1. Conference 2015
HIGH PERFORMING HEALTH CARE
UCOL U-Kinetics Te Huinga Waiora
Delivery & Effectiveness of Specialised
Clinical Exercise Programmes for Cardiac,
Respiratory and Diabetic Clients
Dreyer, L.I.1,2
, Rankin, D.1,2
,
Dreyer, S.1
& Wormgoor, S.1
1Exercise & Sport Science Department
UCOL, Palmerston North,
2Clinical Exercise Physiology NZ

2. U-Kinetics Te Huinga Waiora
RATIONALE

3. CHRONIC DISEASE
(NCD’S)
• NCD’s Leading Cause of Mortality
– 2020 – 7 out every 10 deaths
– 2030 – Estimated Worldwide Mortality = 52 million/year
• Major Public Health and Economic Burden
• Importance of Physical Activity
– Direct cost of inactivity estimated to be $60 million in NZ in 1991
– 2 in every 3 NZ’s diagnosed with at least 1 NCD
– Indirect cost of physical inactivity in 1991 estimated at $104 million
• Loss in productivity due to premature morbidity, and mortality
– Hospitalisations and Readmissions
– Access to Exercise Rehabilitation
– Survivorship & Prolonged Functional Weakness

4. • Research: Cardiovascular Disease (Van Hees et al.,1994)
– 527 men with CVD, VO2 directly measured, 6.1 year study
– Highest all-cause mortality = FC < 4.4 METs
– No deaths in cohort with FC > 9.2 METs
• Research: Cardiac Exercise Rehabilitation (Martin et al., 2013):
– Trained MI patients for 12-weeks
– 5600 men; 1300 females
– Each 1 MET increase in FC = 22% reduction in mortality 1 year later
• Research: Heart Failure Patient Study (Feuerstadt et al., 2007)
– 600 patients; Ejection fraction <35%
– 12-weeks training
– Each 1 MET increase in FC = 28% reduction in
mortality
FUNCTIONAL CAPACITY
(RESEARCH)

5. CLINICAL EXERCISE
PHYSIOLOGY – THE GAPS
• 80% of health care cost from 10-20% of population
• Traditional Health Care does not generally target
improvement of functional ability (or prevention)
• How to attain sufficient levels of fitness in groups that
can benefit most is the major challenge
– Along with providing a safe exercise environment
• No specific profession targeting Exercise Rehabilitation
– Along with Associated Funding Issues

6. U-Kinetics Te Huinga Waiora
Clinical Exercise Physiology Centre Development

7. “Development of an Applied Clinical Exercise Physiology
Qualification to prepare graduates to work with medically
‘at-risk’ individuals”
“Developing the role of the ‘Clinical Exercise Physiologist’ in
New Zealand”
Considerations:
• International Recognition/Models for Specialised Exercise Physiology
• Fit with Current Health Services and Health & Allied Professionals
• Support from the Health System
• Future Health Needs for NZ
CLINICAL EXERCISE
PHYSIOLOGY EDUCATION

8. WHAT IS A ‘CLINICAL
EXERCISE PHYSIOLOGIST?’
“Development of an Advanced Applied Exercise Physiology
Qualification to prepare graduates to work with medically
‘at-risk’ individuals”
“Developing the role of the ‘Clinical Exercise Physiologist’
in New Zealand”
Considerations:
• International Recognition/Models for Specialised Exercise Physiology
• Fit with Current Health Services and Health & Allied Professionals
• Support from the Health System
• Future Health Needs for NZ
A clinical exercise physiologist can be defined as an individual who
specialises in the delivery of exercise, lifestyle and behavioural
modification programmes for the prevention and management of
chronic conditions and diseases, and
musculo-skeletal injuries
(adapted from Exercise and Sport Science Australia, 2010)

9. POSTGRADUATE
QUALIFICATION
Entry to Programme:
• Bachelor of Exercise & Sport Science or Equivalent
• Completion of a Health-related degree with industry experience in
Exercise
• Pathway for other Health & Allied Health Professionals (Training Scheme)
Clinical Requirements
Minimum of 540 Hours Clinical Exercise Physiology Experience:
 180 hours – Cardiovascular or Metabolic (incl. Diabetes) conditions
 120 hours – Respiratory, Neurological conditions or Cancer
 180 hours – Orthopaedic/Musculoskeletal injuries or conditions
 60 hours either additional to above or
other clinical exercise activities
POSTGRADUATE DIPLOMA IN CLINICAL EXERCISE PHYSIOLOGY

10. WORK INTEGRATED
LEARNING (APPLIED)
• What we needed:
– Delivery of Individualised & specialised
Exercise Testing and Training for:
• Cardiac Conditions
• Respiratory Conditions
• Diabetics
• Musculoskeletal Conditions & Injuries
• Other Medical Conditions
– Exercise for Management of Co-Morbidities
• Services were not currently available to meet
requirements

11. • Concept Paper/Business Case
• Qualification - Curriculum
Development & NZQA
Approval
• Exercise Programme
• Facility
• Research Programme
• Equipment
– Technogym Wellness System
• Health & Safety
• Client Reporting
COLLABORATION:
KEY PARTNERS
UCOL MIDCENTRAL DHB / CENTRAL PHO
• Funding
• Targeted Conditions
Respiratory, Cardiac, Diabetes
• Existing Programmes/ Services
• Referral pathways
• Client Safety
• On-going
Collaboration/Communication

12. • Physiotherapy, Occupational
Therapy, Orthopaedic Surgeons
& Exercise Therapists
• Multi-Disciplinary Philosophy
• Services Related to
Musculoskeletal Rehabilitation,
Chronic Pain, Vocational
Rehabilitation
• Shared U-Kinetics Reception
TBI HEALTH HEALTH WORKFORCE NZ
• Demonstration Site
• New Workforce Development
COLLABORATION:
KEY PARTNERS

13. U-Kinetics Te Huinga Waiora
SERVICE DELIVERY

14. CLINIC SERVICES &
STAFFING
• Merging Education with Health Service Delivery
– Curriculum with Practical Learning Focus
• Student Progression through the programme
– Observation to Delivery
• Client pathway through the service
– One-on-One through to Self-Managing Exercise
– Staffing
• Dual Professionals - Senior Academic / Clinical Exercise Physiologists
• Our Graduates & Internships
• Students Utilised to Supervise Clients
– Safety
• Supervision (Client & Students)
• Entry requirements
• Emergency procedures

15. Referral Pre-Assessment Consultation
Client Exercise Testing
Client Reports
Client, Referrer & Clients GP
Client Exercise Programme
Client Exercise Retesting
1
2
DHB Reports
Every 3 Months
6 Month Report of Data
CLIENT JOURNEY

16. U-Kinetics Te Huinga Waiora
ENVIRONMENT & CLIENT BENEFITS

17. CLIENT OUTCOMES
Data Presented in these Results are for:
366 Clients – completed 12 week program
117 = Cardiac clients
103 = Respiratory clients
146 =Diabetic clients
133 Clients - completed 24 week program
46 = Cardiac clients
53 = Respiratory clients
34 = Diabetic clients

18. CLIENT STATUS AT START
OF PROGRAMME
Cardiac:
• Low functional capacity
• Impaired ejection fraction
• Low/high resting BP
• Orthostatic intolerance
• Angina
• Peripheral arterial disease
• Overweight/fragile
• Poor response on exercise
– Post-exercise dizziness
– ECG changes
– Poor BP response
– Intermittent claudication
Respiratory:
• Low functional capacity
• Regular exacerbations
– Chest Inflammation
– Hospitalization
• Borderline resting O2
saturation levels
• Fragile
• Muscle atrophy/circulatory
steal
• Exercise desaturation
Diabetic:
• Foot ulcers
• Overweight
• Poor glucose control
• Limited understanding of
need to control glucose
• Poor dieting habits
• High insulin usage
• Multiple conditions
– Heart disease
– PAD
– Elevated BP
– Stroke
• Poor exercise response
– Post exercise hypoglycemia
– Rhythm changes
– Silent angina
– Intermittent claudication

19. Functional Capacity in METs
<4.31 4.32-4.99 5.0-7.99 8.0-9.99 10+
28.3% 15.9% 48.5% 6.9% 0.5%
Dyspnoea and Angina During Cycling
None Mild Moderate Severe
37.0% 30.1% 17.6% 15.3%
Resting Blood Pressure (mmHg)
<110/70 112-140/72-90 160-180/90-100 180/102+
SBP 8.5% 63.4% 27.3% 0.8%
DBP 19.3% 67.6% 11.1% 2%
Peak Cycle Wattage
<25 watt 25-35 watt 36-50 watt 51-100 watt > 100 watt
6.8% 17.3% 24.9% 46.2% 4.8%
CLIENT STATUS AT START
OF PROGRAMME

20. CLIENT SAFETY
Early Warning Score (EWS)
SCORE 3 2 1 0 1 2 3
Respiratory
Rate
< 8 9-14 15-19 20-30 >30
Pulse/min < 40 40-50 51-100 101-110 111-130 >130
30 sec ECG Normal Some
arrhythmia’s
< 6 PVC/min >6 PVC/min
Systolic Blood
Pressure
(mmHg)
< 90 90-99 100-110 111-140 141-160 161-170 >170
Medication All meds
taken
Took meds later
or earlier
Forgot to take
medication
Glucose Levels
mmol.l-1
< 5.55 >13.8 with no
ketosis
>16.6 with no
ketosis
>13.8 with
ketosis
Complexion Red, hot,
confused
Fully alert Slow to respond Confused Pale, cold and
low alertness
Symptoms No Angina
or other
symptoms
Light barely
noticeable
symptoms
Moderate
bothersome
angina or
symptoms

21. ENVIRONMENT – SUPERVISION
& STUDENT CONDUCT
• Scope of Practice
• Profession Development
• Team Work
– Off the ball contributions
• Professional conduct
• Running a Tight Ship
– Privilege, Not a Right
– Rather Safe than Sorry
• Building partnerships
– Understand the history of CEP
– Cherish and nurture the privilege
to have place to serve
“Creating an
Environment where
Clients feel
Comfortable,
Supported and Safe”

22. U-Kinetics Te Huinga Waiora
CLIENT OUTCOMES

23. Variable Pre-training Post-training P-value
X SD X SD
Physical Function 39.3 11.3 44.0 10.4 0.0001
Role-Physical 39.2 11.1 45.0 10.5 0.0001
Body Pain 45.0 11.2 48.9 9.7 0.0001
General Health 40.5 11.0 45.2 11.1 0.0001
Vitality 45.4 10.1 50.7 11.1 0.0001
Social Function 43.9 11.7 48.9 10.4 0.0001
Role-Emotion 42.6 14.4 48.2 10.9 0.0001
Mental Health 49.1 10.5 52.7 9.6 0.0002
Physical Component 39.2 10.3 43.9 9.2 0.0001
Mental Component 47.9 11.4 52.8 10.1 0.0001
CES-D 12.9 10.2 9.5 7.9 0.0004
HADS Anxiety 5.9 3.8 4.5 3.1 0.0001
HADS Depression 4.8 3.3 3.2 2.8 0.001
QUESTIONNAIRE RESULTS
SF-36v2QUESTIONNAIRE
ALLQUESTIONNAIRESSHOWED
SIGNIFICANTIMPROVEMENTS

24. Variable Pre-training Post-training P-value
MEAN SD MEAN SD
RSBP 136.0 16.5 131.6 14.6 0.0001
RDBP 80.8 9.9 78.1 9.4 0.0001
Body Weight 92.6 23.7 91.8 22.9 0.62
BMI 33.5 8.2 32.1 8.4 0.31
Percentage body fat 28.1 14.2 26.9 13.4 0.32
Watt3 58.9 25.7 80.7 35.1 0.0001
VO2 peak 19.6 6.1 23.2 7.0 0.0001
MET 5.6 1.7 6.6 2.0 0.0001
PHYSICAL FUNCTION
RESULTS

25. EFFECT ON HAEMODYNAMIC
VALUES OF CARDIAC PATIENTS
Baseline
Assessment
12 Week
Assessment
Final
Assessment % Change
Category Mean
(± STDEV)
Mean
(± STDEV)
Mean
(± STDEV)
Baseline
to 12
Weeks
Baseline
to 24
Weeks
% of Total Change
Achieved in First 12
Weeks
Systolic BP 136.6 (±16.7) 131.1 (±14.2) 126.4 (±12.2) -4% -8% 50%
Stroke Volume 56.2 (±16.5) 53.8 (±14.1) 52.0 (±12.9) -4% -7% 57%
mVO2 87.2 (±18.1) 84.4 (±16.9) 78.5 (±15.0) -3% -10% 30%
MAP 99.1 (±10.5) 95.2 (±10.9)* 91.8 (±6.75)* -4% -7% 57%
SBPslope 205.7 (±49.5) 189.8 (±39.5) 187.4 (±32.2) -8% -9% 89%
Wattpeak 60.2 (±21.8) 89.2 (±35.9)* 110.4 (±46.2)* 48% 83% 58%
RPEslope 19.9 (±8.47) 15.2 (±5.19)* 13.9 (±7.44)* -18% -22% 82%
mVO2 s3 218.3 (±37.9) 223.4 (±34.9) 240.3(±49.9) 2% 10% 20%
VO2peak 19.6 (±5.67) 24.7 (±7.22)* 28.2 (±6.88)* 26% 44% 59%
CRI 39.3 (±13.3) 36.2 (±10.3) 32.5 (±6.67) -8% -17% 85%

26. PROGRAMME EFFECT ON
FUNCTIONAL CAPACITY (VO2peak)
28.3
15.5
47.5
6.4
2.3
10.5 11.9
47
23.3
7.3
0
5
10
15
20
25
30
35
40
45
50
<4.30 4.31-4.99 5.0-7.99 8.0-9.99 10.0+
Percentagerespondents
Functional capacity in MET
Pre
12-wks
N=366'Functionally able'
increased from
8.7% to 30.6%

27. 25
22.1
47
5.9 01.5
8.8
51.5
26.4
11.8
0
10
20
30
40
50
60
<4.3 4.31-5.0 5.1-8.0 8.1-10.0 10.1+
Pre
24-wks
N=133
Reduce functionally
Impaired from
47.1% to 10.3%
Functionally
dependent
Functionally
restricted
Borderline
Percentagerespondents
38.2% of ‘strugglers’
functionally able after
24-wks
PROGRAMME EFFECT ON
FUNCTIONAL CAPACITY (MET)

28. TRAINING EFFECT LOW FINISHERS
(Post exercise MET <4.3)
Angina Scale
1 Light,
Barely Noticeable
2 Moderate, Bothersome
3 Severe,
Very Uncomfortable
4 Most severe pain ever
experienced in the past
Variable Pre-exercise Post-exercise p-value ES
x SD x SD
RSBP 140.3 18.8 135.1 13.8 0.27 0.27
RDBP 80.8 12.6 76.4 11.1 0.21 0.35
Weight (kg) 105.8 34.3 104.8 33.1 0.91 0.03
Watt3
32.7 7.1 40.3 9.3 0.01 0.81
RPEslope
18.1 6.5 14.9 6.6 0.10 0.48
SBPslope 203.0 65.1 186.8 70.4 0.41 0.23
Angina 3.2 1.5 2.6 1.7 0.23 0.35

29. CLIENT FEEDBACK THEMES
• Well-resourced
• Friendly, well trained and encouraging staff and students
• Supervision is excellent
• Removed my fear for exercise
• Significant impact on my health and well-being
• My blood sugar levels mean I need to inject less insulin during
the day.
• Love the personal approach
• I feel more in control of my health
• Feel I can cope with my situation now
• The program has given me my life back

30. FUTURE CHALLENGES &
OPPORTUNITIES
• Rehabilitation vs Prevention Focus
• Recognition of Clinical Exercise Physiologist Role
– Professional Registration – CEPNZ
– Recognition from Health Funders
• Determining Cost-Effectiveness of Programme
• Expansion of Clinical Exercise Physiology Services
– Other Areas & Other Conditions
• Showcasing Role Within Other Settings
• Increasing Graduate Opportunities
– Making use of this new workforce

31. Appendix slides
Additional slides for Q&A part

32. MidCentral Award
2013 MidCentral DHB Peoples’ Choice Award
The judges commented that this is a service that has been
very well received by its clients:
“This is a new programme demonstrating exciting potential
to achieve improved outcomes from participants.”
Respiratory Client:
In one case, a 22-year-old patient came into the clinic suffering from
severe asthma. Unable to distinguish the difference between being
short of breath due to exercise and asthma, the client had very little
exercise IQ as she had always been scared of triggering an asthmatic
episode.
By the end of her 12-week programme, the client had learned to
distinguish between the two; increasing her confidence and making
huge improvements to all aspects of physical and psychological
measured parameters. The patient now aims to walk a half marathon
later this year.

33. CLIENT
EXAMPLE
Client Data
Pre-training
• Age: 48
• Height: 187.6
• Weight: 235.8 kg
• Resting BP: 150/98
• Random Glucose: 9.2
• Type 2 diabetic on Metformin
• Obstructive sleep apnoea score: 9/24
• Using GTN spray 3 to 4 times per week
• Walk with crutches; can’t walk more than 150
meters
• Wattmax: 60 Watt
• Bpmax: 174/110
• RPEmax: 14
After 11 weeks of training
• Lost 24 kg
• Taken off Metformin
• Pre-exercise glucose dropped from always above
8.5 (spiking to 11 some days) to rarely being
higher than 6.0
• Training Watt increased form 40 Watt to 60 Watt
(+67%)
• Highest training RPE: 12
• Pre-exercise BP: 120-130/86
• Highest Exercise BP: 168/90
• Use GTN less than once a week
• Sleep apnoea score: 5/24
• Can walk 60 minutes non-stop without crutches
Letter From Client
I thought long and hard if I wanted to write this letter.
But as many steps as I was taking during my
participation in Relay for Life – held in my hometown
Porirua – I know I had to put it on paper.
Last year – captured in the world of the obese; ashamed
of myself; staying homebound; food was my comfort; I
moved around on specially made crutches.
When I did try to get my A into G – trying to go for a
walk; I managed 100 to 150 meters before running out
of puff; had extreme pain in legs and back, and legs
cramping. So much pain that when I got home I wanted
to be left alone and didn’t want to hear or think about
my problem.
This weekend – an unlimited amount of laps have been
completed without crutches; my family showed - for the
first time- pride in me for the weight I’ve lost, how I look
and for walking without crutches.
Now I am looking forward to dancing with my daughter
on her 21st this coming Saturday. Our first
father/daughter waltz – something that I didn’t even
imagined possible just a few months ago.
My goal was to lose 10 kg but with your help I’ve now
lost 24 kg since starting at U-Kinetics 3 months ago.

34. Anxiety PAI Sway
Grip
Strength
% Change -22 121 -15 23
-22
121
-15
23
-60
-40
-20
0
20
40
60
80
100
120
Percentagechange
Effect on anxiety, activity patterns,
body sway and grip strength