Case: Miss Jane ****** is a 13 year old full time middle school student. She is 5’ 2” and weighs 143 pounds. Her father is a full time supervisor at the local manufacturing plant. Her mother works part time as a cashier. She has 2 younger siblings. Jane has played softball for the past 2 years at her school. A recent sports physical has revealed some health risks. She is borderline diabetic (A1C level 5.9) with resting BP of 133/79 (high, BP <120/80mmHg). Her resting heart rate is 82 BPM (normal). She has recently developed exercise induced asthma that is controlled with an inhaler (usually corticosteroid + bronchodilator). She would like to participate in softball this year but her parents are concerned that her asthma will worsen with athletics.
SCREENING AND RISK STRATIFICATION:
According to the given information, Miss ******’ current health fitness status was established (Table 1) and was used to establish her risk factor profile. According to ACSM’s Guidelines for Exercise Testing and Prescription, Miss ****** is considered to be at moderate risk for coronary artery disease (Table 2). Therefore, it is recommended that she participate in moderate exercise, but should consult with a physician before engaging in vigorous exercise.
Table 1: Current Health Fitness Status
Test Patient’s Score Preference Interval Patient’s Status Goal
BMI 26.2 Normal: 18.5-24.5 Overweight Improve: Lose weight to be in normal range
A1C 5.9 Normal: <5.7 Prediabetes Improve: decrease AIC level to normal range
Blood pressure 133/79 mmHg Normal: <120/80 mmHg Pre-hypertensive Improve: decrease blood pressure to normal range
Heart rate 82 BPM 60-90 BPM Normal maintain
Table 2: Miss ******’ Risk Factor Profile
Risk factor Yes No
Age x
Family history x
Cigarette smoking x
Hypertension x
Dyslipidemia N/A N/A
Impaired fasting glucose x
High BMI x
Sedentary lifestyle x
Miss Jane ****** is a 13 year old girl, who is overweight and has borderline diabetes and pre-hypertension. Miss ****** has exercise-induced asthma that is controlled with coracosteroid and her parents are concerned that her asthma will worsen with athletics. Although this is a legitimate concern, it is important to note exercise benefits and how they may “prevent secondary complication of a sedentary lifestyle … because obesity can contribute to the inflammatory process associated with asthma” (Patho book page number). Furthermore, exercise is especially important to Jane, as it is essential for “bone growth …[as it] affects bone width, density, and strength” (Ex Phys book, 428). Although Jane’s asthma is exercise-induced, it is important that she avoids being inactive.
Before giving Miss ****** her exercise program, I would like to first perform a lifestyle screening to see what lifestyle changes need to be made. For example, how much exercise does she do and what does she do when she exercise. Furthermore, before prescribing her exercises, I would like to do a couple strength test so that the exercises I prescribe are appropriate for her strength level. Finally, flexibility exercises are part of Miss ******’ exercise program. Before prescribing her stretches, I would like to do several tests to see where she is lacking in flexibility so that I may prescribe stretches in areas where she is lacking flexibility. After these tests are completed, I would feel I have a comprehensive evaluation to prescribe exercises that specifically targets areas Miss ****** needs to strengthen and improve overall health and fitness.
I want to know where Miss ****** lives. If she lives somewhere with a lot of pollution, or in places such as the Valley, where there are pesticides, insecticides, and herbicides constantly being sprayed, exposure to these may result in asthma exacerbation. If she does live in a place such as this, she may want to exercise indoors and consider sports such as indoor volleyball, indoor soccer, ect.
GOAL SETTING:
One of the main goals of Miss ******’ exercise prescription is to find exercises that she may be able to tolerate without exacerbating her asthma. For her exercise prescription, exercises that were given decrease the possibility of exacerbating her asthma during activity and are functional for strengthening Miss ****** for return to softball. Because softball really requires short bursts of energy, the possibility of an exercise-induced asthma attack is lesser in this activity in comparison to endurance exercise such as running; therefore, participating in the game of softball itself should not be a concern for her asthma worsening with athletics. Before and after exercise, it is important that Miss ****** performs warm up and cool down exercises to reduce incidence of exercise-induced asthma. Also, during exercise, Miss ****** should be encouraged to breathe in through the nose and out with pursed-lips to warm and humidify inspired air to prevent narrowing of the airway.
The 2008 Physical Activity Guidelines for Americans gives the following recommendations for adolescents. Adolescents should: (a) engage in at least engage in at least one hour of exercise every day (b) the majority of the one hour of exercise should be moderate to vigorous intensity aerobic physical activity (c) vigorous intensity activity should be performed at least three times per week (d) muscle and bone strengthening activities should be performed at least three times per week. Because of Miss Collin’s risk of an asthma attack during exercise, it is safest for her to exercise at a moderate intensity, which may be monitored by heart rate or using the Rate of Perceived Exertion (RPE) Scale. Moderate intensity is 50-70% of the patient’s maximum heart rate. Using Karvonen’s formula, Miss Collin’s training heart rate for moderate intensity exercise should be kept at 104-145 BPM. Moderate activity on a RPE scale is a 13-14, where the patient is exercising at a comfortable pace, enough where she is breathing heavier, but can still converse comfortably. Vigorous intensity exercise is also beneficial in helping decrease body fat. Vigorous exercise that involve short bursts of energy are less likely to induce asthma. Training heart rate for Miss ******’ prescribed vigorous intensity exercise should be kept at 145-176 BPM. Vigorous intensity on a RPE scale is a 15-16, where the patient is short of breath, but can still speak a sentence.
Before giving Miss ******’ her exercise program, it is important that she is educated on how exercise helps to control diabetes and blood pressure. Furthermore, Miss ****** should be educated on the importance of a healthy diet and exercise habits. A healthy diet that is low in sodium, exercise, and weight loss are work together in decreasing fat and controlling hypertension. Furthermore, because she is considered overweight Miss ****** will be educated on decreasing portion sizes, avoiding calorie-dense foods, and the dangers of living a sedentary lifestyle. To address her BMI, Miss Collin’s training plan will include exercises that should be performed at an intensity where she will decrease body weight or fat mass and increase muscle mass.
The primary focus of Miss ******’ goals are to increase cardiovascular fitness to address her blood pressure and weight and to improve strength and flexibility.
Short term goals:
• To exercise at moderate intensity with heart rate at 145-170 beats per minute to maximize benefits of exercise.
o Heart rate is a great indicator on how much the heart is working during exercise, which is especially important for cardiovascular fitness. Heart rate has been calculated and included in the home exercise program.
o Patient may monitor heart rate using a heart rate monitor or by taking manually counting beats per minute using her radial pulse.
Long term goals:
• To increase cardiovascular fitness and endurance to better control blood pressure
o Begin cardiovascular training and build up to 60 minutes of moderate intensity swimming 3-5x per week.
• To gradually and healthily lose ten pounds to be within normal BMI range.
o Follow the home exercise program provided consisting of cardiovascular and strength training to decrease body fat and improve muscle tone and fitness.
• To build a healthier lifestyle through diet and exercise
o Will educate patient on eating a balanced diet and the consequences of living a sedentary lifestyle
COMPREHENSIVE EXERCISE PLAN
Because Miss ****** is considered to be moderate risk for coronary artery disease as explained above, she should exercise at moderate intensity and should consult a physician before engaging in vigorous intensity exercise. For moderate intensity exercise, target heart rate during exercise should be kept at 50-70% maximum heart rate (HRmax). Calculated heart rate for moderate intensity for Miss ****** is 104-145 beats per minute.
Cardiovascular fitness plan: Improving Miss ******’ aerobic fitness is critical in addressing her high BMI and high blood pressure. The following cardiovascular fitness plan includes swimming, as it is “well tolerated by people with exercise-induced asthma, partly because they are breathing air fully saturated with moisture, but [also because]…exhaling under water, which is essentially pursed-lip breathing, is beneficial because it prolongs each expiration and increases the end-expiratory pressure within the respiratory tree” (Patho book cite).
Cardiovascular Fitness Plan: Phase I
• Warmup: dynamic stretches for 7 minutes – knee hug walks
o RPE: 8-9
o Heart Rate: 80-89 BPM
• Activity (type): Swimming
• Frequency: 3 days per week
• Intensity: moderate intensity.
o Heart rate: 104-120 BPM
o RPE: 13-14
• Time: 30 minutes of aerobic activity per session
• Cool down:
o swim at light intensity to cool down.
RPE: 8-9
o finish with static stretches – for example, a sumo stretch
• Goal: to improve cardiovascular fitness and endurance to address high BMI and blood pressure. Patient should not proceed to phase II until engaging in cardiovascular exercise becomes habitual. Once the habit has been established and no longer feels challenged, patient may proceed to phase two.
Cardiovascular Fitness Plan: Phase II (progression)
• Warmup: dynamic stretches for 7 minutes – knee hug walks, walking at a faster pace than in phase one
o RPE: 9-10
o Heart Rate: 90-100 BPM
• Activity (type): Swimming
• Frequency: 4-5 days per week
• Intensity: moderate intensity.
o Heart rate: 120-145 BPM
o RPE: 13-14
• Time: 30-45 minutes of aerobic activity per session
• Cool down:
o swim at light intensity to cool down.
RPE: 8-9
o finish with static stretches – for example, a sumo stretch
• Goal: to improve cardiovascular fitness and endurance to address high BMI and blood pressure.
Cardiovascular Fitness Plan: Phase II (progression and periodization – to maintain patient interest in exercise program and reduce the likelihood of injury. Patient should rotate between different types of appropriate cardiovascular exercise – swimming and sprints)
• Warmup: dynamic stretches for 7 minutes – knee hug walks, walking at a faster pace than in phase one
o RPE: 9-10
o Heart Rate: 90-100 BPM
• Activity (type): interval sprints
• Frequency: 3 days per week
• Intensity: vigorous intensity.
o Heart rate: 145-176 BPM
o RPE: 15-16
• Perform: 7 sets, 30 second sprints, 2 min 30 sec break in between each run
• Cool down:
o Proceed to strength training and static stretches
• Goal: to improve cardiovascular fitness with short high intensity power exercise to address high BMI and blood pressure without exacerbating asthma.
Strength Plan:
• Phase One Exercises:
o Frequency: 3 days a week
o Complete: 3 sets, 10 repetitions
o Intensity: RPE at 10-12
o Time: 20-30 minutes
o Goal: Improve muscle strength.
• Phase Two (progression) Exercises:
o Frequency: 3 days a week
o Complete: 3 sets, 10 repetitions
o Intensity: RPE at 13-14
o Time: 20-30 minutes
o Goal: Improve muscle strength and endurance.
• Both Phase One and Two:
o Warm Up: 7-10 Minutes – knee hug walks
Purpose: gradually increase heart rate and muscle temperature to decrease risk of exacerbation of asthma and to decrease risk of injury. Furthermore, warm up exercises are important in preventing lung tightness. Light activity before strengthening should be done before proceeding to strengthen exercises.
RPE: 9-10
o Activity: strength training with given exercises (Figure 3)
o Frequency: 3 days a week
o Intensity: moderate intensity
o Perform: sets and reps are attached
o Cool down: 10 minutes
Purpose: gradually decrease heart rate to resting heart rate.
Figure 3: Exercise Selection for Miss ******
Exercise Selection Intensity Sets Repetitions
Phase 1: theraband shoulder external rotation RPE: 10-12
104-120 BPM
3 10
Phase 2: 90/90 theraband external rotation RPE at 13-14
120-145 BPM 3 10
Phase 1: Mountain Climber RPE: 10-12
104-120 BPM 3 15
Phase 2: Mountain climbers with twist RPE at 13-14
120-145 BPM 3 15
Phase 1:
Squatted Side Step RPE: 10-12
104-120 BPM 3 10 steps each direction
Squatted side step with theraband RPE at 13-14
120-145 BPM 3 10 steps each direction
Flexibility Plan: To increase flexibility and range of motion in tight muscles and joints that are important for functional activities.
• Frequency: at least 3-5 times per week, after every cardiovascular or strength training session
• Intensity: stretch should be uncomfortable, but never to the point of pain
• Duration (time): hold each stretch for 30 seconds.
A home exercise program of both Phase One and Phase Two programs have been created and attached. The preferred RPE and heart rate for exercise for Miss ****** is discussed in the “Goals” section. Before sending Miss ****** home with the exercise prescription, I would educate the patient on monitoring intensity during exercise to gain maximal benefits from the program. Miss ****** will be taught two ways to monitor her intensity during exercise: 1) heart rate 2) Rate of Perceived Exertion Scale. A heart rate monitor is nowadays is fairly inexpensive and is a good motivator to exercise. One may wear a heart rate monitor to passively measure their heart rate. Furthermore, one may use the heart rate monitor to compete with friends, making exercise a little bit more fun and competitive. If Miss ******’ parents do not with to buy a heart rate monitor for their daughter, Miss ****** will be taught how to take her heart rate by finding her pulse and seeing how many times her heart beats per minute. Intensity may also be measured using a Rate of Perceived Exertion Chart. For the most part, I would like for the patient to be exercising at moderate intensity, where she is starting to breathe more heavy, but is still able to maintain a short conversation while exercising. At the top of the home exercise program, I have included a heart rate and RPE range I would like her to be at for her exercises. A RPE scale will be attached to Miss ******’ home exercise program for her to refer to. With this prescribed exercise program, soon, Miss ****** will be able to feel better and live better.
Originally published 15.10.2019