Transcript EH304 Exercise Prescription.ppt

Cardiac Rehabilitation
Eve Scarle
Senior Physiotherapist and
Lecturer in Exercise and Health
Sciences
Aims of the session
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Explanation of coronary heart disease
and cardiac rehabilitation
Rationale for the use of physical
activity in cardiac rehabilitation
Exercise prescription for Phase IV
cardiac rehabilitation
Professional development
opportunities in CR.
Group Task
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Plan a short exercise regime you may use for a 50 year
old patient who has suffered a heart attack 4 months ago.
Consider the;
 Frequency
 Intensity
 Duration
 Progression
 Type
of exercise that you would prescribe for this patient
Are there any types of activity you think should be avoided?
Cardiovascular Disease (CVD)
 CVD accounts for one of two of all deaths in UK
accounting for approximately 238,000 deaths in
2002
 Leading cause of premature death in both men
and women.
 CHD most common form of CVD and is
responsible for 60% of all deaths from CVD.
Our Healthier Nation target –
CHD and Stroke - reduce death rate in people
under 75 years by two fifths
CARDIOVASCULAR
DISEASE
(CVD)
STROKE
CORONARY HEART
DISEASE (CHD)
PERIPHERAL
VASCULAR
DISEASE
Coronary Heart Disease (CHD)
♥ Refers to the deposition of fatty substances in
the lumen of the coronary arteries
♥ This can start as early as the teenage years
♥ Only when the artery is ~ 70% occluded do
symptoms start to appear
♥ Symptoms may appear as angina or a
myocardial infarction (MI)
♥ Angina occurs when demand for oxygen does
not meet the supply as the coronary arteries
are narrowed
Coronary Atherosclerotic Plaque
Atherosclerosis
Atherosclerosis is
the build up of
fatty and fibrous
material
(atheroma) on
the inside
surfaces of
arteries
Atherosclerosis
Angina
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A symptom of CHD
Occurs during ischaemia when supply of oxygen
does not meet the demand for oxygen
When do you think individuals may get angina
symptoms?
What will the symptoms be?
Stable Angina
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Exertion
Stress
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Extreme
temperatures
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After a heavy meal
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Chest pain
/tightness/discomfort
Burning/dull sensation
Pain/heavy feeling in left
arm or both
Discomfort in throat, jaw
or abdomen
Short of breath on
exertion
Myocardial Infarction
(Heart Attack)
♥ Occurs when a fatty
plaque becomes unstable
and ruptures
♥ This causes a blood clot
to form stopping blood
getting any further
♥ This leads to areas of
myocardial ischaemia
which if it persist can
lead to tissue damage
♥ Needs prompt
management to limit
damage and reduce
complications
Coronary Artery Bypass Graft
♥ Where narrowing occurs in
multiple areas
♥ Veins and arteries are
harvested from elsewhere
in the body and used to
bypass the narrowing
♥ This involves open heart
surgery, being on the
bypass machine and a
prolonged recovery period
Coronary Angioplasty
♥ Procedure done under
local anaesthetic
♥ Catheter passed from
the groin up to the aorta
♥ Then pass into the
narrowed area and
inflate a small balloon to
squash plaque into the
artery wall
♥ Small cylindrical stents
can be left in place to
hold the artery open
Aims of Cardiac
Rehabilitation
‘To promote physical, psychological and
emotional recovery, enabling patients to
achieve and maintain better health, with a
reduced risk of death from continuing heart
disease.’
(Effective Health Care, 1998)
History of Cardiac Rehabilitation
♥ Cardiac rehab first started in the 1960s when
the benefits of active mobilisation were
recognised (Kavanagh et al, 1973).
♥ Disease processes in CHD may be slowed or
even reversed by the instigation of lifestyle
modification (Ornish et al, 1990 and 1998;
Berlardinelli et al, 2001).
♥ National Service Framework for CHD (DoH,
2000) sets national standards for CHD
management
What exactly is
Cardiac Rehabilitation?
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What is it?
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How long does it last?
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Combination of exercise, education and
counselling
Varies across the country
Where does it occur?
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Hospital and community-based
What exactly is
Cardiac Rehabilitation?
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Who is it delivered by?
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Delivered by a ,multi-disciplinary team which can
consists of:
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Counsellor
Nurse
Occupational therapist
Physiotherapist
Psychologist
Exercise physiologist
Phase IV instructor
Phases of CR
Phase I
In Hospital
Phase II
Immediate post discharge period
Phase III
Out-patient programme
Phase IV
Ongoing maintenance phase
Phase I
♥ Acute phase in hospital
♥ A member of the cardiac team provides specific
information on:
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heart disease
management of chest pain
how to handle serious cardiac symptoms
gradual increase in PA
use of medication
risk factor modification and lifestyle changes
feelings and relationships
driving, insurance and airline travel.
Phase II
♥ Patient at home under care of GP, lasts
2 - 6 weeks.
♥ Often neglected phase of rehab.
♥ Ideal time to reinforce important
messages and behaviour change.
♥ Telephone advice service
♥ Home visiting
Phase III
♥ Consists of exercise, health education, risk
factor modification, relaxation and stress
management, and occupational counselling.
♥ Can take place in hospital or community
♥ Exercise and education for up to 12 weeks.
♥ Exercise aim is to educate individuals on
safe and effective ways to make exercise a
part of their lives
Phase IV
♥ Community-based CR
♥ Little community provision for this group and
previous structured sessions make it difficult for
patients to exercise independently.
♥ British Association of Cardiac Rehabilitation
(BACR) developed protocol for CHD patients to
move from Phase III to Phase IV.
Phase IV
♥ Aims of Phase IV:
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provide regular supervised CV training sessions
establish individualised ex. prescription for
independent activity.
review participants progress over time (or
regression) and amend prescription accordingly.
offer general advice and support in lifestyle changes
encourage independence , self help and self
motivation.
Phase IV
♥ Class format could take the following: integration of individuals with CHD
into mainstream classes
 specialist phase IV classes
 one to one training
♥ What are the disadvantages/advantages of
these different sessions? Write down your
ideas
Classroom Task
Advantages
Disadvantages
Mainstream Class
*Get back to normal
life
*Integration
*Not geared up to heart
patients
*? correct exercise
Phase IV Class
*Social support
*Regular exercise
groups
*Specifically for heart
patients
*Reinforce message
that something is
wrong with you
*Does the exercise
have progressions
One-to-one training
*Individual advice
*Easy to progress
exercise
*No social support for
other patients
Exercise Prescription
for Phase IV
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Inclusion criteria (BACR, 2003):
 Post Myocardial infarction
 Post coronary artery bypass graft (CABG)
 Post angioplasty (with or without pre cardiac event)
 Post transplant
 Post valve replacement
 Stable angina
 Permanent pacemaker
 Implanted defibrillator
Also partners/spouses encouraged to attend.
Phase IV Exercise Prescription
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Frequency
At least 3 times a week
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Intensity
60-80% of max HR
13-15/3-5 RPE
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Time
20-60 mins
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Type
Aerobic endurance training
Session components –
Warm-up
♥ Content
♥ Pulse raising and mobility
♥ Preparatory stretching.
♥ Rationale
♥ Gradual, progressive w/up extends ischaemic and angina
threshold. Too strenuous can lead to arrhythmias and a reduced
ejection fraction.
♥ Duration
♥ 15 mins. minimum.
♥ Intensity
♥ HR to within 20 bpm of training HR or RPE no higher than 1011 on 6-20 scale.
Interval Training Approach
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Effective in early stages of recovery and
those who are deconditioned
Allows a greater total duration of exercise
per session
Allows easy management of a group of
individuals of differing abilities
Ultimate Aim
To achieve continuous
cardiovascular work for 20- 60 minutes
Active Recovery
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Low intensity activity e.g. walking at a
slower speed
Alternative activity e.g. muscular strength
work (with feet moving)
Can fit with different activities e.g. circuit
programme, gym, walking, home
programme
SQUATS
BACK LUNGE
AR STATION
5 EXERCISES
SIDE STEPS
LEVEL 1
LEVEL 2
HAMSTRING
CURLS
BIKE
Session components –
Cool down
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Content
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Rationale
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Older adults take longer to return to pre-exercise states
due to aging and baroreceptor changes.
Increased risk of arrhythmias with increased intensity
and lack of cool down
Duration
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Recovery period, slow walking, gentle movements, large
muscle groups, stretching.
10 mins.
Intensity
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Reduced, aim to return to pre-exercise state
Session components – MSE
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Content
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Rationale
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Increases strength and endurance of specific muscle groups
Duration
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Floor based has to be done out of main circuit
Could Integrate standing MSE as active recovery in the aerobic
section.
Dependent on location within class
Intensity
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Low resistance high repetitions, 1 x10-15 reps
8-10 exercises
Professional development
opportunities in CR
British Association for Cardiac
Rehabilitation (BACR)
♥ BACR - founded in 1993, national
organisation for professional involved in
CR.
♥ Phase IV Exercise Instructor Training
Module
Evidence of Benefit of CR
♥ Improved survival (25-31% reduction) (1,2)
♥ Improved functional capacity and VO2MAX (3)
♥ Reduced angina (4)
♥ Improved lipid profiles
♥ Lowers BP (5)
♥ Reduced anxiety and depression (6)
♥ Increased confidence and well being (7)
♥ Improved return to work and leisure (8)
♥ Effect of improved health education in family
and friends
♥ Improved compliance with lifestyle modification
Rationale for the use
of PA in CR
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Jolliffe et al., 2001;
 Enhanced coronary blood flow
 Increased angina threshold
 Improved peripheral muscle metabolism
efficiency
 Improved quality of life.
Review of lecture
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What is cardiac rehabilitation?
Evidence base for exercise component
in cardiac rehabilitation
Exercise prescription for Phase IV
Professional development
opportunities in CR.
Group Task
♥ Look back to your original ideas for
exercise prescription
♥ Is there anything you would change
now you know more about the
recommendations?
♥ Dot down your ideas in your groups
References
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O’Connor, G. Buring, J. & Yusuf, S. (1989) An Overview of Randomised Trials of
Rehabilitation with Exercise after Myocardial Infarction, Circulation, 80, pp. 234-44.
Jolliffe, J. Rees, K. Taylor, R. Thompson, D. Oldridge, N. & Ebrahim, S. (2000) ExerciseBased Rehabilitation for Coronary Heart Disease (Cochrane Review). In: The Cochrane
Library, Issue 2, Chichester: John Wilet and Sons Ltd.
Laughlin. M, Oltman. C, Bowles. D. (1998) Exercise Training-induced Adaptations in the
Coronary Circulation, Medicine and Science in Sport and Exercise, 30, pp 352-60.
Stahle, A. Mattsson, E. Rydent, L. Unden, A. & Nordlandert, R. (1999) Improved Physical
Fitness and Quality of Life following Training of Elderly Patients after Acute Coronary Events,
European Heart Journal, 20, pp 1475-1484.
Ades, P. Waldmann, M. & Gillespie, C. (1995) A Controlled Trial of Exercise Training in Older
Coronary Patients, Journal of Gerontology, 50A (1), M7-11.
Dugmore, L. Tipson, R. Phillips, M. Flint, E. Strentford, N. Bone, M. and Littler, W. (1999)
Changes in Cardiorespiratory Fitness, Psychological Well-Being, Quality of Life, and
Vocational Status following a 12-month Cardiac Exercise Rehabilitation Programme, Heart,
51, pp. 359-66.
References
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Westin, L. Carlsson, B. Israelsson, B. Willenheiner, R. Cline, C. & McNeil, T. (1997) Quality of
Life in Patients with Ischaemic Heart Disease: A Prospective Controlled Study, Journal of
Internal Medicine, 242, pp. 239-247.
Petrie, K. Weinman, J. Sharpe, N. & Buckley, J. (1996) Role of Patient’s View of their Illness
in Predicting Return to Work and Functional Capacity after Myocardial Infarction:
Longitudinal Study, British Medical Journal, 312, pp. 1191-94.
9.
Department of Health (1999) Saving Lives: Our Healthier Nation, London: The Stationery
Office.
10.
Department of Health (2000) The National Service Framework for Coronary Heart Disease,
London: HMSO.
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12.
Law, M. Morris, J. (1998) By how much does Fruit and Vegetable Consumption reduce the
Risk of CHD?, European Journal of Clinical Nutrition, 52, pp. 549-556.
Marckmann, P. and Gronbaek, M. (1999) Fish Consumption and Coronary Heart Disease
Mortality. A Systematic Review of Prospective Cohort Studies, European Journal of Clinical
Nutrition, 53 (8), pp. 585-590.