Verrill 1996

Sports Med.
1996 May; 21 (5): 347-383

REVIEW ARTICLE 0112-1642/96/0005-0347 /S 18.50/0
Adis International Limited. All rights reserved.
Resistive Exercise Training in

Cardiac Rehabilitation
An Update
David E. Verril[1 and Paul M. RibisF
1 Mid Carolina Cardiology, Charlotte, North Carolina, USA
2 Department of Health and Sport Science, Wake Forest University, Winston-Salem,
North Carolina, USA
Contents
Summary ................ . 347
1. Research Background . . . . . . . . . . 348
2. Physiological Responses: Acute Effects 349
2.1 Heart Rate and Oxygen Consumption 349
2.2 Blood Pressure and Cardiac Function 351
3. Physiological Adaptations: Training Effects 354
3.1 Heart Rate and Cardiac Function 354
3.2 Blood Pressure . . . . . . . . . . . 355
3.3 Maximal Oxygen Consumption . 356
3.4 Muscular Strength .... . 357
3.5 Body Composition . . . . . . . 358
3.6 Haematological Variables. . . 359
4. Isometric and Isodynamic Exercise 361
5. Resistive Modalities. . . . . . . . . . 364
6. Patient Screening and Contraindications . 367
7. Exercise Prescription . . . . . . . . . . . . 369
7.1 Circuit WeightTraining . . . . . . . . 370
7.2 Determining Resistive Training Load 372
7.3 Patient Instruction and Safety . 373
7.4 Haemodynamic Monitoring. 375
8. Conclusion .. . . . . . . . . . . . . 376
Summary Resistive exercise training has become very popular for patients of cardiopul-
monary rehabilitation programmes (CRPs). For decades, CRPs focused almost
exclusively on improving cardiorespiratory endurance and most programmes ig-
nored muscular fitness development. Moreover, resistance training was thought
to be potentially hazardous for the cardiac patient due to the risk of cardiovascular
complications from adverse haemodynamic responses. We now know that resis-
tive exercise testing and training is very safe for properly screened patients, even
at relatively high workloads. Improvement in muscular strength facilitates return
to daily vocational and avocational activities and is important for the CRP par-
ticipant to regain lost strength and resume work soon after a cardiac event. Circuit
348 Verrill & Ribisl
weight training (CWT) is helpful in this respect and has been shown to increase
muscular strength, cardiovascular endurance, body composition, bone density
and mineral content, self-confidence, and self-efficacy in various populations.
This article presents an update on current research in cardiac patients and also
presents guidelines for implementing a properly supervised cardiac resistive ex-
ercise programme.
Resistive exercise training, weightlifting, and How soon after a cardiac event should resistive
muscular development has gained widespread ac- training be initiated?
ceptance in cardiopulmonary rehabilitation pro- Can cardiac patients safely perform resistive
grammes (CRPs). Improvement in muscular strength training intermittently with aerobic exercise
is important to facilitate return to daily vocational during training sessions?
and recreational activities after a cardiac event. In How safe is 1 repetition maximum (lRM) test-
spite of earlier concerns, resistive exercise has con- ing for older cardiac patients?
sistently been shown to be haemodynamically safe These and similar questions have previously
for selected individuals with cardiovascular impair- been difficult to answer because of the limited re-
ment, even at relatively high workloads. This form search directed solely towards resistive training in
of training increases muscular strength/endurance cardiac populations. Many published guidelines
and may favourably alter body composition, blood and recommendations for resistive exercise in car-
lipid and lipoprotein levels, cardiovascular endur- diac patients have recently been presented which
ance, and other cardiovascular risk factors. How- help to address some of these concerns.l19.22-28]
ever, further research is needed, particularly in car- This monograph will examine resistive exercise in
diac populations and women. [I-II] Self-efficacy and cardiac rehabilitation through an analysis of cur-
psychosocial well-being may also be enhanced rent research and will provide a framework for the
through strength training.[12-14] Modalities currently implementation of safe and effective resistive ex-
being used in CRPs include free weights, dumb- ercise testing and training for CRP participants.
bells, cuff and hand weights, wall pulleys, isotonic/
isokinetic machines, and elastics. Circuit weight 1. Research Background
training (CWT) has been recommended for cardiac
patients due to the added benefit of enhanced car- In the past, resistive exercise training was com-
diovascular endurance.[2.5.6,15-17] Non-sustained monly regarded as haemodynamically unsafe for
isometric or isodynamic exercise, previously con- patients with coronary artery disease (CAD). Weight
traindicated for cardiac patients, has now been rec- lifting has been associated with a large increase in
ommended since many vocations and everyday heart rate (HR) and/or blood pressure (BP) in healthy
activities require frequent lifting/pushing move- individuals[29-32] and in patients with CAD.l33,34]
ments which involve isometric muscle contrac- Earlier studies have associated isometric exercise
tions.[18-21] with large increases in left ventricular (LV) end-
Although many recent resistive studies have fo- diastolic pressure and BP, a greater incidence of
cused upon cardiac popUlations, questions still re- cardiac dysrhythmias, and ventricular decompen-
main regarding cardiac resistive exercise. These sation in patients with CAD or impaired LV func-
include: tion,l35-38] Sustained or high intensity resistive
Should moderate to high risk patients perform exercise has generally been contraindicated in car-
CWT? diac patients because of the abrupt increase in BP
Which patients should not participate in resis- and myocardial oxygen demand (MV0 2) and po-
tive training? tential for myocardial ischaemia or LV wall motion
Adis International Limited. All rights reserved. Sports Med. 1996 May: 21 (5)
Exercise Training in Cardiac Rehabilitation 349
abnormalities from isometric components.l 39-42 ] tients,[17,69-78] it is now recommended that eRP
Patients with a low ejection fraction and/or poor staff incorporate isodynarnic arm and leg exercise
LV function may be at risk of developing arrhyth- into exercise sessions to improve muscular strength
mias or LV dysfunction with heavy resistive move- and endurance and facilitate earlier return to
ments or sustained isometric contractionsp1,43-45] work.l 18 ] These exercises should correspond with
Moreover, with increasing age, HR, stroke volume tasks performed by the patient during their daily
(SV), ejection fraction, and maximal oxygen up- vocational and recreational activities PO] Higher
take CV02max) decline, while resting and exercise patient confidence levels with strength-specific
BP increases.[46-51] Hence, an exaggerated HR or tasks have been reported following resistive train-
BP response may elicit an elevated rate-pressure ing,[13] and monitored exercise tests that involve
product (RPP) which could place an excessive bur- weight lifting or carrying to simulate vocational
den on the cardiovascular system of the older car- activities may be useful in this respect.[20,24,68-79]
diac patient. Overall, resistive and isodynamic exercise can be
More recently, several studies have demon- a safe and viable form of training for many cardiac
strated that isotonic and circuit training programmes popUlations if those who participate are screened
using low, moderate, and even high levels of resis- properly and the exercise is conducted with proper
tance are physiologically safe and effective for medical supervision.
strength development in many cardiac popula-
tionsP,5,14,33,34,39,52-59] Aerobically trained cardiac 2. Physiological Responses:
patients have shown significant gains in strength Acute Effects
(up to 53%) without cardiovascular complications
following resistive training up to 80% of a IRM 2.1 Heart Rate and Oxygen Consumption
liftP,5,54,56] Moreover, recent investigations which
In healthy individuals, acute HR and V0 2 re-
have examined acute and chronic physiological ad-
sponses during eWT have been variable, ranging
aptations with moderate to high intensity resistive
from 60 to 83% of HRmax and 30 to 50% of V0 2max
exercise in older, healthy men and women have respectively.l23,80-86] Lower HRs have been ob-
shown that weight lifting is a safe activity for these
served during eWT when compared with graded
populations, as well. Resistive workloads of 50 to exercise in cardiac patients. Typically, a mild in-
80% of lRM have been shown to increase muscle crease in HR occurs during eWT (72 to 116 beats/
size and strength, improve balance, increase endur- min) with somewhat higher values observed dur-
ance, and be physiologically safe for older individ- ing isodynamic activity (87 to 123 beats/min) in
uals up to 90 years of age.l 60-66 ] Further research is cardiac populations.[2,5,53,58,59] In general, HR ap-
required to fully assess the cardiovascular risks, pears to increase proportionately with the amount
benefits and complication rates of higher intensity of weight lifted/carried, the intensity/duration of
resistive exercise in older cardiac patients or those muscle contraction, and the number of repetitions
with impaired LV function. performedJ31,33,58,84,85] For a given dynamic sub-
After a cardiac event, many individuals lack the maximal workload, arm exercise (which uses a
physical strength and confidence to perform daily smaller muscle mass) is performed at a greater
activities effectively. Patients who have vocations physiological cost than leg exercise and elicits a
which require moderate manual labour with fre- higher HR response than leg exercise. However, at
quent lifting or frequent isometric contractions maximal effort, physiological responses are gener-
should be rehabilitated to resume those activities ally greater in dynamic leg exercise than arm exer-
through resistive exercise training.[21,67,68] Since cise, except in individuals who are limited by pe-
the safety of repetitive weight lifting and carrying ripheral vascular disease.[87,88] Although exercise
has been well documented in selected cardiac pa- HR has been shown to be inversely related to the
Adis International Limited. All rights reserved. Sports Med. 1996 May; 21 (5)
amount of muscle mass when resistance is con- reported no significant differences between HR re-
stant, some investigators have shown that resistive sponses at mid, end, or post CWT exercise per-
exercise which uses a larger muscle mass elicits a formed at 40 to 60% of IRM and HRs taken during
greater HR response than resistive exercise involv- aerobic exercise performed at 85% of predicted
ing a smaller muscle mass,!31,33,58,85] HRmax in selected cardiac patients. This trend was
In studies of cardiac patients, Vander et aI,[59J apparent in a follow-up study of phase II (early
reported peak responses during CWT exercise (40 outpatient) cardiac patients who performed 2 cir-
to 60% of estimated lRM) at 56 to 64% of values cuits of 8 upper body exercises.[89) In this study,
observed during maximal graded exercise testing. peak HR responses during aerobic and resistive ex-
These values were considered to be well below the ercise were also similar. Haslam et aI,[33] found that
target HR range for aerobic exercise prescription. mean peak HR increased progressively with the
Featherstone et al.[53) observed that mean peak HR amount of weight lifted from 20 to 80% of lRM
responses during seated overhead press, supine in patients with CAD. In a study of middle-aged
overhead bench press, biceps curl, and quadriceps adults with CAD risk factors, Hurley et aI,(85) ob-
extension exercises performed at 40 to 100% of served significantly higher HRs during high inten-
maximal voluntary contraction were substantially sity CWT with short rest intervals between stations
lower (range =74 to 92 beats/min) than mean peak compared with HRs taken during treadmill walk-
HR responses observed during maximal treadmill ing at the same level of \'0 2. In studies of weight-
exercise (mean = 157 beats/min). Haennel et aI,(2) loaded treadmill walking, HR generally increases
found similar lower HR responses (56% of HR progressively with the amount of weight lifted or
reserve) during 3 consecutive bouts of CWT in pa- carried [17,74-76,78) However, peak HRs observed
tients who had undergone recent coronary artery during weight-loaded walking protocols have been
bypass grafting (CABG). Kelemen et aI,(5) ob- shown to be lower than peak HRs observed during
served peak HRs that were 12% below prescribed graded exercise in cardiac patients.[69]
aerobic target zone during CWT, compared with Few investigators have examined ventilatory
peak HRs during a walk/jog exercise that were 4% parameters during resistive exercise in patients
above target zone. This relationship held true for with cardiac impairment. Average \'0 2 responses
patients on ~-blockade therapy, although absolute during CWT have ranged from 32 to 46% of
HRs were understandably lower. Squires et aI,(57) \,02max [5 to 7 METS (1 MET = 3.5 ml/kg/min) or
reported HR responses to be only 37 and 30 beats/ 6 to 9 kcallmin] in healthy men and women.[80,84,86)
min higher than pre-exercise values for leg and Sheldahl et al.[76) observed that individuals with
chest press exercise in CRP participants who were CAD who were more than 8 weeks post MI or
4 to 8 weeks post myocardial infarction (MI) or CABG surgery had \'0 2 values that averaged 85%
CABG surgery. Stralow et aI,(58) found an increase of \,02max during repetitive lifting of 13 to 23kg
in HR from 83.5 18.1 to 96.9 20.8 beats/min (30 to 50lb) boxes. Schram and Hanson[75J found
(mean SEM) during leg weight lifting and from similar results with weighted walking in patients
89.2 19.7 to 110.3 23.8 beats/min during arm with CAD. They determined that \'0 2 increased
weight lifting on Nautilus variable resistance linearly during treadmill walking with progressive
equipment. In this study of CRP participants, HR addition of 5 to 20kg (11 to 441b) weights in back-
increased progressively with the amount of weight packs. \'0 2 values averaged 80% of\,02max across
lifted for most of the arm and leg exercises which individuals with the 20kg (44Ib) workload.
were performed at 40 to 80% of lRM in a non- HR and ventilatory response during resistive
circuit manner. exercise depends upon several factors, induding:
Other investigators have reported higher HR re- mode of resistive exercise
sponses during resistive exercise. Butler et aI,(39) amount of resistance
volume of work (i.e. number of sets, stations, fected by many different variables during weight
repetitions) lifting. Few studies have evaluated \102 during
joint angle of contraction resistive training in cardiac populations and venti-
duration of rest intervals between exercises latory parameters may vary by the mode of weight
degree of Valsalva manoeuvre and/or isometric training or by the condition of the patient.
component
fitness level or cardiac impairment of the par- 2.2 Blood Pressure and Cardiac Function
ticipant
timing of actual measurements Earlier studies reported marked elevations in
prescribed medications.l 32-34,39,90] systolic and diastolic pressures with heavy weight
lifting or isometric exercise. [29,31 ,32] Elevated pres-
For a given submaximal workload, HR, systolic
and diastolic BP, \102, and lactate production are sures could greatly increase the RPP which is re-
flective of M\102.[94] This could potentially in-
higher with arm exercise than with leg exer-
cise.[91,92] However, lower body resistive exercises crease the likelihood of dysrhythmias, myocardial
ischaemia, or LV dysfunction in patients with car-
that use a larger muscle mass have been shown to
diac impairment.[9] Conversely, increased diastolic
elicit greater haemodynamic responses than resis-
pressures could increase myocardial perfusion
tive exercises using a smaller muscle mass in car-
pressure, which could facilitate enhanced coronary
diac patients.[31,33.58] Higher levels of noradrena-
perfusion even in the presence of high RPPS.[53.95-97]
line (norepinephrine) and adrenaline (epinephrine)
Clinically acceptable elevations in systolic BP
have been observed during high resistive CWT
with somewhat higher diastolic BP responses
than during treadmill walking at the same \10 2 in
have generally been reported during CWT pro-
healthy individuals.l 85 ] Thus, the elevated HR re-
tocols (8 to 16 repetitions at 30 to 60% of mea-
sponses observed with higher intensity weight
sured and predicted 1RM) in selected cardiac pa-
lifting may be attributable to greater sympathetic tients,l39,56-59.83,98] Vander et aU 59] found lower
adrenergenic activation resulting in greater cate-
peak systolic BPs and RPPs during CWT work-
cholamine release. Isometric components during loads of 40 to 60% of 1RM than during maximal
weight lifting or carrying could facilitate a pressor graded exercise testing in patients with CAD. They
response and vasoconstriction in exercising mus- reported that peak resistive diastolic pressures ex-
cles, which in tum could activate the adrenergenic ceeded those attained during maximal exercise
system. Greater recruitment of fast-twitch muscle testing by 100 to 136%, with a mean diastolic pres-
fibres with upper body resistive exercise may also sure of 100mm Hg. They also reported that 2 indi-
contribute to the pressor response.l 80,93] Further viduals having ejection fraction values less than
clinical trials which incorporate continuous inva- 35% showed no ischaemic signs or symptoms dur-
sive and noninvasive monitoring of cardiovascular ing the CWT sessions. Butler et aU39] reported
and ventilatory parameters need to be performed in clinically acceptable systolic (127 6mm Hg) and
other cardiac populations and women, to further diastolic (73 3mm Hg) pressures throughout re-
assess the physiological responses of upper and sistive exercise testing in patients who were 12
lower body resistive activities. weeks or more after a cardiac event. These inves-
In summary, when compared with aerobic exer- tigators noted fewer ischaemic echocardiographic
cise, lower HRs have been observed during CWT segmental LV wall motion abnormalities following
or other forms of resistive training in cardiac par- acute CWT than observed immediately following
ticipants. Resistive exercise HRs may often fall be- graded exercise testing.
low prescribed target zone. Some authors have re- Squires et aU57] observed acceptable BP re-
ported higher HR responses with progressively sponses during chest and leg press exercise in pa-
increasing resistive workloads and HR may be af- tients 17 to 60 days after a cardiac event. The high-
Adis International limited. All rights reseNed. Sports Med. 1996 May: 21 (5)
est systolic BPs observed were 30 and 58mm Hg were observed during resistive exercise than dur-
greater than pre-exercise values for leg and chest ing graded exercise.
press exercises, respectively. The highest systolic Ghilarducci et aU54] observed higher but ac-
BP measured for any individual during resistive ceptable BP responses in aerobically trained CRP
training was 150mm Hg for the leg press exercise. participants who performed higher intensity resis-
Squires et al.[57] reported no signs or symptoms of tive training up to 80% of lRM. Participants were
ischaemia during CWT in any individuals, includ- continuously monitored for HR and ECG via radio-
ing 4 patients with ejection fractions less than 40%. telemetry during resistive testing and were system-
In studies of higher intensity weight lifting (up atically monitored for HR and BP throughout the
to 100% of maximal voluntary contraction), some- 10 weeks of resistive training. No signs or symp-
what higher systolic BPs and significantly higher toms of ischaemia, abnormal HRs, or abnormal BPs
diastolic BPs have been observed in patients with were observed during lRM testing or during resis-
CAD. Featherstone et aU 53 ] found that systolic BP tive training.
measured during weight lifting of 40 to 100% max- Haennel et alP] observed acceptable systolic
imal voluntary contraction was similar to systolic (152 3mm Hg) and diastolic (83 4mm Hg) pres-
BP measured during maximal treadmill exercise sures during 3 repetitive bouts of hydraulic CWT
testing, with a peak range of 158 27 to 174 (20 to 60 second rest intervals) in male patients 9
19mm Hg during weight lifting versus a mean peak to 10 weeks post CABO surgery. Periodic adjust-
value of 168 31mrn Hg during maximal graded ments of the hydraulic cylinders were made over
exercise. Diastolic BPs during all lifts, except the the 8-week training period to ensure that patients
100% maximal voluntary contraction biceps curl could complete the 8 to 16 repetitions required for
and quadriceps extension, were significantly higher upper and lower body exercises. The actual resis-
(:<:::;138mm Hg) than values taken during graded ex- tive training intensity was not reported for these
ercise. Featherstone et aU 53 ] observed no isch- individuals. As with previously cited studies, there
aemic ECG changes during repetitive weight lift- were no significant arrhythmias, ischaemic ECG
ing, whereas 5 of 12 individuals had ST-segment changes, or cardiovascular complications with this
depression greater than or equal to I mm during type of low resistance, high repetition resistive
graded exercise. training.
In a similar study of patients who had partici- Finally, in a classic study of invasive BP moni-
pated in a CRP for 12 weeks or more, Stralow et toring in post MI and CABG patients, Haslam et
al.l 58 ] observed that mean systolic BP values a1P3] reported higher but acceptable BP responses
ranged from 154.7 34.3 to 166.0 27.5mm Hg during weight lifting with intra-arterial pressure
for arm resistive exercise and from 143.1 18.4 to and ECG monitoring as participants performed sin-
16l.3 27.1mm Hg for leg resistive exercise per- gle arm curls and single/double leg presses at 20,
formed at 40 to 80% of maximum voluntary con- 40, 60 and 80% of lRM. Although arterial pres-
traction. These investigators found higher mean di- sures and RPP increased with the relative load, val-
astolic BPs during lower body dynamic variable ues were clinically acceptable up to and including
resistance exercise (range = 87.0 to 98.7mm Hg) 60% of lRM, when compared with values ob-
when compared with mean diastolic BPs observed served during maximal symptom-limited cycle er-
during graded exercise performed at 85% of \!02max gometer testing. Only single and double leg press
(mean = 86.0mm Hg). One participant in this study exercise at 80% of lRM elicited greater RPPs than
had a diastolic BP of 122mm Hg during leg exten- observed at peak ergometer exercise. The mean peak
sion exercise performed at 60% of maximum vol- diastolic BPs at 80% of lRM ranged from 116 to
untary contraction. As reported previously, signif- 124mm Hg for both arm and leg exercise. No isch-
icantly fewer arrhythmias and ST-segment changes aemic ECG changes, anginal symptoms, or signif-
icant ventricular dysrhythmias occurred at any Table I. Resistive exercise instructions for cardiac patients
workload and LV dysfunction was apparently not Participate in the aerobic exercise session or perform at least a
compromised in any of the individuals tested. la-minute full-body warm-up prior to each resistive exercise
session
It should be noted that the BP responses ob-
Breath normally or exhale during muscle contraction. Do not
served by some investigators may reflect the time
hold your breath
at which measurements were taken. Some investi-
Maintain a loose, comfortable grip during muscle contraction on
gators have reported taking auscultatory BP meas- each piece of equipment
urements up to 1 minute following completion of Perform lifting movements through a complete range of motion
a weight lift.[5.56] Many authors have reported that Exercise all the major muscle groups and work large muscles
both systolic and diastolic BP show a rapid decline before small muscles
following a weight lift.[3J,33,34.76] Wiecek et aI.f34] Lift the weight smoothly to a count of 2 and lower slowly to a
observed that both systolic and diastolic pressures count of 4
decreased rapidly immediately following weight Learn and practice proper technique and form for each piece of
apparatus. Ask questions to be sure you understand correct
lifts of 40 to 60% of lRM in patients with CAD. usage of equipment at each station
Thus, indirect measures of BP after weight lifting Never drop the machine weights
will not accurately reflect true peak arterial pres- Avoid injury by adhering to the instructions of the cardiac
sures generated during muscle contraction. Neverthe- rehabilitation staff
less, since ECGs have been taken simultaneously Terminate resistive exercise if you develop symptoms of
in many studies, the failure to elicit ischaemia is intolerance such as chest pain, dizziness, faintness, or fatigue
important to note from the standpoint of safety. Record your rating of perceived exertion (6-20 RPE scale) on
each piece of equipment. You should perceive the resistive effort
Cardiopulmonary rehabilitation personnel are en- as light (11) to somewhat hard (13) during exertion at each
couraged to record BP and HR measurements dur- station.
ing actual lifting movements for more accurate Record the amount of resistance (i.e. colour of elastic band,
haemodynamic assessment and calculation of RPP. number of plates on the machine) at each station. Also record
the number of repetitions you perform on each piece of
There have been no serious cardiovascular com- apparatus
plications associated with acute resistive training
reported in the literature. Investigators who have
compared cardiovascular responses during low, signs or symptoms of cardiovascular impairment
moderate, and high intensity weight lifting have during or immediately following resistive exer-
universally observed fewer cardiac arrhythmias or cise[19,22,25,28] (see section 7.3). Since all studies
ischaemic signs/symptoms during weight lifting reviewed have revealed no apparent systolic hy-
than during graded exercise. However, episodes of pertensive responses during resistive testing or
symptomatic hypotension,[5] non-symptomatic training, we may assume that acute weight lifting
hypotension or wide BP fluctuation,[76] and frequent
does not exacerbate systolic BP to abnormal levels
premature ventricular complexes (PVCs) or ven-
in normotensive or medically controlled hyperten-
tricular bigemi ny l5,58,7o,74,76.78] have been reported
sive or cardiac populations. However, all patients,
in some patients during or immediately following
especially those with a history of hypertension or
weight lifting or weight-loaded walking (i.e. walk-
ing with hand weights, ankle weights or backpacks). hypotensive/syncopal episodes, should be screened
Moreover, diastolic BPs appear to be significantly carefully and instructed on safety precautions be-
higher during weight lifting, weight carrying, or fore participating in a resistive training programme
weight loaded walking than during graded exer- to reduce the potential for cardiovascular compli-
cise. [33,34,53,69,78,99] Thus, CRP staff are encouraged cations. Table I presents a summary of resistive
to monitor selected patients with periodic BP, ra- training instructions which may be distributed to
dial pulse, and/or ECG rhythm strip checks for patients.
In summary, studies of the acute cardiovascular Whereas recent studies have shown that heav-
responses during resistive exercise clearly show ier resistive exercise (up to 100% of lRM) ap-
that this form of training elicits clinically accept- pears to be haemodynamically safe for cardiac pa-
able cardiovascular responses and is physiologi- tients,[2,33,53,54,58] CRP personnel may prefer to use
cally safe for properly screened CRP participants. resistive training workloads of 60% or less of 1RM,
Although affected by many variables, circulatory if this method of training load assessment is
responses during weight lifting appear to increase used)19,27,28,33] This is especially important since
with the amount of resistance, the number of the threshold for making improvements may still
repetitions performed, and shorter duration rest occur at this lower leveP5,26] Selected aerobically
intervals. There have been few reports of dys- trained patients may eventually progress to work-
rhythmias, abnormal HRs/BPs, or indications of loads up to 80% of lRM over time if they are med-
myocardial ischaemia during acute resistive exer- ically stable and have no orthopaedic limita-
cise bouts or weight-loaded walking in selected tionsp2,54] Generally, resistive exercise HRs should
low, moderate, and even high risk cardiac pa- not exceed the prescribed target HRs for aerobic
tients. [2,5, 14,17,33,39,52-59,76,78,100, 101] However, many exercise and may often fall below target range
of these studies have reported significantly higher since resistive exercise appears to produce an in-
diastolic BPs during acute weight lifting. crease in RPP through elevation of systolic BP,
The clinical significance of elevated diastolic with less contribution of HR. Thus, the RPP may
BP during weight lifting in cardiac patients remains be a better indicator of cardiovascular stress during
resistive exercise and patients should not exceed
to be seen, although recent work by Featherstone
et aI.l53] and earlier work by others[67,96] suggests the RPP at which signs or symptoms of myocardial
ischaemia appear during graded exerciseP5,28]
that higher pressures may facilitate increased myo-
cardial perfusion pressure and may enhance coro-
nary blood flow. It has even been speculated that 3. Physiological Adaptations:
brief Valsalva manoeuvres during muscle contrac- Training Effects
tion may reduce transmural pressure across cere-
bral vessels.[97] This may reduce the risk of vascu-
3.1 Heart Rate and Cardiac Function
lar damage under extreme pressures and may serve
as a protective mechanism for the heart and brain In healthy populations, resting HR is reduced by
against cardiovascular complications, provided LV approximately 10 to 15 beats/min following aero-
end diastolic pressure does not increase and SV bic conditioning. This may be due to enhanced para-
is maintained.[31,97] However, since there is little sympathetic tone, increased LV end diastolic vol-
research to back this hypothesis and some investi- ume and SV, or decreased sympathetic discharge
gators have reported episodes of symptomatic hy- resulting in a decrease in the firing rate of the sino-
potension, non-symptomatic hypotension, wide atrial node.[25,102] Resistive exercise has been
BP fluctuation, and frequent PVCs or ventricular shown to elicit a significant decrease (4 to 13%) in
bigeminy in some patients during or immediately resting HR[102-105] or have little or no effect on rest-
following weight lifting or weight-loaded walking HR[106-108J in young men following training.
ing,[5,58,70,74,76,78] CRP personnel are encouraged to Resting and submaximal exercise HRs have been
screen patients carefully and provide for closer car- shown to be lower[83,109] or remain statistically un-
diovascular monitoring in selected patients. Over- changed[85.IIO] in healthy populations following
all, resistive exercise has been shown to be a very CWT. Maximal exercise SV and cardiac output
safe form of conditioning for CRP participants and have been shown to increase up to 8% following
participation should be widely encouraged in many high resistive CWT in healthy adults.[83,109J Others
patient populations. have found no change in sub maximal exercise car-
Adis International Limited, All rights reserved, Sports Med, 1996 May; 21 (5)
diac output following 16 weeks of high intensity men,lI08] middle aged aduits,[4,112] borderline
CWT in middle-aged men. [85] hypertensive adults,ll13] and hypertensive adoles-
The lower resting and submaximal exercise HRs cents.lI03.114] Stone et aLl 108] found a significant re-
observed following chronic resistive training may be duction in resting systolic BP, but no change in dia-
accompanied by an increase in SV due to longer diastolic BP, after 8 weeks of Olympic-style weight
stole (increased venous return), but may not neces- training in young men. Hagberg et al,[I 14] reported
sarily reflect an increase in chamber size.l lo2 ,I09]It a significant decrease in systolic BP in hyperten-
is controversial whether chronic resistive training sive adolescents following a running programme.
promotes concentric LV hypertrophy in either The adolescents then completed a 20 week weight
healthy or cardiac populations. Recently, Derman training programme which resulted in a mainte-
et aU111] found that LV mass did not change signif- nance and in some cases a further reduction in sys-
icantly following 10 weeks of CWT in aerobically tolic BP. Hurley et al,[4] observed a 5mm Hg de-
trained cardiac patients. However, further research crease in resting diastolic BP in middle-aged adults
is needed on this issue in other cardiac populations. after 16 weeks of CWT, although resting systolic
In selected cardiac patients, beneficial central BP remained unchanged. Harris and Holly[113] also
cardiovascular adaptations have resulted follow- reported an approximately 5mm Hg decrease in
ing CWT. Lower resting and submaximal exercise resting diastolic BP (95.8 to 91.3mm Hg) in bor-
HRs, increased resting and submaximal exercise derline hypertensive men following 9 weeks of
SV, and increased maximal exercise cardiac output CWT. Wiley et aLl112] observed a mean decrease
have been observed in CABO patients following 8 in systolic and diastolic BP of 12.5mm Hg and
weeks of high volume, hydraulic CWTP] Simi-
14,9mm Hg, respectively, following 8 weeks of
larly, Wilke et al,[17J observed a reduction in HR at
isometric handgrip training in 20- to 52-year-old
any given submaximal workload and a 5% increase
normotensive men. These investigators concluded
in peak HR during symptom-limited graded exercise
that regular isometric exercise lowers BP equally
testing on a cycle ergometer following 12 weeks of
as well or better than other nonpharmacological
CWT at 40 to 70% of IRM (30 second rest inter-
interventions.
vals between stations). However, these patients
Other investigators have shown no change in
concurrently participated in cycle ergometer train-
resting BP following resistive training in male
ing at 70 to 85% of HRmax for 3 sessions per week.
college athletes,[106] college women,ll15] male body-
Svedhal et aLl16] observed a 15% reduction in
builders,[116] 70- to 79-year-old men and women,[60]
HR at a workload of 90W during cycle ergometry
borderline hypertensive or hypertensive adults,[8,117]
following 12 weeks of exclusive hydraulic CWT
middle-aged, untrained males l8 ,85] and cardiac pa-
in male patients 8 to 12 weeks post MI, when com-
tients.l s6] Cononie et al.[60] found no changes in
pared with the control group, Thus, resistive exer-
cise may enhance cardiac function in selected in- resting systolic, diastolic, or mean BP in either
dividuals with cardiovascular impairment. Further normotensive or hypertensive men and women
research is warranted to fully examine the long aged 70 to 79 years following 24 weeks of resistive
term effects of exclusive resistive exercise on car- exercise training. Blumenthal et aLl ll7 1 reported a
diac dimensions, LV mass, and overall cardiac 7mm Hg decrease in systolic (143 10.3 to 136
function in moderate to high risk cardiac popula- 11.6mm Hg) and 6mm Hg decrease in diastolic (95
tions. 5.4 to 89 6.4mm Hg) BP following 16 weeks
of strength and flexibility training in borderline
3,2 Blood Pressure hypertensive adults. However, the control group
showed similar changes and these investigators
Chronic resistive exercise training has been concluded that resistive exercise did not favoura-
shown to lower resting BP in normotensive young bly alter resting BP in these participants.
Smutok et aP8] found no change in resting BP moderate increases in cardiovascular endurance

following 20 weeks of Nautilus training in either following resistive or combined aerobic/resistive
normotensive or hypertensive men at risk of CAD, training regimens. Haennel et alP] reported an
although there was a trend toward a reduction in 11 % improvement in V'02max following 8 weeks of
systolic BP in the hypertensive group. Sparling et exclusive hydraulic CWT in 8 patients who were 9
aLl56] found no significant differences in either to 10 weeks post CABO surgery. Participants per-
resting or exercise BP measurements following 24 formed 3 circuits per day on stations for upper and
weeks of CWT in patients with CAD or who were lower body exercise (8 to 16 repetitions) with 20
at risk of a future cardiac event. Thus, although to 60 second rest intervals between stations, 3 days
resistive exercise appears to have the potential to per week. These investigators attributed the 11 %
lower BP, conflicting results have been presented increase in V'02max to an increase in maximal SV,
on this issue and further study is warranted. cardiac output, and lower submaximal exercise HR
responses.
3.3 Maximal Oxygen Consumption In a similar study design, Svedahl et al.[l6] ob-
served an increase in cardiovascular endurance in
Research has shown that resistive exercise
male patients 8 to 12 weeks post MI following 12
training (including isometric, high intensity iso-
weeks of exclusive hydraulic CWT. These partici-
tonic, and CWT) either does not increase
V' 0 2ma}4,60,85,1 10.1 18-122] or elicits only mild to moder- pants performed resistive work at 6 stations for 40
ate (4 to 15%) increases in V' 0 2max [23,81-83,108,109,122-129] minutes a day, 3 days per week. Following resistive
in healthy individuals and in borderline hyperten- training, the peak cycle ergometer workload in
sive patients.[ll3,117] A slightly higher increase the CWT group increased by 23% and V'02max
(21.1 %) in arm ergometer V'02max has been re- increased by 19%.
ported in borderline hypertensive patients follow- Butler et aLl89] and Kelemen et aP5] reported
ing upper and lower body strength training. [l13] The mild improvements in cardiovascular endurance
relatively small increase in cardiovascular fitness (11 % increase in Bruce treadmill time) following
level observed following resistive training in healthy CWT in patients with a history of MI, CABO, or
individuals may be attributable to many factors, angina. However, direct measurement of V'02 was
including: not performed and these improvements were based
The relatively low level of V'02 required during solely upon changes in treadmill test duration,
circuit resistive exerciseP3,85,86] which could have been affected by treadmill habit-
Differences in training (i.e. arm, leg or combined uationJl32] Furthermore, the experimental CWT
arm/leg) protocols.[23,85,126] groups in these 2 investigations concurrently par-
Duration of rest intervals between liftingP3,90-98] ticipated in aerobic exercise. Similarly, McCartney
Characteristics of the population examined)122] et al)6] observed that combined weight lifting and
Total volume of work performed. [l 0, 130] aerobic training was more effective for improving
Changes in mitochondrial volume density)131] strength and aerobic performance than aerobic ex-
The initial exercise capacity of the individuals ercise training alone. These investigators found
examined, with greater improvements in V'02max that maximal cycle ergometer power output in-
observed with less fit individualsJ9,23,98, 122] Any creased by 15% (1030 to 1180 kp m/min) and
or all of these factors and their effect on central maximal cycle time increased by 109% (541 to
and/or peripheral adaptations could affect 1128 seconds) following 10 weeks (20 sessions) of
V'02max (V'02 = HR x SV x a - V'02diff). aerobic exercise at 60 to 85% of HRmax and resis-
Several studies have examined cardiovascular tive exercise training at 40 to 80% of lRM. They
endurance following CWT in patients with attributed these improvements to increased lower
CADP,5,6,15-17,26,89,1l1] All have reported mild to limb strength and skeletal muscle power. Direct
metabolic measurements were not performed in tive exercise should not be substituted for aerobic
this investigation. exercise in CRPS,[19.27.28] it should be combined
Derman et al. [1111 also found an improvement in with aerobic training to enhance expected changes
maximal cycle ergometer time to exhaustion (456 in cardiovascular function.
56 to 560 43 seconds) following 10 weeks of
CWT in patients with CAD, although these im- 3.4 Muscular Strength
provements were not as dramatic as those observed
by McCartney et aLl6] or Svedahl et al.[16] Wilke et There is an approximate 30% decline in muscu-
aLlI?] observed that combined aerobic and circuit lar strength and a 40% reduction in muscle cross-
resistive training elicited a 14% increase in V0 2max sectional surface area between the second and sev-
in patients who were more than 24 weeks post MI, enth decades oflife.[50.133]It is vitally important for
CABG, percutaneous translurninal coronary angio- CRP patients of all ages to maintain or regain lost
plasty (PTCA) or who had angina. Participants in strength after a cardiac event. Improvement in up-
this study performed CWT at 40 to 70% of 1RM per and lower body strength allows the CRP par-
with 30 second rest intervals for 3 circuits per ses- ticipant to perform everyday lifting, carrying, and
sion, 3 days per week. These participants also con- moving activities at a lower energy cost and with
greater efficiency of movement. Improved work
currently performed cycle ergometer training for 3
tolerance from peripheral adaptations within trained
sessions per week at 70 to 85% of HRmax. Daub et
skeletal muscle (i.e. increased enzyme activity and
aLl 261 found a 4.4 to 13.4% increase inV0 2max in
intramuscular fuel stores) enhances the ability of
patients 6 to 16 weeks post MI following a 10-
patients to resume routine daily activities after a
week training protocol of combined aerobic exer-
cardiac event and to perform aerobic activities at a
cise at 70 to 85% HRmax and resistive training at
lower oxygen cost. These improvements also give
20 to 60% of lRM. Interestingly, those patients
the patient greater confidence in vocational and
who trained at 60% of lRM should lower improve- avocational activities, as well as improve self-
ments in V0 2max (4.4%) than those who trained at
image. Furthermore, the improved muscular strength
20% of lRM (13.4%). Finally, Stewart et al.[lS]
and increased bone mass observed with resistive
observed a 13% increase in V0 2max following 10 training may reduce the incidence of osteoporosis
weeks of CWT and cycling exercise in patients and complications associated with accidental falls
who were early post MI (2 weeks or more). These in older patients.[134]
authors concluded that CWT is safe and beneficial Improvements in muscular strength have been
for improvements in muscular strength and cardio- universally reported following low to moderate
vascular endurance in properly screened male pa- isotonic, isokinetic, and circuit resistive exercise
tients and that resistive exercise can be initiated training in young and middle-aged individu-
relatively early post MI. als, [81,82,110.122-124,128,135] older individuals, [60-63,66,1361
The aforementioned studies have shown that and cardiac patients or individuals at risk of having
CWT enhances cardiovascular endurance in cardiac a cardiac event.[2,5,6,14-17,26,39,56,5?, 1191 Average in-
patients by 4 to 19%, either when performed solely creases in upper and lower body strength generally
or when combined with aerobic training. One rea- range from 20 to 50% in healthy populations, 9 to
son for this could be that the patients involved in 227% in older populations, and 20 to 40% in car-
these studies had lower pretraining fitness levels, diac populations, depending upon the muscle group
and thus, a greater potential for improvement in studied. This wide disparity in gains is due, in part,
aerobic capacity. However, it certainly appears that to initial levels of strength where the lower the ini-
combined resistive/aerobic training facilitates cen- tial absolute strength, the greater the relative per-
tral and/or peripheral cardiovascular adaptations centage gain. Hypertensive patients have also
better than aerobic training alone. Although resis- shown increases in strength following CWT with-
Adis International Limited, All rights reserved. Sports Med. 1996 May; 21 (5)
out significant effect of ~-blockade or calcium gains for higher risk patients, those with a low
channel blockade therapy) 113, 137] functional capacity, those who have time limita-
Greater overall improvements in strength have tions, or for those who fatigue easily,l25,138]
been reported following higher intensity resistive
programmes using workloads up to 80% of lRM 3.5 Body Composition
in healthy, untrained men,[85] elderly men and
women,[136] and in aerobically trained cardiac pa- It has been well established that resistive train-
tientsp7,54] Therefore, should higher volume, greater ing produces muscle hypertrophy and increases lean
frequency weight training be used to promote bodyweight in healthy individuals.[64,85,113,122,139]
greater increases in strength in CRP participants? However, resistive exercise does not appear to
The American Association of Cardiovascular and produce significant changes in total body-
weight[4,8, 15,60,83,85,107, 109, 117,122,124,128,140,141] and
Pulmonary Rehabilitation (AACVPR)[22] has rec-
may [60, 117,124,128,140,142] or may not[4,8,61,83,107,119]
ommended that 'low risk' cardiac patients perform
resistive exercise a minimum of 2 to 3 times per lower body fat content and/or skinfold measures in
healthy individuals or those considered at risk of
week for adequate improvement in strength. Al-
future cardiac event. In selected cardiac patients,
though the addition of greater sets, repetitions, re-
longitudinal studies have shown no significant
sistance, or days of training may further enhance
changes in bodyweight or fat following 24 weeks
strength development, the magnitude of the gains
ofCWT at 30 to 40% of lRM,[56]10 weeks of high
appears to be relatively small. Patients may be-
intensity isotonic training at 80% of lRM,[54] 10
come fatigued, have more injuries, or have less
weeks of CWT at 40% of lRM,[15] or 8 weeks of
compliance with resistive training because of the
high volume, hydraulic CWT.[2] Kelemen et aJ.l5]
added amount of work required. Whereas some
reported a small but significant decrease in mean
studies have reported a greater improvement in
body fat values (20.8% 4.4 to 19.4% 3.3) fol-
strength with heavier lifting, this appears to repre-
lowing 10 weeks of CWT in CRP participants, al-
sent a curvilinear relationship rather than a linear
though no changes in body weight were observed.
relationship, as is the case with cardiovascular con- However, in a follow-up study ofthese patients, no
ditioning (i.e. beyond a certain intensity improve- significant changes in body fat were seen after 3
ments appear to plateau). For example, where 10 years of resistive and aerobic training.l 14]
weeks of resistive training at 80% of lRM resulted The small changes in bodyweightlbody fat re-
in a 29% increase in overall strength,[54] training at ported in the aforementioned studies may reflect
30 to 40% of lRM over the same period resulted in the small amount of energy expenditure for the spe-
a similar (24%) overall relative improvement)5] cific resistive protocols used, when compared with
These findings suggest that heavy or high-repetitive aerobic activities. The total volume of work per-
resistive training which may potentially increase formed may not have been an adequate stimulus for
the haemodynamic response and cardiovascular body fat loss in many of these reports. Further-
risk of resistive exercise, cause excessive fatigue,[58] more, many of these studies were conducted over
or put excessive stress on the musculoskeletal sys- short training periods. Studies performed with car-
tem offers little additional benefit in strength for diac patients have traditionally emphasised aerobic
cardiac popUlations. Thus, it has been recom- exercise and its beneficial effects. Thus, few stud-
mended that patients perform resistive exercise at ies have examined specific changes in body com-
30 to 60% of lRM (or equivalent), for not more than position parameters (i.e. skinfolds, body mass in-
I to 3 sets per session, 2 to 3 days per week[19,22-27] dex, waist-to-hip ratio, circumferences) following
(see section 7.1). Performance of only 1 set of 12 exclusive, long term resistive training. Since it has
to 15 repetitions for specified muscle groups with been well documented that aerobic exercise can
no time limit may be more appropriate for strength help to maintain lean body mass or decrease body
fat content, resistive exercise may be considered a for age, body fat, training regimen, anabolic ste-
supplement for expected changes in body compo- roid usage, and diet.[3,11,163]
sition. This form of training may indeed enhance Acute changes in lipid and lipoprotein concen-
physical changes in cardiac populations over trations and lipase activity have been observed fol-
longer periods of time or with greater volumes of lowing moderate to high levels of resistive exercise
work. in healthy individuals. Wallace et aUI64] observed
moderate increases in HDL-C and HDL3-C levels
01 and 12%, respectively) 24 hours after low re-
3.6 Haematological Variables
sistance, high repetition CWT. Lower triglyceride
levels were also observed 24 hours post-lifting
The risk for CAD is directly related to plasma concomitant with a significant decrease in lecithin-
levels of total cholesterol (TC) and low density
cholesterol acyltransferase (L-CAT) activity, the
lipoprotein cholesterol (LDL-C) and inversely re-
enzyme which converts HDL3-C to HDL 2-C.
lated to high density lipoprotein cholesterol (HDL-
Shoup and Durstine[165] reported that lipopro-
C) levels.[l43-148] Having high levels of very low
tein lipase, the enzyme which mediates the catab-
density lipoprotein cholesterol (VLDL-C) has been
olism of triglyceride rich lipoproteins (chylo-
shown to be a strong risk factor for cardiac events
microns and VLDL-C), was significantly elevated
in patients with non-insulin-dependent diabetes
24 and 48 hours following CWT in sedentary, middle-
mellitus (NIDDM). [149] Hypertriglyceridaemia has
aged men. However, there were no associated
also been considered a coronary risk factor when
changes in any of the lipid or lipoprotein parame-
combined with low HDL-C levels[15o.151] although
ters. Shoup and Durstine[165] speculated that for
this is currently controversial. [I 52] Furthermore, in-
physiological changes in blood lipid and lipopro-
sulin resistance, glucose intolerance, and hyper-
tein profiles to occur, one or more of the following
insulinaemia have been associated with adverse
lipid levels and CAD in diabetic and non-diabetic is required: (i) a greater increase in lipoprotein li-
individuals.lls3-IS611t has been suggested that re- pase activity; (ii) a more prolonged elevation of
sistive exercise may favourably alter selected lipoprotein lipase activity; (iii) alterations in addi-
haematological risk factors for the development tional enzyme activities (i.e. a corresponding de-
of CAD, including blood lipid and lipoprotein crease in hepatic lipase activity, the enzyme which
levels, glucose tolerance, and insulin sensitiv- mediates the conversion of HDL2-C to HDL3-C),
ityP,4,8,1O,19,22,IS71 However, conflicting data have and/or (iv) an increased caloric requirement for the
been presented in the literature and few studies weight lifting activity.
have examined risk factor modification in high risk A longitudinal study (20 weeks) by Kokkinos et
or cardiac populations over extended periods or al.[l19] also investigated the acute responses of
following exclusive resistive exercise protocols. lipid/lipoprotein and lipase activity up to 72 hours
Studies which have evaluated the influence of post CWT. This study supports, in part, the find-
resistive exercise regimens on lipid and lipoprotein ings of Shoup and Durstine[165] that lipid/lipopro-
profiles have been controversial due to inadequate tein concentrations are not affected acutely by re-
control or a lack of accountability for extraneous sistive exercise. In contrast, Kokkinos et aU119] did
variables such as food intake, body composition not find significant changes in lipase activity at 20,
changes, or work standardisation. Previous cross- 46, or 72 hours post weight lifting. Since Kokkinos
sectional investigations have associated strength et aU119] did not specify the total exercise time, the
training with suppressed HDL-C levels and ele- total volume of work, or the total kcal expended
vated TC to HDL-C ratios in trained athletes.l158-162] for each weight lifting session, comparisons made
However, these studies and others should be based upon work performance between these 2 in-
viewed with caution because of inadequate control vestigations are limited. Exercise intensity may
have accounted for the discrepancy between these possibly independent risk factors for the develop-
two studies. ment of CAD.[171-174] Both acute and chronic aer-
Studies of chronic resistive training in healthy in- obic exercise have been associated with improved
dividuals have reported reductions in TC, [140,142,166-168] glucose tolerance and enhanced insulin sensitivity
LDL_C,[4,140,142,166-168] and TC/ HDL-C ratios.[4] In- at the skeletal muscle in healthy individuals and in
creases in HDL-C and HDL2-C have also been ob- those with NIDDM.l8,151,175-178] Moreover, in-
served following up to 16 weeks of CWT.[4,142] creased insulin sensitivity has been shown to
Other investigators have reported no significant correlate highly with training induced increases in
changes in TC,[4,119,169] HDL_C,[166] or any lipo- \'02max.l179] It has been postulated that resistive ex-
protein parameter[8, 119, 141, 169] following resistive ercise may also have a beneficial effect on glucose
training. tolerance and insulin sensitivity, as both isotonic
Kokkinos et al,l1l9] reported no significant and isometric muscle contractions have been
changes in any lipoprotein parameter following 20 shown to elicit an insulin type of effect on glucose
weeks of CWT (2 sets of 11 upper and lower body uptake in vitro.l 180 ] However, there is little research
exercises, 12 to 15 RMs per set) in individuals at on the acute or chronic effects of resistive exercise
risk for CAD. These investigators also reported, as on these haematological variables in either men or
discussed earlier, no significant changes in lipopro- women with coronary risk factors.
tein lipase or hepatic lipase activity measured at 20, Of the few studies that have been published, im-
46 or 72 hours after circuit weight lifting. Simi- proved insulin sensitivity and enhanced metabolic
larly, Manning et al,l141] found no changes in any control of glucose has been reported following
lipoprotein parameters following 12 weeks of weight chronic resistive training in healthy, young and
training (3 sets of upper and lower body exercises middle-aged men, [4,181] postmenopausal women, [182]
performed at 60 to 70% of lRM, 3 sessions per and middle-aged men considered at risk for the de-
week) in sedentary, obese females when changes in velopment of CAD.l8] Smutok et aU 8] found that
diet and body mass were controlled for. Con- strength training was just as effective as aerobic
versely, Boyden et aI.l166] found a significant de- training in improving the regulation of glucose me-
crease in TC and LDL-C following 20 weeks of tabolism in middle-aged hyperglycaemic or hyper-
resistive training in healthy, premenopausal fe- lipidaemic untrained men who performed Nautilus
males aged 28 to 39 years who had normal baseline strength training over 20 weeks. Glucose and insu-
lipid values, although HDL-C remained unchanged. lin responses to glucose ingestion during an oral
Changes in body composition showed no signifi- glucose tolerance test were reduced in these indi-
cant correlations with changes in either TC or viduals following training, which suggests that
LDL-C and no significant difference in nutrient in- strength training may provide some protection
take was evident between the exercise and control against the development of NIDDM and athero-
groups. sclerosis. To our knowledge, no studies have exam-
In a recent epidemiological study, no beneficial ined this topic in cardiac patients.
effects, and perhaps even an adverse association Under certain conditions, resistive exercise may
between muscular strength and lipid values, was beneficially alter specific haematological variables.
observed in over 7000 men and women who par- However, design and/or methodological limita-
ticipated in exercise training,l170] Improved strength tions preclude definite conclusions concerning the
had no beneficial effect on blood lipids in these efficacy of resistive exercise for lipid/lipoprotein
participants, although there was no account of spe- enhancement.[119,183] Furthermore, this issue be-
cific resistive training protocols. comes clouded with the subclassification of lipid
Glucose intolerance, hyperinsulinaemia, and di- subfractions, i.e. lipoprotein(a) and apolipopro-
abetes mellitus are considered to be significant and teins A-I or B and the potential effect of chronic
resistive training on specific subfractions. It has of exercise in many vocational tasks. Isometric work
been hypothesised that the total energy cost of a (weight lifting, squeezing, or pressing) involves
weight lifting activity is the key factor in determin- constant muscle contraction of a muscle group and
ing chronic lipid or lipoprotein changes and that a is primarily anaerobic since muscle blood flow and
minimal threshold of energy expenditure is neces- oxygen delivery is compromised with sustained
sary to elicit beneficial changes. Thus, the volume compression of arterial vessels during contraction.
of training may be the dependent factor if resistive In healthy individuals, isotonic or dynamic muscle
exercise is to elicit positive changes in blood lipid contraction causes HR and cardiac output to in-
levels)10] crease while arterioles within the contracted mus-
Recent studies tend to indicate that the energy cle dilate and reduce systemic vascular resistance.
expenditure associated with resistive exercise, During sustained isometric or static muscle con-
even in the form of CWT, may not be sufficient to traction, cardiac output and "V0 2 increase second-
attain the minimal threshold needed to beneficially ary to an increase in HR while systemic vascular
alter blood lipid/lipoprotein levels. Long term tri- resistance and SV remain unchanged. This pro-
als which control for the resistive exercise training duces a rapid increase in arterial (particularly dias-
stimulus (i.e. the type, intensity, volume, work rest tolic) BP, RPP, and imposes a greater pressure than
ratio, or duration), participant fitness level, sex, volume load on the left ventriclePO,29,42,44,184.190]
baseline lipoprotein values, plasma volume status, The pressor response elicits an increase in systolic,
medication use, and dietary regimen need to be fur- diastolic, and mean arterial pressure[190] which is
ther assessed and duplicated in high risk and car-
directly related to the tension level generated, in-
diac popUlations before this mode of exercise can
tensity, activated muscle mass, and duration of mus-
be recommended for favourably altering the afore-
cle contraction.l3 2,188.194] The mean arterial pres-
mentioned haematological variables. Although
sure for isometric exercise is much higher for any
glucose tolerance and insulin sensitivity appear to
given "V0 2 at equivalent dynamic exerciseP9,191]
improve with chronic resistive exercise training,
The pressor response is a reflex to metabolic events
limited information is available on the acute re-
in the ischaemic muscle and the time of muscle fa-
sponse of resisti ve exercise in high risk and cardiac
tigue is inversely proportional to the percentage of
populations, and further study is warranted on both
maximal voluntary contraction.l 194 ,195]
of these issues.
Clinical investigators have reported that pa-
In summary, it appears that resistive exercise
tients with mild to severe LV impairment or con-
has the potential to elicit many favourable training
gestive heart failure may demonstrate a decrease in
effects for the cardiac patient. Although body-
cardiac output, SV, and ejection fraction (EF), an
weight, body fat, BP and certain haematological
variables may not be significantly enhanced by increase in LV end diastolic pressure, regional wall
CWT, muscular strength and cardiovascular endur- motion abnormalities, mitral regurgitation, and
ance are beneficially altered following resistive dysrhythmias during sustained isometric exercise
with hand grip or deadlift tests.[20,21,35,36,43,44,196-199]
training and further research may show other ben-
eficial training adaptations which may lower cardio- Thus, sustained or high intensity isometric exer-
vascular risk factors. A summary of resistive train- cise has been regarded as unsafe for patients with
ing studies in male cardiac patients is presented in poor LV function due to the excessive level of myo-
table II. cardial pressure work, and has traditionally been
contraindicated for all cardiac patients due to the
4. Isometric and Isodynamic Exercise potential for adverse effects of increased afterload
and associated ischaemia.[42,197,200]
Isometric exercise occurs repeatedly with many Since RPP is a good indicator of M"V02 during
activities in daily living and is the dominant form dynamic[94,96,20l] and isometrid 94] exercise, activ-
@ w
Table II. A summary of 12 circuit weight training studies in male cardiac patients
0.
IV
'"
".S- Reference n Clinical status Duration of Mode/intensity of CWT Strength gains Aerobic capacity Cardiovascular % Fat/weight
training complications
iD
3 Haennel et a1. 12] 8 CABG (9-10wk post 8 weeks 3 circuits, 8-16 reps, 20 sec. 22% incr. in upper, 11% increase in None No changes
0
g surgery) work intervals 18% incr. in lower V02max
OJ
Q. body strength
Squires et al[57] 13 MI, CABG (4 pts, Averaged 1 circuit, 10-14 reps of a 10 rep. 25% ave. increase in Not measured None Not reported
~
~ EF < 40%, 5-6 wks 6 weight lifting RM estimate; aerobic exercise upper/lower body
0. post-event) sessions strength
= Sparling et al. l51 16 PTCA, CABG, MI, 24 weeks, 1 circuit at 30-40% of 1RM; 22% ave. incr. Not measured None No changes
&l' CAD, 'high risk' 3 times/week aerobic exercise 70-85% of in upper/lower body
:::r
Ui HRmax strength
ill
ill McCartney et al[6] 10 CAD, MI, CABG, 10 weeks, 2 circuits at 40-80% of 1RM; 42% incr. in upper, 15% increase in None Not reported
;: angina 2 times/week aerobic exercise 60-85% of 23% incr. in lower maximum cycle
(1)
0. HRmax body strength power output; 109%
increase in
maximum cycle time
Ghilarducci et al. l54] 9 MI, angina, CABG 10 weeks, 1 circuit at 80% of 1RM; sit-ups; 29% ave. incr. in Not measured None No changes
3 times/week aerobic exercise at 45-64% of upper/lower body
HRmax strength
Kelemen et al[5] 20 MI, CAD, CABG, 10 weeks, 2 circuits at 40% of 1RM, 24% ave. incr. in 12% increase in 1 pI. No weight
angina 3 times/week aerobic exercise at 85% of upper/lower body Bruce treadmill time Hypotensive; 4 change; small
HRmax strength pts. PVC's with decrease in
bigeminy body fat
Svedahl et al. 1161 16 8-12 weeks post-MI 12 weeks, Hydraulic CWT, 40 min/day, 3 29% incr. upper, 23% 190/0 increase in None Not reported
(average EF = 40-45%) 3 times/week days/week, 20 second work: incr. in lower body \102max; 23%
rest intervals strength increase in peak
cycle ergometer
workload
Stewart et al. 1151 8 2:2 weeks post-MI 10 weeks, 2 circuits at 40% of 1RM; 22% incr. upper, 29% 15% increase in None No changes
(no anterior Qwave) 3 times/week aerobic exercise incr. in lower body V02max
strength
Wilke et al[17] 14 MI, CABG, PTCA, 12 weeks, 3 circuits at 40-70% of 1RM; 30% incr. upper, 35% 14% increase in None Not reported
angina, valvular 3 times/week aerobic exercise at 70-85% of incr. in lower body V02max
HRmax strength
Stewart et al. 1141 17 MI, CAD, CABG 3 years, 2 circuits at 40% of 1RM; 13% incr. upper, 40% Not measured None No changes
(follow-up of Kelemen 3 times/week aerobic exercise at 85% of incr. in lower body
et a1.15~ HRmax strength
<n Derman et al. l111 ] 9 CRP participants 10 weeks CWT (intensity not specified); 19% incr. in maximal No change in None Not reported
'0
0 aerobic exercise isometric voluntary \102max; 19%
;} contraction increase in cycle
:;;: time to exhaustion
(1)
0.
Daub et al[26] 57 6-16 weeks post-MI 10 weeks 2 circuits at 20-60% of 1RM; 10.5-13.5% incr. in 4.4-13.4% incr. in None Not reported
0-
aerobic exercise at 70-85% upper body strength V02max ...;;;:
HRmax
'"'" 8
:;;:
0 C{>
:< Abbreviations: ave = average; CABG = coronary artery bypass grafting; CAD = coronary artery disease; CRP = cardiopulmonary rehabilitation programme; EF = ejection fraction; HRmax = maximum
heart rate; incr. = increase; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty; pt = patient; PVC = premature ventricular complex; rep = repetition; RM = repetition :>:l
~ 6-'
maximum; \102ma,= maximal oxygen uptake.
~
ities with isometric components which may cause ing alone or with aerobic training is generally safe
an unexpected increase in RPP because of higher and effective in patients with coronary disease who
systolic responses could potentially induce isch- are medically stable and are in a supervised pro-
aemia and be detrimental to the patient.[42) How- gram.'[18]
ever, studies which have compared isometric (hand- Untoward events associated with isometrics have
grip) exercise with isodynamic exercise in patients usually been the result of the Valsalva manoeuvre
with CAD and without significant LV impairment and patients should always be cautioned against
have shown that handgrip alone, or in combination breath holding or prolonged isometric contrac-
with dynamic exercise, produces less ischaemic tions. Individualised exercise prescriptions for low
ST-segment responses when compared with intensity isometric exercise should consider the
graded exercise testing. [77.96,97,193,198.202,203) There patient's cardiovascular status (i.e. LV function),
is also a view by several investigators that isomet- long term goals, and occupational/leisure require-
ric exercise may actually favour myocardial perfu- mentsPO,21.67.184) Various isometric tests such as
sion at RPPs which normally produce ischaemic handgrip dynamometer, elastic tube, or deadlift
ECG changes during dynamic exercisePO.37.96.198) testing may be useful in this respect. Monitored
The reason for this is that elevated diastolic BPs exercise tests that involve weight lifting or carry-
and decreased venous return and wall tension ob- ing for work simulation may also be used to more
served during isometric exercise[42.188) may in- accurately prescribe vocational or avocational ac-
crease coronary perfusion pressure and improve tivities and may aid in reducing the time it takes
blood flow in coronary stenotic areas and collater- the patient to resume regular activities.l 68 )
als during diastole, thereby reducing the develop- Although isometric/isodynamic testing has
ment of myocardial ischaemia.l19.36.37 .53.54, 71.198.202J been shown to be haemodynamically safe in car-
Investigations utilising isometric, dynamic, or diac populations, many investigators have observed
combined isometric/dynamic components (i.e. frequent PVCs, elevated diastolic BPs, and/or
weight-loaded walking, weight carrying and lift- marked fluctuations in BP during weight lifting/
ing, or vocational work simulation) have not shown carrying tasks in some patients. Male cardiac pa-
adverse cardiac responses such as angina, ST- tients have also been shown to rely more on atrial
segment depression, or significant dysrhythmias in contribution during isometric deadlift testingP04)
patients with CAD or who have had CABG or un- Thus, until gu'idelines for isometric exercise have
complicated MV I7 .67 ,71-79.99-101 ,202-204) been clearly established and further research con-
Two recent studies have shown that patients ducted, patients should continue to be instructed to
with normal LV function and fixed dual chamber avoid heavy lifting and forceful isometric exercise.
pacemakers exhibit a normal increase in mean ar- Patients should also avoid daily activities which
terial pressure during static exercise, due to an in- may involve heavy isometric work (i.e. shovelling
crease in SV and cardiac output without significant wet snow, pushing a car, carrying a heavy suitcase,
changes in systemic vascular resistance or cardiac splitting hardwood) and should continue to be in-
complications.[205,206) These findings suggest that formed of the dangers of forced expiration against
cardiac patients with varying aetiologies are able a closed glottis during exertion (Valsalva man-
to perform some forms of submaximal isometric oeuvre).[207)
exercise safely. Including non-sustained isometric Snow shovelling, traditionally proscribed for
and isodynamic exercises in medically supervised cardiac patients because of the pressor response
programmes will better prepare patients for many and potential for cardiovascular complications,
occupational and leisure activities) 18.20-22) On this has recently been shown to be well tolerated and
issue, the American Heart Association (AHA)[18) haemodynamically safe during modest ambient
has stated the following: 'careful isometric train- temperature alterations in selected low-risk pa-
Adis International Limited, All rights reserved, Sports Med. 1996 May; 21 (5)
tientsP08,2091 However, due to the potential for a cations, or sternotomy complications after sur-
rapid and sustained increase in HR with heavier gery.l l38 1 Dumb-bells, wrist weights, wall pulleys
snow shovelling and the large number of reported and elastic bands or tubes are ideal for phase I and
untoward events associated with this activity,[2101 phase II patients who have a limited range of mo-
factors that must be considered before snow shov- tion from CABG or other types of surgery.
elling can be routinely recommended for cardiac Elastic bands come in different colours which
patients should include: indicate different levels of tension and may be
the density or composition of the snow (i,e, combined together to produce greater resistance
mixed with rain, gravel) during muscle contraction. Bands/tubes may also
ambient temperature may be tied into a loop to avoid isometric gripping
size of the load or placed around the ankles to perform leg exer-
size of the shovel cises. Machines can provide the opportunity to
weight of the snow and shovel train for both muscular strength and endurance and
shovelling rate may be used in a single station or multi station for-
type of clothing worn mat If available, machine exercise is enjoyable,
present cardiac status easy to learn, and may contribute to greater exer-
physical condition of the patient cise compliance. However, some machines are ex-
Adverse combinations of these factors could pensive and may be cost-prohibitive for some
place the patient at greater risk of untoward events CRPs. Recent studies have shown that machine
and should be carefully consideredPlOl Carpentry weights can be safely implemented as early as 4 to
activities which involve static and dynamic arm 6 weeks after a cardiac event[l5, 571 Given these
work performed in various postural positions (i,e, findings, the American College of Sports Medicine
tightening of nuts with a wrench while supine) (ACSM) has recommended that resistive training
have been shown to be haemodynamically safe in be implemented 4 to 6 weeks after an uncompli-
stable patients who were 8 or more weeks post car- cated MI or CABG and 1 to 2 weeks following
diac event[791 Thus, low-risk patients with stable PTCA or other revascularisation procedures.[251
CAD may be able to perform some types of static- Free weights (bar-bells and dumb-bells) can be
dynamic carpentry activities safely with certain used in CRPs although proper technique must be
precautions in non-extreme environments, emphasised and 'spotters' (i.e. staff members avail-
able to help the patients balance the weights) may
5. Resistive Modalities be necessary if patients use heavier weights. Free
A wide variety of resistive modalities are cur- weights may not be suitable for some older patients
rently being used in CRPs for strength develop- since these can be dropped, used ineffectively, or
ment and improvement A summary of the advan- the patient could fall if balance problems are evi-
tages and disadvantages of some of these devices dent Low-level machine exercise may be more
is presented in table III. Gradual progression of suitable than other resistive modalities for older
resistance is possible with many of these modali- patients who have neuromuscular impairment or
ties. Inpatient (phase I) hospital staff often use light problems with balance.
resistive modalities (i.e. squeeze balls and low ten- Cuff weights, hand-held weights, ankle weights,
sion elastic bands) and/or light resistive callisthen- and bands may be used in a station format or in
ics to help patients regain strength after an acute conjunction with aerobic activities in CRPs. These
cardiac event Participants of phase II CRPs are modalities generally range from 0.45 to 11.4kg (1
generally advised to use relatively lighter levels of to 251b) and are portable and inexpensive. Cardiac
resistance during the early phases of rehabilitation patients should use elastics or lighter weights 0.45
to avoid potential joint injury, orthopaedic compli- to 3.2 kg (1 to 71b) during the early CRP sessions
Table III. Resistive training modalities l28]

Advantages Disadvantages
Cuff, hand, and ankle Requires minimal storage space Possible adverse haemodynamic response in
weights Requires minimal exercise space selected patients with hand-gripping
Easily moved Potential for connective tissue damage with
Large number of patients may participate simultaneously excessive arm swinging
No isometric component with cuff or ankle wraps Potential for leg/hip injury when running with
Increased energy cost of activity ankle weights
Cost effective
Dumb-bells Requires minimal storage space Possible adverse haemodynamic response for
Requires minimal exercise space selected patients
Easily moved Isometric component with hand-gripping
Large number of patients may participate simultaneously Weights may be dropped
Gradual progression of resistance
Cost effective
Bands/tubes Requires minimal storage space Possible adverse haemodynamic response for
Requires minimal exercise space selected patients
Easily moved Isometric component with sustained pulling of
Gradual progression of resistance bands/tubes
Large number of patients may participate simultaneously Resistance is lower at the beginning and
Potential for increased joint flexibility highest at the end of muscle contraction
Cost effective
Free weights/bar-bells Gradual progression of resistance 'Spotters' necessary
Greater potential for improvements in strength Increased skill level required
Isometric component
Weights may be dropped
Machine weights Large selection of equipment available Large space requirement
Reduced isometric component Small number of patients may participate
No 'spotters' necessary simultaneously
Easily determined and precise weight exercise prescription Increased cost of equipment
Easily followed weight progression
Enjoyable and motivational
Multistation machines available for increased patient
participation
Circuit weight training Possible to incorporate any of the aforementioned Large space requirement
components into a circuit - offers flexibility/variety Potential for minimal number of patients to
Machine weights most popular due to safety and absence of participate simultaneously due to time and
'spotters' space allotment
Potential for increased strength, aerobic capacity, favourable Increased cost of equipment if machines are
body composition changes, and risk factor reduction used
More time efficient - able to incorporate more resistive
exercise into rehabilitation session
Enjoyable
Greater exercise compliance
and may progress to heavier levels of resistance or patients with musculoskeletal limitations. Using
after the follow-up graded exercise test has been hand-held weights during walking has also been
performed. [138] regarded as unsafe for hypertensive individuals be-
Walking with hand/wrist weights increases the cause of the potential for elevation of BP from in-
metabolic and haemodynamic responses during creased peripheral resistance and muscle tension
exercise, and thus there may be some cardiovascu- with isometric grippingPII-213]
lar benefit to the cardiac participant. However, these Investigations with hypertensive responders,[213]
modalities have previously been criticised because healthy individualspll] older men and women
of the potential for joint injury or orthopaedic com- (mean age 66.2 5.6 years),[214] and cardiac pa-
plications with improper use in untrained patients tients[215] all have shown exaggerated BP responses
Adis International limited. All rights reserved. Sports Med. 1996 May: 21 (5)
as high as 2501110 with handweighted walking in during weighted walking. Amos et al)2 15 1observed
some patients. In cardiac populations, gripping a mild increase in HR and BP and no ischaemic
hand-held weights could potentially increase HR ECG responses during treadmill walking with
and systolic BP through the pressor response which 1.14kg (2.51b) ankle or wrist weights in patients
could increase the RPP and MV0 2. This could be with CAD. In this investigation, wrist weights gen-
potentially dangerous if patients exercised to or be- erally elicited greater haemodynamic responses
yond their ischaemic threshold. Conversely, the is- than ankle weights. One individual had an exagger-
chaemic threshold could be improved with com- ated BP response of 2301120 during weighted
bined static and dynamic exercise in patients with walking and was not allowed to finish the trial.
CAD)IOIJ Moreover, the increase in diastolic BP
Schram and Hanson[75J observed that heavier
reported in many of the aforementioned studies
backpack weight-loaded walking was physiologi-
with weighted walking may potentially improve
cally safe for cardiac patients, although HR, BP,
coronary perfusion and myocardial oxygen supply
in CRP participants) 19,96J
V0 2 , and RPE increased progressively with addi-
tions of 5 to 20kg (11 to 441b) weights during tread-
Overall, the physiological responses of light
mill walking. These investigators concluded that
0.45 to 2.27kg (1 to 51b) cuff or hand weighted
walking are generally mild in healthy or hyperten- weight-loaded walking may assist in training by
sive patients. These include: increasing the metabolic cost of exercise, but may
be contraindicated in patients with musculoskeletal
A small increase in the metabolic cost of walk-
ing (overall increase of 1.2 to 3.8 ml/kg/min). disorders. Landi et aJ.l72J observed that carrying
4kg (8.81b) weights with elbows flexed produced a
No change or a small increase in HR (4 to 13
beats/min). greater rise in systolic BP (154 16) than carrying
weights with elbows extended (142 13). The au-
No change or a small increase in rating of per-
thors concluded that cardiac patients should mod-
ceived exertion (RPE) [generally 0 to 2 units or
11 to 14 on the Borg category scale]. ify activities of daily living that require elbow
flexion to an extended elbow position.
No change or a small increase in systolic BP (12
to 18mm Hg) with a wide variation in hyperten- There has been little research on musculoskele-
sive responders. tal complications or haemodynamic responses as-
sociated with chronic hand, wrist, or ankle weight-
Mild to moderate increases in diastolic BP (2 to
10mm Hg). loaded walking in cardiac populations. Vigorous arm
Mild increase in RPP(20 to 38 units)Pll-213,216-220J and leg movements during weighted exercise could
put excessive pressure on the shoulder, elbow, or
Greater metabolic and haemodynarnic responses
ankle joints and may cause connective tissue dam-
have been reported in older individuals[214J and
with heavier weights or exaggerated arm swings in age. Furthermore, hypertensive patients could po-
younger individuals. Variations observed among tentially exacerbate BP with hand weight gripping
these studies are due to differences in weight load, during extended track or treadmill walking. It is
degree of arm swing, stride length, work intensity, recommended that patients with hypertension or a
participant fitness level and age, time of HRlBP history of musculoskeletal injuries be thoroughly
measurement, and/or the degree of isometric con- screened before participation in weighted exercise.
traction with hand gripping. The increased metabo- If hand/ankle weights are used, patients should
lic demand of weighted exercise may be due to an avoid exaggerated arm swings or stride pattern for
increased recruitment of motor units or increased joint protection. Patients should not jog or run with
muscle mass needed to carry the weights.f2211 hand, wrist, or ankle weights because of the poten-
In cardiac patients, generally no change, or only tial for joint stress or adverse haemodynamic ef-
mild physiological changes, have been observed fects with this type of activity.
Adis International limited. All rights reserved. Sports Med. 1996 May; 21 (5)
Monitored exercise tests on patients with at- for resistive exercise and participation should be
tached cuffs or holding weights may provide useful encouraged.
information regarding the cardiovascular and/or Staff members should also consider the contra-
musculoskeletal responses during weighted exer- indications for exercise testing and/or entry into
cise.l68 ] With this form of testing, exercise pre- cardiac exercise programmes published by the
scriptions may be more accurately developed for ACSM,[25] AACVPR,[22) and AHA.[223) An adapta-
patients who wish to participate in weighted exertion of these criteria specific to resistive exercise
cise and those who have exaggerated HR or BP is presented in table IV.
responses may be identified. Until further research Ideally, patients should have a functional capac-
has documented the potential risks or benefits of ity of 6 to 7 METS or more, assessed from symptom-
weight-loaded walking in cardiac patients, CRP limited graded exercise testing prior to participa-
staff should focus upon other resistive modalities tion in higher intensity resistive training.l 5,24-27,39)
for improvement in muscular strength, and view However, low to moderate risk patients with func-
weight-loaded walking with caution. tional capacities of 6 METS or less may be able to
safely perform resistive exercise in a circuit fash-
6. Patient Screening and ion with lighter workloads. Older cardiac patients
Contraindications may be well suited for resistive training and partici-
Resistive exercise training may pose a risk to pation should be encouraged due to the potential
patients who are predisposed to cardiovascular for enhanced strength, bone mass, and cardiovas-
complications or to those with specific medical cular function.l 225 ) Older patients should be closely
conditions. Therefore, it is important to properly monitored for correct postural alignment, mechan-
screen individuals for participation in resistive ex- ical efficiency, and breathing technique during the
ercise. Generally, patients who have the following early sessions. Monitoring of BP and ECG by te-
symptoms should not participate in resistive exer- lemetry or 'quick-check' techniques may be war-
cise: [5,22,25,27,39,76,222,223] ranted for some higher risk older participants due
An abnormal haemodynamic response or sig- to the potential for a greater haemodynamic re-
nificant ischaemic ECG changes during graded sponse with resistive exercise, which is often seen
exercise. in these individuals,l214,226]
Poor LV function (EF < 30%). Cardiac transplant patients should be encour-
a low functional capacity (4 to 5 METS). aged to perform progressive resistive training to
Uncontrolled angina, heart failure, hyperten- counteract the muscle wasting effects of pred-
sion, or dysrhythmias. nisone therapy. A deficiency in leg strength has
Severe CAD (left main, triple vessel or high left been shown to persist up to 18 months after cardiac
anterior descending disease). transplantation, which may contribute to lower
Severe or symptomatic aortic stenosis. V0 2max values in transplanted patients.[227) Grad-
Clinically limiting orthopaedic or cardiovascu- ual progression of low resistive workloads with
lar symptomology. relatively higher repetitions has been recom-
Characteristics associated with an increased mended for transplanted patients. [228] Patients with
risk for cardiac events during exercise. mitral valve prolapse syndrome should be encour-
Cardiopulmonary rehabilitation staff should aged to perform resistive exercise, but should
generally consider patients who fall under the avoid heavy weight lifting.l229] Those with periph-
ACSM,f25] AACVPR,[22] and/or AHA[223] high risk eral arterial disease may see additional gains in
stratification criteria as unsuitable candidates for strength following a resistive programme, but may
participation in higher intensity resistive exercise. not improve V0 2max or onset time to leg claudica-
Low to moderate risk patients may be well-suited tion pain,l230)
Adis International Limited, All rights reserved, Sports Med, 1996 May; 21 (5)
Table IV. Contraindications for resistive exercise training l22 ,25,223,224j
Absolute contraindications
Resting, changing pattern, or new onset of angina pectoris
Complex supraventricular or ventricular dysrhythmias at rest or dysrhythmias that worsen with exercise
Uncompensated or symptomatic congestive heart failure
Acute MI, suspicion of a MI or chest surgery 1-2 weeks)
Multiple or complicated Mis
Severe or symptomatic aortic stenosis
Recent episode of cardiac arrest
Severely depressed LV function (EF < 30%)
Severe coronary artery disease (high left anterior descending, triple vessel, reversible pharmacological defects)
Exertional hypotension (~15mm Hg) or failure of blood pressure to rise during graded exercise
Orthostatic BP drop >20mm Hg with symptoms
New York Heart Association functional capacity classification Class III or IV, Objective Assessment C or D
Significant exercise-induced STsegment depression (~3mm flat or downsloping)
Recent complicated MI or recurrent/persistent ischemic symptoms post cardiac event
Known history of unrepaired cerebral, thoracic, abdominal, or ventricular aneurysm
Active or suspected myocarditis, pericarditis, or endocarditis
Thrombophlebitis or intracardiac thrombi
Hypertrophic cardiomyopathy
Acute pulmonary embolus or pulmonary infarction
Third-degree or advanced atrioventricular block
Resting systolic BP > 200mm Hg and/or resting diastolic BP >110mm Hg
Previous episode of ventricular fibrillation or cardiac arrest that did not occur in the presence of an acute ischemic event or cardiac
procedure
A medical problem that the physician believes may be life threatening or that warrants contraindication
Orthopaedic problems that would prohibit resistive exercise
Acute systemic illness, fever, or infections (i.e. mononucleosis, hepatitis)
Uncontrolled metabolic disease, (i.e. diabetes mellitus, myoedema, thyrotoxicosis hypo- or hyperkalaemia, thyroiditis)
Severe restrictive or obstructive lung disease
Acute episodes of joint inflammatory or degenerative disease (i.e. bursitis, arthritis, gout)
Advanced or complicated pregnancy
Relative Contraindications
Excessive blood pressure rise with resistive exercise; systolic pressure:" 220mm Hg and/or diastolic pressure ~ 110mm Hg
End stage renal disease
Congenital heart disease or congenital heart defects
Ischaemic cardiomyopathy
Frequent or complex ventricular ectopy
Neuromuscular, musculoskeletal, or rheumatoid disorders that are exacerbated by exercise
Valvular heart disease
Failure to comply with resistive exercise prescription
Survivors of cardiac arrest
Recent coronary artery bypass grafting or other cardiac surgery 4 weeks)
Low exercise capacity 4 METS)
Multiple severe initial thallium defects and/or multiple areas showing thallium redistribution
Stable congestive heart failure
Presence of automatic implantable cardioverter defibrillator
Resting systolic BP ~ 180mm Hg and/or resting diastolic BP :" 105mm Hg
Abbreviations: BP =blood pressure; EF =ejection fraction; LV =left ventricular; MI =myocardial infarction.
It is ultimately the responsibility of the CRP back may also be incorporated into resistive re-
medical director, programme director, and the pa- gimens.
tient's personal physician to determine who should Elderly patients may be well suited for abdom-
participate in resistive exercise. Other contraindi- inal exercise and may benefit through prevention
cations for patient participation may exist and of low back pain and development of better pos-
should be discussed on an individual basis by the ture. Various calisthenics using rhythmic, dynamic
medical director and CRP staff. movements of large muscle groups may be per-
formed with or without resistive devices to sup-
7. Exercise Prescription plement overall strength improvement. Aerobic
equipment (i.e. wind resistance cycle ergometers,
Once properly screened, resistive exercise train- rowing machines, isokinetic arm crank ergome-
ing should be initiated with regard to the patient's ters) may be used for additional strength condition-
cardiovascular status and functional capacity. Low ing through arm, leg, or combined arm/leg exer-
level resistive exercise that includes 0.45 to 4.5kg cise. Any or all of these modalities may be used in
(1 to 1Olb) dumb-bells, hand/wrist weights, light
an individualised station format or may be con-
callisthenics or low tension elastics may be per-
ducted with the classes as a whole. Phase II patients
formed in phase I or phase II programmes early
who have recently had a cardiac event should be
post MI, CABG, or other surgery, provided the
watched closely for proper form, symptoms, or
patient has performed a symptom-limited graded
signs of intolerance as they participate in these
exercise test and is medically stable.[22,25,231] The
lower level resistive activities.
rationale for this is that most patients perform var-
Upon completion of a follow-up symptom-
ious types of isodynamic activities including lift-
limited graded exercise test (usually performed 6
ing, carrying, or pushing in their daily routines.
to 12 weeks post cardiac event or CRP entry) pa-
Therefore, they should be prepared to return to
tients may be able to participate in higher intensity
daily living patterns as soon as possible after a car-
diac event. Resistive exercise should be performed resistive exercise.f 1381 It has previously been rec-
through a full range of motion for maximum bene- ommended that patients participate regularly in
fit and should not impede normal breathing.[232,233] CRP sessions for at least 12 to 16 weeks before
Patients who have had recent chest surgery should beginning heavier resistive exercise.l5.24.27,28] This
avoid exercises which put undue pressure on the time period allows for sufficient clinical observa-
sternum (i.e. bench presses, 'flys'). tion, patient education, wound healing from CABG
Elastic exercise is an excellent resistive mode or other types of cardiac surgery, and for cardio-
for patients who have had recent CABG or other respiratory and musculoskeletal adaptations to oc-
types of chest surgery because of its low intensity, cur. However, some investigators have shown that
graduated resistance, and the potential for range of heavier weight lifting or CWT may be initiated as
motion improvement. Elderly patients may have early as 2 to 10 weeks post MI or CABG surgery
limitations in neuromuscular coordination which in properly screened, low to moderate risk pa-
may be exacerbated by fatigue, thus, light machine tients. [2, 15.26,57,89]
weights may be preferable to free weights for some Haennel et alP] observed that male patients
patients,l157] However, multi station, heavier resis- who were 9 to 10 weeks post CABG surgery (New
tance free weight exercise has been shown to be York Heart Association Class I or II and no angina
safe and to improve balance in some older pa- following surgery) who performed hydraulic CWT
tients,l65] Abdominal muscles should be condi- (3 circuits per day, with 12 to 16 repetitions per
tioned using curl-ups or 'crunches'. Other types of station) had no abnormal cardiovascular or sterno-
exercises which isolate the abdominal muscles and tomy complications during resistive exercise test-
do not put excessive stress on the spine or lower ing or training.
Stewart et al.[lS] found that properly screened, low ejection fractions (12 to 40%) in their investi-
low risk male patients 2 weeks or more post MI gations and have observed no significant cardio-
tolerated CWT (12 to 15 repetitions at 40% of vascular complications with moderate to high re-
lRM) very well without sustained arrhythmias or sistive exercise testing and training. Sheldahl et
ischaemic episodes. They concluded that CWT aI.l76] did report PVCs, elevated diastolic BPs, and
may be incorporated into CRP sessions soon after angina in some patients. Thus, it may be feasible to
MI to promote greater increases in strength and develop resistive exercise prescriptions for prop-
cardiovascular endurance than aerobic exercise erly screened, higher risk CRP participants. How-
alone. Squires et aU S7 ] also concluded that machine ever, this area needs much further study before re-
resistive exercise can be performed safely early (17 sistive exercise can be routinely recommended for
days or more) post CABG surgery or MI in younger higher risk populations.
male participants (mean age 45 15 years). The EF In summary, it has been shown that low level
of the participants in this study ranged from 21 to resistive ex.ercise can be initiated soon after cardiac
83% (mean EF = 48%) and 4 participants had EFs event or entry into a phase II programme. Based on
less than 40%. No abnormal cardiovascular recurrent literature, it may be feasible to start CRP
sponses or sternotomy complications were noted participants with heavier resistive exercise training
during resistive testing or training in this patient or CWT earlier post-cardiac event than previously
population. These findings suggest that heavier re- recommended, i.e. 2 to 10 weeks. Furthermore,
sistive exercise may be performed safely with ma- when adequate precautions have been taken, mod-
erate to high risk CRP participants may be able
chine weights in a circuit fashion relatively early
to perform low to moderate resistive workloads
post cardiac event for carefully screened, low to
safely. Further research is necessary in higher risk
moderate risk patients. However, further research
populations and women before resistive exercise
needs to be performed in female cardiac partici-
can be routinely recommended for these patient
pants. The AACVPRl22] and ACSMl 2S 1 currently
populations. The optimal time to initiate higher
recommends that surgical or MI patients wait 3 to
intensity resistive exercise or CWT post cardiac
6 weeks before beginning resistive exercise.
event is also still under debate. Since no definitive
Resistive training protocols have recently been
guidelines have been stated, this may be an issue
shown to be safe in some moderate to high risk
which is best determined by the CRP staff on an
cardiac patients, including those with cardiomyop-
individual patient basis.
athy or impaired LV function.l s2 ,s7,s9.76] Dossa et
aUS2] studied 5 patients with congestive heart fail-
7.1 Circuit Weight Training
ure (mean age of 72 years) who had ischaemic
cardiomyopathy and low ejection fractions (mean A circuit training approach for resistive exercise
ejection fraction of 29%) during various types of has been widely recommended for cardiac patients
low level resistive exercises which included hand because this type of exercise has been reported to
gripping, Cybex testing, and weight lifting. No cardio- be safer than free weights, easier to learn and par-
vascular complications were reported during resis- ticipate, and may elicit significant gains in mus-
tive testing or training in this patient population. cular strength and lean bodyweight.l s,23,24,27,S9]
Dossa et al.[S2] concluded that low intensity Circuit weight training may also enhance bone
strength training is well tolerated in elderly pa- mineral content (especially in women), cardiovas-
tients with ischaemic cardiomyopathy and conges- cular endurance, and provide additional benefits
tive heart failure, although further research is for the CRP participant through risk factor reduc-
needed in other high risk patient populations. tion.lS.6,17,23,98,122,234-237] This type of resistive train-
Sheldahl et al.l 76] Squires et aI.lS71 and Vander et ing mayl168] or may not[23S] improve joint range of
al.[S9] have all included higher risk patients with motion.
Adis International Lirnited. All rights reserved. Sports Med. 1996 May: 21 (5)
One of the benefits of using machines in a cir- Table V. Circuit weight training parameters for cardiac patients[19.22-28j
cuit fashion is the ability to start with low resis- CWT Parameter Cardiac Recommendations
tance and then progressively add small incremental Resistance 30-60% of 1RM or low to moderate
loads. The 'overload principle' must be applied weight loads
gradually for the safety and effectiveness of re- Repetitions 8-20 (10-15 most often recommended)
sistance training in cardiac populations. If CRPs Exercise duration 20-30 minutes
cannot afford machines or have space limitations, Number of stations 5-18
excellent low-cost resistive circuits may be devel- Number of 1-3
oped using a combination of dumb-bells, elastics, circuits/sets Depends upon patient fitness level and
time allotment for resistive exercise
bar-bells, free weights, wall pulleys, aerobic equip-
Rest interval between ~30 seconds
ment, plastic containers, or cloth bags. If bar-bells
stations Potential for greater improvement in
are used, patients should be allowed adequate time cardiovascular endurance with shorter
for proper orientation and spotters may be re- rest intervals
quired. Each CWT programme should be individ- Greater HR/BP recovery with longer rest
intervals and less risk of cardiovascular
ualised and patients should move through the cir- complications
cuit at a moderate pace. Some CRP participants Speed of muscle Lift to a count of 2, lower to a count of 4
may choose to simply perform machine or free contraction Complete limb flexion/extension
weight exercises over a longer time period, without Placement of CWT After the CRP aerobic phase. Assures
emphasis on CWT. session adequate warm-up, less risk of
muscoskeletal injury, and prioritises
The parameters of CWT include the following aerobic phase
(see table V): Frequency Alternating 2-3 days/week
weight load Progression Increase resistance once 10-15 reps can
repetitions be performed comfortably (RPE 11-13)
Increase sets depending upon time
exercise duration allotment for session, fitness level, and
rest period duration between stations fatiguability of the participant
the number of circuits to be completed each ses- Specificity All major muscle groups. Exercise large
muscles before small muscles
sion
Abbreviations: BP = blood pressure; CWT = circuit weight training;
the number of sessions each week HR = heart rate; reps = repititions; RM = repetition maximum; RPE
Circuit weight training should be performed on = rating of perceived exertion_
alternating days, 2 to 3 days per week, in conjunc-
tion with the regularly scheduled CRP sessions or
under staff supervision. One exercise circuit com- tions and then increase workloads over time, fol-
prised of 8 to 14 stations may be performed ini- lowing the overload principal (see section 7.2). Mus-
tially with low to moderate weight loads. cular endurance is best developed by lifting lighter
Training resistive loads should be 30 to 60% of resistance with a greater number of repetitions, and
1RM, if this method is used to determine training muscular strength is best developed by using heav-
resistance.[7,24-26,33,39, 591 Selected low risk partici- ier weights with fewer repetitionsP2,238-2401
pants who are aerobically trained and medically Typically, patients should perform 8 to 20 rep-
stable who have performed at least 3 months of etitions per station (10 to 15 repetitions have been
CWT may eventually progress to work loads cor- most often recommended in the literature) with 30
responding to 60 to 80% of lRMJ221 A 'titration' to 60 second rest intervals between stations. Rest
technique may also be used for determining resis- intervals of 30 seconds have been shown to facili-
tive training workloadsp5,28, 1381 With this tech- tate higher V0 2 levels than rest intervals of 60 sec-
nique, CRP participants use an initial weight load onds in healthy individuals)901Rest periods shorter
that can be lifted comfortably for 12 to 15 repeti- than 60 seconds also produce a higher elevation in
blood lactate levelsp38,239] Rest periods of 60 sec- eters, increased fatigue and potentially an in-
onds or greater may allow for recovery of HR and creased risk of musculoskeletal injuries.[58,138,240]
BP between stations for cardiac patients, but may It is more important to perform 1 to 2 sets with
also decrease the ability of the circuit to improve proper form and increase the number of different
cardiovascular endurance. Since safety is of vital muscle groups exercised, rather than to do fewer
importance in CRPs, longer rest intervals and/or muscle groups and perform 3 sets of each exercise.
higher repetitions with lighter weights may be war- Patients with CAD should not perform multirepeti-
ranted for some patients. Each CWT session should tion sets to fatigue)58] Stretching and flexibility
last 20 to 30 minutes and preferably be performed exercises should be performed before and/or after
after the aerobic phase of the exercise session. CWT sessions to enhance joint mobility. All resis-
There is little research on the risks and/or bene- tive training should be viewed as supplemental and
fits of combining weight lifting with aerobic exer- should not be substituted for the aerobic phase of
cise in a circuit fashion during CRP sessions. Per- the exercise session.
forming resistive exercise after the aerobic phase Regardless of the type of resistive training equip-
assures adequate warm-up, less risk of muscular or ment used, the circuit should include strengthening
orthopaedic injury, and that the aerobic phase of the exercises for all major muscle groups including:
exercise session is prioritised. Patients should al- The rhomboids, teres, latissimus dorsi, posterior
ways exhale during the weight lifting (concentric) deltoids and elbow flexors using movements
phase of muscle contraction and inhale during the similar to rowing.
weight lowering (eccentric) phase of muscle con- The deltoid and triceps muscle groups using
traction. If patients become confused with these overhead press movements.
instructions, telling them to 'breath regularly and The latissimus dorsi and elbow flexor muscles
do not hold your breath' may suffice for avoidance using pull-down movements.
of the Valsalva manoeuvre. The gluteal, quadriceps and hamstring muscle
Once patients have achieved the maximum de- groups using knee flexion/extension or leg press
exercises.
sired sets, rate of progression should be initiated
by progressively increasing the amount of weight The anterior tibialis and thigh muscle groups
using toe raisers and leg raisers.
lifted each session. Weight progression may be in-
creased by 2.5kg (SIb) to 5kg (lOlb) to when 12 to The biceps using biceps curl exercises.
15 repetitions at a given station can be handled eas- The pectoral and triceps muscle groups with
ily at an RPE of II' to 13)22] movements similar to typical push-ups and bench
presses.
The maximum number of sets performed each
The abdominal muscle groups using partial
session will depend upon the fitness level of the
curl-ups, crunches, or equivalent abdominal ex-
participant, the rest intervals between stations, and
ercises.
the time allotted for the training session. One to
Cardiac patients should exercise large muscle
three sets of each resistive exercise have been rec-
ommended.[2225,138,231] Patients should not perform groups before small muscle groups and should al-
ternate between upper body and lower body exer-
greater than 3 sets per session due to the potential
cises during resistive sessions.
for muscle fatigue and injury. Cardiac participants
may attempt to work up to 3 sets per session, al-
7.2 Determining Resistive Training Load
though the time allotment may not allow for this
amount of work and many patients may be limited Many variations of IRM testing have been used
by fatigue. Longer CWT sessions have been asso- in resistive training protocols for estimating train-
ciated with higher dropout rates, smaller additional ing workloads and exercise prescription in cardiac
gains in strength, increased haemodynamic param- populations.[5,27,54,56,59,138,238,241] How safe is IRM
Adis International Limited. All rights reseNed. Sports Med. 1996 May; 21 (5)
testing for CRP participants? Studies which have ing lRM and maximal isokinetic strength testing
monitored physiological parameters (Le. BP, HR, in apparently healthy men (n = 5460) and women
ECG) in properly screened patients have shown no (n =1193) aged from 20 to 69 years. Moreover, no
significant ST-segment depression or arrhythmias, cardiovascular complications were observed in this
abnormal HRlBP responses, or sternotomy com- medically screened, low-risk population. Thus, this
plications during resistive testing up to 100% of issue warrants further research, especially in vari-
maximum voluntary contraction. [17 ,26.39.53,54,57 ,58] ous cardiac populations.
In many of these studies, resistive testing was per- Since lRM or maximal voluntary contraction
formed relatively early post cardiac event. How- testing has been the standard form of assessment
ever, although apparently physiologically safe, the for determining training resistive workloads in
orthopaedic safety of 1RM testing has been ques- many research studies, this type of testing may be
tioned in older populations. suitable for many patients. However, most CRPs
In a training study of participants aged 70 to 79 have a large percentage of older patients, and lRM
years, Pollock et aLl242] observed that 11 of 57 par- testing may be inappropriate for these individuals.
ticipants incurred an injury during 1RM testing. If the lRM method (or variations thereof) is se-
Five of the injuries were knee related with leg ex- lected for testing, caution should be used and par-
tension testing, five were shoulder/arm injuries, ticipants should be screened carefully. Cardiopul-
and one back injury was related to chest press test- monary rehabilitation participants should not
ing. Four of the five knee injuries were related to undergo testing if they have had recent orthopaedic
limitations or are at risk of musculoskeletal injury.
prior knee complications, whereas the remaining
The ACSM,[25] and others,[28,138,231] have recom-
six injuries were unrelated to any previously known
orthopaedic problem. Pollock et aI.l242] concluded mended the acclimation technique which starts with
the lightest weight or resistance on each resistive de-
that 1RM testing is probably inappropriate for
vice. The tester monitors patient responses for 10
older men and women who have joint problems
to 12 repetitions or has them exercise to an RPE of
specific to the muscle group being tested. In a study
no greater than 13 on the Borg[243] category scale
of resistive testing in cardiac patients, Wilke et
(,somewhat hard'). If the patient is asymptomatic
aLl17] observed shoulder injuries in 2 patients dur-
and tolerates that resistive workload well, the resis-
ing 1RM upper body testing performed at 4 and 12
tance is increased to higher workloads every 1 to 2
week follow-up testing intervals. Both of these pa-
weeks. This technique facilitates better patient orien-
tients had a prior history of shoulder injuries. Con-
tation, puts less initial stress on the patient, and may
versely, Shaw et aLl241] found that 81 of 83 healthy
allow for a more accurate resistive exercise prescrip-
elderly men and women (65.8 6.2 years) per- tion. Cardiopulmonary rehabilitation staff may also
formed 1RM testing with chest press, leg exten- prescribe training workloads by using the Borg cat-
sion, abdominal curl, arm curl and seated calf raise egory or category-ratio RPE scales alone)243] An
exercises safely and without injury. Participants RPE rating of 11 to 14 on the category scale or a 3
were divided into groups with no weight training to 4 on the category ratio scale during resistive test-
experience (n =32), less than 6 months of training ing indicates a suitable initial training workload. It is
(n = 24), and greater than 6 months of training ultimately up to the CRP programme director and
(n = 27). Only 2 participants with no weight train- staff to determine which testing protocol is most
ing experience sustained injuries, which were a suitable for the individuals being tested.
back injury in one participant and a rib fracture in
the other. Shaw et aI.l24 I] concluded that with 7.3 Patient Instruction and Safety
proper preparation, lRM testing can be a safe as-
sessment tool for the geriatric population. Gordon Proper instruction is important to assure that
et aI.l240] found no orthopaedic complications dur- CRP participants perform resistive training safely
Adis International Limited, All rights reserved, Sports Med. 1996 May; 21 (5)
and mechanically efficient with a low risk of mus- (4) Termination criteria for resistive exercise
culoskeletal injury or adverse cardiac events. It is should be identical for all cardiac exercises. A sum-
important that the CRP medical director approves mary of termination criteria adapted from the
any type of heavier resistive training programme AACVPR,[22] ACSM,[25] and AHA[223,224] stand-
for the patient and 'signs off' on the exercise pre- ards is presented in table VI. Strict observation for
scription. Following are suggestions for patient common cardiac symptoms such as angina, dizzi-
instruction and safety which have been recom- ness, syncope, palpitations, and fatigue should be
mended from a variety of published sources and followed. An excessive rise or drop in BP or the
guidelines: development of significant dysrhythmias warrants
(1) Participants of CRPs should be thoroughly termination of the resistive exercise session. Pa-
oriented to each modality or piece of equipment by tients must learn to monitor their own symptoms
an exercise specialist or physical therapist. Initial and to report any unusual symptomatology to CRP
orientation and testing should be performed on an staff. It is important that the patient become self-
individual basis to assure that the patient learns to sufficient in this respect and that he/she does not
perform the exercises safely and efficiently. Ample rely on CRP staff for continuous monitoring or su-
time should be allowed for questions, testing, and pervision during resistive training.
practice on each resistive modality during the ini-
(5) A fully equipped crash cart, defibrillator, oxy-
tial exercise session. A complete description of the
gen, and all necessary emergency equipment should
mechanical function of each piece of apparatus,
be readily available in the event of cardiopulmo-
correct body position, and warnings about the risk
nary complications. Advanced cardiac life support
of improper usage should be provided. [27 .241,244,245]
trained personnel should be ready to respond to
(2) Patients should be instructed to maintain a
emergency situations. Periodic drills with simu-
loose, comfortable grip during muscle contraction
lated code situations should be performed in the
on each piece of equipment or to perform the lift
resistive training area on a regular rotating basis.
with the palm/fingers extended to reduce pure iso-
(6) During the early resistive exercise sessions,
metric exercise components. Sustained hand grip-
the RPE should not exceed 15 on the Borg category
ping on other pieces of resistive equipment (i.e.
scale or 5 on the category-ratio scale. Generally,
bands, dumb-bells) should be avoided. Demonstra-
tion of proper breathing technique (i.e. exhalation RPE values should range from 'fairly light' (11) to
with exertion) and the dangers of the Val salva 'somewhat hard' (13) on the category scale or 'weak'
manoeuvre should be emphasised in the initial (2) to 'somewhat strong' (4) on the category-ratio
training sessions. scale. As the patient adapts to resistive exercise, the
(3) Movements through a full range of motion RPE values may progress to 15 to 16 on the cate-
should be performed on each piece of equipment gory scale or 5 to 7 on the category-ratio scale.[l38]
or with each resistive modality. Range of motion Recording of RPE may also be useful for modifi-
limitation may be warranted for some patients with cation of weight progression.
orthopaedic limitations. Machine weights, if used, (7) An exercise specialist, athletic trainer, or
should be raised with slow, controlled movements physical therapist should be designated to super-
to a count of two and lowered gradually to a count vise the strength training area during cardiac resis-
of four. Large muscle groups should be exercised tive exercise. This person should ensure that the
before small muscle groups for both the upper and patient is using proper training technique and that
lower body. The patient is responsible for log re- the exercise prescription is being followed. This
cording of weight lifted, repetitions, and any phys- person should also ensure that HR and BP, if taken,
iological measurements taken on individual ma- are being measured accurately during muscle con-
chines or with resistive modalities. traction.
Table VI. Criteria for termination of a resistive exercise ses- (9) The resistive equipment should be main-
sion. [22.25.223.224]
tained on a regular schedule of preventive mainte-
Acute MI or suspicion of MI nance and cleaned frequently. Cardiopulmonary
Signs of poor perfusion including pallor, cyanosis, or cold and rehabilitation staff should follow established
clammy skin
guidelines for care and maintenance of all appara-
Central nervous symptoms including ataxia, vertigo, visual or
gait problems tus and risk management should be prioritised for
Lightheadedness, confusion, ataxia, nausea, or severe patient safety. Participants of CRPs should have
peripheral circulating insufficiency knowledge of any potential risks of using resistive
Onset of angina with resistive exercise equipment prior to participationP41,244,245]
Drop in systolic blood pressure accompanied by
signs/symptoms or drop below standing resting pressure
7.4 Haemodynamic Monitoring
Excessive blood pressure rise measured during lifting: systolic
2220mm Hg or diastolic 21 OOmm Hg
Haemodynamic monitoring is an important com-
Inappropriate bradycardia (decrease in heart rate >10 beats/min)
during resistive exercise ponent of cardiac resistive training for selected in-
Symptomatic supraventricular tachycardia or other dividuals. Moderate to high risk patients should
exercise-induced complex supraventricular dysrhy1hmias always be carefully screened and may require more
Pronounced ST changes (22 mm) from rest from telemetered extensive monitoring to help identify cardiac in-
EGG recordings
sufficiency and to prevent cardiovascular compli-
Onset of frequent ventricular ectopy and/or ventricular
tachycardia (3 or more consecutive PVCs)
cations during resistive training. However, most of
Exercise induced left bundle branch block which cannot be
the aforementioned studies have shown that resis-
distinguished from a wide QRS tachycardia tive training is very safe for low, moderate, and
Severe dyspnoea, wheezing, fatigue even selected high risk patients and this topic war-
Onset of second and/or third degree atrioventricular block from rants further study. It is our opinion that little
telemetry or quick look recordings haemodynamic monitoring is needed for most
New onset or aggravation of pre-existing orthopaedic or properly screened patients based on current re-
muscular problem that would prohibit continuation of the
resistive session search and published guidelines. Too much moni-
Fai[ure to comply with exercise prescription, proper lifting toring could potentially distract the CRP partici-
technique, and/or appropriate log recording (i.e. recording of pant from achieving the full benefits of resistive
physiological parameters, amount of resistance, number of
training and could promote more dependency on
repetitions)
CRP staff. This would defeat the purpose of attain-
Discomfort related to past surgery (i.e. CABG, i[ia[ bypass,
rotator cuff) ing the goals of improved self-efficacy and self-
Rating of 17 or above on the Borg category RPE scale image.
Abbreviations: CABG =coronary artery bypass grafting; PVC =pre- The RPP has generally been shown to be a good
mature ventricular complex; MI = myocardial infarction; RPE = rating indicator of MV'02. Recording of HR and BP dur-
of perceived exertion.
ing muscle contraction may be valuable in some
patients to provide an estimate of MV'02 during
resistive exercise. BP should be recorded prior to
(8) The CRP staff should periodically review
and periodically during the resistive training ses-
the patient's exercise logs to monitor rate of pro-
sions for hypertensive patients, those who may be
gression and to specify changes in the resistive ex-
at risk of cardiovascular complications, or those
ercise prescription. Resistive progression will vary who are predisposed to hypertensive/hypotensive
depending upon the patient's functional capacity, episodes. If taken, it has been recommended that
cardiovascular status, bodyweight and strength. BP be recorded mid-way and/or at the end of the
Generally, advancement of resistance should be no circuit. [27]
greater than 2.2kg (SIb) for arm exercise and up to Due to the rapid drop in BP seen immediately
4.5kg (lOlb) for leg exercise per session. post-lifting,[33,34] recordings taken at non-moving
body sites (i.e. ankles) during lifting may provide exercise prescription, the RPP at which signs or
a more accurate measurement of arterial pressure. symptoms of myocardial ischaemia or cardiac in-
Measurements may also be taken in one arm while sufficiency appear during sign or symptom limited
the patient continues to exercise with the other arm graded exercise.
or with the legs. Staff members may need to mon- The aforementioned monitoring recommenda-
itor some patients for postural hypotensive changes tions are based upon studies which have monitored
as they move from station to station. Since BP often haemodynamic variables in cardiac patients during
cannot be accurately assessed at the brachial artery resistive training and on previously published
during repetitive upper body weight lifting due to guidelines. The degree ofhaemodynamic monitor-
limb movement, measurements taken at the dor- ing will vary based upon risk stratification, cardiac
salis pedis artery with a pneumatic cuff and Dopp- pathology, and the patient's level of cardiovascular
ler stethoscope (if available) may provide greater endurance. In general, when performing resistive
accuracy and a better indication of arterial BP dur- exercise, CRP participants should not elicit haemo-
ing upper body resistive activities.l 19 ,58 1 Ambula- dynamic responses greater than those observed at
tory BP units may also be useful in this respect, 85% of Y0 2max or at the ischaemic threshold from
although the measurement site must be stationary the symptom-limited graded exercise test.l 33 ,581
for accurate BP analysis. Until further research has been published and
HR should be taken during or immediately fol- guidelines for cardiac monitoring during resistive
lowing muscle contraction in selected patients dur- training have been presented, it may be best to take
ing resistive training. Those who are known inten- a prudent approach with more-vigilant monitoring
sity violators of exercise prescription should have for higher risk patients, especially during the early
HRs closely monitored and should be instructed phases of resistive training. However, no additional
not to exceed their prescribed aerobic target HR monitoring or staff supervision is necessary for
resistive exercise than what would normally be re-
zone. Periodic 'quick check' rhythm strip checks,
quired for a CRP session. It is important that car-
radiotelemetry, or ambulatory Holter monitoring
diac patients become self-sufficient and that they
may be useful for monitoring HRIECG for inten-
do not rely on CRP staff for continuous monitoring.
sity violators or higher risk patients with known
Less haemodynamic monitoring will probably be
dysrhythmias. Those who are at higher risk of car-
acceptable in the future for most CRP participants
diac complications or who cannot monitor their HR
and presently low risk patients may require little
due to physical or intellectual impairment[ 2461 may
or no cardiovascular monitoring during resistive
be well-suited for continuous telemetered ECG
exercise.
monitoring to assure accurate HR estimation and
arrhythmia documentation. The RPP can be calcu-
lated accurately if HR and BP are recorded during
8. Conclusion
actual lifting movements and may provide a better Cardiopulmonary rehabilitation programmes
indication of cardiovascular stress than either HR are designed to enhance the quality of life and mod-
or BP alone. Resistive training will elicit an in- ify CAD risk factors so that participants may return
crease in RPP through a higher systolic pressure to everyday job duties and recreational pursuits as
response while HR may be lower than with tradi- soon as possible after a cardiac event. Restoration
tional aerobic exercise. Periodic monitoring of of muscular strength and range of motion to resume
RPP may be warranted for some patients to ensure daily living habits is essential for all patients, par-
that they do not exceed the RPP at which signs/ ticularly the elderly. Since most daily activities in-
symptoms of myocardial ischaemia appear during volve upper and lower body movements, resistive
graded exerciseP51The resistive activity recording exercise training should become an important ad-
form should include, within the patient's resistive junct for all CRPs. Appropriately prescribed resis-
tive exercise has been shown to be safe for many daily strength tasks safely, more efficiently, and
cardiac patients, even at relatively high workloads. with greater self-confidence.
Resistive exercise has not been shown to exacer-
bate HR or systolic BP responses beyond clinically Acknowledgements
acceptable levels. However, diastolic BP may be The authors wish to extend sincere appreciation to Eric
greater than that observed during aerobic exercise. Shoup, Greg McElveen, Ken Witt and Don Bergey for their
The benefits or risks of higher diastolic BPs remain work on the Resistive Exercise Task Force and for their
to be seen. contribution to this manuscript. The authors would also like
to thank the members of the North Carolina Cardiopulmo-
Circuit weight training has been shown to im-
nary Rehabilitation Association members for their support,
prove strength, bone mass, lean body mass, self- suggestions, and implementation of cardiac resistive exer-
efficacy, and decrease some risk factors for CAD. cise training in their programmes.
Many cardiac studies have provided evidence that
CWT, when combined with aerobic exercise, pro- References
I. Goldberg AP. Aerobic and resistive exercise modify risk factors
vides beneficial central and/or peripheral cardio- for coronary heart disease. Med Sci Sports Exerc 1989; 21:
vascular adaptations over aerobic training alone. 669-74
However, CWT may not supply the needed stimu- 2. Haennel RG, Quinney HA, Kappagoda CT. Effects of hydraulic
circuit training following coronary artery bypass surgery.
lus to beneficially alter BP or lipid/lipoprotein lev- Med Sci Sports Exerc 1991; 23: 158-65
els. Since few investigators have examined long 3. Hurley BF, Kokkinos PF. Effects of weight training on risk
factors for coronary artery disease. SportsMed 1987; 4: 231-8
term resistive training adaptations in cardiac or 4. Hurley BF, Hagberg JM, Goldberg AP, et al. Resistive training
high risk populations, there is a need for further can reduce coronary risk factors without altering V02max or
percent body fat. Med Sci Sports Exerc 1988; 20: 150-4
research on the effects of chronic resistive exercise 5. Kelemen MH, Stewart KJ, Gillilan RE, et al. Circuit weight
on blood chemistry and other CAD risk factors. training in cardiac patients. J Am Coli Cardio11986; 7: 38-42
Overall, there are significant benefits with little 6. McCartney N, McKelvie RS, Haslam DRS, et al. Usefulness of
weightlifting training in improving strength and maximal
risk of untoward events for participants of properly power output in coronary artery disease. Am J Cardiol 1991;
supervised cardiac resistive training programmes. 67: 939-45
7. McKelvie RS, McCartney N. Weightlifting training in cardiac
Important issues which should be examined further patients: considerations. Sports Med 1990; 10: 355-64
include the acute and long term cardiovascular and 8. Smutok MA, Reece C. Kokkinos PF, et al. Aerobic versus
strength training for risk factor intervention in middle-aged
metabolic effects of resistive exercise in patients men at high risk for coronary artery disease. Metabolism 1993;
with impaired left ventricular function, cancer, re- 42: 177-84
9. Stewart KJ. Resistive training effects on strength and cardio-
nal disease, obstructive lung disease, and diabetes. vascular endurance in cardiac and coronary prone patients.
There have been few studies on resistive training Med Sci Sports Exerc 1989; 21: 678-81
in women with CAD. Future investigators should 10. Stone MH, Fleck SJ, Triplett NT, et al. Health- and performance-
related potential of resistance training. Sports Med 1991; II:
continue to incorporate continuous invasive and 210-31
noninvasive cardiovascular monitoring techniques II. Stone MH, Wilson GO. Resistive training and selected effects.
Med Clin North Am 1985; 69: 109-21
to fully assess the risks, benefits, and complication 12. Ewart CK, Stewart KJ, Gillilan RE, et al. Self-efficacy mediates
rates of resistive exercise in higher risk and elderly strength gains during circuit weight training in men with cor-
onary artery disease. Med Sci Sports Exerc 1987; 18: 531-40
individuals, and provide recommendations for these 13. Ewart CK. Psychological effects of resistive weight training:
patients. Guidelines for isometric and isodynamic implications for cardiac patients. Med Sci Sports Exerc 1989;
exercise also need to be developed for all patient 21: 683-8
14. Stewart KJ, Mason M, Kelemen MH. Three-year participation
populations. Presently, CRP personnel may safely in circuit weight training improves muscular strength and
prescribe resistive exercise for most of their partic- self-efficacy in cardiac patients. J Cardiopulm Rehabil 1988;
8: 292-6
ipants. Risk factor intervention of this nature will 15. Stewart KJ, McFarland LD, Weinhofer JJ, et al. Weight training
hopefully encourage lifetime behaviour changes, soon after myocardial infarction [abstract]. Med Sci Sports
Exerc 1994; 26 Suppl. I: 32
improve strength and endurance, improve self- 16. Svedahl K, Haennel RG, Hudec R, et al. The effects of circuit
image, and better prepare the patient to return to training on the physical fitness of post-myocardial infarction
(MI) patients [abstract]. Med Sci Sports Exerc 1994; 26 38. Siegel W, Gilbert CA, Nutter DO. Use of isometric handgrip for
Suppl. I: 185 the indirect assessment of left ventricular function in patients
17. Wilke NA, Sheldahl LM, Levandoski SG, et al. Transfer effect with coronary atherosclerotic heart disease. Am J Cardiol 1972;
of upper extremity training to weight carrying in men with 30: 48-54
ischemic heart disease. J Cardiopulm Rehab 1991; II: 365-72 39. Butler RM, Beierwaltes WH, Rogers FJ. The cardiovascular
18. Fletcher GF, Blair SN, Blumenthal J, et al. American Heart response to circuit weight training in patients with cardiac
Association statement on exercise - benefits and recommen- disease. J Cardiopulm Rehabil 1987; I: 402-9
dations for physical activity programs for all Americans. Cir- 40. Effron MB. Effects of resistance training on left ventricular
culation 1992; 86: 340-4 function. Med Sci Sports Exerc 1989; 21: 694-7
19. Franklin BA, Bonzheim K, Gordon S, et al. Resistance training 41. McKool K, Nelson KM. A practice of cardiac rehabilitation.
in cardiac rehabilitation. J Cardiopulm Rehab 1991; II: 99-107 Cardiol Clin 1985; 3: 269-80
20. Hanson P, Nagle F. Isometric exercise: cardiovascular responses 42. Saito M, Yamazaki T, Goto Y, et al. Cardiovascular responses
in nonnal and cardiac populations. Cardiol Clin 1987; 5: 157-70 during ordinary activities in healthy subjects: predominance
21. Painter P, Hanson P. Isometric exercise: implications for the of blood pressure response over heart rate in activities with
cardiac patient. In: Hall LK, Meyer GC, editors. Cardiac re- isometric components. J Cardiopulm Rehabil 1987; 7: 253-8
habilitation: exercise testing and prescription. Champaign 43. Elkayam U, Roth A, Weber L, et al. Isometric exercise in pa-
(IL): Life Enhancement Publishers, 1984: 223-42 tients with chronic advanced heart failure: hemodynamic and
22. American Association of Cardiovascular and Pulmonary Reha- neurohumoral evaluation. Circulation 1985; 72: 975-81
bilitation. Guidelines for cardiac rehabilitation programs. 44. Keren G, Katz S, Gage J, et al. Effect of isometric exercise on
Champaign, (lL): Human Kinetics, 1995; 44-51 cardiac perfonnance and mitral regurgitation in patients with
23. Gettman LR, Pollock ML. Circuit weight training: a critical severe congestive heart failure. Am Heart J 1989; 118: 973-9
review of its physiological benefits. Physician Sports Med 1981; 45. Sagiv M, Hanson P, Besozzi M, et al. Left ventricular responses
9: 44-60 to upright isometric handgrip and deadlift in men with coro-
24. Kelemen MH. Resistive training safety and assessment guide- nary artery disease. Am J Cardiol 1985; 55: 1298-302
lines for cardiac and coronary prone patients. Med Sci Sports 46. Clausen JP. Circulatory adjustments to dynamic exercise and
Exerc 1989; 21: 675-7 effect of physical training in normal subjects and in patients
25. American College of Sports Medicine. Guidelines for exercise with coronary artery disease. Prog Cardiovasc Dis 1976; 18:
testing and prescription. Philedelphia: Williams and Wilkins, 459-95
1995: 189-191,231-233 47. Miles DS, Cox MH, Bomze JP. Cardiovascular responses to
26. Daub WD, Knapik GP, Black WR. Strength training early after upper body exercise in nonnals and cardiac patients. Med Sci
myocardial infarction. J Cardiopulm Rehabil1996; 16: 100-8 Sports Exerc 1989; 21 Suppl. 2: 126-31
27. Sparling PB, Cantwell JD. Strength training guidelines for car- 48. Green JS, Crouse SF. Aging, cardiovascular function, and en-
diac patients. Physician Sports Med 1989; 17: 190-6 durance exercise: a review of the literature. Med Exerc Nutr
28. Verrill D, Shoup E, McElveen G, et al. Resistive exercise train- Health 1993; 2: 299-309
ing in cardiac patients: recommendations. Sports Med 1992; 49. Smith EE, Guyton AC, Manning RD, et al. Integrated mecha-
13: 171-93 nisms of cardiovascular response and control during exercise
29. Asmussen E. Similarities and dissimilarities between static and in the normal human. Prog Cardiovasc Dis 1976; 18: 421-43
dynamic exercise. Circ Res 1981; 48 Suppl. l: 3-10 50. Smith EL, Serfass RC. Exercise and aging: the scientific basis.
30. Lewis SF, Taylor WF, Graham RM, et al. Cardiovascular re- New York: Enslow Publishers, 1981
sponses to exercise as functions of absolute and relative work- 51. Stratton JR, Levy WC, Cerqueira MD, et al. Cardiovascular
load. J Appl Physiol1983; 54: 1314-23 responses to exercise - effects of aging and exercise training
31. MacDougall JD, Tuxen D, Sale DG, et al. Arterial blood pres- in healthy men. Circulation 1993; 89: 1648-55
sure response to heavy resistance exercise. J Appl Physiol 52. Dossa A, LaRaia JP, Clifford J. Effects of low intensity strength
1985; 58: 785-90 training in elderly patients with congestive heart failure due
32. Mitchell JH, Schibye B, Payne FC, et al. Response of arterial to ischemic cardiomyopathy [abstract]. Cardiopulm Phys Ther
blood pressure to static exercise in relation to muscle mass, J 1993; 4: 12
force development, and electromyographic activity. Circ Res 53. Featherstone JF, Holly RG, Amsterdam EA. Physiologic re-
1981; 48 Suppl. I: 70-6 sponses to weight lifting in coronary artery disease. Am J
33. Haslam DRS, McCartney N, McKelvie RS, et al. Direct meas- Cardiol 1993; 71: 287-92
urements of arterial blood pressure during formal weightlift- 54. Ghilarducci LE, Holly RG, Amsterdam EA. Effects of high re-
ing in cardiac patients. J Cardiopulm Rehabil1988; 8: 213-25 sistance training in coronary artery disease. Am J Cardiol
34. Wiecek EM, McCartney N, McKelvie RS, et al. Comparison of 1989; 64: 866-70
direct and indirect measures of systemic arterial pressure dur- 55. McClintock S, Bendick P, Franklin B, et al. Myocardial de-
ing weightlifting in coronary artery disease. Am J Cardiol mands of circuit weight training: comparison with aerobic
1990; 66: 1065-9 prescription [abstract]. J Cardiopulm Rehabil1988; 10: 407
35. Atkins JM, Matthews OA, Blomqvist CG, et al. Incidence of 56. Sparling PB, Cantwell JD, Dolan CM, et al. Strength training
arrhythmias induced by isometric and dynamic exercise. Br in a cardiac rehabilitation program: a six-month follow up.
Heart J 1976; 38: 465-71 Arch Phys Med Rehabil 1990; 71: 148-52
36. Kivowitz C, Parmley WW, Donoso R, et al. Effects of isometric 57. Squires RW, Muri AJ, Anderson LJ, et al. Weight training during
exercise on cardiac performance: the grip test. Circulation Phase II (early outpatient) cardiac rehabilitation. J Cardio-
1971; 44: 994-1002 pulmRehabill991; 11: 360-4
37. Mullins CB, Blomqvist G. Isometric exercise and the cardiac 58. Stralow CR, Ball TE, Looney M. Acute cardiovascular re-
patient. Texas Med 1973; 69: 53-8 sponses of patients with coronary disease to dynamic variable
resistance exercise of different intensities. J Cardiopulm 80. Collins MA, Cureton KJ, Hill DW, et al. Relationship of heart
Rehabil 1993; 13: 255-63 rate to oxygen uptake during weight lifting exercise. Med Sci
59. Vander LB, Franklin BA, Wrisley D, et al. Acute cardiovascular Sports Exerc 1991; 23: 636-40
responses to Nautilus exercise in cardiac patients: implica- 81. Gettman LR, Ayres n, Pollock ML, et al. The effect of circuit
tions for exercise training. Ann Sports Med 1986; 2: 165-9 weight training on strength, cardiorespiratory function, and
60. Cononie CC, Graves JE, Pollock ML, et al. Effect of exercise body composition of adult men. Med Sci Sports Exerc 1978;
training on blood pressure in 70- to 79-year old men and 10: 171-6
women. Med Sci Sports Exerc 1991; 23: 505-11 82. Gettman LR, Ayres n, Pollock ML, et al. Physiological effects
61. Fiatarone MA, Marks EC, Ryan ND, et al. High intensity on adult men of circuit strength training and jogging. Arch
strength training in nonagenarians. JAMA 1990; 263: 3029-34 Phys Med Rehabill979; 60: 115-20
62. Frontera WR, Meredith CN, O'Reilly KP, et al. Strength con- 83. Haennel RG, Koon-Kang T, Quinney HA, et al. Effects of hy-
ditioning in older men: skeletal muscle hypertrophy and im- draulic circuit training on cardiovascular function. Med Sci
proved function. J Appl Physiol 1988; 64: 1038-44 Sports Exerc 1989; 21: 605-12
63. Kauffman TL. Strength training effects in young and aged 84. Hempel LS, Wells CL. Cardiorespiratory cost of the Nautilus
women. Arch Phys Med Rehabil 1985; 65: 223-6 express circuit. Physician Sports Med 1985; 13: 82-97
64. Moritani T, de Vries HA. Potential for gross muscle hypertro- 85. Hurley BF, Seals DR, Ehsani AA, et al. Effects of high-intensity
phy in older men. J Gerontol 1980; 35: 672-82 strength training on cardiovascular function. Med Sci Sports
65. Parsons D, Sherrill K, Foster V, et al. Strength training improves Exerc 1984; 16: 483-8
balance and endurance for seniors. Your Patient Fitness 1993; 86. Wilmore JH, Parr RB, Ward P, et al. Energy cost of circuit weight
7: 21-4 training. Med Sci Sports Exerc 1978; 10: 75-8
66. Perkins LC, Kaiser HL. Results of short-term isotonic and iso- 87. Fardy PS, Webb D, Hellerstein HK. Benefits of arm exercise in
metric exercise programs in persons over sixty. Phys Ther cardiac rehabilitation. Physician Sports Med 1977; 5: 30-41
Rev 1961; 41: 633-5 88. Franklin BA. Exercise testing, training, and arm ergometry. Sports
67. Ferguson RJ, Cote P, Bourassa MG, et al. Coronary blood flow Med 1985; 2: 100-19
during isometric and dynamic exercise in angina pectoris pa- 89. Butler RM, Palmer G, Rogers FJ. Circuit weight training in
tients. J Card Rehabil 1981; I: 21-7 early cardiac rehabilitation. J Am Osteopath Assoc 1992; I:
68. MacGowan GA, Murali S, Loftus S, et al. Comparison of me- 77-89
tabolic, ventilatory, and neurohumoral responses during light 90. Gordon NF, Kohl HW, Villegas JA, et al. Effect ofrest interval
forearm isometric exercise and isotonic exercise in conges- duration on cardiorespiratory responses to hydraulic resis-
tive heart failure. Am J Cardiol 1996; 77: 390-6 tance circuit training. J Cardiopulm Rehabil 1989; 2: 325-30
69. Campbell BF, Sheldahl L, Wilke N, et al. Effects of upper ex- 91. Astrand PO, Ekblom B, Messin R, et al. Intra-arterial blood
tremity blood distribution on weight carrying in men with pressure during exercise with different muscle groups. J Appl
ischemic heart disease. J Cardiopulm Rehabil1993; 13: 37 -42 Physiol1965; 20: 253-6
70. DaFoe WA, Cupper L, Tan KW, Case report: a vocational as- 92. Franklin BA, Scherf J, Pamatmat A, et al. Arm-exercise testing
sessment that required a weight lifting and carrying test. J and training. Pract Cardiol 1982; 8: 43-70
Cardiopulm Rehabil 1990; 10: 126-9 93. Kozlowski S, Brzezinska Z, Nazar K, et al. Plasma catechola-
71. DeBusk R, Valdez R, Houston N. Cardiovascular response to mines during sustained isometric exercise. Clin Sci Mol Med
dynamic and static effort soon after myocardial infarction: 1973; 45: 723-31
application to occupational work assessment. Circulation 94. Jorgensen CR, Wang K, Wang Y, et al. Effect of popranolol on
1978; 58: 368-75 myocardial oxygen consumption and its hemodynamic cor-
72. Landi J, Wygand J, Otto R, et al. Hemodynamic and metabolic relates during upright exercise. Circulation 1973; 48: 1173-82
responses to two modes of load transport in patients with 95. Fleck SJ. Cardiovascular adaptations to resistive training. Med
cardiac disease. J Cardiopulm Rehabil 1994; 14: 43-6 Sci Sports Exerc 1988; 20 Suppl. I: 146-51
73. Markiewicz W, Houston N, DeBusk R. A comparison of static 96. Lowe DK, Rothbaum DA, McHenry PL, et al. Myocardial
and dynamic exercise soon after myocardial infarction. Isr J blood flow response to isometric (handgrip) and treadmill exer-
Med Sci 1979; 15: 894-7 cise in coronary artery disease. Circulation 1975; 51: 126-31
74. Rod JL, Braun JQ, Rehm LM, et al. Simulated work activity in 97. McCartney N. Acute physiological responses to resistive train-
patients with coronary artery disease: a clinical protocol. J ing. Presented at the 1993 American Association of Cardio-
Cardiopulm Rehabil 1989; 9: 439-44 vascular and Pulmonary Rehabilitation meeting: 1993 Oct
75. Schram V, Hanson P. Cardiovascular and metabolic responses 14-17; Orlando, Florida, 1993
to weight-loaded walking in cardiac rehabilitation patients. J 98. Kelemen MH, Stewart KJ. Circuit weight training: a new direc-
Cardiopulm Rehabil 1988; 8: 28-32 tion for cardiac rehabilitation. Sports Med 1985; 2: 385-8
76. Sheldahl LM, Wilke NA, Tristani FE, et al. Response to repet- 99. Wilke NA, Sheldahl LM, Tristani FE, et al. The safety of static-
itive static-dynamic exercise in patients with coronary artery dynamic effort soon after myocardial infarction. Am Heart J
disease. J Card Rehabil 1985; 5: 139-45 1985; 110: 542-5
77. Taylor JL, Copeland RB, Cousins AL, et al. The effect of iso- 100. Saldivar M, Frye WM, Pratt CM, et al. Safety of a low weight,
metric exercise on the graded exercise test in patients with low repetition strength training program (STP) in patients
stable angina pectoris. J Card Rehabil 1981; I: 450-8 with heart disease (HD) [abstract]. Med Sci Sports Exerc
78. Wilke NA, Sheldahl LM, Levandoski SG, et al. Weight carrying 1983; 15 Suppl. I: 119
versus handgrip exercise testing in men with coronary artery 101. Sheldahl LM, Wilke NA, Tristani FE, et al. Response of patients
disease. Am J Cardiol 1989; 64: 736-40 after myocardial infarction to carrying a graded series of
79. Sheldahl LM, Levandoski SG, Wilke NA, et al. Responses of weight loads. Am J Cardiol 1983; 52: 698-703
patients with coronary artery disease to common carpentry 102. Kanakis C, Hickson RC. Left ventricular responses to a pro-
tasks. J Cardiopulm Rehabil 1993; 23: 283-90 gram oflower-limb strength training. Chest 1980; 78: 618-21
103. Fixler ED, Laird WP. Acute hemodynamic responses of hyper- 124. Gettman LR, Ward P, Hagan A. A comparison of combined
tensive adolescents to strenuous weightlifting [abstract]. Med running and weight training with circuit weight training. Med
Sci Sports Exerc 1979; 78 Suppl. I: 78 Sci Sports Exerc 1982: 14; 229-34
104. Kusinitz I, Keeny Cw. Effects of progressive weight training 125. Hickson RC. Interference of strength development by simulta-
on health and physical fitness in adolescent boys. Res Q 1958; neously training for strength and endurance. Eur I Appl Phys-
29: 294-301 iol 1980; 215: 255-63
105. Stone MH, Nelson JK, Nader S, et al. Short-term weighttraining 126. Hickson RC, Rosenkoetter MA, Brown MM. Strength training
effects on resting and recovery heart rates. Athletic Training effects on aerobic power and short tenn endurance. Med Sci
1983; 18: 69-71 Sports Exerc 1980; 12: 336-9
106. Lusiani L, Ronisvalle G, Bonanome G. Echocardiographic evalu- 127. Kimura Y, Hoh H, Yamazaki S. The effects of circuit weight
ation of the dimensions and systolic properties of the left ven- training on VOZ max and body composition of trained and un-
tricle in freshmen athletes during physical training. Eur Heart trained college men. I Physiol SOF Ipn 1981; 43: 593-6
11986; 7: 196-203 128. Messier SP, Dill ME. Alterations in strength and maximal oxy-
107. Ricci G, Lajoie 0, Petitclerc R, et al. Left ventricular size fol- gen uptake consequent to Nautilus circuit weight training. Res
lowing endurance, sprint, and strength training. Med Sci Sports Q Exerc Sport 1985; 56: 345-51
Exerc 1982; 14: 344-7 129. Kass IE, Castriotta RI. The effect of circuit weight training on
108. Stone MH, Wilson GO, Blessing 0, et al. Cardiovascular re- cardiovascular function in healthy sedentary males. I Cardio-
sponses to short term Olympic style weight training in young pulm Rehabil1995: 14: 378-83
men. Can I Appl Sport Sci 1983; 8: 134-9 130. Stone MH, O'Bryant H, editors. Weight training: a scientific
109. Petersen SR, Haennel RG, Kappagoda CT, et al. The influence approach. Edina (MN): Bellwether Press, 1987
of high-velocity circuit resistance training on VOzmaxand car- 131. Fleck SI, Kraemer WI. Resistance training: physiological re-
diac output. Can J Sport Sci 1989; 14: 158-63
sponses and adaptations (Pt 2 of 4). Physician Sports Med
110. Allen TE, Byrd RJ, Smith DP. Hemodynamic consequences of 1988; 16: 108-24
circuit weight training. Res Q 1976; 47: 299-306
132. Gardner AW, Ades PA. Reliability of cardiopulmonary exercise
III. Derman EW, Scales N, Clark DR, et al. Circuit weight training measures and their response to endurance training in older
improves exercise tolerance of cardiac rehabilitation patients
patients with coronary disease. I Cardiopulm Rehabil 1993;
without causing left ventricular hypertrophy [abstract]. Med
13: 188-93
Sci Sports Exerc 1994; 26 Suppl. I: 142
133. Rogers MA, Evans WI. Changes in skeletal muscle with aging
112. Wiley RL, Dunn CL, Cox RH, et al. Isometric exercise training
effects of exercise training. In: Holloszy 10, editor. Exercise
lowers resting blood pressure. Med Sci Sports Exerc 1992;
and sports science reviews. Baltimore: Williams & Wilkins,
24: 749-54
1993:65-102
113. Harris KA, Holly, RG. Physiological response to circuit weight
134. Brown AB, McCartney N, Sale DG. Positive adaptations to
training in borderline hypertensive subjects. Med Sci Sports
Exerc 1987; 19: 246-51 weightlifting training in the elderly. I Appl Physiol 1990; 69:
1725-33
114. Hagberg 1M, Ehsani AA, Goldring 0, et al. Effect of weight
training on blood pressure and hemodynamics in hypertensive 135. Stone MH, Blessing 0, Byrd R, et al. Physiological effects of a
adolescents. J Pediatr 1984; 104: 147-51 short-term resistive training program on middle-aged un-
115. O'Conner PJ, Bryant CX, Veltri JP, et al. State anxiety and am- trained men [abstract]. I Natl Strength Cond Assoc 1982; 16: 20
bulatory blood pressure following resistive exercise in fe- 136. Pyka G, Lindenberger E, Charette S, et al. Muscle strength and
males. Med Sci Sports Exerc 1993; 25: 516-21 fiber adaptations to a year-long resistance training program in
116. Colliander EB, Tesch PA. Blood pressure in resistance-trained elderly men and women. J Gerontol1994; 49: 22-7
athletes. Can J Sports Sci 1988; 13: 31-4 137. Stewart KJ, Effron MB, Valenti SA, et al. Effects of diltiazem
II? Blumenthal lA, Siegel WC, Appelbaum M. Failure of exercise or popranolol during exercise training of hypertensive men.
to reduce blood pressure in patients with mild hypertension. Med Sci Sports Exerc 1990; 22: 171-7
lAMA 1991; 266: 2098-104 138. Pollock ML, Welsch MA, Graves IE. Exercise prescription for
118. Fahey TO, Brown CH. The effects of an anabolic steroid on the cardiac rehabilitation. In: Pollock ML, Schmidt DH, editors.
strength, body composition, and endurance of college males Heart disease and rehabilitation. Champaign (IL): Human
when accompanied by a weight training program. Med Sci Kinetics, 1995: 265-6
Sports Exerc 1973; 5: 272-6 139. Ballor DL, Katch VL, Becque MD, et al. Resistance weight
119. Kokkinos PF, Hurley BF, Smutok MA, et al. Strength training training during caloric restriction enhances lean body weight
does not improve lipoprotein-lipid profiles in men at risk for maintenance. Am J Clin Nutr 1988; I: 19-25
CHD. Med Sci Sports Exerc 1991; 23: 1134-9 140. Johnson CC, Stone MH, Lopez SA, et al. Diet and exercise in
120. Muller EA. Physiological methods of increasing human physi- middle-aged men. I Am Diet Assoc 1982; 81: 695-701
cal work capacity. Economics 1965; 8: 409-24 141. Manning 1M, Dooly-Manning CR, White K, et al. Effects of a
121. Nagle FI, Irwin LW. Effect of two systems of weight training resistive training program on lipoprotein-lipid levels in obese
on circulorespiratory endurance and related physiological women. Med Sci Sports Exerc 1991; 1222-6
factors. Res Q 1960; 31: 607-15 142. Ullrich IH, Reid CM, Yeater RA. Increased HDL-cholesterol
122. Wilmore IH, Parr RB, Girandola RN, et al. Physiological alter- levels with a weight training program. South Med I 1987; 80:
ations consequent to circuit weight training. Med Sci Sports 328-31
Exerc 1978; 10: 79-84 143. Gotto AM, LaRosa IC, Hunninghake 0, et al. The cholesterol
123. Gettman LR, Cutler LA, Stratham TA. Physiologic changes af- facts. A summary of the evidence relating dietary fats, serum
ter 20 weeks of isotonic vs. isokinetic circuit training. I Sports cholesterol, and coronary heart disease. Circulation 1990; 81 :
Med Phys Fitness 1980; 20: 265-74 1721-33
144. Grundy SM, Greenland P, Herd A, et al. Cardiovascular and risk 163. Hurley BF, Seals DR, Hagberg JM, et al. High-density lipopro-
factor evaluation for healthy American adults. Circulation tein cholesterol in bodybuilders vs powerlifters: negative ef-
1987; 7S: 1340-62 fects of androgen use. JAM A 1984; 252: 507-13
14S. Kannel WB, Castelli W, Gordon T. Cholesterol in the prediction 164. Wallace MB, Moffatt RJ, Haymes EM, et al. Acute effects of
of atherosclerotic disease. Ann Intern Med 1979; 90: 8S-91 resistance exercise on parameters of lipoprotein metabolism.
146. Kitamura A, Iso H, Naito Y, et al. High-density lipoprotein cho- Med Sci Sports Exerc 1991; 23: 199-204
lesterol and premature coronary heart disease in urban Japan- 16S. Shoup EE, Durstine JL. Acute circuit weight lifting and its ef-
ese men. Circulation 1994; 89: 2S33-9 fect on postheparin lipoprotein lipase activity [abstract]. Med
147. National Cholesterol Education Program Expert Panel. Sum- Sci Sports Exerc 1991; 23 Supp!. I: 4
mary of the second report of the NCEP expert panel on detec- 166. Boyden TW, Pamenter RW, Going SG. Resistance exercise
tion, evaluation, and treatment of high blood cholesterol in training is associated with decreases in serum low density
adults (adult treatment panel II). JAMA 1993; 269: 301S-23 lipoprotein cholesterol levels in premenopausal women. Arch
148. Wilson PWF. High-density lipoprotein, low-density lipoprotein Intern Med 1993; IS3: 97-100
and coronary artery disease. Am J Cardiol 1990; 66: 7-10 167. Goldberg L, Elliott DL, Schultz RW, et al. Changes in lipid and
149. Laakso M, Lehto S, Penttila I, et al. Lipids and lipoproteins pre- lipoprotein levels after weight training. JAMA 1984; 2S2:
dicting coronary heart disease mortality and morbidity in pa- 504-6
tients with non-insulin-dependent diabetes. Circulation 1993; 168. Weltman A, Janney C, Rians B, et al. The effects of hydraulic
88 (Pt I): 1421-30 resistance strength training on serum lipid levels in prepuber-
ISO. Grundy SM, Vega GL. Two different views of the relationship tal boys. Am J Dis Child 1987; 141: 777-80
of hypertriglyceridemia and coronary heart disease. Arch In- 169. Kokkinos PF, Hurley BF, Vaccaro P, et al. Effects of low- and
tern Med 1992; IS2: 28-34 high-repetition resistive training on lipoprotein-lipid profiles.
lSI. Lampman RM, Schteingart DE. Effects of exercise training on Med Sci Sports Exerc 1988; 20: SO-4
glucose control, lipid metabolism, and insulin sensitivity in 170. Kohl HW, Gordon NF, Scott CB, et al. Musculoskeletal strength
hypertriglyceridemia and non-insulin dependent diabetes and serum lipid levels in men and women. Med Sci Sports
mellitus. Med Sci Sports Exerc 1991; 23: 703-12 Exerc 1992; 24: 1080-7
IS2. Criqui MH, Heiss G, Cohn R, et al. Plasma triglyceride level 171. American College of Sports Medicine. Position stand on exer-
and mortality from coronary heart disease. N Engl J Med cise for patients with coronary artery disease. Med Sci Sports
1993; 328: 1220-S Exerc 1994; 26: i-v
IS3. Fujiwara R, Kutsumi Y, Hayashi T, et al. Relation of an- 172. Kaplan NM. The deadly quartet: upper-body obesity, glucose
giographically defined coronary artery disease and plasma intolerance, hypertriglyceridemia, and hypertension. Arch In-
concentrations of insulin, lipid, and apolipoprotein in normo-
ternMed 1989; 149: 1514-20
lipidemic subjects with varying degrees of glucose tolerance.
173. Ley CJ, Swan J, Godsland IF, et al. Insulin resistance, lipopro-
Am J Cardiol199S; 7S: 122-6
teins, body fat and hemostasis in nonobese men with angina
154. Jiang X, Srinivasan SR, Webber LS, et al. Association offasting
and a normal or abnormal coronary angiogram. J Am Coli
insulin level with serum lipid and lipoprotein levels in chil-
Cardiol1994; 23: 377-83
dren, adolescents, and young adults: the Bogalusa Heart
StUdy. Arch Intern Med 1995; 155: 190-6 174. Wallberg-Henriksson H. Exercise and diabetes mellitus. In:
Holloszy JO, editor. Exercise and sports sciences reviews
ISS. Reaven G, Ca1ciano A, Cody R, et al. Carbohydrate intolerance
and hyperlipemia in patients with myocardial infarction with- Baltimore: Williams & Wilkins, 1992: 339-68
out known diabetes mellitus. J Endocrinol Metab 1963; 23: 175. Mikines KJ, Sonne B, Farrell PA. Effect of physical exercise on
1013-23 sensitivity and responsiveness to insulin in humans. Am J
156. Young MH, Jeng C-Y, Shew W, et al. Insulin resistance, glucose Physiol 1988; 254: 248-59
intolerance, hyperinsulinemia and dyslipidemia in patients 176. Devlin JT, Hirshman M, Horton ED. Enhanced peripheral and
with angiographically demonstrated coronary artery disease. splanchnic insulin sensitivity in NIDDM men after a single
Am J Cardiol 1993; 72: 458-60 bout of exercise. Diabetes 1987; 36: 434-9
157. Stewart KJ. Weight training in coronary artery disease and hy- 177. Notelovitz M. Exercise and health maintenance in menopausal
pertension. Prog Cardiovasc Dis 1992; 35: 159-68 women. Ann NY Acad Sci 1990; 592: 204-20
IS8. Berg A, Keul J, Ringwald G, et al. Physical performance and 178. Horton ES. Exercise and physical training: effects on insulin
serum cholesterol fractions in healthy young men. Clin Chern sensitivity and glucose metabolism. Diabetes Metab Rev
Acta 1980; 106: 325-30 1986; 2: 1-17
159. Berg A, Ringwald G, Keul J. Lipoprotein cholesterol in well- 179. Rosenthal M, Haskell WL, Solomon R. Demonstration of a
trained athletes. A preliminary communication: reduced HDL- relationship between level of physical training and insulin-
cholesterol in power athletes. Int J Sports Med 1980; I: 137-8 stimulated glucose utilization in normal humans. Diabetes
160. Clarkson PM, Hintermister R, Fillyaw M, et al. High density 1983; 32: 408-11
lipoprotein cholesterol in young adult weight lifters, runners, 180. Holloszy JO, Constable SH, Young DA. Activation of glucose
and untrained subjects. Hum Bioi 1981; 53: 251-7 transport in muscle by exercise. Diabetes Metab Rev 1986;
161. Farrell PA, Maksud MB, Pollock ML, et al. A comparison of I: 409-23
plasma cholesterol, triglycerides, and high density Jipoprotein- 181. Miller WJ, Sherman WM, Ivy JL. Effect of strength training on
cholesterol in speed skaters, weight lifters and non athletes. glucose tolerance and post-glucose insulin response. Med Sci
Eur J Appl Physiol1982; 48: 77-82 Sports Exerc 1984; 16: 539-43
162. Morgan DW, Cruise RJ, Girardin BW, et al. HDL-C concentra- 182. Van Dam S, Gillespy M, Notelovitz M. Effect of exercise on
tions in weight -trained, endurance trained, and sedentary fe- glucose metabolism in postmenopausal women. Am J Obstet
males. Physician Sports Med 1986; 14: 166-81 Gynecol 1988; 159: 82-6
Adis International limited. All rights reserved. Sports Med. 1996 May; 21 (5)
183. Hurley BF. Effects of resistive training on lipoprotein-lipid 203. Haissly JC, Messin R, Degre S, et al. Comparative response to
profiles: a comparison to aerobic exercise training. Med Sci isometric (static) and dynamic exercise tests in coronary dis-
Sports Exerc 1989; 21: 689-93 ease. Am J Cardio11974; 33: 791-6
184. Fardy PS. Isometric exercise and the cardiovascular system. 204. Sagiv M, Ben-Sira D, Goldhammer E, et al. Left ventricular
Physician Sports Med 1981; 9: 42-56 diastolic function during acute increase in after-load in men
185. Hossack KF, Bruce RA. Maximal cardiac function in sedentary with coronary artery disease. J Cardiopulm Rehabil 1993; 13:
normal men and women: comparison of age-related changes. 418-23
J Appl Physiol 1982; 53: 799-804 205. Alexander T, Friedman DB, Levine BD, et al. Cardiovascular
186. Julius S, Amery A, Whetlock LS, et al. Influence of age on the responses during static exercise - studies in patients with
hemodynamic response to exercise. Circulation 1967; 36: 222-9 complete heart block and dual chamber pacemakers. Circula-
187. Lind AR, McNicol GW. Circulatory responses to sustained tion 1994; 89: 1643-7
handgrip contractions performed during other exercises, both 206. Williamson JW, Nobrega ACL, Garcia JA, et al. Cardiovascular
rhythmic and static. J Physiol 1976; 192: 595-607 responses at the onset of static exercise with fixed heart rates
188. Misner JE, Going SB, Massey BH, et al. Cardiovascular re- [abstract]. Med Sci Sports Exerc 1994; 26 Suppl. I: 131
sponse to sustained maximal voluntary static muscle contrac- 207. Stopford JL. Static exercise - physiologic dangers and proper
tion. Med Sci Sports Exerc 1990; 22: 194-9 training techniques. Nurse Pract 1988; 13: 7-18
189. Nutter DO, Schlant RS, Hurst JW. Isometric exercise and the 208. Dougherty SM, Sheldahl LM, Wilke NA, et al. Physiologic re-
cardiovascular system. Mod Concept Cardiovasc Dis 1972; sponses to shovelling and thermal stress in men with cardiac
41: 11-5 disease. Med Sci Sports Exerc 1993; 25: 790-5
190. Lind AR, McNicol Gw. Muscular factors which determine the 209. Sheldahl LM, Wilke NA, Dougherty SM, et al. Effect of age and
cardiovascular responses to sustained and rhythmic exercise. coronary artery disease on response to snow shovelling. J Am
Can Med Assoc J 1967; 96: 706-15 Coli Cardiol 1992; 20: 1111-7
191. Donald KW, Lind AR, Phil D, et al. Cardiovascular responses 210. Franklin BA, Hogan P, Bonzheim K, et al. Cardiac demands of
to sustained (static) contractions. Circ Res 1967; 21 Suppl. I: heavy snow shovelling. JAMA 1994; 273: 880-2
15-30 211. Graves JE, Martin AD, Miltenberger LA, et al. Physiological
192. Lind AR, Taylor SH, Humphreys PW, et al. Circulatory effects responses to to walking with hand weights, wrist weights, and
of sustained voluntary muscle contraction. Clin Sci 1964; 27: ankle weights. Med Sci Sports Exerc 1988; 20: 265-71
229-44 212. Graves JE, Pollock ML, Montain SJ, et al. The effect of hand-
193. Mitchell JH, Wildenthal K. Static (isometric) exercise and the held weights on the physiological responses to walking exer-
heart: physiological and clinical considerations. Annu Rev cise. Med Sci Sports Exerc 1987; 19: 260-5
Physiol1974; 36: 369-78 213. Graves JE, Sagiv M, Pollock ML, et al. Effect of hand-held
194. Mitchell JH, Payne FC, Saltin B, et al. The role of muscle mass weights and wrist weights on the metabolic and hemodynamic
in the cardiovascular response to static contraction. J Physiol responses to submaximal exercise in hypertensive responders.
(Lond) 1980; 309: 45-54 J Cardiopulm Rehabil 1988; 8: 134-40
195. Lewis SF, Snell PG, TaylorWF. Role of muscle mass and mode 214. Evans BW, Potteiger JA, Bray MC, et al. Metabolic and
of contraction in circulatory responses to exercise. J Appl hemodynamic responses to walking with hand weights in
Physiol 1985; 58: 146-51 older individuals. Med Sci Sports Exerc 1994; 26: 1047-52
196. Brown BG, Lee AB, Bolson EL, et al. Reflex constriction of 215. Amos KR, Porcari JP, Bauer SR, et al. The safety and effective-
significant coronary stenosis as a mechanism contributing to ness of walking with ankle weights and wrist weights for pa-
ischemic left ventricular dysfunction during isometric exer- tients with cardiovascular disease. J Cardiopulm Rehabil
cise. Circulation 1984; 70: 18-24 1992; 12: 254-60
197. Helfant RH, DeVilla MA, Meister SG. Effect of sustained iso- 216. Auble TE, Schwartz L, Robertson RJ. Aerobic requirements for
metric handgrip exercise on left ventricular performance. Cir- moving handweights through various ranges of motion while
culation 1971; 44: 982-93 walking. Physician Sports Med 1987; 15: 133-40
198. Kerber RE, Miller RA, Najjar SM. Myocardial ischemic effects 217. Garber CE, Fiske CH, Manfredi TG, et al. Circulatory responses
of isometric, dynamic and combined exercise in coronary ar- to walking and jogging exercise with hand-held weights in
tery disease. Chest 1975; 67: 388-94 young women. Med Exerc Nutr Health 1992; I: 92-6
199. Perez-Gonzales JF, Schiller NB, Parmley, Ww. Direct and non- 218. Maud PJ, Stokes GD, Stokes LR. Stride frequency, perceived
invasive evaluation of the cardiovascular response to isomet- exertion, and oxygen cost response to walking with variations
ric exercise. Circ Res 1981; 48: Suppl. 1: 138-48 in arm swing and hand held weight. J Cardiopulm Rehabil
200. McHenry PL, Ellestad MH, Fletcher GF, et al. Statement on 1990; 10: 294-9
exercise - a position statement for health professionals by the 219. Miller JF, Stamford BA. Intensity and energy cost of weighted
committee on exercise and cardiac rehabilitation ofthe coun- walking vs. running for men and women. J Appl Physiol 1987;
cil on clinical cardiology, American Heart Association. Cir- 62: 1497-501
culation 1990; 81: 396-8 220. Zarandona JE, Nelson AG, Conlee RK, et al. Physiological re-
201. Nelson RR, Gobel FL, Jorgensen CR, et al. Hemodynamic pre- sponses to hand-carried weights. Physician Sports Med 1986;
dictors of myocardial oxygen consumption during static and 14: 113-20
dynamic exercise. Circulation 1974; 50: 1179-89 221. Thompson WR, Goodroe EA, Johnson KD, et al. The effect of
202. DeBusk R, Pitts W, Haskell W, et al. Comparison of cardiovas- hand-held weights on the physiological responses to aerobic
cular responses to static-dynamic efforts and dynamic effort dance. J Appl Sports Sci Res 1991; 5: 208-12
alone in patients with chronic ischemic heart disease. Circu- 222. Balady GJ, Weiner DA. Risk stratification in cardiac rehabili-
lation 1979; 59: 977-84 tion. J Cardiopulm Rehabil 1991; II: 39-45
Adls International Limited. All rights reserved. Sports Med. 1996 May; 21 (5)
223. Fletcher GF, Balady G, Froelicher VF, et al. Exercise standards 236. Gleeson PB, Protas EJ, LeBlanc AD, et al. Effects of weight-
- a statement for healthcare professionals from the American lifting on the bone mineral density in premenopausal women.
Heart Association. Circulation 1995; 91: 580-615 J Bone Miner Res 1990; 5: 153-8
224. American Heart Association. 1994 revisions to classification of 237. Heinrich CH, Going SB, Pamenter RW, et al. Bone mineral
functional capacity and objective assessment of patients with content of cyclically menstruating female resistance and en-
diseases of the heart. Circulation 1994; 90: 644-5 durance trained athletes. Med Sci Sports Exerc 1990; 22:
225. Munnings F. Strength timing - not only for the young. Physician 558-63
Sports Med 1993; 21: 133-40 238. Fleck SJ, Kraemer WJ. Designing resistance training programs.
226. Williams MA, Sketch MH. Strength training can help older Champaign (lL): Human Kinetics, 1987
cardiac patients. Your Patient Fitness 1993; 7: 5-11 239. Kraemer WJ, Noble BJ, Clark MJ. Physiologic responses to
227. Braith RW, Limacher MC, Leggett SH, et al. Skeletal muscle heavy-resistance exercise with very short rest periods. Inter-
strength in heart transplant recipients. J Heart Lung Trans- nationalJ Sports Med 1987; 8: 247-52
plant 1993; 12: 1018-23 240. Gordon NF, Kohl HW, Pollock ML et al. Cardiovasular safety
228. Painter P, Tomlanavich S. Organ transplantation: a second chance of maximal strength testing in healthy adults. Am J Cardiol
at fitness. Your Patient Fitness 1993; 7: 6-17 1995; 76: 851-3
241. Shaw CE, McCully KK, Posner JD. Injuries during the one
229. Frederickson L. Confronting mitral valve prolapse syndrome.
repitition maximum assessment in the elderly. J Cardiopulm
San Marcos (CA): Avant Books, 1988
Rehabil1995; 15: 283-7
230. Hiatt WR, Wolfel EE, Meier RH, et al. Superiority of treadmill
242. Pollock ML, Carroll JF, Graves JE, et al. Inquires and adherence
walking exercise versus strength training for patients with
to walk/jog and resistance training programs in the elderly.
peripheral vascular disease. Circulation 1994; 90: 1866-74
Med Sci Sports Exerc 1991; 23: 1194-200
231. Pollock ML, Wilmore JH. Exercise in health and disease - 243. Borg G. Psychophysical bases of perceived exertion. Med Sci
evaluation and prescription for prevention and rehabilitation. Sports Exerc 1982; 14: 377-81
Orlando: WB Saunders, 1990 244. Herbert DL, Herbert WG. Legal aspects of preventive, rehabil-
232. American College of Sports Medicine. The recommended itative and recreational exercise programs. Canton (OH): Pro-
quantity and quality of exercise for developing and maintain- fessional Reports Corporation, 1993
ing cardiorespiratory and muscular fitness in healthy adults. 245. Sol N, Foster C. ACSM's health/fitness facility standards and
Med Sci Sports Exerc 1990; 22: 265-74 guidelines. Champaign (IL): Human Kinetics, 1992
233. Graves JE, Pollock ML, Jones AE, et al. Specifity of limited 246. American College of Cardiology. Recommendations of the
range of modem variable resistance training. Med Sci Sports American College of Cardiology on cardiovascular rehabili-
Exerc 1989; 21: 84-9 tation. J Am Coli Cardiol 1990; 1: 451-3
234. Conroy BP, Kraemer WJ, Maresh CM, et al. Adaptive responses
of bone to physical activity. Med Exerc Nutr Health 1992; I:
64-74
235. Girovard CK, Hurley BE Does strength training inhibit gains Correspondence and reprints: David E. Verrill M.S., Cardio-
in range of motion from flexibility training in older adults? vascular Testing Laboratory, Mid Carolina Cardiology, 1718
Med Sci Sports Exerc 1995; 27: 1444-9 East 4th Street, Suite 501, Charlotte, NC 28204, USA.
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Resistive Exercise Training in

Smutok et aP8] found no change in resting BP moderate increases in cardiovascular endurance

Table III. Resistive training modalities l28]

Table IV. Contraindications for resistive exercise training l22 ,25,223,224j

Abbreviations: BP =blood pressure; EF =ejection fraction; LV =left ventricular; MI =myocardial infarction.

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