TRAINING FOR CARDIOPULMONARY AND

CARDIOVASCULAR ENDURANCE

Presenter: Laxmi Bhattarai

MPT II
 Objective

◦ What is fitness?
◦ What is maximum oxygen consumption?
◦ What is endurance and its types?
◦ What are the general training principles?
◦ What is aerobic exercise training?
◦ Physiological changes seen in the cardiovascular and cardiopulmonary system
◦ Determination of exercise programme
◦ Aerobic exercise training programme progression
◦ Clinical question
Background
◦ Fitness: is a general term used to describe the ability to perform physical work
that requires cardiorespiratory functioning, muscular strength and endurance, and
musculoskeletal flexibility.
◦ Fitness levels can be described on a continuum from poor to superior based on
energy expenditure during physical work.
◦ These ratings are often based on direct or indirect measurements of the body’s
maximum oxygen consumption (VO2 max).
Maximum oxygen consumption (VO2max)

◦ It is the maximum amount of oxygen consumed per minute when the

individual has reached maximum effort. It is usually expressed relative to body
weight, as millilitres of oxygen per kilogram of body weight per minute
(mL/kg per minute).
◦ It is dependent on the transport of oxygen, the blood's oxygen-binding
capacity, cardiac function, oxygen extraction capabilities, and muscular
oxidative potential. It is usually measured when performing an exercise that
uses many large muscle groups, such as swimming, walking, and running.
Endurance

◦ Endurance is the ability to work for prolonged periods of time and resist
fatigue.
◦ It includes muscular endurance and cardiovascular endurance.
◦ Muscular endurance refers to the ability of an isolated muscle group to
perform repeated contractions over a period of time.
◦ cardiovascular endurance Endurance refers to the ability to perform
prolonged dynamic exercise involving large muscle groups, such as walking,
swimming, or cycling.
GENERAL TRAINING PRINCIPLES

Overload Principle:
◦ states that habitually overloading a system causes it to respond and adapt. The
overload principle is quantified according to load (intensity and duration),
repetition, rest and frequency. Load refers to the intensity of exercise stressor,
i.e.. In strength training, it can refer to the amount of resistance. The greater
the load, the greater the fatigue and recovery time needed. Repetition implies
the number of times that a load is applied. Rest refers to the time interval
between repetitions, and frequency refers to the number of training sessions
per week.
Specificity Principle

◦ Exercise training specificity refers to adaptations in metabolic and physiologic

systems that depend on the overload imposed and muscle mass activated.
◦ The specificity principle also encompasses activities with identical metabolic
components. For example, aerobic fitness for swimming, bicycling, running, or
rowing improves most effectively when the exerciser trains the specific muscle
required for the activity.
Individual Differences Principle
◦ It states that while physiological responses to a particular stressor can be
mostly predictable, the precise responses and adaptions will still differ among
individuals.
◦ All individuals do not respond similarly to a given training stimulus. Many
factors contribute to variations in training responses among individuals,
including relative fitness levels at the start of training. People vary in initial
fitness and state training at the start of a conditioning program and thus
respond differently to the same stimulus.
Reversibility Principle

◦ referred to as detraining, occurs relatively rapidly when a person quits his or

her exercise training regimen.
◦ After only a week or two of detraining, measurable reductions occur in
physiologic function and exercise capacity, with a total loss of training
improvements occurring within several months.
◦ Individuality principle :
Aerobic Exercise Training(Cardiovascular Endurance )
◦ The improvement of the muscle’s ability to use energy is a direct result of
increased levels of oxidative enzymes in the muscles, increased mitochondrial
density and size, and an increased muscle fibre capillary supply.
◦ ■ Training is dependent on sufficient frequency, intensity, and time for
exercise.
◦ ■ Training produces cardiovascular and/or muscular adaptation and is reflected
in an individual’s endurance.
◦ ■ Training for a particular sport or event is dependent on the specificity
principle, i.e. the individual improves in the exercise task used for training
and may not improve in other tasks. For example, swimming may enhance
one’s performance in swimming events but may not improve one’s
performance in treadmill running.
Physiological Response to Aerobic Exercise
A. Metabolic Adaptations
1. Metabolic machinery: increased mitochondrial size in skeletal muscles and
improved to generate ATP by oxidative phosphorylation.
2. Enzymes: A twofold increase in the level of aerobic system enzymes
complements the increase in mitochondrial size and number and coincides
with increased mitochondrial capacity to generate ATP.
3. Fat catabolism: Regular aerobic exercise profoundly improves the ability to
oxidise fatty acids, mainly triacylglycerols stored within active muscle during
steady-rate exercise. Greater blood flow within trained muscle and a higher
quantity of fat-mobilizing enzymes from adipocytes and fat-metabolizing
enzymes within muscle fibres leads to an increase in lipolysis, which enables
endurance athletes to exercise at a higher absolute level of submaximal
exercise before experiencing the fatiguing effects of glycogen depletion, as
compared to an untrained person.
4. Carbohydrate Catabolism: Aerobically trained muscle exhibits an enhanced
capacity to oxidise carbohydrates. Consequently, a considerable quantity of
pyruvate moves through the aerobic energy pathways during intense endurance
exercise. A trained muscle’s greater mitochondrial oxidative capacity and
increased glycogen storage contribute to the enhanced capacity for carbohydrate
breakdown.
5. Muscle fibre type and size: Endurance training produces aerobic metabolic
adaptations in both muscle fibre types. This enhances each fibre’s aerobic
capacity and LT level without modifying the muscle fibre type. Selective
hypertrophy also occurs in different muscle fibre types in specific overload
training. Highly trained endurance athletes have larger slow than fast-twitch
fibres in the same muscle.
B.Cardiovascular Adaption
◦ 1. Heart size: Long-term aerobic training generally increases the heart’s mass
and volume with greater left ventricular end-diastolic volumes during rest and
exercise. This enlargement, characterised by the increased size of the left
ventricular cavity (eccentric hypertrophy) and modest thickening of its walls
(concentric hypertrophy), improves the heart’s stroke volume. With reduced
training intensity, or when training ceases, myocardial structure returns to
control levels.
◦ 2. Plasma Volume increases the plasma volume, enhancing circulatory and
thermoregulatory dynamics and facilitating oxygen delivery to muscle during
exercise. It also contributes to training-induced eccentric hypertrophy with
concomitant increases in stroke volume.
3. Stroke Volume increases with the intensity of the activity.
The adjacent stroke volume graph shows that stroke volume increases between
standing, walking and jogging. The reason for the increase in blood flow to the
heart is due to the greater volume of blood returning to it. When a person is
lying or sitting, their stroke volumes are higher compared to when they are
standing. This is because gravity has less effect on blood flow when in these
positions, making it easier for blood to return to and fill the heart. The stroke
volume continues to increase up to a certain point. However, when the exercise
intensity exceeds 50-60% of an individual's maximum heart rate, the stroke
volume ceases to rise. This happens mainly because the increase in heart rate
does not allow enough time for the heart to fill between each heartbeat.
4. Heart Rate: With aerobic training, resting HR decreases. At any given
workload, the maximum HR remains unchanged.
5. Cardiac output: The cardiac output increases because of the increase in
myocardial contractility, with a resultant increase in stroke volume, heart rate,
blood flow through the working muscle, and an increase in the constriction of
the capacitance vessels on the venous side of the circulation in both the working
and nonworking muscles, raising the peripheral venous pressure.
6. Oxygen Extraction: Aerobic training increases the maximum quantity of
oxygen extracted from arterial blood during exercise.
7. Blood Flow and Distribution: During aerobic training, muscle blood flow
increases due to an improvement in maximum cardiac output. Blood flow gets
redistributed from non-active areas that temporarily compromise blood flow
during all-out exercise efforts.
8. Blood pressure: Regular aerobic exercise decreases systolic and diastolic
blood pressures during rest and sub-maximal exercise. A training-induced
reduction in sympathetic nervous system hormones (catecholamines) contributes
to the lowering effect of regular exercise on blood pressure, perhaps via a
reduction in peripheral vascular resistance to blood flow.
C.Pulmonary Adaptations:
1.Maximal Exercise: Improvements in maximal oxygen uptake with training
increase maximal exercise minute ventilation. This adaptation makes sense
physiologically because improved aerobic capacity reflects larger oxygen
utilisation and the need to eliminate greater quantities of carbon dioxide by
increased alveolar ventilation.
2.Submaximal Exercise: Exercise training improves the ability to sustain high
levels of submaximal ventilation. For example, 20 weeks of regular run training
increased the endurance of ventilatory muscles by 16% in healthy adult men and
women. Less lactate accumulated during submaximal breathing exercises,
probably from the increase in aerobic enzyme levels in the ventilatory
musculature. Enhanced ventilatory endurance reduces the feeling of
breathlessness and pulmonary discomfort frequently experienced by untrained
persons who perform prolonged submaximal exercise.
3. Blood Lactate Concentration: The effect of endurance training in lowering
blood lactate levels and extending exercise duration before the onset of blood
lactate accumulation (OBLA) during the exercise of increasing intensity.
4. Body Composition Changes: regular aerobic exercise reduces body mass
and fat.
Determinants of an Exercise Program
A. FREQUENCY: Exercising at least 3 days a week generally initiates adaptive
aerobic system changes. If training is at a low intensity, greater frequency
may be beneficial.
B. INTENSITY: it is an important measure to improve aerobic power. Intensity
generally reflects the activity’s energy requirements per unit of time and
specific energy systems activated in relation to an individual’s energy-
generating capacity. One can express exercise intensity in one of six ways:
◦ 1. Calories expended per unit of time
◦ 2. Exercise level or power output
◦ 3. Level of exercise below, at, or above the blood LT
◦ 4. Percentage of V. O2max
◦ 5. Heart rate or percentage of maximum heart rate
◦ 6. Multiples of resting metabolic rate (METs)

C. TIME (DURATION): Duration is the time spent exercising in one session.

The combination of exercise intensity and duration establishes an exercise
session's energy expenditure.
o The ACSM recommends a duration of 20-60 mins of aerobics exercise. If the
exercise is intermittent rather than continuous, the ACSM suggests that each
bout of exercise be at least 10 minutes and the bouts be repeated to reach 20-
60 min.
◦ D. AEROBIC EXERCISE PREPARATION: It is part of aerobic exercise
prescription; the client should be educated about the preparation for exercise
activities such as warm-up. Warm-up can be active or passive. Both warm-ups
help improve performance times and increase tissue temperature. The effects of
thermal response include increased blood flow to the muscle, improved oxygen
dissociation from myoglobin, an increase in nerve conduction velocity, and
increased elasticity of the muscle-tendons units. The proper warm-up before the
exercise does not lead to injury. Cool Down helps to keep blood from pooling in
the lower extremities and facilitates venous return to the heart, thereby
preventing dizziness. It helps in the removal of metabolic waste products from
the tissue. If there is no proper cool-down period, individuals run the risk of
slowing recovery and also increasing cardiovascular complications. The cool-
down period should last 5 to 10 min and include light aerobic and stretching
activities.
E. AEROBIC EXERCISE MODE:
◦ Aerobic training is effectiveness depends on training volume rather than the
specific exercise mode used.
Clinical exercise testing
◦ Screening: Before embracing any aerobic endurance training exercise
programme, it is essential to determine the participant's general health status
and physiological response to exercise.
◦ Graded exercise testing: Appropriate development of a therapeutic exercise
prescription for cardiopulmonary endurance involves accurate rate testing of
vo2max, known as graded exercise testing. This provides the knowledge that
provides feedback about the individual’s aerobic capacity to perform
endurance exercises.
◦ Maximal graded exercise testing: The individual must exercise to the point
of fatigue. Direct measurement via open-circuit spirometry is used to assess
vo2max. It is noted that the average individual's vo2max and HRmax values
vary when they are measured on different pieces of equipment. Vo2max can be
estimated from the prediction equation and submaximal tests. It is mainly used
to measure cardiopulmonary endurance.
◦ Submaximal graded exercise testing: provides the individual’s aerobic
fitness level.
Laboratory testing :
◦ Treadmill testing: Submaximal treadmill tests have been developed for low-
fit to high-fit individuals. The goal of the test is to raise the subject's steady-
state heart rate to 85% of the predicted maximal heart rate (HRmax) for at
least two consecutive stages. According to ACSM, the stages of the test should
be 3 minutes or longer. This limitation is placed in an effort to ensure a steady
heart rate response for each stage.
◦ Cycle Ergometer: The Astrand-Rhyming test is a six-minute single-stage test
with the work rate based on gender and activity status. In this test, HR is
measured during the fifth and sixth minutes of work. A nomogram is then used
to estimate VO2 max from the average of the two heart rates, which is then
adjusted for age (since HR decreases with age) according to a correction
factor.
AEROBIC EXERCISE PROGRESSION
Aerobic exercise initiation (Phase I): The ACSM recommends that the initial
stage of a conditioning program include easy muscular endurance exercise and
moderate-level aerobic activities (40-60 %HRR). The training intensity of 45%
VO2R in fit individuals and 30% VO2R in less fit individuals is the minimum
training intensity for aerobic fitness. This period lasts four to six weeks,
depending on individual response to exercise. By the end of this stage,
individuals should be able to exercise three to five times per week for 30
minutes each session without undue muscle soreness, fatigue, or injury.
◦ Aerobic Exercise Advancement (Phase II): Phase II aims to increase
exercise load and stimulate improvement in individual cardiopulmonary and
cardiovascular fitness. The ACSM recommends that aerobic exercise intensity
range between 55% and 90% of HRmax and 45 to 85% of VO2R or HRR.
Determination of how quickly and how much intensity has increased is based
on individual previous exercise history, age, and tolerance of and response to
exercise. The rehabilitation trainer has to consider the total training volume
( intensity * duration* frequency) and monitor for muscle soreness, fatigue,
and injury. This period of training lasts for 4 to 6 months and should result in
improvements in the physiological response to exercise and achievement of
weight loss goals.
◦ Aerobic Exercise Maintenance (phase III): This phase of exercise involves
maintaining the level of aerobic fitness achieved in the first two phases of the
exercise program.
◦ Create a plan of care for a patient with a D6 spinal cord injury in a
manual wheelchair to improve cardiopulmonary endurance.
A. Treadmill Training: Body-weight–supported treadmill training (BWSTT) is
an exercise protocol that has been used to potentially affect a number of
domains, including motor recovery, bone density, cardiovascular fitness,
respiratory function, and quality of life. BWSTT improves cardiac autonomic
balance in persons with tetraplegia and paraplegia.
◦ (with similar results for varying degrees of lesion level and severity). It also
helps to increase peak oxygen uptake and heart rate and decreases the dynamic
oxygen cost for persons with SCI.
◦ Jeffries et al. 2015 suggest that standing and stepping exercises with BWSTT
can increase VO2 and heart rate levels and improve arterial compliance in
individuals with motor-complete SCI.
B. Upper Extremity Exercise: Ordonez et al. suggest moderate-intensity
aerobic arm training (20–60 min/day, three days/week for at least 6-8 weeks)
effectively improves the aerobic capacity and exercise tolerance of persons with
SCI.
◦ De Groot et al. suggest vigorous intensity (70%–80% HR reserve) exercise
improves aerobic capacity more than moderate intensity (50-60% HR reserve)
exercise. It should be noted that many individuals with SCI cannot tolerate
vigorous intensity initially, so they must adapt often using a submaximal or
interval-type approach.
◦ Nooijien et al. suggest that a hand cycling interval training program increases
peak power output and peak VO2 in individuals with paraplegia and
tetraplegia. Jae et al. suggest that upper-body strength training exercises can
improve arterial structure and function in those with SCI.
3. FES Leg Cycle Ergometry: uses electrical impulses to stimulate the
paralysed muscles in the legs, enabling them to engage in cycling exercises.
This approach has significantly improved aerobic fitness, as evidenced by
increased Vo2 Peak during exercise.
◦ Taylor et al. suggest that combining FES-LCE with upper limb exercise has
resulted in greater gains in aerobic fitness than using either modality alone.
This is due to increased sympathetic flow, decreased circulatory hypokinesis, a
larger cardiac volume load, higher VO2 training, and activation of upper and
lower muscle mass. This approach has been found to lead to a greater
reduction in body fat %.
◦ Kahn et al. state that FES leg cycle ergometry decreases platelet aggregation
and blood coagulation in persons with SCI. Interventions that involve FES
training a minimum of 3 days per week for 2 months may improve muscular
endurance, oxidative metabolism, exercise tolerance, and cardiovascular
fitness.
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