1 Your Passion Exercise Prescription for Cardiac Rehabilitation Azran Ahmad Exercise Physiologist Your 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 Passion Fancy to do this? Your Passion Your Passion Are they at risk? Can you prescribe them an Exercise ? Your Passion 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, , dizziness GTN Relevant past medical history Risk factor for CHD Weight/ BMI Psychological status/ mood Orthopedic limitations Your Passion 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 Your Passion Risk Stratification 1.
2 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 Passion 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 Your Passion Risk Stratification Criteria for Cardiac Patients (AACVPR) Low Risk Moderate Risk High Risk Uncomplicated , 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.
3 FC equal or greater than 6 METs 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 Your Passion Exercise Test Your Passion Risk Assessment Form sample sample Your 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.
4 -Duration & rate of work achieved -HR & BP response via Exercise -HR, BP & Exercise level @ peak/ changes -Medication during test -RPE (rate perceive exertion) Your Passion 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 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 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 Your Passion 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) ) + 70 = 125 bpm 85% Intensity: ((180 70) ) + 70 = 163 bpm Predicted maximal HR 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 .
5 Please take off 20- 30 BPM (Adapted from ACSM/ AACVPR) Your 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 Your Passion 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 Your Passion 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 mph 3 mph 2 mph 1 mph 5 3 2 1 6 4 3 2 BACR, 2005 Your Passion Exercise programme for CRP Exercise Programme Planned Structured Goals/ aims Create exs habits Achieved an improvement in exs capacity Return pts to their pre morbid activity level 4-12 weeks Posed by a leader Has a clear purposed & objective Well facilitated Periodization Fun & enjoyable Suit pts needs Your Passion Exercise Program Card SAMPLE 1 SAMPLE 2 Your Passion Exercise Program Card Patients Name Diagnosis Medications HR pre & post HOSPITAL ABC Contact no.
6 Vital Signs Pre- Ass Body Composition Comments Program review & staff in charge signature Post- Ass Body Composition Completing METs/ 6 MWT Distance/ Shuttle Walk Test Reason for non completion Staff Name, signature, stamp & date Your Passion 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 Your Passion 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.
7 More attention should be paid to upper extremity of ROM & pts can resume normal activities (light mod) 24-48 hrs after PTCA Your Passion 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 Your Passion 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 Passion Prescription Considerations of fitness up / cooling down of activity/ Method of training (continuous, cumulative or interval) capacity conditioning conditioning Your Passion 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 Your Passion Your Passion 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.
8 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 Your Passion 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 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.
9 Significant lethargy. Your Passion 10 Rules for Exercise Patients a form of exs that suits pts build up gradually pts have a break for whatever reason, build up gradually again warm up & cool down not allow pts to exs if they are ill exs if pts c/o of pain/ feel dizzy/ uncomfortable/ palpitation/ irregular should be able to talk & exs @ the same time not exs pts immediately after a meal sure pts wear suitable clothing & good footwear in doubt consult a health professional Your 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 respects Your Passion Thank You Your 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.
10 (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, & Burton, (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, , Frankin , ,Porcari, , & Vernil, (1998). Training Techniques in Cardiac Rehabilitation Human Kinetics : Leeds Squires, (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 Your Passion References British Heart Foundation (2002) British Heart Foundation CHD Statistics British Heart Foundation Campble, , Grimshaw, , Ritchie, and Rawles ,JN ( 1996) `Outpatient` Cardiac Rehabilitation .