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Relationship between Arm and Leg Training Work Loads in Men with Heart Disease
exercise and the heart Relationship between Arm and Leg Training Work Loads in Men with Heart Disease* Implications
for Exercise Prescription
Susan Wetherbee, M.S ., R.D.;t Barry A. Franklin, Ph.D.;t Vu;toria Hollingsworth, M.A.;§ Seynwur Gordon, M.D., F.C .C.P.;II and Gerald C. Timmis, M.D ., F.C.C.P.~
(Chest 1991; 99:1271-73) CABGS =coronary artery bypass graft surgery; HRmax =maximal heart rate; Ml =myocardial infarction; RPE = rating of perceived exertion on conventional Borg scale.
The lack of interchangeability of training benefits from one set of limbs to the other appears to discredit the general practice of limiting exercise training to the legs alone . 1·3 Since many recreational and occupational activities require arm work to a greater extent than leg work, 4 it is reasonable to encourage individuals to train their arms as well as their legs, with the expectation of attenuating the cardiorespiratory, hemodynamic, and perceived exertion responses to both forms of effort. Guidelines for arm exercise prescription should include recommendations regarding three variables: (a) the "target" or training heart rate , (b) the proper training equipment or modalities; and (c) the power output that will elicit the required metabolic load for training. 5 •6 Although the work load recommended for upper body training should ideally be derived from the results of a progressive arm ergometer test, this may not always be practical. Accordingly, we studied whether arm training work loads can be estimated with reasonable accuracy from leg training work loads in men with heart disease.
who had sustained a previous myocardial infarction (MI), four who had undergone coronary artery hypass graft surgery (CABGS), four with a history of hoth MI and CABGS, and one with a history of percutaneous transluminal coronary angioplasty. Nine of the 20 (45 percent) were re<.-eiving beta-blockers. Their mean (::!: SD) age was 63.2::!: 7.3 years; height , 176.3::!: 6.2 em ; and weight, 84.0::!: 17.1 kg. All snhjects were participants in the William Beaumont Hospital outpatient cardiac rehahilitation program (phase Ill). Each had completed a rece nt Bruce treadmill exercise test' to volitional fatif..,'Ue to estahlish , in part, the maximal or symptom-limited heart rate (HR.,..) response for the purpose of exercise prescription. Mean (::!: SD) peak exercise duration was ll.l::!: 2.5 min. Leg training work loads for these active suhjects rdnged from 450 to 1,050 kgom•min - ' .
Ann and Leg Exercise Subjects reported to the laboratory li>r arm and leg exercise sessions on the same day. Leg exercise houts were performed on a Schwinn model EX 2 cycle ergometer, and arm work was done on a modifled version of the device (Fig 1), as previously descrihed.• This ergometer is designed to be rate-independent within a specifled range (ie, physical work and oxygen uptake are independ-
SUBJECfS AND METHODS
Subjects Our study population consisted of 20 men with cardiac disease: one with angiographically documented coronary artery disease, ten *From the Department of Medicine, Division of Cardiology (Cardiac Rehabilitation), William Beaumont Hospital, Royal Oak, Mich. tExercise Physiologist and Registered Dietitian. iProgram Director, Cardiac Rehabilitation and Exercise Laboratories. §Assistant Manager, Cardiac Catheterization Laboratories. IIMedical Director, Cardiac Rehabilitation and Exercise Laboratories. 11Medical Director, Clinical Research . Reprint requests: Dr. Wetherbee, Beaumont Rehabilitation & Health Center; Cardiac Rehabilitation Department, 746 furdy Street, Birmingham , Michigan 48009
FIGURE 1. Cycle ergometer as adapted li>r arm cranking exercise. Bicycle handgrips are fltted over the pedals, clamps secure the ergometer to a sturdy metal tahle at a height of74 em , and a padded hreastplate helps to standardize arm position. CHEST I 99 I 5 I MAY. 1991
1271
20
-·e 'c
600 Cl
·=iii....
E Cl
~
'It
300
Arm
Leg
2. Mean (::!: SD) values for arm and leg training work loads. Average work load during arm training (443 kgom•min · 1) was significantly lower than that during leg training (668 kgom•min - 1) (p<0.001). FIGURE
ent of the pedaling rate). Protocols for arm and leg exercise bouts were identical; the initial work load was 150 kg-mom in - 1 , with increments of 150 kgom•min - 1 at each 2-m in stage to attainment of the work load that elicited a steady-state heart rate response mrresponding to the midpoint of that patient"s relative heart rate recommendation for training (70 to 85 percent HRmax); a 5 to 10-min rest period separated each by telemetry, exercise hout. The ECG was monitored t~mtinuously with single-channel (CM,) remrdings made at the end of each exercise stage. Perception of the intensity of physical exercise was evaluated with use of the conventional Borg scale for rating of perceived exertion (RPE).• The scale t~msists of 15 grades from 6 to 20; with 7 indicating very, very light; 9 , very light; II. fairly light; 13, somewhat hard; I5, hard; 17, very hard; and I9. very, very hard. Data Analyses
Means, SD, and SE were calculated for selected variahles and analyzed using the paired t test. A two-tailed p value of < 0.05 was considered statistically significant. The arm versus leg work load relationship was subjected to tre nd analyses with the use of linear
..
'c
115
Arm
FJ<:lJRE 4. Mean (::!: SD) values for rating of perceived exertion at the arm and leg training work loads. Average perceived exertion for these modalities was I3.9 (""somewhat hard"") for both .
regression techniques. Statistical methods were those outlined by Steel and Torrie . 1" RESULTS
Mean ( ± SD) values for arm and leg training work loads, achieved heart rate, and RPE responses are shown in Figures 2-4, respectively. Heart rate and RPE responses were comparable for arm and leg training work loads; however, the average work load eliciting 70 to 85 percent HRmax during arm training (443 kg-m•min - •) was only 66 ± 8 percent of that during leg training (668 kgem•min - •; p
For most deconditioned patients with cardiac disease, the threshold for training probably lies between 40 and 60 percent of aerobic capacity (Vo 2 max), equivalent to 55 to 70 percent of HRmax. 11 However,
;:'c:
i
e
(1)
0
c.
.
..,
::!.
• 105
.A
0
~ 0 ;t
/
~
E
/
Arm
/
/
/
/
/(7)
0~~~----~----r---~----~--~ 0 400
,r;,
/
/
/
(~)
•(2)
800 Leg Workload (kg•m•mlrr')
Leg
FIGURE 3. Mean (::!: SD) values for heart rate at the arm and leg training work loads. Average responses were I04 and 105 beats • min - 1 , respectively.
/
/
/
•(3)/ • ,"" (2)
400
<
1272
•
r•0.91 p < 0.0001 y. 0.70• 27.9 Sy•x • 67 .0
800
e
;•
Leg
-
1200
..........
( ) denotee """'"' ot
.5. Relationship hetwee n arm and leg training work loads, using individual data (S~~x =standard error of estimate). FlG liRE
Arm and Leg Training Work Loads in Heart Disease (Wetherbee et at)
the optimal intensity for aerobic exercise training probably lies between 60 and 80 percent Vo2max, which generally approximates 70 to 85 percent of HRmax and RPE ratings of 12 ("somewhat hard") to 15 ("hard"). 12 With these guidelines, it appears that the heart rate and RPE responses during arm and leg exercise were compatible with aerobic exercise training. In establishing the appropriate work load for arm training, it is important to emphasize that, at a given submaximal work load, arm exercise is performed at a higher heart rate and oxygen consumption than is leg exercise, but maximal responses are generally lower during arm exercise. 13- 16 Consequently, chronotropic and aerobic reserves, relative to incremental loading, are attenuated for arm training as compared with leg training, necessitating reduced work loads for the former. Our findings indicate that work loads approximating two-thirds of those used for leg training are generally appropriate for arm training. In other words, a patient using 450 kg•m•min- 1 for leg training and 300 kg-m•min -I for arm training would be expected to demonstrate similar heart rates and perceived exertion ratings at these work loads. Eleven of our 20 subjects used exactly 66 percent of their leg training work load to achieve a comparable training heart rate during arm exercise. Of the remaining nine subjects, six used arm training work loads that corresponded to 57 to 75 percent of the work loads used for leg training. One of the two subjects with the highest leg training work load (1 ,050 kg-m•min -I) demonstrated the greatest deviation from the norm, using 900 kg-m•min- 1 , or 87 percent of this power output, for arm training. In summary, our data indicate that arm training work loads can be estimated with reasonable accuracy from leg training work loads in men with cardiac disease. These findings provide practical guidelines for arm exercise prescription in the absence of a preliminary arm ergometer evaluation.
REFERENCES 1 Clausen JP, Trap-Jensen J, Lassen NA. The effects of training on the heart rate during arm and leg exercise. Scand J Clio Lab Invest 1970; 26:295-301 2 Klausen K, Rasmussen B, Clausen JP, Trap-Jensen J. Blood lactate from exercising extremities before and after arm or leg training. Am J Physiol1974; 227:67-72 3 Rasmussen B, Klausen K, Clausen JP, Trap-Jensen J. Pulmonary ventilation, blood gases, and blood pH after training of the arms or the legs. J Appl Physiol1975; 38:250-56 4 Hellerstein HK. Prescription of vocational and leisure activities: practical aspects. Adv Cardiol1978; 24:105-15 5 Franklin BA. Exercise testing, training and arm ergometry. Sports Med 1985; 2:100-19 6 Franklin BA. Aerobic exercise training programs for the upper body. Med Sci Sports Exerc 1989; 21:S141-48 7 Bruce RA, Kusumi F, Hosmer D. Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease. Am Heart J 1973; 85:546-62 8 Franklin BA, Vander L, Wrisley D, Rubenfire M. Aerobic requirements of arm ergometry: implications for exercise testing and training. Physician Sportsmed 1983; 11:81-90 9 Borg G. Perceived exertion as an indicator of somatic stress. Scand J Rehabil Med 1970; 2:92-98 10 Steel RG, Torrie JH. Principles and procedures of statistics. New York: McGraw-Hill, 1960 11 American College of Sports Medicine. Guidelines for graded exercise testing and exercise prescription. Philadelphia: Lea & Febiger, 1986; 34 12 Franklin BA, Hellerstein HK, Gordon S, limmis GC. Cardiac patients. In: Franklin BA, Gordon S, limmis GC, eds. Exercise in modern medicine. Baltimore: Williams & Wilkins, 1989; 4480
13 Astrand PO, Saltin B. Maximal oxygen uptake and heart rate in various types of muscular activity. J Appl Physiol1961; 16:97781 14 Gleim GW, Coplan NL, Scandura M, Holly T, Nicholas JA. Rate pressure product at equivalent oxygen consumption on four different exercise modalities. J Cardiopulmonary Rehabil 1988; 8:270-75 15 Bergh U, Kanstrup IL, Ekblom B. Maximal oxygen uptake during exercise with various combinations of arm and leg work. J Appl Physiol1976; 41:191-96 16 Stenberg J, Astrand PO, Ekblom B, Royce J, Saltin B. Hemdynarnic response to work with different muscle groups, sitting and supine. J Appl Pbysiol1967; 22:61-70
CHEST I 99 I 5 I MAY, 1991
1273
for Exercise Prescription
Susan Wetherbee, M.S ., R.D.;t Barry A. Franklin, Ph.D.;t Vu;toria Hollingsworth, M.A.;§ Seynwur Gordon, M.D., F.C .C.P.;II and Gerald C. Timmis, M.D ., F.C.C.P.~
(Chest 1991; 99:1271-73) CABGS =coronary artery bypass graft surgery; HRmax =maximal heart rate; Ml =myocardial infarction; RPE = rating of perceived exertion on conventional Borg scale.
The lack of interchangeability of training benefits from one set of limbs to the other appears to discredit the general practice of limiting exercise training to the legs alone . 1·3 Since many recreational and occupational activities require arm work to a greater extent than leg work, 4 it is reasonable to encourage individuals to train their arms as well as their legs, with the expectation of attenuating the cardiorespiratory, hemodynamic, and perceived exertion responses to both forms of effort. Guidelines for arm exercise prescription should include recommendations regarding three variables: (a) the "target" or training heart rate , (b) the proper training equipment or modalities; and (c) the power output that will elicit the required metabolic load for training. 5 •6 Although the work load recommended for upper body training should ideally be derived from the results of a progressive arm ergometer test, this may not always be practical. Accordingly, we studied whether arm training work loads can be estimated with reasonable accuracy from leg training work loads in men with heart disease.
who had sustained a previous myocardial infarction (MI), four who had undergone coronary artery hypass graft surgery (CABGS), four with a history of hoth MI and CABGS, and one with a history of percutaneous transluminal coronary angioplasty. Nine of the 20 (45 percent) were re<.-eiving beta-blockers. Their mean (::!: SD) age was 63.2::!: 7.3 years; height , 176.3::!: 6.2 em ; and weight, 84.0::!: 17.1 kg. All snhjects were participants in the William Beaumont Hospital outpatient cardiac rehahilitation program (phase Ill). Each had completed a rece nt Bruce treadmill exercise test' to volitional fatif..,'Ue to estahlish , in part, the maximal or symptom-limited heart rate (HR.,..) response for the purpose of exercise prescription. Mean (::!: SD) peak exercise duration was ll.l::!: 2.5 min. Leg training work loads for these active suhjects rdnged from 450 to 1,050 kgom•min - ' .
Ann and Leg Exercise Subjects reported to the laboratory li>r arm and leg exercise sessions on the same day. Leg exercise houts were performed on a Schwinn model EX 2 cycle ergometer, and arm work was done on a modifled version of the device (Fig 1), as previously descrihed.• This ergometer is designed to be rate-independent within a specifled range (ie, physical work and oxygen uptake are independ-
SUBJECfS AND METHODS
Subjects Our study population consisted of 20 men with cardiac disease: one with angiographically documented coronary artery disease, ten *From the Department of Medicine, Division of Cardiology (Cardiac Rehabilitation), William Beaumont Hospital, Royal Oak, Mich. tExercise Physiologist and Registered Dietitian. iProgram Director, Cardiac Rehabilitation and Exercise Laboratories. §Assistant Manager, Cardiac Catheterization Laboratories. IIMedical Director, Cardiac Rehabilitation and Exercise Laboratories. 11Medical Director, Clinical Research . Reprint requests: Dr. Wetherbee, Beaumont Rehabilitation & Health Center; Cardiac Rehabilitation Department, 746 furdy Street, Birmingham , Michigan 48009
FIGURE 1. Cycle ergometer as adapted li>r arm cranking exercise. Bicycle handgrips are fltted over the pedals, clamps secure the ergometer to a sturdy metal tahle at a height of74 em , and a padded hreastplate helps to standardize arm position. CHEST I 99 I 5 I MAY. 1991
1271
20
-·e 'c
600 Cl
·=iii....
E Cl
~
'It
300
Arm
Leg
2. Mean (::!: SD) values for arm and leg training work loads. Average work load during arm training (443 kgom•min · 1) was significantly lower than that during leg training (668 kgom•min - 1) (p<0.001). FIGURE
ent of the pedaling rate). Protocols for arm and leg exercise bouts were identical; the initial work load was 150 kg-mom in - 1 , with increments of 150 kgom•min - 1 at each 2-m in stage to attainment of the work load that elicited a steady-state heart rate response mrresponding to the midpoint of that patient"s relative heart rate recommendation for training (70 to 85 percent HRmax); a 5 to 10-min rest period separated each by telemetry, exercise hout. The ECG was monitored t~mtinuously with single-channel (CM,) remrdings made at the end of each exercise stage. Perception of the intensity of physical exercise was evaluated with use of the conventional Borg scale for rating of perceived exertion (RPE).• The scale t~msists of 15 grades from 6 to 20; with 7 indicating very, very light; 9 , very light; II. fairly light; 13, somewhat hard; I5, hard; 17, very hard; and I9. very, very hard. Data Analyses
Means, SD, and SE were calculated for selected variahles and analyzed using the paired t test. A two-tailed p value of < 0.05 was considered statistically significant. The arm versus leg work load relationship was subjected to tre nd analyses with the use of linear
..
'c
115
Arm
FJ<:lJRE 4. Mean (::!: SD) values for rating of perceived exertion at the arm and leg training work loads. Average perceived exertion for these modalities was I3.9 (""somewhat hard"") for both .
regression techniques. Statistical methods were those outlined by Steel and Torrie . 1" RESULTS
Mean ( ± SD) values for arm and leg training work loads, achieved heart rate, and RPE responses are shown in Figures 2-4, respectively. Heart rate and RPE responses were comparable for arm and leg training work loads; however, the average work load eliciting 70 to 85 percent HRmax during arm training (443 kg-m•min - •) was only 66 ± 8 percent of that during leg training (668 kgem•min - •; p
For most deconditioned patients with cardiac disease, the threshold for training probably lies between 40 and 60 percent of aerobic capacity (Vo 2 max), equivalent to 55 to 70 percent of HRmax. 11 However,
;:'c:
i
e
(1)
0
c.
.
..,
::!.
• 105
.A
0
~ 0 ;t
/
~
E
/
Arm
/
/
/
/
/(7)
0~~~----~----r---~----~--~ 0 400
,r;,
/
/
/
(~)
•(2)
800 Leg Workload (kg•m•mlrr')
Leg
FIGURE 3. Mean (::!: SD) values for heart rate at the arm and leg training work loads. Average responses were I04 and 105 beats • min - 1 , respectively.
/
/
/
•(3)/ • ,"" (2)
400
<
1272
•
r•0.91 p < 0.0001 y. 0.70• 27.9 Sy•x • 67 .0
800
e
;•
Leg
-
1200
..........
( ) denotee """'"' ot
.5. Relationship hetwee n arm and leg training work loads, using individual data (S~~x =standard error of estimate). FlG liRE
Arm and Leg Training Work Loads in Heart Disease (Wetherbee et at)
the optimal intensity for aerobic exercise training probably lies between 60 and 80 percent Vo2max, which generally approximates 70 to 85 percent of HRmax and RPE ratings of 12 ("somewhat hard") to 15 ("hard"). 12 With these guidelines, it appears that the heart rate and RPE responses during arm and leg exercise were compatible with aerobic exercise training. In establishing the appropriate work load for arm training, it is important to emphasize that, at a given submaximal work load, arm exercise is performed at a higher heart rate and oxygen consumption than is leg exercise, but maximal responses are generally lower during arm exercise. 13- 16 Consequently, chronotropic and aerobic reserves, relative to incremental loading, are attenuated for arm training as compared with leg training, necessitating reduced work loads for the former. Our findings indicate that work loads approximating two-thirds of those used for leg training are generally appropriate for arm training. In other words, a patient using 450 kg•m•min- 1 for leg training and 300 kg-m•min -I for arm training would be expected to demonstrate similar heart rates and perceived exertion ratings at these work loads. Eleven of our 20 subjects used exactly 66 percent of their leg training work load to achieve a comparable training heart rate during arm exercise. Of the remaining nine subjects, six used arm training work loads that corresponded to 57 to 75 percent of the work loads used for leg training. One of the two subjects with the highest leg training work load (1 ,050 kg-m•min -I) demonstrated the greatest deviation from the norm, using 900 kg-m•min- 1 , or 87 percent of this power output, for arm training. In summary, our data indicate that arm training work loads can be estimated with reasonable accuracy from leg training work loads in men with cardiac disease. These findings provide practical guidelines for arm exercise prescription in the absence of a preliminary arm ergometer evaluation.
REFERENCES 1 Clausen JP, Trap-Jensen J, Lassen NA. The effects of training on the heart rate during arm and leg exercise. Scand J Clio Lab Invest 1970; 26:295-301 2 Klausen K, Rasmussen B, Clausen JP, Trap-Jensen J. Blood lactate from exercising extremities before and after arm or leg training. Am J Physiol1974; 227:67-72 3 Rasmussen B, Klausen K, Clausen JP, Trap-Jensen J. Pulmonary ventilation, blood gases, and blood pH after training of the arms or the legs. J Appl Physiol1975; 38:250-56 4 Hellerstein HK. Prescription of vocational and leisure activities: practical aspects. Adv Cardiol1978; 24:105-15 5 Franklin BA. Exercise testing, training and arm ergometry. Sports Med 1985; 2:100-19 6 Franklin BA. Aerobic exercise training programs for the upper body. Med Sci Sports Exerc 1989; 21:S141-48 7 Bruce RA, Kusumi F, Hosmer D. Maximal oxygen intake and nomographic assessment of functional aerobic impairment in cardiovascular disease. Am Heart J 1973; 85:546-62 8 Franklin BA, Vander L, Wrisley D, Rubenfire M. Aerobic requirements of arm ergometry: implications for exercise testing and training. Physician Sportsmed 1983; 11:81-90 9 Borg G. Perceived exertion as an indicator of somatic stress. Scand J Rehabil Med 1970; 2:92-98 10 Steel RG, Torrie JH. Principles and procedures of statistics. New York: McGraw-Hill, 1960 11 American College of Sports Medicine. Guidelines for graded exercise testing and exercise prescription. Philadelphia: Lea & Febiger, 1986; 34 12 Franklin BA, Hellerstein HK, Gordon S, limmis GC. Cardiac patients. In: Franklin BA, Gordon S, limmis GC, eds. Exercise in modern medicine. Baltimore: Williams & Wilkins, 1989; 4480
13 Astrand PO, Saltin B. Maximal oxygen uptake and heart rate in various types of muscular activity. J Appl Physiol1961; 16:97781 14 Gleim GW, Coplan NL, Scandura M, Holly T, Nicholas JA. Rate pressure product at equivalent oxygen consumption on four different exercise modalities. J Cardiopulmonary Rehabil 1988; 8:270-75 15 Bergh U, Kanstrup IL, Ekblom B. Maximal oxygen uptake during exercise with various combinations of arm and leg work. J Appl Physiol1976; 41:191-96 16 Stenberg J, Astrand PO, Ekblom B, Royce J, Saltin B. Hemdynarnic response to work with different muscle groups, sitting and supine. J Appl Pbysiol1967; 22:61-70
CHEST I 99 I 5 I MAY, 1991
1273