Card Rehab Final

Diuretics - a.k.a. "Water Pills"

treatment population:

-HTN, CHF, edema, certain kidney disorders

mechanism:

-in kidneys to inhibit absorption of NA

-flush out extra salt and water

-may also cause vasodilation or relaxation

common names

-thiazides: hydrochlorothiazide (HCTZ)** (microzide)

-loop diuretics: furosemide (lasix)- depletes K

-potassium-sapring: pyazide and HCTZ

-aldosterone receptor blockers

side effects

-may lose K, electrolytes

-dehydration

-may raise cholesterol

-increased urination, increased thirst

-muscle cramps, low BP

special considerations:

-maintain hydration

beta blockers

treatment population

-angina, SVT, rate control for afib, MI, CHF, 2ndary for HTN

-migraines, anxiety tremor

mechanism

-blocks effects of epinephrine

-slows HR, less force

-vasodilates

common names

-antenolol (tenormin)

-metoprolol (lapressor, tropol-XL)

-bisoprolol (zebeta)

side effects

(+) decrease mortality rate w/ MI

(+) slows progression of CHF

(+) suppress minor arrhythmias

(-) can cause impotence

(-) fatigue, decrease in energy, nightmares

(-) weight gain

special considerations:

-can trigger attacks in asthmatics

-may block signs of low BG (rapid HR) for diabetes

-class 11 anti arrhythmic: reduce oxygen consumption

-prevent recurrence of tachy, decrease MI mortality

effects on ex

-side effects may decrease desire to ex

-HR: decrease; target HR ~10% less than normal

-may increase asthma symptoms

-Q: decrease or stay same

-BP: decrease

calcium channel blockers

treatment population

-HTN, angina

mechanism

-block Ca from entering cell wall

-promotes relaxation in cell walls

-effective against vessel stiffness

common names

-amlodipine (norvasc)

-feldodipine

-nicaradipine

-diltiazem (cardizem)

-verapramil (verelen)

side effects

-edema --> cells relax, cannot pump blood back up

-constipation

-dizziness, weakness, decrease HR

effects on ex

-ex is best to help reduce side effects

-Q: stay same

-HR: decrease or stay same

-BP: decrease

ACE inhibitors

treatment population

-HTN, CHF, post MI

-chronic kidney disease

mechanism

-prevent creation of angiotensin 11 by inhibiting angiotensin-converting enzyme

-relaxes blood vessels

-reduces amount of H2O reabsorped by kidneys

common names

-enalapril (vasotec)

-lisinopril (zestril)

-rampirpril (altace)

-captopril (capoten)

-fosinopril (monopril)

side effects

(+) decrease heart attacks, strokes, mortality in CAD

(-) dry persistent cough

(-) renal impairment

(-) hyperkalemia

(-) fatigue

(-) dizziness, headaches

Angiotensin 11 Receptor Blockers (ARBS)

treatment population

-HTN, CHF, kidney failure in DM

-reduced risk of stroke and may prevent diabetes for HTN

-may prevent recurrence of afib

mechanism

-prevent angiotensin 11 from binding to receptors on muscles surrounding blood vessels; therefore causing vasodilation

common names

-valsartan (diovan)

-losartan (cozar)

-irbesartan (avapro)

-candesartan (atacand)

side effecrs

-cough

-dizziness, headache

special considerations

-OAs using ACE1 or ARBS may have better function ex capacity and muscle strength

cardiac glycosides

treatment population

-CHR, arrhythmias

mechanism

-act on sodium-potassium pump

-increase out put force

-decrease rate of contraction

common names

-digoxin (lanoxin)

-digitalis

side effects

-high level of toxicity "dig effect"

-liver enzymes must be check regularly

-may increase HR

effects on ex

-do not over ex someone w increased HR

-decrease HR

-BP: stay same

antiarrythmics

treatment population

-afib/flutter, SVT, VT, PVCs, etc

mechanism

-suppress ectopic stimuli

-redirect electrical activity back to correct node

-slow rate of impulse generation and conduction

-decrease myocardial irritability

common names

-IA

procainamide, quindine

-IB

lidocaine, phenytoin

-IC

flecainide, propafenone

-11

beta blockers

-111

amiodarone, tikosyn, dronedarone

-1V

diltalzem, verapamil

nitrates

treatment population

-angina, MI, CHF, HTN

mechanism

-vasodilation

-lowers preload and afterload, lowering mVO2

common names

-nitroglyerin

inhaled

lingual spray

sublingual

transdermal

-isosorbide mono- or dinitrate

side effects

-can decrease BP, can increase HR

-do NOT take w viagra- BP can bottom out

-dizziness, headaches, face flushing

effects on ex

-take 5-10 min prior; monitor for side effects

-HR; increase or same

-BP: decrease or same

-discontinue ex?- call 911 on 3rd nitrate given

Lipid lowering drugs

treatment population

-dyslipidemia

mechanism

-HMG-CoA reductase inhibitors

-inhibits production of cholesterol in liver

-lower cholesterol- decrease LDL, increase HDL

classes and common names

-statins

simvastatin (zocor), atorvastatin (lipitor), pravastatin (pravachol)

-bile acid binding resins

coleservelam (welchol)

-cholesterol absoprtion inhibior

ezetimibe (zetia)

-fibrates

fenofibrate (tricor), gemfibrozil (lopid)

-niacin

niaspan

side effects

-interactions w grapefruit juice

-leg cramps more frequent

-joint inflammation

-facial and neck flushing

-liver toxicity

anti coagulants and anti platelets

treatment population

-afib/ flutter

-valve replacement

-prevention of clots post surgery

mechanism

-reduce platelet aggregation, prevent further thromboemblic events

-thins blood proteins

common names

-heparin (IV only)

-warfarin (coumadin)

-endoxaparin (lovenox)

-dabigatran (pradaxa)

-apixaban (eliquis)

-clopidigrel (plavix)

-asprin (abbrev: ASA)

other considerations

-minor concerns for excessive bleeding, bruising

-mostly from more intensive ex

-risk of falls the greatest concern

heart failure meds

-entresto (sacubitril/valsaratan combo)

-to treat long term CHF

-lowers risk of hospitalization and death

-side effects: hypotension, hyperkalemia, angiodema, kidney problems

emergency cardiac meds

-adrenaline (1st given during cardiac arrest; increases circulating blood, helps restore rhythm)

-amiodarone (if defib is unseccessful after 3 attempts)

-atropine (given to reverse brady and or PEA)

-calcium chloride (may stablize and or strengthen contraction, if adrenaline has failed)

-magenisum sulfate (may stablize arrhythmias cause by low potassium and digoxin toxicity)

diabetic meds

-insulin

-metformin

helps body produce insulin and decreases glucose production and absoprtion

side effects: GI upset, weakness, lactic acidosis

-januvia

often prescribed in addition to metformin to further drop HBA1C

only in type 2

side effects: pancreatitis, kidney dysfunction

not for CHF or kidney disease

other meds

-respiratory- inhaled corticosteroids, bronchiodilators

-cough/cold- antihistamines, expecorants

-hormonal- HGH, contraceptives, thyroid, anti diabetic

-thyroid meds- increase hr and bp

-CNS- anti depressants, psychotics, nicotine replacement

a note about HTN drug recalls 2018-19

-valsartan, losartan, ibesartam; some combos; amlodipine valsartan, valsartan HCTZ

-federal investigators discovered potentially cancer causing impurities that occur during manufacturing process; may cause liver and blood cell damage

an update on aspirin

-low dose ASA risk may outweigh the benefit

-millions of americans have been taking as a preventative; based on theory

-20,000 subject new study; ineffective; risk of bleeding and early death

-no longer recommended for those who do not have high risk or existing heart disease

-instead implement lifestyle habits to control HTN and cholesterol

why exercise test?

"exercise testing should be an extension of the history. A physician obtains the most information by being present to talk to, observe and examine the patient with the test... and physical examination"

indications for GXTs (ACSM)

-diagnosis: presence of dx or abnormal physiologic response

-prognosis: risk for an adverse event, arrhythmias

-evaluation: physiologic response to ex; pre and post op status

exercise measurement concepts

-during ex the physical stress places on the heart and other organs may cause various signs and symptoms that can reflect the presence of chronic disease (CHD, COPD, etc)

-look for: physical s/sxs of exercise tolerance

-ECG focus: ischemia/arrhythmias

pretest

-contraindications: absolute vs relative

-characteristics associated w problems

-pre test likelihood of CAD

-pre test instructions

contraindications to exercise testing

absolute

(we are absolutely not doing the test, RFs too high)

-a recent significant change in the resting ECG suggesting significant ischemia, recent MI (w/ in two days) or other acute cardiac event

-unstable angina

-uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise

-severe symptomatic aortic stenosis

-decompensated heart failure

-acute pulmonary embolus, pulmonary infarction or DVT

-acute myocarditis or pericarditis

-acute infections, endocarditis

-physical disability that precludes safe and adequate testinf

contraindications to exercise testing

relative

(use judgement to preform test)

-known obstructive left main coronaty stenosis (widow maker)

-moderate stenotic valvular heart disease

-advanced or complete heart block

-recent strike or TIA (mini stroke)

-resting HTN: (SBP >200mmHg and or DBP >110mmHg)

-tachyarrhythmias w uncontrilled vent rates

-mental impairment w limited ability to copperate

-hypertrophic cardiomyopathy and other forms of outflow tract obstruction

-neuromuscular, musculoskeletal or rheumatoid disorders that are exacerbated by ex

-ventricular aneurysm

-chronic infectious disease (AIDS, hepatitis)

-uncorrected medical conditions: anmeia, electrolyte imbalance, hyperthyroidism

patient pre test instructions

-no food, alcohol, caffeine or tobacco products for least 3 hrs prior to testing

-rested for the assessment

avoid strenuous ex 24 hrs prior, adequate sleep

-wear clothing that permits free movement

walking or sunning shoes

-take normal medications

patient instructions for GXT (ACSM)

-if the evaluation is on an outpatient basis, pts should be made aware that the evaluation may be fatiguing and that they may wish to have someone accompany them to drive them home afterward

-if the test is for diagnostic purposes, or may be helpful for pts to discontinue prescribed CV meds, but only w physician approval

-currently prescribed antianaginal agents alter the hemodynamic response to ex and reduce the sensitivity of ECG changes for ischemia

-pts taking intermediate or high dose B blocking agents may be asked to taper their med over a 2-4 day period to minimize hyperadrenergic withdrawal responses

-if the test is for functional purposes, pts should continue their med regimen on their usual schedule so that the ex responses will be consistent w responses expecting during ex training

-pts should bring a list of their meds, including dosage and frequency of administration to the assessment and should report the last actual dose taken. as alternative, pts may wish to bring them w them

sequence of measures during ex test

pre test

-12 lead ECG in supine and ex postures

-BP measurements in supine and ex posture

exercise

-12 lead ECG recorded during last 15 secs of every stage and peak ex

-bp measurements should be obtained during last min of each stages

-rating scales: RPE at end of each stages

post test

-12 lead immediately after ex, then every 1-2 mins for least 5 mins to allow any ex indued changed to return to baseline

-BP obtained immediately after ex, then every 1-2 mins until stabilized near baseline

-symptomatic ratings should be obtained using appropriate scales as long as symptoms persist after ex

Absolute Indications for Terminating Exercise Testing

-drop in SBP >10 when accompanied by other evidence of ischemia

-mod to severe angine

-increasing nervous system symptoms (ataxia, dizziness or near syncope)

-signs of poor perfusion

-technical difficulties w ECG or SBP

-desire to stop

-sustained VT or 2nd-3rd HB that interferes w normal maintenance of Q during ex

-ST elevation (>1.0mm)

relative Indications for Terminating Exercise Testing

-drop in SBP >10 when in the absense of other evidence of ischemia

-ST or QRS changes such as ST depression (>2mm horiz/down slopping)

-arrhythmias other than sustained VT, including multifocal PVCs, triplets of PVCs, SVT, BP, brady

-fatigue, SOB, wheezing, leg cramps, claudication

-increasing CP

-hypertensive response

-SpO2 >80%

-development of BB or conduction delay that cannot be distinguished from VT

bruce TM (65%)

-1963: non invasive test to assess pts w suspected CHD

also common for estimating VO2max

stages protocol

-pros:

good to predict VO2max

short duration (8-12mins)

increased ischemic sensitivity bc of abrupt increases in workload

-cons:

4.6 METs for 1st stages

stages are unequal and large increases in workload

awkward 4th stage

overestimates capacity if no SSHR

bruce TM stages

stage 1= 1.7 mph at 10%

stage 2= 2.5 mph at 12%

stage 3= 3.4 mph at 14%

stage 4= 4.2 mph at 16%

stage 5= 5.0 mph at 18%

stage 6= 5.5 mph at 20%

stage 7= 6.0 mph at 22%

stage 8= 6.5 mph at 24%

stage 9= 7.0 mph at 26%

balke and naughton protocols

-pros:

smaller incremntal increases (~1MET)

better for decomintioned, OA, or diseases

balke protocol

-speed is contant at 3.3mph, begin at 0% grade

-elevation goes to 2% at min 2

-elevation then increases 1% each min

-test continues to exhaustion, time is recorded

naughton protocol

-has 2 min warm up: 1 mph/0% grade

-next speed 2 mph and stays consistence for remainder of test

-6, 2 min intervals

-elevation increases by 3.5% every 2 mins

6 min walk test

-appropriate for pulmonary pts, severely deconditioned, gait concerns etc

-measured distance in 6 mins

-rate dyspnea, RPE

-pt can stop and rest if need be; chair along course

causes of false negative test results

-failure to reach ischemic threshold

-monioring an insifficient number of leads to detect ECG changes

-failure to recognize non ECG s/sx that may be associated w underlying CVD

-angiographically significant CVD compensated by collateral circulation

-musculoskeletal limitations to exercise preceding cardiac abnormalities

-technical or observer error

causes of false positive test results

-ST depression >1.0mm at rest

-LVH

-accelerated conduction defects (WPW)

-digitalis therapy

-nonischemic cardiomyopathy

-hypokalemia

-vasoregulatory abnormalities

-MV prolapse

-pericardial disorders

-technical or observer error

-coronary spams

-anemia

review of types of testing

-GXT

-nuclear med

-chemical

-cycle ergometer

-supine testing

what to do w the results?

-take data from GXT: peak speed and grade

-convert speed from mph to m/min (*26.8); use decimal for grade (14%= .14)

-use walking or running equation from ACSM

example

mary completed 7 mins, 38 sec of a bruce protocol. test was terminated due to achieving THR and dynspnea. calculated her VO2 and METs

VO2= 3.5 (1.0 X S) + (1.8 X S X G)

VO2= 3.5 (1.0 X(3.4 X 26.8) + (1.8(3.4 X 26.8) X .14)

=35.57mL/kg/min

METS= 35.57mL/kg/min / 3.5 = 10.16 METs

characteristics of athlete's heart

-ventricular hypertrophy; allows for increase in CO

combo of both endurance and strength/power

-enhanced CO

-lower RHR and exercising HR

-improved vasovagal tone

ECG of an athlete

common findings:

-1st degree AVB

-LCH by voltage

-LA/RA enlargement

-ST segment elevation

-Tall T waves

-partical RBBB

arrhythmias in the athlete

-PAC and PVCs common, no clinical significance

-low level AVB

-potentially life threatening arrhythmias would indicate underlying condition

sports participation and SCD (ACC 2016)

-100-150 SCD events per year (between 1/100,000- 1/300,000); 9X higher in males

-HCM ~ 50% SCD

healthy heart vs heart with HCM

healthy heart

-blood flow out of heart

-blood w/ in heart

-heart wall

heart with HCM

-reduced blood flow out of heart

-less room for blood w in heart

-thickened heart wall

commotio cordis

-SCD not related to disease; caused by blunt chest impact produced by either a projectile or a collision w another athleye

-low energy chest impact direcetly over the heart

-precise timing of the blow to a narrow 15 ms segment of the cardiac cycle; just prior to T-wave peak

-narrow, compliant chest wall; typical of young children

primary determinants and triggers

-pericardial impact size

-timed during upstroke of T wave

contributing variables

-greater hardness of projectile

-smaller sphere

-direct orientation

-thinner, more compliant chest wall

D 111 football study on CVD risk

-whitworth university (spokeane, washington)

-89 football players SD age 19.6 +- 1.7 yrs

-21 linement, 68 non linemen

-ht, wt, BMI, bp (lineman did blood glucose level and cholesterol analysis, waist and hip circumference and body fat %)

-85.7% of linemen had a BMI >30

-9.5% were shown to have HTN

-42.9% had <40mg/dL HDL

-19% had metabolic prevalence syndrome

cardiac implications after SARS-COV-2 infection

complications include:

-myocardial injury

-CHF

-cardiogenic shock

-arrhythmias

-myocarditis

-MIS-C

pre participation screening

-to reduce the prevalence of SCD, differentiating between physiological and pathological changes in crucial

-includes family hx, vitals, meds, drug use hx

-debate exists in efficacy of screenings

also cost and time; secondary follow up

cardiovascular preparticipation screening in athletes

pros:

-can potentially save the lives of athletes that aren't aware that they have a heart disease

-give athletes a further look into their health

-gives a better look on the patient compared to a family history questionnaire

-some include a 12-lead ECG

cons:

-the echocardiography and cardiopulmonary stress tests take time and a sufficient amount of money

-the U.S. is opposed to adding the 12 lead ECG to the screening, they feel as if it doesn't give any more evidence than a family/history questionnaire

NOTable cardiac events w/ athletes

-1971: chuck hughes, detroit lions, suffered MI during games

-1998: Chris Pronger, NHL st. louis blues, suffered commotio cordis after being struck by puck

-2003: marc-viven foe; cameroon soccer player, suffered fatal MI during match; later determined HCM

-2020: Jay Bouwmeester, NHL St Louis Blues, collapsed following cardiac event; now has ICD

-2021: Christian Eriksn, Denmark Soccer player; suffered cardiac arrest during match

JJ watt

defensive end, Arizona Cardinals

-at age 33, experienced an episode of afib 9/28/22

-had cardioversion the next day

-played on 10/2/22

Damar Hamlin

safety, Buffalo Bills

-at age 24, suffered cardiac arrest during game on 1/2/23

-defibrillated X, intubated and in critical condition for over a week

principles of ex prescription

considerations for a clinical population

core components of CR

-baseline pt assessment

-nutrition counseling

-RF management

-psychosocial management

-activity counseling

-appropriate prescribed ex therapy

-outcomes analysis

inpatient rehab programs (Ph 1)

REMEMBER THE FOCUS!

-early mobilization

-identification and education of CVD RF's

-assessment of pts readiness for PA

-comprehensive discharge planning

referral to outpatient CR

goals of inpatient CR

-by discharge, pt should demonstrate understanding of PA that may be inappropriate or excessive

-safe progressive plan of ex should be in place

-referral/recommendation for outpatient CR and information about the use of home ex equipment

benefits of inpatient CR

-offsetting negative psychological and physiologic effects of bed rest during hospitalization

-providing additional medical surveillance of pt

-identifying pts w significant CV, physical or cognitive impairments that may influence prognosis

-enabling pts to safely return to ADLs w/ in limits of their disease

-preparing pt and support system at home to optimize recovery following discharge

recommendations for inpatient exercise programming

intensity

-RPE <13

-post MI: HR <120bpm or RHR + 20bpm

-post surgery= RHR + 30 bpm

-to tolerance if asymptomatic

recommendations for inpatient exercise programming

duration

-begin w intermittent bouts lasting 3-5mins as tolerated

-rest periods can be a slower walk or complete rest at pt's discretion; shorter than exercise bout duration; attempt to achieve 2;1 exercise/rest ratio

recommendations for inpatient exercise programming

frequency

-early mobilization two to four times per day (days 1-3)

-later mobilization two times per fay (on day 4) w/ increased duration of exercise bouts

recommendations for inpatient exercise programming

progression

-when continuous exercise duration reaches 10-15 mins increase intensity as tolerated

goals of out patient CR

-appropriate monitoring/supervision to detect deterioration in clinical status, and to provide communication to referring physician

-return to pt to premorbid vocation and/or recreational activities activities, make modifications as necessary or find alternative activities

-develop and implement safe, effective formal exercise and lifestyle activity program

-provide pt and family education about risk reduction and predicted outcomes- maximize secondary prevention

some things to consider....

-sefety first

-Risk strification!- low, mod, high risk

-pts vocational requirements

-orthopedic limitations

-premorbid and current activities

-personal health and fitness goals of pt

exercise intensity

-above minimal level required to induce "training effect" yet blow the metabolic load that evokes abnormal clinical s/sx

recommendations for intensity

-40-80% using HRR or VO2peak

-rpe 11-16

-below ischemic threshold <10 beats

heart rate reserve method (karvonen)

-appropriate for cardiac pts, those on beta blockers and diabetics

-appears to closely appropriate percentage of O2 uptake reserve

-220-age = 200 - RHR= __________ X % THR= ________+RHR

-be aware of other variables: ischemic ST depression, angina symptoms, dysrhythmias, BP responses, perceived exertion

RPE

-"11-13" fairly light to "somewhat hard" corresponds w upper limit of prescribed training heart rates during early stages of CR

-"14-16" may be appropriate if no s/sx of ischemia or serious dysrhythmias

-beware of individuals variations!

ischemic threshold

-peak ex HR should be 10bpm below threshold

-silent ischemia identified as link between lack of premonitoring sx and increased risk of cardiac arrest during physical stress

-you can use HR observed as highest "safe" workload achieved on stress test

consider medication effects

-B blockers blunt HR/BP response

-pts taking single dose of med in the morning are more likely to experience tachy and ischemic ST depression during late afternoon than during morning exercise bouts

-prescribed HRs should be based on ETT if available!

modes of exercise

-encourage to use multiple modes to promote total physical conditioning if clinically appropriate

treadmills, cycles, arm ergometers, stair climbers, Nustep, rowing machines, swimming

ROM/flexibility exercises

resistance training

walking!

progression of exercise

RPE depends on

-individuals functional capacity

-orthopedic and musculoskeletal status

-comorbid conditions (diabetes, obesity)

-individual's activity goals and preferences

ExRx with out ETT

-be conservative to start w/ close medical surveillance (ECG monitoring)

-oberve pt closely for s/sx of ex tolerance, and observe ex BP frequency

-use other tools such as DASI to estimate individuals function capacity

-THR set at 20bpm above standing rest and gradually increased using RPE, ECG, sx

resistance training for cardiac pts

-many cardiac pts lack physical strength and/or self confidence to preform common ADLs

-resistance training appears to decrease cardiac demands (reduced RPP) during ADLs like carrying groceries of lifting moderate to heavy objects while at the same time increasing endurance capacity

who can resistance train?

-min 5 wks post MI or surgery, including 4 wks consistent participation in CR

-min 3 wks post intervention (OTCA) including 2 wks in CR

-no evidence of:

CHF

uncontrolled dysrhythmias

uncontrolled HTN

severe valvular disease

unstable symptoms

resistance training guidelines

-to prevent soreness and minimize risk of injury, initial load should allow 12-15 reps comfortably

-1 set, 8-10 exercises, 2-3 d/wk (major muscle groups)

one more set may be added, but gains not proportionate

-exercise large muscle groups before small

-raise wt w slow, controlled movements, emphasize complete extension of limbs when lifting

-avoid straining, valsalva maneuver

-exhale during exertion phase of lift

-avoid sustained, tight gripping, which may evoke an excessive BP response

-RPE 11-13

-stop ex if warning s/sx occur: dizziness, dysrhythmias, unusual SOB, anginal discomfort

ExRx for Resistance Training

-50% of 1RM

-use of elastic bands, light (1-5lbs) weights, wall pulleys may be used progressively at CR entry w out contraindications

-low wt, 1 set 10-15 reps to mod fatigue using 8-10 different exercises

-progression: 2-5lbs/wk arms, 5-10lbs/wk legs

-RPE 11-13

-appropriate instruction!

OMNI-RES scale

0-10 scale for resistance training

ex prescription modifications

angina

monitor occurrence of sx onset, freq, duration, triggers, associated workload/intensity

ex prescription modifications

revascularization

monitor occurrence of pretreatment s/sx especially during 1st 6 mths post procedure

ex prescription modifications

LV dysfunction, CHF

-recognize increased potential for complex arrhythmias, HTN, wt gain, SOB, edema, fatigue

ex prescription modifications

pacemakers

review type of device and reason for placement and discharge threshold for ICD

ex prescription modifications

heart transplant

recognize potential for altered HR, BP, symptom response

ex prescription modifications

leg claudication

evaluate responses to varying ex modalities: sx onset, walking distance, pain ratings

ex prescription modifications

diabetes

recognize importance of glucose management and specific sx related to ex

ex prescription modifications

COPD

monitor for occurrence of O2 desaturation and understand role of supplemental O2 and dyspnea ratings

"dyspneal spiral"

ex prescription modifications

HTN

recognize the BP responses to varying activities

ex prescription modifications

obesity

recognize potential for orthopedic stress and understand behavioral factors associated w disease

ex prescription modifications

arthritis

limit excessive jt stress by altering exercise format

how to write an ExRx

-take data from GXT, if available to prescribe target heart rate zone (THRZ) and MET Rx

-consider the pt: special considerations? what makes this pt unique or different from your last?

-use FITT guidelines!!!!!!!

-consider what additional components of CR your pt may benefit from

smoking cessation

dietary counseling

THRZ: karvonen (HRR)

-determine intensity range (40-80%)

-220-age= _______ - RHR= ______ X low range= ________+ RHR= _______

-220-age= _______ - RHR= ______ X high range= ________+ RHR= _______

-then give THRZ as a range

ex: 123 -148 bpm

-ALWAYS ROUND HRS TO NEAREST WHOLE #

MET RX

-take the data from GXT: peak speed and grade

-convert speed from mph to m/min (X 26.8); use decimal for grade (14%= .14)

-use walking or running equation from ACSM

-VO2= 3.5 + (1.0 X S) + (1.8 X S X G)

-VO2 will be calculated in mL/kg/min

-divide by 3.5 for max MET

-the calculate % based on intensity range

-if you calculate VO2 to equal 42.7ml/kg/min

42.7/3.5= 12.2 max METs

if desired range for RX is 50-70% then do this:

12.2 X .5= 6.1 AND 12.2 X .75= 9.2

MET RX is 6.1-9.2 METs

calculate BMI

-wt in kg/ht in M^2

-final answer will be something like kg/m2

X by 0.0253 to find meters

special considerations

things like:

-orthopedic limitations

-meds that may effect ability to ex or create the need to alter how we prescribe x

-occupational considerations

-pts readiness, affect, attitiude, etc

other assessments to enhance ExRx

-flexibility

-muscular endurance

gallon, jug shelf transfer

-nutritional counseling

-QOL questionnaires

-lifestyle interviews

new supporting data

-change in fitnes at 12 wks was related to better survival

-pts who increase their fitness by 1 MET has a 13% lower risk of death compared to pts w no change

-this is true for increase 2 METs vs Increase 1 MET or increase 3 METs vs increase 2 METs etc

-this relationship is independent of a pt's starting MET level

-note: increase 2 METs vs no change is 24% lower risk

-increase 2 METS vs 0 METs or increase 3 METS vs increase 1MET etc

-MET increase in ex workload from start of CR tp 1 mnth= 35% decrease risk of death

behavior change

theories that relate to health and wellness behavior and aid in risk factor management

common psychological and sociological barriers

-motivation is the biggest perceived barrier

-other barriers include: stress, lack of self efficacy, lack of social support and or lack of child care, lack of time

behavior change theories

definition: framework for understanding the process through which a complex behavior is initiated and sustained over time

-all theories posses constructs:

personal traits inferred by researcher to describe behavior (self efficacy, motivation, extroversion, self esteem etc

common theories applied to health behavior change

-the stages of motivations for readiness for change model (transthoretical model)

-social ecology theory

-decision making theory

-the theory of reasoned action

-social support theroy

-social cognitive theory

-the theory of planned behavior

-health belief mode

-theory of relapse prevention

Transtheoretical Model of Change

precontemplation

contemplation

preparation

action

maintenance