Clinical exercise prescription, one patient at a time

A CEP designs an exercise prescription for a patient 6 weeks post-lumbar spinal fusion. Which component is CONTRAINDICATED at this stage of recovery?

1. Partial bodyweight wall squats
   Partial squats against a wall keep the trunk supported and upright.
2. Isometric abdominal bracing
   Bracing builds trunk stability with no spinal motion, which suits early rehabilitation.
3. Torso rotation weight machine
   Loaded trunk rotation stresses the fused segment and the levels next to it; twisting is one of the standard early restrictions.
4. Short-bout level-ground walking
   Walking is encouraged early after fusion and puts no rotational load on the spine.
5. Seated neutral-spine rowing
   Light rowing with the spine held neutral trains the back muscles without bending or twisting.

When instructing a 75-year-old patient with hypertension in resistance training, which technique is strictly contraindicated due to the risk of provoking an excessive pressor response?

1. Concentric muscle action
   The lifting phase is fine when the patient keeps breathing through it.
2. Full range of motion
   Moving through a comfortable full range is standard technique and does not raise pressure by itself.
3. Eccentric muscle loading
   Lowering phases are a normal part of resistance training and do not create the breath-holding pressor surge.
4. The Valsalva maneuver
   Holding the breath against a closed glottis while straining drives blood pressure sharply upward, which is the risk in an older hypertensive patient.
5. Diaphragmatic breathing
   Steady breathing is what prevents the pressure spike.

A 72-year-old post-stroke patient with a functional capacity of 3 METs and compromised balance requires an aerobic exercise prescription. Which modality is most appropriate?

1. Motorized treadmill walking
   A moving belt is a fall hazard for someone with compromised balance.
2. Recumbent cross-trainer
   A seated, supported stepper lets a low-capacity patient with poor balance work arms and legs without the risk of falling.
3. Stair climbing intervals
   Climbing is both too demanding for 3 METs and risky with poor balance.
4. Elliptical machine training
   Standing on moving pedals demands balance this patient lacks.
5. Outdoor track walking
   Walking on an open track gives no support if balance fails, and 3 METs leaves little reserve for uneven ground.

In a patient with COPD, supplemental oxygen is typically indicated if exercise oxygen saturation (SpO2) falls to or below which threshold?

1. 88%
   Desaturation to 88% or lower during exercise is the usual threshold for prescribing supplemental oxygen in COPD.
2. 95%
   95% is within the normal range.
3. 92%
   92% is above the usual threshold for oxygen during exercise in COPD.
4. 85%
   Waiting until saturation reaches 85% allows a deeper desaturation than guidelines accept.
5. 98%
   98% is a normal saturation and calls for no treatment.

A patient undergoes a symptom-limited stress test. The results are displayed below. To ensure safety, the aerobic exercise prescription should set the upper heart rate limit at:

1. 136 bpm
   This is only 2 bpm below angina onset, too close to the ischemic threshold.
2. 128 bpm
   Angina began at 138 bpm, so the upper limit sits at least 10 bpm below that ischemic threshold.
3. 138 bpm
   This is the heart rate where angina began; training there would provoke symptoms.
4. 146 bpm
   This is the heart rate at which the test stopped for moderate-to-severe angina.
5. 115 bpm
   This sets the ceiling lower than needed and discards usable training range.

A severely deconditioned patient performs a GXT with a functional capacity of 2.5 METs. Which initial FITT prescription is most appropriate?

1. Resistance training only until capacity improves
   Leaving out aerobic work removes the main route to raising functional capacity.
2. High-intensity interval training (HIIT) once weekly
   Once a week is too infrequent, and high intensity is a poor starting point at 2.5 METs.
3. Continuous exercise for 20–30 minutes, 3 days/week
   Continuous 20–30 minute bouts are a later goal, beyond what a 2.5-MET patient can sustain at the start.
4. Continuous aerobic exercise for 60 minutes on weekends
   Hour-long weekend sessions are too long and too infrequent for this patient.
5. Multiple bouts of 5–10 minutes, 3–4 times daily
   At 2.5 METs, short bouts spread across the day accumulate volume without exhausting the patient.

For patients with cardiovascular disease, the primary physiological rationale for implementing a prolonged cool-down of 5–10 minutes is to:

1. Accelerate the clearance of accumulated blood lactate
   Lactate clearance is a minor side benefit, not the safety reason in cardiac patients.
2. Facilitate rapid restoration of parasympathetic tone
   Vagal tone returns after exercise regardless; the hemodynamic reason for a cool-down is venous return.
3. Maintain venous return to prevent post-exercise hypotension
   Continued light movement keeps the muscle pump working, so blood does not pool in the legs when exercise stops.
4. Promote faster replenishment of muscle glycogen stores
   Glycogen is restored by diet over hours; a cool-down does not speed it meaningfully.
5. Reduce the risk of delayed onset muscle soreness
   Cool-downs have little effect on next-day soreness.

A patient with COPD undergoes an exercise assessment. Based on the desaturation profile shown below, which training strategy is most appropriate to maximize work volume while maintaining safety?

1. Continuous vigorous-intensity cycling for 15 minutes
   Sustained vigorous work would drive saturation lower than continuous walking already does.
2. High-intensity intervals of 30 s work and 30 s rest
   Saturation falls after a few minutes of continuous work and recovers within a minute, so short work bouts with rest allow more total work above the desaturation point.
3. Continuous moderate-intensity walking for 20 minutes
   Twenty continuous minutes would repeat the desaturation seen at 4 minutes.
4. Supine cycling to reduce orthostatic stress
   The problem is oxygen saturation, not orthostatic intolerance.
5. Low-intensity continuous walking for 45 minutes
   The profile shows desaturation within 4 minutes of continuous walking; extending it to 45 minutes worsens that.

When prescribing exercise for a client with type 2 diabetes, which of the following approaches is MOST effective for improving insulin sensitivity?

1. Flexibility training with an emphasis on relaxation techniques
   Flexibility work does not meaningfully improve insulin action.
2. Low-intensity resistance training as the only mode of exercise
   Light resistance work alone gives a smaller effect than a combined program.
3. Combined aerobic and resistance training in the same program
   Pairing aerobic and resistance work improves insulin sensitivity and glucose control more than either alone.
4. High-intensity aerobic training as the only mode of exercise
   Aerobic work helps, but leaving out resistance training forgoes added benefit.

A patient with proliferative diabetic retinopathy requests a heavy Olympic lifting program. Which response best balances autonomy support with safety?

1. Prohibit all resistance training
   A blanket ban ignores the patient's goal when a safer form of resistance work exists.
2. Require Valsalva during the lifts
   Breath holding is exactly what this condition requires the patient to avoid.
3. Allow the lifts with a spotter present
   A spotter protects against a dropped bar, not against the blood pressure surge.
4. Suggest lower-weight machine circuits
   With proliferative retinopathy, heavy lifting and breath holding raise retinal risk; lighter circuits keep the patient training while avoiding them.
5. Approve the requested lifting program
   Heavy Olympic lifts produce the pressure spikes that can cause vitreous hemorrhage.

Using the CPET threshold data below, which heart rate range correctly targets the moderate-to-vigorous intensity zone for aerobic conditioning?

1. 65–118 bpm
   This runs from rest to VT1, which is light intensity.
2. 100–140 bpm
   This range does not match the patient's measured thresholds.
3. 154–172 bpm
   This sits above VT2, a severe-intensity zone that cannot be sustained for conditioning.
4. 85–129 bpm
   This range does not match the patient's measured thresholds and starts well below VT1.
5. 118–154 bpm
   The heart rates at VT1 and VT2 bracket the moderate-to-vigorous zone.

A 68-year-old female with severe osteoporosis (T-score -3.2) requires a resistance training program for bone health. No recent 1RM testing has been performed. Which intensity prescription is MOST appropriate?

1. RPE 5–8 intensity on a 0–10 scale
   Bone responds to moderate-to-high loads; without a 1RM, a 5–8 effort rating lets the patient work hard enough with progression under supervision.
2. Bodyweight moves without external load
   Bodyweight alone is too light a stimulus to change bone in most older adults.
3. RPE < 3 intensity on a 0–10 scale
   Very light effort is safe but too weak to stimulate bone.
4. Isometric contractions at 30% MVC
   Low static contractions give little bone-loading stimulus and need a maximal test to set.
5. Resistance of 80% of 1RM load
   A percentage of 1RM cannot be set when no 1RM has been measured.

Based on the patient profile below, what is the recommended resistance training intensity prescription?

1. RPE 8–9 on CR10
   Near-maximal effort is a poor and risky starting point for frailty.
2. Low load to failure
   Training to failure is exhausting and unnecessary for this patient.
3. Body weight plyometrics
   Jumping drills carry high fall and injury risk in sarcopenia.
4. RPE 5–7 on CR10
   When 1-RM testing is unsafe, a moderate-to-somewhat-hard effort rating sets the load for frail older adults.
5. 90% of estimated 1-RM
   Near-maximal loads are far too heavy for a frail 82-year-old starting out.

A stable patient in cardiac rehabilitation is starting resistance training. Which load and repetition range fits AHA recommendations for cardiac patients?

1. 8–12 repetitions at 60–80% of 1-RM
   This range is the recommendation for healthy adults under about 50–60, not for cardiac patients starting out.
2. 3–5 repetitions at 85–90% of 1-RM
   Near-maximal loads bring large pressure spikes and are not used in cardiac rehabilitation.
3. 1–3 repetitions at 90–95% of 1-RM
   Maximal singles are strength testing, not a training load for cardiac patients.
4. 20–25 repetitions at 20–30% of 1-RM
   Such light loads give too little stimulus to build strength.
5. 10–15 repetitions at 40–60% of 1-RM
   A lower relative load with more repetitions is recommended for cardiac patients, mainly to prevent injury.

A breast cancer survivor who finished chemotherapy 3 months ago reports persistent cancer-related fatigue. Which prescription matches the ACSM exercise guidelines for cancer survivors?

1. Rest until the fatigue resolves, then resume activity
   Rest worsens deconditioning; regular moderate exercise is what reduces this fatigue.
2. Moderate aerobic 30 min 3×/wk plus resistance 2×/wk
   Moderate aerobic work about three times a week, with or without twice-weekly resistance training, reduces cancer-related fatigue.
3. Resistance training only, avoiding aerobic exercise
   Aerobic exercise is the core of the fatigue recommendation; leaving it out removes the best-supported part.
4. Vigorous intervals 6×/wk to rebuild capacity quickly
   Near-daily vigorous work is too much for a recently treated patient and is not the recommended dose.
5. Flexibility work only until treatment effects fade
   Stretching alone does not provide the aerobic and resistance stimulus that relieves fatigue.

A patient with stage 1 hypertension, cleared for exercise, asks for an aerobic plan aimed at lowering blood pressure. Which dose matches the 2017 ACC/AHA blood pressure guideline?

1. 90–150 min/wk at 65–75% of heart rate reserve
   The guideline's aerobic dose for lowering blood pressure is 90–150 minutes a week at 65–75% of heart rate reserve.
2. 45–60 min/wk at 90–100% of heart rate reserve
   Maximal-intensity work is not the prescription, and the weekly time is too short.
3. 300–400 min/wk at 85–95% of heart rate reserve
   Hours of near-maximal work each week far exceed the dose and add risk without extra benefit.
4. 150–200 min/wk at 20–30% of heart rate reserve
   The time is ample, but 20–30% of reserve is very light and below the guideline intensity.
5. 30–45 min/wk at 40–50% of heart rate reserve
   Both the weekly time and the intensity are below this guideline's dose of 90–150 minutes at 65–75% of heart rate reserve.

A patient with diabetic autonomic neuropathy and postural hypotension is joining a circuit class. Which type of exercise should be left out of the circuit?

1. Burpees and other floor-to-standing moves
   Autonomic neuropathy with postural hypotension can drop blood pressure on rapid posture changes, so moves that go quickly from the floor to standing risk fainting and falls.
2. Stationary cycling at a steady cadence
   Steady cycling keeps the body in one position for the whole bout.
3. Steady walking on level ground
   Continuous walking involves no sudden change in posture.
4. Seated upper-body band rows
   Seated work keeps the posture steady and does not provoke a pressure drop.
5. Wall push-ups at a slow tempo
   Standing wall push-ups keep the head above the heart throughout, with no rapid transition.