Progressive Resistance Training

1
Progressive Resistance Training

• Use in Cardiovascular Disease
• and
• Safety Considerations

Professor Maria A. Fiatarone Singh, MD, FRACP
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Introduction and Background

• Progressive resistance training may be used in
  individuals at high risk for cardiovascular
  disease
• Progressive resistance training may be used in
  individuals with coronary artery disease,
  hypertension, congestive heart failure, cardiac
  rehabilitation following heart surgery, and
  cardiac transplantation

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Benefits of PRT in Cardiovascular Disease

• Reduction in cardiac risk factors
• hypertension,
• visceral obesity,
• hyperinsulinemia,
• insulin resistance,
• dyslipidemia,
• sedentariness

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Benefits of PRT in Cardiovascular Disease

• Improvement in ischemic symptoms
• claudication
• angina
• Less need for medications
• angina
• diabetes
• hypertension
• lipid lowering agents
• depression

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Benefits of PRT in Cardiovascular Disease

• Improvement in peripheral skeletal muscle
  morphology and function
• mass,
• strength,
• oxidative capacity,
• glycogen storage,
• glucose transport
• blood flow,
• amino acid uptake and protein synthesis,
• A/V O2 extraction

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Benefits of PRT in Cardiovascular Disease

• Improvement in functional and exercise capacity
• increased submaximal and maximal cardiovascular
  exercise capacity
• increased anerobic threshold
• decreased double product (HR x SPBP)
• decreased perceived exertion
• improved performance of activities of daily
  living

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Benefits of PRT in Cardiovascular Disease

• Antidote to glucocorticoid side-effects in organ
  transplant recipients
• myopathy
• osteopenia

8
PRT after cardiac transplantationeffect on
muscle mass

• Braith, MSSE 30483-89 1998

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Benefits of PRT in Cardiovascular Disease

• Improvement in psychological function
• depressive symptoms,
• self-efficacy

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Permanent cardiovascular contraindications to PRT

• End stage congestive heart failure
• Inoperable critical aortic stenosis
• Uncontrolled malignant arrhythmias
• Unstable angina at rest
• Inoperable aortic or cerebral aneurysm
• Severe proliferative diabetic retinopathy

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Potential cardiovascular risks of PRT

• Hypertension
• Hypotension
• Arrhythmias
• Ischemia
• Aneurysm leak or rupture
• Hemorrhage
• Retinal hemorrhage, worsening of proliferative
  retinopathy

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Potential cardiovascular risks of PRT

• Hypertension
• Acutely, PRT increases systolic and diastolic BP,
  MAP, Total peripheral resistance
• Chronically PRT has a sustained effect to reduce
  systolic and diastolic BP for at least 24 hrs
  post-exercise
• PRT may be initiated in controlled hypertensives
  in concert with other RX
• Uncontrolled hypertension should be treated prior
  to the initiation of PRT

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Blood pressure monitoring during leg press 1RM
72 yo with type 2 diabetes
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Blood pressure monitoring during seated row 1RM
72 yo with type 2 diabetes
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Blood pressure response to PRT

• Rapid rise in systolic and diastolic blood
  pressure with onset of isometric or concentric
  contraction
• Fall in blood pressure during eccentric
  contraction to baseline or below within 1-2
  seconds of release of contraction
• Normal levels during rest intervals between sets

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Magnitude of blood pressure response to PRT

• Increase proportional to
• Relative load (MCV or 1RM)
• Size of muscle mass involved (variable)
• Duration of contractions
• Onset of muscular fatigue
• Use of isometric handgrip
• Use of Valsalva maneuver (attempting to exhale
  against a closed glottis)

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Potential cardiovascular risks of PRT

• Hypotension during exercise
• May reflect left main coronary artery disease,
  dehydration, venous pooling, autonomic
  neuropathy, cardiac denervation, cardiac failure,
  critical aortic stenosis, bradycardia, heart
  block, drug effect
• Do not start or continue PRT if this occurs until
  consultation with physician

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Prevention of Hypotension during PRT

• Maintain fluid intake
• Walk between exercisesalternate arms and legs
  maintain normal breathing pattern perform
  standing calf raises, avoid overhead press end
  session with 5-min cool down walk

• Dehydration
• Venous pooling
• Cardiac transplant
• Autonomic neuropathy
• Diabetes
• Drugs

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Potential cardiovascular risks of PRT

• Arrhythmias
• Ventricular or atrial arrhythmias may occur with
  increased myocardial oxygen demand (double
  product)
• Lower HR during PRT compared to aerobic exercise
  may reduce relative risk
• May indicate ischemia, electrolyte disturbance,
  fluid imbalance, heart failure, other systemic
  disease

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Potential cardiovascular risks of PRT

• Ischemia
• Elevation of diastolic pressure and modest
  increase in heart rate may reduce risk relative
  to aerobic exercise
• Coronary perfusion pressure maintained during
  diastole (better supply)
• Myocardial oxygen demand lower than during
  aerobic exercise (such as stairclimbing)

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No cases of myocardial infarction, angina, or
sudden death in literature during PRT (including
CAD and CHF patients) Over 26,000 subjects
undergoing 1RM testing every 2 years at Cooper
Clinic and Univ FloridaNo cardiovascular events
22
Strong Medicine Unit Balmain 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

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Potential cardiovascular risks of PRT

• Aneurysm leak or rupture
• Rise in mean arterial pressure predisposes to
  dissection/rupture
• Aortic aneurysm which is gt 5cm in transverse
  diameter is at greatest risk of rupture
• Repaired aneurysms not a contraindication to
  exercise training (aerobic or resistive)
• Case reports of subarachnoid hemorrhage
  associated with weight lifting may have been
  intracerebral aneurysms (1 of population)

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Potential cardiovascular risks of PRT

• Hemorrhage
• Patients at risk
• anticoagulation/aspirin for atrial fibrillation,
  valve replacement, stroke, venous thrombosis,
  cardiac prophylaxis or surgery
• Soft tissue injury due to pressure of weight
  machines or free weights
• Fall
• Muscle or ligament tear during contraction

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Potential cardiovascular risks of PRT

• Retinal hemorrhage, worsening of proliferative
  retinopathy
• Position stands proscribe strenuous aerobic
  activity or weight lifting in severe
  proliferative diabetic retinopathy
• Case reports of hemorrhage or retinal detachment
  no rigorous studies
• Intraocular pressure proportional to mean
  arterial pressure (MAP)

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Minimizing risk of ocular complications, elevated
intraocular pressure

• Avoid direct trauma to eye
• Keep head above level of heart
• Avoid high impact, jarring activities
• Minimize IOP by lowering load, avoiding sustained
  isometric contractions, Valsalva maneuver
• No strenuous exercise early after laser or other
  ocular surgery (? 2 wks)

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General PRT training principles to minimize
cardiovascular risks

• No Valsalva maneuver during lifts
• No breath holding
• No isometric contractions
• No sustained contractions
• Increase rest intervals between repetitions
• Keep load between 60 and 80 of 1RM
• No sets to fatigue

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PRT training principles to minimize
cardiovascular risk

• No training if
• New onset chest pain
• Unstable angina
• Uncontrolled arrhythmias
• Uncontrolled hypertension
• Untreated aortic or other aneurysm
• Overanticoagulation
• Recent MI or cardiac surgery until cleared
• Recent intracerebral hemorrhage until cleared
• Severe proliferative retinopathy
• Recent ophthalmologic surgery until cleared

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Summary

• PRT is indicated in the prevention and treatment
  of cardiovascular disease
• Stable patients with CAD, CHF, Hypertension,
  Peripheral vascular disease, Diabetes, Stroke,
  Organ transplant are candidates for PRT
• Standard PRT principles which should be used in
  all individuals minimize cardiovascular risk