The only notes from chapter 9 & 10 you will need to know for the final

Chapter 9Exercise Prescription for

Patients with Cardiac Disease

Chapter 9Exercise Prescription for

Patients with Cardiac Disease

http://upload.wikimedia.org/wikipedia/commons/0/05/Coronary_artery_bypass_surgery_Image_657B-PH.jpg

Coronary Angiogram Showing Area of Occlusion

Outpatient Programs

• 1-2 weeks post discharge• Phase 1: is in patient. Ambulate 2-4 times per day

for 3-5 minutes to 10-15 minutes. Limit HR to + 20 bpm above rest for CHF and Post MI. For post surgery limit HR to + 30 bpm above rest.

• Phase 2: Review entire medical history. 12 weeks monitored, outpatient basis. BP taken at regular intervals. Pre, during, post exercise. RPE as well.

• Phase 3: Outpatient, unmonitored but supervised.

Exercise Prescription: Frequency• Most days of the week (4–7 d·wk-1)• If very limited, multiple short (1- to 10-minute)

sessions• Encourage independent exercise. Hobbies, work,

shopping. Walking ~ 30 mins/day or 3,000-4,000 steps.

Exercise Prescription: Intensity

• RPE of 11 to 16 on scale of 6 to 20• GXT data available– 40% to 80% exercise capacity using HRR, %VO2R, or

VO2peak

• GXT data not available • HR below ischemic threshold (if determined)• Concerns: medication effects

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Exercise Prescription: Intensity (Without GXT Data)Table 9-1

Exercise Prescription: Time (Duration)• Warm-up (5–10 minutes) and cool-down (5–10

minutes)– Static stretching– Range-of-motion exercises– Low-intensity aerobic activities

• Aerobic conditioning (20–60 minutes)

Exercise Prescription: Progression

• Initial duration of 5 to 10 minutes per session• Progress 1 to 5 minutes per session (or increase time

10%–20% per week), continuous or intermittent• Individualized to patient tolerance considering:physical fitness level,patient motivation and goals,signs and symptoms, andmusculoskeletal limitations.

Exercise Prescription: Type

• Rhythmic, large muscle group activities with emphasis on caloric expenditure to include both upper extremity and lower extremity

• May include:– ergometers (arm, leg, or combination),– elliptical,– rower,– stair climber, and– treadmill.

Chapter 10Exercise Prescription for Other

Clinical Populations

Chapter 10Exercise Prescription for Other

Clinical Populations

Diabetes Mellitus• Diabetes mellitus is a group of metabolic diseases

characterized by an elevated fasting blood glucose level (i.e., hyperglycemia) as a result of either defects in insulin secretion or an inability to use insulin.

• Sustained elevated blood glucose levels place patients at risk for micro- and macrovascular diseases as well as neuropathies (peripheral and autonomic).

Diabetes Mellitus • Currently, 7% of the U.S. population has diabetes

mellitus, with 1.5 million new cases diagnosed each year.

• Four types of diabetes are recognized based on etiologic origin: type 1, type 2, gestational (i.e., diagnosed during pregnancy), and other specific origins (i.e., genetic defects and drug induced); however, most patients have type 2 (90% of all cases) followed by type 1 (5%–10% of all cases).

Diabetes Mellitus (cont.)• Type 1 diabetes mellitus is most often caused by the

autoimmune destruction of the insulin producing beta-cells of the pancreas, although some cases are idiopathic in origin.

• The primary characteristics of patients with type 1 diabetic mellitus are absolute insulin deficiency and a high propensity for ketoacidosis. No insulin is available so fat is used as a fuel source.

Exercise and Diabetes• Lower fasting blood glucose• Improves insulin sensitivity• Improves glucose tolerance• Reduces disease risk - CVD, dyslipidemia, HTN and obesity.• Improves quality of life• Stress Management• Prevents and delays Type II – epidemilogical evidence

showing sedentary lifestyle plays a large role

Diabetes Mellitus (cont.)• Type 2 diabetes mellitus is caused by insulin resistance

with an insulin secretory defect. • Type 2 diabetes mellitus is associated with excess body

fat. • A common feature of type 2 diabetes is an upper body fat

distribution regardless of the amount of total body fat. • In contrast to type 1 diabetes mellitus, type 2 is often

associated with elevated insulin concentrations.

Diabetes Mellitus: Exercise Prescription

• Frequency: 3 to 7 d·wk-1

• Intensity: 50% to 80% VO2R or HRR corresponding to a rating of perceived exertion (RPE) of 12 to 16 on a 6 to 20 scale

• Time: 20 to 60 min·d-1 continuous or accumulated in bouts of at least 10 minutes of activity to total 150 min/w of moderate physical activity with additional benefits of increasing to 300 minutes or more of moderate physical activity

• Type: emphasize activities that use large muscle groups in a rhythmic and continuous fashion. Personal interest and desired goals of the exercise program should be considered.

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Diabetes Mellitus: Exercise Prescription (Resistance Training)

• Frequency: 2 to 3 d·wk-1 with at least 48 hours separating the exercise sessions

• Intensity: two to three sets of 8 to 12 repetitions at 60% to 80% 1-RM

• Time: 8 to 10 multijoint exercises of all major muscle groups in the same session (whole body) or sessions may be split into selected muscle groups

Diabetes Mellitus: Exercise Prescription (Resistance Training) (cont.)

• Type: given that many patients may present with comorbidities, it may be necessary to tailor the resistance exercise prescription accordingly. Emphasize proper technique including minimizing sustained gripping, static work, and the Valsalva maneuver to prevent an exacerbated BP response.

© 2009 Human Kinetics

Precautions for AvoidingExercise-Induced Hypoglycemia

• Measure blood glucose immediately before and 15 min after exercise.

• Consume carbohydrate if glucose is less than 100 mg · dl–1.

• Delay exercise if glucose is more than 250 mg · dl–1 with ketone bodies or over 300 mg · dl–1 without ketones.

• Avoid exercising during times of peak insulin action.

(continued)

Hypoglycemia• AKA Insulin shock and insulin reaction• Side effect that occurs with glucose levels at 60-70.• Causes:– Too much insulin or oral agents– Too little CHO intake– Missed meals– Excessive or poorly planned exercise

• May occur during exercise or hours later.

HYPOGLYCEMIA• Monitor blood glucose before and after exercise. • Autonomic symptoms:– Shaking, weakness, sweating, anxiety– Nervousness, tingling in mouth & fingers

• Neuroglycopenic symptoms:– Headache, visual disturbances, mental dullness,

confusion, amnesia, seizures or coma• Some have hypoplycemic unawareness

TREATMENT OF HYPOGLYCEMIA• Test blood• Ingest 15g of CHO with no fat & allow 20 minutes for symptoms to resolve• Tablets• 1 cup of nonfat milk• ½ cup of orange juice• ½ can of regular soda• 6-7 Life Savers• 1 tbsp of sugar, honey, or corn syrup• Unconscious – glucagon injection or 911

Pulmonary Diseases• Pulmonary diseases typically result in dyspnea or

shortness of breath with exertion. • As a result of dyspnea, patients with pulmonary disease

limit physical activity and deconditioning results. • Consequently, patients with pulmonary disease

experience dyspnea even at low levels of physical exertion.

Pulmonary Diseases (cont.)• This adverse cycle can lead to eventual functional impairment

and disability. • Exercise is an effective intervention that lessens the

development of functional impairment and disability in patients with pulmonary disease.

• Chronic bronchitis, emphysema, and cystic fibrosis are classified as chronic obstructive pulmonary diseases (COPDs), resulting in a permanent diminution of airflow, whereas asthma has a reversible component to airway obstruction.

• Emphysema

Definitions

SYMPTOMScoughcough

sputumsputum

dyspneadyspnea

EXPOSURE TO RISKFACTORS

tobaccotobacco

occupationoccupation

indoor/outdoor pollutionindoor/outdoor pollution

SPIROMETRYSPIROMETRY

Diagnosis of COPDDiagnosis of COPD

Pulmonary Diseases: Exercise Prescription

For individuals with well-controlled asthma or mild COPD, the following exercise prescription for cardiovascular fitness is recommended.• Frequency: at least 3 to 5 d·wk-1

• Intensity: presently there is no consensus as to the “optimal” exercise intensity for patients with pulmonary disease.

Pulmonary Diseases: Exercise Prescription

• Time: 20 to 60 min·d-1 of continuous or intermittent physical activity

• Type: walking is strongly recommended because it is involved in most activities of daily living. Stationary cycling may be used as an alternate type of training. Additionally, resistance training and flexibility exercises should be incorporated into the exercise prescription.

Pulmonary Diseases: Exercise PrescriptionFor individuals with moderate to severe COPD, the following exercise prescription for cardiovascular fitness is recommended.• Frequency: at least 3 to 5 d·wk-1

Pulmonary Diseases: Exercise Prescription

• Intensity: for those patients with severe COPD whose exercise tolerance may be ventilatory limited, exercise intensities as high as 60% to 80% of peak work rates are suggested. Intensity may also be based on dyspnea ratings determined from the graded exercise test with ratings between 3 (moderate shortness of breath) and 5 (strong or hard breathing) on a scale of 0 to 10 corresponding to the desired exercise intensity that can be tolerated.

Pulmonary Diseases: Exercise Prescription

• Time: persons with moderate or severe COPD may be able to exercise only at a specified intensity for a few minutes at the start of the training program. Intermittent exercise may also be utilized for the initial training sessions until the patient tolerates exercise at sustained higher intensities and durations of activity.

• Type: walking and/or cycling. Additionally, resistance training and flexibility exercises should be incorporated into the exercise prescription.