1. The document presents a case study on developing an exercise program for a 45-year-old man who had a myocardial infarction 6 months ago and also has diabetes. 2. An assessment of the man's medical history, physical abilities, and goals is provided to inform a long-term exercise plan divided into beginner, transition, and independent phases. 3. The plan recommends aerobic activities like walking and cycling at a moderate intensity and contraindicates high-intensity activities. Example sessions, motivational techniques, and risk management are discussed to help the man safely increase his physical activity.

1. 1
Adapted Physical Education and Sport, PZTV169C (2014)
C A S E S T U D Y
EXERCISE INTERVENTION AFTER MYOCARDIAL INFARCTION
Johanne Marie Jørlo
14.04.2014
Faculty of Physical Education and Sport, Charles University, Prague, Czech Republic
ABSTRACT
Objective: The objective was to create a case study on
adapted physical education of a virtual or real person with
disability. We were given the option of selecting one out of
8 offered virtual cases or to make an alternative. The
content of the essay should include assessment methods
needed for exercise prescription, proposal of long-term
plan, recommended and contraindicated activities, example
of an exercise session with special aids, adaptation and
devices, a suggestion for motivation and adherence to the
program, eventual competitive sports recommendations,
expected problems and solution to these, expected benefits
of the activity program and finally references used in the
essay. I chose to present task D, about a man who ½ a year
ago had a Myocardial Infarction.
Method: A research was conducted through EBSCO host
database the 15.04.14 for academic articles containing the
keywords “exercise”, “rehabilitation” and “myocardial
infarction”. Further research was conducted through
PubMed database 20.04.14 and through trusted Internet
pages the following days. Other information was retrieved
through lectures from Charles University, Prague.
Results: 14 academic articles were found to be relevant to
my thesis. These articles were used to further understand
the theory behind exercise prescription in real cases with a
history of myocardial infarction.
Conclusion: With an appropriate clinical examination,
customized program and drive from the person himself, the
benefit of exercise can be very satisfactory and have much
benefit for a high-risk patient in recovering from a
myocardial infarction.
Key words: Myocardial Infarction ! Diabetes II ! Exercise
Prescription ! Activity ! Health
Teacher/guarantor: Mgr. Eva Prokešová
Dept. of Sports Medicine and Adapted Physical Education
ACRONYMS
BP – Blood pressure
ECG – Electromyography
HR – Heart rate
MI – Myocardial Infarction
NYHA – New York Heart Association
RR – Respiration rate
S&S – Signs and symptoms
CASE PRESENTATION
The client is a 45 year old obese man who ½ year ago had
Myocardial infarction. In addition to this, he has Diabetes
Mellitus II and is on a special diet. He works as a bank
manager and the work situation is stressful for him. He
also smokes, 20 cigarettes daily.
ASSESSMENT METHOD
1. Anamnesis
2. Kinesiologic Examination
3. Special tests
4. Planning and preparations
1. Anamnesis
The anamnesis must be thorough and attention must be
given to the referral from the medical doctor. The doctor
should be contacted for complete assessment of the client’s
current health condition and an overview of his
pharmacotherapy and prescribed assistive devices. One test
the doctor should have performed is a physical stress test
that gives information about how much stress (physical
effort) the heart can endure before arrhythmias or angina
occurs. The test is done with a treadmill or a bicycle. ECG
and blood pressure are measured. The level of impairment
might be classified according Weber (A - E) or NYHA (I -
IV). In addition the doctor should have done a

2. 2
pharmacological stress test, as well as an assessment of the
diabetic response to physical strain.
Level of physical activity of daily living, both present and
past experiences with exercise, as well as related needs,
events, pains, etc. should be assessed in the anamnesis.
How is his standard week? Does he have any destructive
habits? Why? How can they be improved? Does he have
any hobbies/preferred activities? We have to assess how an
improved activity level/health plan can fit in with his
current schedule. His diabetes diagnosis and its
management are also important to assess. How long has he
had diabetes? Does he recognise the symptoms of low/high
blood level glucose? How does he treat it, and what is his
special diet? Will the diet need alterations, now when his
activity level will be increased? One should also note the
client’s stress situations and the managing of these
situations. He should be consulted about his smoking
habits, and whether or not he is willing to quit to improve
the result of the exercise program. Finally, the anamnesis
should end with an overview of the client’s motivation and
goal setting towards the new lifestyle alterations.
Close contact between trainer/physiotherapist and the
client’s health team should be present throughout the
whole program. Physical and pharmacological stress tests
should be taken regularly to assess effect of the program.
In addition, the client should go to regular specialist check
up’s according normal schedule.
2. Kinesiologic Examination
The kinesiologic examination should include a full
aspection of the client’s body, gait and functional
examinations. This analysis will give a clear view over the
person’s individual movement stereotype and problem
areas. Measuring weight in addition to breast, waist and
hip circumference should be done. The information can be
valuable in constructing an individual training program
with lower risk of injuries and a better result. Comparing
results between before and after training can show the
effectiveness of the program.
3. Special Tests
There are many physiological tests of fitness one can use
to analyse the client’s present condition. Examples of tests
are Balke fitness test and W170 test. Blood pressure (BP),
respiration rate (RR) and heart rate (HR) should be noted.
In addition, the person can perform a subjective test of
perceived exertion. This is merely used as a tool of
evaluating subjective changes.
4. Planning and preparations
To reduce the risk of drop-off, the client should be
involved in making the plan together with the
trainer/physiotherapist. One should assess what is available
of resources: family, friends and financial support,
equipment and facilities, etc. Whether the person must
adapt his environment to his new needs or buy necessary
equipment, this must also be taken into consideration.
PROPOSAL OF LONG-TERM EXERCISE PLAN
As a proposal for a long-term plan, I have chosen to divide
it into 3 main parts consisting of beginner, transition and
independent training phase. This is to better meet the
persons changing needs as the program progresses,
expecting he will be committed and increase knowledge,
technique and independence. The length of each phase is
not fixed, but rather individual acc. the clients need.
Beginner Phase (Week 1 - 8)
Observing the client, giving education, feedback and
instruction, as well as trying different styles of exercise,
marks the beginner phase. It is a phase of trial and error for
both the client and the medical team. The client should be
given assignments/tips to increase physical activity in his
daily life. Another focus should be on teaching the client
body awareness and relaxation. He should be given
education from a cardiologist/sports doctor about the
dangerous symptoms he should look out for, and how to
respond. In addition he must learn about expected negative
and positive exercise effects. The information is provided
to reduce the fear of exercise, which is one of the causes
why many post MI patients avoid physical activity. The
beginner phase should be performed under close
supervision by the medical team.
Before and during each session HR, RR and BP should be
monitored. The person should be fitted with a HR monitor
during the exercise. Close attention should also be on his
blood level glucose, and it should be taken under
consideration that he should eat before he exercises and
take regular breaks.
Goal:
• Basic health, exercise and relaxation theory
• Basic activity, exercise and relaxation practice
• Body awareness
• Knowledge about harmful vs. normal signs
• Initial assessment
• Educate client

3. 3
Transition Phase (Month 2 - 6)
The person should be given more independence in the
transition phase. After assessing the effect of the beginner
phase, techniques should be improved and adapted
according to his results and the available resources. The
trainer/physiotherapist should assess the level of
motivation, and teach motivational strategies to ensure
continuation. By the end of the phase the client should be
able to exercise independently, or with an exercise buddy.
The most applicable activities should be done with a
proper technique to prevent future injury.
Goal:
• Proper technique in preferred activities
• Becoming exercise independent
• Practice in own environment
• Educated exercise partner
• Motivated
• Final Assessment
• Educate client and exercise partner
• Evaluation
Independent Phase (Month 6 +)
In this phase the person should be independent and able to
use his own resources and environment. He still might
have regular meetings in local heart groups, or might have
chosen to sign up for a gym or a weekly fitness group, etc.
He should come for regular meetings to measure the effect
of his activity tenacity, and assess eventual new problems.
The intensity of exercise should regularly be monitored by
a sports doctor/cardiologist to be prescribed to a safe level.
Goal:
• Independent, safe and educated
• Continuation of fitness
• Regular meetings (biannual/ yearly)
• Assess effect of exercise plan
• Making improvements
• Giving counselling
• Treating eventual new problems
RECOMMENDED AND CONTRAINDICATED
ACTIVITIES
When recommending (A) or contraindicating (B) activities
for a person with a physical limitation, we can break the
activities down according characteristics: mode, frequency,
duration, intensity and progression of exercise (Van Camp,
1994).
A. Recommended activities
Mode: (Aerobic, big muscle groups)
• Brisk walking
• Jogging
• Swimming
• Cycling
• Stairs climbing
• Group aerobics
• Rowing
• Gardening
Frequency: Minimum 3 days/week. 5 days/week is
optimal.
Duration: Min. 10 min. warm up, 20-40 min. main part and
5 min. cool down.
Intensity: Should be comfortable with a gradual ascent and
descent, 40 – 85 % of functional capacity/max HR. The
person should be able to talk throughout the whole
activity.
Progression: Should be slow and gradual, increasing
duration before intensity.
B. Contraindicated activities
The contraindicated activities have a high intensity above
the recommended functional capacity. Activities with
explosive force, jumping, sudden intensity change or high
stress pose a high strain on the heart and blood pressure,
and can lead to unwanted cardiac situations. Examples of
the modes: Shovelling wet snow, sprinting, weight lifting,
ball sports, combat sports, extreme sports, etc.
The progression of the program should be halted if the
client has a break from exercise of more than 3 days.
When the person is exercising unsupervised, he should do
so at a lower intensity than he normally would under
supervision.
Symptoms and signs of sudden and abnormal pain or
fatigue, angina pectoris, arrhythmia and tachycardia,
swelling pressure or tingling in the extremities can indicate
a cardiac event needing emergency medical care. In such a
situation the exercise should be stopped immediately and
the emergency service should be contacted.

4. 4
EXAMPLE OF EXERCISE SESSION
Brisk Nordic walking session, Outdoors
Type: Group/individual
Intensity: Medium/Adaptable
Duration: 45 min
Tools: Nordic walking sticks
Warm-up 10 min
• Demonstration, technique, practice
• Walking
• Circles with wrists, elbows, shoulders, ankles, knees
and hips
• Stretching
Main part 30 min
• Walking normal terrain
Break
• Walking low inclination hill (ascend, descend)
Break
• Walking normal terrain increased tempo
HR: 40% - 85% of HR Max (comfortable)
Cool down 5 min
• Walking norm terrain (slow deceleration of speed)
• Stretching
• Feedback (both ways)
• Information about next session
AIDS, ADAPTATION, DEVICES
Increasing daily physical activity doesn’t require much
other than a good pair of shoes, some exercise clothing and
commitment. In this case, regular medical check ups and
proper medication are essential to ensure safety. In
addition the person should learn how to pay attention to
and respect the signs of his own body. His eating regimen
must be good and balanced to keep a steady blood level
glucose. When active, he should keep a high sugary snack
with him at all times and take regular breaks for water.
Additionally, he is encouraged to use a heart rate monitor
to assist him in monitoring a safe intensity.
Even though medications are beneficial for the client,
some of them might have effects that act against physical
activity. Beta-adrenergic blockers may decrease the
person’s functional capacity and power because of its
action (Vilikus, 2013).
SUGGESTION FOR MOTIVATION AND
ADHERENCE
• The client should be encouraged set goals and to renew
them when they are completed
• He can get an exercise “buddy”
• Positive feedback and cheering should be given after
every session. (Reinforcement)
• The client should be encouraged to make room for the
program in his calendar.
• The client should be included in the program making
process
• Exercise books, inspirational web-pages/conferences
• “I can do it” attitude, positive self-talk
• Regular assessments to see progressive effect of
exercise
• Enrolment to an exercise group with people at a similar
fitness level
• Writing an exercise log can be helpful to see progress.
• There are also many smartphone applications, such as
“RunKeeper”, “MyFitnessPal”, “Noom Walk” or
“Nike+ Running”, which can be installed (if the person
has such equipment) and used to record activity and
exercise. In such programs the client receives feedback
and cheers from friends or others, which can be quite
motivating.
Illustration 1: Mashable Inc. “RunKeeper”
COMPETITIVE SPORTS RECOMMENDATIONS
Aggressive sports are not usually recommended because
contests trigger high intensities in the practitioners. In a
person recovering after an MI, too high intensities too soon
might produce fatal strain on the heart.
Group exercises, under medically educated supervision,
can be beneficial for the more competitive client, as there
are naturally some rivalries among the group members.
Having an educated exercise partner can also be a safer
way of mild competition.

5. 5
EXPECTED PROBLEMS AND SOLUTIONS TO
THESE
It is not possible to exercise without risk. Instead we have
to be aware of and create a plan to reduce, prevent or
respond to the risks.
Risk Management
Severity
Low Mild High
Likelihood
Low
Mild
High
TABLE 1: Jørlo, 2014 ”Risk Assessment”
First and foremost the trainer must be well-educated and
responsive, pay attention to the client and respect his
condition to ensure a safe exercise environment. In order
to do this, we need to assess the potential risks. In the table
above there is illustrated the relation between likelihood
and the severity of the potential risks. The area marked in
green is where severity and likelihood are both at it’s least
and more acceptable. Orange is more hazardous, while red
is posing the most likely and most severe threat.
Our goal of the risk assessment is to understand all the
potential risks of our activity, in other words the red, the
orange and the green field of this table. After assessing
these risks we need to plan how to respond to, manage or
decrease each situation, in other words decreasing the red
and orange area of the table.
Some high severity risks associated with exercise
following myocardial infarction is a new myocardial
infarction or cardiac arrest. According Van Camp and
associates with their article “Exercise for Patients with
Coronary Artery Disease” published in 1994, the estimated
incidence of cardiovascular complications in a supervised
cardiac rehabilitation program were 1 MI per 294,000, 1
Cardiac arrest per 112,000 and 1 death per 784,000 patient
hours. According Miller et al., the risk of training induced
cardiac arrest is closely linked to the intensity of exercise.
To manage this risk, the exercise intensity must be planned
and monitored closely throughout the program. Follow up
fitness tests can be executed by a medical doctor. There
should be established a procedure plan for emergency
situations and a first aid kit must be available at all times.
In addition, a portable defibrillator should always be
accessible. Education of personnel and exercise partner
should be done to ensure that everyone knows the signs
and symptoms and the management procedures for such
events.
S&S of myocardial infarction
• Shortness of breath, gasping for breath
• Chest pain that doesn’t ease with rest
• Dizziness
• Heartburn (mild)
• Faintness/collapse
• Sweating and nausea
• Squeezing pain sensation of the heart (severe)
• Fear of impending doom
• Referred pain around neck, between scapula’s and
down left arm
Treatment:
• Make casualty comfortable (half sitting position)
• Call for emergency help
• Give 300 mg. aspirin
• Let him administer angina medication: aerosol
spray, tablets, pump-action
• Monitor vital signs
• Avoid stress
S&S of cardiac arrest
• Sudden collapse
• No pulse
• No breathing
• Loss of consciousness
Treatment:
• Call for emergency help
• CPR (“CAB”)
• Defibrillation
• Advanced care (by paramedics)
In this case, hypo/hyper-glycaemia is a more likely, but
less severe risk. Hypoglycaemia is defined as a blood
level glucose below 70 mg/dl according American
Diabetes Association. We can consider this as a more
acceptable risk. It can easily be managed by the client
himself, or with having extra high sugary foods available,
giving regular breaks, as well as paying close attention to
the client’s symptoms. However, hypoglycaemia can in
severe cases lead to coma and even death. Therefore the
recognition of signs and symptoms of a critically low
blood glucose level should be known to all associated to
the exercise plan and a response plan should be a part of
the standard operating procedures.

6. 6
S&S of hypoglycaemia
• Shakiness
• Nervousness
• Sweating/clammy
• Rapid heart beat
• Hunger/thirst
• Blurred vision
• Fatigue
• Irritability, anger or sadness
• Confusion
• Unconsciousness
• Seizures
Treatment:
• Make casualty rest, sit down
• Give high sugary gel/drink/food to raise blood sugar
if the person is conscious
• Let him rest and monitor him until completely
recovered
• If the condition doesn’t improve, call for emergency
help
S&S of hyperglycaemia
• Warm/dry skin
• Rapid pulse/breathing
• Fruity/sweaty breath
• Excessive thirst
• Drowsiness
• Unconsciousness
Treatment:
• Call for emergency help
• Monitor vital signs
Other expected problems might be muscular strain and
ligament sprains, which is quite common injury when
exercising. To reduce the likelihood of such events we can
choose less risky activities such as walking or stationary
bicycling, and/or the person can be encouraged to have the
proper shoes, equipment and use the right technique.
EXPECTED BENEFITS OF PROGRAM
There are many benefits of being active, both for sick and
healthy individuals. Being obese and stressed, having
diabetes and a history of a cardiac event can feel like
having reached the bottom and making exercising very
difficult, if not frightening. To look at the bright side, the
greatest improvements often occur among the most unfit
(Franklin, 2011). Below is listed the benefits of exercise in
cases both for persons recovering from MI and for those
having diabetes type II (Chudyk, 2011; Heldal, 1998;
Franklin, 2011; Van Camp, 1994; Thompson, 2003):
• Decrease in body weight and fat stores (can help
control hyperglycaemia)
• Decreased blood pressure (resting blood pressure)
• Decrease of LDL (bad) Cholesterol
• Increase in HDL (good) Cholesterol
• Less fatigue, Increased functional capacity
• Increased maximal oxygen uptake
• Facilitation of smoking cessation, cessation
maintenance
• Decreased cardiovascular morbidity and mortality
(with 20 - 25 % acc. Van Camp, 1994)
• Improved quality of life
• Improved sexual function
• Reduction of depression
• Reduction in medical care costs
• Reduction of insulin resistance and glucose
intolerance
• Decreased waist circumference
The most effective regimens consist of nutritional
education, stress management, quit-smoking counselling
and medication.
“Voluntary Exercise is Better”, Shober and Knollmann
suggest, with their editorial published in Circulation
Research in 2009. They describe the importance of
voluntary drive, for the effect of exercise by comparing
mice to other animals in studies of exercise benefits. Mice,
animals that naturally likes to run, were under considerably
less stress and had greater benefits of exercise compared to
the effects from other animal trials. Having this in mind,
the client himself must be considered the driver for any
exercise program.
CONCLUSION
The combination of several diagnoses, in this case, poses a
higher risk than what is normal in the recovery after a
myocardial infarction. Yet, with an appropriate clinical
examination, exercise program and drive from the person
himself, the benefit can be very satisfactory.
EVALUATION
This is a theoretical essay, which doesn’t bear in mind the
unpredictability of a practical application. Certainly there
are many more factors, which could have been mentioned,
that influence such a complex clinical case. Nevertheless, I
have tried to assemble what I believe to be most important.

7. 7
ILLUSTRATIONS
Mashable Inc. (n.d.). 8 Fantastic Fitness Apps to Keep You Motivated. Mashable. Retrieved April 29, 2014, from
http://mashable.com/2013/02/27/8-fantastic-fitness-apps/
TABLES
Jørlo (2014). Risk Assessment. Acquired from Jennifer Benson’s “Sports and Recreation Management” course taken in
through Open2Study.com
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8. 8
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