Terapi Latihan

Kelompok 4 :
1. Nurul Dian Efendi
2. Claudia Margarani
3. Gungde Yudhanta
4. Bellawa
 Key Terms and Concepts
Exercise : Planned and structured physical activity
designed to improve or maintain physical fitness.
Fitness is a general term used to describe the
ability to perform physical work.
Maximum oxygen consumption (VO2 max) is a
measure of the body’s capacity to use oxygen.
Endurance (a measure of fitness) is the ability to
work for prolonged periods of time and the ability
to resist fatigue.
Aerobic exercise training, or conditioning, is
augmentation of the energy utilization of the muscle by
means of an exercise program.
Adaptation results in increased efficiency of the
cardiovascular system and the active muscles
Myocardial oxygen consumption is a measure of the
oxygen consumed by the myocardial muscle.
Deconditioning occurs with prolonged bed rest, and its
effects are frequently seen in the patient who has had an
extended, acute illness or long-term chronic condition.

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 Energy Systems, Energy Expenditure,
and Efficiency
Energy systems are metabolic systems involving
a series of biochemical reactions resulting in the
formation of adenosine triphosphate (ATP),
carbon dioxide, and water.
1. Phosphagen, or ATP-PC, System
2. Anaerobic Glycolytic System
3. Aerobic System
4. Recruitment of Motor Units
5. Functional Implications
Energy Expenditure
Energy is expended by individuals engaging in physical
activity and is often expressed in kilocalories.
1. Quantification of Energy Expenditure
Energy expended is computed from the amount of
oxygenconsumed. Units used to quantify energy expendit ure
are kilocalories and METs.
2. Classification of Activities
Activities are classified as light, moderate, or heavy
according to the energy expended or the oxygen consumed
while accomplishing them.

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Efficiency
Efficiency is usually expressed as a percentage
Total net oxygen cost is multiplied by the total time
in minutes the exercise is performed. The higher
the net oxygen cost, the lower the efficiency in
performing the activity. Efficiency of large muscle
activities is usually 20% to 25%.

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 Physiological Response to Aerobic
Exercise
Cardiovascular Response to Exercise
1. Exercise Pressor Response
Stimulation of small myelinated and unmyelinated
fibers in skeletal muscle involves a sympathetic
nervous system (SNS) response. The central
pathways are not known. The SNS response includes
generalized peripheral vasoconstriction in
nonexercising muscles and increased myocardial
contractility, an increased heart rate, and an increased
systolic blood pressure.
2. Cardiac Effects
■ The frequency of sinoatrial node depolarization
increases, as does the heart rate.
■ There is a decrease in vagal stimuli as well as an
increase in SNS stimulation.
■ There is an increase in the force development of the
cardiac myofibers. A direct inotropic response of the SNS
increases myocardial contractility.
3. Peripheral Effects
Net reduction in total peripheral resistance, Increased
cardiac output, Increase in systolic blood pressure.

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Respiratory Response to Exercise
■ Respiratory changes occur rapidly, even before the
initiation of exercise.
■ Minute ventilation increases as respiratory frequency and
tidal volume increase.
■ Alveolar ventilation, occurring with the diffusion of gases
across the capillary-alveolar membrane, increases 10- to
20-fold during heavy exercise to supply the additional
oxygen needed and excrete the excess CO2 produced.

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Responses Providing Additional Oxygen to
Muscle Increased Blood Flow
1. The increased blood flow to the working muscle
previously discussed provides additional oxygen.
2. Increased Oxygen Extraction. There is also
extraction of more oxygen from each liter of blood.
There are several changes that allow for this.
3. Oxygen Consumption Vascularity of the
muscles, Fiber distribution, Number of
mitochondria, Oxidative mitochondrial
enzymes present in the fibers.
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 Testing as a Basis for
Exercise Programs
Fitness Testing of Healthy Subjects
Field tests for determining cardiovascular fitness include
the time to run 1.5 miles or the distance run in 12 minutes.
These measures correlate well with VO2 max, but their use
is limited to young persons or middle-aged individuals who
have been carefully screened and have been jogging or
running for some time. Other field tests include the 1-mile
walk test, 6-minute walk test, and step tests. These tests are
more suitable for individuals who are not as physically
active.
Stress Testing for Convalescing Individuals and
Individuals at Risk
1. Principles of Stress Testing
■ Changing the workload by increasing the speed and/or grade
of the treadmill or the resistance on the bicycle ergometer
■ An initial workload that is low in terms of the individual’s
anticipated aerobic threshold
■ Maintaining each workload for 1 minute or longer
■ Terminating the test at the onset of symptoms or a definable
abnormality of the ECG
■ When available, measuring the individual’s maximum
oxygen consumption

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2. Purpose of Stress Testing
■ Helps establish a diagnosis of overt or latent heart disease.
■ Evaluates cardiovascular functional capacity as a means of clearing
individuals for strenuous work or exercise programs.
■ Determines the physical work capacity in kilogram-meters per minute
(kg-m/min)
■ Evaluates responses to exercise training
■ Assists in the selection and evaluation of appropriate modes of
treatment for heart disease.
■ Increases individual motivation for entering and adhering to exercise
programs.
■ Is used clinically to evaluate patients with chest sensations or a
history of chest pain to establish the probability that such patients have
coronary disease. It can also evaluate the functional capacity of patients
with chronic disease.

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3. Preparation for Stress Testing
■ Have had a physical examination.
■ Be monitored by ECG and closely observed at rest, during exercise,
and during recovery.
■ Sign a consent form.
4. Termination of Stress Testing
■ Progressive angina.
■ A significant drop in systolic pressure in response to an increasing
workload.
■ Lightheadedness, confusion, pallor, cyanosis, nausea, or peripheral
circulatory insufficiency.
■ Abnormal ECG responses including ST segment depression greater
than 4 mm.
■ Excessive rise in blood pressure.
■ Subject wishes to stop.

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Multistage Testing
Each of the four to six stages lasts approximately 1
to 6 minutes. Differences in protocols involve the
number of stages, magnitude of the exercise
(intensity), equipment used (bicycle, treadmill),
duration of stages, endpoints, position of body,
muscle groups exercised, and types of effort

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 Determinants of an
Exercise Program
Frequency
Optimal frequency of training is generally three to
four times a week. If training is at a low-intensity,
greater frequency may be beneficial. A frequency of
two times a week does not generally evoke
cardiovascular changes, although older individuals
and convalescing patients may benefit from a
program of that frequency.
Intensity
Determination of the appropriate intensity of exercise to use is
based on the overload principle and the specificity principle
1. Overload Principle
• Individuals at Risk. Maximum heart rate and exercise heart rate
used for the exercise prescription for individuals at risk for
coronary artery disease, individuals with coronary artery disease
or other chronic disease, and individuals who are elderly are
ideally identified based on their performance on the stress test.
• Variables. Exercising at a high-intensity for a shorter period of
time appears to elicit a greater improvement in VO2 max than
exercising at a moderate intensity for a longer period of time.

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2. Specificity Principle. The specificity principle as related to
the specificity of training refers to adaptations in metabolic
and physiological systems depending on the demand imposed.
• Time (Duration). The optimal duration of exercise for
cardiovascular conditioning is dependent on the total work
performed, exercise intensity and frequency, and fitness
level. Generally speaking, the greater the intensity of the
exercise, the shorter the duration needed for adaptation; and
the lower the intensity of exercise, the longer the duration
needed.
• Type (Mode). Many types of activity provide the stimulus
for improving cardiorespiratory fitness. The important factor
is that the exercise involves large muscle groups that are
activated in a rhythmic, aerobic nature.

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3. Reversibility Principle
■ Detraining occurs rapidly when a person stops
exercising. After only 2 weeks of detraining,
significant reductions in work capacity can be
measured, and improvements can be lost within several
months
■ The frequency or duration of physical activity
required to maintain a certain level of aerobic fitness is
less than that required to improve it.

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 Exercise Program
Warm-Up Period
Physiologically, a time lag exists between the onset of activity and the
bodily adjustments needed to meet the physical requirements of the body.
The purpose of the warm-up period is to enhance the numerous adjustments
that must take place before physical activity.
1. Physiological Responses
■ An increase in muscle temperature.
■ An increased need for oxygen to meet the energy demands for the muscle.
■ Dilatation of the previously constricted capillaries with increases in the
circulation, augmenting oxygen delivery to the active muscles and
minimizing the oxygen deficit and the formation of lactic acid.
■ Adaptation in sensitivity of the neural respiratory center to various
exercise stimulants.
■ An increase in venous return.
2. Guidelines. The warm-up should be gradual and
sufficient to increase muscle and core temperature
without causing fatigue or reducing energy stores.
Characteristics of the period include:
■ A 10-minute period of total body movement exercises,
such as calisthenics and walking slowly.
■ Attaining a heart rate that is within 20 beats/min of the
target heart rate.

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Aerobic Exercise Period
1. Continuous Training
■ A submaximum energy requirement, sustained throughout the
training period, is imposed.
■ Once the steady state is achieved, the muscle obtains energy by
means of aerobic metabolism. Stress is placed primarily on the slow-
twitch fibers.
■ The activity can be prolonged for 20 to 60 minutes without
exhausting the oxygen transport system.
■ The work rate is increased progressively as training improvements
are achieved. Overload can be accomplished by increasing the exercise
duration.
■ In the healthy individual, continuous training is the most effective
way to improve endurance.

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2. Interval Training. The work or exercise is followed by
a properly prescribed relief or rest interval. In the
healthy individual, interval training tends to improve
strength and power more than endurance.
3. Circuit Training. Circuit training employs a series of
exercise activities. At the end of the last activity, the
individual starts from the beginning and again moves
through the series. The series of activities is repeated
several times.

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4. Circuit-Interval Training
■ Combining circuit and interval training is effective
because of the interaction of aerobic and anaerobic
production of ATP.
■ In addition to the aerobic and anaerobic systems being
stressed by the various activities, with the relief interval,
there is a delay in the need for glycolysis and the
production of lactic acid prior to the availability of oxygen
supplying the ATP.

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Cool-Down Period. The cool-down period is similar to the
warm-up period in that it should last 5 to 10 minutes and
consist of total-body movements and static stretching. The
purpose is to:
■ Prevent pooling of the blood in the extremities by
continuing to use the muscles to maintain venous return.
■ Prevent fainting by increasing the return of blood to the
heart and brain as cardiac output and venous return decreases.
■ Enhance the recovery period with the oxidation of
metabolic waste and replacement of the energy stores.
■ Prevent myocardial ischemia, arrhythmias, or other
cardiovascular complications.

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 Physiological Changes that
Occur with Training
Cardiovascular Changes
1. Changes at Rest
■ Decreasing levels of norepinephrine and epinephrine, a
decrease in atrial rate secondary to biochemical changes in
the muscles and levels of acetylcholine, norepinephrine,
and epinephrine in the atria. increase in parasympathetic
(vagal) tone secondary to decreased sympathetic tone.
■ A decrease in blood pressure
■ An increase in blood volume and hemoglobin
2. Changes During Exercise
■ A reduction in the pulse rate occurs in some individuals
because of the mechanisms listed earlier in this section.
■ Increased stroke volume may.
■ Increased cardiac output
■ Increased extraction of oxygen by the working muscle
■ Decreased blood flow per kilogram of the working
muscle
■ Decreased myocardial oxygen consumption (pulse rate
times
systolic blood pressure) for any given intensity of exercise

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Respiratory Changes
1. Changes at Rest
■ Larger lung volumes
■ Larger diffusion capacities
2. Changes During Exercise
■ Larger diffusion capacities, the maximum capacity of
ventilation is unchanged.
■ A smaller amount of air is ventilated at the same oxygen
consumption rate; maximum diffusion capacity is unchanged.
■ The maximal minute ventilation is increased.
■ Ventilatory efficiency is increased.

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Metabolic Changes
1. Changes at Rest
■ Muscle hypertrophy and increased capillary density occurs.
■ The number and size of mitochondria are increased, increasing the capacity to
generate ATP aerobically.
■ The muscle myoglobin concentration increases, increasing the rate of oxygen
transport and possibly the rate of oxygen diffusion to the mitochondria.
2. Changes During Exercise
■ A decreased rate of depletion of muscle glycogen at submaximum
work levels may occur.
■ Lower blood lactate levels at submaximal work may occur.
■ Less reliance on phosphocreatine (PC) and ATP in skeletal muscle and an
increased capability to oxidize carbohydrate may result because of an increased
oxidative potential of the mitochondria and an increased glycogen storage in the
muscle.

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4. Other System Changes
■ Decrease in body fat.
■ Decrease in blood cholesterol and triglyceride levels.
■ Increased heat acclimatization.
■ Increase in the breaking strength of bones and ligaments
and the tensile strength of tendons.

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 Application of Principles of an Aerobic
Conditioning Program for the Patient with
Coronary Disease
Inpatient Phase (Phase I)
The inpatient phase of the program occurs in the hospital following
stabilization of the patient’s cardiovascular status after MI or coronary
bypass surgery, and generally lasts 3 to 5 days.
1. Purpose
■ Initiate risk factor education and address future modification of
certain behaviors, such as eating habits and smoking.
■ Initiate self-care activities and progress from sitting to standing to
minimize deconditioning (1 to 3 days postevent).
■ Provide an orthostatic challenge to the cardiovascular system (3 to 5
days postevent).
■ Prepare patients and family for continued rehabilitation and for life
at home after a cardiac event.
Outpatient Phase (Phase II)
The outpatient phase of the program is initiated either upon
discharge from the hospital or, depending on the severity of the
diagnosis, 6 to 8 weeks later.
1. Purpose
■ Increase the person’s exercise capacity in a safe, progressive
manner, so adaptive cardiovascular and muscular changes occur.
■ Enhance cardiac functions and reduce the cardiac cost of work.
■ Produce favorable metabolic changes.
■ Determine the effect of medications on increasing levels of
activity.
■ Relieve anxiety and depression.
■ Progress the patient to an independent exercise program.

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Outpatient Program (Phase III)
The outpatient phase of cardiac rehabilitation includes a
supervised exercise conditioning program, which is often
continued in a hospital or community setting.
1. Purpose
The purpose of the program is to continue to improve or
maintain fitness levels achieved during the phase II program.
2. Guidelines
■ Swimming, which incorporates both arms and legs. However,
there is a decreased awareness of ischemic symptoms
while swimming, especially when the skill level is poor.
■ Outdoor hiking, which is excellent if on level terrain.

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Adaptive Changes
■ Increased myocardial aerobic work capacity.
■ Increased maximum aerobic or functional capacity
■ Increased stroke volume following high-intensity training 6 to
12 months
■ Decreased myocardial demand for oxygen.
■ Increased myocardial supply by the decreased heart rate
■ Increased tolerance to a given physical workload before angina
occurs.
■ Improved psychological orientation and, over time, an impact on
depression scores, scores for hysteria, hypochondriasis, and
psychoasthenia on the Minnesota Multiphasic Personality
Inventory.

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 Applications of Aerobic Training for the
Deconditioned Individual and the Patient
with Chronic Illness
 Deconditioning
Implications of the changes due to deconditioning brought on by
inactivity resulting from any illness or chronic disease
are important to remember.
■ There is decreased work capacity, which is a result of
decreased maximum oxygen uptake and decreased ability to use
oxygen and perform work.
■ There is decreased circulating blood volume that can be as
much as 700 to 800 mL.
■ There is a decrease in plasma and red blood cells, which
increases the likelihood of life-threatening embothrombolic
episodes and prolongation of the convalescent period.
■ There is a decrease in lean body mass, which results in
decreased muscle size and decreased muscle strength and
ability to perform activities requiring large muscle groups.
■ There is increased excretion of urinary calcium, which
results from a decrease in the weight-bearing stimulus
critical in maintaining bone integrity, in bone loss or
osteoporosis, and in an increased likelihood of fractures
upon falling because of osteoporosis.

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Reversal of Deconditioning
■ A decrease in the resting heart rate, the heart rate with any
given exercise load, and urinary excretion of calcium.
■ An increase in stroke volume at rest, stroke volume with
exercise, cardiac output with exercise, total heart volume,
lung oxygen uptake, circulating blood volume, plasma volume
and red blood cells, and lean body mass.
■ A reversal of the negative nitrogen and protein balance.
■ An increase in levels of mitochondrial enzymes and energy
stores.
■ Less use of the anaerobic systems during activity.volume
(ventilatory volume), vital capacity, maximum

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Adaptations for Participation Restrictions
(Disabilities), Activity Restrictions (Functional
Limitations), and Deconditioning
■ Adaptations must be made when testing the physically
disabled using a wheelchair treadmill or, more frequently,
using the upper extremity ergometer.
■ Exercise protocols may emphasize upper extremities and
manipulation of the wheelchair.
■ It is important to remember that energy expenditure is
increased when the gait is altered, and wheelchair use is
less efficient than walking without impairment.

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Impairments, Goals, and Plan of Care
The goals of an aerobic exercise program are
dependent on the initial level of fitness of the
individual and on his or her specific clinical needs.
The general goals are to decrease the
deconditioning effects of disease and chronic illness
and to improve the individual’s cardiovascular and
muscular fitness.

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 Age Differences
Children
Between the ages of 5 and 15 there is a threefold increase in
body weight, lung volume, heart volume, and maximum
oxygen uptake.
1. Heart rate. Resting heart rate is on the average above
125 (126 in girls, 135 in boys) at infancy. Resting heart
rate drops to adult levels at puberty. Maximum heart
rate is age-related (220 minus age).
2. Stroke volume. Children 5 to 16 years of age have a
stroke volume of 30 to 40 mL.
3. Cardiac output. Cardiac output increases
with increasing stroke volume. it is the same
in the child as in the adult.
4. Arteriovenous oxygen difference. Children
tolerate a larger arteriovenous oxygen
difference (a-VO2) than adults. The larger a-
VO2 difference makes up for the smaller
stroke volume.

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5. Maximum oxygen uptake. The VO2max increases with
age up to 20 years (expressed as liters per minute).
Cardiac output in children is the same as in the adult for
any given oxygen consumption. Endurance times
increase with age until 17 to 18 years.
6. Blood pressure. Systolic blood pressure increases from
40 mm Hg at birth to 80 mm Hg at age 1 month to 100
mm Hg several years before puberty. Diastolic blood
pressure increases from 55 to 70 mm Hg from 4 to 14
years of age, with little change during adolescence.

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7. Respiration. Respiratory rate decreases from 30 breaths
per minute at infancy to 16 breaths per minute at 17 to
18 years of age.
8. Muscle mass and strength. Muscle mass increases
through adolescence, primarily owing to muscle fiber
hypertrophy and the development of sarcomeres. Girls
develop peak muscle mass between 16 and 20 years,
whereas boys develop peak muscle mass between 18
and 25 years. Strength gains are associated with
increased muscle mass in conjunction with neural
maturation.

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9. Anaerobic ability. Children generally
demonstrate a limited anaerobic capacity. This
may be due to a limited amount of
phosphofructokinase, a controlling enzyme in
the glycolytic pathway. Children produce less
lactic acid when performing anaerobically. This
may be due to a limited glycolytic capacity.

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Young Adults
1. Heart rate. Resting heart rate reaches 60 to 65 beats per
minute at 17 to 18 years of age (75 beats per minute in a
sitting, sedentary young man). Maximum heart rate is
age-related (190 beats per minute in the same sedentary
young man).
2. Stroke volume. The adult values for stroke volume are
60 to 80 mL (75 mL in a sitting, sedentary young man).
With maximum exercise, stroke volume is 100 mL in
that same sedentary young man.

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3. Cardiac output for the sedentary young man at rest.
Cardiac output at rest is 75 beats per minute × 75 mL,
or 5.6 liters per minute. With maximum exercise,
cardiac output is 190 beats per minute × 100 mL, or 19
liters per minute.
4. Arteriovenous oxygen difference. Approximately 25%
to 30% of the oxygen is extracted from blood as it runs
through the muscles or other tissues at rest. In a normal,
sedentary young man, it increases threefold (5.2 to 15.8
mL/dL blood) with exercise.

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5. Maximum oxygen uptake. The difference in VO2 max
between males and females is greatest in the adult. In
the sedentary young man, maximum oxygen uptake
equals 3,000 mL/min (oxygen uptake at rest equals 300
mL/min).
6. Blood pressure. Systolic blood pressure is 120 mm Hg
(average). At peak effort during exercise, values may
range from as low as 190 mm Hg to as high as 240 mm
Hg. Diastolic blood pressure is 80 mm Hg (average).
Diastolic pressure does not change markedly with
exercise.

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7. Respiration. Respiratory rate is 12 to 15 breaths per
minute. Vital capacity is 4,800 mL in a man 20 to 30
years of age. Maximum voluntary ventilation is
dependent on age and the surface area of the body.
8. Muscle mass and strength. Muscle mass increases with
training as a result of hypertrophy. This hypertrophy can
be the result of an increased number of myofibrils or
increased actin and myosin, sarcoplasm, and/or
connective tissue. As the nervous system matures,
increased recruitment of motor units or decreased
autogenic inhibition by Golgi tendon organs appears
also to dictate strength gains.

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9. Anaerobic ability. Anaerobic training increases
the activity of several controlling enzymes in the
glycolytic pathway and enhances stored
quantities of ATP and phosphocreatine. Anaerobic
training increases the muscle’s ability to buffer
the hydrogen ions released when lactic acid is
produced. Increased buffering allows the muscle
to work anaerobically for longer periods of time.

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Older Adults
1. Heart rate. Maximum heart rate is age-related
and decreases with age (in very general terms,
220 minus age). The average maximum heart
rate for men 20 to 29 years of age is 190
beats/min. For men 60 to 69 years of age, it is
164 beats/min.
2. Stroke volume. Stroke volume decreases in the
aged and results in decreased cardiac output.

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3. Cardiac output. Cardiac output decreases with
age as the result of a decrease in stroke
volume and other age-related health changes
which affect preload and afterload.
4. Arteriovenous difference. Arteriovenous
oxygen difference decreases as a result of
decreased lean body mass and low oxygen-
carrying capacity.

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5. Maximum oxygen uptake. if men 60 to 69 years of age
of average fitness level are compared with men 20 to 29
years of age of the same fitness level, the maximum
oxygen uptake for the older man is lower (20 to 29
years is 31 to 37 mL/kg per minute; 60 to 69 years is 18
to 23 mL/kg per minute). Maximum oxygen
consumption decreases on an average from 47.7 mL/kg
per minute at age 25 years to 25.5 mL/kg per minute at
age 75 years.

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5. Blood pressure. Blood pressure increases because
of increased peripheral vascular resistance
(average systolic blood pressure of the aged is
150 mm Hg; average diastolic blood pressure is
90 mm Hg). If the definition of high blood
pressure (stage II hypertension) is 160/100, then
22% of men and 34% of women 65 to 74 years of
age are hypertensive. Using 150/95 mm Hg as a
cutoff, 25% of individuals are hypertensive at age
50 years and 70% between the ages of 85 and 95
years.

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6. Respiration. Respiratory rate increases with
age. Vital capacity decreases with age. There is
a 25% decrease in the vital capacity of the 50-
to 60-year-old man compared with the 20- to
30-year-old man with the same surface area.
Maximum voluntary ventilation decreases with
age.

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7. Muscle mass and strength. Generally, the strength
decline with age is associated with a decrease in muscle
mass and physical activity. The decrease in muscle mass
is primarily due to a decrease in protein synthesis, in
concert with a decline in the number of fast-twitch
muscle fibers. Aging may also affect strength by
slowing the nervous system’s response time. This may
alter the ability to recruit motor units effectively.
Continued training as one ages appears to reduce the
effects of aging on the muscular system.

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Thank’s…