Chapter 20 Clients with Cardiovascular and Respiratory Concerns

1. Chapter 20 Clients with Cardiovascular and Respiratory Concerns NSCA’s Essentials

2. 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

3. 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

4. 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.)

5. 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

6. Hypertension • Elevated blood pressure puts a person at risk for: • Heart attack • Stroke • Both • Mildly elevated can lead to: • Kidney disease • Generalized vascular disease

7. 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…

8. 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

9. 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

10. 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.

11. 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

12. 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?

13. 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

14. 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)

15. 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)

16. 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

17. 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

18. 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

19. 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!

20. Risk Factors • Hypertension • Hypercholesterolemia • Diabetes • Smoking • Obesity • Family history

21. 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

22. 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

23. 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

24. 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.

25. 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

26. 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

27. 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…

28. 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.

29. 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.

30. 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

31. 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).

32. 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

33. 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

34. 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

35. 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

36. 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.

37. 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