Soon to be “Dr.” Melissa Marotta joins me to discuss the findings of a study she created:
Are There Psychological Effects of Heart Rate Monitor Use During Exercise?
Background
Biofeedback, the process through which individuals learn to direct their physiological responses by being presented with precise, rapid measurements of heart rate, body temperature, and even neural and muscle firing patterns and being taught to link these changes with their thoughts, emotions and behavior, is consistently supported in the medical literature for the treatment of anxiety, depression, migraine, cognitive and attention disorders, sleep disorders, and other conditions. Through biofeedback, people are taught that they can control their physiological states via diaphragmatic breathing and other mechanisms, and learn how to do so through self-correction.
This is the same concept that coaches and trainers use to teach athletes to direct their heart rates during training.
It stands to reason, therefore, that use of a heart rate monitor during exercise may achieve similar results to the heart rate component of biofeedback.
The present study seeks to explore:
1 ) Are there psychological effects of heart rate training — both that relate to exercise, and that apply to non-exercise(specifically relating to self-concept, self-confidence, and coping mechanisms)?
2 ) Are there specific ways that coaches and trainers can incorporate cuing language to reflect the potential psychological benefits of heart rate training?
I feel this information will be be of value to anyone wanting to improve the percentage of Heart Rate monitor usage in their classes.
This article from yourlife.usatoday.com says my home town is the fittest and healthiest city in the USA!
The Twin Cities Minneapolis-St. Paul are the healthiest, fittest cities in the USA, followed by Washington, D.C., and Boston, according to a new analysis of the 50 most populous metro areas.
Oklahoma City ranks last, and Louisville is second to last.
The annual American Fitness Index, out today from the American College of Sports Medicine, is based on a number of health factors, including percentage of residents who smoke, obesity rates, percentage of people who exercise and availability of parks, walking trails and farmers' markets.
“It takes a healthy community to produce a healthy population, and Minneapolis-St. Paul is a beautiful place to live if you're interested in a physically active lifestyle,” says Barbara Ainsworth, president-elect of the sports medicine group and a professor in Arizona State University's exercise and wellness program in Phoenix.
Where does your city fall in the fitness rankings?
1. Minneapolis-St. Paul
2. Washington, D.C.
3. Boston
4. Portland, Ore.
5. Denver
6. San Francisco
7. Hartford, Conn.
8. Seattle
9. Virginia Beach
10. Sacramento
11. San Jose, Calif.
12. Richmond, Va.
13. San Diego, Calif.
14. Cincinnati, Ohio.
15. Salt Lake City, Utah
16. Austin, Texas
17. Pittsburgh, Pa.
18. Atlanta
19. Providence
20. Baltimore
21. Milwaukee, Wisc.
22. Kansas City, Mo.
23. Buffalo
24. Raleigh,N.C.
25. Cleveland
26. St. Louis, Mo.
27. Philadelphia
28. Chicago
29. Orlando
30. New York City
31. Jacksonville, Fla.
32. Phoenix
33. San Antonio
34. New Orleans, La.
35. Miami
36. Charlotte
37. Nashville
38. Columbus
39. Dallas
40. Tampa
41. Los Angeles
42. Houston
43. Las Vegas
44. Riverside, Calif.
45. Indianapolis
46. Detroit
47. Birmingham, Ala.
48. Memphis
49. Louisville
50. Oklahoma City, Okla.
Source: American Fitness Index from the American College of Sports Medicine
Among the reasons the Twin Cities ranked No. 1: a lower-than-average obesity rate, an above-average percentage of residents who exercise, a relatively low smoking rate and moderate-to-low rates of chronic health problems such as asthma, heart disease and diabetes. Plus the area has lots of parks and recreational facilities.
Minneapolis was one of the first cities to have organized bicycle trails and to prohibit smoking in public places, she says, and it has many parks and public golf courses. You can read the rest here.
Is it possible – even imaginable – that nearly everyone has been wrong about saturated fat and its connection to heart disease? Brace yourself. Based on a wave of new research, all the dietary admonitions about saturated fat could end up being little more than a huge mistake.
“The question is whether saturated fat is harmful or is just a bystander,” says Ronald M. Krauss, MD, a lipid specialist and the director of atherosclerosis research at the Children’s Hospital Oakland Research Institute. “Saturated fat may have an effect on cardiovascular disease (CVD) risk, but the effect is so small that we just can’t detect it. We shouldn’t be demonizing saturated fat.”
And what did the expert's mistake contribute to society?
Food manufacturers responded by creating thousands of products in which saturated fat and cholesterol were replaced with refined carbohydrates, sugars and trans fats. And therein lies the problem. Not only do trans fats drive bodywide inflammation, but foods rich in refined carbohydrates and sugars trigger sharp increases in blood-sugar and insulin levels, which then set the stage for weight and blood-sugar problems – the leading risk factors for type 2 diabetes and CVD. “Replacing saturated fat with refined carbohydrates and sugars does not decrease CVD risk,” says Krauss. “More and more, the evidence shows that eating more refined carbs and sugars increases CVD risk.”
The late Robert C. Atkins, MD, sounded the alarm about the increase in carb and sugar consumption in the 1980s, when he noticed a dramatic rise in obesity and type 2 diabetes. But his solution, a diet rich in saturated fats, was roundly criticized – mostly because people believed that Atkins advised avoiding all carbs, including vegetables, when, in reality, he meant refined carbs. It took years of research before his approach was eventually vindicated.
This may sound like heresy, but the science behind it is solid. Sabina Sieri, PhD, of Italy’s National Cancer Institute, for example, tracked almost 48,000 people over eight years and found that women who ate more refined carbs and sugars had a significantly greater risk of coronary heart disease than those with a lower refined-carb intake.
It's been easy to blame the food manufactures for the obesity epidemic… but they were simply responding to market forces… that started when the “experts” convinced us that eating eggs and red meat was going to kill us all.
My money is on some future study confirming that stress and anxiety, from from listening to “experts”, is the real cause of CVD.
I was completely over-the-top ecstatic to come across an article in this month's Sports Medicine relating to new recommendations for exercise during pregnancy (Zavorsky & Longo, 2011). My experience during my medical training thus far is that, with pregnant patients just as non-pregnant patients, there is not a whole lot of discussion about exercise intensity. It's either “it's safe to exercise, and you should” vs. “it's not safe to exercise; don't.” For some pregnant patients, this is adequate; for many, it's not. So when this latest contribution to the medical literature purported to provide recommendations for exercise intensity during pregnancy with specificity unlike any before it, I was beside myself. That's what I get for getting this excited over a journal article…
A bit of history: In 2002, the American College of Obstetricians and Gynecologists issued guidelines for exercise during pregnancy and the immediate postpartum period. While very helpful in terms of issuing absolute and relative contraindications for exercise, criticism arose in response to its lack of specificity about intensity and duration. In 2003, the Society for Obstetricians and Gynecologists of Canada took a stab at its own guidelines, and prescribed a thorough set of heart rate guidelines (as in, specific heart rates — imagine?) for women with uncomplicated pregnancies, theoretically based on modified calculations for maximum heart rate (Zavorsky & Longo, 2011). Sigh. So here we are in 2011, where the authors of this latest review of evidence are advocating for calculating heart rate reserve percentages (as in, another formula that includes maximum heart rate). You know how we at ICI feel about maximum heart rate formulas.
But rather than be disappointed about the lack of practicality that I feel these specific intensity guidelines provide for me both for the pregnant women I train or the pregnant women I see in clinic, I think there is still some general principles we can learn from my synopsis of all three sets of recommendations. Note: I will be speaking with reference to only uncomplicated pregnancies.
1. In the absence of medical contraindications, regular exercise during pregnancy is good.
There is evidence that it can prevent and help manage gestational diabetes, help reduce excessive weight gain during pregnancy (Zavorsky & Longo, 2011) – for women with normal pre-pregnancy weights, we aim for pregnancy weight gain of 25–35 lbs. All pregnant women should be evaluated by their physician to evaluate whether there are any absolute or relative contraindications to exercise (Artal & O'Toole, 2003; Davies et al, 2003). If you have riders in your indoor cycling class who are pregnant, you should ask them if they have been evaluated by their doctors and whether they have been advised of any restrictions. There are a lot of good books from respected experts you may want to read.
2. ACOG has described warning signs that pregnant women should stop exercising. You should be aware of these warning signs in case you see them, and refer your clients to medical attention.
These include vaginal bleeding, shortness of breath before beginning exercise, dizziness, headache, chest pain, weakness, calf pain/swelling (I actually saw this during my 1st week as an indoor cycling instructor — I'd had no medical training at that time but decided it didn't look right, and told my client I thought she should leave class and call her doctor immediately. She did and, turns out, she had a deep venous thrombosis — or blood clot — in her calf. High levels of estrogen during pregnancy predispose people to blood clots.), amniotic fluid leakage, signs of preterm labor (Artal & O'Toole, 2003; Davies et al, 2003).
3. If I leave you with nothing else: Turn the AC/fans on.
Go dig up Gene Nacey's epic article about why we need ventilation to facilitate evaporative cooling during an indoor cycling class, and how dangerous it is to fail to do so. Take that, and magnify the risk for a pregnant woman. During pregnancy, core body temperature is elevated at baseline. During exercise, core body temperature rises further. If a pregnant women exercises in a neutral or cool temperature, as well as maintains adequate hydration and electrolyte balance, there should be no negative impact on the fetus. The best indicator of whether thermoregulation is going ok is the pregnant woman's subjective account (Artal & O'Toole, 2003). If she feels too hot, she is too hot and needs to change her environment; she should feel comfortable at all times, regardless of her (or her co-riders') desire to sweat buckets in your class.
4. Pregnant women need to accommodate for the normal physiological changes that occur to their musculoskeletal and cardiovascular (among other) systems. With knowledge about what is happening, modifications to exercise regimens should be based on common sense.
During pregnancy, connective tissue gets more lax (one might reason that looser ligaments are a pretty convenient adaptation, given what needs to happen during labor). With ligament instability in addition to weight gain causing increase force across the hips and knees, pregnant women may be more prone to musculoskeletal injury. Walking lunges may be particularly risky with lax pelvic ligaments, and should be avoided. Strength-training is best done with light weights/high repetitions (we know that women won't be accomplishing much in the way of muscle strength building — and that's ok. The idea is to keep building muscular endurance). Heavy weights or isometric exercises should be avoided, due to theoretical compromise in fetal blood flow. Women should also be advised not to lift anything while laying on their backs — this position puts pressure on an important vein called the inferior vena cava, which decreases cardiac output (doing the same exercise on an inclined bench is fine). Strength-training with resistance bands may be safer than free weights, given the possibility of inadvertently knocking into the abdomen (Zavorsky & Longo, 2011). Speaking of which: Contact sports should be avoided, as should activities that increase risk of falling (a stationary bike should theoretically be fine). With increased basal metabolic rate, pregnant women have increased nutritional requirements — she needs to replete even more fuel before, during, and after exercise than she did prior to pregnancy. Lastly, there are dramatic changes to the cardiovascular system: increase in blood volume, heart rate, stroke volume (how much blood is ejected from the heart with each heart muscle contraction) increase; the resistance within blood vessels decreases (leading to a drop in blood pressure). So even a well-trained athlete is going to experience a different response to the same intensity of exercise, and may need to scale back her efforts (Artal & O'Toole, 2003).
5. Stay aerobic.
For all the discussion of METs and % HRR and blah blah maximum heart rate formulas, it all comes down to this: all the research on safety in exercise, even “vigorous” exercise, during pregnancy is referring to intensity levels that we would still define as sub-lactate threshold, even if the researchers never call it that. I am not a doctor yet, but I will be recommending to my future patients that they “stay aerobic” during pregnancy. If you have a pregnant rider in your class where you are incorporating anaerobic intervals, I would strongly suggest encouraging her to modify her efforts. Use of a heart rate monitor during pregnancy is difficult — evidence is mixed for how HR responds to exercise during pregnancy (Zavorksy & Longo, 2011): some women have a blunted HR response (as in taking a beta blocker!); some do not. Most women have an increase in resting HR (Artal & O'Toole, 2003). Due to these irregularities, rate of perceived exertion (RPE) is the way to go.
6. Pregnancy is not a time for achieving peak fitness or any sort of hardcore training. The idea is to keep moving and keep comfortable.
30 minutes most, if not all, days at that “light” to “somewhat hard” RPE (Davies et al, 2003). If a woman is exercising longer or more intensely than that, the number of days per week can be decreased (Artal & O'Toole, 2003). If a woman had been previously inactive, she should begin with 15 minute sessions and gradually increase to 30 minutes (Davies et al, 2003). As explained earlier, attention should be given to adequate nutrition, hydration, and proper evaporative cooling (i.e., turn the AC on). In the absence of complications and medical restrictions, this should be continued throughout the pregnancy (Zavorsky & Longo, 2011).
You can go a long way with your pregnant clients just by asking if there is anything that is making them uncomfortable, and making common-sense recommendations for them to modify what they're doing. For example, early in my career I had a rider in an indoor cycling class who refused to acknowledge my gentle cueing to hold onto the handlebars during class. I was a substitute instructor and lacked confidence that I'd be able to accomplish anything, so decided to “let it go.” Then it occurred to me to ask her about it. “I can't help but notice that you're not holding onto the handlebars. How did you come to decide to do that?” She told me that she was pregnant, and that leading forward on to grasp the handlebars caused her a lot of pressure in her abdomen. I smiled and showed her that we could raise the handlebars so that she wouldn't have to lean over (remember: proper handlebar setup is only based on comfort!). She was thrilled! And just like that, we worked together so that she could enjoy her indoor cycling experience and derive all of its physical and psychological benefits — safely.
Both in pregnancy and non-pregnancy, the idea is that folks should listen to their bodies. We all have clients who struggle with this, and perhaps we struggle with it ourselves. In pregnancy, however, there is the “permissive” external motivation to decide when enough is enough — and for that to be perfectly okay. (Note: it's always okay.)
References
Artal R, O'Toole M. (2003) Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy the postpartum period. British Journal of Sports Med; 37:6-12
Davies GAL, Wolfe LA, Mottola MF, MacKinnon C. (2003). Exercise in Pregnancy and the Postpartum Period. Joint SOGC/CSEP Clinical Practice Guidelines, No. 129, June 2003
Zavorsky GS, Longo LD. (2011). Exercise Guidelines in Pregnancy: New perspectives. Sports Medicine, 41(5): 345-360
The author is in her final year of medical school at the University of Vermont College of Medicine in Burlington, Vermont. Author of the popular coaching motivation blog, Spintastic (http://spintastic.blogspot.com), her research interests include the psychological effects of heart rate training and use of heart rate monitors for anxiety treatment.
Have a medical research question for the ICI team? E-mail melissa.marotta@uvm.edu.
Dear Melissa,
One of my “regulars” was recently diagnosed with diabetes. She's on medicine for it. Does this impact how she is able to participate in my indoor cycling classes? What do I need to know?
Sincerely,
G.H., Concord, NH
In response to G.H.'s excellent question, here is a crash course on diabetes treatment and how to maximize your riders' safety.
Shortest Background Section Ever
I could write ten pages on diabetes — but you'll probably stop reading before you get to The Good Stuff. So let us begin with the barest-bones background required for working with clients who have diabetes.
There are two basic “kinds” of diabetes.
Type 1 (DM-1) is an autoimmune disorder with typical peak onset in childhood-young adulthood (but can occur at any age) characterized by antibodies against pancreatic beta cells, the cells responsible for producing insulin. Insulin is one of the “mastermind” hormones, responsible for governing how the body uses fuel. Without insulin, the body cannot absorb glucose out of the blood stream and into working tissues that it needs for fuel.
Type 2 diabetes (DM-2), in contrast, is a state of insulin resistance. Typically associated with obesity and its resulting metabolic/hormonal disturbances, patients with Type 2 diabetes do make insulin early in the disease — but tissues stop being sensitive to it, and thus cannot use it for fuel. In response, pancreatic beta cells release even more insulin — and more insulin, and more insulin — but the tissues still cannot use it. Eventually, the beta cells “burn out” and the disease is characterized as both insulin resistance AND insulin depletion. Recent projections predict that by 2050, 1 in 3 American adults will have DM-2.
The Stakes are High
Complications of uncontrolled diabetes are vast. There are microvascular (small vessel) complications, caused by these vessels becoming chronically coated with toxic amounts of glucose and metabolites: kidney disease that can eventually require dialysis, damage to the retina that can lead to blindness, and damage to the body's longest nerves in the feet, legs, and hands that leads to problems ranging from numbness/loss of sensation, to a burning-type pain that is very difficult to treat, to ulcers and infections possibly resulting need for amputation. There are also macrovascular (large vessel) complications in the heart and brain: Patients with diabetes are at least twice as likely to incur a heart attack or stroke (and more likely to die from either).
Treatment of Diabetes Mellitus
Again, let's keep this simple. We have two principles of diabetes treatment:
Avoid the complications of chronically elevated blood glucose, a described above;
Avoid hypoglycemia (blood sugar that is too low, typically thought of as < 70), which has its own dangers if untreated. Hypoglycemia usually resolves quickly (by eating/drinking glucose) — but if left untreated, it can lead to confusion, fainting, or more seriously seizures or even death. Avoiding this is key.
With these principles in mind, diabetes treatment can be broken down into oral medications and injected medications, the latter most commonly to include insulin. We make treatment decisions based on the pathophysiology of the disease. In DM-1, folks do not make enough insulin — thus, their treatment is always to be given insulin. In DM-2 wherein folks either make insulin (but are resistant to insulin) or do not make insulin (such as in the case of “beta cell burnout”), treatment varies accordingly.
There are many different types of DM-2 treatment that target various points in the body's glucose processing and insulin-responding pathways. Some reduce the liver's production of glucose; some make body tissues more sensitive to insulin; some make the pancreas secrete more insulin; some mimic the hormones in the brain that control insulin release. Each class of medications carries with it certain benefits (i.e, greater efficacy, weight loss) and side effects (i.e., weight gain, cardiovascular risks, hypoglycemia). Patients with DM-1 need to be on insulin since their pancreas is not releasing their own. In DM-2, there is some evidence that using more aggressive therapy (i.e., insulin) early in milder disease vs. waiting until the disease progresses can minimize severe disease complications; more commonly, however, the treatment algorithm for DM-2 proceeds in an orderly progression from metformin to other oral agents to insulin. Treatment decisions should be a collaborative process between patients and their clinicians, to account for this balance between risks and benefits in the context of the patient's other medical conditions, lifestyle considerations, goals and values.
I am happy to explain all of these medications in a later piece. For now, here's what you need to know about the most commonly used diabetes medications that your riders may tell you they're taking:
Finally, What You Asked For: How Diabetes Impacts Exercise
Exercise is an important part of the non-pharmacologic treatment for diabetes mellitus, by reducing cardiovascular risk in both DM 1 and 2 and by improving glycemic control in DM-2 (through weight loss and improved insulin sensitivity). The American Heart Association and American Diabetes Association recommend at least 150 minutes of moderate-intensity or 90 minutes of vigorous aerobic exercise per week. Note use of the word “aerobic.” Everyone with a major medical condition affecting the cardiovascular system should consult with their physician regarding the intensity of recommended exercise — given the severity of cardiovascular complications and individual conditioning levels, some patients may be advised to avoid high intensity anaerobic exercise. Other restrictions may apply, depending on the level of complications. Folks with proliferative retinopathy should avoid anything that causes a dramatic increase in blood pressure (i.e., heavy weight lifting) because this may cause bleeding within the eye. Those with severe neuropathy in the feet should take care to avoid intense high-impact activity (i.e., running, Step aerobics) and be careful to wear well-fitting protective footwear to minimize the risk of ulcerations.
And now to talk about what happens to blood sugar. In folks without diabetes, the body has a functioning regulatory mechanism to control insulin release and blood sugar during exercise. For many of your clients with diabetes, these regulatory mechanisms do not work properly — nor do they apply to exogenously injected insulin. During exercise, increased temperature and blood flow may increase insulin absorption — which drops blood sugar. For DM-2 patients on oral drugs, blood sugar may also drop during exercise depending on timing with meals.
As described previously, we need to take care to avoid hypoglycemia in patients with diabetes. If your riders state that they “feel funny,” you should be aware that this may be what is going on. Many people describe feeling light-headed, woozy, dizzy, nauseated, clumsy, shaky, twitchy, or sweating profusely.
The most common cause of exercise-induced hypoglycemia is inadequate replacement of carbohydrates before, during, and after exercise. This is further complicated if your student is also taking a beta blocker. Folks most commonly become aware that they “feel funny” (sweating, fast heart rate, and other symptoms caused by activation of the sympathetic nervous system). You may recall from my previous article (https://www.indoorcycleinstructor.com/icipro-instructor-training/icipro-team-member-articles/melissa-marotta/beta-blockers-qa/) that beta blockers inhibit many of these sympathetic nervous system signals — thus, many people experience “hypoglycemic unawareness.” This means what it sounds like: folks are unaware that their blood sugars are low, and thus do not take actions to address this. This is very dangerous.
Suggested modifications that your clients can do to enhance their own safety:
More frequent fingerstick blood glucose monitoring (at least to start, to gather data about how their body responds to different forms/conditions of exercise) — before, during and after exercise. They should pay attention to the effects of time of day, timing and content of meals. For those using insulin injections, they should also pay attention to the timing of injections (generally 60-90 minutes before exercise), and effects of various injection sites (arm vs. leg vs. abdomen), remembering that insulin is absorbed faster from an exercising muscle.
Work with their physician/certified diabetes educator to develop a plan for insuling reductions — particularly for those on a continuous insulin infusion pump. Generally insulin requirements are reduced by 30% during exercise.
For those on any of the oral medications in my “Likely to Cause Hypoglycemia” chart above, they should document their low blood sugars and review them with their physician/CDE.
Since the risk of hypoglycemia extends until 4-8 hours after exercise due to glycogen depletion, folks should consume a slowly absorbed carbohydrate (i.e., whole grains) immediately after exercise
Always come to class/the gym with a source of 15-30 grams of quick glucose: juice, a glucose gel or tablet
This is a lot of information, I know. So let us finish off with a recap.
What You Can Do — Right Now — to Improve the Safety of Your Clients with Diabetes:
1. Ask what medications they’re taking (refer to my charts to see if their meds are likely/unlikely to cause lows). If they’re not on anything in the former category, you can generally stop here.
2. Ask if they check their blood sugars. Ask them if they get hypoglycemic episodes/”lows,” and if they can tell when they happen.
3. Ask if they have any restrictions from their physicians as to exercise intensity. Encourage them to discuss exactly what happens in an indoor cycling class with their physicians, as most have no idea.
4. Remind them to always have an emergency glucose supply with them (quick carbs) and to bring a whole grain snack to consume immediately thereafter.
As coaches and instructors, we should encourage the folks we train to refuse to be defined by their chronic medical conditions. With proper planning and attention to safety, we can ensure that our riders derive a meaningful and a rewarding experience from our indoor cycling classes. By educating yourself about these important safety concerns, you are one step closer to being an important resource for those who need you.
The author is in her final year of medical school at the University of Vermont College of Medicine, in Burlington, Vermont. She is also a STAR 3 Spinning(R) instructor, ACE-Certified Personal Trainer, and author of the popular coaching motivation blog, Spintastic (http://spintastic.blogspot.com/). Her research interests include health literacy, patient-physician relationships, and the psychological effects of Heart Rate Training.
Do you have a question that you would like addressed by the ICI Medical Research Correspondent? E-mail melissa.marotta@uvm.edu.
References:
Chipkin SR, Klugh SA, Chasan-Taber L. (2001). Exercise and diabetes. Cardiol Clin. Aug;19(3):489-505.
Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, Chasan-Taber L, Albright AL, Braun B (2010). Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association joint position statement. Diabetes Care Dec;33(12):e147-67.
McKulloch DK (2011). Effects of exercise in diabetes mellitus in adults. UpToDate.http:// www.utdol.com/
National Diabetes Information Clearinghouse (NDIC) Information Sheet. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institute of Health. http://diabetes.niddk.nih.gov/dm/pubs/stroke/#risk
Center for Disease Control (CDC). Number of Americans with Diabetes Projected to Double or Triple by 2050. 22 October 2010. www.cdc.gov
Note: Melissa is getting close to being called Dr. Melissa. The crush of work necessary to complete her degree has left her with little time for anything else, hopefully explaining her infrequent postings. We certainly appreciate hearing from you when we can Melissa! John
In mid October, the American Heart Association (AHA) released updated guidelines for the practice of cardiopulmonary resuscitation (CPR). The guidelines, which are updated every five years to reflect the latest efficacy research, were published in Circulation: the Journal of the AHA (1), and endorsed by the American Red Cross (2).
What we’ve known for a long time:
1. The #1 predictor of survival is how fast you can apply the automatic external defibrillator (AED), a device that comes with easy to follow instructions (even for a layperson) to affix to the victim, analyze his or her heart rhythm for the presence of the fatal arrhythmia called ventricular fibrillation, and use electrical voltage (“shock”) the heart back into normal (“sinus”) rhythm.
2. Chest compressions are vital if circulation has collapsed (evidenced by a lack of pulse).
3. Delaying chest compressions is bad.
So, the new guidelines (1):
1. You still start off by “activating the emergency response system” (i.e., calling for someone to get the AED) and use it as soon as it arrives.
2. We cut out anything that risks delaying chest compressions (i.e., rescue breaths, checking for a pulse). That is, we start with chest compressions.
3. Thus, the age-old (40+ years, at least) sequence of “ABCs” (airway → breathing → circulation) has been replaced with “CAB” (compressions → airway → breathing).
Why? According to one of the new guidelines’ authors, the previous protocol was off-putting to a lot of the general public: too much to remember, too confused about counting, too wary of “mouth to mouth” (3). As a result, the potential Good Samaritan is up against too much adversity to even begin to get involved to help, and potentially save the life of, a stranger.
Studies have shown that the lay public has a very hard time finding a pulse (i.e., verifying whether circulation has collapsed and, thus, whether chest compressions are necessary (4). Healthcare professionals often take too long to find one, too (5). So, in the new guidelines: non-healthcare professionals are not to waste time looking for a pulse altogether – just start chest compressions; healthcare professionals can take 10 seconds to find one; otherwise, they should just start chest compressions.
(Note: there is no evidence demonstrating greater efficacy of chest compressions alone to the old standard CPR protocol. According to the AHA, the evidence that starting chest compressions sooner is sufficiently compelling (1).)
Much like understanding the new healthcare bill, sometimes all we need in the world is a set of “How Does This Affect Me?” bullet points. Done, and done:
The new guidelines make a distinction between whether you’re a healthcare professional vs. a trained non-healthcare professional vs. an untrained layperson.
FOR UNTRAINED LAYPERSONS If this is you, it is strongly encouraged that you to get certified in CPR/AED for at least adults… for the safety of your riders!
1. Yell out to someone to “get an AED!” (activate your emergency response system)
2. Initiate chest compression: Place the heel of one hand over the middle of the victim’s chest (the sternum), midway between the nipples. Stack your other hand on top of the first hand and interlace your fingers for greater force/support. Push hard and fast (think: the tempo of “Stayin’ Alive,” which is 100 beats per minute). Push down hard enough for the chest to sink 2 inches down, and give time for the chest to rise to baseline before pushing again.
3. Continue until AED arrives or EMS takes over
FOR TRAINED NON-HEALTHCARE PROFESSIONALS (“trained laypersons,” in the guidelines) “Trained” implies that you have had CPR/AED certification. This is probably you, unless you’re also a healthcare professional.
1. Activate emergency response system: “get the AED!”
2. Do not check for pulse
3. Begin chest compressions immediately.
4. If able to give rescue breaths, add rescue breaths in ratio of 30 compressions to 2 breaths
5. Continue until AED arrives or EMS takes over
FOR HEALTHCARE PROFESSIONALS
* Follow BLS protocol as per usual
1. Alert emergency response system… “get the AED”
2. Take 10 seconds only to find pulse; otherwise, move to Step 3.
3. Chest compressions 30: 2 ventilations until advanced airway placed. Then, continuous chest compressions with ventilation rate of 8-10 breaths per minute.
4. AED when available
5. If lone healthcare provider, for child victim: follow protocol; for adult, may give 5 cycles of CPR before activating emergency response system
If you want more information than this brief synopsis I’ve provided, click here for the full text of the 2010 guidelines.
Click here to view a short video on the new guidelines, including a demonstration of chest compressions:
In an upcoming article, I will pay more attention to AEDs themselves. Using one is super-easy: 1) turn it on, 2) follow the diagram to attach the stickers to the patient, 3) listen to the prompts. It talks to you, and walks you through anything it wants you to do.
But in the meantime, the single best thing you can do as an instructor is find out exactly where the closest AED is located to the cycling studio where you teach. Develop a plan for EXACTLY what you’d do in the event that a student has a cardiac emergency. How would you instruct someone to fetch the AED? How far are you from the front desk? Who would you ask to call 911? Is there a phone in the studio?
We hope you’ll never need to use this information — but in the event that you do, you’ll be grateful you took the time to track down these details in advance. As will your student/client!
About the Author
Melissa Marotta, ICI’s medical research correspondent, is a third-year medical student at the University of Vermont College of Medicine. She is also a STAR 3 Spinning® instructor and a Certified Personal Trainer (American Council on Exercise). She is author of the popular blog, Spintastic (http://spintastic.blogspot.com), themed on motivational coaching strategies, which she promises to actually update now that her surgery rotation is over. Her research interests include the psychological effects of heart rate training, and the application of heart rate training to the treatment of anxiety.
References
(1) Berg RA, Hemphill R, Abella BS, Aufderheide TP, Cave DM, Hazinski, Lerner EB, Rea TD, Sayre MR, Swor RA. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: Part 5 — Adult Basic Life Support. Circulation. 2010;122:S685-S705.)
(2) American Red Cross. Revised American Red Cross Statement on 2010 CPR guidelines. 21 Oct 2010. www.redcross.org/
(3) Gordon S. New CPR Guidelines Emphasize Compressions First. Business Week. 18 Oct 2010. http://www.businessweek.com/lifestyle/content/healthday/644464.html
(4) Bahr J, Klingler H, Panzer W, Rode H, Kettler D. Skills of lay people in checking the carotid pulse. Resuscitation. 1997;35:23—26
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you may want to read.
