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Excerpt from ‘A Heart Book’

This excerpt of “A Heart Book” is printed here with the permission of author, Jennifer Hakkarainen. Please note, the information in this book is not intended to fully diagnose or treat any medical condition, or to replace the advice of your health care professional.

Question 23: Can I exercise with problems like heart failure?

Exercise training:

1. Improves the strength and endurance of the muscles of respiration.

2. Reduces shortness of breath during exercise and even during rest.

3. Increases the ability of the heart, lungs, and muscles to use oxygen more effectively.

Physicians are increasingly prescribing exercise to decrease morbidity and mortality associated with congestive heart failure (CHF). The long-term effects of exercise have been shown to strengthen cardiac muscle. This improves the ejection fraction (squeezing power) of the heart. Additionally, exercise reduces the occurrence of heart beat irregularities in CHF patients. If you have heart failure, and you are working with your doctor on an exercise plan, you may notice over time that you will be breathing more efficiently. Why? The muscles in your chest and heart are working together better. You may do very well in a supervised cardiac rehab environment.

Exercise training can significantly benefit heart failure patients. “Exercise Training for Heart Failure Patients with and without Systolic Dysfunction: An Evidence-Based Analysis of How Patients Benefit,” assesses the expected clinical benefits of exercise training for heart failure patients. Meta analyses and randomized, controlled trials of exercise training in heart failure patients were reviewed by the author from a search of PubMed, Cochrane Controlled Trial Registry (CCTR), CINAHL, and EMBASE. His research indicates that exercise training improves functional capacity, quality of life, and systolic and diastolic function in heart failure patients. I provide more information on the topic of heart failure in Part 2 of A HEART BOOK.

Question 24: Exercise. Is it all about heart health?

When you are fit, your quality of life improves. The body adapts to the level of stress placed on it. Muscles are made of many fibers which are active only if you are! Moving the body recruits the inactive fibers, and strengthens them over time. It is like an awakening. Lack of physical activity causes a phenomenon called disuse atrophy. This is where the condition of the muscle deteriorates because of disuse or minimal use. There are other important processes that can occur with age and lack of physical exercise:

1. The heart becomes less effective as a pump, decreasing how well the lungs use oxygen.

2. Blood pressure may increase as the heart tries to compensate for the increased demand on it.

3. Calorie expenditure is considerably reduced if you do not exercise. You may see an increase in body fat in the belly, hips and/or thighs.

4. Studies may show a decrease in bone mass from lack of weight bearing activities in later life, like walking and running.

5. A notable decrease in flexibility and muscle strength occurs over time. Inflexibility and muscle weakness can lead to injury.

Is exercise good for the brain too?

“Exercise sparks new brain cell growth,” writes John Ratey, MD, the author of Spark: The Revolutionary New Science of Exercise and the Brain. He writes that “exercise is the single most powerful tool you have to optimize your brain function.” He supports this statement with scientific facts and he reviews common exercise practices to getting fit and sticking with it. In Happiness, Lessons from a New Science, Richard Layard cites a study where the examiner asked people how satisfied they were with their overall health. A standardized testing model called SF-36 records eight main types of poor functioning: poor mobility, physical pain, mental disturbance, etc. Data collection results indicated mental disturbance caused the greatest dissatisfaction with overall health. In chapter nine of The Secret Life of the Grown-Up Brain, author Barbara Strauch cites animal and human studies about exercise and the effect on the brain noting improved blood flow, which may correlate with the growth of new brain cells!

Question 25: Can I get started with an exercise program?

Below is a checklist to review before starting an exercise program. Not every medical condition is listed. Generally it is a good idea to consult with your health care practitioner before starting a concerted exercise program.


• Age 35 or over

• Overweight or obese according to BMI

• Sedentary or inactive for several months or longer


• Heart Disease

• Family history of cardiovascular disease

• Respiratory disease

• High blood pressure

• Elevated total cholesterol/HDL ratio

• Diabetes

• Tobacco use

• Concerns that I have about starting to exercise:



Your medical provider will counsel you about your cardiac risk. Medical history, past or present, may limit your exercise capacity. Talk with your medical provider and work out a plan as a team!

Question 26: How do you measure “fitness”?

Exercise strengthens the heart muscle and makes it more efficient in using oxygen. The structure of the heart is composed of four flexible muscular chambers. As the heart beats, it forces blood in and out of the chambers, allowing the flow of blood to either pick up oxygen or release oxygen to the organs. If the heart is generally healthy, but just out of shape, exercise will make this process more efficient by improving oxygen delivery. With improvement in oxygen delivery, you won’t have to breathe as hard when you exercise. Your blood pressure may go up during exercise, but it will recover back to normal in a shorter period of time. Just think flexibility. The heart becomes stronger and more flexible. This is all in the setting of the arteries becoming more elastic and more accepting of increased blood flow! Arteries carry blood with oxygen to the organs of the body and your arms and legs. If the arteries are more elastic they are more efficient at their job.

“Fitness” always factors into the ability of the patient’s body to handle the demands placed upon it. These demands could be part of what is expected of them at their job, their housework, or a sport or recreational activity. The more efficiently the body functions, the higher the level of fitness. The higher the level of fitness, the greater the chance the body will be free of disease, maintain a healthy state, and be free of injuries. I view fitness as an overall “preventive medicine” approach to health.

Our fitness checklist includes:

Flexibility — The muscle movement around a joint can also apply to the muscle of the heart!

Strength — The force produced from a maximal muscular contraction.

Endurance — The ability of the body to sustain physical work.

First of all, focus on flexibility.

The only way to become more flexible is to regularly stretch all the muscles and joints through their natural ranges of motion. If you have an “Achilles problem” or a “knee problem,” daily stretching will be very beneficial. I always recommend that you learn a home exercise plan of stretching exercises if you have had an injury. Physical therapists know about how to strengthen muscles and avoid further injury. Don’t be discouraged if results are slow. It is worth the effort to reduce the risk of incurring exercise injuries.

Strong joints = strong muscles

Strong muscles = strong joints

Improving flexibility is important and not just a message for athletes. I have numerous patients that complain of low back pain. Low back pain is worsened by tight muscles in the front and back of the legs. These muscles consist of the quadriceps (large muscle in the front of the leg), the hamstrings (large muscles in the back of the leg attached to the buttocks), and the gastrocnemius muscles (calf muscle). Muscles are connected to the bones by tendons. I use an analogy that always sticks with patients: “You know when you eat chicken and you pull the muscle off the chicken leg, and there is a rubber-like thing attached at the end? That is the tendon.” If the muscle and tendons are not stretched out, they will shorten when they are used and tug and pull at the back and the legs.

Inflexibility may lead to injury. If you have not had knee or hip replacements, and do not currently have an injury, try this to check your flexibility. Lie on your stomach and ask a friend to gently bend your leg so that your knee is flexed. The heel of your foot should touch your butt. If the heel is far from your butt, your front quadriceps muscle is too tight. This can cause knee pain by pulling the knee cap up when that muscle becomes tight, causing low back and knee pain. For the second test, lie on your back and have your friend lift your leg gently. Stop if you feel any pain! If you can’t lift the leg very high without pulling in the back of the leg, then you need to work on stretching the hamstrings. The calf muscles are often neglected as well as the ankles. Strong stretched calves and strong ankles are absolutely essential to avoiding injury during exercise. If you have had a previous ankle injury, and the ankle is weak and not fully rehabilitated, weakness and poor balance can throw off your stride in any game or race. This places you at further risk of injury for a lengthier period of time! Patients typically want to exercise at home. I recommend working with a certified physical therapist or trainer on specific exercises for your specific problem. This can make the difference between enjoying exercise and your sport, and missing out. Physical therapy is like school. You learn at school then do the homework. If you don’t do your PT exercises at home, you are not going to improve.

Secondly, focus on strength

Improving muscle strength increases your metabolism. Increasing the metabolic rate increases the daily caloric requirements by approximately fifteen percent at rest. The body burns calories at a faster rate after weight training. Secondly, weight/ resistance training places stress on the muscles, tendons, and the bone, increasing their strength over time. The human body responds to this by becoming more adept at handling increased workloads and reducing the risk of osteoporosis. As we age, we lose muscle mass and bone density, so this activity counteracts these effects. The intensity and the amount of time you work the muscle, also factors into the strength equation.

Intensity of workload in weight training

Workload is the amount of weight times the number of repetitions plus the number of sets that you do of an exercise, factoring the time it took to complete. Intensity is more complicated to measure in resistance training than in cardio respiratory training. The “workload” is measured by the amount of weight you lift during an exercise, amount of repetition, and the number of sets of repetitions that you performed of that exercise. A repetition is one complete movement e.g., a bicep curl, and a set is the number of repetitions performed before a brief rest period. We also take into consideration as our third point, the length of time the training set took to complete.

Lift weights with supervision. Free weights can be tricky, so when you choose weights, use hand weights that you can lift pretty easily eight to twelve times in a set. When you first start, even if you are a seasoned athlete, the weight will eventually fatigue the muscle at the end of the set. This generally means that you are training to failure of the muscle. The muscle will adapt to the load and become stronger over time. When you can do twelve repetitions of that weight pretty easily, you add a bit more the next time you do your sets. If you cannot do more than seven or eight repetitions, then you do a bit less weight, working up to twelve again. What if you are training your whole body in one exercise session? Choose one or two exercises, three at most, as my trainer taught me, for each muscle group and do three sets. Do different muscle groups on different days, a couple days a week for beginners or cross training, and three to four days a week for seasoned athletes. Remember your recovery time!

Workout time and type of muscle group

After factoring intensity and workload, the right amount of workout time is also vital. Training too fast at the beginning won’t allow you to handle reasonable weights, and training too slow will not give you an efficient and high intensity workout. In the initial stages it is common to rest two to three minutes in between sets of exercises. As your muscles adjust to the demand, you can try to get to one minute between sets or even to thirty seconds on some of the assistance or lighter exercises. Train the type of muscle group correctly. Exercise the large muscle groups without neglecting the smaller muscle groups. The large muscle groups consist of the gluteus maximus and gluteus medius, the quadriceps, back, chest and hamstrings. The smaller muscle groups are typically your shoulders, triceps, biceps and calves. A certified trainer can set you up with a program. This way you can get the maximum benefit out of your workouts.

Thirdly, add endurance.

To improve your endurance we now factor in aerobic (with oxygen) activity to improve your cardiovascular fitness. Aerobic activity must occur regularly at least three times each week, and it doesn’t have to be the same routine! I personally believe that that is why people stop doing their exercise. They think that they have to run five miles five days a week. If they cannot get the run in, they start feeling guilty. The happiest patients are those that, say, mix in a zumba class in the morning and perhaps a walk with their dog in the afternoon. In the next day or two, they might take a trip to the gym to go on the treadmill or work in a bike ride or pick up a spinning class at a health club or even try a 5k!

A word about heart rate (HR)

Some athletes I know use the target heart rate training zone. I generally defer to trainers and specialists in clinics or in the gym to work with people on their particular HR zone.

• The Target Heart Rate Zone is determined by your fitness level and your age.

• Low fitness individuals will attain results training at fifty percent to seventy percent of their maximum heart rate as their Target Heart Rate Zone.

• Higher fitness individuals will train at seventy to 85 percent of their maximum heart rate as their Target Heart Rate Zone.

Monitoring your heart rate while you exercise is important if you are at a low fitness level and/or have cardiovascular or cardiopulmonary disease. It is necessary to maintain the proper intensity (target heart rate zone) for a duration that will create a training benefit. Certain medications like beta blockers will keep the heart rate down, even if the intensity of the exercise is increased. This is the function of the medication to help protect the heart.

It is easy to obtain a heart rate monitor if you are not adept at checking your pulse frequently. I get a lot of assistance at the gym from certified trainers. Physical therapists have been trained to properly evaluate and treat patients coming to them with specific problems like rotator cuff tendinitis. They provide the appropriate exercises and treatments, which will reduce the pain and improve the function of the injured area.

If you are starting an exercise program or returning to one after a break, you should consider maintaining a heart rate in your target zone for a minimum of twelve to fifteen minutes. This does not include warm-up or cool-down periods. As your fitness level increases, the exercise time in your target heart rate zone can be extended to twenty to sixty minutes of continuous aerobic activity. Competitive athletes can train beyond sixty minutes and they generally have fancier gadgets.

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