Episode 42: Upper Body vs Lower Body Exercise Response

The goal is to learn , inspire and bring cardiopalm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to today's episode of Talking All Things , cardiopalm . I am your host , dr Rachel Berezian . Our episode today is sponsored by Jane and all-in-one practice management software .

The team at Jane recognizes how hard you work to support your patients or clients and they aim to do the same for you . That's why Jane offers unlimited phone , email and live chat support with every subscription . First , we recommend booking a personalized one-on-one demo with a member of their team .

It's a great way to make sure Jane will be the right fit for you and your practice and to see Jane's features in action . And Jane even offers a free data import , an account setup , consultation and online training tools to help set you up for success . To get started , head over to Janeapp backslash start .

Their team would love to connect with you to see how Jane could help you and your practice . You can also use the code Cardiopalm1MO at the time of sign up for a one-month grace period applied to your account . I want to throw one more plug in for Jane . They're actually hosting a live free webinar to do just that .

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All right ? Well , let's jump into today's episode . Happy New Year . Let's catch up . What is today ? Today is January 12th and I am I don't even know what's happening . This has been a weird start to the year . So I'm not a resolution person , but I definitely am someone who does set yearly goals , but I'm also someone who sets goals throughout the year .

It just helps keep us accountable . Last year this time I did a episode on creating smart goals and what that looks like and how you can translate smart goals from either your PT practice or student practice to life , and I very much stand behind that .

I think it's super important to check in with your goals throughout the year and see where you're at and adjust if you need and progress . So once you are hitting a goal , that you're pushing that envelope and that you're kind of pushing for those things .

So I was really hoping to come out the gate this January and get after it , and the universe had different plans for us . So Nikki got sick and I thought it was going to be me . Right , I had just traveled from New York . I did the flight . I am very cautious . I do mask on planes , but I have loosened so many restrictions that it's inevitable .

But I figure , even before COVID I would always get sick when I flew , so I just take that precaution . Three hours in a small vessel is high possibility , so I was surprised that it wasn't me . Hey , it was Monday and I looked at Nikki and I said you're getting stuffy . And she's like no , no , no . And I was like , okay , here we go .

And sure enough , tuesday it hit her hard and fast . Wednesday morning I was like , ah , maybe I got a little sore throat thing starting , not really sure . Thursday I felt fine . I was like , okay , I may have just totally bypassed this . Friday it hit me like a ton of bricks . We were pretty just down for the count for the whole week .

We don't do that very often where we're just like watching movies for multiple days in a row , but I literally , we literally were horizontal for damn near seven days . When she was bad , I was okay . When I was bad , she was okay . So it was a good trade-off in helping each other make dinner and doing all those things .

And then week two just really we're on the end of week two . Week two has just been a little bit difficult to like giddy up and go and I'm human , I like to be transparent with you . I think we sometimes over sensationalize the hustle and all the things and I think you have to go with the flow . I think you have to adjust to what your body is doing .

I think you need to push when you have the energy to push and I think when your body's telling you to back off . You need to back off , and that goes throughout the season , right ? Not just January 1st . So anyway , here we are . It's Friday . This is not my normal recording day , but we're gonna see where this goes .

This episode is actually a little bit more geared to the student , specifically the NPTE prep students . I've actually gotten this question a lot over the past few weeks and actually probably a few months before . I think I've made a post or two on it , kind of throughout the last three or three to six months . I wanted to talk about it .

I had a student actually say I think you could add this to your prep course and like maybe it'd be a 15 minute module . I'm gonna tell you this is gonna be a pretty short . This is gonna be a pretty short podcast . I don't know if it's gonna take me 15 minutes to talk through this , but who knows , I'm long-winded , all right .

So today's topic I wanna talk about upper body versus lower body , rhythmic exercise , and so there's just some nuances here . They like to ask about this question on prep tests the PEET , maybe the NPTE . This one comes up a lot and it has come up for a number of people who have been doing practice tests and reaching out and asking like but why so ?

Just a couple of things before we even jump in . When the test is asking , or anyone is asking , about rhythmic exercise , they're typically talking about aerobic exercise biking , walking , swimming , arm ergometer , anything that is rhythmic or cyclical in nature . So that typically indicates that we're talking about something in an aerobic capacity .

The big question that has come up is what is the difference in blood pressure response when a patient is exercising with their upper body versus exercising with their lower body ? So basically , an arm ergometer exercise versus a bicycle right . So that would be two cyclical motions . Pretty much mirror each other , but opposite upper and lower body .

What is the difference ? Who's gonna have a higher blood pressure , a higher heart rate response ? It's the upper body . The upper body rhythmic exercise has an increased physiologic , metabolic demand across the board increased heart rate , increased blood pressure , increased respiratory rate . This has tripped up a lot of people . The answer is actually relatively simple .

The reason why you have an increased blood pressure , heart rate response with upper body ergometer , upper body exercise is because the muscle mass in the arms are smaller than the legs , so they are less efficient with energy consumption and they have smaller vessels .

So this kind of pulls us back to , I believe , poussée's law is gonna help us the most with this . So Poussée's law says you have , flow is dependent on the length of the vessel , the viscosity of the blood and the diameter of the vessel . And so when we talk about Poussée's law , typically we're talking about vasoconstriction versus vasodilation .

But just being an entity of itself , it still works . So that's also a common question that comes up Pusse's law . They don't typically ask about Pusse's law , but they're gonna potentially ask the difference in flow . What's gonna affect blood flow ? Change in vessel size , length of vessel or viscosity of blood .

So now the part that you need to understand is that the blood viscosity doesn't really change from second to second , minute to minute . Yes , there can be changes over time , but it's not something that's gonna change pretty quickly and the length of your vessels is the length of your vessel .

So sometimes the question might be worded as to what has the most significant change from minute to minute with exercising blood flow , and so it would be vasoconstriction , vasodilation , something in the world , to the size , the radius of the vessel . The other two don't change . Long story short with Pusse's law and kind of pulling that physiology piece back out .

Essentially , you're gonna have increased resistance with a decreased radius . So it's an inverse relationship . If I have a smaller radius , I have increased resistance .

So systolic blood pressure is the left ventricle pushing blood out to the entire arterial system , and if we are , in theory , pushing while we're upper body or gommeter , you're gonna have increased resistance to blood flow because those vessels are smaller and therefore have a higher blood pressure response . So that's it . That's the answer .

The answer is you have an increased blood pressure , increased heart rate , increased pulmonary response with upper body or gommeter , essentially because you have a smaller muscle mass that's less efficient at O2 consumption and extraction and you have smaller vessels . So therefore you have increased resistance to those vessels .

Another way that they could oh , one more thing they can also extrapolate , and not all textbooks mention this , but one does that when you are using upper body or gommeters or upper body rhythmic exercise , you are also getting torso motion and so that could increase the oxygen demand in theory .

In my opinion , it's the small muscle mass and the vessel size that is causing the most dramatic response to that . So that's not what they're gonna ask you , they're not just gonna say and this is an MPTE thing right . So , especially as people come back to me with questions , the MPTE , or just questions in general , aren't typically rote memory questions .

They're usually two to three step questions , meaning you need to know this piece of information in order to apply it . And so that's a two step process , and in the situation of upper body versus lower body exercise , they could even go further . So RPP was brought up in this world .

So instead of asking which will cause an increased blood pressure response upper body or gommeter versus lower extremity bicycle they may ask something like which will cause an increased RPP response ? So now you have to know what RPP is .

So now you need to know that upper extremity or gallimeters gonna cause an increased heart rate , increased blood pressure , and then you need to understand that RPP rate pressure product is heart rate times , systolic blood pressure . So if you know this information and you know this information , it's still the same question .

It has increased difficulty because they're throwing an extra thing at you . So which is going to have a higher rate pressure product ? The answer is the same it's the upper extremity or gallimeter . Now I personally don't love that question , not because it's a bad question , but because when you think of RPP . There's other things that might be more important .

So rate pressure product is a way to measure clinically mild cardio oxygen demand , and so typically when you talk about RPP , you're talking about angina threshold . So maybe a better question and it's also a multi-step question here is how can you determine angina threshold in a patient ? So the answer is RPP rate pressure product . Well , what does that mean ?

That means that if I have a patient on a bruise protocol and I have them increasing grade and speed every three minutes and I'm assessing heart rate , blood pressure each increment , then I'm gonna know if it's a symptom limited exercise stress test .

Symptom limited meaning the exercise stress test is over when the patient starts having symptoms , which in most cases is angina . So if you have a patient who's performing a bruise protocol , you could ask at what mild cardio oxygen demand did the patient experience angina ?

And then the answer could be something like rate pressure product and it could be literally the math for heart rate times systolic blood pressure . Now my mentee who was sitting for the CCS last year asked me a really good question .

She's , like you , always make a big deal about RPP and myocardial oxygen demand and how it can help predict angina , which is really a cool thing , right . Like if you were in cardiac rehab .

In theory you could predict when angina is going to occur based on , historically , where their heart rate and systolic blood pressure hit at what myocardial oxygen demand in real time . But the actual applicability to that isn't , as I don't know , isn't as applicable clinically .

So in theory you would do heart rate times , systolic blood pressure and you're gonna get something like 6,000 , right ? So unless you are calculating where that myocardial oxygen demand is , you're not gonna actually know if they're approaching angina threshold . Typically we say maintain angina threshold less than 10 beats from that mark . So off of their bruised protocol .

Wherever their max heart rate was , you're gonna basically stay off 10 . In the world of RPP , from an NPT perspective and just life , the main thing about RPP is that it helps predict myocardial oxygen demand , which can help predict angina .

The question about upper body ergometer is still asking about myocardial oxygen demand and I think that was maybe the verbiage like will upper body versus lower body cause a higher myocardial oxygen demand ? So you have multi-step things coming in with that question .

Any time you are sitting for a question , what I recommend for students to do is number one read the whole question because more times than not , mistakes are made because you either have test fatigue or you just you know you're going too fast and you don't really read the question .

So I really do emphasize to all my students to make sure that you read the entire question and then kind of pull out some of those things right , like upper body versus lower body , mild cardio oxygen demand I'm already thinking RPP and maybe what those facts are Then look at the answer choices and if you can come up with the answer before looking at the answer

choices , in my opinion that is the easiest way to answer because it doesn't allow you to let those questions mess you up , trip you up , because you have increased decrease and they're really trying to like make it a fair question , but then it feels

tricky . So read the whole question , pull out the big important points , make sure you understand what the question is asking you . Then look at the answer choices . So big piece with this in the world of students and PTE upper body versus lower body rhythmic exercise .

You're going to have a higher physiologic , metabolic , mild cardio oxygen demand with upper body versus lower body exercise and it was all due to lower or smaller muscle mass as well as smaller radius of vessels . I do want to flip this and throw in a clinical piece here .

So the reason why you care and I am always going to do this , and this is kind of why I sit here too and when these questions come out me and I'm like , well , why do we care ? And that's the important piece why do you care about the different responses between upper body and lower body ?

You care because when you're working with your patient and , for instance , let's say cardiac rehab cardiac rehab is a really great way to parallel this . In cardiac rehab , when you're working with a patient , you have a lot of information prior to starting with them .

That includes their sub max or max exercise stress tests that they performed typically a bruised protocol if they were able to tolerate it and from that you're going to have their true max heart rate , not their theoretical 220 minus age . From that real max heart rate you can have a few pieces of information . One , keep them under angina threshold .

If you have that , you can also do percent of target heart rate , which is what we typically do in cardiac rehab , except for patients with beta blockers . So if you have a patient and typical modern intensity for cardiac rehab is 60 to 80 percent of max heart rate .

You need to understand that when your patient is on the arm ergometer in their circuit training , they may hit that target heart rate faster than if they are on the bike or the treadmill , and so , as you are progressing them , it is important to understand the level of intensity that you're adding , the speed in which they're going , and to understand that you may

have to coach them to back off on speed or not increase the intensity as quickly , whatever it might be , and if you're like , why is his heart rate jumping so high so quick ? That's why , so clinically , it's actually a really important piece to know . Now here's some things about the upper body . I personally love an arm ergometer .

I think it's underused in the inpatient setting , like in the hospital setting . I love me an arm ergometer . Get me an arm ergometer in the ICU . We'll get back to that . But when you're in cardiac rehab , you have to monitor the patient throughout , and so there are two things about the arm ergometer that were typically tricky .

Number one when you are cycling with bilateral uproach If you're on YouTube you can actually see me moving my arms you're going to get chest motion , and so now all your patients are on telly .

The one issue you do have with these patients is that you get a lot of noise from their telemonitor and so it might be more difficult to track their target heart rate because there's constantly noise .

I do have to say , sometimes you have to stop them to make sure that you're in a good spot , and typically that's what we did at the the five minute mark versus just documenting it at the five minute mark because you want a true and accurate reading . Same is true for blood pressure .

If the person's on the treadmill , you can technically take that blood pressure while they're walking and you don't have to fully stop at that five minute mark On the arm ergometer . If you don't stop , now you have your person one arm ergometer ring I've made up a new word while you're checking blood pressure on the left .

So now you have noise from that movement because it will , there will be more movement , and now you're asking one arm to continue doing the work that two arms was were was doing we're doing , having a hard time with English today , so you're literally doing double the work .

What I do recommend is just have them stop at that five minute mark when you're reassessing so you can get a true value . Otherwise that person might end up quitting or hitting their you know target heart rate or maxing their heart rate with that one arm period while you're assessing blood pressure . So that's just a clinical piece . Let's go to the underutilized .

In the inpatient setting . I love using arm ergometers , especially if you're in the ICU . So if you're a person that is stationed in the ICU and you ever have the opportunity to bring equipment in things like that , get a couple of arm ergometers .

They're super cheap , they're portable and they can be very helpful in helping your patient increase aerobic demand while they're in bed .

So even if they're not physically capable of tolerating an upright position , but they can physically move bilateral upper extremity , get them on that arm ergometer and now be aware that their heart rate response will peak pretty quick . I have had patients in the ICU as well as pulmonary rehab .

Do intervals of 30 seconds , one minute or even inpatient I should say heart failure , copd , icu on vent . Get them getting some aerobic exercise in there and then you don't have to also combat gravity and not or right . So you can't do this , but maybe I can do that . Get the most out of your patient arm ergometer . Do not sleep on it .

Pots , my pot's patients . I'm going to do a pot's case , maybe later this month , maybe later this year . I was going to do a pot's case at pre-con but pre-con got canceled so I'll bring back pots . I know I did my story but I was going to do it a little bit more systematic about pathophysiology and signs and symptoms and all that stuff .

I like to use arm ergometer with patients with pots . Why ? Because if they're asymptomatic in sitting , you can get more activity out of them and actually have increased muscle contraction , increased blood flow , increased heart rate in a seated position . That can help then when they are upright and that can also be a progression .

I have also had patients do standing arm ergometer , which brings me to my next patient population that can very much benefit from this , and that is my patients with amputations . So I've had a number of patients come through cardiac rehab that also have severe PAD and some had amputations , some had prosthetics and some did not .

I also saw lots of patients in the inpatient setting , but we had a gym that we can treat our inpatients in , as well as CLC at the VA , which was basically a subacute setting , and that is another great way to get aerobic capacity and balance and postural training . So I've had patients go from a sitting position to a standing position and it's awesome .

So you can literally progress this , not just with speed and resistance , but position , if it's physically possible . So don't sleep on that arm ergometer . And it's not enough .

It's actually going to give you a higher blood pressure , heart rate response , so you actually need to kind of pay attention that they don't overdo it more quickly , which I think people can underestimate . So just a recap upper body versus lower body .

Upper body is going to have higher heart rate , higher blood pressure , increased respiratory rate , just an overall increased metabolic , physiologic and myocardial oxygen demand compared to lower extremity rhythmic exercises . All based on size of the muscle mass and radius of the vessel . Smaller vessels Overall .

If you were to talk about VO2 max and I don't know if I mentioned this one yet , so this is my last fact If you , you cannot compare . So if you do a sub max stress test with two people or same person , let's do same person for ease .

The VO2 max on an arm ergometer versus a treadmill is going to be about 25% less in the arm ergometer and so I hope that's tracking for you . You're going to increase heart rate more quickly , more exaggerated , therefore quit sooner . So you're just less efficient .

Okay , so upper body versus lower body , you're going to have a decrease in VO2 max by about 25% or so . So just one last piece of information there . Okay , for my students . I hope that answered that question and thought process For my clinicians . I hope this was helpful for you . I hope it gave you another piece of information to utilize in your day .

I hope that you maybe think about bringing an arm ergometer into the ICU or your inpatient patients . So great for anyone with lung disease who's having dyspnea with exertion . It's a great way to increase aerobic capacity to some extent .

It's also wonderful for heart failure patients , and all of which you're doing with interval training right and eventually progressing hopefully to something more steady state , which I think is fantastic . So utilize the things that are at your disposal . Do not underestimate something that is portable .

It can be super beneficial for a number of patients and actually help you progress them more quickly . Once you add in another piece of that trifecta , all right . So I hope that was helpful for you .

If this was , share it with a friend , share it with a colleague . Drop me some stars , maybe write a review . All of that helps , and reach out to me Again . If anything lands , let me know . If you have more questions , please let me know . I am always looking for more content , more things to talk about .

The list is endless , but when it's more important to you , it's more important to me . So if you have any questions , reach out to me via text at 913-308-4494 or DM me on Instagram . At all things , cardio palm , underscore between all things and cardio palm . All right , I hope you all have a wonderful day and whatever you have to do , get after it .