Effects

of
Resistance
Training
on
Distance
Walked in the Six Minute
Walk
in
A
Cardiac
Rehabilitation Setting: A
Control Trial
Nick Butchart

Introduction
Designing an exercise program with
resistance training is important to the
progression of quality of life of
coronary heart disease (CHD) patients
and improving their ability to perform
activities of daily living. The purpose
of this project is to determine the
effects of a resistance training
program by comparing it to a strictly
aerobic program on six minute walk
distances in patients in a cardiac
rehabilitation setting.
Resistance
training can lead to increases in
strength, stability, and overall capacity
for physical activity. There are many
different ways of prescribing exercise
to individuals; the two main focuses
being low volume high intensity
training
and
moderate
volume
moderate
intensity
training.
Continuous moderate intensity is
widely accepted has the traditional
method of exercise training in cardiac
patients (Conraads et al, 2013).
However, high intensity training has
shown to be more beneficial for
increasing VO2max than moderate
intensity training (Currie, 2013). A
study done by Cornish et al (2010)
proved the increased effectiveness of
high intensity interval training over
continuous
moderate
intensity

training.
It would be beneficial to
examine the effects of high intensity
interval training for the entire duration
of the study, but due to the diverse
population of individuals participating
in exercise we cant assume every
patient is capable of high intensity
exercise. Each clinical case is different
and the needs of each individual vary
depending on their characteristics and
type of cardiac events and procedures
they have had. Specific guidelines
have been created by the ACSM
stating how each individual under
each circumstance will begin exercise
and how they will progress towards
their goals throughout the program.
Once
SMART
goals
have
been
determined it is up to the healthcare
team to create a specific exercise
program tailored to each client to
maximize their outcomes from cardiac
rehab. As stated before each patient
is different and requires a treatment
plan created specifically for them
based off of their data and not just a
general population with the same
cardiac issue. This project is meant to
determine
the
guidelines
for
individuals of all types ranging from
obese to normal weight, diabetics and
non-diabetics, as well as trained and
un-trained
individuals
and
how
resistance training will benefit their
time spent in the program. Resistance
training improves muscle endurance
and strength, exercise capacity, bone
density, and even confidence to
perform certain activities (Wise and
Patrick, 2011). The two main areas of
concern with exercise include: Aerobic
exercise and resistance training both
of which have different guidelines from
one another.
These guidelines for

exercise will be discussed in this

project as well as the contraindications
to each type of exercise in each
situation. There is a large literature
base on the benefits of resistance
training in cardiac rehab alongside the
use of aerobic training. This project
will
determine
the
benefits
of
resistance training in a diverse group
of individuals going through cardiac
rehab.
Methods
Participants
From
the
cardiac
rehabilitation
program at Howard Young Medical
Center patients were offered to chance
to participate in this mini study. Each
patient was given a description and
purpose of the study where they could
then decide if they wished to
participate. We gathered 8 patients
that stated they would partake in the
aerobic training group and 4 patients
that wanted to participate in the
resistance training group. Of the 8
aerobic training patients, 3 of them
were women and the remaining 5
were men where the resistance
training group had 1 woman and the
remaining 3 were men. From the 12
total patients 4 of them had a
myocardial infarction (MI), 3 had a
coronary artery bypass (CABG) and
the remaining 5 had a percutaneous
intervention (PCI).
An eight week resistance training
program will take place two days per
week on Mondays and Wednesdays for
one full hour at the Howard Young
Medical Center in Woodruff. A full
hospital rehabilitation gym will be

used during bouts of exercises and all

resting variables will be measured
prior to exercise in the rest lobby.
Blood pressure, heart rate and O2
saturation will be measured during
peak exercise for safety purposes of
the study. Many of the patients have
been educated on the benefits of
participating in a resistance training
program where some became very
interested and others were still against
trying. After asking the patients who
would and would not be willing to
participate in resistance training
inclusion and exclusion criteria were
created.
It is expected that lower body strength
will increase more through the use of a
two day per week resistance training
program. It is also expected that as
strength of the lower body increases
the total distance each patient walks
should also increase. A study done by
Halviala et al (2014) states that
isometric leg strength and walking
capacity correlate with one another. In
order for a total body workout to occur
upper body fitness will be assessed
with grip strength, however the main
focus of this study is walking distance.
To determine if lower body strength
increases a 30 second sit to stand will
be used on all patients.
Exercise Prescription
Exercise
prescription
will
be
determined using intensity, frequency,
duration and modality of exercise for
each individual. Exercise will always
begin with a 5 minute warm up that
the patient gets to decide what
intensity the wish to warm up at. After
warm up they are to begin their

exercise and finish at the end with a 5

minute cool down prior to leaving
whatever machine they were on.
Duration and Intensity
The resistance training program will
consist of 8 exercises which Wise and
Patrick (2011) state a single set of 810 exercises will take 20-25 minutes.
Given that none of the patients
currently participate in resistance
training I assume it will take a little
longer to perform each exercise. Each
exercise will be performed one time at
intensity 2-3 repetitions prior to
fatigue. They must be able to perform
the exercise at least 8 times no more
than 12 for the exercise to be most
beneficial. According to the ACSM for
an individual to increase hypertrophy
and strength 8-12 repetitions is
needed. A study done by Mandic et al
(2009) utilized 10-15 repetitions for
the
resistance
training
group
supporting our choice of repetitions.
Exercises will consist of 4 upper body
exercises and 4 lower body exercises
with a 48 hour rest period between
exercise
sessions.
The
ACSM
guidelines state a minimum of 48
hours is required to allow for proper
muscle recovery prior to beginning a
new exercise session. The 4 upper
body exercises include: bench press,
seated rows, bicep curls and triceps
curls; the 4 lower body exercises will
include: wall squats, single leg lunges,
leg extension and leg curls.
Aerobic exercise will be performed at
the same intensity for both the
resistance training group and the
aerobic training group. According to
ACSM guidelines aerobic endurance

should be performed at 40-60% of

HRR in cardiac rehab. Ministry
Healthcare policy is to have patients
exercise at 50-70% HRR in their
program. In the study by Mandic et al
(2009)
aerobic
exercise
was
completed at 50-70% of HRR to
achieve the greatest benefit. Initially
exercise will begin at 40% HRR to
ensure all patients are able to finish
the
program
prior
to
intensity
increases. Duration will begin at 60
minutes for the aerobic group to equal
the amount duration of exercise of the
resistance training group. Resistance
training group will perform 30 minutes
of aerobic exercise prior to beginning
resistance training. A total of 15
minutes on each machine will be used
for the resistance training group and a
total of 30 minutes will be used for the
aerobic training group.
Frequency
All 8 exercises will be performed both
days and no resistance training is to
be
done
outside
of
cardiac
rehabilitation.
The ACSM states
resistance training, when appropriate,
should be performed 2-3 days per
week with at least 48 hours of rest
between exercise sessions for muscle
recovery. Although 3 days would be
most beneficial for resistance training
patients are only able to be seen
Monday and Wednesday due to a
location switch on Fridays.
Aerobic exercise will also be performed
two days per week due to location
changes on Friday.
Modality

Exercises will be done using body

weight, dumbbells, and resistance
bands in order to perform all exercises
properly. Each exercise will have a
specific modality associated with and
if the patient cannot complete the
exercise as given they will not be able
to participate.
Aerobic exercise is to be done using
the treadmill and the NuStep to ensure
all patients are getting the same type
of exercise. Time will be split evenly
between the two machines which is
mention in the duration and frequency
section.
Inclusion/Exclusion
Clients are required to come in for all
of their sessions unless previously
specified they were not going to
attend or had an emergency to attend
to in order to prevent reverse effects
from missing exercise. Looking back
in the records made it possible to
track how often patients came in for
their scheduled visits and determine if
they would be able to make it enough
sessions each week to see the benefits
of resistance training. Patients must
be at least five weeks post operation
or post cardiac event. Patients will
also be required to perform all of the
testing procedures so we have data
that we can compare between the two
groups. One patient excluded from
resistance training by the request of
the hospital due to the need for a left
ventricular assistive device.
Any
significant orthopedic issues will
exclude patients from the resistance
training portion of exercise, but not
from participating in the strictly
aerobic group. Patients must be able

to complete all exercises as given with

the correct modality as well. Patients
that come to rehab 3 days per week
will be excluded from the study due to
a greater volume of exercise that
would skew the data we collect.
Patients that participate must be
Monday and Wednesday exercisers
only.
Measurements
A total of six different measurements
will be taken at baseline, 4 weeks and
end of the study to determine the
short term effects of resistance
training. The measurements that will
be taken are as follows: Upper/Lower
body strength, six minute walk, Waist
Girth, Body Weight, and Blood
Pressure. Data will be compared for
the purpose of the study every 4
weeks from baseline measurements all
the way through the 8th week.
Body Weight
Body weight will be taken to the
nearest half pound before exercise
using a Health-o-Meter electronic scale
in pounds to determine if resistance
training will yield greater weight loss
than
strictly
aerobic
exercise.
Normally every week is too soon to
measure body weight, but it is
important to get body weight each
week to determine if the body is
retaining water in cardiac patients.
Blood Pressure
Blood pressure will be measured
before, during and after every exercise
session for safety and to determine
the effects of resistance training on
resting blood pressure. Blood pressure

will be taken using a standard manual

sphygmomanometer
and
master
cardiology stethoscope.

Waist Girth
Waist girth measurement will be taken
each
week
using
a
standard
measuring tape to determine how
resistance
training
affects
waist
circumference. Waist girth will be a
target of the resistance training
program in order to decrease the
circumference to less than the criteria
for obesity. Decreasing visceral fat is
beneficial to reducing the risk of
cardiovascular disease and type II
diabetes.
Along with those measurements, all
patients will be hooked up to an ECG
monitor to watch for any changes in
heart rhythm during exercise that
would require stopping exercise. Also,
SpO2 will be monitored and heart rate
will be monitored to prevent patients
from going above the max heart rate
given by the cardiologist.
Exercise Testing
Strength will be measured by using a
hand grip strength test and a 10
repetition timed sit to stand test to
assess the overall strength increases
or decreases that come with each
mode of exercise. A hand grip
dynamometer is a valid and well
accepted test to assess upper body
physical fitness (Taekema et al, 2010).
A test run by Takai et al (2009) states
the use of the timed sit to stand was a
useful tool in assessing the force
generating capacity of the lower body,

especially the knee extensors. These

tests will be measured at baseline, 4
weeks and 8 weeks to determine the
effects of resistance training on
cardiac patients. The 6 minute walk
will
be
used
to
assess
cardiorespiratory
fitness
to
accommodate all individuals in the
program that would like to participate
in the study. According to Haltuala et
al (2013) the 6 minute walk test is a
reliable test for assessing exercise
capacity in individuals with CAD.
Using the distance walked over 6
minutes we will calculateVO2max to use
for exercise prescription purposes. The
6 minute walk will be done at baseline
and 8 weeks to determine if resistance
training has any effect on aerobic
endurance.
Outcomes
Overall, the purpose of resistance
training is to increase the size and
strength of the major muscle groups in
the body. Although we will not see
increases in size of muscles after just
8 weeks, strength increases will occur.
If strength increases the total capacity
for work will allow for more vigorous or
longer duration physical activity. The
exercise program will last 8 weeks and
there are specific goals we would like
to see in that time frame. Patient
strength should progress by at least 2
pounds per week for upper body and 5
pounds per week for lower body
according to ACSM guidelines. These
minimum goals have been placed
according
to
the
progression
guidelines for resistance training given
by the ACSM.
Realistically, an
individual can lose a maximum of 2

pounds per week with maximal effort

given toward their exercise and diet.
We expect each patient to be able to
lose around .5 pounds per week with
proper exercise and even more than
that if they follow a diet plan provided
by the dietician. Exercising 150
minutes per week at a moderate
intensity will provide weight loss, but
due to only having 120 minutes per
week of exercise in this study the
results will be less (Donnelly et al,
2009). On average an individual will
reduce their waist girth by one inch
with 5 pounds of fat loss allowing us to
expect each patient to have lost at
least one inch off of their waist girth
by the end of the study.

Monitoring
Patients will have blood pressure,
heart
rate,
and
O2
saturation
monitored every session for safety
reasons during exercise. Every patient
will be hooked up to an ECG monitor
with the Scottcare Telemetry system
to monitor rhythms the entire duration
each patient is exercising. If any
patient is diabetic they will need to
provide fasting and pre-exercise
glucose levels prior to starting
exercise each session. A post-exercise
glucose will also need to be provided
prior to the patient leaving the facility.
Patients will be asked about their
current health status and if there are
any changes in health it will be noted
and determined if they can participate
in resistance training for that session.
During exercise patients will be sked
to provide their rate of perceived
exertion to determine how hard they

believe they are working. RPE should

not reach above a 15 on the scale and
if it does they are doing either too
many repetitions or too much weight
and one will need to be decreased.
According to the ACSM guidelines 2-3
repetitions prior to fatigue is a 15-16
on the RPE scale. Normally 16 would
be the set maximum RPE for this
study, but Ministry Healthcare as a 15
RPE maximum for patients in their
cardiac rehab program. Signs and
symptoms will be monitored during
exercise which includes: chest pain,
dizziness, light head, nausea, leg
cramping, and severe shortness of
breath.
Statistical Analysis
The data between the two groups will
be analyzed using a one way ANOVA
and standard t-Test. These two tests
will be used to compare baseline data
for independent samples. The effects
of each mode of exercise will be
analyzed using the same one way
ANOVA long with a Post Hoc ANOVA.
Correlations are determined using a
linear regression and data is reported
as mean and standard deviation (SD).
Results
The data shown in table 1 represents
the
patient
characteristics,
medications, and exercise information
for both the aerobic group and the
resistance
training
group.
No
significant differences in patient age,
height, body weight, or blood pressure
were noted between the two exercise
groups. Both groups had very good
attendance with one individual in the
aerobic group missing two sessions

due to a pre-planned family vacation.

No major differences were noted in
CAD events between the two groups.
Table
1.
Represents
patient
characteristics,
medications,
CAD
event,
and
exercise
Variable
Age,
y
Resistance
(n=4)
Height,
in

Aerobic
(n=8)
Variable
Six Minute
Walk
Peak MET
Level

Pre

3.41.4

4.21.4

Speed, mph

2.91.1
1,53158
1

3.4.9
1,695
475

102

92

4111

408

407

387

389

359

312

293

302

Distance, m
RPE
Hand Grip
Strength
Left Arm
Right Arm
Timed 10
Rep Sit to
Stand

Post

Pre

CAD Event

Aerobic
(n=8)
648

Resistance
(n=4)
612

666
4

3.81.6

CABG
4.61.6

31

PCI
3.7.8

Medication
1,689528
s
113

1,9534
22
102
Ace
Inhibitors
Beta
4410
Blockers
4111
Calcium
Channel
Blockers
283

Antiplatelet
s

Table 1.

Statins
Exercise
Attendanc
e

Diuretics

Measurements from the exercise tests run

both pre and post are represented in Table 2.
Peak MET levels, speed, distance walked
and RPE were similar in both groups at
baseline. The group that participated in
resistance training showed greater increases
in all categories when compared to the
group that only participated in aerobic
exercise. Increases are shown in the
resistance training group in the hand grip
strength test where decreases were shown in
the aerobic group. A significant increase was
noted in the resistance training group for the
30 second sit to stand test where the aerobic
training group showed very little increase.

Table 2.

673

MI

attendance.

Note: The data is

represented
using
the
meanSD.

Post

Table 2. Represents the data collected pre

and post for six minute walk, hand grip
strength, and timed 10 rep sit to stand. Data
was compared between the two groups to
determine the effects of each exercise
program.

Note: The data is

represented using
the meanSD.

Anthropometric
measurements are
6
3
given in table 3
3
2
for baseline, 4
weeks, and final.
Both groups were
4
1
almost identical
at baseline to
1
1
begin the study.
2
3
The
resistance
training
group
7
2
had
slightly
231
240
higher
average
initial
body
weight although they did not have the
heaviest patient in their group. There were
no significant changes in any of the
variables after 4 weeks with exception to an
initial drop in body weight for the aerobic
group.
Aerobic
(n=8)
Pre

Four
Weeks

Post

Systolic

12018

12115

1201
2

Diastolic

779

777

16831

16533

Variable
Blood Pressure

Weight, lbs

766
1642
8

Waist Girth, in
Resting Heart Rate,
bpm

332

332

6211

6113

Table 3. Represents the anthropometric

measurements collected at baseline, 4
weeks, and final.
Figure 1. Represents the total distance walked during
the six minute walk at baseline and final. It is shown
here that the resistance training group was able to
walk further and had greater increases from baseline.

Six Minute Walk

2,500
2,000
1,500
Distance (m)

Pre

1,000

Post

500

Discussion
The studys purpose was to determine if
increasing lower body strength with a
resistance training program would increase
six minute walking distances. This data was
compared to the effects of a strictly aerobic
exercise program over 8 weeks of exercise.
The data collected supports both hypotheses
that were created at the beginning of the
study. First, the use of a resistance training
program twice per week will yield greater
increases on lower body strength than a
strictly aerobic program alone. Second,
increasing the strength of the lower body
through resistance training does increase
distances walked in the six minute walk as
shown by table 2 and figure 1.

Group

The majority of research is now done

studying the effects of high intensity interval
training on healthy individuals and in some
cases individuals in cardiac rehab. This
study was conducted to determine the effects
of a moderate intensity exercise program
that is designed to be completed by anyone
in cardiac rehab. Some individuals will not
be able to perform high intensity exercise
and this program is designed to be tailored
to each individual. Although individuals
may have been exercising at different
workloads they were all exercising at the
same intensity.
Our finding that an exercise program that
incorporates resistance training into the
sessions will increase lower body strength is
consistent with that or previous research
studies. This confirms that further benefits
in cardiac rehab are possible if patients are

willing to participate in resistance training.

It was also hypothesized increasing lower
body strength would increase the distance
walked in the 6 minute walk test. When
analyzing the data both total walking
distance and increases from baseline to final
were greater in the resistance training group.
There are studies that suggest increasing
lower body strength does not increase
walking capacity however our research does
not support that. The only difference
between the two groups was 30 minutes of
resistance training suggesting that is the
reason for the increased walking capacity.
With just 8 short weeks at two days per
week totaling 16 sessions increases in lower
body strength were confirmed through the
use of a timed 10 repetition sit to stand test.
Although an isometric leg strength test for
both extension and flexion would have been
more beneficial the equipment was not
available.
The other variables that were measured in
this study were similar to one another when
compared between the two groups. No
significant differences were noted in any
anthropometric measures.
There were several limitations to the study
that limited the amount of research that was
able to be done. Larger sample size is
needed in order to apply this data to a larger
population of people. Having equipment that
could take isometric strength measurements
of the lower body would be more beneficial
than the timed 10 repetition sit to stand.
Although benefits were seen in the 8 weeks
the study lasted it the possibility for

clinically significant benefits are available if

the study lasts longer.
Conclusion
Through the use of resistance training it is
possible to improve walking capacity in
cardiac rehabilitation patients. Following the
ACSM guideline of 2-3 days of resistance
training allows for greater increases in lower
body strength than strictly performing
aerobic training. The program that was
created and delivered to the patients resulted
in increases in lower body strength. These
increases were seen through the use of a
lower body strength test. These increases in
strength resulted in an increased walking
capacity which is shown by data collected
from a six minute walk. This study proves
how effective resistance training is even
over a short period time and should be
recognized for implementation in all cardiac
rehab programs. With the information
gathered from this study it can be stated the
addition of resistance training is more
beneficial than performing only aerobic
exercise.
Implementation
In the future it would be beneficial to have a
longer study with more patient participants.
Having a larger population will allow for
possible randomization of the study
increasing the benefits from the data
collected. Also, the addition of a diet plan to
the program could also benefit patients even
greater. If a diet plan is going to
implemented a dietician will need to be
willing to participate in the study.
From the information gathered in this study
cardiac rehab programs can see using

resistance training is necessary for maximal

benefits. Just two days per week for 30
minutes can yield significant gains in
walking capacity. It is important to increase
home exercise in cardiac rehabilitation so
patients are getting enough aerobic exercise
with the substitution of resistance training in
the program. If patients can accumulate 150
minutes of exercise each week with at least
60 minutes of resistance training the benefits
will be far greater than that of strictly
aerobic training.
References

Conraads, V. M., Shivalkar, B., Beckers, P.

J., Cornelissen, V. A., Pattyn, N.,
Craenenbroeck,
E. M., et al. (2013). Rationale and
design of a randomized trial on the
effectiveness of
aerobic interval training in patients
with coronary artery disease: The
SAINTEX-CAD
study. International Journal of
Cardiology, 168(4), 3532-3536.
Retrieved June 11, 2014,
from
http://dx.doi.org/10.1016/j.ijcard.201
3.05

Cornish, A. K., Broadbent, S., & Cheema, B.

S. (2011). Interval training for
patients with coronary artery disease:
a systematic review. European
Journal of Applied Physiology,
111(4), 579-589. Retrieved June 12,
2014,
from

http://dx.doi.org/10.1007/s00421010-1682-5
Currie, K. D. (2013). Effects of acute and
chronic low-volume high-intensity
interval exercise on cardiovascular
health in patients with coronary
artery disease. Applied Physiology,
Nutrition, and Metabolism, 38(3),
359-359. Retrieved June 11, 2014,
from http://dx.doi.org/10.1139/apnm2012-0428
Donnelly, J. E., Blair, S. N., Jakicic, J. M.,
Manore, M. M., Rankin, J. W., &
Smith, B. K. (2009). Appropriate
Physical Activity Intervention
Strategies for Weight Loss and
Prevention of Weight Regain for
Adults. Medicine & Science in
Sports & Exercise, 41(2), 459-471.
Retrieved August 13, 2014, from
http://dx.doi.org/10.1249/MSS.0b01
3e3181949333
Hautala, A. J., Kiviniemi, A. M.,
Karjalainen, J. J., Piira, O.,
Lepojrvi, S., Mkikallio, T., et al.
(2013). Peak exercise capacity
prediction from a submaximal
exercise test in coronary artery
disease patients. Frontiers in
Physiology, 4, 1-6. Retrieved June
12,
2014,
from
http://dx.doi.org/10.3389/fphys.2013
.00243
Holviala, J., Hkkinen, A., Alen, M.,
Sallinen, J., Kraemer, W., & Hkkinen,
K. (2014). Effects of prolonged and
maintenance strength training on force
production, walking, and balance in
aging women and men. Scandinavian
Journal of Medicine & Science in

Sports, 24(1), 224-233.

doi:10.1111/j.1600-0838.2012.01470.x
Mandic, S., Tymchak, W., Kim, D., Daub,
B., Quinney, H. A., Taylor, D., et al.
(2009). Effects of aerobic or aerobic
and resistance training on
cardiorespiratory and skeletal muscle
function in heart failure: A randomized
controlled pilot trial. Clinical
Rehabilitation, 23(3), 207-216.
Retrieved from
http://search.ebscohost.com.pioproxy.ca
rrollu.edu/login.aspx?
direct=true&AuthType=cookie,ip,cpid
&custid=s6222004&db=aph&AN=364
89729&site=ehost-live&scope=site
Takai, Y., Ohta, M., Akagi, R., Kanehisa, H.,
Kawakami, Y., & Fukunaga, T.
(2009). Sit-to-stand Test to Evaluate
Knee Extensor Muscle Size and
Strength in the Elderly: A Novel

Approach. Journal Of Physiological

Anthropology,
28(3),
123-128.
Retrieved August 10, 2014, from
http://dx.doi.org/10.2114/jpa2.28.123
Taekema, D. G., Gussekloo, J., Maier, A. B.,
Westendorp, R. G., & Craen, A. J.
(2010). Handgrip strength as a
predictor
of
functional,
psychological and social health. A
prospective population-based study
among the oldest old. Age and
Ageing, 39(3), 331-337. Retrieved
August
11,
2014,
from
http://dx.doi.org/10.1093/ageing/afq
022
Wise, F. M., & Patrick, J. M. (2011).
Resistance exercise in cardiac
rehabilitation.
Clinical
Rehabilitation, 25(12), 1059-1065.
Retrieved June 11, 2014, from
http://dx.doi.org/10.1177/026921551
1423408