EXP 600

Case Report and Work Sample

Brock Guetzke
December 5, 2014

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Assessment for Entry
Client Profile
The patient is a retired 55-year-old male, who was measured at
five feet and five inches tall and weighed 150 pounds at his initial
intake. His body mass index of 25.1 kg/m2 (BMI) was calculated using
his current height and weight. With a BMI greater than 25 kg/m2 the
American College of Sports Medicine (ACSM) classifies him as being
overweight. His resting heart rate was measured at 67 beats per
minute (bpm), which is classified as normal. According to the American
Heart Association (AHA) a normal resting heart rate is 60 bpm to 100
bpm. His resting blood pressure was measured at 110/70 mmHg, which
according to the American College of Sports Medicine (ACSM, 2013) is
not considered to be hypertensive. The patients most recent
measurements for cholesterol were as follows: total cholesterol was
145 mg/dL, HDL cholesterol 29 mg/dL. LDL cholesterol 55 mg/dL, and
triglycerides were 306 mg/dL. The patient self reported that he does
have a family history of cardiac disease, as his father experienced a
heart attack in his 60s. If a male first-degree relative is greater than
the 55 years old, family history is not considered to be a risk factor
(ACSM, 2013). The patient self-reported that he used to smoke 1 pack
per day but quit in 1990. He also reported that he is not physically
active, as he has not participated in at least 30 minutes of physical
activity for three days per week over the past three months.
TABLE 1. Physical exam.
Examination
Blood pressure
Heart rate
Height
Weight
BMI
Ejection Fraction
Total Cholesterol
HDL Cholesterol
LDL Cholesterol
Triglycerides
HbA1c

Result
110/70 mmHg
67 bpm
65 in (1.65 m)
150 lb (68.2 kg)
25.1 kg/m2 (overweight)
55 percent
145 mg/dL
29 mg/dL
55 mg/dL
306 mg/dL
9.7 %

Millimeters of mercury (mmHg), beats per minute (bpm), inches (in), pounds (lb), body mass index (BMI), kilograms per meter
squared (kg/m2), milligrams per deciliter (mg/dL), hemoglobin A1c (HbA1c)

The patient has experienced heart disease in the past, when he

had a stent placed in 2010 and was found to have a mitral
regurgitation in 2011. A mitral regurgitation results in the heart having
to work harder and can eventually lead to heart failure (Chen, 2014).
The patient was then diagnosed with heart failure in April of 2014. He
is currently attending cardiac rehab due to a recent percutaneous

2
transluminal coronary intervention (PTCI) to his left anterior
descending (LAD) and diagonal arteries, placed on September 18,
2014. After his catheterization, the patient was referred to cardiac
rehabilitation by his cardiologist. During his initial intake into cardiac
rehabilitation, the patient was found to have a normal sinus rhythm.
In addition to the problems that the patient has experienced with
his heart, he has a medical history that includes a long list of health
issues. These issues include risk factors for cardiovascular disease
such as hypertension, dyslipidemia, and type II diabetes. Many of his
other health issues have resulted due to those risk factors, with many
because of his uncontrolled diabetes. The patients glycated
hemoglobin or HbA1c was most recently measured at 9.7 percent.
According to Zoungas et al. (2012) lower risk of death and
cardiovascular events occur when a diabetic patient keeps their HbA1c
below 7 percent. With not having control over his diabetes, he has
developed a diabetic foot in both feet, diabetic nephropathy with
proteinuria, and has developed ulcers on his feet in the past. Among
those problems, the patient experienced a transient ischemic attack
(TIA) 3 years ago. A TIA is a temporary blockage of blood flow to the
brain, but does not cause any permanent damage (American Stroke
Association, 2013). With his heart failure development he has also
been found to have diastolic dysfunction or an abnormality with how
the heart fills with blood during diastole. In the past couple of months,
he has also been experiencing vertigo (dizziness/lightheadedness),
also linked to his heart failure. The patients ejection fraction was
measured at 55 percent. The patients current risk factors for a
recurring heart issue and current medications are as follows:

TABLE 2. Risk factor classification.

Risk Factor
Age

Hypertension

Dyslipidemia

Diabetes
Sedentary
Lifestyle

Defining Criteria
Male older than 45 years
old
Systolic BP 140 mmHg
Diastolic BP 90 mmHg
Taking blood pressure lowering
medication
Total cholesterol 200 mg/dL
LDL cholesterol 130 mg/dL
HDL cholesterol < 40 mg/dL
Taking cholesterol lowering
medication
HbA1c > 6 percent
Not participating in at least 30
min of moderate intensity
physical activity on at least 3 days

Patient Information
55 years old
110/77 mmHg
Taking blood pressure
lowering medication
Taking cholesterol lowering
medication

HbA1c 9.7 percent

Does not participate in regular
physical activity

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per week for at least 3 months
Millimeters of mercury (mmHg), milligrams per deciliter (mg/dL)

TABLE 3. Current medications

Medication

Prescribed For

Acetaminophe Treats
n
minor
aches and
pain and
reduces
fever
ASA Therapy

Atorvastatin
(Lipitor)

Amlodipine
(Norvasc)

Treats pain,
fever,
arthritis,
and
inflammati
on, also
used to
reduce the
risk of
heart
attack
Lowers
high
cholesterol
and
triglyceride
levels in
the blood.
Lowers risk
of chest
pain,
stroke, and
heart
attack.
Treats high
blood
pressure or
chest pain

Side Effects

Exercise HR

Exercise BP

Exercise
Capacity

Itching,
No effect
swelling of
face or hands,
chest
tightness,
trouble
breathing
Drowsiness,
No
fatigue,
effect
impaired
cognition,
weakness

No
effect

No
effect

No
effect

No
effect

Fever, muscle
pain,
tenderness,
unusual
tiredness

No
effect

No
effect

Decreas
es

Increas
es in pt.
with
angina;

No
effect

Chest pain,
No
lightheadedn effect
ess, dizziness,
unusual

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tiredness

Furosemide
(Lasix)

Diuretic
treats
edema and
high blood
pressure

Chest pain,
shortness of
breath,
confusion,
weakness

Metoprolol
tartrate
(Lopressor)

Treats high
blood and
angina, and
lowers risk
or repeated
heart
attacks.
Also used
to treat
heart
failure.
Blood
thinner
used to
help
prevent a
stroke,
heart
attack, or
other heart
problems
Works in
the brain to
prevent
seizures
and relieve
pain for
certain
conditions
in the
nervous
system
Used to
treat
diabetes

Drowsiness,
Decreas
dizziness,
es
tiredness, and
slow heart
beat

Decreas
es

Problems with
vision,
speech, or
walking,
trouble
breathing,
fast
heartbeat,
unusual
bruising
Problems with
coordination,
behavior
problems,
dizziness,
sleepiness

No
effect

No
effect

no
effect in
pt. w/o
angina
No
effect,
except
may
increase
in pts.
w/ CHF
Increas
es in pt
w/
angina;
decreas
es or
may
stay the
same in
pt w/o
angina
No
effect

No
effect

No
effect

No
effect

Shaking,
sweating, fast
or pounding
heartbeat,
rapid weight
gain, trouble

No
effect

No
effect

No
effect

Clopidogrel
(Plavix)

Gabapentin
(Neurontin)

Insulin
Glargine
(Lantus)

No
effect

No
effect or
may
decreas
e

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Insulin Lispro
correctional
scale
(Humalog)
Losartan
(Cozaar)

Fast-acting
insulin,
used to
treat
diabetes
Treats high
blood
pressure.
Reduces
the risk of
stroke in
patients
with high
blood
pressure
and
enlarged
heart.
Treats
kidney
disease in
patients
with type 2
diabetes
and a
history of
high blood
pressure.

breathing
Dizziness,
No
lightheadedn effect
ess, increased
thirst,

No
effect

No
effect

Confusion,
weakness,
trouble
breathing,
numbness or
tingling in
hands or feet,
rapid weight
gain,
tiredness

Increase
s or
may
stay the
same

Decreas
es

No
effect;
except
may
increase
in pts
with
CHF

Spironolactone Potassium
(Aldactone)
sparing
diuretic

Chest pain,
confusion,
dizziness,
drowsiness,
weight gain

No
effect

No
effect or
may
decreas
e

Hydrocodone- Treats
acetaminophe moderate
n
to
moderately
severe pain

Extreme
weakness,
shallow
breathing,
slow
heartbeat,
dizziness
Confusion,
weakness,
fast or
uneven heart
rate,

No
effect

No
effect

No
effect,
except
may
increase
in pts.
w/ CHF
No
effect

Increase
or stay
the
same

Decreas
e or
stays
the
same

Trazodone
(Desyrel)

Treats
depression

No
effect

6
dizziness,
fainting,
trouble
sleeping
Milligram (mg), heart rate (HR), blood pressure (BP)

The patient has a cluster of risk factors including his age,

hypertension, dyslipidemia, and diabetes that place him at an
increased risk for coronary artery disease. Before his most recent
operation, the patient presented with all six cardiovascular disease risk
factors and had a history of heart disease that placed him as a high
risk to exercise (ACSM, 2013). According to the National Heart, Lung,
and Blood institute (2014), the patient is considered to be at a 5%
chance for developing a heart attack within the next 10 years. His TIMI
(2013) score was 13% risk at 14 days of: all-cause mortality, new or
recurrent MI, or severe recurrent ischemia requiring urgent
revascularization. According to the Yancy et al. (2013) the American
College of Cardiology Foundation (ACCF)/American Heart Association
(AHA) criteria would classify is heart failure as class C (patient has
structural heart disease with prior or current symptoms of heart
failure).
Client Intake

Why are you coming into cardiac rehabilitation?

I recently had a stent placed in my heart and my cardiologist told
me that I should attend cardiac rehabilitation. I realize that I need to
make changes to my life and I feel like I cannot do many of the
things that I used to do. I feel weaker and have been kind of
depressed.

What are the changes you feel you need to make?

I need to eat healthier, exercise more, and find a way to get control
of my diabetes. I currently go to a diabetes clinic, but I need to be
educated on ways to increase my exercise.

What do you feel are your current limitations to exercising?

Especially since I was diagnosed with heart failure, I have felt
especially weak and tired a lot of the time. I have a significant lack
of motivation, especially once I get home from whatever Im doing
and sit down on the couch.

Even with those limitations, once we start the program, are you
willing to exercise at home once a home exercise program is given?

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Yes I am. I have been trying to walk more, but I get tired very easily
and then dont feel like doing anything the rest of the day. But I am
going to try and walk more regularly and do the things they taught
me when I was in the hospital.
Exercise Experiences

Describe the physical activities that you were doing before your
event.
Ive never really exercised regularly in my life. I would sometimes go
for a walk 1-2 times per week, but that was not very far or for very
long. Lately I have only been able to walk for a couple minutes
before I get tired or dizzy.
What new activities or experiences would you like to try while in
cardiac Rehab?
I am willing to do whatever you want me to try. I would like to try
walking on the treadmill eventually since I do have one at home.
But right now I am not comfortable with my legs fatiguing as quickly
as they do and sometimes I get dizzy or lightheaded after standing
or walking for a while.

Do you experience any pain or discomfort with any exercises or

activities?
Due to my diabetes, I cant feel either of my feet. I also experience
pain in my legs from nerve damage. It radiates from my ankle up
my leg. The pain in my legs is mostly just in my left leg. Its
something that Im learning to live with.
When have you typically experienced muscle soreness in the past?
How did you deal with it?
I typically have experienced muscle soreness when I have tried to
overdo it. After my surgery I tried to go for a longer walk then I
should have and I was very fatigued and my legs hurt for a couple
hours. I just rested on the couch and took a nap afterwards, and felt
a little bit better.

How long was your walk that you felt you over did it?
I would say I walked for 10 minutes or so. I had to stop and rest a
couple times because of my dizziness

What challenges have you faced in increasing your activity level in

the past and how can we overcome them?
Feeling like I just dont have time to exercise and not really knowing
what I am doing was the primary reason before all of my problems.
In order to help me, you can help to teach me the exercises that I
should be doing, what I can do, and for how long. Not really sure
about how long I should be exercising and I dont want to overdo it
again.

Diet/Nutrition

How is your current diet?

After my surgery, I havent been really hungry for much of anything.
But in the past week or so I feel like I have been starting to get my
appetite back. I also realize after talking with my doctor that I need
to make changes to my diet, since I realize that it is not very good.

How many days per week do you eat out?

I would say that I eat out probably 3-4 times per week

When you do eat out, or at home, do you typically add salt to food
without tasting or while cooking?
I have added salt to my food in the past, but I have been trying to
limit the amount that I have been putting on now. But I will typically
still add just a little bit for flavor right away. Its just a habit that I
know that I need to change.

How often do you eat meats, how many servings per week?
I usually eat meat at least 3-4 times per week. When I do eat them I
have been trying to eat more fish and chicken. But in the past, I ate
a lot of red meat.
Rate your plate score: 50 (there are some ways the patient can
make your eating habits healthier)

Psychosocial

How would you rate your current stress level? What do you
currently do to manage stress?
I do have some stress due to my diabetes and not being able to feel
my foot, but I have been learning to cope with that a little better
and it hasnt been bothering me as much. I experience most of my
stress when Im around my son. We have been arguing a lot lately. I

have been trying to just walk away from the situation to help relax,
but hasnt been seeming to help much. But I also am on medication
to help with some of my stress. I have also been a little anxious
since my surgery and feel like I have more pains then usual.
Sounds like you have been able to identify your stressors, do you
have support at home?
Yes, my wife has been supportive and so have my brothers. Since I
cant drive right now, they will be bringing me to rehab and have
been making this process a lot easier.

Are you open to attending our stress management class to learn

different ways to help manage or eliminate your stress?
Yes, I have been trying to look into other ways of eliminating my
stress, because I know that it isnt good for me to be stressing as
much as I do.

Do you feel as though you get enough quality sleep on a regular

basis?
I usually sleep pretty well. Get up like 1-2 times per night to go to
the bathroom, but can usually fall right back to sleep. Id say I
usually get around 7-8 hours per night.

TABLE 4. Intake surveys

Survey
Rate your plate

50

PHQ9

Interpretation
There are some ways you can make your eating
habits healthier
Mild depression

After reviewing the patients health history and talking with him,
it became evident that he will benefit greatly from cardiac
rehabilitation. He was recently referred by his cardiologist to attend
cardiac rehabilitation, as it will help him make the lifestyle changes
that he needs. Cardiac rehabilitation will be beneficial to this patient to
introduce regular exercise into his life and to find ways for him to
exercise without pain and discomfort that he has experienced from his
diabetic neuropathy. It will also be beneficial for him to learn what he
should be doing so that he can begin a regular exercise program at
home. It will be necessary for him to perform lower body strengthening
exercises, as his legs are very weak at this point (myalgia and
myositis). After talking with him, stress management and nutrition are
going to be important areas for education. He desperately needs to
gain a greater control of his diabetes by controlling his diet and
exercise. He is also willing to see a nutritionist since nutrition is an

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important area of education for him and he needs to change what he is
eating. Pairing with the nutritionist, it will greatly help to make his diet
changes that he needs, such as not eating out as much and limiting
the amount of salt he is adding to his food. With these changes, it is
possible that he can help to reduce some of his risk factors and to
reduce his risk of having another heart issue.

Secondary Prevention
Areas for secondary prevention for this client include decreasing
his blood pressure, decreasing his cholesterol, and to gain control over
his diabetes. Secondary prevention in these areas would allow this
patient to decrease his risk of having another heart related event.
Marx, Hockberger, and Walls (2013) state that the average American
consumes close to 3500 milligrams of sodium per day, which is more
than the recommended amount of 1500 milligrams per day. Without an
accurate dietary analysis it cannot be specified the exact amount of
sodium that this patient consumes, but he does add salt to all of his
meals, which will most likely place him over the limit of 1500
milligrams per day. According to Blumenthal et al. (2010), increasing
his exercise and in combination with dietary changes, such as the
dietary approaches to stop hypertension (DASH) diet, can lead to a
reduction in blood pressure and other cardiovascular biomarkers.
Decreasing his blood pressure would allow him to decrease his
medication or possibly even eliminate his need for medication. In
combination with his diet, exercise, and medications, he will be able to
control his blood pressure and decrease his risk for heart disease.
Lowering his triglycerides and increasing his high-density
lipoprotein (HDL) cholesterol will help to decrease his risk for heart
disease. As he is on a lipid lowering medication, having him continue to
be compliant with taking his medication will keep his cholesterol lower
and will attempt to increase his HDL cholesterol. Having him make
dietary changes and beginning a regular exercise program, will allow
for a decrease in cholesterol and to increase his HDL cholesterol.
According to Stone (2008), a diet that is lower in carbohydrates may
also be effective in reducing triglyceride levels and increasing HDL
cholesterol. With a decrease in triglycerides and an increase in HDL
cholesterol, he can see a decrease in his medication as well.
Gaining an improved control over his diabetes will be a beneficial
area of prevention for him. He will be able to improve his HbA1c, again
by making changes to his diet and his exercise level. Zoungas et al
(2012) states that improving diet and exercise can help to lower HbA1c
levels and therefore help to decrease the risk of developing further
heart disease. HbA1c levels below 7 percent have been found to
reduce the risk of death and cardiovascular events.

11
It would also be beneficial for him to see a therapist and attend
the stress management class for his stress and anxiety issues. In a
study completed by Carroll et al., (2012), they found that acute stress
can lead to an increase in both systolic and diastolic blood pressure. An
increased blood pressure response can lead to an increase in
cardiovascular mortality. It will be important for him to continue to
adhere to his medications so that he can limit his stress and anxiety
levels. As with this client, stress can lead to a decrease in physical
activity level. With a decrease in physical activity, it will affect his
blood pressure, cholesterol, and diabetes equally.

Being able to decrease risk factors such as hypertension,

dyslipidemia, losing weight, quitting smoking, and relieving stress can
have a big impact on this patients quality of life. Being able to add
exercise as a regular part of his life, make necessary dietary changes,
adhering to his medications, and relieving stress can help him to get
control of his blood pressure, dyslipidemia, and diabetes. Gaining
control of those areas can lead to a decrease in risk factors for
cardiovascular disease and decrease his chances of experiencing a
second cardiac event.
Considerations for Exercise Prescription
This patient does have a couple of considerations that should be
accounted for when developing an exercise prescription. One of the
areas is that he is currently taking metoprolol and other medications
that can affect his exercise heart rate, blood pressure and exercise
capacity. Metoprolol will decrease not only his resting heart rate and
blood pressure, but it will also decrease his exercise heart rate and
blood pressure. Other medications that may also affect his exercise
include his anti-depressant medications. As an exercise professional, I
need to be aware of the effects of all drugs and how they are going to
affect him during exercise. Due to physician orders, the
recommendation for his exercise heart rate is going to be his resting
heart rate plus 30 beats per minute while being on metoprolol.
Knowing that if his exercise heart rate would exceed this limit, he
would need to slow down or take a rest break from his exercise. His
resting heart rate is to not exceed 30 beats per minute higher than his
resting unless the physician provides clearance. With this particular
patient, the physician did not provide clearance, so his exercise heart
rate will typically be 95-105 bpm.
This patient has been diagnosed with diabetes and it has
affected his life quite severely. With this disease and it effects on his
life, I need to pay attention to factors such as his blood sugar level, his

12
diabetic foot, and making sure he does not develop any ulcers. As with
any diabetic patient, the frequency with which I will have to check his
blood sugar depends on a number of different factors. According to
Lopez-Jimenez et al. (2012), there are no specific guidelines, but
depends on the patients medications, co-morbid conditions, medical
history, meal plan, time of exercise, and history of hyperglycemia or
hypoglycemia. Using those factors as a guideline, and with him not
having a great medical history with having control of his diabetes, it
will be necessary to monitor his blood sugar before and after every
session. During sessions, it is important to be aware of his diabetic foot
and making sure that he is performing the exercises correctly and
making sure his foot is in the correct position when performing the
exercises. Since he cannot feel his foot, he may not realize that it is
slipping out of strap or may be pointing the wrong way. This may only
cause injury. Along with those factors, I will also need to make sure that
he is aware of checking his feet and letting me know if he has any
issues with his foot, like a developing ulcer. If he is developing another
ulcer on his foot, I will need to change his exercise prescription so that
he is not using his foot to the same extent and that the exercise that
we are doing will not make it any worse.
The other area for concern when developing his exercise
prescription is that he has severe weakness in his lower body as he has
myalgia and myositis. This patient has problems with his gait due to
the weakness in his legs and will not be able to walk for an extended
period of time until he improves the strength in his legs. It will be
necessary to perform strengthening exercises in his lower body and
perform weight-bearing exercises so that it is beneficial to him gaining
leg strength. Along with this he also has vertigo, which will also limit
his ability to perform some exercises. Until he feels like he has not
been experiencing any lightheadedness or dizziness during exercise, it
will be necessary to keep him seated while he is exercising and to
remind him to stop and rest if he is experiencing these symptoms.
This patient has many different considerations that need to be
made when developing his exercise prescription. These vary from
knowing the effects of his medication, to managing his diabetes, to
increasing his strength in his lower body and being aware of how he is
feeling during exercise. Managing his diabetes and improving his leg
strength will play a large factor in the success of his exercise
prescription and his ability to regain his quality of life that he used to
have. As an exercise professional it will be my responsibility that he is
made aware of what and when he needs to be eating before coming to
rehab and what he needs to be doing to take care of his feet when he
goes home, so that he can continue to exercise.
Exercise Testing
Cardiovascular

13
The patient is a 55-year-old male that is considered to be a high
risk to exercise because he has had multiple cardiac events in the past
and still presents with a cluster of cardiac risk factors. This patient has
also been diagnosed with Heart failure and is considered to be in class
C of the ACCF/AHA heart failure classification. At this site, we did not
perform a cardiovascular exercise test, but following best practice; I
would have him complete one. With his diagnosis of heart failure that
is currently symptomatic, previous cardiac events, and inability to walk
on a treadmill or for long periods of time, I would have him perform a
six-minute walk test. Although this patient is attending cardiac rehab
due to his recent PTCI, the exercise testing and prescription will be
based on his diagnosis of heart failure and the signs and symptoms
that he is experiencing. In a study completed by Lavie, Berra, & Arena
(2013), they found that a 6 minute walk test has shown to have
statistical significance in determining a heart failure patients peak VO 2.
Ades et al. (2013) also states that
Exercise testing is recommended prior to enrollment in
an exercise program to screen for patients at high risk
for adverse effects and to assist in the determination of
an exercise training intensity range.
A six-minute walk test would be beneficial for him, since it is a way to
measure his Peak VO2 with statistical significance and it is a safer test
for him to perform. Prior to performing the exercise testing, the patient
would be informed on the directions of the test: the test measures the
distance that he can travel in six minutes; that he needs to be aware of
signs and symptoms such as dizziness, lightheadedness, pain, nausea,
cramping, and chest pain; and if he needs to he can stop and rest at
any time.
Since no exercise testing occurred, there were no results to interpret at
this time. However, exercise prescription was based on guidelines
provided by research completed. Exercise prescription guidelines will
be discussed later.
Musculoskeletal
The cardiac rehabilitation program at Waukesha Memorial
Hospital does not complete musculoskeletal testing on their patients.
Based on guidelines and recommendations, I chose tests that could be
completed once he would have a baseline of cardiovascular training.
Ades et al (2013), states, Once patients demonstrate a tolerance of
aerobic training levels, resistance training activities are added. With
his diagnosis of heart failure, diabetes, and the signs and symptoms
caused by them, his exercise tests were chosen based on research and
clinical decision-making.
Once he has a baseline of cardiovascular training, it would be
recommended that he complete some musculoskeletal fitness testing
to determine his current level of fitness and to develop an accurate
exercise prescription for him. According to Ehrman et al., (2013), it is

14
recommended that when performing the resistance training tests, that
you use machine weights or isokinetic dynamometer for performing a 1
RM or indirect 1 RM method. Due to the client being currently
sedentary and not having a resistance training background, I would
want to test to see where he currently is with upper body strength and
lower body strength. To test his lower body strength, I decided to have
him perform a 30 second sit to stand test. This test was used in a study
completed by Billek-Sawhney (2012), which looked at exercise testing
for patients with type 2-diabetes. A sit to stand test was also used in a
study by Schurr et al., (2012) and was found to be an accurate
measurement of lower body muscular endurance. This test will give us
information as to what his lower body muscular endurance is and will
allow us to set an accurate amount of repetitions that is tailored to him
for when he would perform the sit to stand exercise.
For an upper body muscular strength test we are going to have
him perform a 30 second arm curl. This test was also used in the study
by Billek-Sawhney (2012), and is typically used for someone that is
currently sedentary and is considered to be greater than 45 years old
with diabetes or an elderly individual. The purpose of this test would be
to see how many correct repetitions that he can perform in 30 seconds.
Upon completion his score would be compared with what is considered
normal for someone in his age population. Based on his rating, the
development of an exercise prescription with repetitions and intensity
that is designed to his current level would occur. This test was also
chosen since increasing his lower body muscular endurance is
important for improving his ability to perform his activities of daily
living and therefore improving his quality of life. The last set of exercise
testing that we would have him perform would be to have him
complete some range of motion tests.
Since Waukesha Memorial Hospital- cardiac rehabilitation does
not complete exercise testing, the results of the tests cannot be found.
With the results of the exercise testing, the results would then be used
to develop an individualized and accurate exercise prescription for this
patient. All tests were chosen as he should be successful in completing
them, they are based off of research, and they are designed to limit the
amount of signs and symptoms that he would experience with other
tests. With all tests, the results can be shown and interpreted as they
all have age specific norms that have been developed for his age
group. Age specific norms allow the patient to be assessed of where he
currently is at with his physical fitness when compared to other
individuals of his same age group. Performing these tests will show the
patient that he is making progress and that the exercise prescription is
helping to improve his activities of daily living and his quality of life.
With the results of all testing, a more accurate exercise prescription
would then have been developed.
Exercise Prescription/Work Sample

15
Cardiovascular
The main goal of his cardiovascular fitness program was to focus
on increasing the amount of time that he can exercise per session. His
cardiovascular exercise prescription was created off research and goals
that were developed with the patient. Since he suffers form heart
failure, which is the main cause of many symptoms, his exercise
prescription was created off of heart failure guidelines and tailored to
also meet guidelines for recent cardiac rehab. According to the ACSM
(2013), it is recommended for any individual to work towards achieving
150 minutes per week of planned exercise. In the first couple of weeks
his exercise prescription focused on starting slow and building him up
to the point where he is able to successfully perform 30-40 minutes per
session of exercise. In a study completed by Brubaker, Moore, Stewart,
Wesley, & Kitzman (2009) they had subjects exercising 3 times per
week for at least 30 minutes each session and then gradually
increased duration each session. This study started the patients at an
initial exercise intensity of 40-50 percent of heart rate reserve for the
first two weeks, and the gradually increased in intensity as well until
they were between 60 to 70 percent of heart rate reserve. 40-50
percent of heart rate reserve would be equal to a light to moderate
intensity workload or a rating of perceived exertion (RPE) of 9-12 on
the Borg 6-20 RPE scale. Studies by Brubaker et al (2009), Lavie Barrie,
& Arena (2013), Ades et al (2013), and Arena et al (2013), all
participants should complete a 5 to 10 minute warm up, about 30 to 40
minutes of aerobic exercise, followed by a 5 to 10 minute cool
down/stretching period. The modality of training was similar between
studies, as they participants completed walking, stationary cycling, or
rowing. The heart failure guidelines are similar to diabetes guidelines.
In an article by OHagan, De Vito, and Boreham (2013), they
recommend that a diabetic patient participate in activity that is at least
40 percent of their heart rate reserve. OHagan et al., (2013), also
recommend progressing exercise intensity every two weeks, which was
done throughout the eight week program. Using this progression and
increasing his intensity every two weeks, he will be in the
recommendation of 50% or greater by week six. Having him exercise at
this intensity has been shown by Rejewski et al., (2014) to help with
not only gaining better control of his diabetes, but also to help with his
peripheral artery disease.
In order to develop an accurate exercise prescription tailored to
him, I calculated his workload dependent on heart rate guidelines
placed by his cardiologist. Based on his heart rate guidelines I was able
to create an exercise program that started him at a low level of
exercise, increasing the amount of time that he was exercising with
each session. For the first week I started him at completing one to two
bouts of 10-15 minutes as I felt that was appropriate for him and
Yohannes et al (2010) recommend starting with bouts of 10-15
minutes. With every two weeks, a new exercise prescription would
increase in intensity of the exercise. An increase in intensity was done

16
with the goal of increasing his MET level and aerobic endurance.
Guidelines were used following recommendations by Ehrman &
Keteyian (2013), for cardiac rehabilitation patients. Since he is
currently taking metoprolol a starting intensity was developed based
off of recommendations by his cardiologist.
TABLE 5. Week 1 aerobic exercise prescription
Session

Intensity

Time

Type

Monday

2 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 15 minutes
of exercise. 20
minutes total.

NuStep on
level 2, 30
Watts
-RPE
9-12/20

Wednesda
y

2 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 17 minutes
of exercise. 22
minutes total.

Friday

2 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 5
minutes. 25
minutes total.

NuStep on
level 2, 30
Watts
-RPE
9-12/20
-NuStep
on level 2,
30 Watts
Recumben
t bike on
level 1, 40
watts
-RPE
9-12/20

Post-session
comments
- Ex BP:
116/66
- NSR w/
occasional
PVCs
-Tolerated
exercise
well
- Was not
at
internship
-Was not
at
internship

Heart rate (HR), Oxygen consumption (VO2), Metabolic equivalent (MET), Rating of perceived exertion (RPE),

TABLE 6. Week 2 aerobic exercise prescription

Session
Intensity
Time
Monday

2 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1

Type
-NuStep
on level 2,
30 Watts

Post-session
comments
- Was not
at
internship

17
bout of 6
minutes. 26
minutes total.

Wednesda
y

2 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 7
minutes. 27
minutes total.

Friday

2 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 8
minutes. 28
minutes total.

Recumben
t bike on
level 1, 40
watts
-RPE
9-12/20
-NuStep
on level 2,
30 Watts
Recumben
t bike on
level 1, 40
watts
-RPE
9-12/20
-NuStep
on level 2,
30 Watts
Recumben
t bike on
level 1, 40
watts
-RPE
9-12/20

-Ex BP:
116/66
-NSR w/
rare PVCs
-Tolerated
exercise
well

- Was not
at
internship

Heart rate (HR), Oxygen consumption (VO2), Metabolic equivalent (MET), Rating of perceived exertion (RPE),

TABLE 7. Week 3 aerobic exercise prescription

Session
Intensity
Time
Monday

2.5 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 8
minutes. 28
minutes total.

Wednesda
y

2.5 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 9
minutes. 29
minutes total.

Type
-NuStep
on level 3,
40 Watts
Recumben
t bike on
level 3, 50
watts
-RPE
9-12/20
-NuStep
on level 3,
40 Watts
Recumben
t bike on
level 3, 50

Post-session
comments
- Was not
at
internship

-Ex BP:
134/72
-NSR
-Tolerated
exercise
well

18

Friday

2.5 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 10
minutes. 30
minutes total.

watts
-RPE
9-12/20
-NuStep
on level 3,
40 Watts
Recumben
t bike on
level 3, 50
watts
-RPE
9-12/20

-Was not
at
internship

Heart rate (HR), Oxygen consumption (VO2), Metabolic equivalent (MET), Rating of perceived exertion (RPE), Normal sinus
Rhythm (NSR)

TABLE 8. Week 4 aerobic exercise prescription

Session
Intensity
Time
Monday

2.5 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 8
minutes. 28
minutes total.

Wednesda
y

2.5 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 9
minutes. 29
minutes total.

Friday

2.5 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 12
minutes. 32
minutes total.

Type
-NuStep
on level 3,
40 Watts
Recumben
t bike on
level 3, 50
watts
-RPE
9-12/20
-NuStep
on level 3,
40 Watts
Recumben
t bike on
level 3, 50
watts
-RPE
9-12/20
-NuStep
on level 3,
40 Watts
Recumben
t bike on
level 3, 50
watts
-RPE
9-12/20

Post-session
comments
- Was not
at
internship

-Ex BP:
134/72
-NSR
-Tolerated
exercise
well

-Was not
at
internship

19
Heart rate (HR), Oxygen consumption (VO2), Metabolic equivalent (MET), Rating of perceived exertion (RPE), Normal sinus rhythm
(NSR)

TABLE 9. Week 5 aerobic exercise prescription

Session
Intensity
Time
Monday

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 12
minutes. 32
minutes total.

Wednesda
y

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 13
minutes. 33
minutes total.

Friday

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
15 minutes, 1
bout of 15
minutes. 35
minutes total.

Type
-NuStep
on level 4,
50 Watts
Recumben
t bike on
level 4, 60
watts
-RPE
9-13/20
-NuStep
on level 4,
50 Watts
Recumben
t bike on
level 4, 60
watts
-RPE
9-13/20
-NuStep
on level 4,
50 Watts
Recumben
t bike on
level 4, 60
watts
-RPE
9-13/20

Post-session
comments
- Was not
at
internship

-Ex BP:
142/60
-NSR
-Tolerated
exercise
well

-Was not
at
internship

Heart rate (HR), Oxygen consumption (VO2), Metabolic equivalent (MET), Rating of perceived exertion (RPE), Normal sinus rhythm
(NSR)

TABLE 10. Week 6 aerobic exercise prescription

Session
Intensity
Time

Type

Post-session

20
Monday

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
16 minutes, 1
bout of 16
minutes. 37
minutes total.

Wednesda
y

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
17 minutes, 1
bout of 16
minutes. 38
minutes total.

Friday

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
18 minutes, 1
bout of 16
minutes. 39
minutes total.

-NuStep
on level 4,
50 Watts
Recumben
t bike on
level 4, 60
watts
-RPE
9-13/20
-NuStep
on level 4,
50 Watts
Recumben
t bike on
level 4, 60
watts
-RPE
9-13/20
-NuStep
on level 4,
50 Watts
Recumben
t bike on
level 4, 60
watts
-RPE
9-13/20

comments
- Was not
at
internship

-Ex BP:
142/62
-NSR
-Tolerated
exercise
well

-Was not
at
internship

Heart rate (HR), Oxygen consumption (VO2), Metabolic equivalent (MET), Rating of perceived exertion (RPE), Normal sinus rhythm
(NSR)

TABLE 11. Week 7 aerobic exercise prescription

Session
Intensity
Time
Monday

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
18 minutes, 1
bout of 16
minutes; 1
bout of 2
minutes. 41
minutes total.

Type
-NuStep
on level 5,
60 Watts
Recumben
t bike on
level 5, 70
watts
Treadmill
1.0 mph
-RPE
9-13/20

Post-session
comments
- Was not
at
internship

21
Wednesda
y

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
20 minutes, 1
bout of 16
minutes. 1
bout of 3
minutes. 42
minutes total.

Friday

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
20 minutes, 1
bout of 18
minutes. 1
bout of 4
minutes. 44
minutes total.

-NuStep
on level 5,
60 Watts
Recumben
t bike on
level 5, 70
watts
Treadmill
1.0 mph
-RPE
9-13/20
-NuStep
on level 5,
60 Watts
Recumben
t bike on
level 5, 70
watts
Treadmill
1.0 mph

-Ex BP:
138/62
-NSR
-Tolerated
exercise
well

-Was not
at
internship

-RPE
9-13/20
Heart rate (HR), Oxygen consumption (VO2), Metabolic equivalent (MET), Rating of perceived exertion (RPE), Normal sinus rhythm
(NSR)

TABLE 12. Week 8 aerobic exercise prescription

Session
Intensity
Time
Monday

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
20 minutes, 1
bout of 20
minutes. 1
bout of 5
minutes. 46
minutes total.

Wednesda
y

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
20 minutes, 1
bout of 20

Type
-NuStep
on level 5,
60 Watts
Recumben
t bike on
level 5, 70
watts
Treadmill
1.0 mph
-RPE
9-13/20
-NuStep
on level 5,
60 Watts
-

Post-session
comments
- Was not
at
internship

-Ex BP:
140/64
-NSR
-Tolerated

22
minutes. 1
bout of 5
minutes. 46
minutes total.

Friday

3.0 METs
HR <Resting
HR + 30 bpm

5 minute warm
up; 1 bout of
20 minutes, 1
bout of 20
minutes. 1
bout of 6
minutes. 46
minutes total.

Recumben
t bike on
level 5, 70
watts
Treadmill
1.0 mph
-RPE
9-13/20
-NuStep
on level 5,
60 Watts
Recumben
t bike on
level 5, 70
watts
Treadmill
1.0 mph
-RPE
9-13/20

exercise
well

-Was not
at
internship

Heart rate (HR), Oxygen consumption (VO2), Metabolic equivalent (MET), Rating of perceived exertion (RPE), Normal sinus rhythm
(NSR)

Resistance Training
A resistance training program was inserted into his rehabilitation
program once he had a baseline of aerobic training. An article
completed by Ades et al (2013), stated, once patients demonstrate a
tolerance of aerobic training levels, resistance training activities are
added. For this patient, he was cleared to begin resistance training in
week 6 of his program. The goal of his exercise prescription is
increasing his upper body muscular strength, as well as lower body
muscular endurance. All exercises chosen focus on strengthening all
major muscle groups in his upper body including his chest, biceps,
triceps, and shoulders and lower body including his quadriceps and
hamstrings. Research studies by Ades et al (2013) and Cheuh-Lung,
Chen-Lin, & Ying-Tai (2010), agreed that resistance training should
involve all major muscle groups, which involves 5 to 6 exercises. These
exercises should involve the upper body, trunk, and lower body, but
also dependent on an individuals orthopedic condition. All exercises
were introduced starting at 1 set and having him perform 8-12
repetitions of each exercise. Ades et al., (2013) recommend this level
since they found that resistance training should consist of 1 to 2 sets of
10 to 12 repetitions per each exercise session. Progression of weight
used was done using the 2 for 2 rule, where once the client was able to
complete 14 or more repetitions on two consecutive sessions the
weight was increased. The client was instructed to perform a chest
press, seated row, bicep curl, and a triceps extension exercise using
hand weights. The lower body strengthening exercises were also
introduced in order to strengthen his leg muscles. The leg-

23
strengthening exercises included a sit-to-stand and calf raise. The
exercises that were prescribed to him were exercises that are low-level
exercises that are designed for unfit individuals. His resistance-training
program was completed at least two times per week, on Monday, and
Friday the first two weeks. Ades et al (2013) found that resistance
training should be completed between a minimum of 2 to 3 times per
week, in order to see benefits. After the first two weeks he had a good
understanding of all exercises and was not experiencing a lot of muscle
soreness and was feeling like the exercises were becoming pretty easy.
For that reason a second set of 8-12 repetitions were introduced in
weeks 3 and 4. All movements should be slowed and controlled and
the heart failure patient should focus on proper breathing and avoiding
the Valsalva maneuver. (Cheuh-Lung, Chen-Lin, & Ying-Tai, 2010).
TABLE 13. Week 1 resistance training
Exercise
Sets
Reps
1
10
Chest press
1
10
Seated row
1
10
Bicep curl
1
10
Triceps
extension
1
6
Sit to stand
1
10
Calf raise

TABLE 14. Week 2 resistance training

Exercise
Sets
Reps
1
12
Chest press
1
12
Seated row
1
12
Bicep curl
1
12
Triceps
extension
1
8
Sit to stand
1
12
Calf raise

TABLE 15. Week 3 resistance training

Exercise
Sets
Reps
1
10
Chest press
1
10
Seated row
1
10
Bicep curl
1
10
Triceps

Weight/Directions
2 pounds
2 pounds
2 pounds
2 pounds

Equipment
Hand weight
Hand weight
Hand weight
Hand weight

Non-moving chair
Balance beam for balance

Body weight
Body weight

Weight/Directions
2 pounds
2 pounds
2 pounds
2 pounds

Equipment
Hand weight
Hand weight
Hand weight
Hand weight

Non-moving chair
Balance beam for balance

Body weight
Body weight

Weight/Directions
3 pounds
3 pounds
3 pounds
3 pounds

Equipment
Hand weight
Hand weight
Hand weight
Hand weight

24

extension
Sit to stand
Calf raise

1
1

8
10

Non-moving chair
Balance beam for balance

Body weight
Body weight

Goal Setting
It is important to set goals that are specific, measureable,
attainable, realistic, and that are bound by time (SMART). These types
of goals are found to have the most successful outcomes at helping
individuals reach their goal. With the patient we co-created short-term
and long-term goals based on the SMART goal format. Using the SMART
goal format, we co-created short-term goals that focused on increasing
his walking endurance, decreasing/maintaining systolic blood pressure,
and decreasing signs and symptoms. The first goal of increasing his
walking distance was a goal that was created through increasing his
time exercising each session in cardiac rehabilitation, but also by
increasing the amount he was exercising per week outside of cardiac
rehab. To reach his long-term goal of being able to walk over 1 mile, we
needed to make short-term goals. In an article by Kruidenier et al.
(2012), they looked at increasing walking distance in patients with
intermittent claudication. They found that increasing the amount of
exercise time, could lead to increases in walking distance. Using the
SMART goal format, the goal was to increase his walking distance by
300 feet every week until he reached his total distance of 1 mile or
5,280 feet. This was a progressive goal that is going to take longer
than the 12-week cardiac rehab program to achieve. So we set the goal
of having him walk 4,000 feet by the end of cardiac rehabilitation. At
the end of the eight week period, he was walking around 3200 feet
without experiencing any signs or symptoms.
Another goal for this patient was to decrease his resting blood
pressure. When joining cardiac rehabilitation, his resting blood pressure
was measured at 110/70, but he is currently taking medication for his
blood pressure. So we developed a goal with the intention of possibly
decreasing his blood pressure. Using research from a previous study
completed by Semlitsch et al., (2013), that showed that systolic and
diastolic blood pressure can be lowered due to exercise helped to
develop this goal. While coming to cardiac rehabilitation, the patient
wanted to set a goal of decreasing his systolic blood pressure by 5
mmHg and his diastolic blood pressure by 1-2 mmHg by the end of
cardiac rehabilitation. According to Semlitsch et al., (2013), this was a
realistic goal for him. By the end of the eight weeks that I had been
working with him, he was coming into cardiac rehabilitation with a
blood pressure that was measured at 106/70 mmHg. Maintaining this
blood pressure will allow him to place less stress on his heart and
decrease the risk of another cardiac issue.
With this patients goals, he can expect to see other
physiological outcomes, such as a decrease in cholesterol and more

25
energy to perform his daily activities. He can also see psychological
benefits. Aerobic training has many beneficial effects for everyone, but
especially can help someone that has heart failure. In a study
completed by Mueller et al (2007), they found that aerobic exercise
could decrease a heart failure patients resting heart rate, systolic
blood pressure, diastolic blood pressure, as well as increasing their
maximum heart rate, VO2, exercise time, and peak watts. These are all
huge effects that lead to an increase in a persons quality of life and
allow a heart failure patient to exercise longer and harder during a
period of time. Ghanbari-Firoozabadi et al (2014) also looked at the
effects of a cardiac rehabilitation program on heart failure patients
quality of life. They found as well, that cardiac rehabilitation could lead
to an increase in quality of life due to an increase in cardiopulmonary
functioning allowing the patients to participate in an increased amount
of physical activity. Belardinelli, Georgiou, Cianci, & Purcaro, (2012)
looked into quality of life being improved through increased ventilatory
function and increased peak VO2. They saw that through aerobic
training, gas exchange ratio was improved for up to ten years as long
as the individual continued with their exercise training. Belardinelli,
Georgiou, Cianci, & Purcaro, (2012), also saw a decrease in resting
heart rate, which also aids in increasing quality of life and helps to
increase ejection fraction. Another study such as one by Alves et al
(2012), looked at how aerobic activity could improve a heart failure
patients diastolic function. In this study they found that through proper
aerobic training, the left ventricular ejection fraction improved where
as in usual care, it stays the same. Alves et al (2012) also saw
improvements in mitral valve inflow patterns, helping to aid in the
ejection fraction. Downing & Balady (2011) found that exercise training
could lead to positive effects of maximal VO2, central hemodynamic
function, autonomic nervous system function, peripheral vascular
function, muscle function, and exercise capacity. By the end of the
eight weeks, he was repeatedly making statements about how much
better he was feeling. He self-reported that he had more strength and
was feeling like with the increase in strength he also had more energy
and endurance while walking. The signs and symptoms that he was
experiencing from his heart failure had also decreased as the amount
of dizziness/lightheadedness that he was experiencing before or during
exercise was greatly less. Another way to increase his quality of life
and help him to reach these goals was to provide tailored education to
him.
Education
When delivering education to patients, it is important to tailor
the education they receive to their particular needs. The education
that he needed was involved with making lifestyle changes that can
lower his blood pressure, cholesterol, manage his diabetes, and stress
levels. Education topics for him included healthier eating, tips on
eating out, healthier thanksgiving meals, reading food labels,

26
medication adherence and information on medications, tips on
lowering cholesterol, stress management, diabetes, and lowering
sodium intake. All education handouts are in Appendix A. Most of the
education that was presented to this patient was based on the effects
that exercise and dietary changes can improve his quality of life.
Dietary changes are necessary for this patient in order to
decrease his blood pressure, lower his triglycerides, and diabetes
management. In an article by England et al. (2014), they found that
educating patients on dietary changes could lead to improvements in
HbA1c levels. These changes have also been found to be successful in
an article by Edwards et al. (2011), when they looked at the
improvements the DASH diet can have on reducing blood pressure.
These tips and education topics will be useless unless he knows how to
read a food label effectively. Knowing how to see how much sodium,
cholesterol, and fat are in foods is going to be an important process
and one of the first steps to making his changes stay. The week before
Thanksgiving, it was important to provide him with options that are
healthier meals that he can still enjoy the holiday and some of the
foods that come with it. Applying these changes while he is at home
and while he is eating out, if there are no other options, are going to be
a great part of him becoming a healthier individual and living an
improved quality of life.
The other education topics such as information on his
medications, stress management, and his diabetes are to provide him
with additional information on his health problems and what his
medications are trying to help him with. These information topics will
further influence his knowledge about his body and why the changes
he is making are necessary for him to live a happier and fuller life. The
combination of his education, medications, exercise, and dietary
changes will help him to get back to his old self before his cardiac
events.

27

References
Ades, P. A., Keteyian, S. J., Balady, G. J., Houston-Miller, N., Kitzman, D.
W., Mancini, D. M., et al. (2013). Cardiac Rehabilitation Exercise
and Self-Care for Chronic Heart Failure. JACC: Heart Failure, 1(6),
540-547.
All About Heart Rate (Pulse). (2014, September 30). Retrieved
December 2, 2014, from
http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStr
okeNews/All-About-Heart-Rate-Pulse_UCM_438850_Article.jsp
Arena, R., Myers, J., Forman, D. E., Lavie, C. J., & Guazzi, M. (2013).
Should high-intensity-aerobic interval training become the
clinical standard in heart failure? Heart Failure Reviews, 18(1),
95-105. doi:10.1007/s10741-012-9333-z
Belardinelli, R., Georgiou, D., Cianci, G., & Purcaro, A. (2012). 10-Year
Exercise Training in Chronic Heart Failure. Journal of the American
College of Cardiology, 60(16), 1521-1528.
Billek-Sawhney, B. (2012). Applying principles of exercise testing and
prescription to a patient with type 2 diabetes. Journal of Acute
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direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=rzh
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Blumenthal, J. A., Waugh, R., Johnson, J., Caccia, C., Lin, P., Craighead,
L., et al. (2010). Effects of the DASH Diet Alone and In
Combination with Exercise and Weight Loss on Blood Pressure
and Cardiovascular Biomarkers in Men and Women with High
Blood Pressure: The ENCORE Study. Archives of Internal Medicine,
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Brubaker, P. H., Moore, J. B., Stewart, K. P., Wesley, D. J., & Kitzman, D.
W. (2009). Endurance exercise training in older patients with

28
heart failure: Results from a randomized, controlled, single-blind
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