B

need a much more defined interval approach than will fitter participants (see rationale for interval training p. 135).

Active recovery stations should last for no more than one minute. The time between consecutive stations should be kept to a minimum, and, as a guide, should only last long enough for participants to walk from one station to the next. Different ways of controlling the circuit time and movement are discussed later in this chapter.

Figure 5.5. Concentric circles circuit.

Group A B

Figure 5.6.

Line circuit.

Mat or floor work should never be included in the main circuit. During aerobic exercise training, exercises which involve lying down are contraindi-cated for several reasons. Lying down creates a sudden increase in the volume of blood returning to the heart (preload). This causes an increase in the left ventricular end diastolic volume, which could cause arrhythmias and angina. Second, there is a risk of orthostatic hypotension when returning to upright posture. In cardiac patients, ACE inhibitors, nitrates and beta blockers may exacerbate this. Finally, participants may have physical difficulty getting up and down and, with a limited time at each station, this can result in participants not adopting the correct starting position or not performing exercises correctly. If exercises on the floor are to be included, they should be used after the cool-down.

Easy

Moderate

Hard

Alternate bicep

Lift arms to

Lift alternate bent arms

curls

shoulder height

holding small weights

Station 1 Teaching points

• Keep head up, shoulders back

• Bend supporting knee

• Place front heel lightly

Station 1 Teaching points

• Keep head up, shoulders back

• Bend supporting knee

• Place front heel lightly

Figure 5.7. Example of a circuit chart. The heel dig is the basic step, with arm pattern providing increasing intensity.

Use of Circuit and RPE Training Cards

Circuit cards act as a prompt but can never replace proper instruction. They can be colour coded for easy recognition - e.g. to identify different intensities or types of exercise (see Figure 5.7). When used, circuit cards must have the following characteristics:

• clearly visible and identifiable (ideally A2 size);

• include large, clear diagrams;

• with minimal text - only key teaching points;

In addition to circuit cards, there should be an RPE scale of the same size beside the circuit card. The exercise leader and assistants can refer the patients to the appropriate self-monitoring during the class.

Class Management: Control of Class Movement

The control of the circuits also needs to be carefully considered, as it can be done in a number of ways.

Time control

• Exercise leader uses a stopwatch and calls out prescribed times to stop, start and move on to the next exercise.

• Exercise leader uses stop watch, blows a whistle when it is time to change.

• Exercise leader uses pre-recorded tapes, where the work time at each station and changeover times are controlled by recording the playing time and breaks in the music.

Repetition control

This method uses one of the stations to dictate time. For example, a pre-set number of shuttle walks completed by participants at one station is the cue for the whole group to move on to the next station. Alternatively, the exercise leader prescribes individuals with a set number of repetitions to complete before moving on to the next station, e.g. 8,12,16 or 20 of each exercise. This method is not often adopted in CR programmes, as it may result either in participants rushing through the exercises (thus at an inappropriate intensity) or all finishing their conditioning component at different times. However, it can be employed effectively in an unsupervised home programme.

Examples of Phase III Circuit Format and Their Progressions

Figure 5.8 and Table 5.4 show a format that would be ideal in a gym situation, where there is a small number of participants and a selection of different types of CV equipment.

Here the aerobic exercise stations alternate with a lower intensity aerobic exercise (walking). The lower intensity walking between stations acts as an active recovery. The timings used in this circuit work only when using cardiovascular machines, where it is preferable to have a longer duration. The total time for one circuit is 12 minutes. Participants need to go round the circuit twice in order to achieve the standard training duration.

Table 5.4. Example of phase III circuit and progression with CV equipment

Different stages CV time AR time

Stage 1: Perform 1 minute at each station, then 6mins 6mins

1 minute of walking around gym, before moving on to next station.

Stage 2: Perform 11/2 minutes at each station, 9mins 3mins then 1/2 minute of walking around gym, before moving on to next station.

Stage 3: Perform 2 minutes at each station 12mins 0

before moving on to next station.

Figure 5.8.

Circuit format with

CV equipment.

Advantages of Figure 5.8

• It is easily adopted in a fitness studio environment.

• There are fewer stations, making the circuit straightforward to follow. Circuit progresses through duration first.

• The small number of stations allows the exercise leader to move around and observe the group more easily (important when using CV machines, where there is a risk of injury/misuse).

• Fewer stations make it is easier for the exercise leader to manage and for beginners to learn the circuit.

• The use of CV equipment allows the exercise leader to alter the workload more exactly (better individualisation). Less time urgency, so that participants can focus more on their exercise technique, sensation of effort, etc.

• Longer time intervals at each station mean that the exercise leader has more opportunity to talk to participants and offer teaching points without interruption.

• Less competitive - participants are not as rushed to get started because they know they have a reasonable length of time in which to settle into the exercise.

Disadvantage of Figure 5.8

• With this circuit arrangement, unless there is more than one item of gym equipment per station, the number of participants is limited to six.

• Due to the small number of stations, it may become repetitive or boring for participants.

• Exercise leader may become complacent and simply operate as a timekeeper.

• There is no MSE work within the circuit.

• Exercise leader has to provide separate individual induction for all equipment.

• New participants may need a lot of help with programming the equipment and, for example, altering the seat position of a bicycle.

• The order of the stations may be fixed because the equipment cannot be moved around the room.

• The exercise durations will not work well for participants with a very low functional capacity or a mobility problem.

Figure 5.9 and Table 5.5 show aerobic stations with MSE exercises as an active recovery. The even numbered stations are aerobic, while the odd numbered stations are active recovery. Progression is achieved by increasing CV time at the expense of the AR time. It is advisable to change the aerobic stations before the start of the third circuit, to prevent boredom. Participants must keep feet moving while performing upper body exercises. The total time for one circuit is six minutes 20 seconds. Participants need to go round the circuit three to four times in order to achieve the standard training duration.

Station 10 Toe taps onto step

Station 2 Heel digs

Station 10 Toe taps onto step

Station 2 Heel digs

Station 8 Back heel lifts

Station 6 Rear toe taps

Station 4 Alternate Side steps

Figure 5.9. Circuit showing aerobic stations with MSE exercises as an active recovery.

* Keep feet moving entire time.

Table 5.5. Example of phase III circuit and progression with aerobic and AR using

MSE stations

Stages CV time AR time

Stage 1 Perform 40 seconds of exercise at all stations. 3mins 10secs 3mins 10secs

Stage 2 Perform 60 seconds of exercise at the even 5mins 1min 20secs numbered stations and 20 seconds of exercise at the odd numbered stations.

Stage 3 Perform 1 minute 20 seconds at the even 6 mins 20 secs 0

numbered stations and miss out all the odd numbered stations.

Advantages of Figure 5.9

• Plenty of variety of exercises can be included.

• Plan can accommodate a greater number of patients, before having to double up at stations.

• It can cater for a wide variety of fitness levels, provided progression options are clearly stated.

• It does not require aerobic exercise equipment.

• The active recovery period incorporates MSE work.

• Circuit can be arranged in different ways according to the dimension of the room.

Disadvantages of Figure 5.9

• Plan requires a large area of floor space.

• More stations = more time-consuming to set up at the start.

• Timings may be confusing, especially for novices.

• There is less opportunity for MSE work as the participants progress. (If the AR time is not reduced as the CV time increases, participants move on at different times, and consequently there could be a bottleneck at some stations.)

• More staff are required, in order to provide adequate supervision at each station.

• Patients are more likely to perform the MSE exercises at the speed of an aerobic exercise (especially when using music), thereby not providing active recovery.

Figure 5.10 and Tables 5.6 and 5.7 show aerobic stations with MSE exercises as an active recovery.There are 12 stations, and at each station there is a choice of an aerobic or an active recovery exercise. The circuit cards are colour coded so that they are easily identifiable (e.g. green = aerobic, red = active recovery). Beginners are told to alternate between green and red exercises. The exercise duration at each station is fixed at 45 seconds, with 10 seconds allowed for changeover to next station. If the circuit is performed once then the training period is approximately 10 minutes. If it is repeated, this would give a training period of approximately 20 minutes. The circuit would need to be repeated three times in order to produce a training period of approx 30 minutes. Alternatively, a 10-minute exercise to music section could be used instead of a third circuit. Progression is then achieved by substituting an AR station with an aerobic station. Total time for one circuit is nine minutes. Participants need to go round the circuit three to four times in order to achieve the standard training duration.

Advantages of Figure 5.10

• Timings are straightforward -everyone moves at the same time, prevents queuing when there is more of a chance of participants standing waiting.

• Variety of stations prevents boredom and accommodates a wide variety of fitness levels.

• Circuit cards act as prompts and reinforce good technique.

Station 12

Station l

Station

Station ll

Station

Station 4

Station lO

Station 5

Station

Station 6

Station 8

Station 8

Station l

Station l

Figure 5.10. Circuit showing aerobic stations with MSE exercises as an active recovery.

Disadvantages of Figure 5.10

• Plan requires considerable group management skills.

• Individual participants have to remember what type of work to do at each station (i.e. aerobic or active recovery work) and not just copy what the person ahead of them is doing.

• If there is more than one person per station, it may be confusing if they are doing different exercises.

Table 5.6. Example of phase III circuit and progression with colour-coded aerobic and AR using MSE stations

Stages

CV time

AR time

Stage 1 4.5mins

Perform 1 (green) aerobic station followed by

1 (red) active recovery station Stage 2 6mins

Perform 2 (green) aerobic stations followed by

1 (red) active recovery station Stage 3 7.5mins

Perform 5 (green) aerobic stations followed by

1 (red) active recovery station Stage 4 9 mins

Perform all 12 (green) aerobic stations

Table 5.7. Aerobic stations and MSE stations: examples of exercises

Station

CV option

AR option

Number

1

Side lunges off low step with

Half squat (back against wall)

half arm swing

2

Shoulder pulley above head*

Theraband shoulder pull back*

3

Knee lifts + butterfly (pectorals)

Walk around gym

4

Heel digs + forward arm lifts

Bicep curls while slow walking around

gym

5

Shuttle walk

Theraband hip extension (looped band

secured around bottom rung of

wallbars)

6

Elbow circles with step kicks

Theraband shoulder diagonal extension*

7

Tap backs behind with shoulder

Hand on wall, hip abductions 5 one leg

girdle retractions

(turn round then rpt with opposite leg)

8

Alternate arm diagonals with

Theraband shoulder lateral rotation*

step touch

9

Box step - passing small ball

Shoulder abductions holding

around body at waist height

dumbbells*

10

Hamstring curl with upright row

Standing calf raises and toe raises

11

Low march on spot

Overhead shoulder llift*

12

Shuttle walk

Triceps kickback holding dumbbells*

*Keep feet moving entire time.

*Keep feet moving entire time.

Figure 5.11 and Table 5.8 show aerobic stations followed by command led MSE station.

This circuit is a modified concentric circles arrangement. The outer circuit is made up of 10 aerobic stations (1-10). Circuit cards on the wall act as aids for the outer circuit. Class exercise leader walks around perimeter of the room to observe patients. During the aerobic circuit, active recovery is incorporated

Station 9

Station 8

Station 8

Station 7

Station 9

Station 7

Station 2

Station 4

Figure 5.11. Circuit showing aerobic and command MSE.

Station 2

Station 3

Station 3

Station 4

Figure 5.11. Circuit showing aerobic and command MSE.

by reducing the intensity of the aerobic exercise according to the needs of the patient. The outer circuit is completed once, followed by an active recovery walk to allow heart rate to reduce before performing MSE work. The inner circuit is made up of 8 different MSE exercises (A-H) that are command led.

Advantages of Figure 5.11

It is fairly simple to teach

It is very flexible.

The large variety of aerobic stations keeps participants interested.

All the patients perform the MSE work at the same time for the same number of reps and are taught by the exercise leader who is able to reinforce all the teaching points.

Exercise Leadership in Cardiac Rehabilitation Table 5.8. Aerobic and command MSE

Cardiovascular stations

Musculoskeletal endurance stations

Station 1 Heel digs with forward arm reach

Station 2 Rear tap backs with bicep curls

Station 3 March on spot with above-

head arm raise every 4th count

Station 4 Side tap with short lever arm abduction

Station 5 3 steps forward then heel strike then 3 steps backwards then heel strike

Station 6 Alternate knee raises (hand to opposite knee)

Station 7 Forward toe taps

Station 8 Side steps - 2 to the left then 2 to the right

Station 9 Half squat Station 10 Back heel lifts

MSE station A - Standing L hip abduction holding onto chair MSE station B - Standing R hip extension MSE station C - Standing calf raises

MSE station D - Standing L hip extension MSE station E - Standing R hip abduction

MSE station F - Seated chest press with elastic band (triceps and pectorals) (continue with heel lifts) MSE station G - Seated shoulder lateral rotations with elastic bands (continue with alternate heel lifts) MSE station H - Seated abdominals (continue with ankle dorsiflexions)

• For the command-led circuit (no cards needed, easy to offer alternatives, instructor always does the easiest version)

If using music then the bpm selected can match the type of exercise being performed.

Disadvantages of Figure 5.11

• It needs a large floor space to accommodate all 10 stations and have space for staff to observe participants and correct when needed.

• If circuit cards are stuck on the wall, then patients do the exercises facing the wall!

• In order to keep class management simple, progression of the aerobic workload is achieved by increasing intensity rather than duration, otherwise beginners will finish the circuit before the rest of the class. This may not be a problem if you have a second exercise leader to take them through their MSE work and cool-down.

Figure 5.12 and Tables 5.9 and 5.10 show aerobic circuit with alternative method of controlling exercise time. In this layout, all the stations are aerobic in nature. Circuit cards are pinned on the wall at eye level. Each circuit card shows two options: one to make the intensity lower and the other to make the intensity harder.

Station 9 is the time-controlling station, e.g. 10 step-ups leading with right leg, then go to another step to do 10 step-ups leading with left leg.

Participants at station 9 are given a hooter and perform a preset number of repetitions that has been calculated to take the majority of participants one minute to complete. Once completed, the participant finishing at station 9 sounds the hooter to cue the rest of the class to move on to the next station, before handing over to next person. Total time for one circuit is ten minutes. Participants need to go round the circuit three to four times in order to achieve the standard training duration.

Station -

Station 2

Station 8

Station 8

Station 3

Station 3

Station 7

Station 4

Figure 5.12. Aerobic circuits with a control station 9.

Figure 5.12. Aerobic circuits with a control station 9.

Table 5.9. Aerobic circuit of 1 minute stations

Stages

CV time AR time

Stage l

- Do 2 circuits then 2 minute walk between circuits

20 mins 2 mins

Stage 2

- Do 3 circuits then 2 minute walk between circuits

30mins 4mins

Table 5.10. Variety of

exercises with options for each station

Station

Exercise

Option 1 (lower)

Option 2 (higher)

l

Knee lift with hand

Hands rest on hips

Hand to opposite

to opposite knee

shin

2

Step back with

Alternate calf

Take larger steps

tricep kickback

raises instead of

step back

3

Half squat with

Only do arm reach

Hold light

single arm reach

every 4th count

dumbbells

across body

4

Hamstring curl with

Toe tap behind

Substitute bicep

bilateral bicep

curls with chest

curls

press

5

Heel dig with pec

Elbows lower, hands

Alternate between

dec keeping

at eye level

4 pec decs then 4

elbows high

punches above

head

6

Side toe taps with

Hands rest on hips

Pass softball around

arm swing across

body

body

7

March on spot with

Substitute leg work

Jog on spot and

shoulder

with alternate

punch

retractions

heel lifts, keep

same arm work

8

Box step, hands in/

Change arm work

Change to arm

out at chest

to bicep curl

raises above head

height

9

10 step-ups (L leg leading) at one end of room (toe taps onto step, easier)

instead use higher step then shuttle walk to other step to do another

l0 step-ups (R leg leading) - x2

l0

2 sidesteps with

Single arm lifts

Increase speed of

bilateral forward

instead

arm work to arm

flexion arm lift

pump

Class Design and Use of Music Advantages of Figure 5.12

• Keeps all participants interested and involved.

• Exercise leader is not tied up with timings and can spend time inducting new participants

Disadvantages of Figure 5.12

• Fitter participants will finish the controlling station sooner, and

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