Support Responses of the Cardiovascular System to Exercise

Support Responses of the Cardiovascular System to Exercise Part I ELIZABETH H. LITTELL, PhD Exercise can be sustained only if there is increased blood flow to those tissues with increased metabolic needs. Blood flow to particular working muscles can be increased either by increasing cardiac output or by redirecting peripheral blood flow. The nature and extent of changes in cardiovascular function that occur during exercise are dependent on the type of exercise, the muscles involved, and the severity of the exercise stress. The normal range of changes in heart rate, stroke volume, and patterns of peripheral blood flow are discussed in relation to different types of exercise stress. Key Words: Cardiovascular system, Exertion. Contraction of skeletal muscles during exercise imposes an increased metabolic demand that must be supported by increased oxygen and substrate supply to exercising muscles. The cardiovascular system is the primary pathway for supply of metabolic substrates and removal of end products. Therapy involving exercise relies on an intact cardiovascular system. This article describes the support responses of the cardiovascular system to the increased metabolic demands of exercise. CHANGES IN CARDIOVASCULAR FUNCTION A working muscle of a well-trained person may increase its metabolic rate as much as 20 times its Fig. 1. Time course of utilization of intramuscular (ATP and CP) and extramuscular energy stores during exercise. Dr. Littell was a graduate student in the Department of Physiology, Baylor College of Medicine, Houston, TX, when this material was prepared. She is now Associate Director for Education, Department of Physical Therapy, The Institute for Rehabilitation and Research, 1333 Moursund Ave, Houston, TX 77030 (USA). This article was submitted July 31, 1980, and accepted March 31, 1981. resting level. Depending on the type of muscle working and the type of exercise being performed, all or much of this increased metabolic rate is due to an increase in aerobic metabolism of intramuscular and extramuscular stores of carbohydrate and fat, as indicated in Figure l. 1-3 Aerobic metabolism (oxidation) of carbohydrates and fats does not predominate over other sources of energy until about the second minute of exercise. 4 Anaerobic metabolism (glycolysis) is the major source of energy from the 30th to the 90th second and may continue at a low rate throughout exercise, becoming a major source of energy again if the exercise intensity exceeds the aerobic capacity of the muscle. The ease with which oxygen can be dissociated from hemoglobin also increases during exercise. 1,5 These biochemical changes may increase the arteriovenous oxygen difference across working muscles up to three times the resting level. Several recent reviews describe in detail the biochemical responses of muscle and blood to exercise. 1,3-6 In order to permit this increase in aerobic metabolism, there must be a corresponding increase in the supply of oxygen to the working muscle tissue. Two basic mechanisms exist for meeting this demand for more oxygen: 1) increased blood flow to the working muscle and 2) increased oxygen extraction from the blood. The factors responsible for increased oxygen extraction will not be discussed in detail in this series. Blood flow to working muscle is increased by alterations in both central cardiac and peripheral vascular function. Centrally, the cardiac output is increased, providing a greater absolute volume of blood, and thus oxygen, to the working muscle. Peripherally, 1260 PHYSICAL THERAPY

the pattern of distribution of blood shifts, providing an increase in relative blood flow to the working muscle. The combined effect of these two functional changes can cause an increase in the flow of blood to the working muscle of 30 to 50 times the resting level in well-trained subjects, as illustrated in Figure 2. 1,5 Cardiac Output The cardiac output the volume of blood pumped by the heart per unit time may increase as much as six times during maximum voluntary exercise in welltrained men, from the resting level of 5 liters/min to a maximum of 30 liters/min. The increase in cardiac output results from a combined increase in heart rate, which may change by a factor of four, and in stroke volume, which may increase by 1.5 times the resting level. Figure 3 shows that the increase in heart rate is usually linear with exercise, although there may be deviations from linearity at the extreme of exercise intensity. 1 Maximum heart rate remains constant but is reached at a different level of intensity in different types of exercise. For some individuals, heart rate may reach a plateau before maximum sustainable exercise intensity is reached. The resting heart rate is greater in the sitting than in the supine position. The linear relationship is the basis for using heart rate as an index of degree of exercise stress during exercise tests. 7 Whereas the linearity of the relationship remains constant under a wide variety of physiologic and pathologic conditions, 7-9 heart rate during submaximal exercise can be used as a predictor of maximal exercise capability only when the type of exercise and the predicted maximum heart rate for the type of subject are clearly known and specified. 10,11 The slope of the relationship varies with different types of exercise, and maximal heart rates are dependent on the age, sex, physical condition, and state of health of the subject. Stroke volume does not increase linearly with increased exercise intensity. At exercise intensities less than 30 to 40 percent of maximum, stroke volume rises rapidly. The initial rise occurs more rapidly in the sitting position, so that a plateau is reached at about the same level of stress in both positions. The resting stroke volume is lower in the sitting than in the supine position. 1,12 Comparison of Figures 3 and 4 shows that at low levels of exercise intensity the increase in stroke volume is the predominant factor in providing increased cardiac output, whereas at about 30 to 40 percent of maximum stress the increase in heart rate assumes major importance. Under normal circumstances an increase in heart rate does not impair the heart's ability to pump a maximum stroke volume. End-diastolic volume is nearly the same in both sitting and supine positions, but stroke volume decreases in the sitting position, leaving a large end- Fig. 2. Changes in blood flow distribution among tissues in terms of absolute volume and percent of cardiac output (CO.) between rest and heavy exercise. systolic volume. During exercise the stroke volume is increased both by ejecting a large part of this systolic reserve (positive inotropy) and by increasing the filling or end-diastolic volume of the heart with an increase in venous return to the heart. Usually the increased stroke volume is pumped out against an increased aortic pressure, so that the requirements on Fig. 3. Changes in heart rate with increasing exercise intensity. At rest, the heart rate is greater in the sitting than in the supine position (isolated points). During exercise, heart rate increases to maximum more rapidly with arm than with leg exercise (solid lines). Heart rate may plateau before Vo 2max is reached (dashed line). Adapted from Stenberg J and associates. 12 Volume 61 / Number 9, September 1981 1261

Fig. 4. Changes in stroke volume with increasing leg exercise stress. Adapted from Stenberg J and associates. 12 the heart are to pump a greater volume of blood against a greater pressure in the same time as is available at rest. Therefore, the myocardium must be able to increase its force of contraction. Any factors interfering with meeting these inotropic demands will impair the heart's ability to support exercise. The resting stroke volume varies with changes in position, being 1.5 to 2.0 times greater in the supine than in the sitting position. 12,13,28 The decrease in stroke volume when moving from supine to sitting results from three mechanisms: 1) peripheral pooling of blood in lower extremity veins, caused by the downward force of gravity, 2) a decrease in the absolute volume of the heart itself, and 3) a shift in cardiac reserve volumes (Fig. 5). These shifts in blood volume account for the more marked increases in stroke volume seen at the onset of exercise in the sitting position as opposed to the supine position. 12 mobilized during exercise by neurally mediated decreased compliance of the veins of the pulmonary and splanchnic circulations, and a combination of decreased compliance and active muscle pumping in the working muscles. Blood is forced out of deep veins near working muscles by the increased interstitial pressure during muscle contraction. The venous valves prevent retrograde flow, forcing the increased venous volume to move toward the heart. Use of the leg muscles as a vascular pump in mild leg exercise may account for an additional 400 to 500 ml/min of extra venous return. The increased conductance of blood through working muscles (except during strong isometric contractions) is also of major importance in increasing venous return. The changes in blood flow distribution discussed below provide the additional extra venous return needed to support increased cardiac output. Changes in Peripheral Blood Flow The second major change in cardiovascular function supporting exercise occurs in the peripheral arteries. Working muscles may receive four to five times the proportion of the cardiac output of resting muscles (Fig. 2). Two events contribute to this shift in flow: 1) vasodilation in the working muscles and 2) vasoconstriction in splanchnic, renal, and nonworking muscle tissue. The vasodilatation occurring in working muscle has been a well-known phenomenon since the 1870s. 15,17 The mechanisms regulating this vasodilatation, however, are still a matter of dispute. Because total working muscle blood flow increases proportionally much more than cardiac output does, blood flow The sustained increase in cardiac output must be supported by a matching increase in venous return to to some other tissues must decrease by a similar the heart. 14 The veins are a major reservoir of blood proportion. Tissues that can afford to provide the because of their great distensibility. Primary reserve extra volume are those that do not increase their volumes exist in the veins of the pulmonary and metabolic activity with exercise and that have resting splanchnic circulations, and also in the lower extremities when the person is erect. These reserves are Major tissues fitting these criteria are the kidneys, the blood flows in excess of their resting metabolic needs. spleen, the liver, the gastrointestinal tract, and nonworking muscle. 5,6,18 Studies of renal 19,20 and splanchnic 21,22 blood flow indicate an approximately linear decrease in flow in these circulations occurring with an increase in exercise intensity. Studies of blood flow to nonworking extremities also show an inverse linear relationship between flow through relatively inactive regions and exercise intensity. 23-26 Figure 2 indicates that the proportion of cardiac output to the renal and splanchnic circulations combined may be reduced to as little as 5 percent of its resting value at high exercise intensity (down from 45% of cardiac output to 2%). These combined decreases in flow effectively free about 10 liters (40%) of the cardiac output for use by the working muscle. The contribution from nonworking muscle is variable, depending Fig. 5. Cardiac volumes at rest in the supine and sitting positions and during heavy exercise in the sitting position. on the type of exercise being performed, but may 1262 PHYSICAL THERAPY

amount to 20 percent of the added volume. Other regional circulations either maintain their flow at a nearly constant level (brain, bone), increase it (myocardium, adipose tissue 27 ), or show a variable flow (skin 18 ). Central Arterial Pressure The pattern of increase of central arterial pressure during exercise shown in Figure 6 is a function of all of the above variables, being particularly affected by the degree of vasoconstriction in nonworking tissues and by the extent of the conductance changes in the working muscle. Mean blood pressure increases more rapidly during arm than leg exercise and reaches a peak at a lower percentage of maximum minute oxygen consumption ( o 2max ). Total peripheral resistance declines with exercise of both arms and legs, but is on the average lower during leg exercise. As a general rule, systolic blood pressurerisesmore rapidly than mean pressure, while diastolic pressure may remain constant, fall slightly, or rise gradually depending on the type and stage of exercise. At the initiation of exercise, the mean central arterial pressure may drop because of a predominance of vasodilatation. With continued exercise, systolic pressure rises continuously or until a steady state is reached. The increase in mean pressure is due to the great increase in cardiac output, which cannot be sufficiently countered by the decreasing total peripheral resistance resulting from vasodilatation in working muscles. The rate of rise of central arterial pressure changes with the type of exercise. CLASSIFICATION OF EXERCISE Comparisons of results of exercise tests and studies are facilitated by classification of different types of standard exercises and an appreciation of their varying demands on the cardiovascular system. Any type of exercise can vary in intensity. Intensity can be graded either as the absolute value of the work load (expressed as ergs, watts, kilopon-meters per minute) or as a percentage of the maximum work of which an individual is capable. Maximum exercise capacity (Vo 2max ) varies greatly among individuals, and most cardiovascular variables have a direct relationship to the degree of exercise intensity expressed as a percentage of this maximum. Therefore, indications of percent voluntary capacity, such as percent maximal voluntary capacity (%MVC) for static work or percent maximum minute oxygen consumption (%Vo 2max ) for dynamic work, are preferable when comparisons among individuals are to be made. The validity of using %Vo 2max as a measure of exercise capacity and as a standard reference for changes caused by exercise Fig. 6. Changes in central arterial blood pressure (BP) and total peripheral resistance (TPR) with exercise. Adapted from Stenberg J and associates. 12 has been discussed in detail by a number of authors. 6,7,10,11,18 The general conclusion is that %Vo 2max is the most reliable measure available in spite of difficulties in measuring Vo 2max itself. The Vo 2max is a valid standard when applied to populations having similar cardiovascular capabilities and performing similar exercise protocols. 10, 11,18 Percent MVC is also a fairly standard and valid measure for isometric or static exercise where the involvement of different muscles can be well-controlled among subjects, such that there is a constant relationship between %MVC and %Vo 2max. The many different types of exercise used in exercise testing and physical conditioning can be described by the system outlined in the Table. 10,11 The principal characteristics considered are whether the exercise is static (predominantly isometric) or dynamic (isotonic, isokinetic, or mixed), whether large (legs) or small (arms) muscle masses are being used, and whether the exercise is performed in an erect (sitting or ) or recumbent position. Arm and leg exercises could be combined to make a further subset, but in examining acute (as opposed to training) responses to exercise, the distinction is specious, inasmuch as there is very little difference in response when arm exercise is added to leg exercise. 12,28 AC TABLE Categorization System for Various Modes of Exercise Mode Static Dynamic Upper Extremity 1. a. supine 3. a. supine Lower Extremity 2. a. supine 4. a. supine Volume 61 / Number 9, September 1981 1263

cording to this system, some typical exercise modes would be categorized as follows: Treadmill (4-b) erect posture, dynamic exercise with the legs Bicycling (4-b) erect posture, dynamic exercise with the legs Arm cranking (3-a or 3-b) erect or recumbent posture, dynamic exercise with the arms Handgrip (1-a or 1-b) erect or recumbent posture, static exercise with the arms The major cardiovascular variables that were discussed progress in a more or less direct continuum through these categories. For example, the maximum minute oxygen volume (Vo2peak) induced by exercise is lowest for arm exercise and highest for uphill treadmill running. 1,7 The rate of rise of heart rate is greater for arm and static exercise than for leg and dynamic exercise. Total peripheral resistance decreases less in arm and static exercise than it does in leg and dynamic exercise, thus causing a greater and more rapid increase in central arterial pressure in the first two cases. The effect of changes in posture has been suggested above; the stroke volume increases more rapidly with exercise in the erect position than in the supine position. CONCLUSION The cardiovascular system supports the increased metabolic demands of exercise by increasing cardiac output through a combination of heart rate and stroke volume increases. Blood flow through working muscle is increased as a result of the increase in cardiac output coupled with shifts in the quantity of blood flowing to various regional circulations. The timing and the extent of the supportive changes in cardiovascular function vary with different types of exercise, but the basic interrelationships among system components remain constant. When the function of the heart or the peripheral vasculature is impaired by injury or disease, the body's ability to sustain muscular exercise is also impaired. Whenever exercise is used as a treatment, the physical therapist needs to be aware of the interrelated functions of the cardiovascular system. Evaluation of the patient should include checks on the ability of the cardiovascular system to supply support for prescribed activities. REFERENCES 1. Åstrand P-O, Rodahl K: Textbook of Work Physiology, ed 2. New York, NY, McGraw-Hill Book Co, 1977, pp 141-199 2. Keul J, Doll E, Keppler D: Energy metabolism of human muscle. In Jokl E (ed): Medicine and Sport. Baltimore, MD, University Park Press, 1972, vol 7, pp 19-51 3. Newsholme EA: The control of fuel utilization by muscle during exercise and starvation. Diabetes 28 (suppl 1):1-7, 1979 4. Holloszy JO, Booth FW: Biochemical adaptations to endurance exercise in muscle. Ann Rev Physiol 38:273-291, 1976 5. Horvath SM: Review of energetics and blood flow in exercise. Diabetes 28 (suppl 1 ):33-38, 1979 6. Clausen P: Effect of physical training on cardiovascular adjustments to exercise in man. Physiol Rev 57:779-815, 1977 7. Åstrand P-O: Quantification of exercise capability and evaluation of physical capacity in man. Prog Cardiovasc Dis 19: 51-67, 1976 8. Corbett JL, Frankel HL, Harris PJ: Cardiovascular changes associated with skeletal muscle spasm in tetraplegic man. J Physiol (Lond) 215:381-393, 1971 9. Knutsson E, Lewenhaupt-Olsson E, Thorsen M: Physical work capacity and physical conditioning in paraplegic patients. Paraplegia 11:205-216, 1973. 10. Cardus D: Exercise testing: Methods and uses. In Hutton RS (ed): Exercise and Sport Science Review. Philadelphia, PA, The Franklin Institute Press, 1978, vol 6, pp 59-103 11. Sheffield LT, Roitman D: Stress testing methodology. Prog Cardiovasc Dis 19:33-49, 1976 12. Stenberg J, Åstrand P-O, Ekblom B, et al: Hemodynamic response to work with different muscle groups, sitting and supine. J Appl Physiol 22:61-70, 1967 13. Rushmer RF: Cardiovascular Dynamics, ed 4. Philadelphia, PA, W. B. Saunders Co, 1976, p 273 14. Smith EE, Guyton AC, Manning R, et al: Integrated mechanisms of cardiovascular response and control during exercise in the normal human. Prog Cardiovasc Dis 18:421-443, 1976 15. Gaskell EH: On the changes of the blood stream in muscle through stimulation of their nerves. J Anat 11:360-402, 1877 16. Gaskell EH: Further researches on the vasomotor nerves of ordinary muscles. J Physiol (Lond) 1:262-302, 1878 17. Heidenhain R: Regulation of muscle blood flow. Pfluegers Arch 16:1, 1877 18. Rowell LB: Human cardiovascular adjustments to exercise and thermal stress. Physiol Rev 54:75-159, 1974 19. Grimby G: Renal clearances during prolonged supine exercise at different loads. J Appl Physiol 20:1294-1298, 1965 20. Hohimer AR, Smith OA: Decreased renal blood flow in the baboon during mild dynamic leg exercise. Am J Physiol 236: H141-H150, 1979 21. Bishop JM, Donald KW, Taylor SH, et al: Changes in hepatic arterial-venous oxygen content difference during and after supine leg exercise. J Physiol (Lond) 137:309-317, 1957 22. Rowell LB, Blackmon JR, Bruce RA: Indocyanine green clearance and estimated hepatic blood flow during mild to maximal exercise in upright man. J Clin Invest 43:1677-1690, 1964 23. Bevegård BS, Shepherd JT: Reaction in man of resistance and capacity vessels in forearm and hand to leg exercise. J Appl Physiol 21:123-132, 1966 24. Bishop JM, Donald KW, Taylor SH, et al: The blood flow in the human arm during supine leg exercise. J Physiol (Lond) 137:294-308, 1957 25. Blair DA, Glover WE, Roddie IC: Vasomotor responses in the human arm during leg exercise. Circ Res 9:264-274, 1961 26. Eklund B, Kaijser L, Knutsson E: Blood flow in resting (contralateral) arm and leg during isometric contraction. J Physiol (Lond) 240:111-124, 1974 27. Bülow J, Madsen J: Human adipose tissue blood flow during prolonged exercise: 2. Pfluegers Arch 376:1:41-45, 1978 28. Green HJ: Metabolic consequences of supramaximal arm work performed during prolonged submaximal leg work. J Appl Physiol 46:249-255, 1979 1264 PHYSICAL THERAPY