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Fitness Professional’s Handbook, Seventh Edition With HKPropel Access, provides current and future fitness professionals with the knowledge to screen participants, conduct standardized fitness tests, evaluate the major components of fitness, and prescribe appropriate exercise. The fully updated text uses the latest standards, guidelines, and research from authorities in the field to prepare readers for certification and arm them with the knowledge to work with a variety of clients and populations.
This full-color text incorporates information from the 10th edition of ACSM’s Guidelines for Exercise Testing and Prescription and the Physical Activity Guidelines for Americans exercise and physical activity recommendations for adults, older adults, children, and those with special needs. The text embraces the importance of communication between allied health and medical professionals with those in the fitness arena to provide readers with a foundation for prescribing exercise and delivering need- and goal-specific physical activity and fitness programs.
Every chapter has been updated, allowing readers to explore the newest theories and research findings and apply them to real-world situations. The following are among the most significant changes to the seventh edition:
• Related online content delivered via HKPropel that includes an online video library containing 24 video clips to help readers better apply key techniques covered in the book, as well as fillable forms that students can use beyond the classroom
• A new chapter, “Training for Performance,” helps professionals expand their practice to work with recreational athletes who have performance-related goals
• New information, including the consequences of exercise-induced muscle damage (rhabdomyolysis), devices used to track physical activity and estimate energy expenditure (e.g., accelerometers), relative flexibility and the role of lumbopelvic rhythm in back function, the importance of progression in an exercise prescription, and the professional standard of care associated with HIIT programs reflects recent topics of interest and research
• Updated statistics on CVD and CHD from the American Heart Association, adult and childhood obesity, and the prevalence of COPD, asthma, bronchitis, and emphysema ensure accurate representation of data
• Chapter quizzes have been added to an updated ancillary package that also includes an instructor guide, test package, presentation package, and image bank
With a comprehensive and practical approach, this text enables readers to help individuals, communities, and groups gain the benefits of regular physical activity in a positive and safe environment. It provides background to the field, scientific fundamentals, and up-to-date recommendations to help readers better understand the role of physical activity in the quality of life and guidelines for screening, testing, supervising, and modifying activity for various populations.
Note: A code for accessing HKPropel is included with all new print books.
Part I. Physical Activity: Links to Health, Fitness, and Performance
Chapter 1. Health, Fitness, and Performance
Edward T. Howley
Chapter 2. Health Risk Appraisal
Michael Shipe
Part II. Scientific Foundations
Chapter 3. Functional Anatomy and Biomechanics
Clare E. Milner
Chapter 4. Exercise Physiology
Edward T. Howley
Chapter 5. Nutrition
Dixie L. Thompson
Chapter 6. Measurements of Energy Cost in Physical Activity
Edward T. Howley
Part III. Fitness Assessment
Chapter 7. Assessment of Cardiorespiratory Fitness
Edward T. Howley
Chapter 8. Assessment of Body Composition
Dixie L. Thompson
Chapter 9. Assessment of Muscular Fitness
Avery Faigenbaum
Chapter 10. Assessment of Flexibility and Low-Back Function
Laura Horvath Gagnon
Part IV. Exercise Prescription for Health, Fitness, and Performance
Chapter 11. Exercise Prescription for Cardiorespiratory Fitness
Edward T. Howley
Chapter 12. Exercise Prescription for Weight Management
Dixie L. Thompson
Chapter 13. Exercise Prescription for Muscular Fitness
Avery Faigenbaum
Chapter 14. Exercise Prescription for Flexibility and Low-Back Function
Laura Horvath Gagnon
Chapter 15. Training for Performance
Scott A. Conger
Part V. Special Populations
Chapter 16. Exercise for Children and Youth
Edward T. Howley
Chapter 17. Exercise and Older Adults
Edward T. Howley
Chapter 18. Exercise and Women’s Health
Dixie L. Thompson
Chapter 19. Exercise and Heart Disease
David R. Bassett, Jr.
Chapter 20. Exercise and Obesity
Dixie L. Thompson
Chapter 21. Exercise and Diabetes
Dixie L. Thompson
Chapter 22. Exercise and Pulmonary Disease
David R. Bassett, Jr.
Part VI. Comprehensive Exercise Program Considerations
Chapter 23. Behavior Change
Janet Buckworth
Chapter 24. ECG and Exercise Performance
David R. Bassett, Jr.
Chapter 25. Injury Prevention and Treatment
Jenny Moshak
Chapter 26. Legal Considerations
JoAnn M. Eickhoff-Shemek
Edward T. Howley, PhD, FACSM, FNAK, earned his bachelor’s degree from Manhattan College and his master’s and doctorate degrees from the University of Wisconsin at Madison. He then completed a one-year postdoctoral appointment at Penn State University and was hired in 1970 as a faculty member at the University of Tennessee at Knoxville. Howley taught a variety of courses, including an undergraduate course in fitness testing and prescription and undergraduate and graduate courses in exercise physiology. He retired in 2007 and holds the rank of professor emeritus.
In addition to the previous editions of this book, Dr. Howley has authored three books, four book chapters, and more than 60 research articles dealing with exercise physiology, fitness testing, and prescription. He is a fellow in the National Academy of Kinesiology and served as chair of the Science Board of the President’s Council on Physical Fitness and Sports in 2006-2007. In 2007-08 he served on the Physical Activity Guidelines Advisory Committee that evaluated the science related to physical activity and health and generated a report for use by the U.S. Department of Health and Human Services to write the 2008 Physical Activity Guidelines for Americans.
Most of Dr. Howley’s volunteer efforts have been with the American College of Sports Medicine (ACSM). He was involved in the development of certification programs and served as president in 2002-03. He served as editor in chief of ACSM’s Health & Fitness Journal for seven years and as chair of the program planning committee for the annual ACSM Health and Fitness Summit meeting. In 2007, Howley was recognized for his professional contributions with the ACSM Citation Award. In his leisure time, he likes to golf, ride his bike, travel, and play with his grandchildren.
Dixie L. Thompson, PhD, FACSM, FNAK, is vice provost and dean of the graduate school at the University of Tennessee at Knoxville and is a professor in the department of kinesiology, recreation, and sports studies. She graduated from the 2008 class of the Higher Education Resource Services (HERS) Bryn Mawr Summer Institute, held at Bryn Mawr College. The Summer Institute is a professional development program dedicated to the advancement of female leaders in administration of higher education. She also participated in the 2009-2010 Academic Leadership Development Program sponsored by the Southeastern Conference Academic Consortium.
Dr. Thompson focuses her research on the health benefits of exercise for women and techniques used for body composition assessment. She is the author of over 70 peer-reviewed publications and numerous articles for fitness professionals and general audiences. She is a former associate editor in chief for ACSM's Health & Fitness Journal and former editor in chief for ACSM's Fit Society Page Newsletter.
Dr. Thompson is a fellow of the American College of Sports Medicine (ACSM) and a member of the ACSM Board of Trustees. She is a fellow of the National Academy of Kinesiology. She is a past president of the Southeast Chapter of ACSM and former chair of the Physical Fitness Council for the American Alliance for Health, Physical Education, Recreation and Dance.
Dr. Thompson received her BA in physical education and MA in exercise physiology from the University of North Carolina at Chapel Hill. She eaarned her PhD from the University of Virginia.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of
O2max or HRR; or RPE 12-16 (on a 20-point scale) - Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
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Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Exercise and heart disease: Typical prescription
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process.
Fitness professionals who work in health clubs and other fitness settings often encounter clients who have gone through a cardiac rehabilitation program. Thus, it is important to have an understanding and appreciation of what these clients have experienced during their recovery process. In addition, many individuals with a master's degree in exercise physiology can, with the proper training, find jobs in cardiac rehabilitation. As part of a team of medical professionals that includes physicians, nurses, dietitians, physical therapists, and clinical psychologists, the fitness professional can play an important role in helping patients to resume a healthy life after a heart event (28). A fitness professional working in cardiac rehabilitation must be vigilant about monitoring the signs and symptoms of heart disease. This involves knowing how to read an ECG, take BP readings, and administer the angina rating scale (refer back to table 19.1). Fitness professionals should be trained in emergency procedures and preferably should achieve certification in ACLS.
The details of how to design and implement cardiac rehabilitation programs, from the first steps taken after patients are confined to bed to the time that they return to work and beyond, are provided in the AACVPR guidelines (2). This section briefly introduces these programs.
Cardiac rehabilitation programs are organized in progressive phases of programming to meet the needs of clients and their families. Phase I (the acute phase) begins when a patient arrives in the hospital step-down unit after leaving the intensive or coronary care unit (18). Within 1 to 3 days of the MI or revascularization procedure, the patient has already been taught the risk factors for atherosclerotic disease and has begun the rehabilitation process. Patients are exposed to orthostatic or gravitation stress by intermittently sitting and standing. Later, bedside activities and slow ambulation (i.e., walking) in the hallways are recommended (2).
Phases II and III refer to outpatient exercise programs conducted in a hospital environment. Rhythmic activities using large muscle groups are recommended for physical conditioning; these activities include treadmill exercise, cycle ergometry, combined arm and leg exercise, rowing, and stair-climbing. Light to moderate resistance training is accomplished with free weights (dumbbells) and elastic tubing. Special care must be taken when prescribing upper-body exercises to clients who have undergone CABG procedures because of limitations related to the chest incision. See chapter 13 for more details on resistance training in cardiac populations.
Recommendations for aerobic exercise programming in outpatient cardiac rehabilitation (phases II and III) are as follows, with patients progressing on an individual basis (4, 12-14):
- Frequency: 3 to 5 days per wk
- Intensity: moderate intensity equivalent to 40% to 80% of O2max or HRR; or RPE 12-16 (on a 20-point scale)
- Duration: 20 to 60 min per day of continuous or accumulated exercise; if patient is unable to exercise continuously for 30 min, use intermittent exercise bouts of 10 min, interspersed with rest or light intensity
- Type: prolonged, rhythmic, dynamic exercises using large muscle groups (e.g., treadmill, cycle ergometer, rower, elliptical, stair climber, arm ergometer, or combined arm-and-leg ergometer)
- 5 to 10 min of warm-up and cool-down exercises
Fitness professionals who work in cardiac rehabilitation must have knowledge of cardiovascular medications (for a description of these, see chapter 24). Patients who are on beta-blockers require special consideration, because the Karvonen formula for computing THR range is invalid if the client was not on beta-blockers at the time of testing. For these patients, a THR is sometimes computed by adding 20 to 30 beats · min-1 to the client's standing, resting HR. However, in view of the wide differences in physiological responses to beta-blockade, another approach is to use RPE ratings around somewhat hard, which correspond to 11 to 14 on the original Borg RPE scale (2).
In phase II, clients are monitored carefully for vital signs (HR, BP, ventilation), and the ECG is monitored at a central observation station via telemetry (radio signals). A single-channel recording of 6 to 10 patients can be monitored simultaneously on a computer screen, and in the event of arrhythmias or ST segment changes, a rhythm strip is printed out. The rate - pressure product (SBP ∙ HR) is sometimes used as an indicator of myocardial oxygen demand. After training, the rate - pressure product at a fixed work rate is reduced, allowing the cardiac patient to exercise at higher work rates before the onset of angina (28). In addition to exercise classes, patient education classes are offered, and they cover topics such as healthy eating, stress management, cardiovascular medications, and principles of behavior modification. Phase II programs typically last about 12 wk and are covered by health insurance.
Phase III programs are hospital-based programs in which outpatients are encouraged to continue their exercise regimens and are provided access to continuing health care and patient education. In these cases, the client's ECG usually is not monitored by telemetry, but clients continue to follow an individualized exercise prescription and attend patient education classes. Eventually, clients may enter the maintenance phase and move to a phase IV program in a nonhospital setting (e.g., sports medicine clinic).
For heart patients who are unable to attend a traditional cardiac rehabilitation outpatient program due to geography or finances, there are other options. Many hospitals offer rehabilitation programs following a distance-education model and can even monitor a client's ECG over the Internet. In addition, a group called Mended Hearts (http://mendedhearts.org) offers support-group meetings and online resources to help clients with heart disease and their families deal with the physical and emotional effects of heart disease.
Save
Save
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Aerobic training methods
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome.
Once a training base has been established, the focus can shift to specific aspects of performance during each training session. A variety of aerobic training methods can be used to achieve performance goals, and each method is unique in how it adjusts training intensity and duration to achieve a particular outcome. The major methods of aerobic training are tempo training, aerobic interval training, fartlek training, and anaerobic interval training (discussed later in the chapter).
Tempo Training
Tempo training uses an intensity that is at or slightly below that used in the competition (14). For improvements in O2max, this type of training is superior to LSD training (33). The purpose of these training sessions is to develop a sense of an appropriate pace for competitions, and the duration of each session is usually 20 to 40 min. Hanc (29) suggests four methods to choose the appropriate intensity for these runs:
- Recent race: Add 30 to 40 sec to the current 5K pace or 15 to 20 sec to the 10K pace.
- HR: Should be 85% to 90% of maximum HR.
- Perceived exertion: Should be an 8 on a scale of 1 to 10 (a comfortable effort would be 5; racing would be close to 10).
- Talk test: A question like "Pace okay?" should be possible, but conversation won't be.
Jack Daniels has written extensively about this topic in his book Daniels' Running Formula (14). In addition, a website with a calculator based on Daniels' principles is available to determine the pace for a tempo training session (www.runsmartproject.com/calculator). This calculator was used to determine the pace for the following two runners: Anna, who is currently able to run a 10K at a race pace of 10 min · mi-1 (62:10 finishing time), and Rodney, who is able to run a 10K at a race pace of 7 min · mi-1 (43:30 finishing time). The pace during their tempo training session will vary slightly depending on the total duration of the session. For a 20 min tempo run, each should be able to maintain an intensity similar to their LT pace but below race pace. For each additional 5 min of exercise duration, the pace should slow by about 1% (14). Table 15.1 shows the tempo training pace for each runner based on the exercise duration and the runner's personal performance in the 10K using Daniels' calculator.
Save
Save
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
Pre-activity screening procedures
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants.
The AHA and ACSM recommend that exercise facilities provide their adult members with a preparticipation HSQ that is consistent with the exercise programs they plan to pursue. Although an exercise facility may not have a legal responsibility to conduct a preparticipation HSQ, this screening is in the best interest of exercise participants. Further, the results of the preparticipation HSQ should be interpreted and documented by qualified staff (1-5).
Regarding apparently healthy people, the risk of cardiovascular events during physical activity is remarkably low (adjusted risk of 1 to 3 per 1,000,000 participant hr), although increased age, greater physical activity level, and the presence of CVD risk factors are associated with greater risk (10, 11, 17). A well-designed and properly evaluated preparticipation HSQ serves several purposes, including identifying symptoms of chronic diseases that increase the risk of cardiovascular events during exercise participation, recognizing people with clinically significant diseases or conditions that warrant participation in medically supervised programs, and determining if people should seek medical clearance prior to fitness testing or exercise participation (5). Preparticipation screening is the first step in the fitness professional's health risk appraisal of exercise participants, and it includes the following categories:
- Make a classification as to whether or not the individual currently exercises regularly
- Review medical history for established CV, metabolic, or renal disease
- Pertinent signs and symptoms of CV, metabolic, or renal disease identified
- Level of desired aerobic exercise intensity
- Establish if medical clearance is necessary
- Administration of fitness tests and evaluation of results
- Setup of exercise prescription
- Evaluation of progress with follow-up tests
It may help the fitness professional to remember the recommended health risk appraisal categories and the order in which they are performed by using the acronym MR. PLEASE, which could represent the participant asking, "Mister, may I please exercise?" This protocol expands on previous recommendations for working with new clients in fitness settings (12).
Two standard preparticipation screening questionnaires commonly used in the fitness industry are the PAR-Q+ and the preparticipation HSQ (1, 3, 28). Each level of MR. PLEASE is discussed in detail following the descriptions of the PAR-Q+ and the preparticipation HSQ, and additional categories of the health risk appraisal in Fitness Professional's Handbook, Seventh Edition With Web Resource.
Changing lifestyle to promote a healthy weight
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following.
Although each individual must assess which areas of her lifestyle contribute to excessive weight accumulation, common steps that benefit the majority of people who are attempting to lose weight include the following:
- Reduce total calories.
- Reduce fat and carbohydrate (particularly simple sugar) intake.
- Increase physical activity.
- Adopt healthy eating behaviors.
As previously mentioned, a negative caloric balance must be established for weight loss. The number of calories consumed while attempting to lose weight should be determined by the client's health, caloric need, and ultimate weight-loss goals. Most healthy adults who need to lose weight can institute a short-term low-calorie diet (LCD) consisting of 800 to 1,500 kcal · day-1 without major adverse consequences. Very-low-calorie diets (VLCDs) consisting of -1 are sometimes used in specialized settings to treat individuals with extreme obesity (22). In these cases, physicians and dietitians provide patient oversight (22). VLCDs can lead to substantial weight loss, and years of study with this approach have yielded carefully monitored protocols with few negative side effects (42).
ACSM recommends that weekly weight-loss goals should target a loss of 1 to 2 lb or 0.5 to 0.9 kg (1). A general guideline is to establish a caloric deficit of 3,500 to 7,000 kcal · wk-1 (500-1,000 kcal · day-1), which theoretically results in a 1 to 2 lb loss (0.5 to 0.9 kg) of fat each week (1 lb of fat = 3,500 kcal). ACSM also recommends that people restricting their caloric intake limit their fat intake to less than 30% of total calories (1). These are general recommendations, and people with special needs (e.g., athletes, older adults, people with metabolic disorders) may require a different approach to weight loss. Caloric restriction can lead to decreased RMR and fat-free mass. The decrease in RMR and loss of fat-free mass will be greater in dieters with large daily caloric deficits (34).
Exercise prescription for weight management and weight loss
ACSM recommends a combined approach of exercise and moderate caloric restriction for people attempting weight loss (1, 2). Although debate continues over the precise contribution of exercise to weight management, a combination of exercise and moderate calorie restriction appears to be most effective in maintaining lean mass and avoiding excessive decreases in RMR. Existing data clearly demonstrate that people who are successful in maintaining weight loss engage in regular aerobic activity (47). Studies also show that regular exercise helps prevent weight gain (10, 17, 21). From a theoretical perspective, adding exercise to everyday life can significantly alter body weight. For example, expending just 100 kcal · day-1 beyond daily caloric need for a year creates a caloric deficit of 36,500 kcal. ACSM recommends that individuals engage in a minimum of 150 min of moderate-intensity exercise per wk and further states that additional exercise (200-300 min per wk) is more likely to be associated with successful weight control (1, 2). The following are specific recommendations for weight management and weight loss with exercise (1):
- Frequency: ≥5 days per wk.
- Intensity: Begin with moderate intensity (40%-60% HRR), eventually progressing to higher intensity (≥60% HRR).
- Time: Begin with short, easily tolerated bouts preferably totaling 30 min per day. Progress to 60 min per day. Multiple daily bouts can be used with bout duration of 10 min or longer.
- Type: Aerobic exercise targeting large muscle groups. Resistance and flexibility exercise is recommended as a supplement to aerobic activity.
In addition to the physical benefits, psychological variables improve with exercise. Improvements in self-esteem and self-efficacy are commonly reported outcomes of regular exercise. The empowerment that comes from becoming more fit can add to the resolve to live a healthy lifestyle and maintain a healthy weight.
Learn more about Fitness Professional's Handbook, Seventh Edition With Web Resource.
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