Cardiovascular Exercise Prescription

Why This Matters for MTs

• Aerobic exercise is a frontline intervention for many conditions RMTs treat: chronic low back pain, fibromyalgia, depression/anxiety, hypertension, diabetes, and osteoarthritis all have strong evidence for aerobic exercise as part of management
• Clients ask for guidance. "Should I be exercising?" and "What kind of exercise is safe for me?" are common questions in MT practice. RMTs who can provide basic, safe recommendations add significant value.
• Deconditioning is a treatment barrier. Clients who are deconditioned respond differently to manual therapy and take longer to recover. Aerobic capacity affects tissue healing, pain tolerance, sleep quality, and mood.
• FOMTRAC expects it. PC 3.3d specifically addresses cardiovascular exercise prescription as a massage therapy competency.

Key Principles

The FITT Principle

FITT is the standard framework for exercise prescription across all healthcare disciplines: These guidelines align with the Canadian Society for Exercise Physiology (CSEP) and the American College of Sports Medicine (ACSM) recommendations.

Intensity Monitoring Methods

#### 1. Heart Rate Monitoring Target heart rate zone = percentage of estimated maximum heart rate (HRmax)

• HRmax formula: 220 - age (Fox formula — simple, widely used, has limitations)
• Moderate intensity: 50-70% of HRmax
• Vigorous intensity: 70-85% of HRmax

Limitations of HR monitoring:

• Beta-blockers blunt heart rate response — HR targets are unreliable for clients on beta-blockers (use RPE instead)
• Caffeine, dehydration, illness, and emotional stress all affect resting and exercise HR
• The 220-age formula has a standard error of +/-10-12 bpm — it is an estimate, not a precision tool
• Atrial fibrillation and other arrhythmias make pulse rate monitoring unreliable

#### 2. Rating of Perceived Exertion (RPE) — Borg Scale The RPE scale measures subjective effort intensity. It is more practical than HR monitoring in most MT contexts and is valid for clients on beta-blockers. Modified Borg Scale (0-10): How to teach RPE to clients: > "I'd like you to walk at a pace where you're breathing harder than normal but you can still carry on a conversation. If you can sing, you're going too easy. If you can barely talk, you're going too hard. Aim for about a 3-4 out of 10 on the effort scale." #### 3. Talk Test The simplest intensity monitor — no equipment needed:

• Too easy: Can sing or recite a passage without effort
• Moderate (target): Can talk in full sentences but conversation requires effort
• Too hard: Can only say a few words between breaths
• Way too hard: Cannot speak at all

Progression Principles

• Start low, go slow. For deconditioned clients, begin with 5-10 minutes of walking at a comfortable pace, 3 days per week.
• Increase duration before intensity. Add 5 minutes per week until reaching 30 minutes, then consider increasing pace.
• 10% rule: Do not increase total weekly duration or intensity by more than 10% per week.
• Rest days are training days. Ensure at least 1-2 rest days per week, especially for deconditioned or older clients.
• Symptom-limited progression. If the client experiences increased pain, excessive fatigue, dizziness, or chest discomfort, reduce intensity and reassess.

Clinical Application

Prescribing Walking Programs (The Most Common MT Recommendation)

Walking is the most accessible, lowest-risk aerobic exercise and the most common cardiovascular recommendation RMTs provide. Beginner walking program (deconditioned client): Verbal script for prescribing a walking program: > "One of the most helpful things you can do for your recovery is regular walking. I'd suggest starting with 10 minutes, 3 times a week, at a comfortable pace — think of a casual stroll. Each week, try to add about 5 minutes. The goal over a couple of months is to get to 30 minutes, 5 times a week, at a pace where you're breathing a bit harder but can still have a conversation. If you have more pain after walking, shorten the time or slow down — then try again the next day."

Modifications for Common Conditions

Absolute Contraindications to Aerobic Exercise

If any of these are present, do not recommend exercise — refer to the client's physician:

• Unstable angina
• Uncontrolled heart failure
• Uncontrolled arrhythmia
• Severe aortic stenosis
• Acute myocarditis, pericarditis, or endocarditis
• Acute pulmonary embolism or DVT
• Acute systemic infection with fever
• Uncontrolled hypertension (>200/110 at rest)

Relative Contraindications (Modify and Monitor)

• Controlled hypertension on medication (use RPE, not HR if on beta-blockers)
• Controlled diabetes (timing, glucose monitoring, foot care)
• Moderate valvular heart disease
• Electrolyte abnormalities
• Chronic infectious disease (HIV — exercise beneficial but intensity should match capacity)

When to Refer to an Exercise Specialist

Refer to a kinesiologist, exercise physiologist, or physiotherapist when:

• The client has a cardiac condition requiring monitored exercise
• The client has complex comorbidities that require specialized programming
• The client needs sport-specific training beyond general conditioning
• The client has a pulmonary condition (COPD, severe asthma) requiring respiratory monitoring during exercise
• The client is post-surgical and needs progressive loading guidance beyond basic walking
• The client is not progressing with your recommendations and needs formal exercise testing