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Virtual coaching for the high-intensity training of a powerlifter following coronary artery bypass grafting.

Patients recovering from coronary artery bypass grafting (CABG) are routinely given weight and activity restrictions to protect the sternum. Instead of cautioning these patients about what they cannot do, the cardiac rehabilitation (CR) program at Baylor Heart and Vascular Hospital in Dallas, Texas, teaches them to modify their desired movements and activities in a way that minimizes shoulder joint abduction, extension, and flexion. We present the case of a powerlifter who, with long-distance coaching by the Dallas CR staff, returned to his sport after CABG.


A 55-year-old man presented with unstable angina pectoris at an emergency department in Memphis, Tennessee, in June 2013. Cardiac catheterization revealed severe three-vessel coronary artery disease with well-preserved left ventricular function, and the patient underwent quadruple CABG. He had always been physically active, was not diabetic, and did not smoke. His body mass index was 33.4 kg/[m.sup.2], and his waist circumference was 38 inches. Medications included amlodipine besylate, modafinil, clonazepam, and testosterone cypionate. His father had a myocardial infarction at age 55 and was found to have an aortic arch aneurysm at that time.

Before CABG, the patient exercised 10 to 12 times per week, including four sessions per week of resistance training appropriate for powerlifting--a sport that consists of three events: squat, bench press, and deadlift. At 3 weeks post-CABG he began attending CR sessions, spending 10 minutes each on a treadmill, recumbent bike, and upper body ergometer, followed by weightlifting that was restricted to 2-pound dumbbells. After completing 10 CR sessions at the hospital, he chose to continue the regimen on his own, using heavier dumbbells that were within the 10-pound weight restriction imposed by his surgeon. He also began researching how to sensibly return to his normal exercise program and especially how to resume powerlifting.

An Internet search on the phrase "recovery from CABG powerlifting" eventually led the patient to a Wall Street Journal article about the Dallas CR program for "industrial athletes," which allows patients to use specificity of training to achieve their goals (1). He called the department and told the exercise physiologist that he wanted to lift heavy weights again and perform at powerlifting competitions (the next of which would occur 44 weeks post-CABG). The patient's location and work schedule made it impossible for him to attend the Dallas program in person, so the exercise physiologist proposed a virtual coaching model: a sport-specific, symptom-limited exercise program with long-distance support that would enable the patient to train at a higher intensity than is typically allowed in traditional CR.


The patient was sent a wrist blood pressure cuff for heart rate and blood pressure monitoring and was advised to keep his rate-pressure product (heart rate multiplied by systolic blood pressure) below 36,000 (2). He was also taught about exercises that would not negatively affect the sternum. Through e-mail, he was sent the Athletic Identity Measurement Scale-Plus (3, 4); his score of 1660 confirmed the importance of powerlifting in his life, as high scores for athletic identity range from 1467 to 2200.

The patient and the Dallas CR staff kept in touch by e-mail and phone; together they developed a powerlifting exercise regimen that he did from week 11 post-CABG (when he was cleared to lift >10 pounds) to week 27 (after which, he had been told, his sternum would be completely healed). The core of this training program consisted of exercises that were similar to powerlifting exercises but safer for a healing sternum. Safety bar squats were substituted for low-bar back squats; overhead presses, which had always been part of his training, were substituted for bench presses; and glute-ham raises were substituted for deadlifts. The patient performed 41 workouts over the 17-week period, and the weight loads were increased incrementally. By week 26 post-CABG, he had returned to his pre-CABG exercise loads.

Training was symptom limited, meaning that no specific blood pressure or heart rate limits were used to restrict exercise intensity. The patient monitored himself for elevated rate-pressure product ([greater than or equal to] 36,000), angina, dizziness, pain, and shortness of breath. He had no adverse events that required him to discontinue any powerlifting exercise session.

Peak heart rate and blood pressure were successfully recorded a total of 35 times during the virtual coaching period, and the resulting rate-pressure product values were calculated. Because the wrist cuff instructions recommend use of the device with the wrist at chest level, the measurements taken during the overhead press were deemed inaccurate, so those calculations are not reported here. The rate-pressure product values that were calculated for the other two exercises were well below the threshold of 36,000. During the glute-ham raises, the maximum rate-pressure product was 28,566; the mean peak value was 20,369 (SD, 3723). During the safety bar squats, the maximum was 29,328 and the mean peak value was 23,231 (SD, 3782).


In weight training, the amount of work done is expressed as volume and can be calculated as the number of repetitions multiplied by the amount of weight lifted. Figure 1 tracks the patient's average volume per workout for the overhead press during four periods: normal (pre-CABG) training, immediate post-CABG recovery, virtual coaching, and resumption of normal training. Two observations stand out: 1) the volume during the traditional CR regimen was dramatically lower than the volume during virtual coaching, and 2) the volume was higher after full recovery than it was before CABG. Likewise, at a powerlifting competition 44 weeks after CABG (Figure 2), he lifted heavier loads than he did before CABG (average increase, 16%).

CR in general has the potential to improve patient outcomes (6); however, a significant number of patients cannot attend because of logistical conflicts. Of the 2576 patients who were referred to the Dallas CR program in 2013, 919 (37%) could not attend the on-site sessions because they lived too far away. The remote monitoring and guidance of cardiac patients, which is already being studied in the USA and abroad (7, 8), could lead to a much-needed alternative. The long-distance coaching described in this case report has sparked the idea of developing a virtual CR program in Dallas for patients who are self-motivated and disciplined about reaching their fitness goals.


Richard Adams, Jenny Adams, PhD, Huanying Qin, MS, Tim Bilbrey, BS, and Jeffrey M. Schussler, MD

From the Cardiac Rehabilitation Department, Baylor Jack and Jane Hamilton Heart and Vascular Hospital (R. Adams, J. Adams, Bilbrey, Schussler); the Quantitative Science Department, Baylor Scott & White Health (Qin); and the Division of Cardiology, Department of Internal Medicine, Baylor University Medical Center at Dallas and Baylor Heart and Vascular Hospital, and the Texas A&M Health Science Center, College of Medicine (Schussler).

Grant support was provided by the Harry S. Moss Heart Trust and the Baylor Health Care System Foundation, Dallas, Texas, through the Cardiovascular Research Review Committee and in cooperation with the Baylor Heart and Vascular Institute. The authors thank the committee for their continued support of cardiovascular rehabilitation research projects.

Corresponding author: Jenny Adams, PhD, Department of Cardiac Rehabilitation, Baylor Heart and Vascular Hospital, 411 N. Washington Street, Suite 3100, Dallas, TX 75246 (e-mail:


Thanks go to David Allen at NBS Fitness in Cordova, Tennessee, for supporting the patient in his powerlifting training following CABG, and to Jim Wendler, whose encouragement and suggestions guided the patient in his search for an appropriate CR program. Beverly Peters, MA, ELS, a freelance medical editor, assisted with manuscript development and preparation.

(1.) Landro L. After surgery, time to sweat. Wall Street Journal, August 6, 2013:D1, D4.

(2.) Adams J, Cline MJ, Hubbard M, McCullough T, Hartman J. A new paradigm for post-cardiac event resistance exercise guidelines. Am J Cardiol 2006; 97(2):281-286.

(3.) Brewer BW, Van Raalte JL, Linder DE. Athletic identity: Hercules' muscles or Achilles heel? Int J Sport Psychol 1993; 24(2):237-254.

(4.) Cieslak TJ 2nd. Describing and Measuring the Athletic Identity Construct: Scale Development and Validation [dissertation]. Columbus, OH: Ohio State University, 2004. Available at http://rave.; accessed August 19, 2014.

(5.) Wendler J. 5/3/1: The Simplest and Most Effective Training System for Raw Strength, 2nd ed. London, OH: Jim Wendler LLC, 2011.

(6.) American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 5th ed. Champaign, IL: Human Kinetics, 2013:2.

(7.) Black JT, Romano PS, Sadeghi B, Auerbach AD, Ganiats TG, Greenfield S, Kaplan SH, Ong MK; BEAT-HF Research Group. A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better Effectiveness After Transition--Heart Failure (BEAT-HF) randomized controlled trial. Trials 2014; 15:124.

(8.) Kraal JJ, Peek N, van den Akker-Van Marle ME, Kemps HM. Effects and costs of home-based training with telemonitoring guidance in low to moderate risk patients entering cardiac rehabilitation: The FIT@Home study. BMC Cardiovasc Disord 2013; 13:82.
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Article Details
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Author:Adams, Richard; Adams, Jenny; Qin, Huanying; Bilbrey, Tim; Schussler, Jeffrey M.
Publication:Baylor University Medical Center Proceedings
Article Type:Report
Geographic Code:1U7TX
Date:Jan 1, 2015
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