progressive resistance training

Progressive Progressive Resistance TrainingResistance Training

Use in Cardiovascular Use in Cardiovascular DiseaseDisease

and and

Safety ConsiderationsSafety ConsiderationsProfessor Maria A. Fiatarone Singh, MD, FRACP

Introduction and Introduction and BackgroundBackground

Progressive resistance training may be Progressive resistance training may be used in individuals at high risk for used in individuals at high risk for cardiovascular diseasecardiovascular disease

Progressive resistance training may be Progressive resistance training may be used in individuals with coronary artery used in individuals with coronary artery disease, hypertension, congestive heart disease, hypertension, congestive heart failure, cardiac rehabilitation following failure, cardiac rehabilitation following heart surgery, and cardiac heart surgery, and cardiac transplantationtransplantation

Benefits of PRT in Benefits of PRT in Cardiovascular DiseaseCardiovascular Disease

Reduction in cardiac risk factors: Reduction in cardiac risk factors: - hypertension, hypertension, - visceral obesity, visceral obesity, - hyperinsulinemia, hyperinsulinemia, - insulin resistance, insulin resistance, - dyslipidemia, dyslipidemia, - sedentarinesssedentariness


Improvement in ischemic symptoms:Improvement in ischemic symptoms:- claudicationclaudication- anginaangina

Less need for medications:Less need for medications:- anginaangina- diabetesdiabetes- hypertensionhypertension- lipid lowering agentslipid lowering agents- depression depression


Improvement in peripheral skeletal muscle Improvement in peripheral skeletal muscle morphology and function:morphology and function:- mass,mass,- strength, strength, - oxidative capacity, oxidative capacity, - glycogen storage, glycogen storage, - glucose transportglucose transport- blood flow, blood flow, - amino acid uptake and protein synthesis, amino acid uptake and protein synthesis, - A/V OA/V O22 extraction extraction


Improvement in functional and exercise Improvement in functional and exercise capacity:capacity:- increased submaximal and maximal increased submaximal and maximal

cardiovascular exercise capacitycardiovascular exercise capacity- increased anerobic thresholdincreased anerobic threshold- decreased double product (HR x SPBP)decreased double product (HR x SPBP)- decreased perceived exertiondecreased perceived exertion- improved performance of activities of daily improved performance of activities of daily

livingliving


Antidote to glucocorticoid side-Antidote to glucocorticoid side-effects in organ transplant effects in organ transplant recipients:recipients:- myopathymyopathy- osteopeniaosteopenia

PRT after cardiac transplantation:PRT after cardiac transplantation:effect on muscle masseffect on muscle mass

Braith, MSSE 30:483-89 1998Braith, MSSE 30:483-89 1998


Improvement in psychological Improvement in psychological function:function:- depressive symptoms, depressive symptoms,

- self-efficacyself-efficacy

Permanent cardiovascular Permanent cardiovascular contraindications to PRTcontraindications to PRT

End stage congestive heart failureEnd stage congestive heart failure Inoperable critical aortic stenosisInoperable critical aortic stenosis Uncontrolled malignant arrhythmiasUncontrolled malignant arrhythmias Unstable angina at restUnstable angina at rest Inoperable aortic or cerebral aneurysmInoperable aortic or cerebral aneurysm Severe proliferative diabetic Severe proliferative diabetic

retinopathyretinopathy

Potential cardiovascular Potential cardiovascular risks of PRT risks of PRT

HypertensionHypertension HypotensionHypotension ArrhythmiasArrhythmias IschemiaIschemia Aneurysm leak or ruptureAneurysm leak or rupture HemorrhageHemorrhage Retinal hemorrhage, worsening of Retinal hemorrhage, worsening of

proliferative retinopathyproliferative retinopathy


HypertensionHypertension- AcutelyAcutely, PRT increases systolic and diastolic , PRT increases systolic and diastolic

BP, MAP, Total peripheral resistanceBP, MAP, Total peripheral resistance- ChronicallyChronically PRT has a sustained effect to PRT has a sustained effect to

reduce systolic and diastolic BP for at least 24 reduce systolic and diastolic BP for at least 24 hrs post-exercisehrs post-exercise

- PRT may be initiated in controlled PRT may be initiated in controlled hypertensives in concert with other RXhypertensives in concert with other RX

- Uncontrolled hypertension should be treated Uncontrolled hypertension should be treated prior to the initiation of PRTprior to the initiation of PRT

Blood pressure monitoring during leg press 1RM:

72 yo with type 2 diabetes

Blood pressure monitoring during seated row 1RM:

72 yo with type 2 diabetes

Blood pressure response to Blood pressure response to PRTPRT

Rapid rise in systolic and diastolic Rapid rise in systolic and diastolic blood pressure with onset of blood pressure with onset of isometric or concentric contractionisometric or concentric contraction

Fall in blood pressure during Fall in blood pressure during eccentric contraction; to baseline or eccentric contraction; to baseline or below within 1-2 seconds of release below within 1-2 seconds of release of contractionof contraction

Normal levels during rest intervals Normal levels during rest intervals between setsbetween sets

Magnitude of blood Magnitude of blood pressure response to PRTpressure response to PRT

Increase proportional to:Increase proportional to:- Relative loadRelative load (%MCV or %1RM) (%MCV or %1RM)- Size of muscle mass involved (variable)Size of muscle mass involved (variable)- Duration of contractionsDuration of contractions- Onset of muscular fatigueOnset of muscular fatigue- Use of isometric handgripUse of isometric handgrip- Use of Valsalva maneuver Use of Valsalva maneuver (attempting to (attempting to

exhale against a closed glottis)exhale against a closed glottis)


Hypotension during exerciseHypotension during exercise- May reflect left main coronary artery May reflect left main coronary artery

disease, dehydration, venous pooling, disease, dehydration, venous pooling, autonomic neuropathy, cardiac autonomic neuropathy, cardiac denervation, cardiac failure, critical denervation, cardiac failure, critical aortic stenosis, bradycardia, heart aortic stenosis, bradycardia, heart block, drug effectblock, drug effect

- Do not start or continue PRT if this Do not start or continue PRT if this occurs until consultation with physicianoccurs until consultation with physician

Prevention of Hypotension Prevention of Hypotension during PRTduring PRT

DehydrationDehydration Venous poolingVenous pooling

- Cardiac transplantCardiac transplant- Autonomic Autonomic

neuropathyneuropathy- DiabetesDiabetes- DrugsDrugs

Maintain fluid intakeMaintain fluid intake Walk between Walk between

exercises;alternate arms exercises;alternate arms and legs; maintain and legs; maintain normal breathing pattern; normal breathing pattern; perform standing calf perform standing calf raises, avoid overhead raises, avoid overhead press; end session with press; end session with 5-min cool down walk5-min cool down walk


Arrhythmias:Arrhythmias:- Ventricular or atrial arrhythmias may Ventricular or atrial arrhythmias may

occur with increased myocardial oxygen occur with increased myocardial oxygen demand (double product)demand (double product)

- Lower HR during PRT compared to Lower HR during PRT compared to aerobic exercise may reduce relative riskaerobic exercise may reduce relative risk

- May indicate ischemia, electrolyte May indicate ischemia, electrolyte disturbance, fluid imbalance, heart disturbance, fluid imbalance, heart failure, other systemic diseasefailure, other systemic disease


Ischemia:Ischemia:- Elevation of diastolic pressure and Elevation of diastolic pressure and

modest increase in heart rate may modest increase in heart rate may reduce risk relative to aerobic exercise:reduce risk relative to aerobic exercise:Coronary perfusion pressure maintained Coronary perfusion pressure maintained

during diastole (better supply)during diastole (better supply)Myocardial oxygen demand lower than Myocardial oxygen demand lower than

during aerobic exercise (such as during aerobic exercise (such as stairclimbing)stairclimbing)

No cases of myocardial No cases of myocardial infarction, angina, or sudden infarction, angina, or sudden death in literature during PRT death in literature during PRT

(including CAD and CHF (including CAD and CHF patients)patients)

Over 26,000 subjects Over 26,000 subjects

undergoing 1RM testing every undergoing 1RM testing every 2 years at Cooper Clinic and 2 years at Cooper Clinic and

Univ Florida:Univ Florida:No cardiovascular eventsNo cardiovascular events

Strong Medicine UnitBalmain Hospital, Sydney

1999-2002

•Over 8,000 individual training sessions in elderly subjects with chronic disease

•No significant cardiovascular events

•2,000 muscle strength testing sessions•No significant injury

•3 falls, no fracture, one heart block on testing


Aneurysm leak or rupture:Aneurysm leak or rupture:- Rise in mean arterial pressure predisposes to Rise in mean arterial pressure predisposes to

dissection/rupturedissection/rupture- Aortic aneurysm which is Aortic aneurysm which is > > 5cm in transverse 5cm in transverse

diameter is at greatest risk of rupturediameter is at greatest risk of rupture- Repaired aneurysms not a contraindication to Repaired aneurysms not a contraindication to

exercise training (aerobic or resistive)exercise training (aerobic or resistive)- Case reports of subarachnoid hemorrhage Case reports of subarachnoid hemorrhage

associated with weight lifting may have been associated with weight lifting may have been intracerebral aneurysms (1% of population)intracerebral aneurysms (1% of population)


HemorrhageHemorrhage- Patients at risk:Patients at risk:

anticoagulation/aspirin for atrial fibrillation, valve anticoagulation/aspirin for atrial fibrillation, valve replacement, stroke, venous thrombosis, cardiac replacement, stroke, venous thrombosis, cardiac prophylaxis or surgeryprophylaxis or surgery

- Soft tissue injury due to pressure of weight Soft tissue injury due to pressure of weight machines or free weightsmachines or free weights

- FallFall- Muscle or ligament tear during contractionMuscle or ligament tear during contraction


Retinal hemorrhage, worsening of Retinal hemorrhage, worsening of proliferative retinopathy:proliferative retinopathy:- Position stands proscribe strenuous aerobic Position stands proscribe strenuous aerobic

activity or weight lifting in severe proliferative activity or weight lifting in severe proliferative diabetic retinopathydiabetic retinopathy

- Case reports of hemorrhage or retinal Case reports of hemorrhage or retinal detachment; no rigorous studiesdetachment; no rigorous studies

- Intraocular pressure proportional to mean Intraocular pressure proportional to mean arterial pressure (MAP)arterial pressure (MAP)

Minimizing risk of ocular Minimizing risk of ocular complications, elevated intraocular complications, elevated intraocular

pressurepressure Avoid direct trauma to eyeAvoid direct trauma to eye Keep head above level of heartKeep head above level of heart Avoid high impact, jarring activitiesAvoid high impact, jarring activities Minimize IOP by lowering load, avoiding Minimize IOP by lowering load, avoiding

sustained isometric contractions, Valsalva sustained isometric contractions, Valsalva maneuvermaneuver

No strenuous exercise early after laser or No strenuous exercise early after laser or other ocular surgery (? 2 wks)other ocular surgery (? 2 wks)

General PRT training General PRT training principles to minimize principles to minimize cardiovascular riskscardiovascular risks

No Valsalva maneuver during liftsNo Valsalva maneuver during lifts No breath holdingNo breath holding No isometric contractionsNo isometric contractions No sustained contractionsNo sustained contractions Increase rest intervals between Increase rest intervals between

repetitionsrepetitions Keep load between 60 and 80% of Keep load between 60 and 80% of

1RM1RM No sets “to fatigue”No sets “to fatigue”

PRT training principles to PRT training principles to minimize cardiovascular riskminimize cardiovascular risk

No training if:No training if:- New onset chest painNew onset chest pain- Unstable anginaUnstable angina- Uncontrolled arrhythmiasUncontrolled arrhythmias- Uncontrolled hypertensionUncontrolled hypertension- Untreated aortic or other aneurysmUntreated aortic or other aneurysm- OveranticoagulationOveranticoagulation- Recent MI or cardiac surgery until clearedRecent MI or cardiac surgery until cleared- Recent intracerebral hemorrhage until clearedRecent intracerebral hemorrhage until cleared- Severe proliferative retinopathySevere proliferative retinopathy- Recent ophthalmologic surgery until clearedRecent ophthalmologic surgery until cleared

SummarySummary PRT is indicated in the PRT is indicated in the prevention and prevention and

treatmenttreatment of cardiovascular disease of cardiovascular disease Stable patients with CAD, CHF, Stable patients with CAD, CHF,

Hypertension, Peripheral vascular Hypertension, Peripheral vascular disease, Diabetes, Stroke, Organ disease, Diabetes, Stroke, Organ transplant are transplant are candidatescandidates for PRT for PRT

Standard PRT principles which should be Standard PRT principles which should be used used in all individualsin all individuals minimize minimize cardiovascular riskcardiovascular risk

progressive resistance training

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