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Assessment of Physical Activity

Assessment of Physical Activity. Mgr. Robert Vysoký, Ph.D. Department of Public Health – Faculty of Medicine - Masaryk University Brno. Programme : General Medicine , Seminar : Public Health II. Introduction.

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Assessment of Physical Activity

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  1. AssessmentofPhysicalActivity Mgr. Robert Vysoký, Ph.D. Department of Public Health – FacultyofMedicine - Masaryk University Brno Programme: General Medicine, Seminar: Public Health II

  2. Introduction • Physicalactivity has a fundamental role in theprevention and treatmentofchronicdisease • Increasingphysicalactivityis a keycomponentofrecommendations to decerease morbidity and mortality (Haskell WL, Lee IM, Pate RR et al., Med SciSportsExerc, 2007) • Monitoring physicalactivitylevelsisimportantforsurveillance, forassessingtheeffectivenessofinterventions and forphysicalactivityprescription • Investigationofthe dose-response relationshipbetweenphysicalactivity and healthoutcomesisdependent on a reliable and validresponsiveassessmentofphysicalactivity • Physicalinactivityisdefined as thefourthofthe major risk factorsofglobal mortality

  3. Introduction • Approximately 60 years ago, Jeremy Morris and colleaguesshowedthattheincidence ofcoronaryarterydiseasein bus conductorswhoclimbed up and downstairsof double-deckbuses and postalcarrierswhodeliveredthe mail on footwasloverthanthatofrelativelyinactivebus driversorpostalofficeworkers, whospent most oftheiroccupationaltimesitting • Sincethen – numerousotherinvestigatorshaveconfirmedthestrong link betweenphysicalactivity and health • In 1992, theAmericanHeartAssociationincludedphysicalinactivity as a major risk factorforcoronaryarterydisease • Thedeleteriouseffectsofphysicalinactivityare associatedwith many ofthe most commonchronicdiseases - cardiovasculardiseases, T2DM, hypertension, obesity, osteoporosis, depression and breast and colorectalcancers

  4. Introduction • In USA chronicdiseases cause 7 in 10 deaths and accoutfor 70% ofallhealthcarespending • Thefinancialimpactofphysicalinactivityforall US adultswas 251 billion USD • Thefirst public healthrecommendationsforphysicalactivity in USA werereleasedand in 2008 EBM culminated in thefirs-everfederalguidelinesforphysicalactivity • Itincludesthefollowingrecommendations: • adultsshouldavoidinactivity (somephysicalactivityisbetterthannone) • substantialhealthbenefits are obtainedfromaccumulating, in boutsof≥ 10 minutes, 150 mintes per weekofmoderate-intensity or 75 minutes per weekofvigorous-intensity aerobic activity • additionaland more extensivehealthbenefits are obtained by increasing aerobic activity to 300 minutes per weekatmoderate intensity or 150 minutes per weekatvigorous intensity • musclestrenghteningactivitiesofmoderate to high intensity shouldbeperformed≥ 2 days per week

  5. Introduction • Forassessingphysicalactivitywehavesubjective (self-report) andobjective (accelerometry) measurementmethods • Theassessmentof PAisneeded to allowtheclinician to providespecificrecommendationsforpatientsidentified as insufficientlyactive • Withdocumentedhealthbenefitsofphysicallyactivelifestyle as itsguidingprinciple, scientificstatementrecommendsthat PA beassessedregularly, as are theother risk factors • Theprimaryobjectivesofthisstatement are: • providetherationalefortheimportanceofassessing PA • explainkeyconceptsinvolved in theassessmentof PA • provideanoverviewofoptionsforassessmentof PA available to cliniciansandresearchers

  6. Significanceandpromotionof optimum movementactivity in preventionandtreatmentofcivilizationdiseases Chronic non-infectious diseases of mass occurrence in the prevention context • Metabolic diseases (T2D, obesity), cardiovascular diseases, certain oncologic diseases and diseases of the movement apparatus -high incidence in the general population • Connected with life style and are a result of the discrepancy between slowly changing human genotype and fast changing environment (as a result of anthropogenic acivities) • Genetic (non-influenced) risk factors are interacting with strong (but influenced) risk factors of environment and life style • Physicalinactivity as risk factor is a cause of 1.9 million of deaths a year worldwide • Identified as 4th out of the major risk factors of total mortality (6% deaths worldwide)

  7. Promotion of physical activity – global and European strategy Documents on promotion of physical activity in Europe: • are based on a complex preventive program “Global strategy for nutrition, physical activity and health” (WHO 2004) • The green book (2005): to enforce and promote healthy nutrition and movement activity • The white book of sport (2007)

  8. The importance of optimalPA for primary prevention of civilization diseases and movementapparatus disorders • Humans - morphologicaland functional adaptationfor life style which required good physical fitness • We are phylogenetically adapted to bipedal locomotion, periodical and uniform static and dynamic load • Current life style – up to 60% of world population suffers from major lack of physical activity, sedentary lifestyle • Excessive static postures • Lack of medium intensity dynamic load • Population groups at risk: women and seniors, children and youth, individuals with special needs (need of targeted applied MA) • each population group – different requirements on intensity, duration and type of MA to fulfill the criteria for optimum MA

  9. The importance of optimalPAfor primary prevention of civilization diseases and movement apparatus disorders • Optimization of PAespecially for untrained population • The expected effect: increase of health oriented fitness level • Not a need to reach maximum physical performance regardlessthe possibility of health complications • No quantification or evaluation of physical performance – evaluation of PAin regards to risk factors or increased markers of these risk factors, in regard to limitation in clinical state or movement limitations Optimal levelofPApositively supports and affects: • cardiorespiratory and neurohumoral system • optimum shape and function of movement system (muscular balance, physiologic vertebra and spinal position, rangeofmotion, joins flexibility and strength) • PA should not overload movement apparatus, the aim is to add PAto successful functional and morphological adaptation for environmental burden

  10. Recommended PAis “individually optimal” under these conditions: • Currenthealth status, PA andfunctional and morphological components of healthoriented physical fitness Functional components of physical fitness: cardiorespiratory system and neuromuscular fitness Morphological (structural) components of physical fitness: anthropometry (height and weight), selected circumference characteristics and indexes (BMI), assessment of nutrition lifestyle

  11. Negative results of insufficient PA level • Due to lackofPA, thephysiological fitness leveldecreasesduringlife • It has major role in occurrence of cardiometabolic and oncologic diseases • Development of supportive movement apparatus disorders • Movementapparatusdiseases – second place in the cause of absence at work, cause longest lasting absence at work • MA diseases – low mortality rate Secondarily, they lead to health complications in late adult and senior age: -stressing the RF -limited movement, limits everyday life activity -movement immobilization leads to health complications (osteoporosis, fractures, bronchopneumonia, urinary infections, depressive state)

  12. Physicalacivityassessment - introduction Observation of actual individual PAlevels includes: • Determination of the type, frequency, intensity and total amount of performed PA • data are collected using questionnaires • Disadvantages : under or overestimation • For ongoing monitoring and obtaining details – use of aids (step meter, accelerometer) • For the possibility of international comparison of MA level in population – GPAQ/IPAQ • Observing PAperformed not only at leisure time, but also at work and sport • ObservedPAmonitored during 7 days (minimum continual PA 10 minutes) • Total amount of PAdisplayed in MET minutes • MET is a unit of intensity of physical load • 1 MET equals to common oxygen consumption (=3.5 mL/kg/min equals to resting metabolism)= resting energy consumption of organism ca 1 kCal/kg/hour

  13. Recommended total amount of physicalactivity Adults -600 MET minutes per week – 150 minutes MA of medium intensity -frequency: 3-5 times a week -recommended also postural therapy, muscular dysbalances therapy -for adults over 65, resistancetrainingand balance therapy Children (5-17 years old) -minimum of 60 minutes PAof medium to high intensity -variety of exercises -balanced development of aerobic fitness and muscular strength -flexibility exercises, deftness and balance -prevention of one-sided burden -compensational exercises

  14. KeyConceptsforUnderstandingPhysicalActivityAssessment PhysicalActivity – definition • The most popular and widelyciteddefinitionof PA waspublishedby Caspersen et al. (1985): „anybodilymovementsproduced by skeletalmusclesthatresult in energyexpenditure“ • PA canbeclasified as structured (planned, orincidentalto promotehealth and fitness benefits) and incidental (not plannedand usuallyistheresultofdailyactivitiesatwork, athome, orduring transport)

  15. Dimensionsof PA Domainsof PA • Central to undrestandingtheassessmentof PA

  16. QuantifyingUnitsofMeasureIndicativeof PA Level • Exercise (orexercisetraining) is a componentofleisuretime PA, and iswhereplanned, structured and repetitivebodilymovementsare performed to improveormaintainoneor more componentsofphysical fitness (Howley ET, Med Sci Sport Exerc 2001) • Physical fitness (PF) comprisescardiorespiratoryendurance (assessed by measuredorestimated VO2max , muscleendurance and musclestrenght • Flexibility, balance, agility nad coordination are additionalcomponentsof PF • Distinctionbetween PA and PF istheintraindividualday-to-day variability • PA will vary on a dailybasis, whereas PF willremainrelatively static, takingtime to change

  17. QuantifyingUnitsofMeasureIndicativeof PA Level • PA results in anincerease in energyexpenditure (EE)aboverestinglevels, and therateof EE isdirectlylinked to the intensity ofthe PA • Theenergyexpendedduring PA is just ofthe 3 componentsoftotaldailyenergyexpenditure (TEE): 60-75% restingenergyexpenditure 15-30% physicalactivityrelatedenergyexpenditure (PAEE) 10% thermiceffectof food • PAEE isthe most variableportionof TEE • In extremlyactiveindividuals, PAEE mayconstitute 60-70% of TEE • PA are commonlyquantifiedby determiningthe EE in kilocaloriesor by usingmetabolicequivalent (MET) oftheactivity

  18. QuantifyingUnitsofMeasureIndicativeof PA Level Kilocalories • One liter of oxygen consumptionisaproximatellyequal to 5 kcal energy Example: 70kg individualwalkingfor 30 minutesat 4 mph, whichresults in an oxygen consumptionof 1 L/min. For 30-minute walk, theindividualwouldconsume 30 L of oxygen. EE wouldbe 150kcal (30 Lx5 kcal/L). PAEE wouldbe 112,5 kcal (30 Lx5-1.25[5-1.25 (restingkilocaloriesexpenditure)] kcal/L) MetabolicEquivalent (MET) • Iscommon unit used to express exercise intensity • 1 MET representstherestingenergyexpenditureduringquietsittingandisdefined as 3.5 mL O2.kg-1.min-1 or 250 mL/min of oxygen consumed, whichrepresentstheaveragevaluefor a standard 70-kg person

  19. QuantifyingUnitsofMeasureIndicativeof PA Level MetabolicEquivalent (MET) • METscanbeconverted to kilocalories (1 MET=1kcal.kg-1.min-1 • Oxygen consumptionincreaseswith intensity of PA, forquantifyingthe intensity of PA is to use multiplesofresting EE PhysicalActivity Intensity • Moderateandvigorous intensity PA canbedefined in bothabsoluteandrelativeterms • Absolute intensity isdetermined by theexternalworkperformed, whereasrelative intensity isdeterminedrelative to anindividual´s levelofcardiorespiratory fitness (VO2max)

  20. QuantifyingUnitsofMeasureIndicativeof PA Level

  21. AvailableMethodsofAssessing PA • Subjectivemethodologiesrely on theindividualeither to recordactivities as theyoccur to recallpreviousactivities (questionnairesanddiaries/logs) • Objectivemethodologiesincludeallwearablemonitorsthatdirectlymeasure 1 or more biosignals, such as acceleration, heartrate, orsomeotherindicatorof PA or EE, as theyoccur.

  22. SubjectiveMethodsofAssessing PA Considerationforresearcherswhenusing questionnaires • Whatexactlyisthequestionnairedesigned to measure: whichdimension (s) anddomain (s) of PA? • Whatisthetimeframeforthequestionnaire? • Has the instrument beentestedforreliability? • Has appropriatevalidationbeenundertaken, thatis, againstanobjectivemeasure? • Wasthevalidationundertaken in a similarpopulation? • Whatistheprimaryoutcomeofthequestionnareanddoesthis fit withtheresearchquestion? • Howwillthequestionnairebeadministered (face-to-face, by telephone, Internet, through post)? • Howwillbe data cleaned, reducedandanalysed? • Whatwillconstituteanoutlieroran invalid recording? • Whatwillbedonewithmissing data, and in case ofinputing data whatwillthe basis of these decisionsbe? • Forwhichpopulation has thequestionnairebeendesigned? • Whatistheresponsivenessofthequestionnaire?

  23. SubjectiveMethodsofAssessing PA A) PhysicalActivityQuestionnaires • To identifythedimensionsanddomainsof PA behaviorsfromeitherself-reportedresponsesorinterviews 1. GlobalPhysicalActivityQuestionnaires • Provide a quickoverviewof a person´s PA level • Typicallyshort (2 – 4 items) andused to identifywhetheranindividualmeets a PA standard (e.g. 150 min/wkofmoderate to vigorous PA) orprovide a classification (e.g. active versus inactive) • Preferred in many clinicalsettings, epidemiologicalstudiesandsurveillancesettingsfortheireaseadministration, brevityandability to determine a PA score 2. ShortRecallPhysicalActivityQuestionnaires • Provide a quickassessmentofthetotal volume of PA classified by dimensionof intensity levelor by domain • Are oftenused to determinetheproportionofadults meeting national PA guidelinesin surveillanceanddescriptive epidemiology settingsand to identify PA behaviorchange in interventionstudies • Generallyhavefrom 7 to 12 itemsandcanbeself-administeredorintervieweradministered • A physicalactivityscorecanbe a simpleordinalnumber, withhighernumbersreflectinggreaterlevelsofactivity, or a volume scorecomputed by multiplyingthefrequency in sessionspreweek (ormonth), minutes per session, and intensity oftheactivityrecalled. The intensity oftenexpressed as METs. • InternationalPhysicalActivityQuestionnaire (IPAQ)

  24. SubjectiveMethodsofAssessing PA • The„CompendiumofPhysicalActivitiesofEnergyCostsofHuman PA“waspublished in 1993, withupdates in 2000 and 2011. • Thispublicationprovides a comprehensive list ofphysicalactivity MET valuesfor use in scoring PA questionnaires 3. QuantitativeHistoryPhysicalActivityQuestionnaires • Are detailedsurveysoftenperformedoverthe past monthofyearorover a lifetime • May contain 20 to 60 detailedquestionsand are usuallyintervieweradministered • Are usedin epidemiologicalstudies to understandwhattypesandintensitiesof PAcontribute to mortality, as well as to examinevarioustypesofmorbiditiesandhealth-enhancingbehaviors • Bone LoadingHistoryQuestionnaire (PA performedatvariousagesfromchildhood to the past yearfordeterminationofhipandspineweight-bearingand bone-loadingactivities)

  25. SubjectiveMethodsofAssessing PA B) PhysicalActivityDiaries/Logs • Oftenused to obtain a detailedhour-by-houroractivity-by-activityrecordofone´s PA and sedentarybehaviors • To evaluatethepsychometricpropertiesof PA questionnaires and as anadjunct to objective monitoring • Are completed by the user and canbeformof a paper-and-pencil booklet or a cell phoneprogrammed to remindtheperformed in the past 1 to 4 hours. • Recordedinformations: thetimeanactivitystarted and stopped,arating of intensity, and themode/typeofactivity • Canbescored by use ofthe „CompendiumofPhysicalActivities“ • TheBouchardPhysicalActivityRecordis a well-known PA log that has usersidentify 1 of 9 typesofmovementbehaviorspreformedevery 15 minutes. Theactivities are rated on a 1 to 9 scalethatcorresponds to a rangeof 1.0 to 7.8 METs

  26. ObjectiveMethodsofAssessing PAAccelerometers Considerationsforresearcherswhenusingaccelerometers • One, twoorthree-dimensionalaccelerometry? • Decidetheprimaryoutcomeofthe study; totalactivity, type, timespentatdifferent intensity, orestimates PAEE • At theoutset make a decisionabouttheminimalwearingtime to constitute a validday • Whatwillconstituteanoutlieroran invalid recording? • Whattime interval willbeselected? • Whatwillbe dome withmissing data? • How many dayswillbemeasured? • Istheregoing to be a timelagbetweeninitializingthe monitor and participant wearing? If so, canthe data analysisprogramme handle thisdelay? • How are accelerometersgoing to bedistributed and returned (face-to-face/mail)? • Havesufficientinstruction on placement, wearing and contactdetailsbeensupplied? • Are participantsgoing to becontacted by phone, SMS or mail duringtheplannedassessment to encouragecompliance? • Are participantsgoing to beasked to keepconcurrentactivitylogsor detail wearing and non-wearingtimes?

  27. ObjectiveMethodsofAssessing PAAccelerometers • When a person moves, the body isaccelerated in relation to muscularforcesresponsiblefortheaccelerationofthe body and to EE • Measure in one (vertical), two (vertical and medo-lateral) orthree (vertical, medo-lateral and anterior-posterior) planes by measuringtheamplitude and frequencyofacceleration • Thedeviceisenclosed in a case and thenattached to the body (hip, ankle, wrist, lowerback) • Able to recordhigh-resolution data data, as well as store data forseveralweeks

  28. ObjectiveMethodsofAssessing PAAccelerometers Accelerometer Data Transformation • Themain data outcomefromaccelerometersis a recordingof body accelerationanddeceleration • Thismeasurement (raw data) istypicallyrecorded in unitsofaccelerationdue to gravity (g) andexpressed as acceleration in meters per secondsquared (m/s2) • Thisisthenfurthertransformedintootherunits, most common unit ofmeasureisthecount, whichcanbeexpressed in differentways: counts per second, counts per minute, orsummed as totalcounts per day. • Detailed data are collectedbetween 5 and 60 s • Published data on cut point forsedentaryactivitiesfromonethe most frequentlyusedbandstypicallyrangesfrom 100-800 counts per minute, formoderateactivities 1900-8200

  29. ObjectiveMethodsofAssessing PAAccelerometers Accelerometer Data Converted to Meaning PhysicalActivityOutcomes • Thestrongestrelationshipisseen in walkingand jogging activities • Typicallyused to determinehabitualactivity, whichnecessitatesmeasurementover multiple days (4-9 dayschildren, 3-5 daysadults) • Isimportant, thattherecording period allowsforthemeasurementofactivityduringtheweekandalsoatweekends. • To correctly interpret theinformationfromtherecording period, itisimportant to accountforthefactthattheactivitylevelmayalso vary according to theseason (higherlevelduringspringandsummercoimparedwithautumnandwinter) • Forassessmentof PA, accelerometersmustbecalibrated to translate monitor signalsintoenergyexpenditureunits (kcalorMETs) oractivity intensity categories • More information: Ward DS, Evenson KR, Vaughn A, Rodgers AB, Troiano RP. Accelerometer use in physicalactivity: bestpracticesandresearchrecommendations. Med SciSportsExerc 2005; 37:S582-588.

  30. ObjectiveMethodsofAssessing PAHeartRate Monitoring • Thereis a linearrelationshipbetweentheincrease in HR andtheincrease in EE duringdynamicexerciseinvolvingthelargemusclegroups • Relationshipvarieswithin and betweenindividuals; factors such as age, sex, weightand fitness levelmodulatethisrelationship as do ambient temperature, body posture and emotionalstate (anxietyor stress) • Measuresof PA derivedfrom HR monitoring are typicallytimespent in physicalactivitiesatdifferent intensity levels (moderate and vigorous) and PAEE • Theaccuracyofestimatingoutcomesindicativeof PA from HR monitoring isimproved by calibratinganindividual´sheartrate nad EE response (via oxygen consumptionmeasurement) to differentlevelsofactivity, thusaccountingforvariationacrossindividual HR response

  31. ObjectiveMethodsofAssessing PAHeartRate Monitoring Considerationsforresearcherswhenusing HR • Whatlevelofcalibrationisrequired? • Ifindividualcalibrationis to beundertakenusingindirectcalorimetry, decide on whichactivities most likelywillbeperformed by thevolunteerswhile free living • How many dayswillthe monitor beworn? • In data analysiswhatisgoing to constituteanoutlier? • Providepracticalinformation on how to use the monitor • How are monitorsgoing to bedistributedandreturned (face-to-face, mail), havesufficientinstructions on placementandwearingandcontactdetailsbeensupplied? • Are participantsgoing to becontacted by phone, SMS or email duringtheplannedassessment to encouragecompliance? Canincentivesbeused?

  32. ObjectiveMethodsofAssessing PACombinedAccelerometer and HeartRateMonitors • Animportantdevelopment in theassessmentof PA • An early model wasdeveloped and pilotednearly 10 years ago • In these devices, the pros ofeachmethod are combined • At lowerlevelsof intensity, HR islessaccurateatestimating EE; thisisthelevelthataccelerometers are most accurateat • Advantageis, that these newmonitors are waterproof and theintentionisthatparticipants do not remove, except to replacepadsthathaveperished • Thecombinedmotion sensor isanaccuratepredictorof EE

  33. ObjectiveMethodsofAssessing PACombinedAccelerometer and HeartRateMonitors Considerationforresearcherswhenusingcombinad accelerometer and HR monitor sensors • Whatlevelofcalibrationisrequired? Willcalibrationmethodsusedcommonlyfor fitness testingbeadequate? • Isthe participant confident and competentatplacingthedevice, thatis, havesufficientexplanation and writteninstructionshavebeengiven? • Supply participantswithadditionalpads to replace as required

  34. ObjectiveMethodsofAssessing PAPedometers • Pedometers are relativelysimple and inexpensivedevices, whichmeasurethenumberofstepstaken • Betteraccuracy has beenreportedatfasterwalkingspeeds but not running • Most pedometers are accurate in themeasurementofthenumberofaccumulatedstepsduringwalking, and maybeusefulwhen monitoring theeffectofaninterventionaimed to increasingwalking • Oneofthe most promisingusesofpedometersisas a motivationaltool to achieve a predeterminedtargetofdailyaccumulatedsteps • Anadvantageofpedometersisthattheycanalsobeused in elementaryschoolchildren and preschoolchildren

  35. ObjectiveMethodsofAssessing PAPedometers Considerationforresearcherswhenusingpedometers • Theaimsandprimaryoutcomeofthe study shouldbecarefullyconsidered to ascertainwhether a pedometerwouldbeanadequatemeasureofactivity • What type ofactivitiesisthepopulation to bestudiedlikely to engage in? • Numberofmonitoreddays, whatwillconstitutevalidwearingtime

  36. Selectionofanappropriatetool to assess PA • Selectionofthemethodis a crucialdecision • Carefulconsiderationmustbegiven to theresearchquestion in thefirstplace, andthedimensionordomainof PA to beassessed

  37. Influence of study type on methodologychoice • Thespecific study type and design has animportantbearing on thechoiceofmethod to measure PA

  38. Assessment of cardiorespiratory fitness – outputs for prescription of cardiometabolic or other internal diseases Need of evaluation of absolute and relative contraindication of physical training before any prescription of PA! Perform complex examination and cardiorespiratory fitness examination: • determine maximalaerobic capacity by stress test = CPX = cardiopulmonaryexercisetesting (spiroergometry) • always risk factors CVD • also for asymptomatic individuals, who have been inactive for more than 3 years and are planning on doing systematic PAof medium to high intensity (men below 40, women below 50) The benefits: exact evaluation of physical fitness and effective setting up of PA trainingplan, finding of non-physiological states unprofound until now

  39. Assessment of cardiorespiratory fitness – outputs for prescription of cardiometabolic or other internal diseases • Need of finding any possible contraindications before testing (blood circulation insufficiency, inflammation of myocardium, any other serious cardiopulmonary diseases) Outputs: • assessment of maximalaerobic capacity (VO2 max), volume of exhaled CO2, ratio of respiratory exchange, breath frequency, total ventilation, lung volume, hemodynamic reaction to stress • maximum heart rate • anaerobic thershold

  40. Assessment of cardiorespiratory fitness – outputs for prescription of cardiometabolic or other internal diseases • ParameterVO2max showsthemaximum oxygen amount that can be transported from outside, absorbed and used to cover energy needs during PAby individuals • Cardiacpatients – parameter VO2peak Average listed values for the Czech untrained population: • women 35 mL/kg/min • men 45 mL/kg/min Maximum aerobic capacity is displayed in the multiples of one metabolic equivalent: 1 MET=3.5 mL/kg/min

  41. Assessment of cardiorespiratory fitness – outputs for prescription of cardiometabolic or other internal diseases Recommended training intensity with cardio protective results: • 50-85 % VO2max • by percentage of heart rate reserve (HRR) 50-85% • Start at low end of HRR percentage (min 10 minutes of training), after 30 minutes slowly increases load intensity • During training: check HR and blood pressure (pause-load-rest), check symptoms during training (emphysema, tiredness, chest pain, lower limb pain) VO2maxis an important prognostic marker for individuals with CVD • Kavangh et al. (2002, 2003) reports that with every improvement of VO2max by 1 mL/kg/min improves the prognosis by 9% (Kavanagh T, Mertens DJ, Hamm LF, et al. Prediction of long-term prognosis in 12 169 menreffered for cardiac rehabilitation. Circulation. 2002;106(6):666 671.) • reaching 22 mL/kg/min is an optimum results (prognosis improved by 40-60%)

  42. Thankyouforyourattention! Robert Vysoký, PT., Ph.D. Department of Public Health – FacultyofMedicine MU Brno E-mail: vysoky.rob@gmail.com

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