Exercise Programming for Post-Cardiac and Pulmonary Rehabilitation Clients

American Fitness, May, 2001 by Maribeth Salge

As personal trainers, we focus on our client's health and fitness. Each program is developed with the client's special needs in mind. Many times, the client will be a healthy person with no known illness or disease. However, we have to be prepared to successfully fill a relatively new niche--that of personal trainer to the post-rehabilitation client. In order to work with these clients safely and effectively, the trainer must understand the guidelines, precautions and contraindications to exercise associated with each diagnosis.

Before working with post-rehab clients, it is essential for the personal trainer to be aware of their scope of certification and the legal issues that may arise as a result of practicing outside such parameters. Additionally, trainers must be careful not to misrepresent themselves (either directly or indirectly) to the public, other healthcare professionals and/or third party payers (insurance carriers). Under no circumstances should trainers refer to themselves as a PT, CPT, RPT, LPT or any other similar designation as an abbreviation for personal trainer unless they're also a licensed physical therapist. To do so is a violation of statutes in all 50 states and subjects the violator to prosecution. Misrepresentation of credentials will only diminish the integrety of the personal training profession.

Discussion Context

This article is specific to post-cardiac and pulmonary rehab patients (i.e., those who have completed a medically prescribed and monitored formal cardiac or pulmonary rehab program). It presumes rehabilitation was successfully completed and the physician and rehab team agree that the patient no longer requires medical monitoring (e.g., blood pressure, ECG, pulse oximetry, etc.) but would benefit from entering an exercise program with a certified personal trainer. It is not intended as a comprehensive guideline to establishing a cardiac or pulmonary rehab program. Furthermore, it is not intended to outline an exercise program for clients with known cardiac or pulmonary disease who have not completed a formal rehab program or obtained a physician's referral and approval. This piece is intended solely as an educational tool for the personal trainer interested in developing ongoing exercise programming for rehabilitation graduates.

Preparation

Prior to initiating an exercise program for the post-rehab client, the trainer will need to obtain a health history form, a signed informed consent, a physician's referral/release for exercise and, if possible, a copy of the client's rehab records. The physician's referral/release form should indicate the trainer's credentials and state that no medical monitoring (e.g., blood pressure, ECG, pulse oximetry, etc.) will be performed. The physician should be asked to provide a training intensity if age-predicted target heart rate range is not appropriate. A request for exercise precautions should also be included.

In order, to provide continuity of care, it is advisable for the personal trainer to contact the rehab professional (exercise physiologist, physical therapist, cardiac nurse and/or respiratory therapist) regarding the client's current exercise program. The rehab professional is a valuable source of information. Rather than starting from scratch, it is preferable to simply update the client's current program. In doing so, the transition from rehab to post-rehab fitness can be made smoothly. Once the rehab records have been reviewed and the exercise program updated, the trainer should forward a copy to the physician for written approval prior to implementation. It is vital to follow the physician's orders regarding exercise guidelines!

Exercise Programming

Cardiac and pulmonary patients have many similarities with respect to exercise programming. Oftentimes, the pulmonary patient will have concomitant cardiac disease. Aerobic and strength training methods will most likely require modification to meet clients' limitations. The suggested order for the exercise program is:

* warm-up

* cardio training

* cool-down

* strength training

* stretching

A client with cardiac and/or pulmonary problems will need longer warm-up and cool-down periods than the average client (at least 10 minutes each). Make absolutely sure the client has cooled down adequately before ending the exercise session, as the incidence of cardiac events increases immediately after exercise. Also, it is essential for cardiac and pulmonary clients to avoid exercising in an environment that's too warm and/or humid because it puts excessive stress on the client and may provoke serious disease-related symptoms. Ideal room temperature ranges from 65 [degrees] F to 68 [degrees] F, but the client's comfort level may vary with different humidity levels.

Aerobic Activity

When developing the aerobic training portion of an exercise program, it is important to realize that many of these clients may be on medication that will negate the use of training heart rate range to monitor intensity. For example, beta blockers and the calcium channel blocker verapamil will blunt heart rate response, while nitrates may artificially elevate it. With these patients, another method of assessing exercise intensity (e.g., the Borg Scale of Perceived Exertion) must be used. Some clients will experience symptoms that will limit exercise intensity, such as the onset of angina (chest pain), shortness of breath, oxygen desaturation or irregular heart rhythm. For these clients, it will be necessary for the physician or rehab professional to set the exercise intensity, via exercise testing, at a level below that where symptoms occur.