Exercise Prescription for Cardiac Rehabilitation

Exercise Prescription for Cardiac Rehabilitation Azran Ahmad Exercise Physiologist Your Heart…Our Passion

Objectives • To understand the process of assessment & exs prescription pts for CRP • To define risk of progression & stratification • To understand the exs prescription process for CRP

Your Heart…Our Passion

Fancy to do this?



Are they at risk? Can you prescribe them an exercise ?


Assessment & Risk Stratification • Clinical examination : – – – – – – – – – – – – –

The site & size infarct & operation details Current cardiac status Any complications Current medication Progress since D/C Current exs level – including the recent results Any symptoms, ex: chest pain, s.o.b, dizziness GTN Relevant past medical history Risk factor for CHD Weight/ BMI Psychological status/ mood Orthopedic limitations


Risk Stratification Process of assessing the risk of pts having a further event. The main risk factors is : •Extensive cardiac damage •Residual ischaemia •Ventricular arrhythmias on exs


Risk Stratification 1. History of : - more than one previous infarct - an anterior rather than inferior infarct - ↑ cardiac enzyme levels @ the time of infarct - complications ie: LV failure/ CS 2. Symptoms severe exertional breathlessness & orthopnea. 3. Finding of large heart/ Pulmonary venous congestion & ↓ EF. 4. A low capacity on the ex. Test with significant ECG changes/ poor HR/BP response. 5. Current angina Your Heart…Our Passion

Risk Stratification sample

sample

Note: Pts with extensive cardiac damage & associated cardiological complications may not be able to join the formal exercise session& may be limited to a significantly modified home exs till their recovery has been stabilized & complete


Risk Stratification Criteria for Cardiac Patients (AACVPR) Low Risk

Moderate Risk

High Risk

Uncomplicated MI.CABG, angioplasty

FC less than 5-6 Mets 3 or more wks after event

Severely depressed LVF (≤30%). Complex ventricular arrhythmias @ rest/ appearing/ increasing with exs.

FC equal or greater than 6METs 3 or more wks after event

Mild – moderately depressed LVF (EF 31to 49%)

↓ SBP of › 15mmHg during exs or failure to rise consistent with exs workloads

No resting/ exs induced myocardial ischaemia manifested as angina & or ST seg displacement

Failure to comply with Exercise Prescription

MI complicated by CHF, cardiogenic shock & or complex ventricular arrhythmias

No resting/ exs induced complex arrhythmias

Exercise induced ST-seg depression of 1-2mm/ reversible ischaemic defects (echo/ nuc radio)

Pt with severe CAD & marked (›2mm) exs induced STsegment depression

No significant LV dysfunction (EF = / ↑ than 50%)

Survivor of cardiac arrest

AACVPR, 2005 Your Heart…Our Passion

Exercise Test


Risk Assessment Form

sample

sample Your Heart…Our Passion

ECG Stress Test Objective: - Assess the pt response to exercise - Enable risk risk stratification for future events - Determine medical & rehab mgmt Info from the result: - Duration & rate of work achieved - HR & BP response via exercise - HR, BP & exercise level @ peak/ changes - Medication during test - RPE (rate perceive exertion)


6 Minutes Walk Test (FC) • Strongest indication measuring the response to medical interventions in patients with moderate to severe heart or lung disease • Used as a one-time measure of functional status of patients, as well as predictor of morbidity and mortality Your Heart…Our Passion

2D ECHO • stress echo sign of viability is a stress induced improvement of function in a region that is abnormal at rest • Stress echocardiography can detect CAD with an accuracy that is similar to that of stress myocardial perfusion imaging and superior to exercise ECG alone Your Heart…Our Passion

Exercise Monitoring

Standard monitoring

Additional Monitoring Techniques

1. RPE (Borg Scale)

1. BP

2. Talk Test

2. HR

3. Self Monitoring

3. Telemetry ECG

4. Symptoms

4. METs

5. General Observation

5. Pulse Oxymeter

BACR,2005


Heart Rate Karvonen Formula THR = ((HRmax − HRrest) × % intensity) + HRrest Example for someone with a HRmax of 180 and a HRrest of 70: 50% Intensity: ((180 − 70) × 0.50) + 70 = 125 bpm 85% Intensity: ((180 − 70) × 0.85) + 70 = 163 bpm

Predicted maximal HR e.g. if patient is 40 years of age and is required to work at 60% - 75% of MHR 220 – Age = 220 – 40 = 180 (MHR) 180 x 60% = 108 180 x 75% = 135 Therefore the THR is (108 -135) Note: Remember that Beta Blockers reduces the heart rate @ rest & during exercise. Please take off 20- 30 BPM

(Adapted from ACSM/ AACVPR) Your Heart…Our Passion

Borg Scale •

• • •

RPE is well established tool for approximations of max FC (VO2max) Only can be use for those who can reliably use RPE Useful in changes of medication when cannot assess HR accurately (AF)


Gunnar Borg, 1998

Borg RPE Scale Vo2 Max

RPE Chart 11-14 Frequently used for moderate exercise

SING

30%

TALK

49%

50-74% GASP

12 - 16

75% 84% > 85%

12 -16 are consistent with improvements in exs tolerance. Corresponding to exs @ 75% 84% Vo2 Max


Gunnar Borg, 1998

Metabolic Equivalent (METs) energy cost Activity

METs (min)

METs (Max)

Skipping 120-140 min ‹ 80/min

11 8

11 9

Cycling 13mph 10mph 5 mph

8 5 2

9 6 3

Swimming (freestyle) (breast st)

9 8

10 9

Dancing (aerobic) (ballroom)

6 4

9 5

Tennis

4

9

5 3.5 3 2 1

6 4 3.5 3 2

Walking 4 mph 3.5 mph 3 mph 2 mph 1 mph


BACR, 2005

Exercise Programme

Exercise programme for CRP

Planned Structured

Goals/ aims

• Periodization • Fun & enjoyable • Suit pts needs • • • •

i.e 4-12 weeks Posed by a leader Has a clear purposed & objective Well facilitated

• Create exs habits • Achieved an improvement in exs capacity • Return pts to their pre morbid activity level


Exercise Program Card

SAMPLE 1


SAMPLE 2

Exercise Program Card Patients Name

HOSPITAL ABC

Contact no. Vital Signs

Diagnosis Medications

Pre- Ass Body Composition

HR pre & post

Comments

Program review & staff in charge signature

Reason for non completion

Post- Ass Body Composition Completing METs/ 6MWT Distance/ Shuttle Walk Test

Staff Name, signature, stamp & date


FITT Principles F FREQUENCY 2 – 3 WEEKLY (2 REHABILITATION CLASSES & 1 HOME CURCUIT) OTHER DAYS WALK/ LEISURE ACTIVITIES

I INTENSITY 60% - 75% OF MAXIMAL HEART RATE 12 – 13 RPE (BORG SCALE) 40% - 60 % OF VO2 PEAK OR HRR

T TIME / DURATION 20 – 30 MINUTES CONDITIONING PERIOD (not inclusive of w/up or cool down)

T TYPE/ MODE AEROBIC, ENDURANCE TRAINING


AACPVR 2005

Exercise Recommendation (ACSM & AACPVR Guidelines) Modes Aerobics • Large muscle activities (arm/leg ergometry)

Goals • •

Increase aerobic capacity Decreased BP & HR response to sub max exercise

Intensity • • • • • •

Strength • Circuit training

•

•

Increase ability to perform leisure, occupational & daily living activities Increased muscular strength

• • • •

Flexibility • Upper & lower body ROM

• •

Decreased risk of injury Improved ROM in post sternotomy

Time to Goal

Borg RPE 12- 14 40-85 VO2max/ HRR Intensity to be kept below ischaemic threshold 3-7 days a week 20-60 mins continuous exs 5-10 mins warm up/down

• 4-6 months

40-50% maximal voluntary contraction (avoid vasalva) 2-3 days/ week 1-3 sets, 10-15 repetitions Resistance should be gradually increased over time (1-2 lbs)

• 4-6 months

2-3 days/ week

• 4-6 months

Note: more attention should be paid to upper extremity of ROM & pts can resume normal activities (light – mod) 24-48 hrs after PTCA


Other consideration/ minimum standard to run CR • Exs session must be led & supervised by qualified staff • Staff - pts ratio, depend upon the composition of the group (1 vs 5) • Room size • Temperature & humidity • Induction/ programme orientation


Exercise Programme

Pts should not take part if they present with: • Fever & acute systemic illness • Unresolved unstable angina • Resting BP systolic > 200mmHg, diastolic > 110mmHg • Significant unexplained drop in BP • New/ recurrent symptoms of SOB, palpitations, dizziness or lethargy Your Heart…Our Passion

Prescription Considerations 1. 2. 3. 4.

Component of fitness Warm- up / cooling down Stretching Mode of activity/ Method of training (continuous, cumulative or interval) 5. Functional capacity 6. CV conditioning 7. Muscular conditioning


Circuit Training for Group Exercise CRP

Resistive Exercise Tubing

Recumbent Bicycle

Squat with Gym Ball

Rowing Machine

Warm-up/ Cool Down & Stretching Your Heart…Our Passion

Dumbbell Exercise

Step Board


Group Exercise vs One 2 One Group Exercise

One to One

Advantages: • Standardized & comprehensive screening & risk stratification • Individualization of prescription • Social support from one to another • Special variation in format

Advantages: • Allows complete individualization of screening & exercise prescription • Enables flexibility of choices as to training modes/ venues/ times

Disadvantages: • May perpetuate the ‘sick people’ image • Restricts availability & choice of classes • Male predominance may discourage participation by women

Disadvantages: • Less effective in terms of fostering independence • Lack of social support


Termination Criteria from Exercise • Any angina symptoms or feeling too breathless to continue • Feeling dizzy or faint • Leg pain limiting further exercise • Exceeds level of perceived exertion > 15 (Borg Scale) • Increased Heart Rate > 85% as of THR. Your Heart…Our Passion

Contraindication for Exercise • Unstable or unresolved angina. • Fever and acute systemic illness. • Patient in severe pain. • Resting blood pressure: SBP> 180mmHg, DBP> 100mmHg • Significantly unexplained drop in blood pressure. • Tachycardia > 100bpm. • New or recurrent symptoms of breathlessness, palpitation, dizziness. • Significant lethargy. Your Heart…Our Passion

10 Rules for Exercise Patients 1. Choose a form of exs that suits pts 2. Always build up gradually 3. If pts have a break for whatever reason, build up gradually again 4. Always warm up & cool down 5. Do not allow pts to exs if they are ill 6. Stop exs if pts c/o of pain/ feel dizzy/ uncomfortable/ palpitation/ irregular 7. Pts should be able to talk & exs @ the same time 8. Do not exs pts immediately after a meal 9. Make sure pts wear suitable clothing & good footwear 10. If in doubt consult a health professional Your Heart…Our Passion

General Considerations • Content must be simple & adaptable • Adopt educational approach • Monitor type A behavior • Ensure that goals are agreed upon rather than imposed & readily achievable • Exercise prescription must reflect individual differences,pts will differ greatly in most other Your Heart…Our Passion respects

Thank You Your Heart…Our Passion

References • • • • • • • • • •

•

ACSM`s Recourse Manual (2001). Guideline for Exercise Testing and Prescription. (4TH ED) Lippincott Williams & Williams : London ACSM`s Exercise Management for Persons with Chronic Disease and Disabilities. (1997) Human Kinetics: Leeds Braith, R. W. (1998) Exercise training in Patient with CHF and heart transplant recipients. Medicine and Science in Sports and Exercise,30. S367-S378 Cerny, F.J & Burton, H.W (2001). Exercise physiology for Health Care Professional, Human Kinetics : London Frownfelter, D. & Dean, E. Cardiovascular and Pulmonary Physical Therapy Evidence and Practice. 4th edn. Missouri: Mosby Elsevier Fardy, P.S, Frankin , B.A ,Porcari, J.P, & Vernil,D.E (1998). Training Techniques in Cardiac Rehabilitation Human Kinetics : Leeds Squires, R.W (1998) : Exercise Prescription for the High – Risk Cardiac Patient American College of Sport Medicine (ACSM) (1991) Guidelines for Exercise testing and Prescription (4th edn), Philadelphia; Lea and Febiger American College of Sport Medicine (ACSM) (1995) guidelines for Exercise testing and Prescription (5th edn) , Baltimore : Williams and Wilkins American College of Sport (ACSM) (1994) ` Position stand Exercise for Patient with Coronary Artery Disease` Medicine in Science & Sport Exercise,26:4, pp-I-V British Heart Foundation (1998) British Heart Foundation CHD Statistics British Heart Foundation


References •

•

•

British Heart Foundation (2002) British Heart Foundation CHD Statistics British Heart Foundation Campble, N.C , Grimshaw, J.M , Ritchie, L.D and Rawles ,JN ( 1996) `Outpatient` Cardiac Rehabilitation ; are the potential benefits being realised?’ Journal of the Royale College of Physicians,30, pp.514-19 Ewart , C.K , Taylor , C.B, Reese, L.B and de busk , R.F (1983) ` Effects of Early post-myocardial infraction exercise testing on self-perception and subsequent Physical Activity’ American journal Cardiology ,51, pp.1076-80


Exercise Prescription for Cardiac Rehabilitation

Recommend Documents