therefore the exercise time will be less than desired (and vice versa).

• If there are more stations than participants, there will be periods when no one is available to do the timings.

• There is no MSE work in the circuit.

• This may encourage competitiveness between participants.

A cool-down is a period of at least 10 minutes of diminishing intensity exercise and stretching performed immediately after completion of the circuit. The lower intensity exercise gradually returns patients to their pre-exercise state with less risk of hypotension, arrhythmias or angina.

There is a moderate risk of arrhythmia during the period immediately following cessation of exercise because sympathetic activity is still raised. In Van Camp and Peterson's study of 20 cardiac arrests (1989) 30% of cardiac arrests occurred during the cool-down and 10% after the exercise session. Thus, care and monitoring of participants are important during and after the cool-down session.

Older adults have an increased risk of hypotension due to an age-related slowing of baroreceptor responsiveness. There is also an increased risk of venous pooling, as an older adult's HR takes longer to return to pre-exercise state.

Current ACPICR (2003) standards for the phase III exercise component of cardiac rehabilitation stipulate an observation period of at least 15 minutes from the end of the cool-down period, during which relaxation can be taught or education sessions delivered.

Flexibility and stretching

In the cool-down, developmental stretches of the main muscle groups are held for up to 30 seconds (ACSM, 2000). The exercise leader must have sound knowledge of the normal physiological range of movement around the specific joint(s) in order to teach effective stretches. It is also essential to teach supported positions to promote relaxation and allow effective stretching (but not on the floor), for example, quads stretch done while holding or leaning against a wall.

The advice to patients is to stretch until they feel a certain amount of discomfort associated with the stretched position, but no pain. During the stretch normal relaxed breathing should be maintained. As the stretch is held, stressrelaxation occurs, and the force within the muscle decreases. When patients feel less tension because of changes in viscoelasticity they can relax further into the stretch.

Most clinicians believe ballistic stretching increases the risk of injury, because the muscle may reflexly contract if restretched quickly following a short relaxation period. Thus, static stretches are advocated for CR classes.

Special Considerations in Cardiac Rehabilitation Population for Stretching

• Adaptive shortening of muscles due to sternotomy wound (especially of pectorals, shoulder lateral rotators and extensors)

• Valsalva manoeuvre, holding breath

Stretching for surgical patients should focus on the muscles that may have adaptive shortening. In addition, during stretching relaxed breathing should be encouraged and the exercise leader should reinforce the avoidance breath holding.

Marfan's syndrome is a inherited condition that affects the connective tissue. The primary purpose of connective tissue is to hold the body together and provide a framework for growth and development. In Marfan's syndrome, the connective tissue is defective and does not act as it should (decreased ligamentous support). Marfan's syndrome affects many organ systems. Some patients with Marfan's syndrome develop aortic valve problems and require replacement valve surgery. Defective connective tissue also results in either joint laxity (hypermobility) or contractures (hypomobility). Care should be taken with this group so as to prevent damage to joint structures.

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