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Characterising the application of the “progressive overload” principle of exercise training within cardiac rehabilitation: a United Kingdom-based community programme

Khushhal, Alaa; Nichols, Simon; Carroll, Sean; Abt, Grant; Ingle, Lee


Alaa Khushhal

Simon Nichols


BACKGROUND: Recent concerns have cast doubt over the effectiveness of cardiac rehabilitation [CR] programmes for improving cardiorespiratory fitness [CRF] in patients with a history of cardiac disease in the United Kingdom [UK]. We aimed to characterise the weekly progression of exercise training dose over an 8-week Phase III CR programme as we felt this may be partly responsible for the lack of improvement in CRF reported in previous studies. DESIGN: Observational study. METHODS: We evaluated a community-based Phase III CR programme in the UK. During each training session, patients wore an Apple Watch and the weekly progression of exercise training dose/load was quantified. The analysis was based on 332 individual training sessions. Exercise intensity [% heart rate reserve] during the cardiovascular [CV] exercise training component [%HRR-CV], CV training duration; estimated changes in cardiorespiratory fitness [change in estimated metabolic equivalents (METs)]; session rating of perceived exertion [sRPE], sRPE training load [sRPE-TL], and exercise training impulse [TRIMP] were evaluated. RESULTS: Thirty cardiac patients [83% male; age [SD] 67.0 [10.0] years; body mass index [SD] 28.3 [4.6] kg∙m-2] were recruited to an 8-week programme [16 sessions in total]. Bayesian repeated-measures ANOVA indicated anecdotal evidence for the alternative hypothesis for changes in %HRR-CV (BF10 = 0.61), sRPE (BF10 = 1.1), and change in estimated METs (BF10 = 1.2) during CR. Conversely, Bayesian repeated-measures ANOVA showed extreme evidence for changes in CV training duration (BF10 = 2.438e+26), TRIMP (BF10 = 71436), and sRPE-TL (BF10 = 779570). CONCLUSION: The key exercise training principle of progressive overload was only partially applied. Increases observed in exercise dose were due to increases in the duration of CV training, rather than combined with increases in exercise intensity [%HRR-CV and sRPE]. Accordingly, allied health professionals must ensure that exercise intensity is more consistently progressed to optimise the exercise stimulus and improvements in CRF and patient outcomes.


Khushhal, A., Nichols, S., Carroll, S., Abt, G., & Ingle, L. (in press). Characterising the application of the “progressive overload” principle of exercise training within cardiac rehabilitation: a United Kingdom-based community programme. PLoS ONE, 15(8), Article e0237197.

Journal Article Type Article
Acceptance Date Jul 28, 2020
Online Publication Date Aug 13, 2020
Deposit Date Jul 29, 2020
Publicly Available Date Oct 27, 2022
Journal PloS one
Print ISSN 1932-6203
Electronic ISSN 1932-6203
Publisher Public Library of Science
Peer Reviewed Peer Reviewed
Volume 15
Issue 8
Article Number e0237197
Keywords Exercise; Heart rate; Cardiac rehabilitation; Allied health care professionals; Cardiovascular disease risk; Myocardial infarction; Sports and exercise medicine; Walking
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Copyright Statement
© 2020 Khushhal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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