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cardiac rehabilitation and the role of resistance training
exercise after suffering from a heart attack A trend toward resistance training in the programs of cardiac rehab patients may speed their return to productive work and recreation. Cardiac Rehabilitation (CR) exercise programs have traditionally been centered around aerobic training, especially treadmill walking and cycle ergometry. However, numerous recent studies have demonstrated that well-structured, properly supervised resistance training (RT) programs can be safe and beneficial for certain cardiac patients.5,6,9 A greater emphasis is being placed on the need for CR patients to regain adequate levels of upper- and lower-body strength to successfully return to occupational, recreational and domestic activities. Consequently, there will most likely be an increase in the number of CR programs that incorporate RT along with aerobic training. It is imperative that the staff of any CR program considering the addition of resistance training follow conservative, sensible guidelines in designing and implementing this potentially beneficial mode of training. Sustained, high-intensity isometric exercise had long been considered contraindicated for cardiac patients because of the potentially adverse effect of increased afterload and myocardial ischemia.7 However, it appears that RT can be conducted safely in properly screened (see Table 1) cardiac patients.1,2,4 Therefore, non-sustained isometric, as well as isotonic and isokinetic, exercises are now recommended for cardiac patients, especially as a means to facilitate an earlier return to physically demanding employment and/or recreational activities. Designing a resistance training program Various types of equipment and exercises can be utilized for resistance training. The most common modes include free weight dumbells, weight machines and elastic bands. Regardless of which type of equipment is used, it is imperative that the patient receive a thorough orientation covering proper technique (including breathing and gripping), as well as a discussion on how to self-monitor for potentially significant cardiovascular symptoms (e.g., dizziness, shortness of breath) during or following resistance training. |
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Properly screened older cardiac patients may not only
participate in RT, but also stand to receive significant
benefits, especially improved strength, bone mass and
neuromuscular control. These training adaptations typically
result in a reduced risk of sustaining debilitating or
life-threatening injuries resulting from falls. In general,
older and higher risk cardiac patients need to be monitored more
closely during RT. Blood pressure and EKG readings (quick
checks) will help avoid hemodynamic responses in these
individuals. Because blood pressure tends to drop very quickly
after completion of an RT set, readings should be taken during a
given set, preferably on a non-exercising limb.13 The results from several investigations3,10,11 suggest that properly screened cardiac patients may begin their RT program as an inpatient (Phase I CR), often with light activities such as squeeze balls and relatively easy calisthenics in bed or in a chair. Phase II, outpatient RT with light dumbells and/or elastic bands, has been successfully initiated as early as three to eight weeks after a myocardial infarction (MI) or coronary artery bypass graft (CABG), provided the patient is medically stable. Great care must be taken during this time, particularly for CABG patients, to keep the risk of post-surgical complications to a minimum.8 Progression to higher intensity RT typically begins six to 12 weeks post-event in lower-risk patients, especially if they have undergone a successful follow-up outpatient graded exercise test with their cardiologists. Some researchers have even had low- to moderate-risk cardiac patients successfully engage in light circuit weight training as early as two and one-half to six weeks following MI or CABG.3,5,12 The American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) currently recommends that MI and CABG patients wait three to six weeks before initiating RT at light intensities.1 The American College of Sports Medicine (ACSM) recommends that RT start four to six weeks after an uncomplicated MI or CABG, and one to two weeks following a percutaneous transluminal coronary angioplasty.2 |
It appears that circuit weight training is the most common
format currently utilized for resistance training in a cardiac rehab
program. Typical guidelines call for two to three days per week (on
alternate days) of one to three sets of eight to 14 exercises (circuit
stations), performed with light to moderate resistance of approximately 30
to 60 percent of one repetition maximum (RM).1, 2, 8 In reality, probably
the best way to establish the initial resistance level is by having the
patient perform the exercise with little or no external resistance first,
working up or "titrating" toward a load that can successfully be moved for
12 to 15 repetitions. This more conservative approach greatly reduces the
risk of both cardiovascular complications and musculoskeletal injury that
may result from attempting to achieve an actual RM. Rest intervals between
stations should be approximately 60 seconds (or longer) in most cardiac
patients, with perhaps as little as 30 seconds rest for low-risk patients.
Resistance can be added in small increments (usually five to 10 pounds) once
12 to 15 repetitions feels "fairly easy" to "somewhat hard" (Rating of
Perceived Exertion of 11 to 13 on Borg 6 to 20 category scale) for the
patient. The RT session should last approximately 20 to 30 minutes,
preferably after the aerobic training is concluded, and should begin and end
with several properly performed stretching exercises to enhance range of
motion and reduce the risk of musculoskeletal injury. Intensity of RT needs
to be carefully and continuously monitored by both the CR staff and the
patient. The patient should be well-educated in symptom identification, and
must notify the CR staff immediately if a symptom should occur. The staff
should observe the patient closely for any obvious signs of cardiovascular
distress, as well as for improper lifting techniques and, at a minimum,
should record the patients' RPE and heart rate, as well as blood pressure
and EKG findings for higher risk patients.
Resistance training program recommendations
1) Technique. Patients should be instructed to:
* Move the resistance through a full range of motion, but modify the range
for any orthopedic limitations.
* Perform slow and controlled movements. Take approximately two seconds to
complete the concentric phase and approximately four seconds to complete the
eccentric phase.
* Exercise large muscle groups before small muscle groups, whenever
possible.
* Maintain a loose, comfortable grip to avoid isometric contractions of the
forearm muscles and reduce the chance of an abnormally high blood pressure
response.
* Breathe normally throughout the movement by exhaling during the concentric
phase and inhaling during the eccentric phase.
* Warm up prior to RT, as well as before performing static stretching
exercises. A program of quality stretching exercises should be included to
reduce the risk of musculoskeletal injuries, as well as to enhance range of
motion and, therefore, RT performance.
* Be given a thorough orientation to all equipment and each exercise
included in their RT programs, and be monitored closely by highly trained
staff (exercise specialist, physical therapist) to ensure proper technique.
2) Intensity, safety and session termination.
* Patients should be well-schooled in recognizing symptoms that warrant
cessation of a given exercise movement or session, especially chest pain,
dizziness, shortness of breath or excessive muscular fatigue, and report any
symptom to the attending staff immediately.
* Cardiovascular termination criteria for the RT session should be the same
as for aerobic exercise, and should be based upon AACVPR,1 ACSM2 and
American Heart Association4 standards. In particular, a significant rise or
drop in blood pressure and/or development of significant dysrhythmia are two
signs that necessitate the termination of an RT session.
* The intensity of an RT session should not exceed "somewhat hard" (RPE = 15
on Borg category scale, five on category-ratio scale), especially during the
early stages of training. Generally, the RPE should be between "fairly
light" to "somewhat hard" on the category scale, or "weak" to "somewhat
strong" on the category-ratio scale. Eventually, certain low-risk, highly
motivated patients may progress to 15 to 16 on the category scale or five to
seven on the category-ratio scale.
* Blood pressure should be measured during RT at least once per session,
more often in beginning and with high-risk patients. EKG monitoring, either
with telemetry or "quick-check" assessments, should be conducted on every
patient at the onset of their RT program. Periodically thereafter, the
frequency of monitoring should directly correlate to the patient's
cardiovascular risk profile (especially in terms of their dysrhythmia
history).
* All necessary emergency equipment, including crash cart, defibrillator and
oxygen, should be operable and readily available. All staff should be
trained in basic cardiac life support, and at least several staff members
should be trained in advanced cardiac life support. Code drills should be
conducted on a regular basis.
* RT equipment should be regularly maintained and cleaned to reduce the risk
of injury. Any malfunction should be immediately reported to the staff, with
proper corrective action taken promptly.
3) Physician support. Obviously, RT programs for cardiac patients must have
the medical approval, as well as philosophical support of your patients'
physicians, both their primary providers and, of course, their
cardiologists. It is imperative that your CR staff secure the endorsement of
clients' physicians before considering developing the specifics of an RT
program. One suggestion is to refer physicians to certain publications1,2,4
which have demonstrated RT to be safe and beneficial in selective cardiac
patients. Your personal and professional efforts to persuade them may prove
to be essential in receiving the approval to proceed with your RT program.
Summary
When developed carefully, it appears that a program of resistance training
in selected cardiac patients can be conducted safely, and can potentially
benefit patients in important ways, including but not limited to:
* Improved muscular strength and endurance
* Earlier, more successful return to occupational duties and/or recreational
activities
* Improved neuromuscular coordination
* Improved cardiovascular function (especially with circuit training)
* Reduced risk of debilitating musculoskeletal injuries
* Improved metabolism and increased energy expenditure and, therefore,
enhancement of weight management
efforts
* Improved psychosocial function, especially greater self-esteem
For many cardiac patients, the more predominant limiting factors for
physical work are related to musculoskeletal (as opposed to cardiovascular)
deficiencies and de-conditioning. Therefore, a consistent, well-designed
resistance training program has the potential to increase their capacity for
physical work to the point where their muscular strength and endurance no
longer limits their ability and efforts to improve their cardiovascular
functional capacity to a safe and effective level.
REFERENCES
American Association of Cardiovascular and Pulmonary Rehabilitation.
Guidelines for Cardiac Rehabilitation Programs. Champaign, IL: Human
Kinetics, pp.45-51, 1995.
American College of Sports Medicine. ACSM's Guidelines for Exercise Testing
and Prescription. Philadelphia, PA: Williams & Wilkins, pp.189-191, 231-233,
1995.
Butler, R.M., G. Palmer & F. J. Rogers. Circuit weight training in early
cardiac rehabilitation. Journal of the American Osteopathic Association 1:
77-89, 1992.
Fletcher, G.F., G. Balady, V.F. Froelicher, L.H. Hartley, W.L. Haskell &
M.L. Pollock. A Statement for Healthcare Professionals from the American
Heart Association. Circulation 91: 580-615, 1995.
Haennel, R.G., H.A. Quinney & C.T. Kappagoda. Effects of hydraulic circuit
training following coronary artery bypass surgery. Medicine & Science in
Sports & Exercise 23: 158-165, 1991.
Kelemen, M.H., K.J. Stewart, R.E. Gillilian, C.K. Eward, S.A. Valenti, J.D.
Manley & M.D. Kelemen. Circuit weight training in cardiac patients. Journal
of the American College of Cardiology 7: 38-42, 1986.
Painter, P., & P. Hanson. Isometric exercise: Implications for the cardiac
patient. Cardiac Rehabilitation: Exercise Testing and Prescription.
Champaign, IL: Life Enhancement Publishers, pp. 223-242, 1984.
Pollock, M.L., & J.L. Wilmore. Exercise in Health and Disease. Philadelphia,
P.A.: W.B. Saunders, pp.495-548, 1991.
Sheldahl, L.M., N.A. Wilke, F.E. Tristani & J.H. Kalbfleisch. Response to
repetitive static-dynamic exercise in patients with coronary artery disease.
Journal of Cardiac Rehabilitation 5: 139-145, 1985.
Squires, R.W., A.J. Muri, L.J. Anderson, T.G. Allison, T.D. Miller & G.T.
Gau. Weight training during Phase II (early outpatient) cardiac
rehabilitation. Journal of Cardiopulmonary Rehabilitation 11: 360-364, 1991.
Stralow, C.R., T.E. Ball & M. Looney. Acute cardiovascular responses of
patients with coronary disease to dynamic variable resistance exercise of
different intensities. Journal of Cardiopulmonary Rehabilitation 13:
255-263, 1993.
Stewart, K.J., L.D. McFarland, J.J. Weinhofer, C. Brown & E.P. Shapiro.
Weight training soon after myocardial infarction. Medicine & Science in
Sports & Exercise (Supp. 1) 26: 32 (abstract), 1994.
Wiecek, E.M., N. McCartney, R.S. McKelvie & D. MacDougall. Comparison of
direct and indirect measures of systemic arterial pressure during
weightlifting in coronary artery disease. American Journal of Cardiology 66:
1065-1069, 1990.
Contraindications for Participation in Resistance Training
Generally, patients with the following conditions should not participate in
resistive exercise:1,2,4
* Any abnormal hemodynamic response or significant ischemic EKG changes with
exercise
* Poor left ventricular (LV) function (i.e., ejection fraction < 30 percent)
* Low functional capacity (< four to five METS)
* Uncontrolled angina, heart failure, hypertension or dysrhythmias
* Severe coronary artery disease (left main, triple vessel or high left
anterior descending disease)
* Severe symptomatic aortic stenosis
* Clinically limiting orthopedic or cardiovascular symptomology
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