Chapter 20 Clients with Cardiovascular and Respiratory Concerns

NSCA’s Essentials

Introduction Cardiovascular disease and respiratory

conditions are of a great concern for personal trainers

Hypertension is a major consideration when training clients

Heart attacks, strokes and hypertension are the most common cardiovascular diseases personal trainers will encounter

Hypertension Hypertension is NOT a disease of

just elderly people…it also affects younger individuals as well

Over 50 million Americans age 6 and above have this disease, which is defined by: Systolic 140 + mmHg Diastolic 90 + mmHg

Hypertension Hypertension is an idiopathic disease, meaning

it occurs without a known cause This is why it is considered the “silent killer” Look at it this way…a doctor can look at 10

different people in a room and not be able to pick out the ones who have and the ones who do not have it

90% of cases are idiopathic 10% are curable because they are due to

secondary causes (other diseases…hyperthyroidism, renal artery stenosis, etc.)

Hypertension Anyone under age 35 with hypertension needs

to be aggressively evaluated for one of a couple of diagnoses

Any client observed to be hypertensive must be referred to a doctor for further evaluation

Be aware that you cannot diagnose someone as being hypertensive, you can however say that their blood pressure is above the normal range and that you recommend they see a doctor to get a confirmed or unconfirmed reading

Hypertension Elevated blood pressure puts a person

at risk for: Heart attack Stroke Both

Mildly elevated can lead to: Kidney disease Generalized vascular disease

Hypertension Blood pressure risk stratification is shown

in table 20.1 (pg. 523) The stages are identified in four stages;

Normal: <120/<80 Prehypertension: 120-139/80-89 Stage 1 hypertension: 140-159/90-99 Stage 2 hypertension: ≥ 160/≥ 100

These groups are based on presence of major risk factors (e.g. smoking, diabetes, etc.)

Let’s take a look at the table…

Management of Hypertension Non-medicine interventions such as proper exercise,

weight loss and dietary changes are recommended Lifestyle changes include:

Adequate sleep Reduction in daily sodium intake to 1 teaspoon of

salt daily Adequate potassium intake Limiting alcohol intake Increasing aerobic activity to 30-45 minutes four or

more days a week Cessation of smoking Decreasing stress levels with appropriate activities

DASH Diet Is a blood pressure lowering diet

Entails reducing: Saturated fats Cholesterol Total fat intake

Emphasis on increasing: Fruit intake Vegetables intake Low-fat dairy products Whole grains

Hypertension Clients with hypertension will be taking one or

more medications such as beta-blockers, calcium channel blockers, etc. (they all lower blood pressure)

These medications can cause blood pooling, which means you need clients to do a longer cool down

Beta blockers slow heart rates and prevent the heart rate from elevating as a normal response to exercise…this makes it difficult to follow heart rate as a measure of intensity

Use RPE scale instead of heart rate monitor watches, etc.

Safety Considerations for Clients with Hypertension Clients with controlled hypertension can

exercise with limited restrictions Studies have shown that exercise can

reduce resting blood pressure levels after long-term (chronic) exercise

Meta-analysis (review of many studies) studies have indicated that chronic exercise can lower systolic levels 4.5 mmHg and diastolic levels 3.8 mmHg

Safety Considerations for Clients with Hypertension Questions to be raised for clients

with hypertension: 1. At what intensity level can a client

be placed in order to cause the desired response?

2. Are any exercises contraindicated 3. What exercises can be given to the

client?

Safety Considerations for Clients with Hypertension Intensity

Lowering resting blood pressure can achieved with 40-50% maximal oxygen uptake

Lower intensity exercise in the literature appears to be better for lowering BP than high intensity exercise

Safety Considerations for Clients with Hypertension Contraindications

Any type of activity that would increase intrathoracic pressure, which will ultimately decrease necessary blood flow to the heart

Basically any exercise with prolonged valsalva maneuver (longer then 1-2 seconds)

Make sure breathing is proper (exhale on the exertion)

Safety Considerations for Clients with Hypertension Safe Exercises

Controlled hypertensive clients may participate in a variety of exercises including free weights, weight machines, body weight, walking, jogging, etc.

Only change would be clients with comorbid conditions (degenerative joint issues, neurologic, and vascular diseases)

Exercise Guidelines for Clients with Hypertension First note…if in Stage 1 (140-159/90-99) in BP, cancel

session and advise client to speak to his/her doctor Aerobic Conditioning

Goal is improve VO2 max as well as ventilatory threshold

Low-moderate intensity is fine Start at 40-50% VO2 max Ultimately want to attain 50-85% VO2 max RPE should 8-10 initially with a goal of 11-13 Each session should last 15-30 with a goal of 30-60

minutes 3-7 days per week Weekly calorie expenditure of 700-2000 kilocalories

Exercise Guidelines for Clients with Hypertension Resistance Training

Reps: 16-20 per set 50-60% of 1RM 2-3 minutes rest interval Client can do as little as 1 set per exercise

with a maximum of three Over time (4-6 months) reps can decrease

to 8-12 range Frequency should be 2-3 per week 30-60 minutes per session

Exercise Guidelines for Clients with Hypertension

Goals for clients with hypertension Increase VO2 max Increase maximal work and

endurance Increase caloric expenditure Control blood pressure Increase muscular endurance

Myocardial Infarction, Stroke or Peripheral Vascular Disease All of these serious conditions can

have ramifications physiologically and psychologically

True psychological effects can be: Fear of another acute event Fearlessness of participation

Pay attention to these signs!

Risk Factors Hypertension Hypercholesterolemia Diabetes Smoking Obesity Family history

Risk Factors Diabetes can exert an accelerated

effect on vascular disease thus having an independent effect on heart attacks

Obese individuals require more blood vessels to feed the adipose (fat) tissue thereby increasing cardiac workload

Family history: First degree relative (parent or sibling) with

known cardiac disease before age of 55 males or 65 females has an increased risk

Myocardial Infarction As a trainer you might be working with

someone who has had a heart attack and who has gone through cardiac rehabilitation and then been discharged from physician to continue with exercise

Get recent test data on new client: Exercise stress tests Letter of clearance Recommendations from cardiologist

Myocardial Infarction These reports are good as they let

the trainer know where the doctor left off and where you can begin

Be aware though that clients who are post MI and that have existing coronary artery disease without associated pain must be medically monitored while exercising

Myocardial Infarction Exercise Guidelines for Clients Post-

Myocardial Infarction Get clearance Get intensity guidelines from medical

professional Should provide MET or VO2 max base for

personal trainer to work with Program should be placed in client’s medical

file or sent to doctor for approval Monitor abnormal signs and symptoms:

Chest pain Palpitations Shortness of breath, neck pain, arm pain (R or L), back

pain, and a sense of impending doom.

Myocardial Infarction Exercise Program Components for

Clients Post-Myocardial Infarction Goals

Increase VO2 max Decrease blood pressure Reduce risk for further coronary artery

disease events Increase ability to perform leisure,

occupational and daily living activities

Myocardial Infarction Exercise Program Components for Clients

Post-Myocardial Infarction Aerobic

40% of VO2 max or RPE of 9-11 15-40 minute sessions, three to four times per week Additional time devoted to warm up and cool down Follow up stress test performed by a cardiologist

Resistance 20 reps One to three sets Two to three days per week Stress never performing valsalva maneuver

Cerebrovascular Accident (CVA) This is commonly called a stroke These clients generally have

neurological deficits (balance, etc.) and are best served by being monitored by health care professionals

However, if no neurological deficit and released by physician in unmonitored setting, you can provide guidelines coming up here…

Cerebrovascular Accident Exercise Guidelines for Post-

Cerebrovascular Accident Clients Many individuals have problems post CVA with daily

tasks because of decreased motor functioning Usually in arms, legs, face or mouth Some have trouble hearing, speaking, etc. However, a properly instituted program can

definitely improve the life of people who have had CVA

Trainer must stay in close contact with the rehabilitation team in order to ascertain the direction of training and proper establishment of goals.

Cerebrovascular Accident Exercise Program Components for

Post-Cerebrovascular Accident Clients Ergometers need to be the mainstay

of aerobic conditioning for post CVA clients

Balance is an issue with CVA clients No treadmills, etc.

Cerebrovascular Accident Exercise Program Components for Post-Cerebrovascular

Accident Clients Aerobic

Intensity can begin as low as 30% peak VO2 since clients are severely deconditioned

Post-CVA clients may eventually get to 40-70% peak VO2 Sessions between 5-60 minutes Frequency three times per week

Resistance Will help to build new neurologic pathways for affected limbs Start out slow with weights Encourage the client to strive for three sets of 8-12 reps, two to

three days a week Flexibility

Is important to prevent “freezing” and calcification of joints Balance exercise are good to do as well Performed before and after each training session, as well as on

non-training days

Peripheral Vascular Disease PVD clients have a real challenge due to pain

upon walking They cannot walk for more than two to five

minutes without having to stop and rest because of the searing pain in their calves

The goal is to increase the length of their activity to improve quality of life and possibly avoid the need for surgical intervention

If experiencing anything suggestive of cardiac compromise, he or she must stop immediately, sit or lie down flat, and use the prescribed nitroglycerin while someone calls emergency services (typically 911).

Peripheral Vascular Disease Clients must be aware that

exercise may facilitate a cardiac event in PVD clients

Make sure client is cleared form a cardiac viewpoint by an exercise stress test before starting a training program

Peripheral Vascular Disease Exercise Guidelines for Clients with Peripheral Vascular

Disease Aerobic Conditioning

To be able to walk pain free for greater distances The pain will hurt a lot for them, not a little (the pain is the rate-

limiting factor) Walk until it hurts, stop, do it again and so on Duration between 10-30 minutes Goal is to lengthen time and shorten rest until exercise becomes

one long continuous activity Resistance Training

Same as hypertensive client (low intensity) PVD with angina pectoris is a group that is felt to be at too high

a risk for a personal trainer who is functioning in a typical health club

Such clients should be trained and monitored at a medical facility

Chronic Obstructive Pulmonary Disease COPD includes asthma, chronic bronchitis and

emphysema Asthma

Reversible airway disease with associated hyperreactivity, characterized by ease of developing bronchspasm, constriction or both

A common asthma is exercise induced asthma Usually self-limiting Rarely results in hospitalization Begins 15-20 minutes (sometimes as early as five

minutes) into exercise Prevention can be achieved by using a bronchodiolator

15-20 minutes prior to exercise

Asthma Exercise Guidelines

Use RPE scale to monitor intensity, many clients are unable to achieve a training heart rate

Asthmatic clients do better with mid-to late morning exercise sessions because of natural release of cortisol from adrenal glands

Avoid extreme temperatures as they can induce an asthma attack

Asthma Exercise Program Components for

Clients with Asthma Aerobic Training Program

RPE of 11-13 with continuous monitoring for dyspnea (shortness of breath)

1-2 times daily 3-7 days per week Around 30 minutes per session

In the beginning may only be able to perform 5-10 min.

Resistance Training A general resistance training program is

recommended Resistance training should try to increase

maximum repetitions (to desensitize to shortness of breath), increasing the amount of training volume,and increase lean body mass

Lighter loads (16 or less) 2-3 days per week