise duration usually severe headache, and elevated blood pressure. Cerebellar lasts 20 minutes and is performed three times a week. If hemorrhage usually occurs unilaterally and associates with 5- to 15-minute exercise durations are more desirable, disequilibrium, nausea, and vomiting. Table 18.15 pres- exercise frequency should increase to 5 to 7 days weekly. ents the typical physical and psychological traits and comorbidities associated with stroke. Patients with severe pulmonary disease (shortness of breath during most daily activities, and forced vital capac- Cerebral blood flow (CBF) represents the primar ity [FVC] and FEV 1.0 below 55% of predicted values) marker for assessing ischemic strokes. When CBF require a modified approach to exercise testing and pre decreases below 10 mL и100 gϪ1 и minϪ1 (reference range, scription. Usually low-level, discontinuous testing can begin at 2 to 3 METs with increments every several min- utes. Symptom-limited walking speeds and distances pro-

•Chapter 18 Clinical Aspects of Exercise Physiology 657 50–55 mLи100 gϪ1 и minϪ1), synaptic transmission failure occurs, and a CBF of uestions & Notes Q8 mLи100gϪ1 и minϪ1 or below results in cell death. Strokes cause physical and cognitive damage. Left-hemisphere lesions typi- List 2 variables that require monitoring cally accompany expressive and receptive language deficits compared wit during exercise rehabilitation. right-hemisphere lesions. Motor impairment usually results in hemiplegia (paralysis) or hemiparesis (weakness). Damage to descending neural pathways 1. produces an abnormal regulation of spinal motoneurons, resulting in adverse changes in postural and stretch reflexes and difficulty with voluntary mov ment. Deficits in motor control may involve muscle weakness, abnormal syner 2. gistic organization of movement, impaired regulation of force, decreased reaction times, abnormal muscle tone, and loss of active range of joint motion. Exercise Prescription The emphasis for stroke survivors centers on reha- Briefly describe the dyspnea grading scale. bilitation of movement during the first 6 months of recovery (increase flexibili Describe the major clinical feature of a [passive and active-assisted], strength development). The few exercise-training stroke. studies with stroke patients support the use of exercise to improve mobility and functional independence and to prevent or further reduce disease and functional impairment. Stroke survivors vary widely in age; degree of disability; motiva- tional level; and number and severity of comorbidities, secondary conditions, and associated circumstances. The specific exercise prescription interventio should focus on reducing these conditions and improving functional capacity. Multiple Sclerosis Describe the most common clinical symptom of multiple sclerosis. Multiple sclerosis (MS) represents a chronic, often disabling disease character- ized by destruction of the myelin sheath (demyelination) that surrounds nerve fibers of the CNS (see Chapter 11.) Lesions of inflammatory demyelination c be present in any part of the brain and spinal cord. Clinical Features Two or more areas of demyelination confirm the diag nosis of MS. MS usually develops between the ages of 20 and 40 years. Fre- quently, a history emerges of transient neurologic deficits such as numbness o weakness of an extremity, weakness, blurring of vision, and diplopia (double vision) in childhood or adolescence before development of more persistent neurologic deficits that lead to the definitive diagnosis. MS occurs worldwide a higher frequency in latitudes farther from the equator. The prevalence of MS in the United States below the 37th parallel occurs at a rate of 57 to 78 cases per 100,000, but the prevalence rate above the 37th parallel averages 140 cases per 100,000. Reasons for these differences remain unknown. Patients with a defi nite MS diagnosis more likely have a variety of the autoimmune illnesses such as systemic lupus erythematosus, rheumatoid arthritis, polymyositis, and myasthenia gravis. A person with a first-degree relative with MS has a 12- to 20-fold increased chance of developing MS. Table 18.15 Physical and Psychological Conditions and Comorbidities Associated With Stroke Patients PHYSICAL CONDITIONS PSYCHOLOGICAL CONDITIONS COMORBIDITIES Aphasia Cognitive impairment Coronary heart disease Balance problems Emotional instability Diabetes mellitus Falls Depression Hypertension Fatigue Memory loss Hyperlipidemia Muscle weakness Low self-esteem Obesity Obesity Social isolation Peripheral vascular disease Paralysis Paresis Spasticity Visual impairments

•658 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits Fatigue manifests as the most common early MS symp- Exercise Prescription Most exercise prescriptions tom. Other symptoms include one or all of the following: painful blurring or loss of vision in one eye, muscle weak- for PD patients are individualized and directed toward ness in the extremities, clumsiness, numbness and tin- interventions that impact associated motor control prob- gling, bowel and bladder dysfunction, sexual dysfunction, lems. The rehabilitation exercises emphasize slow, con- joint contractures, urinary tract infection, osteoporosis, trolled movements for specific tasks through variou and spasticity. ranges of motion while lying, sitting, standing, and walk- ing. Treatment protocols include ROM exercises that use Exercise Prescription Patients with MS benefi slow, static stretches for all major muscle and joint areas, balance and gait training, mobility, and muscle coordina- from a comprehensive health prescription that involves tion exercises. Little research has assessed the effects of aerobic, strength, balance, and flexibility exercises. On training on aerobic capacity, and no guidelines exist. Anec- important factor that hinders endurance training in about dotal reports indicate that swimming provides a well-tol- 80% of MS patients relates to adverse effects to heat, erated exercise mode. whether generated environmentally by outside climatic changes or internally via fever or exercise-induced thermo- RENAL DISEASE AND DISORDERS genesis. This effect makes continuous exercise training dif- ficult and poorly tolerated. Nevertheless, MS patients stil Treatment modalities for the major metabolic diseases of obe- can improve cardiovascular function. Stationary cycling, sity, diabetes, and renal disease use regular exercise as walking, and low-impact chair or water aerobics provide adjunctive therapy. Obesity and diabetes have been dis- excellent training choices, depending on personal interest cussed in different chapters of this text. This section and level and nature of physical impairment. Ideal exercise reviews aspects of renal disease associated with kidney consists of walking in a climate-controlled area that pro- function as they relate to exercise physiology. vides stable temperatures, a level surface, and the opportu- nity to rest frequently. Controlling body temperature Chronic kidney disease occurs when the kidneys no represents a primary consideration in the exercise pre- longer adequately filter toxins and waste products fro scription. A realistic and achievable goal for structured blood. Acute renal failure occurs from a toxin (e.g., drug exercise provides training three times per week for a mini- allergy or poison) or severe blood loss or trauma. Diabetes mum of 30 minutes each session divided into three 10- is the number one cause of kidney disease and remains minute sessions. responsible for about 40% of all kidney failures; high blood pressure is the second cause, responsible for about 25% of Parkinson’s Disease all kidney failures. Genetic diseases, autoimmune diseases, and birth defects also cause kidney disorders. Parkinson’s disease (PD), a common neurodegenerative dis- ease of the CNS that often impairs motor skills, speech, and Clinical Features Common symptoms of chronic other functions, has a prevalence of 60 to 187 per 100,000 people worldwide (no population is immune to PD). The risk kidney disease, sometimes referred to asuremia (retention of developing this movement disorder increases with age; in the blood of waste products normally excreted in urine), 10% of patients become symptomatic before age 40 years, include the following: 30% become symptomatic before age 50 years, and 40% become symptomatic between 50 and 60 years. 1. Changes in urination: Making more or less urine than usual, feeling pressure when urinating, Clinical Features Clinical symptoms of PD include changes in the color of urine, foamy or bubbly urine, or having to get up at night to urinate. varying degrees of tremor, a decrease in spontaneity and movement (bradykinesia), rigidity, and impaired postural 2. Swelling of the feet, ankles, hands, or face:Fluid reflexes. These conditions produce extreme gait and pos retention in the tissues from failure of kidney tural instability, resulting in increased episodes of falling filtration or freezing and great difficulty walking. Some patient exhibit a complete lack of movement ( akinesia). Func- 3. Fatigue or weakness: A buildup of wastes or a tional problems also include difficulty getting out of bed o shortage of red blood cells (anemia) causes these a car and rising from a chair. Other problems include diffi problems as the kidneys begin to fail. culties dressing, writing, talking, and swallowing. Persons with PD generally experience difficulty with performin 4. Shortness of breath: Kidney failure is sometimes more than one task simultaneously. As the disease pro- confused with asthma or HF because fluid builds u gresses, such problems become more pronounced as the in the lungs. person eventually loses the ability to perform even the most common activities of daily living. In the last stage of 5. Ammonia breath or an ammonia or metal taste in the disease, the person must begin to use a wheelchair for the mouth: Waste buildup can cause bad breath, mobility and may become bed bound. changes in taste, or an aversion to high-protein foods. 6. Back or flank pain: The kidneys are located on either side of the spine in the back. 7. Itching: Waste accumulation can cause severe itching, especially of the legs.

•Chapter 18 Clinical Aspects of Exercise Physiology 659 8. Loss of appetite. Questions & Notes 9. Nausea and vomiting. 10. Increased hypoglycemic episodes, if the person has diabetes. Give 2 clinical symptoms of Parkinson's Chronic uremia eventually progresses to end-stage renal disease (ESRD) disease. that requires lifelong dialysis or a kidney transplant. The number of renal trans- 1. plants has increased steadily in the past decade worldwide and generally offers a more normal lifestyle and full rehabilitation. More kidney transpants are performed in the United States (16,517 in 2008, about two-thirds from cadav- 2. ers) than any other country in the world (almost by a factor of 9). Nearly 80% of transplant patients function at near normal levels compared with 40% to 60% of those treated with various forms of dialysis. Almost 75% of transplant patients resume a normal work schedule compared with about 50% to 60% for dialysis __________________ is the number one patients. cause of kidney disease. Exercise Prescription Regular exercise serves an important role in reha- List 3 common symptoms of kidney disease. bilitating dialysis and kidney transplant patients to better adapt to their illness. The rehabilitation program should begin before the start of dialysis to optimize 1. beneficial effects. Normal low-level endurance training (following America College of Sports Medicine [ACSM] guidelines) reduces muscle protein degra- 2. dation in moderate renal insufficiency, reduces resting blood pressure in som hemodialysis patients, and modestly improves aerobic capacity in patients 3. undergoing hemodialysis. No longitudinal data exist on the effects of aerobic training or a more physi- cally active lifestyle on the survival of patients with chronic uremia or kidney transplants. However, patients with uremia who maintain a lifetime of diverse physical activity do report an enhanced quality of life, including participation in competitive athletics (www.kidney.org/news/tgames/index.cfm). CANCERS List 3 primary breast cancer risk factors. Cancer represents a group of diseases collectively characterized by uncon- 1. trolled growth of abnormal cells. More than 100 different types of cancers exist, most occurring in adults.Carcinomas refer to cancers that develop from epithelial 2. cells that line the surface of the body, glands, and internal organs. They account for 80% to 90% of all cancers, including prostate, colon, lung, cervical, and 3. breast cancer. Cancers also can arise from cells of the blood ( leukemias); the immune system (lymphomas); and connective tissues such as bones, tendons, For Your Information cartilage, fat, and muscle (sarcomas). DECREASED CANCER PREVALENCE Figure 18.12 presents estimated U.S. cancer deaths for 2009. Lung and ASSOCIATED WITH INCREASED bronchus cancers for men and lung and bronchus and breast cancer for women PHYSICAL ACTIVITY account for the majority of cancer deaths in the adult U.S. population. Although Evidence from more than 25 human lung and bronchus cancer relate to smoking and environmental smoke expo- research studies from different conti- sure, much less is known about the causes of breast cancer. nents with different diets, ways of life, environmental circumstances, race, Cancer has currently replaced heart disease as the top killer of Americans ethnicity, and socioeconomic younger than age 85 years, and approximately one-third of the population has backgrounds and laboratory animals some type of cancer (www.cancer.gov/statistics). Minorities (with different cul- undergoing voluntary or forced exer- tural backgrounds and health and nutrition beliefs) consistently have higher cise show that a reduced risk of cancer cancer rates, although the reasons remain unknown. Cancer represents the development associates with higher leading cause of death in women between age 25 and 44 years. levels of regular physical activity. The current population of more than 8 million cancer survivors (many ini- tially diagnosed in the 1970s and 1980s) illustrates the ongoing need for reha- bilitative and maintenance options in this important area of medicine. The most serious outcomes for most cancer patients and survivors include loss of muscle mass and functional status. Reduced functional status encompasses difficult walking (even short distances) and serious fatigue that limits completion of simple household chores. Approximately 75% of cancer survivors report extreme fatigue during and after radiotherapy or chemotherapy, accompanied

•660 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits 2009 Estimated US Cancer Deaths Men Women 292,540 269,800 Lung & bronchus 30% 26% Lung & bronchus Prostate 15% 15% Breast Colon & rectum 9% 9% Colon & rectum Pancreas 6% 6% Pancreas Leukemia 5% 5% Ovary Liver & intrahepatic 4% 4% Non-Hodgkin bile duct lymphoma Esophagus 3% 3% Leukemia Urinary bladder 3% 3% Uterine corpus Non-Hodgkin 2% 2% Liver & intrahepatic lymphoma bile duct Kidney & renal pelvis 2% 2% Brain / ONS All other sites 25% 25% All other sites Figure 18.12 2009 estimated U.S. cancer deaths. (American Cancer Society, 2009.) by weight loss and decreased muscular strength and car- Table 18.16 presents common clinical symptoms diovascular endurance. Maintaining and restoring func- resulting from surgery, radiation therapy, and systemic tional capacity challenges cancer survivors, even patients therapy interventions. considered “cured.” Sufficient rationale now justifies exe cise intervention for cancer patients during and after dif- Exercise Prescription ferent treatment modalities. Regular physical activity helps cancer patients recuperate Clinical Features and return to a normal lifestyle with greater independence and functional capacity. Health and fitness professional Cancer’s clinical features relate to the effects of the three generally recommend a symptom-limited, progressive, and primary cancer treatment modalities: surgery, radiation, individualized exercise prescription. Prudent ambulation and systemic pharmacologic therapy. of any kind proves beneficial for the most sedentary an deconditioned patient. Surgery represents the oldest and most common modal- ity. Surgeries include operations to remove high-risk tis- The benefits of regular exercise include decrease sues to prevent cancer development, biopsies of abnormal fatigue symptoms, improved functional capacity, de- tissue to diagnose cancer, excision of tumors with curative creased neutropenia (abnormally small numbers of neu- intent, insertion of central venous catheters to support trophils in circulating blood), reduced severity of pain and chemotherapy infusions, reconstruction after definitiv diarrhea, and shortened hospital stays. Exercise interven- surgery, and palliative or symptom relief for incurable dis- tion also decreases psychological distress (improves mood ease (i.e., partial bowel removal). state) and enhances immune function. Current research focuses on psychosocial outcomes such as general fatigue, Radiation treatment occurs in more than 50% of all can- satisfaction with life, level of depression, self-concept, and cer survivors. It involves photon penetration into specifi quality of life. Such studies report positive associations tissue, which produces an ionized electrically charged between regular exercise and improvement in psychosocial particle that damages DNA to inhibit cell replication and outcomes. produce cell death. Radiation treatment is typically given daily for between 5 and 8 weeks. Cancer patients can participate in exercise stress tests, which also serve as a basis for exercise prescriptions. Simi- Pharmacologic therapy is prescribed for patients with lar testing procedures apply as with healthy individuals, but many advanced solid tumors if cancer cells are suspected feelings of fatigue require greater attention. Table 18.17 of metastasizing beyond the primary site and regional presents special precautions to consider when testing the lymph nodes. Chemotherapy, endocrine therapy, and functional capacity of cancer patients. Generally, patients biologic therapy represent the three major types of sys- should not exercise to maximum. temic therapy.

•Chapter 18 Clinical Aspects of Exercise Physiology 661 Table 18.16 Cancer Therapies and Their Complications Questions & Notes TYPE OF List the 3 primary cancer treatment TREATMENT DESCRIPTION AND EFFECTS/OUTCOME modalities. Surgery Lung—reduced lung capacity, dyspnea, deconditioning 1. Neck—reduced range of motion, muscle weakness, occasional 2. cranial nerve palsy Pelvic region—urinary incontinence, erectile dysfunction, 3. deconditioning List 3 benefits of regular exercise for Abdomen—deconditioning, diarrhea cancer patients. Limb amputation—chronic pain, deconditioning 1. Radiation Skin —redness, pain, dryness, peeling, sloughing, reduced Therapy 2. elasticity Brain—nausea, vomiting, fatigue, memory loss 3. Thorax—some degree of irreversible lung fibrosis, heart may receive radiation causing pericardial inflammation or fibrosi premature atherosclerosis, cardiomyopathy Abdomen—vomiting, diarrhea Pelvis—diarrhea, pelvic pain, bladder scarring, occasional incontinence, sexual dysfunction Joints—connective tissue and joint capsule fibrosis, possible decreased range of motion Systemic Chemotherapies [depending on type and amount]—extreme Therapy fatigue, anorexia, nausea, anemia, neutropenia, muscle pain, sensory and motor peripheral neuropathy, ataxia, anemia, vomiting, loss of muscle mass, deconditioning, infection Endocrine Therapies [depending on type and amount]—fat redistribution (truncal and facial obesity), proximal muscle weakness, osteoporosis, edema, infection, weight gain, extreme fatigue, hot flashes, loss of muscle mas Biologic Therapies [depending on type and amount]—fevers or allergic reactions, chills, fever, headache, extreme fatigue, low blood pressure, skin rash, anemia From Courneya, K.S., et al.: ACSM’s Resource Manual for Clinical Exercise Physiology for Special Populations. In: Myers, J. (ed.). Baltimore: Lippincott Williams & Wilkins, 2002. Special Precautions for Testing the Functional For Your Information Table 18.17 Capacity of Cancer Patients LIFE EXPECTANCY INCREASED BY COMPLICATION PRECAUTION 73 DAYS Ataxia, dizziness, or peripheral Avoid tests that require balance and According to preliminary data from sensory neuropathy coordination (treadmill, weights). the National Center for Health Sta- tistics (www.cdc.gov/nchs), life Bone pain Avoid high-impact tests that increase risk of expectancy in the United States rose fracture (treadmill, weights). 10.4 weeks to a record 77.9 years, Low blood count from 77.7 in 2006. A continuing (hemoglobin Յ8.0 gиdLϪ1; Avoid tests that require high oxygen uptake decline in mortality rates for the neutrophil count Յ0.5 ϫ 109 и LϪ1) or high impact (risk of bleeding); ensure top two killers—heart disease proper sterilization of equipment. and cancer and a 10% decrease Dyspnea in deaths from the AIDS virus Fever 38ЊC (100.4ЊF) Avoid maximal tests. contributed to the change. Heart dis- May indicate systemic infection; avoid ease and cancer accounted for 48.5% Mouth sores or ulcerations of all deaths, and HIV, the sixth lead- Low functional status exercise testing. ing cause of death among Americans Surgical wounds or tenderness Avoid mouthpieces; use face masks. age 25 to 44 years, accounted for Severe nausea or vomiting Avoid exercise testing. 11,061 deaths. Applied to both Avoid pressure or trauma to surgical site. genders, life expectancy averaged Avoid or postpone exercise testing. 75.3 years for men and 80.4 years for women. Life expectancy for black Modified from Courneya, K.S., et al.: Coping with cancer: can exercise help? Phys. Sports Med., men increased to 70.2 years in 2007 28:49, 2000. from 69.7 years in 2006.

•662 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits General Aerobic Exercise Primary breast cancer risk factors include a family his- Table 18.18 Guidelines for Otherwise Healthy tory of breast cancer, a personal history of cancer, firs menstrual period at an early age, menopause at a late age, Cancer Survivors first childbirth after age 30 years or no childbirth, and high-fat diet. PRESCRIPTION GUIDELINES VARIABLE Daily low- to moderate-intensity aerobic exercise reduces fatigue in women with breast cancer undergoing Frequency At least three to five times per week; chemotherapy and improves a wide range of quality of life Intensity daily activity may be optimal for outcomes from breast cancer treatment. Regular exercise Type (mode) deconditioned patients produces positive improvements in functional capacity, Time (duration) body composition, side effects of treatment, mood, and Depends on fitness status and.GXT self-image. Progression results; usually 50%–70% VO2peak; or 60%–80% HRmax; or RPE A study from one of our laboratories illustrates the ben- 11–14 efits of regular exercise in breast cancer survivors. The pro gram, conducted 4 days per week, consisted of self-paced Large muscle group activity, hydraulic resistance exercises performed in a 14-station particularly walking and cycling aerobic exercise circuit by 28 patients recovering from in some cases breast cancer surgery. Figure 18.13 illustrates that exer- cisers decreased depression by 38% compared with a 13% 20 to 30 continuous minutes per session; this goal can be achieved 12 through multiple intermittent shorter sessions with adequate rest 10 intervals 8 May not always be linear; rather, it may be cyclical with periods of 6 regression, depending on treatments 4 GXT ϭ graded exercise stress.test; HRmax ϭ maximal safe heart rate; RPE ϭ 2Beck depression rating of perceived exertion; VO2peak ϭ peak oxygen consumption. inventory Modified from Courneya, K.S., et al.: Coping with cancer: can exercis 0 help? Phys. Sports Med., 28:49, 2000. 50 The exercise prescription should encourage ambulation Speilberger if the patient has no specific exercise contraindications 45trait anxiety Also encouraged are ROM and flexibility exercises an exercises to improve muscular strength, augment FFM, and 40 improve overall mobility (e.g., submaximal static exercises for antigravity muscles, deep breathing exercises, and 35 dynamic trunk rotation movements). In most cases, pref- erence goes to low-level exercise for short periods per- 30 formed several times daily. Exercise progression and intensity are individualized, with initial work to rest 25 ratios of 1:1 progressing to 2:1. Eventually, continuous exer- cise for up to 15 minutes can replace intermittent exeercise 0 bouts. Table 18.18 presents general aerobic exercise guidelines for otherwise healthy cancer survivors. 45 Breast Cancer Speilberger 40 state anxiety Carcinoma of the breast, one of the most common forms 35 of cancer in white women age 40 years and older, repre- sents the leading cause of death in women between ages 40 30 Control and 60 years. In 2009, nearly 192,370 new cases of breast 25 Exercise cancer for women and 1910 cases for men were reported, with 40,170 deaths for women. Only lung cancer accounts 0 Post for more cancer deaths in women. About one in eight Pre women develops breast cancer at some time during life with a high rate of recurrence. The National Cancer Insti- Figure 18.13 Effects of 10 weeks of moderate aerobic circuit tute estimates that approximately 2.5 million women with a history of breast cancer were alive in January 2006. resistance exercise on depression (top) and trait (middle) and Most of these individuals were cancer free, but others still state (lower) anxiety in women recovering from breast cancer had evidence of cancer and may have been undergoing surgery. (Data courtesy of M. Segar, Applied Physiology Labora- treatment. tory, University of Michigan, Ann Arbor, MI, 1996.)

•Chapter 18 Clinical Aspects of Exercise Physiology 663 increase for nonexercising counterparts For Your Information also recovering from breast cancer sur- gery. Exercisers decreased trait anxiety KEEP YOUR BRAIN YOUNG by 16% and state anxiety by 20% com- pared with increases in both variables for Five behavioral changes that preserve brain functions with age: nonexercisers. These results demonstrate that a planned, moderate aerobic resist- 1. Exercise 30 to 60 minutes daily. Regular exercise reverses age-related ance exercise program exerts positive shrinkage of memory regions in the brain. effects on psychosocial variables during breast cancer rehabilitation. 2. Lose (or at least do not gain) excess body weight. Excess body fat can increase insulin that interferes with enzymes that break down plaque in COGNITIVE AND cerebral blood vessels. EMOTIONAL DISEASES AND DISORDERS 3. Control blood pressure. Hypertension may precipitate silent strokes that diminish brain reserve. 4. Stay socially and mentally active. People who stay mentally and socially engaged throughout life show less decline in mental functions in later years. 5. Consume enough vitamin D by eating more leafy green vegetables, and increase seafood intake. The National Institutes of Mental Health (www.nimh.nih.gov/index.shtml) estimates For Your Information that nearly 19 million Americans older than 18 years of age experience major RESISTANCE TRAINING HELPS BREAST CANCER SURVIVORS depression. Suicide linked to depression, represents the third leading cause of For decades, physicians have advised breast cancer survivors (currently death among 10- to 24-year old individu- 2.4 million Americans) that lifting weights or carrying heavy objects may cause als. Also, 6% to 8% of all outpatients in harmful arm swelling. New research shows that a program of resistance training primary care settings have major depres- (90-minute weightlifting classes twice a week for 13 weeks continued on their sion. Despite the large numbers of own for 39 more weeks) actually helps alleviate the problem of radiation depressed patients, mental disorders treatment–related buildup of fluids that causes painful and unsightly swelling remain underdiagnosed; only about one- of arms and hands. third of people diagnosed receive treat- ment. The five major classifications of cognitive/emotional diseases includ 1. Major depressive disorder: Commonly referred to as “depression” 2. Dysthymia: Mildly depressed on most days over a period of at least 2 years; symptoms resemble major depression but less severe 3. Seasonal affective disorder: Recurrence of the depressive symptoms during certain seasons (e.g., winter) 4. Postpartum depression: Occurs after birth; typically in the first fe months after delivery but can happen within the first year after birt 5. Bipolar disorder (previously known as manic-depressive illness) characterized by extremes in mood and behavior lasting for at least 2 weeks Clinical Features Depression has no single cause but often results from a combination of factors or events. Whatever its cause, depression is not just a state of mind. Rather, it relates to physical changes in the brain and a chemical imbalance of neurotransmitters. uestions & Notes QWomen are roughly twice as likely to experience depression as men, partly from hormonal changes from puberty, menstruation, menopause, and Using the FITT principle, outline an pregnancy. Men are more likely go undiagnosed and less likely to seek help. Men exercise Rx for cancer survivors. may show the typical symptoms of depression; they tend to be angry and hos- tile and mask their condition with alcohol or drug abuse. Suicide becomes a serious risk for depressed men, who are four times more likely than women to kill themselves. Depression among the elderly poses a unique situation. Older people often lose loved ones and have to adjust to living alone. Physical illness decreases normal levels of physical activity. Such changes all contribute to depression. Loved ones may attribute the signs of depression to normal aging, and many older people are reluctant to talk about their symptoms. As such,

•664 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits Twelve Common Signs and influencing the metabolism and availability of central neu Table 18.19 Symptoms of Depression rotransmitters with mood-improving capability. 1. Loss of enjoyment from things that were once pleasurable Researchers continue to study exercise effects on the 2. Loss of energy neurochemistry of mood regulation, specifically turnove 3. Feelings of hopelessness or worthlessness of monoamines and other central neurotransmitters at 4. Difficulty concentratin presynaptic and postsynaptic sites. Antidepressant medica- 5. Difficulty making decision tions, including the selective serotonin reuptake inhibitors 6. Insomnia or excessive sleep (SSRIs), exert their effect by increasing neurotransmitters 7. Stomach ache and digestive problems availability at receptor sites. Exercise may exert its benefi 8. Sexual problems (e.g., decreased sex drive) cial effect on mood by influencing the metabolism an 9. Aches and pains (e.g., recurrent headaches) availability of these central medications. 10. A change in appetite causing weight loss or gain 11. Thoughts of death or suicide The role of ␤-endorphins in mood regulation has 12. Attempting suicide received considerable attention. These endogenous chemi- cals that reduce pain and can induce euphoria have been older people may not receive proper treatment for their linked to the “runner’s high” experienced by intensive depression. exercisers. The ability of exercise to produce enough ␤- endorphins to affect depression remains questionable, but Four common factors in depression include: the possibility still exists for depressed patients. 1. Family situation: Trauma and stress from financia BOX 18.4 CLOSE UP problems, breakup of a relationship, death of a loved one, or other major life changes Benefits of Regular Physical Activity 2. Pessimistic personality: Higher risk for individu- Alleviates symptoms als who have low self-esteem and a negative of depression outlook Simulates formation 3. Health status: Medical conditions such as heart dis- of new brain cells ease, cancer, and HIV contribute to depression Reduces chances of 4. Other psychological disorders: Anxiety disorders, stroke eating disorders, schizophrenia, and substance abuse often appear with depression Lowers blood pressure Table 18.19 presents common signs and symptoms of depression. Reduces heart disease risk Exercise Prescription Exercise studies in clinically Curbs risk of certain depressed populations include hospitalized and ambula- cancers tory patients. Overall, the data support the positive effects of exercise on depressive symptoms. In most cases, exer- Boosts insulin cising patients decreased their depression scores. sensitivity No mode of exercise has a greater impact on depression Limits gain in than other types of exercise, yet most studies have focused visceral fat on running or other aerobic-type activities. Interestingly, positive psychological outcomes do not depend on achiev- Builds muscle ing physical fitness, although fitness-related indicators lower blood pressure and increased aerobic capacity fre- Increases bone mass quently do improve. and bone density Different psychological and physiologic mechanisms Reduces pain and may explain the beneficial effects of exercise on depres disability from sion. Psychologically, exercise enhances one’s sense of arthritis mastery and self-esteem important for depressed individu- als who feel a loss of control over their lives. Exercise also Lowers risk of fall provides a therapeutic distraction that diverts attention in older adults from areas of worry, concern, and guilt. Improving one’s health, flexibility, and physique status can also enhanc mood. Large-muscle activity in exercise may help to dis- charge feelings of pent-up frustration, anger, and hostil- ity. Exercise may exert its beneficial effect on mood b

•Chapter 18 Clinical Aspects of Exercise Physiology 665 Disturbed sleep represents both a symptom and an aggravating factor of Questions & Notes depression making beneficial effects of exercise on sleep take on added impor tance. Depressed individuals demonstrate improved subjective sleep quality List 5 major classifications of cognitiv and a corresponding improvement in depression measures. and emotional diseases. The exercise prescription for patients with depression considers the follow- 1. ing eight factors: 1. Anticipate barriers. Common symptoms of depression, such as fatigue, 2. lack of energy, and psychomotor retardation, pose formidable barriers to 3. physical activity. Feelings of hopelessness and worthlessness also inter- 4. fere with motivation to exercise. 5. 2. Keep expectations realistic. Make exercise recommendations with Name the neurochemical substance usually caution. Depressed patients often self-blame and may view exercise associated with the “runners high.” as another occasion for failure. Do not raise false expectations that can arouse anxiety and guilt. Explain that exercise provides an adjunct to, not a substitute for, primary treatment. 3. Design a feasible plan. Make the exercise prescription realistic and practical, not an additional burden to compound the patient’s sense of futility. Consider the individual’s background and history. For severely depressed patients, postpone exercise until medication and psychother- apy alleviate symptoms. Previously sedentary patients should start with a light exercise schedule such as just a few minutes of daily walking. 4. Accentuate pleasurable aspects. Guide the choice of exercise by the patient’s preferences and circumstances. Use pleasurable activities that can easily add to the patient’s schedule. 5. Include group activities. Depressed, isolated, and withdrawn patients are most likely to benefit from increased social involvement. The stimu lation of being outdoors in a pleasant setting can enhance mood; expo- sure to light exerts therapeutic effects for seasonal depression. 6. State specifics Walking is almost universally acceptable, carries minimal injury risk, and benefits mood enhancement. In keeping wit ACSM recommendations for healthy adults, a goal of 20 to 60 minutes of walking or other aerobic exercise three to five times a week remain reasonable. The ACSM also recommends resistance and flexibility train ing 2 to 3 days per week. 7. Encourage compliance. Improved fitness serves as a valuable consequenc of exercise participation without an antidepressant effect. Compliance increases with less physically demanding exercise programs. 8. Integrate exercise with other treatments. The primary treatments for depression should not present exercise obstacles. Antidepressant med- ication can impair a patient’s ability to function. Combatting depression relies on a For Your Information spectrum of brief and longer term psy- chotherapies, either alone or with antide- JUST A LITTLE EXERCISE ADDS LIFE TO SENIORS 85ϩ YEARS pressant medication. An exercise prescription complements psychother- Little is known about the potential benefits of regular physical activity for the apy when the goal increases the patient’s oldest-old, those in their 80s. Recent finding suggest that even the oldest-old overall activity level and adds pleasura- benefit from regular physical activity. Even previously sedentary 85-year-olds ble, satisfying experiences. The patient’s who participated in 4 hours per week of physical activity (this level of activity difficulties with exercise (e.g., motiva classifies as “active” for this age group) reaped the benefits. Even if the walks tional problems, fear of interpersonal sit- were broken up into 15-minue strolls, the benefits equaled those who partici- uations, a tendency to transform exercise pated for longer durations. The physically active octogenarians also into a burdensome chore), may shed experienced less depression and loneliness and showed greater ability to per- light on dysfunctional attitudes that psy- form tasks of daily living more easily. (Arch. Intern. Med. 169:1476, 2009) chotherapy adequately explores.

•666 SECTION VI Optimizing Body Composition, Successful Aging, and Health-Related Exercise Benefits SUMMARY 15. Graded exercise stress testing provides a low-risk screening for CHD preventive and rehabilitative 1. An exercise physiologist health and fitness professiona exercise programs. becomes part of a team approach in the clinical setting for comprehensive patient health care. The exercise 16. Four possible outcomes from a stress test include true- physiologist focuses on restoring the patient’s mobility positive (test a success), false-negative (heart disease and functional capacity. not diagnosed when present), true-negative (test a success), and false-positive (healthy person diagnosed 2. The major cardiovascular diseases affect the heart with heart disease) results. muscle directly, the heart valves, or neural regulation of cardiac function. 17. Exercise-induced indicators of CHD include angina pectoris, ECG disorders, cardiac rhythm abnormalities, 3. A gene (ATHS) on chromosome 19 near the gene and abnormal blood pressure and heart rate responses. related to LDL-cholesterol receptor functioning accounts for almost 50% of CHD cases. 18. Invasive physiologic tests that include radionucleotide studies, cardiac catheterization, and coronary 4. An imbalance between the oxygen demands of the angiography provide diagnostic information heart and its oxygen supply causes angina pectoris. unavailable through noninvasive procedures. 5. MI results from inadequate perfusion of blood in the 19. Cardiac patients improve their functional capacity coronary arteries or imbalance in myocardial oxygen similar to healthy people of the same age. demand and supply during physical activity. 20. Cardiac patients enter different cardiac rehabilitation 6. Pericarditis, an inflammation of the heart’s oute phases depending on disease severity and degree of risk. pericardial lining, is classified as either acut (recurring) or chronic (constrictive). 21. RLD and COPD represent two major pulmonary disease categories. 7. CHF occurs when cardiac output cannot keep pace with venous return. The heart fails from intrinsic 22. RLD increases chest-lung resistance to lung inflation myocardial disease, chronic hypertension, or structural COPD (including bronchitis, emphysema, asthma, defects that impair pump performance. exercise-induced bronchospasm, and CF) affects expiratory flow capacity and ultimately impede 8. Aneurysm represents an abnormal dilatation in the aeration of alveolar blood. wall of an artery or vein or the myocardium. Vascular aneurysms occur when a vessel’s wall weakens from 23. Pulmonary disease assessment requires different trauma, congenital vascular disease, infection, or diagnostic tools that include chest radiography, CT atherosclerosis. scanning, MRI, and standard spirometric lung volume testing. 9. Aerobic exercise programs implemented for cardiac patients should consider specific disease patho 24. Exercise contributes to pulmonary disease physiology, mechanisms that limit exercise capacity, management if close attention focuses on exercise and individual differences in functional capacity. intensity, patient monitoring, and exercise progression. 10. Heart valve diseases include stenosis, regurgitation, 25. The most prominent neuromuscular diseases and prolapse. impacting the brain include stroke, multiple sclerosis, and Parkinson’s disease. 11. The dysrhythmias bradycardia, tachycardia, and PVCs represent diseases of the heart’s nervous system. 26. Patients with chronic kidney disease benefit fro individualized and structured exercise programs. 12. A thorough cardiac disease assessment includes medical history, physical examination, laboratory 27. More than 100 different types of cancers affect adults, assessments (chest radiography, ECG, blood lipid including carcinomas, leukemias, lymphomas, and analyses, serum enzyme testing), and physiologic tests. sarcomas. 13. The “stress test” describes systematic exercise for two 28. The exercise prescription for cancer patients is purposes: (1) ECG observations and (2) evaluation of symptom limited, progressive, and individualized, physiologic adjustments to metabolic demands that with improved ambulation the primary goal. exceed resting requirements. 29. For women recovering from breast cancer surgery, a 14. Multistage bicycle and treadmill tests represent the carefully planned, aerobic circuit resistance exercise most common modes for exercise stress testing. These program decreases depression and state and trait tests, graded for exercise intensity, include several anxieties. levels of 3 to 5 minutes of exercise that bring the person to self-imposed, symptom-limited fatigue.

•Chapter 18 Clinical Aspects of Exercise Physiology 667 30. Depression relates to physical changes in the brain 31. Exercise-related positive psychological outcomes do produced by neurotransmitter imbalance. No one not depend on achieving physical fitness, yet fitnes kind of exercise has a greater impact on depression related indicators such as lower blood pressure and than others. increased aerobic capacity improve with regular exercise in depressed individuals. THOUGHT QUESTIONS 1. Give two recommendations to a middle-aged man who angina during upper-body work as a plasterer and wants to begin an aerobic training program because he paper hanger? feels breathless and experiences chest discomfort while walking the golf course. 3. List two possible mechanisms that might account for the experience of a mildly depressed person who states: 2. 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•Chapter 6 Human Enerty transfer During Exercise 669 AA P P E N D I X The Metric System and Conversion Constants in Exercise Physiology Appendix A has two parts. Part 1 deals with the metric Units of Volume system, and Part 2 discusses the Système International d’Unités (SI units). EQUIVALNE T EQUIVALNE T MENTRIC E GLISH METRIC UNIT UNITS UNITS THE METRIC SYSTEM liter (L) 1000 mL 1.057 qt Most measurements in science are expressed in terms of milliliter (mL) 0.001 L 0.001057 qt the metric system. This system uses units that are related to one another by some power of 10. The prefix centi means or cubic one-hundredth, milli means one-thousandth, and kilo is centimeter (cc) derived from a word that means one thousand. In the fol- lowing sections, we show the relationship between metric Temperature units and English units of measurement that are relevant to the material presented in this book. To convert Fahrenheit to Celsius: ЊC ϭ (ЊF Ϫ 32) Ϭ 1.8 To convert Celsius to Fahrenheit: ЊF ϭ (1.8 Ϭ ЊC) ϩ 32 Units of Length On the Fahrenheit scale, water freezes at 32ЊF and boils at 212ЊF. EQUIVALENT EQUIVALENT On the Celsius scale, water freezes at 0ЊC and boils at 100ЊC. MENTRIC E GLISH METRIC UNIT UNITS UNITS meter (m) 100 cm; 1000 mm 39.37 in; 3.28 ft; Units of Speed kmиhϪ1 mиsecϪ1 1.09 yd centimeter (cm) 0.01 m; 10 mm mph 1.6 0.47 millimeter (mm) 0.001 m; 0.1 cm 0.3937 in 3.2 0.94 0.03937 in 1 4.8 1.41 2 6.4 1.88 UNITS OF WEIGHT 3 8.0 2.35 4 9.6 2.82 Use the following conversions for common units of mass 5 11.2 3.29 (weight) and volume. For example, 1 oz ϭ 0.06 lb. There- 6 12.8 3.76 fore, 2 oz equals 2 ϫ 0.06 ϭ 0.12 lb, and 16 oz ϭ 0.96 lb 7 14.4 4.23 (16 ϫ 0.06). 8 16.0 4.70 9 17.7 5.17 Units of Weight 10 19.3 5.64 11 20.9 6.11 EQUIVANLE T EQUIVANLE T 12 22.5 6.58 MNETRIC E GLISH 13 24.1 7.05 METRIC UNIT UNITS UNITS 14 25.8 7.52 15 27.4 7.99 kilogram (kg) 1000 g; 35.3 oz; 16 29.0 8.46 1,000,000 mg 2.2046 lb 17 30.6 8.93 gram (g) 18 32.2 9.40 milligram (mg) 0.001 kg; 1000 mg 0.353 oz 19 0.000001 kg; 0.001 g 0.0000353 oz 20 669

•670 Appendix A The Metric System and Conversion Constants in Exercise Physiology Common Expressions of Work, Energy, and Power WATTS KILOCALORIES (kCal) FOOT-POUNDS (ft-lb) 1 ftиlb ϭ 3.2389 ϫ 10Ϫ3 kCal 1 watt ϭ 0.73756 ft-lbиsecϪ1 1 kCal ϭ 3086 ft-lb 1 ftиlb ϭ 0.13825 kg-m 1 watt ϭ 0.01433 kCalиminϪ1 1 kCal ϭ 426.8 kg-m 1 ftиlb ϭ 5.050 ϫ 10Ϫ3 hpиhϪ1 1 watt ϭ 1.341 ϫ 10Ϫ3 hp or 0.0013 hp 1 kCal ϭ 3087.4 ft-lb 1 watt ϭ 6.12 kg-mиminϪ1 1 kCal ϭ 1.5593 ϫ 10Ϫ3 hpиhϪ1 TERMINOLOGY AND UNITS Power: The rate of performing work; the derivative of work with respect to time; the product of force and veloc- OF MEASUREMENT ity (unit: watt). Other related processes, such as energy release and heat transfer, should, when expressed per unit The American College of Sports Medicine (www.acsm.org/) of time, be quantified and presented in watts suggests that the following terminology and units of meas- urement be used in scientific endeavors to promote consis Torque: Effectiveness of a force to produce axial rota- tency and clarity of communication and to avoid ambiguity. tion (unit: Newton meter). The following terms are defined using the units of measure ment of the Système International d’Unités (SI units). Volume: A space occupied, for example, by a quantity of fluid or gas (unit: liter or milliliter). Gas volumes shoul Exercise: Any and all activity involving generation of be indicated as ATPS, BTPS, or STPD. force by the activated muscle(s) that results in disruption of a homeostatic state. In dynamic exercise, the muscle may per- Amount of a substance: The amount of a substance is form shortening (concentric) contractions or be overcome by frequently expressed in moles. A mole is the quantity of a external resistance and perform lengthening (eccentric) con- chemical substance that has a weight in mass units (e.g., tractions. When muscle force results in no movement, the grams) numerically equal to the molecular weight or that, contraction should be termed static or isometric. in the case of a gas, has a volume occupied by such a weight under specified conditions. One mole of a respira Exercise intensity: A specific level of maintenance o tory gas is equal to 22.4 L at STPD. muscular activity that can be quantified in terms of powe (energy expenditure or work performed per unit of time), SI UNITS isometric force sustained, or velocity of progression. The uniform numerical value system is known as the Sys- Endurance: The time limit of a person’s ability to main- tème International d’Unités (SI units). SI was developed tain either a specific isometric force or a specific pow through international cooperation to create a universally level involving combinations of concentric or eccentric acceptable system of measurement. SI ensures that units muscular contractions. of measurement are uniform in concept and style. The SI system permits quantities in common use to be more eas- Mass: A quantity of matter of an object; a direct measure ily compared. Many scientific organizations endorse th of the object’s inertia (note: Massϭ Weight Ϭ Acceleration concept of the SI, and leading journals in nutrition, health, due to gravity; unit: gram or kilogram). and exercise science now require that laboratory data be presented in SI units. The information in this appendix Weight: The force with which a quantity of matter is has been summarized from a detailed description about attracted toward Earth by normal acceleration of gravity the SI published in the following article: Young, D.S.: (traditional unit: kilogram). Implementation of SI units for clinical laboratory data. Style specifications and conversion tables. Ann. Intern. Energy: The capability of producing force, performing Med., 106:114, 1987. work, or generating heat (unit: joule or kilojoule). For SI units in exercise physiology, the termbody weight Force: That which changes or tends to change the state is properly referred to as mass (kg), height should be of rest or motion in matter (unit: Newton). referred to as stature (m), second is sec, minute is min, hour is h, week is wk, month is mo, year is y, day is d, gram Speed: Total distance traveled per unit of time (unit: is g, liter is L, hertz is Hz, joule is J, kilocalorie is kCal, ohm meters per second). is V, pascal is Pa, revolutions per minute is rpm, volt is V, and watt is W. These abbreviations or symbols are used for Velocity: Displacement per unit of time. A vector quan- the singular and plural forms. tity requiring that direction be stated or strongly implied (unit: meters per second or kilometers per hour). Work: Force expressed through a distance but with no limitation on time (unit: joule or kilojoule). Quantities of energy and heat expressed independently of time should also be presented in joules. The term work should not be used synonymously with muscular exercise.

•Appendix A The Metric System and Conversion Constants in Exercise Physiology 671 Definitions of Common SI Units Degree Celsius (ЊC) The degree Celsius (centigrade) is equivalent to K Ϫ 273.15. Radian (rad) The radian is the plane angle subtended by a circular arc as the length of the arc divided by the radius of Joule (J) the arc. The joule is the work done when the point of application of a force of 1 N is displaced through a distance Kelvin (K) Kilogram (kg) of 1 m in the direction of the force. 1 J ϭ 1 Nm. Meter (m) The Kelvin is the fraction 1/273.16 of the thermodynamic temperature of the triple point of water. The kilogram is a unit of mass equal to the mass of the international prototype of the kilogram. Newton (N) The meter is the length equal to 1,650,763.73 wavelengths in vacuum of the radiation that corresponds to Pascal (Pa) the transition between the levels 2p10 and 5d5 of the krypton 86 atom. The Newton is the force that, when applied to a mass of 1 kg, gives it an acceleration of 1 mϪ1иsecϪ2. Second (sec) 1 N ϭ 1 kgиmϪ1иsecϪ2. Watt (W) The Pascal is the pressure produced by a force of 1 N applied, with uniform distribution, over an area of 1 mϪ2. 1 Pa ϭ 1 NиmϪ2. The second is the duration of 9,192,631,770 periods of the radiation that corresponds to the transition between the two hyperfine levels of the ground state of the cesium 133 atom The Watt is the power that, in 1 sec, gives rise to the energy of 1 joule. 1 W ϭ 1 JиsecϪ1. Base Units of SI Nomenclature PHYSICAL QUANTITY BASE UNIT SI SYMBOL Length meter m Mass kilogram kg Time second sec Amount of substance mole mol Thermodynamic temperature kelvin K Electric current ampere A Luminous intensity candela cd Base Units of SI Style Guidelines EXAMPLE INCORRECT STYLE CORRECT STYLE GUIDELINES Lowercase letters are used for symbols or abbreviations kilogram Kg kg Exceptions: k kelvin a K Symbols are not followed by a period ampere l A Exception: end of sentence liter m. L Symbols are not to be pluralized mol. meter kgs m Names and symbols are not to be combined ms mole kilogramиmeterиsecϪ2 mol When numbers are printed, symbols are preferred kilograms 100 meters kg A space should be placed between the number and meters 2 moles m the symbol 50 ml kg-mиsecϪ2 force kg-m/sec2 The product of units is indicated by a dot above the line 100 m Only one solidus (/) should be used per expression 2 mol A zero should be placed before the decimal Decimal numbers are preferable to fractions 50 mL Spaces are used to separate long numbers kg ϫ m/sec2 kg-mиsecϪ2 Exception: optional with four-digit number kg-m/sec2 mmol/L/sec .01 mmol/(Lиsec) 3/4 0.01 75% 1,500,000 0.75 1,000 0.75 1 500 000 1000 or 1 000

•Chapter 6 Human Enerty transfer During Exercise 672 BA P P E N D I X Metabolic Computations in Open-Circuit Spirometry STANDARDIZING GAS VOLUMES: compare the volumes of expired air measured while running in the rain at high altitude, along a beach in the cold of winter, ENVIRONMENTAL FACTORS or in a hot desert environment below sea level.In all metabolic calculations, gas volumes are always expressed at STPD. Gas volumes obtained during physiologic measurements are usually expressed in one of three ways:ATPS, STPD, or 1. To reduce a gas volume to standard temperature BTPS. (ST), the following formula is applied: ATPS refers to the volume of gas at the specific condi Gas volume ST ϭ VATPS ϫ 273ЊK (1) tions of measurement, which are, therefore, at ambient 273ЊK ϩ TЊC temperature (273ЊK ϩ ambient temperatureЊC), ambient pressure, and saturated with water vapor. Gas volumes col- where TЊC ϭ temperature of the gas in the measur- lected during open-circuit spirometry and pulmonary ing device and 273ЊK ϭ absolute temperature function tests are measured initially at ATPS. kelvin, which is equivalent to 0ЊC. The volume of a gas varies depending on its tempera- 2. The following equation is used to express a gas vol- ture, pressure, and content of water vapor, even though the ume at standard pressure (SP): absolute number of gas molecules remains constant. These environmental influences are summarized as follows Gas volume SP ϭ V ATPS ϫ 760 PB Hg (2) mm Temperature: The volume of a gas varies directly with temperature. Increasing the temperature causes the where PB ϭ ambient barometric pressure in mm Hg molecules to move more rapidly; the gas mixture and 760 ϭ standard barometric pressure at sea level, expands, and the volume increases proportionately mm Hg. (Charles’ law). 3. To reduce a gas to standard dry (SD) conditions, the Pressure: The volume of a gas variesinversely with pres- effects of water vapor pressure at the particular envi- sure. Increasing the pressure on a gas forces the mole- ronmental temperature must be subtracted from the cules closer together, causing the volume to decrease volume of gas. Because expired air is 100% saturated in proportion to the increase in pressure (Boyle’s law). with water vapor, it is not necessary to determine its percent saturation from measures of relative humid- Water vapor: The volume of a gas varies depending on ity. The vapor pressure in moist or completely its water vapor content. The volume of a gas is greater humidified air at a particular ambient temperatur when the gas is saturated with water vapor than it is can be obtained in Table B.1 and expressed in when the same gas is dry (i.e., contains no moisture). mm Hg. This vapor pressure (PH2O) is then subtracted from the ambient barometric pressure (PB) to reduce These three factors—temperature, pressure, and the the gas to standard pressure dry (SPD) as follows: relative degree of saturation of the gas with water vapor— must be considered, especially when gas volumes are to be Gas volume SPD ϭ VATPS ϫ PB Ϫ PH2O (3) compared under different environmental conditions and 760 used subsequently in metabolic and physiologic calcula- tions. The standards that provide the frame of reference By combining equations (1) and (3), any volume of for expressing a volume of gas are either STPD or BTPS. moist air can be converted to STPD as follows: STPD refers to the volume of a gas expressed under stan- Gas volume STPD dard conditions of temperature (273 ЊK or 0 ЊC), pressure (760 mm Hg), anddry (no water vapor). Expressing a gas vol- ϭ VATPS a 273ЊK b a PB Ϫ PH2O b (4) ume STPD, for example, makes it possible to evaluate and 273 ϩ TЊC 760 672

•Appendix B Metabolic Computations in Open-Circuit Spirometry 673 Vapor Pressure (PH2O) of Wet Gas at Table B.1 Temperatures Normally Encountered in the Laboratory T (ЊC) PH2O (mm Hg) T (ЊC) PH2O (mm Hg) 20 17.5 31 33.7 21 18.7 32 35.7 22 19.8 33 37.7 23 21.1 34 39.9 24 22.4 35 42.2 25 23.8 36 44.6 26 25.2 37 47.1 27 26.7 38 49.7 28 28.4 39 52.4 29 30.0 40 55.3 30 31.8 Table B.2 Factors to Reduce Moist Gas to a Dry Gas Volume at 0ЊC and 760 mm Hg BAROMETRIC TEMPERATURE (ЊC) PRESSURE 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 700 0.855 851 847 842 838 834 829 825 821 816 812 807 802 797 793 788 783 778 702 857 853 849 845 840 836 832 827 823 818 814 809 805 800 795 790 785 780 704 860 856 852 847 843 839 834 830 825 821 816 812 807 802 797 792 787 783 706 862 858 854 850 845 841 838 832 828 823 819 814 810 804 800 795 790 785 708 865 861 856 852 848 843 839 834 830 825 821 816 812 807 802 797 792 787 710 867 863 859 855 850 846 842 837 833 828 824 819 814 809 804 799 795 790 712 870 866 861 857 853 848 844 839 836 830 826 821 817 812 807 802 797 792 714 872 868 864 859 855 851 846 842 837 833 828 824 819 814 809 804 799 794 716 875 871 866 862 858 853 849 844 840 835 831 826 822 815 812 807 802 797 718 877 873 869 864 860 856 851 847 842 838 833 828 824 819 814 809 804 799 720 880 876 871 867 863 858 854 849 845 840 836 831 826 821 816 812 807 802 722 882 878 874 869 865 861 856 852 847 843 838 833 829 824 819 814 809 804 724 885 880 876 872 867 863 858 854 849 845 840 835 831 826 821 816 811 806 726 887 883 879 874 870 866 861 856 852 847 843 838 833 829 824 818 813 808 728 890 886 881 877 872 868 863 859 854 850 845 840 836 831 826 821 816 811 730 892 888 884 879 875 871 866 861 857 852 847 843 838 833 828 823 818 813 732 895 890 886 882 877 873 868 864 859 854 850 845 840 836 831 825 820 815 734 897 893 889 884 880 875 871 866 862 857 852 847 843 838 833 828 823 818 736 900 895 891 887 882 878 873 869 864 859 855 850 845 840 835 830 825 820 738 902 898 894 889 885 880 876 871 866 862 857 852 848 843 838 833 828 822 740 905 900 896 892 887 883 878 874 869 864 860 855 850 845 840 835 830 825 742 907 903 898 894 890 885 881 876 871 867 862 857 852 847 842 837 832 827 744 910 906 901 897 892 888 873 878 874 869 864 859 855 850 845 840 834 829 746 912 908 903 899 895 890 866 881 876 872 867 862 857 852 847 842 837 832 748 915 910 906 901 897 892 888 883 879 874 869 864 860 854 850 845 839 834 750 917 913 908 904 900 895 890 886 881 876 872 867 862 857 852 847 842 837 752 920 915 911 906 902 897 893 888 883 879 874 869 864 859 854 849 844 839 754 922 918 913 909 904 900 895 891 886 881 876 872 867 862 857 852 846 841 756 925 920 916 911 907 902 898 893 888 883 879 874 869 864 859 854 849 844 758 927 923 918 914 909 905 900 896 891 886 881 876 872 866 861 856 851 846 760 930 925 921 916 912 907 902 898 893 888 883 879 874 869 864 859 854 848 762 932 928 923 919 914 910 905 900 896 891 886 881 876 871 866 861 856 851 764 936 930 926 921 916 912 907 903 898 893 888 884 879 874 869 864 858 853 766 937 933 928 924 919 915 910 905 900 896 891 886 881 876 871 866 861 855 768 940 935 931 926 922 917 912 908 903 898 893 888 883 878 873 868 863 858 770 942 938 933 928 924 919 915 910 905 901 896 891 886 881 876 871 865 860

•674 Appendix B Metabolic Computations in Open-Circuit Spirometry Table B.3 BTPS Factors change in nitrogen in an equation known as the Haldane transformation. BTPSa T (ЊC) T (ЊC) BTPS %N2E %N2I 20 1.102 29 1.051 VI, STPD ϭ VE, STPD ϫ (5) 21 1.096 30 1.045 22 1.091 31 1.039 where %N 2I ϭ 79.04 and %N 2E ϭ percent nitrogen in 23 1.085 32 1.032 expired air computed from gas analysis as: 24 1.080 33 1.026 25 1.075 34 1.020 [(100 Ϫ (%O2E ϩ %CO2)] 26 1.068 35 1.014 . 27 1.063 36 1.007 28 1.057 37 1.000 The volume of O2 in the inspired air (VO2I) can then be determined as follows: aBody temperature, ambient pressure, and saturated with water vapor. VO2I ϭ VI ϫ %O2I (6) . Substituting equation (5) for VI, Vи O2I ϭ Vи E ϫ %N2E (7) 79.04% ϫ %O2I As was the case with the correction to STPD, appropriate BTPS correction factors are available for converting a moist where %O2I ϭ 20.93% gas volume at ambient conditions to a volume BTPS. These BTPS factors for a broad range of ambient temperatures are . The amount or volume of oxygen in the expired air presented in Table B.3. These factors have been computed (VO2E) is computed as: assuming a barometric pressure of 760 mm Hg, and small deviations of Ϯ10 mm Hg from this pressure introduce .. (8) only a minimal error. VO2E ϭ VE ϫ %O2E CALCULATION OF OXYGEN UPTAKE where %O2E is the fractional concentration of oxygen in In determining oxygen uptake by open-circuit spirome- expired air determined by gas analysis (chemical or elec- try, we are interested in knowing how much oxygen has been removed from theinspired air. Because the composi- tronic methods). tion of inspired air remains relatively constant (CO 2 ϭ 0.03%; O 2 ϭ 20.93%; N 2 ϭ 79.04%), it is possible to The am. ount of O 2 removed from the inspired air each determine how much oxygen has been removed from the minute (VO2) can then be computed as follows: inspired air by measuring the amount and composition of .. . the expired air. When this is done, the expired air con- VO2 ϭ (VI ϫ %O2I) Ϫ (VE ϫ %O2E) (9) tains more carbon dioxide (usually 2.5%–5.0%), less oxy- gen (usually 15.0%–18.5%), and more nitrogen (usually By substitution 79.04%–79.60%). It should be noted, however, that nitrogen is inert in terms of metabolism; any change in its Vи O2 ϭ c a VиE ϫ %N2E b ϫ 20.93% d (10) concentration in expired air reflects the fact that the num 79.04% . ber of oxygen molecules removed from the inspired air is not replaced by the same number of carbon dioxide mol- . Ϫ (VE ϫ %O2E) ecules produced in metabolism. This results in the vol- ume of expired air (V E, STPD) being unequal to the where V O2 ϭ volume of oxygen con.sumed per minute, inspired volume (VI, STPD). For example, if the respira- expressed in milliliters or liters, and VE ϭ expired air vol- tory quotient is less than 1.00 (i.e., less CO2 produced in relation to O2 consumed) and 3 L of air is inspired, less ume per minute expressed in milliliters or liters. than 3 L of air will be expired. In this case, the nitrogen concentration is higher in the expired air than in the Equation 10 can be simplified to inspired air. This is not to say that nitrogen has been pro- duced, only that nitrogen molecules now represent a Vи O2 ϭ VиE c a %N2E ϫ 20.93% b Ϫ %O2E d (11) larger percentage of VE compared with VI. In fact, VE dif- 79.04% fers from VI in direct proportion to the change in nitrogen concentration between the inspired and expired volumes. The final form of the equation is (12) Thus, VI can be determined from V E using the relative .. VO2 ϭ VE[(%N2E ϫ 0.265) Ϫ %O2E] The value obtained within the brackets in equations 11 and 12 is referred to as the true O 2; this represents the “oxygen extraction” or, more precisely, the percentage of oxygen consumed for any volume of airexpired. Although equation 12 represents the equation used most widely to compute oxygen uptake from m.easures of expired air, it is also possible .to calcu. late V O2 from direct measurements of both VI and VE. In this case, the Haldane transformation is not used, and oxygen uptake is calculated directly as: .. . VO2 ϭ (VI ϫ 20.93) Ϫ (VE ϫ %O2E) (13)

•Appendix B Metabolic Computations in Open-Circuit Spirometry 675 .. . In situations in which only VI is measured, the VE can be 1. VE, STPD (use equation 4 or STPD correction factor calculated from the Haldane transformation as: in Table B.2). VиE ϭ VиI %N2I VиE, STPD ϭ VиE, ATPS 273 a PB Ϫ PH2O b %N2E a 273 ϩ TЊC b 760 By substitution in equation 13, the computational equa- ϭ 62.1 273 a 750 Ϫ 25.2 b a 299 b 760 tion is: Vи O2 ϭ VиI c %O2I Ϫ a %N2I ϫ %O2E b d (14) ϭ 54.07 LиminϪ1 %N2E . CALCULATION OF CARBON 2. VO2, STPD (use equation 12) .. DIOXIDE PRODUCTION VO2, STPD ϭ VE, STPD[(%N2E ϫ 0.265) Ϫ %O2E] ϭ 54.07[(0.7954 ϫ 0.265) Ϫ 0.1686] . ϭ 54.07(0.0422) The carbon dioxide production per minute (V CO2) is cal- ϭ 2.281 LиminϪ1 . culated as follows: 3. VCO2, STPD (use equation 16) .. .. VCO2 ϭ VE(%CO2E Ϫ %CO2I) (15) VCO2, STPD ϭ VE, STPD(CO2E Ϫ 0.03%) where %CO2E ϭ percent carbon dioxide in expired air deter- ϭ 54.07(0.0360 Ϫ 0.0003) mined by gas analysis and %CO2I ϭ percent carbon dioxide ϭ 54.07(0.0357) ϭ 1.930 LиminϪ1 in inspired air, which is essentially constant at 0.03%. The final form of the equation is (16) 4. RQ (use equation 17 or 18) .. .. VCO2 ϭ VE(%CO2E Ϫ 0.03%) RQ ϭ VCO2/VO2 CALCULATION OF RESPIRATORY QUOTIENT 1.930 ϭ 2.281 ϭ 0.846 The respiratory quotient (RQ) is calculated in one of two or ways: .. (17) RQ ϭ (%CO2E Ϫ 0.03%) 1. RQ ϭ VCO2/VO2 “True” O or (%CO2E Ϫ 0.03%) ϭ 3.60 Ϫ 0.03 2. “True” O2 4.22 RQ ϭ (18) ϭ 0.846 SAMPLE METABOLIC Because the exercise was performed in a steady-rate of aer- CALCULATIONS obic metabolism, the obtained RQ of 0.846 can be applied in Table 7.2 to obtain the appropriate caloric transformation. In this way, the exercise oxygen uptake can be transposed to The following data were obtained during the last minute of kCal oEf neneregrgyyeexxppeenndditeudrepe(rkmCainlиumteinaϪs 1fo)lϭlowV.sO: 2 a steady-rate, 10-minute treadmill run performed at 6 mph 5. (LиminϪ1) ϫ caloric equivalent per liter O2 at the at a 5% grade. given steady-rate RQ: . VE: 62.1 L, ATPS Energy expenditure ϭ 2.281 ϫ 4.862 Barometric pressure: 750 mm Hg ϭ 11.09 kCalиminϪ1 Temperature: 26ЊC %O2 expired: 16.86 (O2 analyzer) Assuming that the RQ value reflects the nonprotein RQ, %CO2 expired: 3.60 (CO2 analyzer) reasonable estimate of both the percentage and quantity of %N2 expired: [100 Ϫ (16.86 ϩ 3.60)] ϭ 79.54 lipid and carbohydrate metabolized during each minute of the run can be obtained from Table 7.2. Determ. ine the following: 1. V. E, STPD Percentage kCal derived from lipid ϭ 50.7% 2. V. O2, STPD Percentage kCal derived from carbohydrate ϭ 49.3% 3. VCO2 STPD Grams of lipid used ϭ 0.267 g per liter of oxygen, or 4. RQ approximately 0.61 g per minute (0.267 ϫ 2.281 L O2) 5. kCalиminϪ1 Grams of carbohydrate usedϭ 0.580 g per liter of oxygen, or approximately 1.36 g per minute (0.580ϫ 2.281 L O2)

•Chapter 6 Human Enerty transfer During Exercise 676 CA P P E N D I X Evaluation of Body Composition—Girth Method This appendix contains the age- and gender-specific equa cloth tape at 10-cm increments. A cloth tape is preferred tions to predict body fat percentage based on three girth over a metal one because of little skin compression when measurements. There are four charts, one each for younger applying a cloth tape to the skin’s surface at a relatively and older men and women. In our experience, it is impor- constant tension. tant to calibrate the tape measure before using it. Use a meter stick as the standard and check the markings on the To use the charts, measure the three girths for your age and gender as follows: AGE (years) GENDER SITE A SITE B SITE C 18–26 M Right upper arm Abdomen Right forearm 27–50 F Abdomen Right thigh Right forearm M Buttocks Abdomen Right forearm F Abdomen Right thigh Right calf Chapter 16 presents the specific measurements sites an each of the Appendix C charts presents specific equatio a step-by-step explanation of how to compute the relative to predict percentage body fat with its corresponding and absolute values for body fat, lean body mass, and desir- constant. able body mass from the Appendix C charts. The bottom of Chart C.1 Conversion Constants to Predict Percentage Body Fat for Young Mena UPPER ARM ABDOMEN FOREARM in cm CONSTANT A in cm CONSTANT B in cm CONSTANT C 7.00 17.78 25.91 21.00 53.34 27.56 7.00 17.78 38.01 7.25 18.41 26.83 21.25 53.97 27.88 7.25 18.41 39.37 7.50 19.05 27.76 21.50 54.61 28.21 7.50 19.05 40.72 7.75 19.68 28.68 21.75 55.24 28.54 7.75 19.68 42.08 8.00 20.32 29.61 22.00 55.88 28.87 8.00 20.32 43.44 8.25 20.95 30.53 22.25 56.51 29.20 8.25 20.95 44.80 8.50 21.59 31.46 22.50 57.15 29.52 8.50 21.59 46.15 8.75 22.22 32.38 22.75 57.78 29.85 8.75 22.22 47.51 9.00 22.86 33.31 23.00 58.42 30.18 9.00 22.86 48.87 9.25 23.49 34.24 23.25 59.05 30.51 9.25 23.49 50.23 9.50 24.13 35.16 23.50 59.69 30.84 9.50 24.13 51.58 9.75 24.76 36.09 23.75 60.32 31.16 9.75 24.76 52.94 10.00 25.40 37.01 24.00 60.96 31.49 10.00 25.40 54.30 10.25 26.03 37.94 24.25 61.59 31.82 10.25 26.03 55.65 10.50 26.67 38.86 24.50 62.23 32.15 10.50 26.67 57.01 10.75 27.30 39.79 24.75 62.86 32.48 10.75 27.30 58.37 11.00 27.94 40.71 25.00 63.50 32.80 11.00 27.94 59.73 11.25 28.57 41.64 25.25 64.13 33.13 11.25 28.57 61.08 11.50 29.21 42.56 25.50 64.77 33.46 11.50 29.21 62.44 11.75 29.84 43.49 25.75 65.40 33.79 11.75 29.84 63.80 12.00 30.48 44.41 26.00 66.04 34.12 12.00 30.48 65.16 676

•Appendix C Evaluation of Body Composition—Girth Method 677 Chart C.1 Conversion Constants to Predict Percentage Body Fat for Young Mena (Continued ) UPPER ARM ABDOMEN FOREARM in cm CONSTANT A in cm CONSTANT B in cm CONSTANT C 12.25 31.11 45.34 26.25 66.67 34.44 12.25 31.11 66.51 12.50 31.75 46.26 26.50 67.31 34.77 12.50 31.75 67.87 12.75 32.38 47.19 26.75 67.94 35.10 12.75 32.38 69.23 13.00 33.02 48.11 27.00 68.58 35.43 13.00 33.02 70.59 13.25 33.65 49.04 27.25 69.21 35.76 13.25 33.65 71.94 13.50 34.29 49.96 27.50 69.85 36.09 13.50 34.29 73.30 13.75 34.92 50.89 27.75 70.48 36.41 13.75 34.92 74.66 14.00 35.56 51.82 28.00 71.12 36.74 14.00 35.56 76.02 14.25 36.19 52.74 28.25 71.75 37.07 14.25 36.19 77.37 14.50 36.83 53.67 28.50 72.39 37.40 14.50 36.83 78.73 14.75 37.46 54.59 28.75 73.02 37.73 14.75 37.46 80.09 15.00 38.10 55.52 29.00 73.66 38.05 15.00 38.10 81.45 15.25 38.73 56.44 29.25 74.29 38.38 15.25 38.73 82.80 15.50 39.37 57.37 29.50 74.93 38.71 15.50 39.37 84.16 15.75 40.00 58.29 29.75 75.56 39.04 15.75 40.00 85.52 16.00 40.64 59.22 30.00 76.20 39.37 16.00 40.64 86.88 16.25 41.27 60.14 30.25 76.83 39.69 16.25 41.27 88.23 16.50 41.91 61.07 30.50 77.47 40.02 16.50 41.91 89.59 16.75 42.54 61.99 30.75 78.10 40.35 16.75 42.54 90.95 17.00 43.18 62.92 31.00 78.74 40.68 17.00 43.18 92.31 17.25 43.81 63.84 31.25 79.37 41.01 17.25 43.81 93.66 17.50 44.45 64.77 31.50 80.01 41.33 17.50 44.45 95.02 17.75 45.08 65.69 31.75 80.64 41.66 17.75 45.08 96.38 18.00 45.72 66.62 32.00 81.28 41.99 18.00 45.72 97.74 18.25 46.35 67.54 32.25 81.91 42.32 18.25 46.35 99.09 18.50 46.99 68.47 32.50 82.55 42.65 18.50 46.99 100.45 18.75 47.62 69.40 32.75 83.18 42.97 18.75 47.62 101.81 19.00 48.26 70.32 33.00 83.82 43.30 19.00 48.26 103.17 19.25 48.89 71.25 33.25 84.45 43.63 19.25 48.89 104.52 19.50 49.53 72.17 33.50 85.09 43.96 19.50 49.53 105.88 19.75 50.16 73.10 33.75 85.72 44.29 19.75 50.16 107.24 20.00 50.80 74.02 34.00 86.36 44.61 20.00 50.80 108.60 20.25 51.43 74.95 34.25 86.99 44.94 20.25 51.43 109.95 20.50 52.07 75.87 34.50 87.63 45.27 20.50 52.07 111.31 20.75 52.70 76.80 34.75 88.26 45.60 20.75 52.70 112.67 21.00 53.34 77.72 35.00 88.90 45.93 21.00 53.34 114.02 21.25 53.97 78.65 35.25 89.53 46.25 21.25 53.97 115.38 21.50 54.61 79.57 35.50 90.17 46.58 21.50 54.61 116.74 21.75 55.24 80.50 35.75 90.80 46.91 21.75 55.24 118.10 22.00 55.88 81.42 36.00 91.44 47.24 22.00 55.88 119.45 36.25 92.07 47.57 36.50 92.71 47.89 36.75 93.34 48.22 37.00 93.98 48.55 37.25 94.61 48.88 37.50 95.25 49.21 37.75 95.88 49.54 38.00 96.52 49.86 38.25 97.15 50.19 38.50 97.79 50.52 38.75 98.42 50.85 39.00 99.06 51.18 39.25 99.69 51.50 39.50 100.33 51.83 39.75 100.96 52.16 40.00 101.60 52.49 40.25 102.23 52.82 40.50 102.87 53.14 40.75 103.50 53.47 41.00 104.14 53.80 41.25 104.77 54.13 41.50 105.41 54.46 41.75 106.04 54.78 42.00 106.68 55.11 Note: Percentage Fat ϭ Constant A ϩ Constant B Ϫ Constant C Ϫ 10.2. aCopyright © 1986, 1991, 1996, 2000, 2006, 2010 by Frank I. Katch, Victor L. Katch, William D. McArdle, and Fitness Technologies, Inc., 5043 Via Lara Ln. Santa Barbara, CA 93111. No part of this appendix may be reproduced in any manner without written permission from the copyright holders.

•678 Appendix C Evaluation of Body Composition—Girth Method Chart C.2 Conversion Constants to Predict Percentage Body Fat for Older Mena BUTTOCKS ABDOMEN FOREARM in cm CONSTANT A in cm CONSTANT B in cm CONSTANT C 28.00 71.12 29.34 25.50 64.77 22.84 7.00 17.78 21.01 28.25 71.75 29.60 25.75 65.40 23.06 7.25 18.41 21.76 28.50 72.39 29.87 26.00 66.04 23.29 7.50 19.05 22.52 28.75 73.02 30.13 26.25 66.67 23.51 7.75 19.68 23.26 29.00 73.66 30.39 26.50 67.31 23.73 8.00 20.32 24.02 29.25 74.29 30.65 26.75 67.94 23.96 8.25 20.95 24.76 29.50 74.93 30.92 27.00 68.58 24.18 8.50 21.59 25.52 29.75 75.56 31.18 27.25 69.21 24.40 8.75 22.22 26.26 30.00 76.20 31.44 27.50 69.85 24.63 9.00 22.86 27.02 30.25 76.83 31.70 27.75 70.48 24.85 9.25 23.49 27.76 30.50 77.47 31.96 28.00 71.12 25.08 9.50 24.13 28.52 30.75 78.10 32.22 28.25 71.75 25.29 9.75 24.76 29.26 31.00 78.74 32.49 28.50 72.39 25.52 10.00 25.40 30.02 31.25 79.37 32.75 28.75 73.02 25.75 10.25 26.03 30.76 31.50 80.01 33.01 29.00 73.66 25.97 10.50 26.67 31.52 31.75 80.64 33.27 29.25 74.29 26.19 10.75 27.30 32.27 32.00 81.28 33.54 29.50 74.93 26.42 11.00 27.94 33.02 32.25 81.91 33.80 29.75 75.56 26.64 11.25 28.57 33.77 32.50 82.55 34.06 30.00 76.20 26.87 11.50 29.21 34.52 32.75 83.18 34.32 30.25 76.83 27.09 11.75 29.84 35.27 33.00 83.82 34.58 30.50 77.47 27.32 12.00 30.48 36.02 33.25 84.45 34.84 30.75 78.10 27.54 12.25 31.11 36.77 33.50 85.09 35.11 31.00 78.74 27.76 12.50 31.75 37.53 33.75 85.72 35.37 31.25 79.37 27.98 12.75 32.38 38.27 34.00 86.36 35.63 31.50 80.01 28.21 13.00 33.02 39.03 34.25 86.99 35.89 31.75 80.64 28.43 13.25 33.65 39.77 34.50 87.63 36.16 32.00 81.28 28.66 13.50 34.29 40.53 34.75 88.26 36.42 32.25 81.91 28.88 13.75 34.92 41.27 35.00 88.90 36.68 32.50 82.55 29.11 14.00 35.56 42.03 35.25 89.53 36.94 32.75 83.18 29.33 14.25 36.19 42.77 35.50 90.17 37.20 33.00 83.82 29.55 14.50 36.83 43.53 35.75 90.80 37.46 33.25 84.45 29.78 14.75 37.46 44.27 36.00 91.44 37.73 33.50 85.09 30.00 15.00 38.10 45.03 36.25 92.07 37.99 33.75 85.72 30.22 15.25 38.73 45.77 36.50 92.71 38.25 34.00 86.36 30.45 15.50 39.37 46.53 36.75 93.34 38.51 34.25 86.99 30.67 15.75 40.00 47.28 37.00 93.98 38.78 34.50 87.63 30.89 16.00 40.64 48.03 37.25 94.61 39.04 34.75 88.26 31.12 16.25 41.27 48.78 37.50 95.25 39.30 35.00 88.90 31.35 16.50 41.91 49.53 37.75 95.88 39.56 35.25 89.53 31.57 16.75 42.54 50.28 38.00 96.52 39.82 35.50 90.17 31.79 17.00 43.18 51.03 38.25 97.15 40.08 35.75 90.80 32.02 17.25 43.81 51.78 38.50 97.79 40.35 36.00 91.44 32.24 17.50 44.45 52.54 38.75 98.42 40.61 36.25 92.07 32.46 17.75 45.08 53.28 39.00 99.06 40.87 36.50 92.71 32.69 18.00 45.72 54.04 39.25 99.69 41.13 36.75 93.34 32.91 18.25 46.35 54.78 39.50 100.33 41.39 37.00 93.98 33.14 39.75 100.96 41.66 37.25 94.61 33.36 40.00 101.60 41.92 37.50 95.25 33.58 40.25 102.23 42.18 37.75 95.88 33.81 40.50 102.87 42.44 38.00 96.52 34.03 40.75 103.50 42.70 38.25 97.15 34.26 41.00 104.14 42.97 38.50 97.79 34.48 41.25 104.77 43.23 38.75 98.42 34.70 41.50 105.41 43.49 39.00 99.06 34.93 41.75 106.04 43.75 39.25 99.69 35.15 42.00 106.68 44.02 39.50 100.33 35.38 42.25 107.31 44.28 39.75 100.96 35.59 42.50 107.95 44.54 40.00 101.60 35.82 42.75 108.58 44.80 40.25 102.23 36.05 43.00 109.22 45.06 40.50 102.87 36.27 43.25 109.85 45.32 40.75 103.50 36.49

•Appendix C Evaluation of Body Composition—Girth Method 679 Chart C.2 Conversion Constants to Predict Percentage Body Fat for Older Mena (Continued ) BUTTOCKS ABDOMEN FOREARM in cm CONSTANT A in cm CONSTANT B in cm CONSTANT C 43.50 110.49 45.59 41.00 104.14 36.72 43.75 111.12 45.85 41.25 104.77 36.94 44.00 111.76 46.12 41.50 105.41 37.17 44.25 112.39 46.37 41.75 106.04 37.39 44.50 113.03 46.64 42.00 106.68 37.62 44.75 113.66 46.89 42.25 107.31 37.87 45.00 114.30 47.16 42.50 107.95 38.06 45.25 114.93 47.42 42.75 108.58 38.28 45.50 115.57 47.68 43.00 109.22 38.51 45.75 116.20 47.94 43.25 109.85 38.73 46.00 116.84 48.21 43.50 110.49 38.96 46.25 117.47 48.47 43.75 111.12 39.18 46.50 118.11 48.73 44.00 111.76 39.41 46.75 118.74 48.99 44.25 112.39 39.63 47.00 119.38 49.26 44.50 113.03 39.85 47.25 120.01 49.52 44.75 113.66 40.08 47.50 120.65 49.78 45.00 114.30 40.30 47.75 121.28 50.04 48.00 121.92 50.30 48.25 122.55 50.56 48.50 123.19 50.83 48.75 123.82 51.09 49.00 124.46 51.35 Note: Percentage Fat ϭ Constant A ϩ Constant B Ϫ Constant C Ϫ 15.0. aCopyright © 1986, 1991, 1996, 2000, 2006 by Frank I. Katch, Victor L. Katch, William D. McArdle, and Fitness Technologies, Inc., 5043 Via Lara Ln. Santa Barbara, CA 93111. No part of this appendix may be reproduced in any manner without written permission from the copyright holders. Chart C.3 Conversion Constants to Predict Percentage Body Fat for Young Womena ABDOMEN THIGH FOREARM in cm CONSTANT A in cm CONSTANT B in cm CONSTANT C 20.00 50.80 26.74 14.00 35.56 29.13 6.00 15.24 25.86 20.25 51.43 27.07 14.25 36.19 29.65 6.25 15.87 26.94 20.50 52.07 27.41 14.50 36.83 30.17 6.50 16.51 28.02 20.75 52.70 27.74 14.75 37.46 30.69 6.75 17.14 29.10 21.00 53.34 28.07 15.00 38.10 31.21 7.00 17.78 30.17 21.25 53.97 28.41 15.25 38.73 31.73 7.25 18.41 31.25 21.50 54.61 28.74 15.50 39.37 32.25 7.50 19.05 32.33 21.75 55.24 29.08 15.75 40.00 32.77 7.75 19.68 33.41 22.00 55.88 29.41 16.00 40.64 33.29 8.00 20.32 34.48 22.25 56.51 29.74 16.25 41.27 33.81 8.25 20.95 35.56 22.50 57.15 30.08 16.50 41.91 34.33 8.50 21.59 36.64 22.75 57.78 30.41 16.75 42.54 34.85 8.75 22.22 37.72 23.00 58.42 30.75 17.00 43.18 35.37 9.00 22.86 38.79 23.25 59.05 31.08 17.25 43.81 35.89 9.25 23.49 39.87 23.50 59.69 31.42 17.50 44.45 36.41 9.50 24.13 40.95 23.75 60.32 31.75 17.75 45.08 36.93 9.75 24.76 42.03 24.00 60.96 32.08 18.00 45.72 37.45 10.00 25.40 43.10 24.25 61.59 32.42 18.25 46.35 37.97 10.25 26.03 44.18 24.50 62.23 32.75 18.50 46.99 38.49 10.50 26.67 45.26 24.75 62.86 33.09 18.75 47.62 39.01 10.75 27.30 46.34 25.00 63.50 33.42 19.00 48.26 39.53 11.00 27.94 47.41 25.25 64.13 33.76 19.25 48.89 40.05 11.25 28.57 48.49 25.50 64.77 34.09 19.50 49.53 40.57 11.50 29.21 49.57 25.75 65.40 34.42 19.75 50.16 41.09 11.75 29.84 50.65 26.00 66.04 34.76 20.00 50.80 41.61 12.00 30.48 51.73 26.25 66.67 35.09 20.25 51.43 42.13 12.25 31.11 52.80 26.50 67.31 35.43 20.50 52.07 42.65 12.50 31.75 53.88 (continued)

•680 Appendix C Evaluation of Body Composition—Girth Method Chart C.3 Conversion Constants to Predict Percentage Body Fat for Young Womena (Continued ) ABDOMEN THIGH FOREARM in cm CONSTANT A in cm CONSTANT B in cm CONSTANT C 26.75 67.94 35.76 20.75 52.70 43.17 12.75 32.38 54.96 27.00 68.58 36.10 21.00 53.34 43.69 13.00 33.02 56.04 27.25 69.21 36.43 21.25 53.97 44.21 13.25 33.65 57.11 27.50 69.85 36.76 21.50 54.61 44.73 13.50 34.29 58.19 27.75 70.48 37.10 21.75 55.24 45.25 13.75 34.92 59.27 28.00 71.12 37.43 22.00 55.88 45.77 14.00 35.56 60.35 28.25 71.75 37.77 22.25 56.51 46.29 14.25 36.19 61.42 28.50 72.39 38.10 22.50 57.15 46.81 14.50 36.83 62.50 28.75 73.02 38.43 22.75 57.78 47.33 14.75 37.46 63.58 29.00 73.66 38.77 23.00 58.42 47.85 15.00 38.10 64.66 29.25 74.29 39.10 23.25 59.05 48.37 15.25 38.73 65.73 29.50 74.93 39.44 23.50 59.69 48.89 15.50 39.37 66.81 29.75 75.56 39.77 23.75 60.32 49.41 15.75 40.00 67.89 30.00 76.20 40.11 24.00 60.96 49.93 16.00 40.64 68.97 30.25 76.83 40.44 24.25 61.59 50.45 16.25 41.27 70.04 30.50 77.47 40.77 24.50 62.23 50.97 16.50 41.91 71.12 30.75 78.10 41.11 24.75 62.86 51.49 16.75 42.54 72.20 31.00 78.74 41.44 25.00 63.50 52.01 17.00 43.18 73.28 31.25 79.37 41.78 25.25 64.13 52.53 17.25 43.81 74.36 31.50 80.01 42.11 25.50 64.77 53.05 17.50 44.45 75.43 31.75 80.64 42.45 25.75 65.40 53.57 17.75 45.08 76.51 32.00 81.28 42.78 26.00 66.04 54.09 18.00 45.72 77.59 32.25 81.91 43.11 26.25 66.67 54.61 18.25 46.35 78.67 32.50 82.55 43.45 26.50 67.31 55.13 18.50 46.99 79.74 32.75 83.18 43.78 26.75 67.94 55.65 18.75 47.62 80.82 33.00 83.82 44.12 27.00 68.58 56.17 19.00 48.26 81.90 33.25 84.45 44.45 27.25 69.21 56.69 19.25 48.89 82.98 33.50 85.09 44.78 27.50 69.85 57.21 19.50 49.53 84.05 33.75 85.72 45.12 27.75 70.48 57.73 19.75 50.16 85.13 34.00 86.36 45.45 28.00 71.12 58.26 20.00 50.80 86.21 34.25 86.99 45.79 28.25 71.75 58.78 34.50 87.63 46.12 28.50 72.39 59.30 34.75 88.26 46.46 38.75 73.02 59.82 35.00 88.90 46.79 29.00 73.66 60.34 35.25 89.53 47.12 29.25 74.29 60.86 35.50 90.17 47.46 29.50 74.93 61.38 35.75 90.80 47.79 29.75 75.56 61.90 36.00 91.44 48.13 30.00 76.20 62.42 36.25 92.07 48.46 30.25 76.83 62.94 36.50 92.71 48.80 30.50 77.47 63.46 36.75 93.34 49.13 30.75 78.10 63.98 37.00 93.98 49.46 31.00 78.74 64.50 37.25 94.61 49.80 31.25 79.37 65.02 37.50 95.25 50.13 31.50 80.01 65.54 37.75 95.88 50.47 31.75 80.64 66.06 38.00 96.52 50.80 32.00 81.28 66.58 38.25 97.15 51.13 32.25 81.91 67.10 38.50 97.79 51.47 32.50 82.55 67.62 38.75 98.42 51.80 32.75 83.18 68.14 39.00 99.06 52.14 33.00 83.82 68.66 39.25 99.69 52.47 33.25 84.45 69.18 39.50 100.33 52.81 33.50 85.09 69.70 39.75 100.96 53.14 33.75 85.72 70.22 40.00 101.60 53.47 34.00 86.36 70.74 Note: Percentage Fat ϭ Constant A ϩ Constant B Ϫ Constant C Ϫ 19.6. aCopyright © 1986, 1991, 1996, 2000, 2006, 2010 by Frank I. Katch, Victor L. Katch, William D. McArdle, and Fitness Technologies, Inc., 5043 Via Lara Ln. Santa Barbara, CA 93111. No part of this appendix may be reproduced in any manner without written permission from the copyright holders.

•Appendix C Evaluation of Body Composition—Girth Method 681 Chart C.4 Conversion Constants to Predict Percentage Body Fat for Older Womena ABDOMEN THIGH FOREARM in cm CONSTANT A in cm CONSTANT B in cm CONSTANT C 25.00 63.50 29.69 14.00 35.56 17.31 10.00 25.40 14.46 25.25 64.13 29.98 14.25 36.19 17.62 10.25 26.03 14.82 25.50 64.77 30.28 14.50 36.83 17.93 10.50 26.67 15.18 25.75 65.40 30.58 14.75 37.46 18.24 10.75 27.30 15.54 26.00 66.04 30.87 15.00 38.10 18.55 11.00 27.94 15.91 26.25 66.67 31.17 15.25 38.73 18.86 11.25 28.57 16.27 26.50 67.31 31.47 15.50 39.37 19.17 11.50 29.21 16.63 26.75 67.94 31.76 15.75 40.00 19.47 11.75 29.84 16.99 27.00 68.58 32.06 16.00 40.64 19.78 12.00 30.48 17.35 27.25 69.21 32.36 16.25 41.27 20.09 12.25 31.11 17.71 27.50 69.85 32.65 16.50 41.91 20.40 12.50 31.75 18.08 27.75 70.48 32.95 16.75 42.54 20.71 12.75 32.38 18.44 28.00 71.12 33.25 17.00 43.18 21.02 13.00 33.02 18.80 28.25 71.75 33.55 17.25 43.81 21.33 13.25 33.65 19.16 28.50 72.39 33.84 17.50 44.45 21.64 13.50 34.29 19.52 28.75 73.02 34.14 17.75 45.08 21.95 13.75 34.92 19.88 29.00 73.66 34.44 18.00 45.72 22.26 14.00 35.56 20.24 29.25 74.29 34.73 18.25 46.35 22.57 14.25 36.19 20.61 29.50 74.93 35.03 18.50 46.99 22.87 14.50 36.83 20.97 29.75 75.56 35.33 18.75 47.62 23.18 14.75 37.46 21.33 30.00 76.20 35.62 19.00 38.26 23.49 15.00 38.10 21.69 30.25 76.83 35.92 19.25 48.89 23.80 15.25 38.73 22.05 30.50 77.47 36.22 19.50 49.53 24.11 15.50 39.37 22.41 30.75 78.10 36.51 19.75 50.16 24.42 15.75 40.00 22.77 31.00 78.74 36.81 20.00 50.80 24.73 16.00 40.64 23.14 31.25 79.37 37.11 20.25 51.43 25.04 16.25 41.27 23.50 31.50 80.01 37.40 20.50 52.07 25.35 16.50 41.91 23.86 31.75 80.64 37.70 20.75 52.70 25.66 16.75 42.54 24.22 32.00 81.28 38.00 21.00 53.34 25.97 17.00 43.18 24.58 32.25 81.91 38.30 21.25 53.97 26.28 17.25 43.81 24.94 32.50 82.55 38.59 21.50 54.61 26.58 17.50 44.45 25.31 32.75 83.18 38.89 21.75 55.24 26.89 17.75 45.08 25.67 33.00 83.82 39.19 22.00 55.88 27.20 18.00 45.72 26.03 33.25 84.45 39.48 22.25 56.51 27.51 18.25 46.35 26.39 33.50 85.09 39.78 22.50 57.15 27.82 18.50 46.99 26.75 33.75 85.72 40.08 22.75 57.78 28.13 18.75 47.62 27.11 34.00 86.36 40.37 23.00 58.42 28.44 19.00 48.26 27.47 34.25 86.99 40.67 23.25 59.05 28.75 19.25 48.89 27.84 34.50 87.63 40.97 23.50 59.69 29.06 19.50 49.53 28.20 34.75 88.26 41.26 23.75 60.32 29.37 19.75 50.16 28.56 35.00 88.90 41.56 24.00 60.96 29.68 20.00 50.80 28.92 35.25 89.53 41.86 24.25 61.59 29.98 20.25 51.43 29.28 35.50 90.17 42.15 24.50 62.23 30.29 20.50 52.07 29.64 35.75 90.80 42.45 24.75 62.86 30.60 20.75 52.70 30.00 36.00 91.44 42.75 25.00 63.50 30.91 21.00 53.34 30.37 36.25 92.07 43.05 25.25 64.13 31.22 21.25 53.97 30.73 36.50 92.71 43.34 25.50 64.77 31.53 21.50 54.61 31.09 36.75 93.35 43.64 25.75 65.40 31.84 21.75 55.24 31.45 37.00 93.98 43.94 26.00 66.04 32.15 22.00 55.88 31.81 37.25 94.62 44.23 26.25 66.67 32.46 22.25 56.51 32.17 37.50 95.25 44.53 26.50 67.31 32.77 22.50 57.15 32.54 37.75 95.89 44.83 26.75 67.94 33.08 22.75 57.78 32.90 38.00 96.52 45.12 27.00 68.58 33.38 23.00 58.42 33.26 38.25 97.16 45.42 27.25 69.21 33.69 23.25 59.05 33.62 38.50 97.79 45.72 27.50 69.85 34.00 23.50 59.69 33.98 38.75 98.43 46.01 27.75 70.48 34.31 23.75 60.32 34.34 39.00 99.06 46.31 28.00 71.12 34.62 24.00 60.96 34.70 39.25 99.70 46.61 28.25 71.75 34.93 24.25 61.59 35.07 39.50 100.33 46.90 28.50 72.39 35.24 24.50 62.23 35.43 39.75 100.97 47.20 28.75 73.02 35.55 24.75 62.86 35.79 40.00 101.60 47.50 29.00 73.66 35.86 25.00 63.50 36.15 40.25 101.24 47.79 29.25 74.29 36.17 (continued)

•682 Appendix C Evaluation of Body Composition—Girth Method Chart C.4 Conversion Constants to Predict Percentage Body Fat for Older Womena (Continued ) ABDOMEN THIGH FOREARM in cm CONSTANT A in cm CONSTANT B in cm CONSTANT C 40.50 102.87 48.09 29.50 74.93 36.48 40.75 103.51 48.39 29.75 75.56 36.79 41.00 104.14 48.69 30.00 76.20 37.09 41.25 104.78 48.98 30.25 76.83 37.40 41.50 105.41 49.28 30.50 77.47 37.71 41.75 106.05 49.58 30.75 78.10 38.02 42.00 106.68 49.87 31.00 78.74 38.33 42.25 107.32 50.17 31.25 79.37 38.64 42.50 107.95 50.47 31.50 80.01 38.95 42.75 108.59 50.76 31.75 80.64 39.26 43.00 109.22 51.06 32.00 81.28 39.57 43.25 109.86 51.36 32.25 81.91 39.88 43.50 110.49 51.65 32.50 82.55 40.19 43.75 111.13 51.95 32.75 83.18 40.49 44.00 111.76 52.25 33.00 83.82 40.80 44.25 112.40 52.54 33.25 84.45 41.11 44.50 113.03 52.84 33.50 85.09 41.42 44.75 113.67 53.14 33.75 85.72 41.73 45.00 114.30 53.44 34.00 86.36 42.04 Note: Percentage Fat ϭ Constant A ϩ Constant B Ϫ Constant C Ϫ 19.6. aCopyright © 1986, 1991, 1996, 2000, 2006, 2010 by Frank I. Katch, Victor L. Katch, William D. McArdle, and Fitness Technologies, Inc., 5043 Via Lara Ln. Santa Barbara, CA 93111. No part of this appendix may be reproduced in any manner without written permission from the copyright holders.

•Chapter 6 Human Enerty transfer During Exercise 683 DA P P E N D I X Evaluation of Body Composition—Skinfold Method Skinfold equations to predict body density (Db) or per- centage body fat (%BF) use regression analyses in which scores obtained on several variables are multiplied by con- stants to arrive at a predicted Db or %BF. Solving these equations requires extensive computations that are ill suited for field work and are subject to error, particularl when done by hand or with calculators. A nomogram is a pictorial method that simplifies com putations by providing a simple “look-up” method to solve the equation. THE NOMOGRAM Figure D.1 presents the nomogram to estimate %BF for college-aged men and women from the sum of three skin- folds plus age using generalized equations. VARIABLES • For men, obtain the following variables: skinfolds in millimeters (chest, abdomen, thigh) and age in years. • For women, obtain the following variables: skinfolds in millimeters (triceps, thigh, suprailiac) and age in years. USING THE NOMOGRAM 1. Sum the three skinfolds. Figure D.1 Nomogram to estimate percentage body fat of 2. Locate on the right scale (sum of the three skinfolds college-aged men and women using the Jackson et al. generalized equations. (From Baun, W.B., Baun, M.R.: A nomogram for the in millimeters). estimate of percent body fat from generalized equations.Res. Q. 3. Locate on the left scale (age in years). Exerc. Sport, 52:382, 1981. Copyright 1981 by AAHPERD. 4. With a ruler, connect the two points (right scale Reprinted by permission. and left scale); read the resulting %BF from the cen- ter scale (male or female). 683

•684 Appendix D Evaluation of Body Composition—Skinfold Method EXAMPLE Convert Db to %BF using the Siri equation (%BFϭ 495 Ϭ Db Ϫ 450). Data for a woman, age 30 y; triceps skinfold ϭ 15 mm; thigh skinfold ϭ 15 mm; suprailiac skinfold ϭ 25 mm. 1. Equation for men: ∑3SKF equals sum of chest, abdomen, and thigh skinfolds: 1. Sum skinfolds ϭ 55 mm. 2. Place rule on right scale over 55 mm; connect to left Db ϭ 1.10938 Ϫ (0.0008267 ϫ ∑3SKF) ϩ ([0.0000016 ϫ ∑3SKF]2) scale at age 30 y. Ϫ (0.0002574 ϫ Age) 3. Read percentage body fat: 23%. 2. Equation for women: ∑3SKF equals sum of triceps, CAUTION thigh, and suprailiac skinfolds: Although nomograms can save time, they are subject to Db ϭ 1.0994921 Ϫ (0.0009929 ϫ ∑3SKF) error, particularly interpolation errors in which precision ϩ ([0.0000023 ϫ ∑3SKF]2) and accuracy can be compromised. At best, interpolation Ϫ (0.0001392 ϫ Age) of the %BF value for men and women in the present nomo- gram becomes limited to no more than half a whole per- REFERENCES centage point. Also, because the nomogram uses the Siri equation to convert Db to %BF, it should not be used with Baun, W.B., Baun M.R.: A nomogram for the estimate of percent populations in which other density-to-percentage fat con- body fat from generalized equations. Res. Quart. Exerc. Sport, versions are more appropriate. 52:382, 1981. EQUATIONS Jackson, A.S., et al.: Generalized equations for predicting body density of women. Med. Sci. Sports Exerc., 12:175, 1980. Check the accuracy of using the nomogram by solving the following equations to predict percentage Db. Jackson, A.S., Pollock, M.L.: Generalized equations for predicting body density of men. Br. J. Nutr., 40:497, 1978.

Index Page numbers in italics indicate figure; those followed by t indicate table A Adipocytes, 175 Alactacid oxygen debt, 196 Adipose tissue-free weight (ATFW), 540 Alcohol abuse, 133 AAAPE (American Association for the Advance- Adolescents ment of Physical Education), 22 warning signs of, 132 fast food and obesity in, 564 Alcohol use, 133–134 AAHPERD (American Alliance for Health, Physi- obesity in, 625, 625 cal Education, Recreation, and Dance), 22 ADP (adenosine diphosphate), 159 body absorption and, 135 Adrenal cortex, 389 effects on body, 135 A band, of sarcomere, 361, 362, 363 changes with age, 606 fluid replacement and, 13 Absolute muscular strength, 458 hormones of, 390–392, 402 physiologic effects, 134 Absolute oxygen uptake, 191 Adrenal glands, 379t, 389, 389 Aldosterone, 69, 391, 402, 498 Acclimatization Adrenal medulla, 389 Alkaline reserve, 211–212, 296 Adrenal medulla hormones, 389–390, 402 Alkalosis, result of, 296 altitude, 515–517, 515t, 516 Adrenergic fibers, 323, 34 Allied health, for exercise physiology education, to cold, 510–511 Adrenocortical hormones, 390–392 heat, 506, 506, 507t Adrenocorticotropin (ACTH), 387, 400 15 at home, 520–521 Adrenopause, 606 All-or-none principle, 351 Acetylcholine, 343 Aerobic, defined, 15 Alpha cells, 392 Acid-base balance Aerobic(VcиaOp2amciatxy). See Maximal oxygen uptake Altitude at altitude, 515t, 516–517 Aerobic glycolysis, 168, 171–172, 172, 173 buffering, 295–297. See also Buffers Aerobic metabolism, 165, 188–192 acclimatization to, 515–517, 515t, 516 intense exercise and, 296–297, 297 oxygen in, 188, 188–192, 191 exercise at, 513–521 Acidosis, result of, 296 steady rate of, 188 illnesses related to, 517–518 Acromegaly, 141, 387 Aerobicuppotawkeer,(V2и O212.mSaexe) also Maximal oxygen oxygen loading at, 514–515 ACSM. See American College of Sports Medicine Aerobic system. See also Aerobic metabolism stress of, 513–515, 514 adjustments at altitude, 518, 518 Altitude sickness, 521 (ACSM) changes with exercise training, 414–422, 414t Alveolar air, 277 ACTH (adrenocorticotropin), 387, 400 measuring and evaluating, 212–232 Alveolar ventilation, 271–273, 273t Actin, 361, 362 Alveoli direct calorimetry, 212–214, 213, 217–218 defined, 26 actin-myosin orientation, 361, 363, 364 doubly labeled water technique, 218 in pulmonary ventilation, 267, 268 ATP and myosin link, 366–367 indirect calorimetry, 214–217 Ambient air, 276–277, 277t crossbridges, 363, 365–366, 366 maximal oxygen uptake, 221–223, 222 Amenorrhea, 538 Active site, 158 respiratory exchange ratio, 219–220 secondary, 64 Active transport, 157 respiratory quotient, 218–219 American Alliance for Health, Physical Actomyosin, 366–367 vs. anaerobic, 168 Acute mountain sickness (AMS), 517 Aerobic training Education, Recreation, and Dance Acute respiratory distress syndrome (ARDS), adaptations to, 413–422 (AAHPERD), 22 continuous, 434 American Association for the Advancement of 653t exercise interval in, 435–436 Physical Education (AAAPE), 22 Acute response, defined, 47 factors affecting response to, 422–427 American College of Sports Medicine (ACSM), Adaptation, defined, 47 formulating a program, 427–428 22, 27t Adaptations goals of, 422 Physical Activity Recommendations, 422t interval training, 434–435, 435t Physical Activity Recommendations for older with exercise training relief interval in, 436 adults, 423t aerobic system, 414–422, 414t resistance training combined with, 474 position statement on steroids, 138 anaerobic system, 413–414, 414 Afferent division, of central nervous system, 339 on progression models in resistance training, 463 cardiovascular system, 416, 416–420 Afferent neurons, 338 publications of, 22 Afterload, 327 qualification and certifications, 27– with resistance training, 476, 476–482, 478t Age American Heart Association (AHA) muscular, 477, 478–482 as CHD risk factor, 621 on cardiovascular disease epidemic, 617 neural, 476–478, 477 heat acclimatization and, 507, 509 heart attack warning signs, 616–617 in maximal oxygen uptake and, 229, 230 on physical activity in elderly, 597 Adenosine 3Ј5Ј-cyclic monophosphate (AMP), Aging. See also Older adults on resistance training, 651–652 178 bodily function and, 604–610, 605 Physical Activity Recommendations, 422t pulmonary system and, 653t Physical Activity Recommendations for older Adenosine diphosphate (ADP), 159 successful, 596–599, 598 adults, 423t 2,3-adenosine monophosphate (cyclic-AMP), 383 AHA. See American Heart Association (AHA) American Journal of Physiology, 14 Adenosine triphosphate (ATP), 153, 159 AI (adequate intakes), 87, 89 American Society of Exercise Physiology (ASEP), 24 Air Amherst College, exercise physiology origins at, aerobic synthesis of, 165 alveolar, 277 8–10 cellular oxidation and, 162–165 ambient, 276–277, 277t Amine hormones, 382t, 383 energy currency, 159–161, 160, 161 tracheal, 277 Amino acids, 46–48 intramuscular high-energy phosphates, 162 Air resistance, running and, 255–256 essential, 47 limited currency, 161 non-essential, 47 phosphocreatine and, 161–162, 162 structure of, 47, 48 phosphorylation and, 162 AMP (adenosine 3Ј5Ј-cyclic monophosphate), 178 yield from fat catabolism, 176 Amphetamines, 143 yield from glucose catabolism, 172–174, 174 AMS (acute mountain sickness), 517 Adenosine triphosphate-phosphocreatine 685 (ATP-PCr) system, 162, 162, 186, 193–194, 432 Adenylate kinase reaction, 162 Adenyl cyclase, 383 Adequate intakes (AI), 87, 89 ADH, 386, 388, 402, 498

•686 Index Anabolic effect, amino acid supplements for, Atherosclerosis susceptibility gene (ATHS), 632 Blood flo 123–125, 124 Athletes aerobic exercise training effects on, 420 to brain with rest and exercise, 329–330 Anabolic reaction, 160, 160 female athlete triad, 63–64, 64 during exercise in heat, 500 Anabolic steroids, 134–139. See also Steroids iron intake for, 69 to heart with rest and exercise, 329–330 Anabolism, 49–50, 60, 62 Atkins, Dr. Robert (1930–2003), 582 regulation of, 322–323 Anaerobic, defined, 15 ATP. See Adenosine triphosphate (ATP) Anaerobic capacity, 208, 210 ATP-PCr system, 162, 162, 186, 193–194, 432 Blood lactate, 170–171 Anaerobic energy system Atrial fibrillation, 31 accumulation of, 186, 186–187 Atrioventricular valves, 302 aerobic exercise training effects on, 421, 421 changes with exercise training, 413–414, 414 Atwater, W. O. (1844–1907), 83, 214 as energy source, 188 in children, 211 Atwater general factors, 83 onset of blood lactate accumulation (OBLA), gender differences, 211 Atwater-Rosa calorimeter, 214 187, 292–294, 293 measuring and evaluating, 204–207 Auscultation causes of, 293 prediction of, 210 of blood pressure, 308–309 endurance performance and, 293–294 vs. aerobic, 168 of heart rate, 320 in short-term energy system, 207, 208 Anaerobic fatigue, 208, 210 Autologous transfusion, 522 threshold, 187 Anaerobic glycolysis, 168–171, 169, 170 Autonomic nervous system, 339, 341, 343 Anaerobic power, 208 Autonomic reflex arc, 343, 345, 345 Blood lipid abnormalities, 618, 618–620 Anaerobic power output equation, 206 AV bundle, 314 in coronary heart disease, 638 Anaerobic threshold, 292 Average energy intakes, 94, 94–99, 96 Anaerobic training, 432–434 Average power output, 208 Blood pressure, 306–311 adaptations to, 413–414, 414 AV node, 314 aerobic exercise training effects on, 420 factors affecting performance, 211–212 A-v O2 difference, 283, 330–332, 331 assessing, 637 Anatomic dead space, 271, 273 exercise training effects on, 419, 419 classification and management, 30 Androgens, 391–392 Axon, of motor neuron, 247, 347, 348 DASH diet to lower, 66–68 Android-type obesity, 569 during exercise Andromax, 139 B resistance, 309, 310 Andropause, 606 rhythmic, 307, 307, 309 Androstat 100, 139 Back exercises, general, 466, 467 upper body, 310 Androstenedione, 137, 139–141 Back-leg lift dynamometer, 448, 448 during exercise in heat, 500 Anemia Bag technique, spirometry, 214, 215 guidelines for desirable, 95 exercise-induced, 70 Ballistic resistance training, 470 measurement of, 308–309 functional, 69 Bang, Olé, 18 racial differences in, 306–307 iron deficiency, 6 Banned substances, 111 during recovery, 310–311 Aneurysm, 634–635 at rest, 306–307 Angina pectoris, 633, 633 ephedrine, 123 chronic stable, 633 NCAA list of, 139 Blood sugar, 34, 34 differential diagnosis, 636, 636t steroids, 135, 137 Blood supply electrocardiogram of, 645 urine testing, 113 Angiography, coronary, 648 Barcroft, Sir Joseph (1872–1947), 20, 20 fetal, 437 Angiotensin, 391 Basal metabolic rate (BMR), 238 to skeletal muscle, 359 Ankle, joint flexibility assessment for, 60 Bases, defined, 29 BMI. See Body mass index (BMI) Antagonism, hormone interaction, 384 BASES (British Association of Sport and Exercise BMR (basal metabolic rate), 238 Anthropometric assessment, of body build, Bock, Arlie, 16 Science), 24 Body composition 10, 11 B-complex vitamins, exercise performance and, achieving optimal, 574–591 Anti-cortisol-producing compounds, 115–116 aerobic exercise training effects on, 421 Antidiuretic hormone (ADH), 386, 388, 402, 58–59 assessment of Beaumont, William (1785–1853), 8 498 Behnke, Dr. Albert (1898–1993), 534, 536 adipose tissue-free weight (ATFW), 540 Antioxidant vitamins, 57–59 Behnke’s reference man and woman, 534, 536 bioelectrical impedance analysis, 551–553, Anxiolytic effects Bench press, one-repetition maximum (1-RM) 552 of alcohol, 134 strength testing, 450, 451 body mass index, 554, 554–555 defined, 13 Bench stepping, measuring work, 199 computed tomography (CT scan), 555–556, Aortic bodies, 288, 288 Bergström, Dr. Jonas, 19, 19 Apical beat, 320 Bernard, Claude (1813–1878), 1, 8 556 Apoprotein, 623 Bertillon, Alphonese (1853–1914), 10 direct, 539–540, 540 Archimedes, 540 Beta-blockers, 319 dual-energy x-ray absorptiometry, 553, Archimedes’ principle, 540–541, 541. See also Beta cells, 392 Beta-endorphins, 665 553–554 Hydrostatic weighing Beta-hydroxy-beat-methylbutyrate (HMB), 116, girth measurements, 550, 550–551, 676, ARDS (acute respiratory distress syndrome), 653t Arm-crank ergometer, stress testing, 643, 644 116–117 676t–682t Arm strength, measures of, 462, 462 Beta-oxidation, 176, 177 hydrostatic weighing, 540–545 Arrhythmias, 319, 635–636 Bicarbonate magnetic resonance imaging, 556, 556 Arteries, structure and functions of, 302–303,304 near-infrared interactance, 555 Arterioles, 303 as buffer, 296 skinfold measurements, 545–550, 683–684 Arteriovenous-oxygen (a-v O2) difference, 283, carbon dioxide as, 285, 286 ultrasound, 555 Bicuspid valve, 302 average values for, 556, 557t 330–332, 331 Bioelectrical impedance analysis, 551–553, 552 Behnke’s reference man and woman, 534, 536 exercise training effects on, 419, 419 Bioenergetics, factors affecting, 157–158 changes with age, 609–610 Asbestosis, 653t Biological work, in humans, 156–157 creatine supplementation and, 120–121 Ascorbic acid, 55t Biologic value, of protein, 48 in exercise efficiency, 24 ASEP (American Society of Exercise Physiology), Biosynthesis, 152 in maximal oxygen uptake and, 228–229 Biotin, 55t multicomponent model of, 534, 535 24 Bipolar disorder, 663 resistance training effects on, 486, 487t Asmussen, Erling (1907–1991), 17, 17 Blood boosting, 522, 522–523, 523t Body density, determining, 541–542 Asthma, 653t hormonal, 523 Body fat Blood distribution, 319, 322–323 assessment of exercise-induced, 279 aerobic exercise training effects on, 420 bioelectrical impedance analysis, 551–553, Åstrand, Per-Olof, MD, PhD (b. 1922), 18, exercise effects, 319, 322 Blood doping, 522, 522–523, 523t 552 18–19, 413 body mass index, 554, 554–555 Atherosclerosis girth measurements, 550, 550–551, 676, development of, 615–616, 616 676t–682t skinfold measurements, 545–550, 683–684