exercise prescription for cardiac rehabilitation - ijn … pre symposium 12.pdf · your heart…our...

Your Heart…Our Passion

Exercise Prescription for

Cardiac Rehabilitation Azran Ahmad

Exercise Physiologist


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


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


Risk Stratification

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

sample sample


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 ST-

segment depression

No significant LV dysfunction

(EF = / ↑ than 50%)

Survivor of cardiac arrest

AACVPR, 2005


Exercise Test


Risk Assessment Form

sample

sample


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


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


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)


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

SING

TALK

GASP

RPE Chart

11-14 Frequently used for

moderate exercise

Vo2

Max

30%

49%

50-74%

75%

84%

> 85%

12 -16 are consistent with

improvements in exs tolerance.

Corresponding to exs @ 75% -

84% Vo2 Max

12 - 16

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

Walking 4 mph

3.5 mph

3 mph

2 mph

1 mph

5

3.5

3

2

1

6

4

3.5

3

2

BACR, 2005


Exercise programme for CRP E

xe

rcis

e

Pro

gra

mm

e Planned

Structured

Goals/ aims • Create exs habits

• Achieved an improvement in exs capacity

• Return pts to their pre morbid activity level

• i.e 4-12 weeks

• Posed by a leader

• Has a clear purposed & objective

• Well facilitated

• Periodization

• Fun & enjoyable

• Suit pts needs


Exercise Program Card

SAMPLE 1 SAMPLE 2


Exercise Program Card

Patients Name

Diagnosis

Medications

HR pre & post

HOSPITAL ABC Contact no.

Vital Signs

Pre- Ass Body

Composition

Comments

Program review &

staff in charge

signature

Post- Ass Body

Composition

Completing METs/

6MWT Distance/

Shuttle Walk Test

Reason for non

completion

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 Goals Intensity Time to Goal

Aerobics

• Large muscle activities

(arm/leg ergometry)

• Increase aerobic

capacity

• Decreased BP & HR

response to sub max

exercise

• 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

Strength

• Circuit training

• Increase ability to

perform leisure,

occupational & daily

living activities

• Increased muscular

strength

• 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

Flexibility

• Upper & lower body

ROM

• Decreased risk of injury

• Improved ROM in post

sternotomy

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


Prescription Considerations

1. Component of fitness

2. Warm- up / cooling down

3. Stretching

4. 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

Step Board Dumbbell Exercise

Rowing Machine

Squat with Gym Ball

Recumbent Bicycle

Resistive Exercise Tubing

Warm-up/ Cool

Down &

Stretching


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.


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.


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


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

respects


Thank You


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 - ijn … pre symposium 12.pdf · your heart…our...

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