Upload
dangnhi
View
215
Download
2
Embed Size (px)
Citation preview
Exercise Prescription for the Certified
Cardiac Rehab Professional
Erik Ostrowski, MS, ACSM-RCEP, CCRPSouthern Illinois Healthcare
Herrin Hospital
Today Exercise prescription (Ex Rx) as it relates to
the CCRP exam Certified Cardiac Rehab Professional Specific Ex Rx recommendations for pulmonary
patients have been omitted Most Ex Rx concepts for cardiac patients remain
interchangeable with other chronic disease conditions
CCRP Exam Categories 10 Categories
1. Patient assessment2. Nutritional management3. Weight management4. Blood lipid management5. Blood pressure management6. Diabetes management7. Tobacco Cessation8. Pyschosocial Management9. Physical Activity Counseling10. Exercise Training
CCRP Exam Blueprint Exercise Training
Design and modify an aerobic exercise training program
(10.11, 10.12, 10.13) Understand and consider
various physiologic measures for use in an Ex Rx
HR, HRR, VO2, VO2R and METs (10.6)
Design and modify a resistance training program (10.15)
Components of the Ex Rx FITT Principle
There are four primary variables that need to be considered when designing a basic Ex Rx
Frequency # of days per week
Intensity (difficulty) %HRmax, %HRR, %VO2max,
%VO2R, METs, RPE Time (duration)
minutes per session Type (mode)
Continuous, rhythmic activities that involve large muscle groups
F – Frequency I – Intensity T – Time T - Type
Components of the Ex Rx What are we
missing???
Progression Volume
FITT Principle becomes the FITT-VP Principle
F – Frequency I – Intensity T – Time T – Type
V – Volume P – Progression
Type (Mode) What types of exercises are appropriate for
patients with CVD? Continuous, rhythmic activities that involve large
muscle groupsEquipment Examples:
Practical Examples:
Frequency How many times per week
should a patient with CVD exercise? 3-5 days/wk Up to 7 days/wk is safe and
effective Cardiopulmonary benefits occur (and can be
maintained) with as little as 2 days/wk (intensity/duration dependent)
Will depend on an individual’s current fitness level and goals
EXERCISE
EXERCISE
EXERCISE
EXERCISE EXERCISE
EXERCISE EXERCISE
Time (Duration) How many minutes should a patient with
CVD exercise during a given session? 20-60 minutes May be accumulated in shorter intervals
of at least 10 minutes per interval In extremely deconditioned individuals, shorter
intervals are acceptable with a goal to attain 10 minutes of continuous exercise before resting
Intensity How intense should exercise be for a CVD
patient? “ACSM Guidelines indicate that a minimal intensity
threshold lies between 30-40% of the patient’s HRR or VO2R, with the upper range at approximately 80% HRR or VO2R”
ACSM Intensity Level Guidelines:Light (low): < 40% HRR or VO2RModerate (medium): 40-60% HRR or VO2RVigorous (high): 60-80% HRR or VO2RNear Maximal (very high): 80-90% HRR or VO2R
Intensity What about an upper limit to exercise intensity
levels for patients with CVD? Up to 80% HRR or VO2R is safe during continuous
exercise Up to 90-95% peak HR for short bouts during HIIT
In other words, don’t be afraid to allow your patients to continue exercising past their age-predicted or estimated values if they are NOT asymptomatic!
Physiological Measures Heart Rate Maximum (HRmax)
An individual’s maximum achievable heart rate
Expressed in beats-per-min (bpm)Heart Rate Reserve (HRR)
The difference between maximal and resting HR values
Expressed in beats-per-min (bpm)Also called “Maximal Heart Rate Reserve (MHRR)”
Heart Rate Reserve (HRR) MethodKarvonen Formula: ((HRmax – HRrest) x %) + HRrest
Also referred to as the Karvonen Method1. Find HRmax
Directly measure using a maximal cardiopulmonary stress test Estimate through equation (220-age)
2. Find HRrest Directly measure via palpation (or pulse oximeter) at rest
3. Pick the desired ACSM intensity level (%)4. Input numbers into Karvonen Formula
HRmax, HRrest, and the desired ACSM intensity level
HRR Example What HR (bpm) would a 60 year-old male need to
maintain in order to be exercising at 50% of his HRR?1. Find HRmax using 220-age equation: 220 - 60 = 160
bpm2. Find HRrest via pulse oximeter: 74 bpm3. Pick desired ACSM Intensity Level: 50% = 0.504. Plug into Karvonen Formula((HRmax – HRrest) x %) + HRrest
((160 – 74) x 0.50) + 74 = 117 bpm
Remember: To find an intensity range (i.e., 50-80%) you must perform this equation twice!
Physiological Measures Maximal Volume of O2 Consumption (VO2max)
The maximal amount of O2 the body can take in and utilize Usually expressed in ml/kg/min Adults with CVD are more likely to have a max capacity of 15-30
ml/kg/min Volume of O2 Consumption Reserve (VO2R)
The difference between maximal and resting O2 consumption values Usually expressed in ml/kg/min
Metabolic Equivalent (METs) An expression of O2 utilization in the body MET = ml/kg/min ÷ 3.5 Adults with CVD are more likely to have a max capacity of 5-10 METs
VO2 Reserve (VO2R) MethodFormula: ((VO2max – VO2rest) x %) + VO2rest
1. Find VO2max Directly measure using a maximal cardiopulmonary
stress test2. Find VO2rest
3.5 ml/kg/min for everyone! (1 MET)3. Pick the desired ACSM intensity level (%)4. Input numbers into formula
VO2max, VO2rest, and the desired ACSM intensity level
VO2R Example What VO2 ml/kg/min would a 200 lb., 50 year-old
female need to maintain in order to be exercising at 50% of her VO2R?
1. Find VO2max using a maximal CP stress test = Ex. 24.5 ml/kg/min
2. Constant VO2rest = 3.5 ml/kg/min
3. Pick desired ACSM Intensity Level: 50% = 0.504. Plug into Karvonen Formula
((VO2max – VO2rest) x %) + VO2rest
((24.5 – 3.5) x 0.50) + 3.5 = 14 ml/kg/min
Remember: To find an intensity range (i.e., 50-70%) you must perform this equation twice!
VO2R Example Continued… So what now? Convert to METs
14 ml/kg/min 3.5 = 4.0 METs Use metabolic equations to determine equipment
settings Treadmill = 3.3/1.0 (speed/incline) Airdyne = 58 watts Arm Ergometer = 41 watts Recumbent Bike = 41 watts Recumbent Stepper (NuStep) = 125 watts
For a helpful calculator visit: http://www.fidel.com/mets/
Intensity – Other Considerations Peak exercise HR should generally be set at least 10 bpm
below the HR associated with any of the below criteria: ICD firing threshold Onset of angina Plateau or decrease in systolic BP > or = 250 SBP > or = 115 DBP > or = 1mm ST-segment depression Increased frequency of ventricular dysrhythmias Other significant ECG disturbances (2nd or 3rd degree AV block) Other signs/symptoms of exercise tolerance
Prescribing Exercise Intensity w/o Exercise Test Data
How do we prescribe exercise intensity w/o an exercise stress test? Use RPE Use HR and/or MET levels derived from the 6MWT as a
target intensity early on If you use HR, remember 220-age with caution because
it is just an estimate and HR is genetically extremely variable!
Remember: 220-age is invalid if a patient is taking beta blockers!
Prescribing Exercise Intensity w/o Exercise Test DataExample: Larry walked 1260 ft. during his 6MWT without any complaints. How can we determine a starting exercise intensity with just this information?1. Convert 6MWT speed to miles-per-hour
1,260 6min/ft x 10 6min/hr. = 12,600 ft/hr 12,600 ft/hr ÷ 5,280 ft/mi = 2.386 mph Treadmill setting = 2.4 mph / 0.0 incline
2. Convert treadmill setting to METs using the metabolic equation See ACSM’s Guidelines for Exercise Testing and Prescription (9th ed.) or
use computer system software if available Larry’s treadmill setting = 2.8 METs Set all equipment workload settings to 2.8 METs Titrate equipment individually every 3 minutes until an RPE of 11-13 is
reached
RPE Rating of Perceived Exertion
(RPE) Subjective scale of exercise intensity
6–20 (traditional); 1–10 (modified) Valuable when exercise stress test
data is unavailable Relative intensity equivalents:
Light: 30-40% HRR/VO2R = RPE ~8-11 Moderate: 40-60% HRR/VO2R = RPE
~12-14 Vigorous: 60-80% HRR/VO2R = RPE ~15-
17
Progression Starting exercise goal:
Attain 30-40 minutes of continuous exercise at a low-moderate intensity (RPE 11-13) per session
Progression goals: Gradually titrate upward the frequency, intensity
and duration of exercise until the patient achieves: 5-7 sessions per week (this includes home exercise!) 150-300 mins per week 50-60 mins per session 12-16 RPE (somewhat hard - hard)
Gradually increase exercise VOLUME
Volume What is exercise volume?
Exercise Volume = Duration x Intensity x Frequency Expressed as MET-min-wk or kcal/wk
Why is understanding exercise volume important? Standardized measurement being used in research Excellent way to track exercise progression
Recommend 5-10% increase in exercise volume per week Strive for 500-1000 MET-min-wk
Exercise volume impact on atherosclerotic lesion progression:
<1000 kcal/wk = Likely progression 1000-1500 kcal/wk = Little/No progression >2200 kcal/wk = Possible regression
Resistance Training One exercise for each major muscle group (8-10 in
total) Upper BodyChestBack
ShouldersBicepsTriceps
Mid/Lower Body
AbdomenGluteals
QuadricepsHamstrings
Calves 1-2 Sets 8-12 Reps 2-3 mins
Rest/Sets 48-72 hrs
Rest/Sessions
Resistance Training Do’s & Don’ts Do
Wait to use with PTCA/PCI/MI patients for 2-3 weeks post procedure Wait to use with CABG/Valve/Surgery patients for 4-5 weeks post procedure Safe for HF patients Avoid excessive isometric contractions Utilize proper breathing technique (avoid Valsalva) Start light and progress gradually
Don’t utilize resistance exercise in patients with: Uncontrolled arrhythmias Symptomatic HF Severe valvular disease Large aortic aneurysms Uncontrolled HTN (resting SBP >160, resting DBP >105)
Take Home Points If you use HR, remember 220-age with caution because it is just
an estimate and HR is genetically extremely variable It’s safe to allow patients to exceed the HR ranges you set for them
so long as they are asymptomatic 220-age is invalid if a patient is taking beta blockers
Even if you do not plan to take the CCRP exam, this material is the foundation for how and why to prescribe exercise for patients with CVD It meets all AACVPR and ACSM guidelines
Most patients enrolled in cardiac rehab (2-3x/wk) achieve < 1000 kcal/wk or 500-1000 MET/min/wk of energy expenditure This is NOT enough exercise to reduce CVD risk All programs should emphasize the need to exercise at home
References AACVPR CCRP Study Guide ACSM’s Guidelines for Exercise Testing and Prescription (9th ed.) Clinical Exercise Physiology (3rd ed.) Brawner, C. (2010). Prescribing Exercise in Cardiac Rehabilitation
without an Exercise Test. ACSM Certified News, 20, 7-13. Brawner, C., et al. (2004). Predicting maximum heart rate among
patients with coronary heart disease receiving β-adrenergic blockade therapy. American Heart Journal, 148, 910-914.
Keteyian, S. et al. (2012). Predicting maximal HR in heart failure patients on β-blockade therapy. Medicine and Science in Sports and Exercise, 44, 371-376.
http://www.fedel.com/mets/