Obesity

Obesity is excess body fat for a given age or gender and can increase the risk of coronary heart disease two-fold (BHF, 2004). Body Mass Index (BMI) is an accepted method of estimating a person's relative weight. BMI is calculated by dividing weight in kilograms by the square of height in metres. The following are the differing ranges of BMI BMI 20-24.9kg m2 healthy, stable, weight range BMI 25-29.9 kg m2 overweight BMI 30-39.9 kg m2 obese BMI 40kg m2 and above severely obese In the last ten...

Emergency procedures

It is well documented that the chances of survival following a sudden cardiac arrest are minimal (Herlitz, et al., 2003 Ramaswammy and Page, 2003 Valenzuela, 2003). In Europe cardiovascular disease accounts for around 40 of all deaths under the age of 75 years. One third of patients with coronary artery disease die before they reach hospital (Evans, 1998 Resuscitation Council UK, 2000). In most of these deaths the presenting rhythm is ventricular fibrillation (VF) or pulseless ventricular...

Repeat Exercise Consultations

Some of the studies evaluating the effectiveness of the exercise consultation have used a repeat exercise consultation at six months. If individuals attend repeat consultations, information recorded during the first exercise consultation should be reviewed. For example, participants should be asked if they achieved the activity goals set during the previous consultation. If clients did not achieve their goals, then the reasons for this should be explored and new goals set. For example, did they...

RPE psychological status and social milieu

Psychosocial factors can influence up to 30 of the variability in an RPE score (Dishman and Landy, 1988 Williams and Eston, 1989). Such influences may help to explain the wider variability of RPE, for a given HRRmax, reported by Whaley, et al. (1997) in cardiac compared to non-cardiac individuals. The patients' psychological status has two aspects, which can influence RPE their state of mental well being and the state of motivation to exercise. The social milieu in which the exercise takes...

Phase I Cardiac Rehabilitation

Phase I is the in-patient stage and includes medical evaluation, reassurance and education, correction of cardiac misconceptions, risk factor assessment, mobilisation and discharge planning SIGN (2002). Risk stratification should begin at this stage (see Chapter 2). For patients post-MI, the site and size of the infarct can affect prognosis. Anterior infarcts often result in greater left ventricular dysfunction (BACR, 2000), and, as a consequence, exercise tolerance may be limited. Progression...

Stage Of Change

Assessing a patient's readiness to change in relation to exercise behaviour should always be a component of the exercise professional's assessment. This topic, however, is covered in Chapter 8. An evaluation of a CR programme which forms part of the Scottish Executive Demonstration Project, Have a Heart Paisley (HHP, 2004), reported that individuals assessed to be pre-contemplative and contemplators at baseline were less likely to attend. Using the stage of change model during assessment can...

Tone and pitch

Tone and pitch of the voice can make it more interesting and can introduce variety and motivational emphasis to the voice. This can work well when emphasising a word or phrase. Using variety also engages the participants, and the leader can use more expression to encourage the group. Varying tone and pitch can be used with emphasis on different types of exercise and can maintain the group's interest and motivation. For example For performing a calf stretch, the tone of voice goes down to...

Assessing current activity levels

Assessing the individual's current physical activity levels can be carried out using a questionnaire, such as the Stanford Seven-Day Physical Activity Recall (Blair, et al., 1985), International Physical Activity Questionnaire (IPAQ) (Craig, et al., 2003) or an activity diary. This assessment provides the exercise consultant with information on the individuals' actual activities and can be used to identify possible opportunities for physical activity in their daily routine (e.g. parking the car...

B

Need a much more defined interval approach than will fitter participants (see rationale for interval training p. 135). Active recovery stations should last for no more than one minute. The time between consecutive stations should be kept to a minimum, and, as a guide, should only last long enough for participants to walk from one station to the next. Different ways of controlling the circuit time and movement are discussed later in this chapter. Figure 5.5. Concentric circles circuit. Figure...

Integrating The Use Of Heart Rate Rpe Mets And Observation

As discussed in the preceding sections, at times there are limitations to the reliability and validity of using either HR, RPE, observation and METs alone to control or monitor exercise intensity in the cardiac patient. Furthermore, the patient's psychological state may be an important factor that holds back or advances too quickly the patient from exercising at the physiologically beneficial intensity. Figure 3.8 summarises these four important facets to guiding the patient towards the...

Demonstration

Demonstration of the exercise is a vital skill for a successful class (Kennedy and Yoke, 2005). Much of the learning and performance of the group will result from a combination of oral command and visual cues from the leader. Many of the CR group will be over 50 years of age (Bethell, et al., 2001), with age-related physical and motor changes. In addition, hearing is often compromised. Therefore, for many in the group visual cues will dominate as the motor skill learning mode. In order to...

Behaviour interventions in CR

Exercise consultation was developed in the UK setting. In the US, a similar procedure is termed physical activity counselling. A recent systematic review concluded that physical activity counselling was effective in increasing physical activity and fitness in the general population (Kahn, et al., 2002). Physical activity counselling is also based on the Transtheoretical Model and uses behaviour change strategies similar to those employed in the exercise consultation process. In addition,...

Definition Of Cardiac Rehabilitation

There are many aspects to the management of coronary heart disease (CHD), including pharmacological treatment, cardiac investigations, secondary prevention and revascularisation. Secondary prevention consists of a number of activities or measures that may be taken by patients with established disease, in order to reduce their risk of a further event (Lockhart, et al., 2000). Cardiac rehabilitation (CR) is acknowledged not only as integral in the management of patients with CHD, but also as the...

Accumulated Activity And Structured Exercise

The cardioprotective and psychosocial benefits require CR participants to engage in regular habitual exercise (SIGN, 2002). Exercise and activity should be integrated into all phases of CR. As there are different methods for prescribing activity and exercise, it is important to define the differences between Exercise Leadership in Cardiac Rehabilitation. An Evidence-Based Approach. Edited by Morag Thow. Copyright 2006 by John Wiley & Sons Ltd. ISBN 0-470-01971-9 physical activity and...

Previous Medical History And Comorbidity

This is possibly the most important non-CHD assessment factor that influences exercise prescription in CR. As the patient population within phase III cardiac rehabilitation expanded and became more inclusive for those with more limited exercise ability, either through age or complex medical history, so our assessment had to expand to consider a diverse and substantial number and combination of orthopaedic, neurological, respiratory, vascular and musculoskeletal conditions. A survey carried out...

Is it perhaps time for CR professionals to look at current practice of risk stratification and to consider how risky

Paul-Labrador, et al. (1999) proposed that the risk shifts over time, the risk being related to the atherosclerotic plaque stability, and suggests that perhaps our initial risk assessment should be revisited regularly and risk stratification performed at regular intervals in relation to disease stability. Angioplasty patients, for example, are currently considered by many to be low risk, but Paul-Labrador, et al. (1999) found in their survey that this patient group had more complications than...

Overview

Guidelines for CHD risk stratification were primarily developed to assess prognosis of CHD patients and used to ensure optimal medical management for those individuals. They were adopted by CR programmes as a tool to direct rehabilitation staff to patients who should be offered the exercise component of cardiac rehabilitation and to screen out those who required further interventions, medical or surgical. Cardiac rehabilitation professionals worldwide have endeavoured to ensure the efficacy and...

Application of the TTM in the general population

Interventions based on the TTM are effective in promoting and maintaining physical activity in the general population (Marcus, et al., 1992a Marcus, et al., 1998a, 1998b Bock, et al., 2001). Marcus randomised 194 sedentary adults to receive either an individualised, stage-matched intervention or a standard intervention over a six-month period (Marcus, et al., 1998a). The stage-matched intervention involved providing participants with individualised feedback about their physical activity...

Heart Rate As A Measure Practicalities of measuring heart rate

If HR is used, it is important that an accurate HR can be measured while the patient is actually exercising. It is the HR while the patient is exercising that provides a marker of both whole body and myocardial strain. The use of a palpated radial pulse requires skill, and for the patient's arm to be very still. Except for static exercise cycling (cycle ergometry), the patient needs to stop the exercise briefly for the pulse to be taken. Even in this very brief period HR drops quickly (De Van,...

Resistance equipment

The type of exercise will depend on both the equipment and space available. Resistance bands and dumbbells are easily accessible and allow for a gradual progression in resistance or weight. Method of delivery can be either circuit-type group sessions or delivered by the exercise leader where the class performs the same exercise. Caution should be used for those with balance or grip problems who may drop weights. RE can be performed using exercise mats on the floor. All floor exercises should be...

Peripheral vascular disease PVD

Exercise should be set at a frequency tolerated by the individual, aiming for three to five times per week, and integrating activity into everyday life. This should be dependent on how well exercise is tolerated by the individual. It is more likely that the symptoms of intermittent claudication will limit mobility, rather than the symptoms of coronary heart disease. The exercise should be performed to a level where the PVD patient is 'nudging' the exercise level to the onset of leg pain. With...

Content Of Cardiac Rehabilitation

Cardiac rehabilitation is a multifaceted intervention offering education, exercise and psychological support for patients with coronary heart disease and their families and involves a variety of specialist health professionals (Bethell, et al., 2001). Cardiac rehabilitation can promote recovery, enable patients to achieve and maintain better health, and reduce the risk of death in people who have heart disease (National Health Service Centre for Reviews and Dissemination, 1998). The challenge...

Conducting An Exercise Consultation

In 1995, Loughlan and Mutrie published guidelines for health professionals on conducting an exercise consultation (Loughlan and Mutrie, 1995). This intervention was originally aimed at sedentary healthy individuals. However, more recently it has been adapted for use with clinical populations, including people with Type II diabetes and CR participants (Hughes, et al., 2003 Kirk, et al., 2004a). This section describes the components involved in delivering the exercise consultation to cardiac...

Osteoporosis

Structured exercise for three to five sessions per week. In addition, some form of weight-bearing activity should be advised on a daily basis, along with an active living approach. The intensity should be between 50 and 75 HRmax. Type Weight-bearing exercises are recommended, i.e. stair climbing, brisk walking, stepping. Falls in this group are more likely to result in a fracture, therefore, exercises that encourage strength, balance and coordination should be encouraged. Strengthening should...

Phase III cardiac rehabilitation

This is traditionally the outpatient education and structured exercise programme component of CR. Phase III continues risk factor changes and education established in previous phases. An individual, menu-based approach continues, with monitoring and feedback regarding risk factors and lifestyle. There is an emphasis on addressing multi-factorial risk factor modification, appropriate to each patient. Baseline patient assessment can be carried out and outcomes reviewed and audited. Traditionally...

RPE modes

The three modes of using RPE are estimation, production and preferred exertion modes. Until 1980, studies evaluating the effectiveness of perceived exertion solely focused on RPE as a dependent response variable, described as estimation mode. The first published report of RPE being used to actively control intensity, as the independent variable, known as production mode, was that of Smutok, et al. (1980). In this study they first assessed participants with a standardised graded exercise...

Phase IV cardiac rehabilitation

Phase IV CR is the long-term maintenance of risk factor modification, with long-term follow-up in primary care. For the benefits of physical activity and lifestyle change to be sustained, the available evidence suggests that both need to be maintained (SIGN, 2002). As clinically indicated, referral to specialist clinicians, such as smoking cessation or psychological support, may still be required (DoH, 2000). This stage is likely to be the most informal stage of cardiac rehabilitation, where...

Transtheoretical Model

The Transtheoretical Model (TTM) was originally developed to understand behaviour change related to smoking cessation (Prochaska and DiClemente, 1983), but has since been applied to exercise behaviour (Prochaska and Marcus, 1994). Interventions based on the TTM have been effective in promoting and maintaining physical activity (Marcus, et al., 1992a Marcus, et al., 1998a, 1998b Bock, et al., 2001). The model proposes that individuals attempting to change their physical activity behaviour...

References

American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) (1999) Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, 3rd edn, Human Kinetics, Champaign, IL. American College of Sports Medicine (ACSM) (1995) Guidelines for Exercise Testing and Prescription, 5th edn, Williams and Wilkins, London. American College of Sports Medicine (ACSM) (1998) The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular...

Ischaemic burden myocardial ischaemia

The presence of ischaemia during exercise can be explained in terms of physiological response. As an individual steps up his or her level of activity, myocardial oxygen consumption rises (Rate Pressure Product (RPP) HR x SBP). Simultaneously, there is a shortening of diastole and subsequently a decrease in coronary perfusion time. Consequently, there is a transient oxygen deficiency to the myocardium. Myocardium deprived of oxygen is unable to meet the demand of the increased activity, and the...

When to start resistance exercise

There is some dispute as to when coronary heart disease patients should commence an RE programme. There is general consensus that patients should complete a period of aerobic exercise prior to initiating resistance training. The ACSM (2001) and SIGN (2002) recommend a period of four to six weeks' aerobic acclimatisation. This period allows for patients' haemodynamic responses to exercise to be assessed and for any complications to be ruled out before progression to RE. Additionally, the patient...

Rationale for interval training

The premise of interval training is that an individual can produce a greater amount of work in a training session if the training bouts are spaced between periods of lower intensity work. Usually these active recovery (AR) periods are between 30 seconds and one minute in duration (see Chapter 4). Key Points on Active Recovery Exercises lower intensity cardiovascular activity, e.g. walking musculoskeletal endurance (MSE) work, e.g. exercises to improve local endurance of muscles NOT used in the...

Choreography And Free Aerobics

Aerobic overload can be delivered using free aerobics. This method sees the exercise leader perform the exercise with the class following the demonstration and cueing of the exercises. The leader should provide alternatives, giving easy and harder options for each exercise. This style of aerobics within the overload section may not be appropriate early in phase III CR until patients have mastered self-monitoring. In free aerobics (exercise to music), where the leader is introducing different...

Resistance Training

Muscle strength, endurance and aerobic function are required for a fully active lifestyle (Pollock, et al., 2000). Muscle strength is defined as the ability of a muscle or muscle group to produce maximal force at a given velocity of movement. Muscle endurance is the ability of a muscle or muscle group to perform repeated muscle actions against a sub-maximal resistance (ACSM, 2001). Resistance exercise (RE) incorporates all types of strength and weight training and will lead to improvements in...

Relapse prevention model

Relapse is a breakdown or setback in a person's attempt to change or modify target behaviour. The relapse prevention model was developed to treat addictive behaviours, such as alcoholism and smoking (Marlatt and Gordon, 1985). The model proposes that relapse may result from an individual's inability to cope with situations that pose a risk of return to the previous behaviour. For example, a former smoker finds himself or herself in a social situation with lots of smokers and is tempted to...

Variability in estimated METs

Ainsworth, et al. (1993) have compiled an extensive compendium on the estimated MET values for a variety of physical activities. It is important to recognise that these values are estimates, which means that each individual patient could be working above or below this estimate. The variability of the estimate depends on the simplicity or complexity of the movements. For example, the variability of pedalling an exercise cycle ergometer will likely be less than that of stepping or walking. The...

Hypertension

The frequency remains at 3-5 sessions per week, integrating activity into everyday life. The intensity should be reduced to 50 to 75 HRmax. SBP increases in proportion to the intensity of the activity. Moderate intensity activity should be prescribed to avoid large increases in SBP. When HR and SBP are elevated, the myocardium is working harder and requires more oxygen due to a large increase in RPP. Hypertensive patients have a higher resting BP and when coupled with the associated increase in...

Cardiac Rehabilitation Phase Iii Overload Frequency

Early studies into phase III cardiac rehabilitation CR programmes were based on exercise education sessions that ran three days per week for eight weeks or longer Jolliffe, et al., 2004 . Various studies have been carried out to determine the optimum frequency for cardiac rehabilitation programmes. There is still on-going debate around this topic, but recent literature has shown that two-three times per week, for a minimum of eight weeks, is sufficient to achieve physiological and psychosocial...