Exercise Prescription for CR & PR (Part 1) Flashcards
Why do we assess exercise capacity?
- Level of functional impairment & activity limitation
- Limiting factors of exercise capacity
- Guide exercise prescription
- Identify O2 desaturation & need for supplemental O2
- Evaluate effectiveness of rehab
What are the goals of exercise in PR & CR?
- Improve exercise capacity & functional ability
- Decrease symptoms
- Empower self-mnitoring, management of symptoms & confidence to exercise
- Find a safe & effective dose of exercise
- Return to work or functional independence
- Improve QOL
What is the overall benefit of exercise?
Increase CR fitness, decrease risk factors & symptoms
What is the main contributor to an increase in CR fitness in cardiac & pulmonary patients?
Peripheral adaptations (muscle)
How would you address a high risk patient in a group exercise class?
- Decrease intensity
- Monitor closely
- Increase staff
- Group high risk patients together
- Decrease class size
- Ensure equipment is nearby (crash cart, O2 etc)
What are some of the other CIs of exercise?
- Uncontrolled/poorly controlled asthma
- Unstable/uncontrolled COPD
- Unstable cancer/blood disorders
- Uncontrolled diabetes
- Osteoporosis/high fracture risk
- Unexplained symptoms that could cause risk of injury or exacerbation
What are the safety considerations in CVD patients?
- Exclude high-risk patients from vigorous activity
- Screen high-risk patients prior to exercise
- Stop exercise & promptly evaluate/refer if any symptoms (chest pain, dizziness, arm/jaw pain, severe SOB, irregular HR, excessive fatigue)
What are the exercise considerations for clinicians in COPD?
- Stratify patients according to need for medical support
- Work closely with PR teams
- Encourage patients to discuss daily exercise plans with their doctor
- Reassure patients that mild SOB is normal
- Ensure they do a warm-up & cool-down
- Aerobic training for major muscle groups of lower limb
- Incorporate endurance & strength training for upper limbs
- Consider interval training
What are the exercise considerations for patients in COPD?
- If SOB, aim to slow down rather than stop
- If persistent severe SOB, stop & rest or take a reliever inhaler
- Always notify someone if exercising in a group/gym
- Stop exercise if feeling nausea, dizziness, headache, pain in chest/neck/jaw
- Start rehab early
What are the exercise considerations in CVD?
- High intensity = higher risk
- Warm-up/cool-down
- ICDs have 10-30s delay between arrhythmia & shock
- Avoid dehydration
- Stroke patients 3 times more likely to fall/suffer hip fractures
What is the BGL CI for diabetes?
BGL outside 6-10mmol
What are the precautions for hyper/hypoglycaemia?
- Check BGLs 2 x before & after exercise
- Keep carb sources handy
- Exercise 1-2 hrs after meal & >1 hr after insulin injection
- Don’t exercise if BGL > 13-15mmol
- If <6mmol take carb source
What is a precaution for exercise in kidney disease?
High BP can aggravate disease progression
What are the precautions for exercise in peripheral neuropathy?
- Avoid high intensity exercise
- Problems managing temperature control
- Safe area with weights
- Grip may be impaired so be careful with weights
What is the most important exercise advice for T2 diabetes?
Check feet before and after exercise & at least twice daily
What does a PA history consist of?
- Current PA/exercise
- PA levels before/since exacerbation
- Intention to do PA/exercise (stage of change)
- Past PA/exercise & preferences
- Current symptoms & past medical history
What are the stages of change?
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Maintenance (>6 months)
- Relapse
What is the principle for exercise prescription?
FITTVE:
- Frequency
- Intensity
- Time
- Type
- Volume
- Progression
What is the normal prescription for CR & PR?
- Twice a week
- Low-mod intensity
- 1 hour
- 4-12 weeks (8-12 weeks heart failure)
- Individually tailored
What should the warm-up include?
- 10-15 mins
- Low-impac, dynamic movements
- Large muscle groups
- AROM all major joints
- Gradually increase size & ROMs
- RPE 3
What is the recommended intensity for aerobic exercise?
- Moderate (40-60%) to vigorous (60-90%)
- Light (30-40%) to moderate in deconditioned adults
What are the prescription guidelines for aerobic exercise for PR & CR patients?
F: 3-5 days per week I: 40-80% intensity, 80% 6MWT, 4-6 Borg T: 20-60 mins T: Rhythmic large muscle group activities V: Interval, continuous P: No standard format
What is a good exercise strategy for reducing SOB in pulmonary patients?
Fixing the shoulder girdle, e.g. walking aid, stationary bike
What are the prescription guidelines for aerobic exercise for PR & CR patients?
F: 2-3 days/weel
I: 3-5 Borg, 30-40% upper body, 50-60% lower body
T: 48hrs between sessions
T: Various equipment
V: 10-15 reps, 1-3 sets
P: Increase resistance/weight, reps, decease rest
What are muscle strength & total muscle cross-sectional area independent predictors of?
Exercise tolerance, clinical prognosis & long-term survival in patients with HF
What does the evidence show regarding resistance training?
- Pulmonary: Focus on upper limbs due to SOBOE
- COPD: IMT may increase exercise tolerance
- Strength training improves strength, no evidence for other outcomes
What falls risk factors are also present in respiratory & cardiac patients?
- Reduced lower limb muscle strength
- Decreased daily PA
- Reduced standing balance capacity
What muscles should be the focus for flexibility training in respiratory & cardiac patients?
- Spine (esp thoracic)
- Pecs
- AROM exercise for cervical/thoracic spine & shoulders
What should the cool-down consist of?
- 10 mins
- Decrease intensity
- Passive stretching
- Patient observation >30 mins post exercise recommended
What does evidence show regarding the PA & sedentary behaviour in people with CHD?
On average
- Mod-vig intensity PA 18 mins/day
- On non-CR days, 11 mins/day
- Sedentary behaviour 9hrs/day
What reassessment tools should be used for CR & PR patins?
- Manual muscle testing (strength)
- 6MWT
- ISWT
- Balance (TUG, Berg balance)
What is the minimum important distance for the 6MWT?
- 25m for patients with CHD
- 36m for patients with chronic HF
What are the 5 As of intervention?
- Ask: Current/past PA
- Assess: Stages of change, PMH
- Advise: Depending on stages of change
- Assist
- Arrange: Follow-up
What is intervention advice based on?
- History (including intentions & co-morbidities)
- Motivational interviewing
- Be realistic (relapse is common, some activities are better than others)
- Reassurance (SOB is good)
- Use “PA” instead of “sport” or “exercise”
What are the key messages that should be given as part of patient advice?
- Sit less, move more, enjoy exercise
- Avoid long period of sitting
- Make walking & PA part of daily life
- Find opportunities (e.g. stairs)
- Use a different floor at work when you need the toilet
- Aim to do more activity
- Patients can be active even with severe disease/illness
What can “assist” include?
- Education (23.5 hrs video)
- Written/visual summary
- Youtube videos
- NHS choices
- Apps/initiatives
- Classes, facilities, groups
- Charity websites
When should follow-ups be arranged?
- 3, 6, 12 months
- Multiple follow ups = more likely to remain active
