Exercise Prescriptions for Cardiac Rehab and Frail Adults

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  • 1. Exercise Prescriptions: Cardiac Rehab and Frail Adults Brian K. Unwin, M.D. Colonel, Medical Corps, USA Uniformed Services University
  • 2. Cardiac Rehab Am Heart J 2006; 152:835-841 Only 15-25% of eligible patients participate!
  • 3. Am Heart J. Nov. 2006. 152(5):835-41 The Evidence Fewer events, reduced all cause mortality 20-34% Diagnosis Fxnl. Capacity QOL Morbidity Mortality AMI +++ +++ ++ +++ CABG +++ +++ ++ ++ Stable angina +++ +++ + + PCI +++ ++ + ? CHF +++ ++ + + Cardiac Transplant +++ ++ ? ? Valve Repl. +++ ++ ? ?
  • 4. Core components of Cardiac Rehab
    • Patient assessment
    • Nutritional counseling
    • Lipid management
    • Hypertension management
    • Smoking cessation
    • Diabetes management
    • Psychosocial management
    • General education (meds, procedures, condition)
    • Physical activity counseling
    • Exercise training
  • 5. Effects of Exercise
  • 6. NICE Guidance
    • Lifestyle
      • Regular activity
      • Stop Smoking
      • Mediterranean Diet
      • 7 gm of Omega-3 fatty acids/week
      • Healthy weight
      • 14 “units” of alcohol per week
      • No beta-carotene
      • No evidence for antioxidants and folic acid
    Heart 2007; 93: 862-864
  • 7. NICE Guidance
    • Cardiac Rehab
      • Exercise offered
      • Includes: exercise, education, stress management
      • Involves partners/carers
      • Can be home based (Edinburgh Heart Manual)
      • Advice for return to activities
      • Sexual activity okay
      • Consider wider social and health needs
  • 8. NICE Guidelines
    • Drug Treatment
      • ACE
      • Aspirin
      • Beta-blocker
      • Statin
      • Clopidogrel x12 months (after non-ST MI), at least 1 month after ST elevation MI.
      • Aldosterone with CHF and LV dysfunction
      • Consider moderate intensity coumadin (INR 2-3)
    • Cardiological assessment
  • 9. General Recommendations Ischemic Heart Disease
    • When stable, regular physical activity
    • Contra-indications
      • Recent MI
      • Unstable angina
      • Exercise induced arrhythmia
    • Intensity
      • Below anginal theshold
      • “ Talk-test”
    • Duration and Frequency = 30 min most days
  • 10. General Recommendations Heart Failure
    • All (almost) CHF patients should be considered
    • Elderly not excluded
    • Intensity initially = “talk test”
    • Duration and Frequency = 30 min most days
    Heart, Lung and Circulation 2007; 16: S83-S87
  • 11. Risk Stratification
    • American Association of Cardiovascular Rehabilitation (AACVPR) (Card Clin 2001; 19: 415-431)
      • Lowest Risk
      • Moderate Risk
      • High Risk
    • American Heart Association (Circulation 2001; 104:1694-1740)
      • Class A
      • Class B
      • Class C
      • Class D
    AHA Guidelines include activity guidelines and supervision requirements See handout…
  • 12. Returning to work
    • Many factors
    • Non-exercise variables are important
    • Gradual exposure to outdoor exercise program
    • See ACSM Guide Appendix E
  • 13. Notes on total dose and volume for cardiac patients
    • For stable cardiac patients progress to expenditure of 1000kcal/week over 3-6 months
    • Higher level than this is associated with atherosclerotic regression (1500-2200kcal/week) (15-20 miles per week)
    • Typical cardiac program is <300kcal per session and <200 on non-program days
    • 19-43% of patients in rehab programs reach these levels
    • Traditional exercise rx falls short of this goal!
    ACSM Guide to Exercise Rx 7th Edition
  • 14. Exercise considerations for the angina patient
    • Goal: increase anginal and ischemic threshold
    • Prolonged warm-up & cool down (gradual rise)
    • Target HR below ischmic level (± 10 bpm)
    • Caution with exertion in the cold
    • Upper body exercise may precipitate symptoms due to higher pressor response
    • NTG
    • Monitor blood pressures before and after exercise (or NTG use)
    • Alternative exercise: frequent, short, intermittent sessions
  • 15. Exercise considerations for the CHF patient
    • Must be on stable medical therapy
    • Monitor hypokalemia and hemodynamic response
    • Malignant dysrhythmia
    • THR 40-70% VO2max 3-7days per week, 20-40 minutes per session
    • Long warm-up and cool down
    • Interval exercise training
    • RPE may be used
  • 16. Exercise considerations for the pacemaker/ICD patient
    • Fixed vs. adjustable rate
    • Monitor systolic pressures
    • Extended warm-up and cool down
    • ICD: ECG monitoring/pulse to titrate intensity
    • Rate modulated pacemakers intensity:
      • MHRR method of Karvonen
      • Fixed percentage of MHR
      • RPE
      • METs
  • 17. Exercise considerations for the cardiac transplant patient
    • 1-3 year survival rates of 86% and 80%
    • Train wreck physically and metabolically
    • Rx from data from testing, graded protocols
    • Long warm up & cool down
    • Denervated heart = no angina, low EKG sensitivity for ischemia, delayed cardioacceleratory (and deceleratory) response
    • Stress echo or radionuclide testing
    • Intensity:
      • 50-75% of VO2peak
      • RPE of 11-15 on the 6-20 scale
      • Dyspnea
  • 18. Exercise considerations for the CABG and PTCI patient
    • CABG
    • ROM and mobility exercises
    • Light hand weights
    • Stretching and flexibility
    • Avoid resistance training until sternum healed (3 months)
    • Initial aerobic training (resting HR +30bpm)
    • Valve patients: longer recovery, slower rate, more limitations
    • PTCI
    • Aerobic and resistance after access site healed
    • May progress rapidly if no myocardial damage
  • 19. Exercise and Frail Elders
  • 20. Why push our frail elders?
    • People live longer with chronic diseases.
    • 10% of nondisabled adults 75 years+ lose independence in 1 or more ADL’s each year.
    • Exercise and physical activity can improve health, functional capacity, QOL, and independence.
  • 21. Exactly What is Frailty?
    • Aging, high burden of chronic disease, malnutrition and extreme lack of activity.
    • Muscle weakness and low muscle mass (sarcopenia), low bone density, cardiovascular deconditioning, poor balance and gait.
    • Inactivity with low energy intake, weight loss or low BMI.
  • 22. Frailty in Relation to Other End of Life States Lunney et al. JAMA ; 289:2387-92, 2003
  • 23. Physiology of Frailty
    • Sarcopenia = decreased quality of muscle
    • Strength decline: diminished walking speed and balance difficulties as a result
    • Grip strength: inversely related to IADL deficits
    • Spinal mobility: affects many functional tasks
  • 24. Exercise (Activity) Prescription for Older Adults Fitness and Functional Status Function Strength Poor Normal Low High Healthy Adults Frail Adults Near Frail THRESHOLD Established Populations for Epidemiologic Studies of the Elderly (EPESE) . J Gerontology, 1994;49(3):M109-15
  • 25. AM J Med. 2007. 120(9):748-753 Chronic Malnutrition Sarcopenia Decreased metabolic rate and activity Decreased appetite Aging Decreased taste Poor dentition Dementia and depression Chronic illness Multiple hospitalizations Aging Weight loss Chronic inflammation Illness Chronic illness Hospitalization Medications Stressful life events Falls Osteopenia Decreased strength Immobility Dependency Impaired balance and falls Frailty Cycle
  • 26. Associations with co-morbidity and disability Overall: 2,762 subjects with comorbidity and/or disability and/or frailty If identified as Frail: 27% reported ADL disability 46% had co-morbid disease 22% had ADL disability and com-morbid illness 27% had neither disability or co-morbidity
  • 27. Pathways to Frailty Lancet. 2007. 369: 1328-29 Prevention Palliation Genetic Factors, atherosclerosis, chronic inflammation Low level of exercise, malnutrition Clinical Disease Primary Frailty Disability Secondary Frailty
  • 28. Frailty Predicted:
    • Predictor of death within 3 yrs (6x mortality)
    • 3x mortality at 7years
    • Increased falls, decreased mobility, injury and ADL disability
    • Hospitalization/institutionalization risk
    • Pre-frail had 2x the risk of progression to being frail
    • Dependency
  • 29. How to Quantify Frailty:
    • From the Cardiovascular Health Study , three or more of the following:
      • Shrinking
        • >10 pounds (or 5%) of body weight in prior year
      • Weakness
        • Lowest 20% adjusted for gender and BMI
      • Self report of exhaustion
        • Correlates with VO2 max and cardiovascular disease
      • Slowness
        • Slowest 20% based on time to walk 15 feet, gender and standing height adjusted
      • Low physical activity level
        • Weighted score of kcals expended per week, lowest 20% adjusted to gender
    Fried. J Gerontol. 2001. 56A(3): M146-156
  • 30. Quantifying Frailty:
    • Frailty
      • 3 or more criteria met
    • Pre-frailty
      • 1-2 criteria met
    Fried, Tangen, et al. Frailty in Older Adults: Evidence for a Phenotype. J of Gerontology. 2001: 56A(3): M146-M156.
  • 31. Criteria #1: Weight loss
    • Weight loss
      • Patients asked if they experienced 10 pounds of unintentional weight loss in last one year
  • 32. Criteria #2: Exhaustion
    • Self-report of exhaustion
      • Two statements provided
        • “ I felt that everything I did was an effort”
        • “ I could not get going.”
      • “ How often in the last week did you feel this way?”
        • 1= some or a little of the time (1-2 days)
        • 2= a moderate amount of time (3-4 days)
        • 3= most of the time
  • 33. Criteria #3: Walk time Time to walk 15 feet: 6.5 secs Height Time Men ≤ 173 cm (68”) ≥ 7 seconds > 173 cm (68”) ≥ 6 seconds Female ≤ 159 cm (62”) ≥ 7 seconds > 159 (62”) ≥ 6 seconds
  • 34. Criteria #4: Grip strength MEN: WOMEN: <30 Kg <18 Kg BMI Strength (Kg) ≤ 24 ≤ 29 24.1-28 ≤ 30 >28 ≤ 32 BMI Strength (Kg) ≤ 23 ≤ 17 23.1-26 ≤ 17.3 26.1-29 ≤ 18 >29 ≤ 21
  • 35. Criteria #5: Low activity
    • Leisure-time physical activity
      • Males < 383 kcal/week
      • Females < 270 kcal/week
    Perspective: 159# person walking at 5kph burns 280kcal/HOUR
  • 36. Frailty: An operational definition
    • The aged person with unintended weight loss
    • Weakness
    • Self-report of exhaustion
    • Slowness
    • Low activity
    WASTING SYNDROME
  • 37. Evidence for Exercise
    • Regular physical activity reduces age-related loss of muscle mass.
    • Resistance training increases muscle mass, counteracts sarcopenia, and improves function.
    • Chronic disease and syndromes respond favorably to exercise.
    • Small improvements in physiological capacity = substantial effect on functional performance.
  • 38. Studies
    • Cochrane Collaboration: falls reduction
    • Fiatarone et al: increased muscle strength = increased daily function
    • FICSIT Trials: balance exercises lowered falls
    • FAST trial: diminished pain and disability in OA patients
    • NEJM Oct 2002: 45% reduction in disability
    • Health ABC Study: exercise = better function
  • 39. Exercise Goals for the Frail Elder
    • Improve ADL and IADL function
    • Improve QOL
    • Enhance: flexibility, balance/postural stability, endurance, coordination, movement speed, strength, and bone health
    • Prevent/decrease the burden of disease
    • Improve patient education
  • 40. Exercise History
    • What is the patient’s lifelong pattern of activities and interests?
      • Patient’s investment in plan
    • What has been the patient’s activity level in the past 2-3 months?
      • Determines current baseline
    • What are the patient’s concerns and perceived barriers regarding exercise?
      • Opportunity for education
  • 41. Evaluating Function
    • Physical Performance Test (PPT)
    • Timed Get Up and Go (TUG)
    • Vulnerable Elders Survey (VES-13)
    • Functional Status Questionnaire (FSQ)
    • EPESE study: Physical performance measures
    • Others: LLFDI, PF-10 and LHS
  • 42. Contraindications for Exercise
    • Frailty or extreme age is not !
    • Caution: acute illness; unstable CP; uncontrolled DM, HTN, asthma, CHF; musculoskeletal pain, weight loss and falling
    • Not during treatment: hernias, cataracts, retinal bleeding or joint injuries
    • Stop!: enlarging AAA, end stage CHF, malignant ventricular arrhythmias, severe AS
  • 43. Risks of exercise for the frail elder
    • Main risk = musculoskeletal injury
      • Higher: vigorous exercise, higher volume, obesity
      • Lower: higher fitness, supervision, protective gear and well designed exercise environment
    • Risk of exercise related MI and sudden death: greatest in least active elders
  • 44. Disease Specific Exercise Rx’s
    • OA: aquatic; flexibility training; isometric exercises
    • Osteoporosis: weight bearing; improve balance
    • Obesity: rotation to minimize orthopedic injury
    • HTN: aerobic activity, large muscle groups
    • COPD: walking; PRT of shoulder girdle, inspiratory and UE muscles. Bronchodilators reduce dyspnea
    • CHF: aerobic and resistance training; improves VO2 max, dyspnea, work capacity and LV function; muscle strength and muscle endurance
  • 45.
    • Mode:
    • Aerobic+Strength +Balance+Flexibility
    • Duration
    • Frequency
    • Intensity:
    • Touch > No Touch > Eyes Closed for balance
    • 5-6/10 self-perceived exertion
    • Timely Follow Up
    • Therapy (Preventive and/or Therapeutic)
    The “MD FITT” Prescription (for the older adult)
  • 46. TOOL TIME!
  • 47. REHAB TOOLS!
    • The Kansas City Cardiomyopathy Questionnaire
    • The Patient Knowledge Questionnaire
    • Medical Outcomes Study: 36-Item Short Form Survey Instrument
    • 6 Minute Walking Test
    • ACSM’s Guidelines for Exercise Testing and Prescritpion (7 th Edition)
  • 48. Vulnerable Elder Survey VES-13 Saliba et al. JAGS ; 49: 1691-99, 2001
  • 49. Timed Up and Go “TUG”
    • Patient sits in a straight-backed high-seat chair
    • Instructions for patient:
      • Get up (without using the armrests)
      • Stand still momentarily
      • Walk forward (10 ft or 3 m)
      • Turn around and walk back to chair
      • Turn and be seated
      • >15 seconds higher risk for fall
  • 50. PPT Reuben DB, Siu AL. JAGS ; 38(10): 1105-12, 1990
  • 51. Exercise (Activity) Prescription for Older Adults http://www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-469B-A508-94CA4E537D4C/0/NIA_Exercise_Guide407.pdf
  • 52. Useful web sites
    • Exercise: A Guide from the NIA http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide
    • ACSM Fit Society Page http://www.acsm.org
    • CDC Physical Activity for Everyone http://www.cdc.gov/nccdphp/dnpa/physical/index.htm