EXP 590

Case Report and Work Sample

Brock Guetzke
August 11, 2014

1
Assessment for Entry
Client Profile
The patient is a 48-year-old male that is five feet and seven
inches tall and weighs 315.3 pounds. Calculated using his current
height and weight, his BMI is 49.38 kg/m2. With a BMI greater than 30,
he is currently classified as being obese class II. His resting heart rate
was measured at 71 beats per minute, classifying as a normal resting
heart rate, as normal is classified between 60-100 beats per minute.
His resting blood pressure was measured at 120/70 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 39 mg/dL. LDL cholesterol 76 mg/dL, and
triglycerides were 152 mg/dL. The patient self reported that he does
not have a family history of cardiac disease, so his family history is not
a risk factor. The patient also self-reports that he had recently quit
smoking on June 14, 2014. Up until then he had smoked 1.5 packs per
day for the past 30 years and over the past couple months only
smoked when he was stressed. The patient self reports that he is not
physically active, as he does not participate in at least 30 minutes of
physical activity for three days per week over the past three months.

Anthropometric Measurements
Height
Weight
BMI
5 7 (1.715 m)
315.3 lbs (142.97 kg)
49.38 kg/m2 (obese)
Table 1. Anthropometric measurements
Resting Measurements
HR
BP
Total
HDL
LDL
Chol.
71 bpm
120/70
145
39 mg/dL 76 mg/dL
mmHg
mg/dL
Table 2. Resting measurements and cholesterol values

Triglycerid
es
152 mg/dL

The patient is not new to heart disease and in November of 2012

he had two stents placed to his circumflex artery. His latest event
occurred in October of 2013, where he had a drug eluding stent placed
to his distal right coronary artery. After his surgery, the patient was not
referred to cardiac rehabilitation and his insurance would not have
covered it. Since the operation, he has been experiencing anxiety
attacks, resulting in him discontinue working as of February 1, 2014. As
of June 2014, the patient has begun to see new doctors and has a new
insurance, in which he was referred to attend cardiac rehabilitation.

2
During his initial intake into cardiac rehabilitation, the patient was
found to have a normal sinus rhythm.
This patient also has a medical history that includes many other
issues. He has a history of being treated for hyperlipidemia and
hypertension. He has been diagnosed with sleep apnea, which is being
treated with a continuous positive airway pressure (CPAP) machine.
Also has a history of gastroesophageal reflux disease (GERD) over the
past 5 years. This patient had a glucose test completed on June 20,
2014 and was found to be pre-diabetic with fasting blood glucose of
6.1 mmol/L. On top of his metabolic diseases, he has also been
diagnosed with arthritis in his left shoulder and upper back that limits
his ability to perform over the head type of movements.
Age: The patient is a 48-year-old male, meeting risk factor criteria for
age. According to ACSM (2013) age is considered a risk factor when a
male is older than 45 years old.
Obesity: Obesity is a risk factor for cardiovascular disease when an
individual has a BMI greater than 30 or a waist circumference for males
greater than 40 inches. He meets the criteria for BMI, as his BMI is
49.38 kg/m2.
Hypertension: Hypertension is a risk factor for this patient even
though his blood pressure was measured at 120/70 mmHg, because he
is on a blood pressure lowering medication. According to the ACSM
(2013), a patient is considered to have hypertension as a risk factor if
their systolic blood pressure is confirmed at greater then 140 mmHg,
their diastolic blood pressure is confirmed at greater than 90 mmHg, or
they are currently taking a blood pressure lowering medication.
Dyslipidemia: This patient is considered to have dyslipidemia since
he is on a cholesterol lowering medication. According to ACSM (2013),
someone that is on a cholesterol lowering medication is considered to
have high cholesterol even if they do not present their numbers.
Cigarette Smoking: According to the ACSM (2013), this patient is
considered to be a current cigarette smoker even though he has quit.
The ACSM (2013) states that cigarette smoking is a risk factor if an
individual is a current smoker of if they have quit within the past 6
months.
Pre-diabetes: This patient is considered to be pre-diabetic since he
had a confirmed fasting blood glucose that was measured at 6.1
mmol/L. According to the ACSM (2013) an individual with confirmed
fasting blood glucose of >110 mg/dL (6.1 mmol/L), is considered to be
pre-diabetic.
Drug

Current Medications and Effect on Exercise

Prescribed For
Side Effects
Exercise
Exercise
HR
BP

Exercise
Capacity

Nitroglycerin

Treats or
prevents
angina

Severe or
ongoing
dizziness,
shortness of
breath, nausea,
joint pain,
weakness

Increased

Decrease
or stays
the same

ASA Therapy

Treats pain,
fever, arthritis,
and
inflammation,
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.
Antidepressant,
sustained
release

Drowsiness,
fatigue,
impaired
cognition,
weakness

No effect

No effect

3
Increase
d in pt w/
angina,
no effect
in pt w/o
angina,
increase
d or no
effect in
pts with
CHF
No effect

Fever, muscle
pain,
tenderness,
unusual
tiredness

No effect

No effect

No effect

Behavior
changes, panic
attacks,
irritable,
hyperactive
(mentally and
physically)

Increase

Decrease

No effect

Bupropion XL
(Wellbutrin XL)

Antidepressant,
extended
release

Increase

Decrease

No effect

Metoprolol
tartrate
(Lopressor)

Treats high
blood and
angina, and
lowers risk or
repeated heart
attacks. Also
used to treat

Behavior
changes, panic
attacks,
irritable,
hyperactive
(mentally and
physically)
Drowsiness,
dizziness,
tiredness, and
slow heart beat

Decreases

Decrease
s

Increase
s,
decrease
s, or may
stay the
same

Atorvastatin
(Lipitor)

Bupropion SR
(Wellbutrin SR)

4
Clopidogrel
(Plavix)

heart failure.
Blood thinner
used to help
prevent a
stroke, heart
attack, or other
heart problems

Duloxetine DR
(Cymbalta)

Treats
depression,
anxiety,
diabetic
peripheral
neuropathy,
fibromyalgia, or
chronic muscle
or bone pain.

Lorazepam
(Ativan)

Treats anxiety,
anxiety with
depression, and
insomnia

Problems with
vision, speech,
or walking,
trouble
breathing, fast
heartbeat,
unusual
bruising
Confusion,
weakness,
muscle
twitching,
lightheadednes
s, dizziness,
fainting,
unusual
bleeding

No effect

No effect

No effect

May
increase

Systolic
blood
pressure
may
increase

No effect

Slow heart rate, May

Decrease No effect
trouble
increase
in blood
breathing,
pressure
blurred vision
or headache,
dizziness,
trouble
concentrating
Melatonin
Helps regulate
Daytime
No effect
No effect No effect
sleep and wake sleepiness,
cycles
dizziness,
headaches,
Ranitidine (Zantac) Treats and
Fast, slow, or
No effect
No effect No effect
prevents
uneven
heartburn with
heartbeat,
acid
nausea, loss of
indigestion,
appetite,
stomach ulcers, unusual
and GERD
bleeding,
yellowing of
skin
Table 3. A list of patients current medications, what they are prescribed
for, side effects, and there effect on exercise heart rate (HR), blood
pressure (BP), and capacity.
The patient has a cluster of risk factors including his age,
obesity, hypertension, dyslipidemia, pre-diabetes, and cigarette
smoking that place him at an increased risk for his heart issue and for

5
more heart related problems in the future. 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 TIMI Risk Score (2013), the
patient was considered to be at a 13% chance for 14 days of all cause
mortality, new MI, or severe ischemia.

Client Intake

What is your reason for coming into cardiac rehabilitation?

I recently switched insurance companies and cardiac rehab is not
covered under my current plan. Also was referred to by my
cardiologist.

How many days per week are you willing to come in to cardiac
rehab?
I can come into cardiac rehab all 3 days

Willing to exercise at home once a home exercise program is

given?
Yes, I have been trying to walk on my own

Exercise Experiences

Describe the physical activities that you were doing before your
event.
Not really any activity, go for a walk one or two times per week

Have you participated in a regular exercise plan in the past?

No, I have been busy with work and do not like going to a gym. Over
the past couple of months I have tried walking but experience
severe cramping in lower leg which then keeps me from moving a
lot over the next 1-2 days.

What new activities or experiences would you like to try?

Anything that will allow me to participate in exercise for a longer
period of time, have heard of water aerobics and would maybe want
to try that.

Do you experience any pain or discomfort with any exercises or

activities?
Experience cramping in my calves after 15 minutes of continuous
walking, have arthritis in my shoulders and upper back but that is
typically not a limiting factor

When have you typically experience muscle soreness in the past?

How did you deal with it?
Just experience cramping in my lower leg after walking for awhile, it
usually takes me a couple of days sitting around the house before I
am able to move around with limited pain again.

What challenges have you faced in increasing your activity level in

the past and how can we overcome them?
Lack of motivation, feeling like I have a lack of time to exercise due
to work, and pain while walking. I am not currently working so I
have more time to exercise and am willing to try anything to get me
to an increased quality of life

How is your current diet?

My appetite goes up and down depending on my level of anxiety
and stress that I am experiencing on a given day.

How many days per week do you eat out?

Dont eat out very often, maybe only once or twice a week

Do you typically add salt to food without tasting or while cooking?

7
I dont add salt to any foods besides popcorn; have seen a
nutritionist in the past and recommended not to salt any foods.
Patient does have a diet heavy in processed foods.

How often do you eat meats, how many servings per week?
Typically eat meat at least 2x per week, claims to be eating steak or
pork. Understanding of portion size was not correct, probably
around 4 servings per week.

How would you rate your current stress level? What do you
currently do to manage stress?
Severe, I have been experiencing sever anxiety over the past
couple of months which caused me to quit work. The anxiety is
mostly due to changes in safety regulations that were occurring at
work and the concerns I have been having over healthcare. I would
have a feeling like I was experiencing a heart attack at least once a
month since my last operation, would call my wife and she would try
to tell me that I was alright.
Since my change in health insurance, I have also begun to see a
therapist regarding my anxiety. Also have been taking medications
for anxiety and depression.

Do you have support at home?

Yes, my family and my wife have been very supportive

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

basis?
Some nights, probably 2-3 a week, I struggle to fall asleep due to
stress and anxiety. I cant relax

This patient has recently been allowed to attend cardiac

rehabilitation due to his recent change in health insurance and has
been referred by his cardiologist. 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. Also to
find ways for him to complete more exercise while at home. Nutrition
an important area of education as patient has seen a nutritionist in the
past but continues to eat processed foods that are high in sodium and
add salt to certain foods. Patient also has severe anxiety and

8
depression issues currently and has been seeing a therapist for those
issues. With all of his issues, there are areas for secondary prevention.

Secondary Prevention
Areas for secondary prevention for this client include decreasing
his blood pressure, weight loss, decreasing his cholesterol, and to quit
smoking for good. Secondary prevention in these areas would allow
this patient to decrease his risk of having another heart related event
occur. Decreasing his blood pressure would allow him to decrease his
medication or possibly even get off of his medication. Since his blood
pressure is currently considered to be hypertensive, this adds an extra
risk factor for him to develop cardiovascular disease. Lowering his
cholesterol will help to decrease his risk. As he is on a lipid lowering
medication, having him continue to be compliant with taking his
medication will keep his cholesterol lower. Having him begin a regular
exercise program, will allow for a decrease in cholesterol and to
increase his HDL cholesterol. With a decrease in total cholesterol and
an increase in HDL cholesterol, he can see a decrease in his medication
as well. Another area that can help with reducing many of his risk
factors would be to decrease his weight. His current weight is 315.3
pounds, which places his BMI at 48.61 kg/m2. With a goal of slowly
decreasing his weight he would be able to see effects for decreasing
other risk factors and could possibly see an improvement with his sleep
apnea. Making sure that he quits smoking for good is something that
he needs to help make changes in his daily lifestyle. Gellert et al.,
(2013) stated that excess risk of cardiac disease due to smoking
disappeared within five years of individuals quitting smoking. Quitting
smoking will not only just get rid of the smoking risk factor, but it can
also have an effect on decreasing his blood pressure. All of these areas
are needs of focus and can help to decrease the risk of developing a
second event.
It is beneficial for him that he has begun to see a therapist 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, which with an increased blood
pressure response can lead to an increase in cardiovascular mortality.
With that being said, it is important for him to continue to see his
therapist and to adhere to his medications so that he can limit his
stress and anxiety levels. As with this client also, stress can lead to an
increase in eating and decrease in physical activity level. With an
increase in eating and decrease in physical activity, weight gain will be
seen. Being able to decrease the amount of stress he is having may
also lead to a decrease in weight due to eating less and exercising or
being physically active more.

9
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 and adhering to his medications,
and relieving stress can help him to get control of his blood pressure,
dyslipidemia, and weight. Getting 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. Decreasing or
eliminating some of these risk factors will also not include him to have
metabolic syndrome.

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. Also need to be aware that he
does have a prescription of nitroglycerin, so that if he is experiencing
any type of signs or symptoms that are abnormal, that he rests and
advise him to take his nitroglycerin. 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.
Another area that I need to be aware of when developing his
exercise prescription is that he does have arthritis in his left shoulder
and upper back. Arthritis may be a limiting factor depending on the
severity of the disease and the location of the disease. The arthritis
should not have an effect on many of the aerobic activities that he is
able to perform, but may have a limiting factor on some of the
resistance training exercises that he can complete. This is an area that
needs to be aware of that could possibly be irritated during exercise, so
it was important to ask him what activities would exacerbate the pain.
The activities that he mentioned would exacerbate the pain were
mainly overhead movements and not so much with a forward and back
motion used on a NuStep.
His weight is an area that needs to be taken under consideration
as well. With a severely obese individual like himself, getting up and
down off of low equipment could be difficult for him. Other pieces of
equipment may also be uncomfortable for him to be on or difficult for

10
him to perform properly due to his central adiposity decreasing the
range of motion at his hips. Taking this into consideration he may not
be able to use certain pieces of equipment and it would be important
not to put him on those pieces, as to avoid any discomfort or an
increase in stress or anxiety for him.

Exercise Testing
Cardiovascular
The patient is a 48-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. At my site, we
did not perform a cardiovascular exercise test, but following best
practice; I would have him complete one. With this particular patient, I
would have him complete a sub-maximal treadmill protocol. According
to the ACSM (2013), a sub-maximal exercise test has been found to
provide an accurate measurement of aerobic fitness for developing an
exercise program. I would have him complete a modified balke
treadmill test. This test was also used in a study completed by East et
al (2010), when they used it to determine aerobic capacity in men and
women with depressive symptoms and metabolic syndrome. This test
was also selected for the patient because he does not present with any
orthopedic issues that would limit his ability to complete the test.
However, a maximal test was not selected because the patient may
not be able to make it through multiple stages using a Bruce protocol.
Using the modified balke test, he would start at a specified grade and
the speed would increase slightly with each stage. This will be
beneficial since he does experience cramping or discomfort in his
calves after walking, especially up a steep incline, after 10-15 minutes.
Although this test does not increase in speed and incline with each
stage like the Bruce, it will effectively increase this individuals heart
rate and will not take a long time to complete. This test can also be
used to determine the patients maximal workload capacity based on
his submaximal numbers that were achieved from the test.
Musculoskeletal
At this time, exercise testing cannot be completed with the
patient because he does not have a baseline of cardiovascular
endurance training. But based on guidelines and recommendations, I
chose tests that could be completed once he does have a baseline of
cardiovascular training.

11
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. To assess his upper body muscular
strength, I would have him complete a handgrip dynamometer test.
Khan and Mahajan (2013), found that this test is an accurate
assessment of upper body muscular strength more specifically of the
forearm and can independently test each arm. I would have him
complete this test, because upper body muscular strength is important
for activities of daily living and this patient also wants to gain upper
body strength so that he is able perform his normal activities of daily
living. A handgrip dynamometer test is also a quick and easy test to
perform and according to ACSM (2013), has age predicted norms that
have been created for his age group.
I would then have him perform an assessment of his lower body
muscular endurance. For this test I would have him perform a sit to
stand test. A sit to stand test was used in a study by Schurr et al.,
(2012) and was found to be an accurate measurement of lower body
muscular endurance. This test was also chosen because it is important
to have a baseline measurement before starting his exercise
prescription for his lower body muscular endurance. 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. He also has a goal of increasing his lower body muscular
endurance so having him tested on it will show if he is making an
improvement in pre and post testing. Having him perform this test will
also allow for an accurate assessment of his current status as ACSM
(2013), has age specific norms developed for his age. Range of motion
and flexibility testing would follow this test.
Flexibility
To assess his upper body range of motion, it would be important
to test his range of motion of his shoulder joint. To assess his range of
motion, a back scratch test would be used. Due to his arthritis, this test
can also be used to assess his pain level and at what point he starts to
feel discomfort. It is also used to determine his ability to perform
activities of daily living such as washing his hair and reaching items off
of a high shelf. This test has age specific norms developed for his age
group and does not take a long time to complete making it a quick and
accurate measurement of shoulder range of motion. Park et al., (2009),
used this test in their study, where they looked into exercise testing of
elderly individuals.
I would also have him complete a test for lower body flexibility.
Since he is obese and has a large amount of central adiposity, I would
have him complete a modified back saver sit and reach test. ACSM
(2013) also recommends this test, as it is a test that can be completed

12
by someone that has back issues or is overweight as they do not have
to get down on the ground and do not have to bend at the waist as far
when performing the test. This test is important to see where his
current range of motion is at in his hamstring and hips, and to assess
his ability to complete everyday activities such as tying his shoes or
picking something off of the ground. This test was also used by Park et
al., (2009), and has age specific norms developed for the patients age
group.
Due to my site not completing 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 and they are designed to limit
the discomfort 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. Having age
specific norms allows the patient to know where he currently is at with
his physical fitness when compared to other individuals of his same
age group. Performing these tests will also 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
Cardiovascular
The main goal of his cardiovascular fitness program was to focus
on increasing the amount of time that he can exercise per session. As
he had a goal of increasing how long he is able to exercise and more
specifically walk.. According to the ACSM (2013), it is going to be
important for him to work towards achieving 150 minutes per week of
planned exercise. In the first couple of weeks, however it is more
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
order to develop an accurate exercise prescription tailored to him, I
calculated his workload dependent on his heart rate guidelines that
were placed by his physician. Based off of 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 2 bouts of
12 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 with the goal of
increasing the amount of calories that he is burning per session as well
as increasing his MET level. The goal of increasing the amount of

13
calories burned per session was done, with the goal of resulting in a
greater amount of weight loss. 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
physician.
Session
Monday

Aerobic Exercise Week 1

Intensity
Time
40 % VO2
2 bouts of 12
reserve
minutes. 24
2 METs
minutes total.
HR <101 bpm

Type
Treadmill at 1.2
mph @ 0%
grade, Scifit
Stepper on level
1 or 30 Watts,
RPE 11/20
Wednesday
40 % VO2
2 bouts of 13
Treadmill at 1.2
reserve
minutes. 26
mph @ 0%
2 METs
minutes total
grade, Scifit
HR <101 bpm
Stepper on level
1 or 30 Watts,
RPE 11/20
Friday
40 % VO2
2 bouts of 14
Treadmill at 1.2
reserve
minutes. 28
mph @ 0%
2 METs
minutes total
grade, Scifit
HR <101 bpm
Stepper on level
1 or 30 Watts,
RPE 11/20
Table 4. Week 1 of aerobic exercise prescription focusing on
introducing pain free exercise.

Session
Monday

Aerobic Exercise Week 2

Intensity
Time
40 % VO2
2 bouts of 15
reserve
minutes. 30
2 METs
minutes total
HR <101 bpm

Wednesday

40 % VO2
reserve
2 METs
HR <101 bpm

2 bouts of 16
minutes. 32
minutes total

Friday

40 % VO2
reserve
2 METs
HR <101 bpm

2 bouts of 17
minutes. 34
minutes total

Type
Treadmill at 1.2
mph @ 0% grade,
Scifit Stepper on
level 1 or 30
Watts, RPE 12/20
Treadmill at 1.2
mph @ 0% grade,
Scifit Stepper on
level 1 or 30
Watts, RPE 12/20
Treadmill at 1.2
mph @ 0% grade,
Scifit Stepper on
level 1 or 30
Watts, RPE 12/20

14
Table 5. Week 2 of aerobic exercise, increasing duration of exercise
completed

Session
Monday

Aerobic Exercise Week 3

Intensity
Time
45 % VO2
2 bouts of 17
reserve
minutes. 34
2.2 METs
minutes total
HR <101 bpm

Type
Treadmill at 1.5
mph @ 0% grade,
Scifit Stepper on
level 3 or 40
Watts, RPE 13/20
Wednesday
45 % VO2
2 bouts of 18
Treadmill at 1.5
reserve
minutes. 36
mph @ 0% grade,
2.2 METs
minutes total
Scifit Stepper on
HR <101 bpm
level 3 or 40
Watts, RPE 13/20
Friday
45 % VO2
2 bouts of 19
Treadmill at 1.5
reserve
minutes. 38
mph @ 0% grade,
2.2 METs
minutes total
Scifit Stepper on
HR <101 bpm
level 3 or 40
Watts, RPE 13/20
Table 6. Week 3 of aerobic exercise, increasing duration of exercise
completed

Session
Monday

Aerobic Exercise Week 4

Intensity
Time
45 % VO2
2 bouts of 15
reserve
minutes. 1 bout
2.2 METs
of 10 minutes. 40
HR <101 bpm
minutes total

Type
Treadmill at 1.5
mph @ 0% grade,
Nu Step on level
3 or 40 Watts,
RPE 13/20,
Wednesday
45 % VO2
2 bouts of 15
Treadmill at 1.5
reserve
minutes. 1 bout
mph @ 0% grade,
2.2 METs
of 12 minutes. 42 Nu Step on level
HR <101 bpm
minutes total
3 or 40 Watts,
RPE 13/20
Friday
45 % VO2
2 bouts of 15
Treadmill at 1.5
reserve
minutes. 1 bout
mph @ 0% grade,
2.2 METs
of 14 minutes. 44 Nu Step on level
HR <101 bpm
minutes total
3 or 40 Watts,
RPE 13/20
Table 7. Week 4 of aerobic exercise, increasing duration of exercise
completed

15
Resistance Training
The goal of his exercise prescription is increasing his upper body
muscular strength, as well as lower body muscular strength. 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. All exercises were
introduced starting at 1 set and having him perform 8-12 repetitions of
each exercise as recommended by Yohannes et al., (2010). Progression
of band 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 band tension was increased. The client was instructed to perform a
chest press, standing row, bicep curl, and a triceps kick back exercise
using a resistance band. A resistance band was chosen for the primary
mode of resistance since he does not have free weights at home and
once he is done with program he does not want to join a gym. The
lower body strengthening exercises were also introduced in order to
strengthen his leg muscles. 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 Thursday the first couple of weeks.
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 resistance
training exercises were given once he had a baseline of cardiovascular
training.

Weeks 1 and 2 Resistance Training Program

Exercise
Sets
Reps
Weight/Directions
Equipment
Chest Press
1
8-12
Light Band
Theraband
Standing Row
1
8-12
Light Band
Theraband
Bicep Curl
1
8-12
3-4 Pounds
Theraband
Triceps Kick back
1
8-12
Light Band
Theraband
Sit to Stand (Quads)
1
8-12
Non-moving chair Body weight
Seated Leg Curl
(Hamstrings)
1
8-12
Light Band
Theraband
Table 8. Weeks 1 and 2 of resistance training program increasing
repetitions and weight for exercise

Exercise
Chest Press
Standing Row

Weeks 3 and 4 Resistance Training Program

Sets
Reps
Weight/Directions
2
8-12
Light Band
2
8-12
Light Band

Equipment
Theraband
Theraband

16
Theraband
Theraband
Body weight

Bicep Curl
2
8-12
3-4 Pounds
Triceps Kick back
2
8-12
Light Band
Sit to Stand (Quads)
2
8-12
Non-moving chair
Seated Leg Curl
(Hamstrings)
2
8-12
Light Band
Theraband
Table 9. Weeks 3 and 4 of resistance training program increasing
repetitions and weight for exercise

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 and reach
their goal. With this patient we co-created short-term and long-term
goals based on the SMART goal format. With an overall goal of him
someday wanting to possibly get bariatric surgery, he would like to
lose around 40 pounds. He currently weights 315.3 pounds; so losing
40 pounds would put him at a weight of 275 pounds and have a BMI of
43.07. With this new weight, he would still be considered to be class II
obese, but he would be a more likely candidate for bariatric surgery.
Keeping that long term goal in mind and using research found by Fayh
et al., (2013), that showed losing five percent of an obese individuals
weight can lead to improvements in decreasing blood lipids and
improve quality of life. This goal was also developed due to an article
by Fujioka (2010), where they looked at the benefits of moderate
weight loss on type two diabetes. Although this patient does not have
type two diabetes, he is pre-hypertensive. Using the SMART goal
format, we co-created short-term goals that resulted in him losing one
to two pounds each week leading to losing five percent of his body
weight, which is 15 pounds, by the time he completes cardiac
rehabilitation in 12 weeks. Losing 15 pounds by the end of cardiac
rehabilitation is a realistic goal, as he would need to lose just over one
pound per week. As seen in table 10 below, the patients goal was
formatted on him t losing around three to four pounds every two
weeks. With him losing three to four pounds every two weeks, I allowed
for some room for not losing two pounds every week, as he may
experience a slight plateau throughout the course of the program. I felt
that this goal was an attainable goal and a safe goal for him as he
would only have to lose one pound per week on some weeks and he
could still reach his overall long-term goal progressively.

Date:
Weight:

7/7/2014
313 lbs

Short-Term Goals
7/14/201 7/21/201 7/28/201
4
4
4
312 lbs
310 lbs
308 lbs

8/4/2014
307 lbs

8/11/2014
305 lbs

17
Table 10. Clients short-term goals for the first 6 weeks of cardiac
rehabilitation
Another goal for this patient was to decrease his resting blood
pressure. When joining cardiac rehabilitation, his resting blood pressure
was measured at 120/70, but he is also 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 is a
realistic goal for him.
With this patients goals, he can expect to see other
physiological outcomes, such as a decrease in cholesterol and more
energy to perform his daily activities. He can also see psychological
benefits, with weight loss adding to an increased self-efficacy. The
benefits that he can see from achieving these goals can help with
improving his quality of life. Another way to increase his quality of life
and help him to reach these goals was to provide tailored education to
him.

Education
With any patient it is important to tailor the education they
receive to their particular needs and that is no different with this
patient. With him, the education that he needed was involved with
making lifestyle changes that can lower his blood pressure, cholesterol,
weight, and stress levels. This can be done by education on those
topics, but also providing him with education on topics that will
improve those areas such as smoking cessation and improving his
nutrition. Most of the education that was presented to this patient was
based on the effects that exercise can have for him. Those education
topics included how exercise can relieve or ease symptoms of
depression and anxiety and how exercise can lower blood pressure.
Another article discussed the top ways to decrease cholesterol,
including a heart healthy diet, exercise, losing weight, quitting
smoking, and limiting the consumption of alcohol. The last education
topic presented to him focused on serving sizes and how to measure a
serving size correctly. This is important for him as he is trying to
decrease his weight and knowing how to properly measure a serving
will help him to decrease his calories and effectively decrease his
weight.

18

Depression and anxiety: Exercise

eases symptoms
Depression symptoms often improve with exercise. Here
are some realistic tips to help you get started and stay
motivated.
By Mayo Clinic Staf

When you have anxiety or depression, exercise often seems

like the last thing you want to do. But once you get
motivated, exercise can make a big diference.
Exercise helps prevent and improve a number of health
problems, including high blood pressure, diabetes and
arthritis. Research on anxiety, depression and exercise
shows that the psychological and physical benefits of
exercise can also help reduce anxiety and improve mood.
The links between anxiety, depression and exercise aren't
entirely clear but working out can definitely help you relax
and make you feel better. Exercise may also help keep
anxiety and depression from coming back once you're
feeling better.

How does exercise help depression and

anxiety?
Exercise probably helps ease depression in a number of

19

ways, which may include:

(

Releasing feel-good brain chemicals that may ease

depression (neurotransmitters and endorphins)

Reducing immune system chemicals that can worsen

depression

Increasing body temperature, which may have calming

efects
Exercise has many psychological and emotional benefits too.
It can help you:

Gain confidence. Meeting exercise goals or challenges,

even small ones, can boost your self-confidence. Getting in
shape can also make you feel better about your appearance.

Take your mind off worries. Exercise is a distraction that

can get you away from the cycle of negative thoughts that
feed anxiety and depression.

Get more social interaction. Exercise may give you the

chance to meet or socialize with others. Just exchanging a
friendly smile or greeting as you walk around your
neighborhood can help your mood.

Cope in a healthy way. Doing something positive to

manage anxiety or depression is a healthy coping strategy.
Trying to feel better by drinking alcohol, dwelling on how
badly you feel, or hoping anxiety or depression will go away
on its own can lead to worsening symptoms.

What kind of exercise is best?

20

The word "exercise" may make you think of running laps

around the gym. But exercise includes a wide range of
activities that boost your activity level to help you feel better.
Certainly running, lifting weights, playing basketball and
other fitness activities that get your heart pumping can help.
But so can gardening, washing your car, or strolling around
the block and other less intense activities. Anything that gets
you of the couch and moving is exercise that can help
improve your mood.
You don't have to do all your exercise at once either.
Broaden how you think of exercise and find ways to fit
activity into your routine. Add small amounts of physical
activity throughout your day. For example, take the stairs
instead of the elevator. Park a little farther away from your
work to fit in a short walk. Or, if you live close to your job,
consider biking to work.

How much is enough?

Doing 30 minutes or more of exercise a day for three to five
days a week can significantly improve depression symptoms.
But smaller amounts of activity as little as 10 to 15
minutes at a time can make a diference. It may take less
time exercising to improve your mood when you do morevigorous activities, such as running or bicycling.
The mental health benefits of exercise may last only if you
stick with it over the long term another good reason to

21

focus on finding activities you enjoy.

How do I get started and stay

motivated?
Starting and sticking with an exercise routine can be a
challenge. Here are some steps that can help. Check with
your doctor before starting a new exercise program to make
sure it's safe for you.
(

Identify what you enjoy doing. Figure out what type of

physical activities you're most likely to do, and think about
when and how you'd be most likely to follow through. For
instance, would you be more likely to do some gardening in
the evening or go for a jog in the pre-dawn hours? Go for a
bike ride or play basketball with your children after school?
Do what you enjoy to help you stick with it.

Get your mental health provider's support. Talk to your

doctor or other mental health provider for guidance and
support. Discuss concerns about an exercise program and
how it fits into your overall treatment plan.

Set reasonable goals. Your mission doesn't have to be

walking for an hour five days a week. Think realistically about
what you may be able to do. Tailor your plan to your own
needs and abilities rather than trying to meet unrealistic
guidelines that you're unlikely to meet.

Don't think of exercise as a chore. If exercise is just

22

another "should" in your life that you don't think you're living
up to, you'll associate it with failure. Rather, look at your
exercise schedule the same way you look at your therapy
sessions or medication as one of the tools to help you get
better.
(

Address your barriers. Figure out what's stopping you from

exercising. If you feel self-conscious, for instance, you may
want to exercise at home. If you stick to goals better with a
partner, find a friend to work out with. If you don't have
money to spend on exercise gear, do something that's
virtually cost-free, such as walking. If you think about what's
stopping you from exercising, you can probably find an
alternative solution.

Prepare for setbacks and obstacles. Give yourself credit

for every step in the right direction, no matter how small. If
you skip exercise one day, that doesn't mean you can't
maintain an exercise routine and may as well quit. Just try
again the next day.

Do I need to see my doctor?

Talk to your doctor to make sure you know which activities,
how much exercise and what intensity level is OK for you.
Your doctor will consider any medications you take and
health conditions you have. He or she may also have some
good advice about getting started and staying motivated.

23

If you exercise regularly but anxiety or depression symptoms

still interfere with your daily living, see your doctor or other
mental health provider. Exercise is a great way to ease
symptoms of anxiety or depression, but it isn't a substitute for
psychotherapy or medications.

Exercise: A drug-free approach to

lowering high blood pressure
Having high blood pressure and not getting enough
exercise are closely related. Discover how small
changes in your daily routine can make a big difference.
By Mayo Clinic Staf

24

Your risk of high blood pressure (hypertension) increases

with age, but getting some exercise can make a big
diference. And if your blood pressure is already high,
exercise can help you control it. Don't think you've got to run
a marathon or join a gym. Instead, start slow and work more
physical activity into your daily routine.

How exercise can lower your blood

pressure
How are high blood pressure and exercise connected?
Regular physical activity makes your heart stronger. A
stronger heart can pump more blood with less efort. If your
heart can work less to pump, the force on your arteries
decreases, lowering your blood pressure.
Becoming more active can lower your systolic blood
pressure the top number in a blood pressure reading
by an average of 4 to 9 millimeters of mercury (mm Hg).
That's as good as some blood pressure medications. For
some people, getting some exercise is enough to reduce the
need for blood pressure medication.
If your blood pressure is at a desirable level less than
120/80 mm Hg exercise can help keep it from rising as
you age. Regular exercise also helps you maintain a healthy
weight, another important way to control blood pressure.

25

But to keep your blood pressure low, you need to keep

exercising. It takes about one to three months for regular
exercise to have an impact on your blood pressure. The
benefits last only as long as you continue to exercise.

How much exercise do you need?

Flexibility and strengthening exercises such as lifting weights
are an important part of an overall fitness plan, but it takes
aerobic activity to control high blood pressure. And you don't
need to spend hours in the gym every day to benefit. Simply
adding moderate physical activities to your daily routine will
help.
Any physical activity that increases your heart and breathing
rates is considered aerobic exercise, including:
(

Household chores, such as mowing the lawn, raking leaves

or scrubbing the floor

Active sports, such as basketball or tennis

Climbing stairs

Walking

Jogging

Bicycling

Swimming
The American Heart Association recommends you get at
least 150 minutes of moderate exercise, 75 minutes of

26

vigorous exercise or a combination of both each week. Aim

for at least 30 minutes of aerobic activity most days of the
week. If you can't set aside that much time at once,
remember that shorter bursts of activity count, too. You can
break up your workout into three 10-minute sessions of
aerobic exercise and get the same benefit as one 30-minute
session.

Weight training and high blood pressure

Weight training can cause a temporary increase in blood
pressure during exercise. This increase can be dramatic
depending on how much weight you lift. But, weightlifting can
also have long-term benefits to blood pressure that outweigh
the risk of a temporary spike for most people.
If you have high blood pressure and want to include weight
training in your fitness program, remember:

Learn and use proper form when lifting to reduce the risk
of injury.

Don't hold your breath. Holding your breath during exertion

can cause dangerous spikes in blood pressure. Instead,
breathe easily and continuously during each lift.

Lift lighter weights more times. Heavier weights require

more strain, which can cause a greater increase in blood
pressure. You can challenge your muscles with lighter
weights by increasing the number of repetitions you do.

27

Listen to your body. Stop your activity right away if you

become severely out of breath or dizzy or if you experience
chest pain or pressure.
If you'd like to try weight training exercises, make sure you
have your doctor's OK.

When you need your doctor's OK

Sometimes it's best to check with your doctor before you
jump into an exercise program, especially if:
(

You're a man older than age 40 or a woman older than age

50

You smoke

You're overweight or obese

You have a chronic health condition, such as high blood

pressure or high cholesterol

You've had a heart attack

You have a family history of heart-related problems before

age 55

You feel pain in your chest or become dizzy with exertion

You're unsure if you're in good health

If you take any medication regularly, ask your doctor if
exercising will make it work diferently or change its side
efects or if your medication will afect the way your body
reacts to exercise.

28

Keep it safe
To reduce the risk of injury while exercising, start slowly.
Remember to warm up before you exercise and cool down
afterward. Build up the intensity of your workouts gradually.
Stop exercising and seek immediate medical care if you
experience any warning signs during exercise, including:

Chest pain or tightness

Dizziness or faintness

Pain in an arm or your jaw

Severe shortness of breath

An irregular heartbeat

Excessive fatigue

Monitor your progress

The only way to detect high blood pressure is to keep track
of your blood pressure readings. Have your blood pressure
checked at each doctor's visit, or use a home blood pressure
monitor. If you already have high blood pressure, home
monitoring can let you know if your fitness routine is helping
to lower your blood pressure, and may make it so you don't
need to visit the doctor to have your blood pressure checked
as often.

29

If you decide to monitor your blood pressure at home, you'll

get the most accurate readings if you check your blood
pressure before you exercise, or at least one hour after
exercising.

Top 5 lifestyle changes to reduce

cholesterol
Lifestyle changes can help reduce cholesterol, keep you
off cholesterol-lowering medications or enhance the
effect of your medications. Here are five lifestyle
changes to get you started.
By Mayo Clinic Staf

High cholesterol increases your risk of heart disease and

heart attacks. You can reduce cholesterol with medications,
but if you'd rather make lifestyle changes to reduce
cholesterol, you can try these five healthy lifestyle changes.
If you're already taking medications, these changes can also

30

improve their cholesterol-lowering efect.

1. Lose weight
Carrying some extra pounds even just a few
contributes to high cholesterol. Losing as little as 5 to 10
percent of your body weight can help significantly reduce
cholesterol levels.
Start by taking an honest, thorough look at your eating habits
and daily routine. Consider your challenges to weight loss
and ways to overcome them.
If you eat when you're bored or frustrated, take a walk
instead. If you pick up fast food for lunch every day, pack
something healthier from home. If you're sitting in front of the
television, try munching on carrot sticks instead of potato
chips as you watch. Take time and enjoy rather than
"devouring" your food. Don't eat mindlessly.
And look for ways to incorporate more activity into your daily
routine, such as using the stairs instead of taking the
elevator. Take stock of what you currently eat and your
physical activity level and slowly work in changes.

2. Eat heart-healthy foods

Even if you have years of unhealthy eating under your belt,

31

making a few changes in your diet can reduce cholesterol

and improve your heart health.
(

Choose healthier fats. Saturated fats, found in red meat

and dairy products, raise your total cholesterol and lowdensity lipoprotein (LDL) cholesterol, the "bad" cholesterol.
As a general rule, you should get less than 7 percent of your
daily calories from saturated fat. Instead, choose leaner cuts
of meat, low-fat dairy and monounsaturated fats found in
olive, peanut and canola oils for a healthier option.

Eliminate trans fats. Trans fat can be found in fried foods

and many commercial baked products, such as cookies,
crackers and snack cakes. But don't rely on packages that
are labeled "trans fat-free." In the United States, if a food
contains less than 0.5 grams of trans fat per serving, it can
be labeled "trans fat-free." Even though those amounts seem
small, they can add up quickly if you eat a lot of foods that
have a small amount of trans fat in them. Instead, read the
ingredients list. You can tell if a food has trans fat in it if it
contains partially hydrogenated oil.

Limit the cholesterol in your food. Aim for no more than

300 milligrams (mg) of cholesterol a day less than 200 mg
if you have heart disease or diabetes. The most
concentrated sources of cholesterol include organ meats,
egg yolks and whole milk products. Use lean cuts of meat,
egg substitutes and skim milk instead.

Select whole grains. Various nutrients found in whole

grains promote heart health. Choose whole-grain breads,
whole-wheat pasta, whole-wheat flour and brown rice.

32

Stock up on fruits and vegetables. Fruits and vegetables

are rich in dietary fiber, which can help lower cholesterol.
Snack on seasonal fruits. Experiment with veggie-based
casseroles, soups and stir-fries. If you prefer dried fruit to
fresh fruit, limit yourself to no more than a handful (about an
ounce or two). Dried fruit tends to have more calories than
does fresh fruit.

Eat foods rich in omega-3 fatty acids. Omega-3 fatty acids

can help lower your LDL ("bad") cholesterol. Some types of
fish such as salmon, mackerel and herring are rich in
omega-3 fatty acids. Other good sources of omega-3 fatty
acids include walnuts, almonds and ground flaxseeds.

3. Exercise on most days of the week

Whether you're overweight or not, exercise can reduce
cholesterol. Better yet, moderate physical activity can help
raise high-density lipoprotein (HDL) cholesterol, the "good"
cholesterol. With your doctor's OK, work up to at least 30
minutes of exercise a day. Remember that adding physical
activity, even in 10-minute intervals several times a day, can
help you begin to lose weight. Just be sure that you can keep
up the changes you decide to make. Consider:

Taking a brisk daily walk during your lunch hour

Riding your bike to work

Swimming laps

Playing a favorite sport

33

To stay motivated, find an exercise buddy or join an exercise

group. And remember, any activity is helpful. Even taking the
stairs instead of the elevator or doing a few situps while
watching television can make a diference.

4. Quit smoking
If you smoke, stop. Quitting may improve your HDL
cholesterol level. And the benefits don't end there. Just 20
minutes after quitting, your blood pressure decreases. Within
24 hours, your risk of a heart attack decreases. Within one
year, your risk of heart disease is half that of a smoker.
Within 15 years, your risk of heart disease is similar to
someone who never smoked.

5. Drink alcohol only in moderation

Moderate use of alcohol has been linked with higher levels of
HDL cholesterol but the benefits aren't strong enough to
recommend alcohol for anyone who doesn't already drink. If
you choose to drink alcohol, do so in moderation. For healthy
adults, that means up to one drink a day for women of all
ages and men older than age 65, and up to two drinks a day
for men age 65 and younger. Drinking too much alcohol can
lead to serious health problems, including high blood
pressure, heart failure and stroke.

34

If lifestyle changes aren't enough ...

Sometimes healthy lifestyle changes aren't enough to lower
cholesterol levels. Make sure the changes you choose to
make are ones that you can continue, and don't be
disappointed if you don't see results immediately. If your
doctor recommends medication to help lower your
cholesterol, take it as prescribed, but continue your lifestyle
changes.

35

What is a Serving?
Updated:Jul 24,2013
Grains: 1 slice of bread, 1 ounce of ready-to-eat cereal, 1/2 cup of cooked
cereal, rice or pasta (about the size of a 1/2 baseball).
Vegetables: 1 cup of raw leafy vegetables (about the size of a small fist), 1/2 cup
of other vegetables or 1/2 cup of vegetable juice.
Fruits: 1 medium fruit (medium is defined as the size of a baseball); 1/2 cup
chopped, cooked or canned fruit; or 1/2 cup juice.
Meat, Poultry, Fish, Dry Beans and Nuts: 2 to 3 ounces of cooked lean meat,
poultry or fish; 1/2 cup cooked dry beans; or 2 tablespoons of peanut butter.
Milk, Yogurt and Cheese: 1 cup of fat-free or low-fat milk or yogurt, 1 1/2
ounces fat-free or low-fat cheese.
I cant possibly eat that many servings of vegetables, etc.!Before you decide
that you cant eat as many servings of ANYTHING as suggested, think small fist,
baseball, hockey puck and a computer mouse. These are all things that describe
a serving size. The comparisons will help you eat more of the things you need
and less of the things you dont.

One serving of raw leafy vegetables or a baked potato should be about the size
of a small fist. A serving is a lot smaller than most people think.
A cup of fat-free or low-fat milk or yogurt, or a medium fruit should equal about
the size of a baseball.
A half a bagel is about the size of a hockey puck and represents a serving from
the grains group.
Three ounces of cooked lean meat or poultry is about the size of a computer
mouse. Three ounces of grilled fish is about the size of a checkbook.
A teaspoon of soft margarine is about the size of one die.
An ounce of fat-free or low-fat cheese is about the size of six stacked dice.

36

Benefits of Quitting
20 Minutes After Quitting:
Your heart rate drops to a normal level.
12 Hours After Quitting:

The carbon monoxide level in your blood drops to normal.

2 Weeks to 3 Months After Quitting:
Your risk of having a heart attack begins to drop.
Your lung function begins to improve.
1 to 9 Months After Quitting:
Your coughing and shortness of breath decrease.
1 Year After Quitting:
Your added risk of coronary heart disease is half that of a
smoker's.
5 to 15 Years After Quitting:
Your risk of having a stroke is reduced to that of a nonsmoker's.
Your risk of getting cancer of the mouth, throat, or esophagus is
half that of a smoker's.
10 Years After Quitting:
Your risk of dying from lung cancer is about half that of a
smoker's.
Your risk of getting bladder cancer is half that of a smoker's.
Your risk of getting cervical cancer or cancer of the larynx,
kidney or pancreas decreases.
15 Years After Quitting:
Your risk of coronary heart disease is the same as that of a
nonsmoker.

37

References
Benefits of Quitting - American Lung Association. (n.d.). American Lung
Association. Retrieved August 8, 2014, from
http://www.lung.org/stop-smoking/how-to-quit/why-quit/benefitsof-quitting/
Carroll, D., Ginty, A. T., Der, G., Hunt, K., Benzeval, M., & Phillips, A. C.
(2012). Increased blood pressure reactions to acute mental
stress are associated with 16-year cardiovascular disease
mortality. Psychophysiology, 49(10), 1444-1448.
doi:10.1111/j.1469-8986.2012.01463.x
Depression (major depressive disorder). (2011, October 1). Depression
and anxiety: Exercise eases symptoms. Retrieved June 28, 2014,
from http://www.mayoclinic.org/diseasesconditions/depression/in-depth/depression-and-exercise/art20046495
East, C., Willis, B. L., Barlow, C. E., Grannemann, B. D., Fitzgerald, S. J.,
Defina, L. F., et al. (2010). Depressive Symptoms and Metabolic
Syndrome in Preventive Healthcare: The Cooper Center
Longitudinal Study. Metabolic Syndrome and Related Disorders,
8(5), 451-457. Retrieved August 8, 2014, from
http://dx.doi.org/10.1089/met.2010.0017
Ehrman, J., Gordon, P., & Keteyian, S. (2013). Clinical Exercise
Physiology (Third ed.) Chicago: Human Kinetics
Fayh, A., Lopes, A., Silva, A., Reischak-Oliveira, ., & Friedman, R.
(2013). Effects of 5 % weight loss through diet or diet plus
exercise on cardiovascular parameters of obese: A randomized
clinical trial. European Journal of Nutrition, 52(5), 1443-1450.
doi:10.1007/s00394-012-0450-1
Fujioka, K. (2010). Benefits of moderate weight loss in patients with
type 2 diabetes. Diabetes, Obesity & Metabolism, 12(3), 186-194.
doi:10.1111/j.1463-1326.2009.01155.x
Gellert, C., Schttker, B., Mller, H., Holleczek, B., & Brenner, H. (2013).
Impact of smoking and quitting on cardiovascular outcomes and
risk advancement periods among older adults. European Journal
of Epidemiology, 28(8), 649-658. doi:10.1007/s10654-013-97760

38
Guidelines for cardiac rehabilitation and secondary prevention
programs. (2013). Champaign, IL: Human Kinetics
High blood pressure (hypertension). (2012, December 7). Exercise: A
drug-free approach to lowering high blood pressure. Retrieved
June 28, 2014, from http://www.mayoclinic.org/diseasesconditions/high-blood-pressure/in-depth/high-blood-pressure/art20045206?pg=2
High cholesterol. (2012, September 6). Top 5 lifestyle changes to
reduce cholesterol. Retrieved June 28, 2014, from
http://www.mayoclinic.org/diseases-conditions/high-bloodcholesterol/in-depth/reduce-cholesterol/art-20045935
Khan, T., & Mahajan, S. (2013). Effect of different arm and forearm
positions on grip strength. International Journal of Sports
Sciences & Fitness, 3(2), 259-269. Retrieved from
http://search.ebscohost.com.pioproxy.carrollu.edu/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=s3
h&AN=90508077&site=ehost-live&scope=site
Park, W., Ramachandran, J., Weisman, P., & Jung, E. (2010). Obesity
effect on male active joint range of motion. Ergonomics, 53(1),
102-108. Retrieved August 8, 2014, from
http://dx.doi.org/10.1080/00140130903311
Pescatello, Linda S. (2013). ACSMs guidelines for exercise test and
prescription. Philadelphia: Wolters Kluwer/Lippincott Williams &
Wilkins Health.
Schurr, K., Sherrington, C., Wallbank, G., Pamphlett, P., & Olivetti, L.
(2012). The minimum sit-to-stand height test: Reliability,
responsiveness and relationship to leg muscle strength. Clinical
Rehabilitation, 26(7), 656-663. Retrieved from
http://search.ebscohost.com.pioproxy.carrollu.edu/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=s3
h&AN=76470346&site=ehost-live&scope=site
Semlitsch, T., Jeitler, K., Hemkens, L., Horvath, K., Nagele, E.,
Schuermann, C., . . . Siebenhofer, A. (2013). Increasing physical
activity for the treatment of hypertension: A systematic review
and meta-analysis. Sports Medicine, 43(10), 1009-1023.
Retrieved from
http://search.ebscohost.com.pioproxy.carrollu.edu/login.aspx?
direct=true&AuthType=cookie,ip,cpid&custid=s6222004&db=s3
h&AN=90374864&site=ehost-live&scope=site
TIMI Risk Score for UA/NSTEMI. (n.d.). MDCalc. Retrieved June August 4,
2014, from http://www.mdcalc.com/timi-risk-score-for-uanstemi/

39
What is a Serving?. (2013, July 24). What is a Serving?. Retrieved June
28, 2014, from
http://www.heart.org/HEARTORG/Caregiver/Replenish/WhatisaSer
ving/What-is-a-Serving_UCM_301838_Article.jsp
Yohannes, A. M., Doherty, P., Bundy, C., & Yalfani, A. (2010). The longterm benefits of cardiac rehabilitation on depression, anxiety,
physical activity and quality of life. Journal of Clinical Nursing,
19(19-20), 2806-2813. doi:10.1111/j.1365-2702.2010.03313.x