Exercise leaders should be aware that target heart rates can be adjusted in the future.The heart rate intensity can be used to increase the training effect.

For some patients the duration may be used as the variable. It is not incorrect to assume that the progression of intensity will automatically occur if the patient exercises to the same given heart rate; the work rate for a given heart rate will increase as ?tness improves. However, this assumption only re?ects56 Exercise Leadership in Cardiac Rehabilitation one of the two main training adaptations to regular aerobic exercise: an increase in VO2max. The other physiological adaptation, as shown clearly in three studies involving cardiac patients, is that with training, individuals can sustain exercise at a higher proportion of their VO2max . In these three studies, this phenomenon was closely allied to the amount of lactic acid produced at a given VO2,a phenomenon which has been known for many years . The importance of this is that improvements in aerobic power and endurance capacity in cardiac patients, compared to healthy individuals, is mostly due to the adaptations of skeletal muscle and not of the myocardium . Because the key agent in increasing VO2max in cardiac patients is skeletal muscle, it is important to ensure that this tissue is challenged as effectively as possible. This is even more apparent in the training adaptations of the older or heart failure patient .

HEART RATE, MYOCARDIAL STRAIN AND PERFORMANCE There is a direct link between HR and myocardial strain, performance and dysfunction. However, the contractility of the myocardium is also a function of the stroke volume that results from the heart wall tension produced during diastole and the force of contraction during systole.This, together with the rate of contraction, produces a given cardiac output. It is both the rate and force of contraction of the myocardium that determine the oxygen demand or uptake of the heart . Hence, the performance of the ventricles is determined by the amount of pressure that can or needs to be created during systole.The systolic pressure therefore provides an indirect means of indicating the force of contraction. A practical index of myocardial strain has thus been described as the product of HR and systolic blood pressure and given the single term rate pressure product or double pressure product . In this study, the use of systolic blood pressure in conjunction with HR provided a better index of MVO2 than HR alone.

The Metaphorical Paraphrase

Interviewers can use metaphor or analogy to capture the central message in a client’s communication. For instance, often clients come to a professional interviewer because Basic Attending, Listening, and Action Skills 65they are feeling stuck, not making progress in terms of personal growth or problem resolution. In such a case, an interviewer might re?ect, “So it seems like you’re spinning your wheels” or “Dealing with this has been a real uphill battle.” Although metaphorical paraphrases might be best suited to kinesthetically oriented clients, many clients respond well to them, perhaps because so much of an experience is captured in so few words. Additional examples follow: Client 1: “My sister is so picky. We share a room and she’s always bugging me about picking up my clothes, straightening up my dresser, and everything else, too. She scrutinizes every move I make and criticizes me every chance she gets.” Interviewer 1: “It’s like you’re in the army and she’s your drill sergeant.” Client 2: “I’m prepared for some breakdowns along the way.” Interviewer 2: “You don’t expect it will be smooth sailing.” Clari?cation Several forms of clari?cation have the same purpose: to make clear for yourself and the client the precise nature of what has been said. The ?rst form of clari?cation consists of a restatement of what the client said and a closed question, in either order. Rogers was a master at clari?cation: If I’m getting it right . . . what makes it hurt most of all is that when he tells you you’re no good, well shucks, that’s what you’ve always felt about yourself. Is that the meaning of what you’re saying? The second form of clari?cation consists of a restatement imbedded in a double question. A double question is an either/or question including two or more choices of response for the client. For example:

• “Do you dislike being called on in class-or is it something else?”

• “Did you get in the argument with your husband before or after you went to the

movie?” Using clari?cation along with a double question allows interviewers to take more control of what clients say during an interview. In a sense, interviewers try to guess a client’s potential response by providing possible choices, similar to the multiple choice test format.