Research Articles Base: Cardiac Patient Rehabilitation

Critically review the case for exercise testing and prescription in cardiac patient rehabilitation.

Exercise prescription as defined by Dr. Amer Suleman, as the specific plan of fitness – related activities designed for a specific purpose, which is often developed by a fitness or rehabilitation specialist for the client or patient. Components of exercise prescription generally includes specific recommendations: (1) type of exercise or activity (walking, swimming, cycling) (2) specific workloads (watts, walking speed) (3) duration of activity or exercise session (4) intensity guidelines – target heart rate range (THR) and estimated rate of perceived perception (RPE) and (5) precautions regarding certain orthopedic or other concern related comments. Dr. Suleman further explains that Heart rate reserve (HRR) is defined as the maximal heart rate (HR max) observed during a symptom-limited exercise stress test minus the resting heart rate (HR rest). A percentage of the HRR range is added to the HR rest to determine a THR range to be used during exercise. This approach accounts for individual variability in the HR rest and better reflects the peak exercise oxygen consumption (VO2). Exercise intensity is generally recommended to be 60-90% of the HR max or 50-85% of the VO2 maximum (VO2 max) or HRR. For example, a patient with coronary heart disease on beta-blockade medication has an HR max of 120 beats per minute (bpm) and an HR rest of 55 bpm. The recommended THR would be calculated as follows: (1) HRR = 120 – 55 = 65 (2) THR range = [(HR max - HR rest) X (0.5 - 0.85)] + HR rest (3) THR = 65 X 70% = 46 + 55 = 101 bpm. Thus, the suggested THR range would be 96-108 bpm. The VO2 max is the maximal amount of oxygen that an individual can consume and use during exercise or physical work. This value may be measured or estimated and is expressed commonly in milliliters of oxygen per kilogram of body weight per minute (mL/kg/min).   src=”http://pagead2.googlesyndication.com/pagead/show_ads.js”>   style=”text-align:justify;text-indent:.5in;line-height:200%”>  style=”text-align:justify;text-indent:.5in;line-height:200%”>  style=”text-align:justify;text-indent:.5in;line-height:200%”> The RPE scale is used widely in exercise science and sports medicine to monitor or prescribe levels of exercise intensity. The 95%-limits-of-agreement technique has recently been advocated as a better means of assessing within-subject (trial-to-trial) agreement. The perception of exertion is a monitoring behavior that uses all sources of information to govern actions that can benefit or preserve health and partake of adaptive pursuits. How a person feels about exertion moderates his or her response to exercise and effort. The perception of what is happening in exercise, and its concomitant effect on physiological function, must be known to further understand the nature of an exercise response. How a person feels modifies reactions to exercise stress and the mechanisms that underlie them. The Borg scale is as follows: (1) Six – No exertion at all (2) Seven to eight – Extremely light (very, very light) (3) Nine to ten – Very light (A1 warm-up / recovery) (4) Eleven – Light (A2 aerobic threshold) (5) Twelve to thirteen – Moderate (EN-1 anaerobic threshold) (6) Fourteen to fifteen – Hard (EN-2 VO2 max or 400 m swimming pace) (7) Sixteen to seventeen – Very hard (AN-1 peak lactate or lactate tolerance, 200 m swimming pace) (8) Eighteen to nineteen – Extremely hard (very, very hard [AN-2 anaerobic power, 25-50 m swimming pace]) (9) Twenty – Maximum all-out effort with absolutely nothing being held in reserve (1998). Instructions for use as suggested by Dr. Amer Suleman:             During the exercise you are to rate your perception of exertion. Use this scale where 6 mean no exertion at all and 20 means a totally maximum effort. The 13, on the scale is somewhat heavy exercise but capable of being performed at steady state (i.e., anaerobic threshold). When at a level of 17, the effort level requires you to push yourself hard even though it is possible to continue for some time. For many people 19, is about as strenuous as exercise becomes because they often reserve a small amount of possible extra effort. Try to appraise the feeling of exertion as honestly as possible. Do not underestimate nor overestimate it. It is of no value to underestimate the level to produce an impression of being “brave” or “tough”. Your own feeling of effort and exertion is all that is of interest. Look at the scale and wordings and decide on the word that best describes your effort level and the number alternative associated with that description. 
color:windowtext">Considering the different modes of exercise: (1) Intensity: This should range from low to moderate for healthy individuals. (2) Duration: Continuous aerobic activity for 20-60 minutes is recommended. (3) Frequency (3a) Individuals with a less than 3-MET capacity should engage in multiple short sessions each day. (3b) Individuals with a 3- to 5-MET capacity should engage in 1-2 sessions per day. (3b) Individuals a greater than 5-MET capacity should engage in 3-5 sessions per week.   ACC/AHA (American College of Cardiology / American Heart Association Task Force on Practice Guidelines) 2002, Guideline Update for Exercise Testing: The weight of evidence was ranked highest (1) if the data were derived from multiple randomized clinical trials that involved large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials that involved small numbers of patients or from careful analyses of non – randomized studies or observational registries. A lower rank (C) was given when expert consensus was the primary basis for the recommendation. The ACC/AHA classifications II, III, and I are used to summarize indications as follow: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful / effective and in some cases may be harmful. The general context for the use of exercise testing is outlined in Figure 1. 
color: windowtext"> src=”new_page_1_files/image002.jpg” v:shapes=”_x0000_s1025″> Figure 1.General context of the exercise testing guidelines Source: ACC/AHA Task Force on Practice Guidelines src=”new_page_1_files/image004.jpg” v:shapes=”_x0000_s1026″> Figure 2: Nomogram of the prognostic relations embodied in the treadmill score Source: Source: ACC/AHA Task Force on Practice Guidelines       The value of exercise testing, according to Bowling, A., Bond, M., McKee, D. et al. is that exercise testing has a sensitivity of 78% and a specificity of 70% in detecting coronary artery disease. Hence a negative test does not adequately rule out disease. A positive test is much more likely to be false in a young person than an older person unless there is a very good history as they are at much lower risk. Therefore testing of young, asymptomatic people is controversial. There is a suggestion that not enough women and the elderly are being tested (2001). Hence, as stated by 
color: windowtext"> Doctor Paul Hewish style=”font-size:11.0pt;line-height:200%;font-family:Helvetica;color:windowtext”>, prognostic testing can be useful. A positive test at a low workload is a poor prognostic sign and it indicates the need for urgent treatment. Bayes’ theorem of diagnostic probability states that the predictive value of an abnormal test varies according to the probability of the disease in the population being study. Therefore, exercise testing is usually performed in patients with a moderate probability of coronary artery disease, rather than in those with a very low or high probability (2004). 
line-height: 200%; vertical-align: top">Bruce protocol is very widely used and has been extensively validated. There are 7 stages of 3 minutes each so that a complete test takes 21 minutes. The level of exercise is estimated in METs. 1 MET or metabolic equivalent is the amount of energy expended at rest or 3.5ml oxygen per kilogram per minute. At rest, the average person has an oxygen consumption of 1 MET (or 3.5 ml/kg-min). MET values increase as more activity is performed. In stage 1 the patient walks at 1.7 mph (2.7 km) up a 10% incline. Energy consumption is estimated to be 4.8 METs during this stage. The speed and incline increase with each stage. The information from an ETT can be used to advise the patient on what activities and exercise levels are reasonable. An example of an MET chart is as follows: cellpadding=”0″ style=”border-collapse: collapse; border: medium none”> 
 Arial">METs 
line-height: 200%; vertical-align: top">Exercise 
line-height: 200%; vertical-align: top">Recreational 
line-height: 200%; vertical-align: top">Occupational 
line-height: 200%; vertical-align: top">Activities of DL 
200%; vertical-align: top">1.5 – 2.0 Strolling 1 – 1.5 mph, 1 mile in 40 – 60 minutes Knitting; playing cards; sewing; watching TV Desk work; driving auto/truck; sitting doing light assembly; typing; using hand tools; writing Brushing hair / teeth, light housework; making bed; partial bath; polishing furniture; washing clothes 
200%; vertical-align: top">2.0 – 3.0 Walking, level 2.0 – 2.5 mph, 1 mile in 24- 30 min cycling, level outdoors – 5mph Horseback riding (walk), light golf (power cart); playing musical instrument; shuffle board; woodworking Bartending; crane operation; standing doing light or medium assembly; TV / auto / car repair; working heavy lever Cooking; driving car; ironing; riding lawn mower; scrubbing floor; walls, cars; widows; showing; sweeping; tub bath 
200%; vertical-align: top">3.0 – 4.0 Walking 3.0 – 4.0 mph, 1 mile in 15 – 20 min cycling, outdoors 5.5mph Billiards; bowling; canoeing; croquet; fly fishing; golf (pulling cart); shopping; volleyball (non – competitive) Baling hay; driving heavy truck; heavy machine assembly; janitorial work; light welding; operating large levers; plastering; plumbing; stocking shelves Cleaning windows; climbing stairs (slowly); General House work; kneeling; light work; pack/unpacking; power lawn mowing (light); sexual intercourse; stocking shelves; vacuuming 
200%; vertical-align: top">4.0 – 5.0 Walking 3.5 – 4.0 mph, 1 mile in cycling, 8mph calisthenics swimming (20 yd/min) Ballet; dancing; gardening (how? Weeding, digging); golf (carrying clubs); table tennis; tennis (doubles); volleyball Building interior of house; carrying trays / dishes; farm work (sporadic); house painting, lifting, carrying objects (20 – 40 lb); light carpentry; mechanic work Raking leaves; shoveling light loads 
200%; vertical-align: top">5.0 – 6.0 Walking 4.0 – 4.5mph 1 mile in 13 – 15 minutes, biking in 10 mph Canoeing (4m/hr); gardening (digging); skating (ice / roller); social / baseball (non- game); stream fishing Handyman work (moving, shoveling); heavy carpentry; putting in sidewalk Raking leaves; shoveling light loads 
200%; vertical-align: top">6.0 – 7.0 Walking/jogging, 4.0-5.0 mph 1 mile in 12-13 min Biking, 11 mph Swimming (breaststroke) Backpacking (light); Badminton; Hiking; Hunting; Horseback riding (trot), Skiing (cross country 2.5 mph); Skiing (light downhill); quare dancing; Tennis (singles) Exterior home building; Lifting, carrying objects (45-64 lb); Shoveling (10/min, 9 lb); Splitting wood Lawn mowing (push mower); Snow shoveling (light snow) 
200%; vertical-align: top">7.0 – 8.0 Walking, 5 mph 1 mile in 12 min Biking (outdoors) 12 mph Swimming (backstroke), 40 yd/min Badminton (competitive); Basketball (non-game); Canoeing (5 mph); golf (carrying bag); Horseback (gallop); Skiing (downhill, vigorous) Ascending stairs with 17 lb load; Lifting, carrying (65-84 lb); Moving heavy furniture; Sawing   
200%; vertical-align: top">8.0 – 9.0 Jog/run 5.5 mph Biking (outdoors) 13 mph Swimming (breaststroke) 40 yd/min Rowing machine; Rope jumping (60-80 skips/min) Basketball (non-game); Handball/squash/racquetball; Mountain climbing; Soccer (non-team); Touch football; Tour skiing Lifting, carrying (85-100 lb); Moving heavy furniture (moving van work); Shoveling (14 lb scoops, 10 scoops / min); Using heavy tools   
200%; vertical-align: top">9.0-10.0 Jog/run, 6 mph 1 mile in 10 min Football (competitive); sledding / tobogganing Heavy labor; Lumberjack; Shoveling (16 lb scoops) Ascending stairs carrying 54 lb 
200%; vertical-align: top">11.0+ Run 7 mph (11.5 METs) 8 mph (13.5 METs) Competitive sports: Basketball, Handball, Racquet, Rowing     
text-indent: .5in; line-height: 150%; vertical-align: top">Figure 3: MET chart 
text-indent: .5in; line-height: 150%; vertical-align: top">Source: University of Iowa: Cardiac Rehabilitation Guide (2006) style=”text-align:justify;text-indent:.5in;line-height:200%”> Patients who are candidates for exercise testing may have stable symptoms of chest pain, may be stabilized by medical therapy after symptoms of unstable chest pain, or may be post-myocardial infarction or postrevascularization patients. Patients who are unable to exercise or who have uninterpretable ECGs because of pre-excitation, electronically paced rhythm, left bundle-branch block, or ST depression greater than 1 mm require imaging studies and are beyond the scope of these guidelines. Imaging studies are considered in other ACC/AHA guidelines (5,348-350). Although some studies suggest an even lower training threshold than the one used in the particular study (i.e., < 70% maximal heart rate), especially in extremely deconditioned subjects, if individuals can regularly attain a training intensity of at least 70% maximal heart rate via brisk walking, it is likely that they will achieve improved aerobic fitness. These findings may be especially relevant for the inactive patient in whom the subjective discomfort of vigorous physical training may serve as a deterrent to long-term compliance with exercise therapy (Anthony, 2002). The ability of exercise training as told by Wannamethee, S.G., Shaper A.G., & Walker, M. (2000) is to reduce morbidity and mortality rates hasn’t been well established for elderly patients, but limited data suggest some benefit (Table 1). style=”border-collapse: collapse; border: medium none; margin-left: 5.4pt”> style=”text-align:center;line-height:200%”> Intervention style=”text-align:center;line-height:200%”> Reduces Mortality style=”text-align:center;line-height:200%”> Reduces Morbidity Control of diabetes mellitus Yes Yes   Control of obesity   Not clear   Not clear   Dyslipidemia therapy   Yes   Yes   Exercise   Yes*   Not clear   Hypertension therapy   Yes   Yes   Psychosocial interventions   Not clear   Not clear   Smoking cessation   Yes   Yes   
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line-height:200%">Table 1: Impact of Interventions on All – Cause Mortality and Cardiovascular Morbidity in Elderly Patients 
line-height:200%">Source: American Family Physician News and Publications (2005) style=”text-align:justify;text-indent:.5in;line-height:200%”> In the British Regional Heart Study, which enrolled men with known CHD (mean age, 63 years), light to moderate physical activity in the form of regular walking, frequent recreational activities (e.g., gardening), or once-weekly sporting activities (e.g., jogging, swimming), was associated with a significant reduction in all-cause mortality at five years of follow-up.
200%;font-family:Arial"> More vigorous types of activities did not show a statistically significant reduction in that same endpoint (2000). A Cochrane review of men and women of all ages with previous MI, revascularization or angina found that exercise-only cardiac rehabilitation reduced all cause mortality by 27%, cardiac death by 31% and a combined end point of mortality, non fatal myocardial infarction and revascularization by 19% (2000). style=”text-align:justify;text-indent:.5in;line-height:200%”> Prior to initiating an exercise program for the post-rehab client, the trainer will need to obtain a health history form, a signed informed consent, a physician’s referral / release for 
normal">exercise and, if possible, a copy of the client’s rehab records. The physician’s referral/release form should indicate the trainer’s credentials and state that no medical monitoring (e.g., blood pressure, ECG, pulse oximetry, etc.) will be performed. The physician should be asked to provide a training intensity if age-predicted target heart rate range is not appropriate. A request for exercise precautions should also be included (Salge, 2001). style=”text-align:justify;text-indent:.5in;line-height:200%”> For most patients, clinical risk stratification based on history, examination and resting ECG combined with a functional capacity test such as a shuttle walking test or a six minute walking test will be sufficient. The test was supervised by a physical therapist and was performed,if indicated by the physician, using telemetry monitoring. Subjectswere asked to walk at their own maximal pace along a 35-m long,flat, and straight hospital corridor. No encouragement was offered.The test was symptom limited, so patients were allowed to stopif signs or symptoms of significant distress occurred (severe dyspnea, dizziness, angina, skeletal muscle pain), though they were instructed to resume walking as soon as possible. The distance covered during the test was recorded in meters. The 6MWT has become one of the most popular clinical exercise tests for evaluating functional capacity. It is a practical, simple, and inexpensive test, and does not require any exercise equipment or advanced training for technicians (The American Thoracic Society, 2004). The shuttle walking test (cited in SIGN Publication No. 57) is a low cost low tech alternative to exercise testing that informs the rehabilitation team on a suitable exercise programme and appropriate training heart rate, and allows assessment of progress during cardiac rehabilitation without the need for cardiac technicians, physicians or expensive equipment (2005). The shuttle walking test protocol is given in Box 1. style=”border-collapse: collapse; border: medium none”> Shuttle Walking Test Equipment required 
150%; margin-left: .25in">Calibrated cassette player and shuttle walk test tape. Two marker cones and non slippery, flat walking surface at least 10 meters in length. Heart rate monitor with record facility and adjustable upper alarm limits. style=”font-family:Arial;color:windowtext”>Protocol 
150%; margin-left: .25in">Each subject should be screened by a member of the cardiac rehabilitation team for any exclusion criteria before proceeding. Place two cones exactly 9 meters apart, thus allowing the subjects to walk 10 meters when they go round the cone at the end of each shuttle. Subjects then listen to the instructions on the audio cassette. These should be repeated verbally to ensure that they understand what is expected during the test. Subjects walk around the 10 meter course aiming to be turning at the first marker cone when the first audio signal is given, and turning at the second cone at the next audio signal. Subjects should be accompanied around the first level of the test to help them keep pace with the audio signals. Thereafter the operator stands mid way between the two marker cones offering advice on completion of a level: ‘Walk a bit faster now if you can’. Progression to the next level of difficulty is indicated by a triple bleep which lets the subject know that an increase in walking speed is required. The full test comprises 12 levels each of one minute duration with walking speeds that rise incrementally from 1.2 miles per hour (1.9 km per hour) to 5.3 miles per hour (8.5 km per hour). style=”font-family:Arial”>The test is completed at 12 minutes or if one of the termination criteria is met. Termination criteria 
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Roman"">                                Any anginal symptoms or feeling too breathless to continue. 
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 color:windowtext">Achieved level of perceived exertion >=15 (Borg Scale) 
 color:windowtext">Achieved heart rate >=85% predicted (detected by audible upper alarm limit). Failure to meet the speed requirements of the test - subject more than half a meter from the cone when the bleep sounds. Following the test 
150%; margin-left: .25in">Subjects should continue to walk slowly around the course a further four times to avoid any syncopal attacks associated with abrupt cessation of exercise. Subjects are then seated and asked to confirm their limiting symptom. Record total distance walked heart rate and perceived exertion for each level completed, peak heart rate and reason for test termination. If subjects have fully recovered after 10 minutes then no further action is required. If they report continuing breathlessness or angina then a further rest period should follow during which they may receive sublingual nitrates, have an ECG or be seen by a doctor as appropriate. 
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line-height:200%">Box 1.Shuttle Walking Test 
line-height:200%">Source: SIGN Publication No. 57 (2005) style=”text-align:justify;text-indent:.5in;line-height:200%”>   style=”text-align:justify;text-indent:.5in;line-height:200%”>   
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Arial;color:black">Cardiac rehabilitation (
Arial">Giannuzzi, P. et al.) today targets people with ischaemic heart disease, congestive heart failure and people with a high risk of developing ischaemic heart disease. The short-term goals of cardiac rehabilitation are to stabilize heart disease, to limit the physical and mental effects of heart disease, to improve the functioning of the people with heart disease and to improve their quality of life. The long-term goals are to reduce patients’ long-term risk of heart disease, to stop the progression of heart disease and to reduce morbidity and mortality. According to current evidence, these goals can best be realized through comprehensive cardiac rehabilitation programmes based on exercise training, patient education, lifestyle intervention, risk factor management and clinical assessment, psychosocial support and optimizing the pharmaceutical treatment of symptoms. Pharmaceutical treatment comprises an important part of overall rehabilitation (2003). 
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Arial"> Efforts to prevent heart disease can be divided into primary, secondary and tertiary prevention. Primary prevention means preventing disease from arising at all. Secondary prevention means identifying patients at high risk of developing ischaemic heart disease and identifying symptoms and disease at early stages to reduce the course of disease and contribute to improving the prognosis. Tertiary prevention means preventing remission of disease and preventing chronic conditions, including reduced functioning as a result of disease (Kamper, Jørgensen F & Almind G , 2003). In summary, the finding of this particular study suggest that physicians and allied health professionals can prescribe brisk walking on a flat surface to their cardiac patients with confidence that this intensity will achieve cardiorespiratory and health benefits. Furthermore, these results serve to discount the lingering notion that cardiac patients need to participate in vigorous exercise such as jogging or running in order to benefit from an exercise training program.  Phase II cardiac 
normal">rehabilitation programs are associated with improvements in exercise tolerance, coronary risk factors, and psychosocial well-being. Nevertheless, previous reports have generally evaluated the global effectiveness of these programs (i.e., on all subjects, collectively), which may serve to camouflage or attenuate the impact of these interventions on specific patient subsets. In one particular study, the researchers investigated the effectiveness of a contemporary, 
normal">exercise-based 
normal">cardiac 
normal">rehabilitation program that included a cardiovascular risk-reduction intervention, using a computerized database on 117 patients (average age, 66.5 years; 68% men; 96% white) who completed pre-phase II and post-phase II evaluations (Gordon, 2002). As pointed out by, (Dr. Bonnie Sanderson, 2004) cardiac rehabilitation begin with a patient assessment that helps us develop an individualized, goal-directed treatment plan with short-term and long-term objectives for reducing cardiovascular risk and improving quality of life. Ideally, patients should be referred to cardiac rehabilitation within 1 month of a coronary event, but they can begin the program (12 to 36 sessions, depending on individual need) for up to 1 year after an event. Therefore, there are short term and long term goals that will benefit the patient in a short term basis and long term basis depending on the program that was intended for the patient and the extent of the disease. Dr. Vera Bittener also added, physicians have an obligation to strongly recommend cardiac rehabilitation and reinforce that message in follow-up visits. More patients would comply with the recommendation if the message — that cardiac rehabilitation increases survival and improves quality of life — were strongly emphasized (2004). Credit:ivythesis.typepad.com

Critically review the case for exercise testing and prescription in cardiac patient rehabilitation.

Exercise prescription as defined by Dr. Amer Suleman, as the specific plan of fitness – related activities designed for a specific purpose,...

Cardiac Rehabilitation Literature Review

II. Literature Review A study by Ades et al (1997), concluded that after comparing other post MI treatment interventions, cardiac rehabilitation is more cost effective than thrombotic therapy, coronary by-pass surgery and cholesterol lowering drugs, though less cost-effective than smoking cessation programmes. In 1997, cost-effectiveness was determined to reflect the UK situation. The results suggested QALY of ₤6,900, and a cost per life year gained three times ₤15,700. Although, it has been proven cost-effective; there are still various factors that influence costs and cost-effectiveness such as the location, patient population and their compliance. Moreover, studies on cardiac rehabilitation program usually focus in two aspects these are the exercised based and influence on the psychological aspect of the patient.             A key concept for health status is health-related quality of life (HRQL). HRQL represents the functional effect of an illness and its consequent therapy, as perceived by the individual. At present, Health – Related Quality of Life (HRQL) is used as a primary outcome measure in rehabilitation programs (Wenger, et al, 1995).  HQRL (DiMatteo, et al.) is recognized as an important dimension of patient care and treatment outcome. This increased recognition is due, in part, to our greater understanding of the role of psychosocial factors, such as depression in medical outcomes, including compliance with medical treatment and subsequent cardiac events (2000). HRQL was measured with the SF-36 at baseline and at completion of the phase II cardiac rehabilitation program. The SF-36 consists of 36 items evaluating eight dimensions of physical and mental health, including physical functioning, physical role limitations, bodily pain, general health, vitality, social functioning, emotional role limitations, and mental health. Ware and colleagues, who developed the SF-36, refer to it as a measure of the physical and mental components of health status. They also state that the SF-36 is a measure of HRQL (2000). At 3 months post-surgery, however, patients who had undergone CABG had similar SF-36 scores to those who had PTCA. Likewise, Barnason et al. showed that CABG patients exceeded preoperative levels of HRQL at 3 months, and all domains of the SF-36 stabilized or gradually improved by 6 months and 12 months post surgery (2000). Interestingly, when these exercise programs are offered on an outpatient basis in hospitals, individuals have demonstrated a high level of compliance while making significant improvements in exercise tolerance and muscular strength (Delagardelle, et al. 1999) In a study conducted by Brubaker and company in 2003, baseline demographics for individuals with CHF and post CABG completing the cardiac rehabilitation program in 2000 and 2001 (≥24sessions) were similar and are shown in Table 1. Cardiac Rehabilitation was well tolerated for both groups with no untoward events occurring during the 12-week program.       Table 1. Patient Characteristics n CHF CABG Male 56 52 Female 20 29 EF% 34±11§ 57±10 Age (yrs.) 73±9 73±7   n Number of participants completing program (≥24 sessions in 12 – weeks) * Ejection Fraction § Values in mean ± standard deviation Pre-post changes for exercise tolerance and quality of life constructs within and between groups are shown in Table 2. Quality of life scores and exercise tolerance in both groups improved significantly statistically with the cardiac rehabilitation program explaining 62% of the variance (F(9,98)=17.9 p<0.001). There was no statistically significant interaction between the CHF and CABG groups (F(9,98)=1.47, p=0.17). In addition, exercise tolerance and the self-reported SF-36 physical functioning (PF) quality of life construct were significantly correlated for both CHF and CABG patients (r 2=0.34, p<0.01). Table 2: Outcomes for QOL Constructs and Exercise Toleranceµ Outcome CHF CABG   Mean ±SD Mean ±SD   Pre – test              12-weeks Pre – test             12-weeks n = 56                          56 52                            52 Body Pain** 59±23                   66±24 54±27                     65±25 General Health** 49±1                     58±23 63±18                     64±17 Health Transition** 3.5±2                   2.3±1.2 3.1±1.2                  2.4±1.2 Mental Health** 69±17                   77±17 71±17                    76±18 Physical Functioning** 42±20                    55±22 43±21                  61±21 Role – Functioning Emotional** 42±44                    67±39 45±43                  69±40 Role – Functioning physical** 15±30                    39±38 17±34                  42 ±37                Social Functioning** 58±5                        81±19 80±20                   85±20 Vitality** 39±22                      54±21 44±19                   55±21 Exercise Tolerance** 163±61                    251±70 208±62                 309±90   µ For readability, all numbers rounded to nearest 1.0 except for Health Transition. n Number of patients completing program (≥24 sessions in 12- weeks). SD Standard Deviation. ¥ Exercise Tolerance Measured in seconds. Significant pre – post changes: **p≤.001.*p ≤.05. Denotes significance within – groups. In this study, Exercise time was distributed between Trackmaster® treadmills, Schwinn® stationary bicycles, Monarch® upper body arm ergometers, Nautilus® resistance equipment, and hand weights. All subjects were encouraged to attend the 12 weekly education seminars taught by cardiac nurses, respiratory therapists, and exercise physiologists. The seminars covered topics such as coronary artery disease, dietary concerns, anatomy and physiology of the heart and lungs, home exercise, risk factors for heart disease, food label reading, stress management, diabetes, cholesterol, smoking cessation, and medications. Subjects had the opportunity to ask questions during and after class or in a one-on-one situation with a clinical staff member. This concludes that interventions must integrate on the wholistic approach of the individual namely: physical, mental, emotional and the social aspects. Trials have been established that psychological and educational interventions can reduce risk factors, improve psychosocial well-being and patient knowledge. On the other hand, in practice, the information provided is often inadequate, inconsistent and is frequently misunderstood by the patients. However, focusing on the non-medical treatment such as walking exercises programmes wherein, walking exercise programmes (Hakim et al, 1998) have a positive effect on the distance that patients with intermittent claudication can walk. An improvement of 90 to 190% in walking distance can be expected. The patient should be advised to exercise daily and to maintain this training programme for at least 3 to 6 months. As well as reducing the complaints of the disease, the walking exercise programme has a longer-term effect of reducing mortality. Cardiac Rehabilitation program is intended for patient with established heart to further reduce the risk or re-occurrence of myocardial infarction and the likes. It is further enhance with psychological and educational interventions. As noted in Effective Health Care Bulletin, exercise as sole intervention has a positive impact on the physical aspects of recovery at no additional risk to the patient (1998). Accordingly, many personsconsider exercise as being synonymous with vigorous physicalactivity, like jogging or running. However, walking especially brisk walking is the most common aerobic training modality utilizedin cardiac rehabilitation programs. A study conducted in 2002, suggest that physicians andallied health professionals can prescribe brisk walking on aflat surface to their cardiac patients with confidence thatthis intensity will achieve cardio – respiratory and health benefits.Furthermore, these results serve to discount the lingering notionthat cardiac patients need to participate in vigorous exercisesuch as jogging or running in order to benefit from an exercisetraining program. Although some studies suggest an even lowertraining threshold than the one used in the present study), especially in extremely deconditioned subjects. It is important not to do too much too quickly and build up on the level of activity gradually. In contrast, a systematic review conducted in 1995, which formed the basis of a US guideline on cardiac rehabilitation, provides detailed information on RCTs of exercise alone. Exercise was found to have a positive impact on patients’ physical ability to exercise, and on physiological measures of cardiac disease. There was not enough evidence to evaluate the effects of different intensities. The second aspect of most research study is with regards to psychological outcomes; to quote Wegner, which in Cardiac rehabilitation should be emphasized that exercise has not found to do any harm to patients and no enough evidence was found to evaluate the effect of exercise alone on psychological or social outcomes, or return to work (1995). This issue was further supported by (Specchia, et al.) by their additional trials examining the effects of exercise alone. However (Singh, et al. 2006), contradicted that patients can get Psychological improvements include reduction of depression, anxiety, and stress. All these improvements enable acquisition and maintenance of functional independence and return to satisfactory and appropriate activity that benefits both the patient and society. As evidenced by the meta-analyses (Linden, et al. 2006) to support its conclusions regarding the effects of psychosocial interventions that includes patient education, counseling and behavioural interventions. These have been shown to affect risk factors including blood pressures and cholesterol levels. They also produce significant improvements in psychosocial well-being and in patient knowledge, especially concerning the benefits of activity. Increases in knowledge may not be sufficient to produce changes in behavior or lifestyle. Overall, quality of life can be meaningfully assessed in most individual rehabilitation programs. That in particular would be in combined exercise and psychological intervention. Even as, some benefits from single modality interventions have been demonstrated, a combine approach of exercise appears to be more beneficial.  However, what is lacking with the above studies is the motivation of patients to comply with the program. The patient’s beliefs, values, and judgments affect his or her perception of treatment. According to Pell, poor uptake rates relate mainly to either service or patient factors. Service factors such as availability and accessibility of the programme and patients perception of the strength of a physician recommendation to attend (1996). There are findings that confirm that adherence to the national guidelines is poor and that few physicians play an active part in rehabilitation programmes. There is little in the way of assessment (a prerequisite for a “menu driven” service) or audit; this is especially worrying as secondary prevention is an important goal of rehabilitation. This research study aims to contribute optimal method of delivering the service. In particular, it is important to compare patient’s rate of speed before and after the duration of the program. In must be also noted the optimal mix of the components and the frequency of the programme. The view to be further tested is the need to maintain improvements in lifestyle and the problems with the continuing compliance, the importance of long-term maintenance of the patient in doing the said rehabilitation programme, regardless of gender. Proper selection of patients is of paramount importance before beginning phase exercise programs. Patients with certain characteristics are at a higher risk, and therefore, require all attempts at correction of the high-risk condition prior to exercise training.           Reference: Barnason, S., Zimmerman, L., Anderson, A., et al. 2000. Functional status outcomes of patients with a coronary artery bypass graft over time. Heart Lung.29:3346. Brubaker, C., Witta, L., & Angelopoulos, T. 2003. comparison of changes in exercise tolerance and quality of life between congestive heart failure and coronary artery bypass graft patients following a hospital – based cardiac rehabilitation. 6:1 Delagardelle, C., Feiereisen, P., Krecke, R., Essamri, B. & Beissel J. 1999. Objective Effects Of A 6 Months’ Endurance And Strength Training Program In Outpatients With Congestive Heart Failure. Med Sci Sports Exerc. 31(8):1102-7. DiMatteo, M.R., Lepper, H.S. & Croghan, T.W. 2000. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med.160:2101-2107. Hakim AA, Petrovitch H, Burchfiel CM, et al.1998. Effects of walking on mortality among nonsmoking retired men. N Engl J Med. 338:94-9. Pell, J., Pell, A. & Morrison C. et al.1996. Retrospective Study of influence of deprivation on uptake of cardiac rehabilitation. BMJ. 313; 267- 268.   Quell, K. J., Porcari, J. P. et al. 2002. Is Brisk Walking an Adequate Aerobic Training Stimulus for Cardiac Patients? American College of Chest Physicians. 122:1852-1856.   Singh, V., Schocken, D. et al. 2006, March. Cardiac Rehabilitation. eMedicine Clinical Base. [Online]. Available: http://www.emedicine.com/pmr/topic180.htm#section~conclusion [8, June 2006]   Specchia G., De Servi, S., Scire, A. et al. 1996. Interaction between exercise training and ejection fraction in predicting prognosis after a first myocardial infarction. Circulation. 94: 978 – 982.   Taylor, R., Kirby, B.1997. The evidence base for the cost-effectiveness of Cardiac Rehabilitaion. Heart; 78:5-6.   Thompson, D. R., Bowman, G.S., Kitson, A. L., de Bono, D.P & Hopkins A. 1996. Cardiac rehabilitation in the United Kingdom: guidelines and audit standards. Heart.;75:89–93.   Ware, J.E., Snow, K.K, Kosinski, M. 1993, 2000. SF-36 Health Survey: Manual and Interpretation Guide. Lincoln, RI: QualityMetric Incorporated Wenger. N., Froelicher, E.S., Smith, L. 1995. Cardiac Rehabilitation, Clinical Practice Guideline No. 17. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care, Policy, and Research, and the National Heart, Blood, and Lung Institute.   Wenger, N. K. , Froelicher E. S, Smith, L. K, et al. 1995. Cardiac Rehabilitation as secondary prevention. Rockville, Maryland: Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute.       Credit:ivythesis.typepad.com

Cardiac Rehabilitation Literature Review

II. Literature Review A study by Ades et al (1997), concluded that after comparing other post MI treatment interventions, cardiac ...

Exercise

Critically review the case for exercise testing and prescription in cardiac patient rehabilitation. Exercise prescription as defined by Dr. , as the specific plan of fitness – related activities designed for a specific purpose, which is often developed by a fitness or rehabilitation specialist for the client or patient. Components of exercise prescription generally includes specific recommendations: (1) type of exercise or activity (walking, swimming, cycling) (2) specific workloads (watts, walking speed) (3) duration of activity or exercise session (4) intensity guidelines – target heart rate range (THR) and estimated rate of perceived perception (RPE) and (5) precautions regarding certain orthopedic or other concern related comments.  further explains that Heart rate reserve (HRR) is defined as the maximal heart rate (HR max) observed during a symptom-limited exercise stress test minus the resting heart rate (HR rest). A percentage of the HRR range is added to the HR rest to determine a THR range to be used during exercise. This approach accounts for individual variability in the HR rest and better reflects the peak exercise oxygen consumption (VO2). Exercise intensity is generally recommended to be 60-90% of the HR max or 50-85% of the VO2 maximum (VO2 max) or HRR. For example, a patient with coronary heart disease on beta-blockade medication has an HR max of 120 beats per minute (bpm) and an HR rest of 55 bpm. The recommended THR would be calculated as follows: (1) HRR = 120 – 55 = 65 (2) THR range = [(HR max - HR rest) X (0.5 - 0.85)] + HR rest (3) THR = 65 X 70% = 46 + 55 = 101 bpm. Thus, the suggested THR range would be 96-108 bpm. The VO2 max is the maximal amount of oxygen that an individual can consume and use during exercise or physical work. This value may be measured or estimated and is expressed commonly in milliliters of oxygen per kilogram of body weight per minute (mL/kg/min). The RPE scale is used widely in exercise science and sports medicine to monitor or prescribe levels of exercise intensity. The 95%-limits-of-agreement technique has recently been advocated as a better means of assessing within-subject (trial-to-trial) agreement. The perception of exertion is a monitoring behavior that uses all sources of information to govern actions that can benefit or preserve health and partake of adaptive pursuits. How a person feels about exertion moderates his or her response to exercise and effort. The perception of what is happening in exercise, and its concomitant effect on physiological function, must be known to further understand the nature of an exercise response. How a person feels modifies reactions to exercise stress and the mechanisms that underlie them. The Borg scale is as follows: (1) Six – No exertion at all (2) Seven to eight – Extremely light (very, very light) (3) Nine to ten – Very light (A1 warm-up / recovery) (4) Eleven – Light (A2 aerobic threshold) (5) Twelve to thirteen – Moderate (EN-1 anaerobic threshold) (6) Fourteen to fifteen – Hard (EN-2 VO2 max or 400 m swimming pace) (7) Sixteen to seventeen – Very hard (AN-1 peak lactate or lactate tolerance, 200 m swimming pace) (8) Eighteen to nineteen – Extremely hard (very, very hard [AN-2 anaerobic power, 25-50 m swimming pace]) (9) Twenty – Maximum all-out effort with absolutely nothing being held in reserve (1998). Instructions for use as suggested by Dr.             During the exercise you are to rate your perception of exertion. Use this scale where 6 mean no exertion at all and 20 means a totally maximum effort. The 13, on the scale is somewhat heavy exercise but capable of being performed at steady state (i.e., anaerobic threshold). When at a level of 17, the effort level requires you to push yourself hard even though it is possible to continue for some time. For many people 19, is about as strenuous as exercise becomes because they often reserve a small amount of possible extra effort. Try to appraise the feeling of exertion as honestly as possible. Do not underestimate nor overestimate it. It is of no value to underestimate the level to produce an impression of being “brave” or “tough”. Your own feeling of effort and exertion is all that is of interest. Look at the scale and wordings and decide on the word that best describes your effort level and the number alternative associated with that description. Considering the different modes of exercise: (1) Intensity: This should range from low to moderate for healthy individuals. (2) Duration: Continuous aerobic activity for 20-60 minutes is recommended. (3) Frequency (3a) Individuals with a less than 3-MET capacity should engage in multiple short sessions each day. (3b) Individuals with a 3- to 5-MET capacity should engage in 1-2 sessions per day. (3b) Individuals a greater than 5-MET capacity should engage in 3-5 sessions per week.   ACC/AHA (American College of Cardiology / American Heart Association Task Force on Practice Guidelines) 2002, Guideline Update for Exercise Testing: The weight of evidence was ranked highest (1) if the data were derived from multiple randomized clinical trials that involved large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials that involved small numbers of patients or from careful analyses of non – randomized studies or observational registries. A lower rank (C) was given when expert consensus was the primary basis for the recommendation. The ACC/AHA classifications II, III, and I are used to summarize indications as follow: Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that the procedure/treatment is not useful / effective and in some cases may be harmful. The general context for the use of exercise testing is outlined in Figure 1. Figure 1.General context of the exercise testing guidelines Source: Figure 2: Nomogram of the prognostic relations embodied in the treadmill score Source: Source:       The value of exercise testing, according to . is that exercise testing has a sensitivity of 78% and a specificity of 70% in detecting coronary artery disease. Hence a negative test does not adequately rule out disease. A positive test is much more likely to be false in a young person than an older person unless there is a very good history as they are at much lower risk. Therefore testing of young, asymptomatic people is controversial. There is a suggestion that not enough women and the elderly are being tested (2001). Hence, as stated by Doctor  prognostic testing can be useful. A positive test at a low workload is a poor prognostic sign and it indicates the need for urgent treatment. ’ theorem of diagnostic probability states that the predictive value of an abnormal test varies according to the probability of the disease in the population being study. Therefore, exercise testing is usually performed in patients with a moderate probability of coronary artery disease, rather than in those with a very low or high probability (2004).  protocol is very widely used and has been extensively validated. There are 7 stages of 3 minutes each so that a complete test takes 21 minutes. The level of exercise is estimated in METs. 1 MET or metabolic equivalent is the amount of energy expended at rest or 3.5ml oxygen per kilogram per minute. At rest, the average person has an oxygen consumption of 1 MET (or 3.5 ml/kg-min). MET values increase as more activity is performed. In stage 1 the patient walks at 1.7 mph (2.7 km) up a 10% incline. Energy consumption is estimated to be 4.8 METs during this stage. The speed and incline increase with each stage. The information from an ETT can be used to advise the patient on what activities and exercise levels are reasonable. An example of an MET chart is as follows: METs Exercise Recreational Occupational Activities of DL 1.5 – 2.0 Strolling 1 – 1.5 mph, 1 mile in 40 – 60 minutes Knitting; playing cards; sewing; watching TV Desk work; driving auto/truck; sitting doing light assembly; typing; using hand tools; writing Brushing hair / teeth, light housework; making bed; partial bath; polishing furniture; washing clothes 2.0 – 3.0 Walking, level 2.0 – 2.5 mph, 1 mile in 24- 30 min cycling, level outdoors – 5mph Horseback riding (walk), light golf (power cart); playing musical instrument; shuffle board; woodworking Bartending; crane operation; standing doing light or medium assembly; TV / auto / car repair; working heavy lever Cooking; driving car; ironing; riding lawn mower; scrubbing floor; walls, cars; widows; showing; sweeping; tub bath 3.0 – 4.0 Walking 3.0 – 4.0 mph, 1 mile in 15 – 20 min cycling, outdoors 5.5mph Billiards; bowling; canoeing; croquet; fly fishing; golf (pulling cart); shopping; volleyball (non – competitive) Baling hay; driving heavy truck; heavy machine assembly; janitorial work; light welding; operating large levers; plastering; plumbing; stocking shelves Cleaning windows; climbing stairs (slowly); General House work; kneeling; light work; pack/unpacking; power lawn mowing (light); sexual intercourse; stocking shelves; vacuuming 4.0 – 5.0 Walking 3.5 – 4.0 mph, 1 mile in cycling, 8mph calisthenics swimming (20 yd/min) Ballet; dancing; gardening (how? Weeding, digging); golf (carrying clubs); table tennis; tennis (doubles); volleyball Building interior of house; carrying trays / dishes; farm work (sporadic); house painting, lifting, carrying objects (20 – 40 lb); light carpentry; mechanic work Raking leaves; shoveling light loads 5.0 – 6.0 Walking 4.0 – 4.5mph 1 mile in 13 – 15 minutes, biking in 10 mph Canoeing (4m/hr); gardening (digging); skating (ice / roller); social / baseball (non- game); stream fishing Handyman work (moving, shoveling); heavy carpentry; putting in sidewalk Raking leaves; shoveling light loads 6.0 – 7.0 Walking/jogging, 4.0-5.0 mph 1 mile in 12-13 min Biking, 11 mph Swimming (breaststroke) Backpacking (light); Badminton; Hiking; Hunting; Horseback riding (trot), Skiing (cross country 2.5 mph); Skiing (light downhill); quare dancing; Tennis (singles) Exterior home building; Lifting, carrying objects (45-64 lb); Shoveling (10/min, 9 lb); Splitting wood Lawn mowing (push mower); Snow shoveling (light snow) 7.0 – 8.0 Walking, 5 mph 1 mile in 12 min Biking (outdoors) 12 mph Swimming (backstroke), 40 yd/min Badminton (competitive); Basketball (non-game); Canoeing (5 mph); golf (carrying bag); Horseback (gallop); Skiing (downhill, vigorous) Ascending stairs with 17 lb load; Lifting, carrying (65-84 lb); Moving heavy furniture; Sawing   8.0 – 9.0 Jog/run 5.5 mph Biking (outdoors) 13 mph Swimming (breaststroke) 40 yd/min Rowing machine; Rope jumping (60-80 skips/min) Basketball (non-game); Handball/squash/racquetball; Mountain climbing; Soccer (non-team); Touch football; Tour skiing Lifting, carrying (85-100 lb); Moving heavy furniture (moving van work); Shoveling (14 lb scoops, 10 scoops / min); Using heavy tools   9.0-10.0 Jog/run, 6 mph 1 mile in 10 min Football (competitive); sledding / tobogganing Heavy labor; Lumberjack; Shoveling (16 lb scoops) Ascending stairs carrying 54 lb 11.0+ Run 7 mph (11.5 METs) 8 mph (13.5 METs) Competitive sports: Basketball, Handball, Racquet, Rowing     Figure 3: MET chart Source:  (2006) Patients who are candidates for exercise testing may have stable symptoms of chest pain, may be stabilized by medical therapy after symptoms of unstable chest pain, or may be post-myocardial infarction or postrevascularization patients. Patients who are unable to exercise or who have uninterpretable ECGs because of pre-excitation, electronically paced rhythm, left bundle-branch block, or ST depression greater than 1 mm require imaging studies and are beyond the scope of these guidelines. Imaging studies are considered in other ACC/AHA guidelines (5,348-350). Although some studies suggest an even lower training threshold than the one used in the particular study (i.e., < 70% maximal heart rate), especially in extremely deconditioned subjects, if individuals can regularly attain a training intensity of at least 70% maximal heart rate via brisk walking, it is likely that they will achieve improved aerobic fitness. These findings may be especially relevant for the inactive patient in whom the subjective discomfort of vigorous physical training may serve as a deterrent to long-term compliance with exercise therapy (2002). The ability of exercise training as told by (2000) is to reduce morbidity and mortality rates hasn’t been well established for elderly patients, but limited data suggest some benefit (Table 1). Intervention Reduces Mortality Reduces Morbidity Control of diabetes mellitus Yes Yes   Control of obesity   Not clear   Not clear   Dyslipidemia therapy   Yes   Yes   Exercise   Yes*   Not clear   Hypertension therapy   Yes   Yes   Psychosocial interventions   Not clear   Not clear   Smoking cessation   Yes   Yes     Table 1: Impact of Interventions on All – Cause Mortality and Cardiovascular Morbidity in Elderly Patients Source:  (2005) In the , which enrolled men with known CHD (mean age, 63 years), light to moderate physical activity in the form of regular walking, frequent recreational activities (e.g., gardening), or once-weekly sporting activities (e.g., jogging, swimming), was associated with a significant reduction in all-cause mortality at five years of follow-up. More vigorous types of activities did not show a statistically significant reduction in that same endpoint (2000). A Cochrane review of men and women of all ages with previous MI, revascularization or angina found that exercise-only cardiac rehabilitation reduced all cause mortality by 27%, cardiac death by 31% and a combined end point of mortality, non fatal myocardial infarction and revascularization by 19% (2000). Prior to initiating an exercise program for the post-rehab client, the trainer will need to obtain a health history form, a signed informed consent, a physician’s referral / release for exercise and, if possible, a copy of the client’s rehab records. The physician’s referral/release form should indicate the trainer’s credentials and state that no medical monitoring (e.g., blood pressure, ECG, pulse oximetry, etc.) will be performed. The physician should be asked to provide a training intensity if age-predicted target heart rate range is not appropriate. A request for exercise precautions should also be included (2001). For most patients, clinical risk stratification based on history, examination and resting ECG combined with a functional capacity test such as a shuttle walking test or a six minute walking test will be sufficient. The test was supervised by a physical therapist and was performed,if indicated by the physician, using telemetry monitoring. Subjectswere asked to walk at their own maximal pace along a 35-m long,flat, and straight hospital corridor. No encouragement was offered.The test was symptom limited, so patients were allowed to stopif signs or symptoms of significant distress occurred (severedyspnea, dizziness, angina, skeletal muscle pain), though they were instructed to resume walking as soon as possible. The distance covered during the test was recorded in meters. The 6MWT has become one of the most popularclinical exercise tests for evaluating functional capacity. It is a practical, simple, and inexpensive test, and does not require any exercise equipment or advanced training for technicians (2004). The shuttle walking test (cited in SIGN Publication No. 57) is a low cost low tech alternative to exercise testing that informs the rehabilitation team on a suitable exercise programme and appropriate training heart rate, and allows assessment of progress during cardiac rehabilitation without the need for cardiac technicians, physicians or expensive equipment (2005). The shuttle walking test protocol is given in Box 1. Shuttle Walking Test Equipment required Calibrated cassette player and shuttle walk test tape. Two marker cones and non slippery, flat walking surface at least 10 meters in length. Heart rate monitor with record facility and adjustable upper alarm limits. Protocol Each subject should be screened by a member of the cardiac rehabilitation team for any exclusion criteria before proceeding. Place two cones exactly 9 meters apart, thus allowing the subjects to walk 10 meters when they go round the cone at the end of each shuttle. Subjects then listen to the instructions on the audio cassette. These should be repeated verbally to ensure that they understand what is expected during the test. Subjects walk around the 10 meter course aiming to be turning at the first marker cone when the first audio signal is given, and turning at the second cone at the next audio signal. Subjects should be accompanied around the first level of the test to help them keep pace with the audio signals. Thereafter the operator stands mid way between the two marker cones offering advice on completion of a level: ‘Walk a bit faster now if you can’. Progression to the next level of difficulty is indicated by a triple bleep which lets the subject know that an increase in walking speed is required. The full test comprises 12 levels each of one minute duration with walking speeds that rise incrementally from 1.2 miles per hour (1.9 km per hour) to 5.3 miles per hour (8.5 km per hour). The test is completed at 12 minutes or if one of the termination criteria is met. Termination criteria o                                Any anginal symptoms or feeling too breathless to continue. o                                Feeling dizzy or faint. o                                Leg pain limiting further exercise. Achieved level of perceived exertion >=15 (Borg Scale) Achieved heart rate >=85% predicted (detected by audible upper alarm limit). Failure to meet the speed requirements of the test – subject more than half a meter from the cone when the bleep sounds. Following the test Subjects should continue to walk slowly around the course a further four times to avoid any syncopal attacks associated with abrupt cessation of exercise. Subjects are then seated and asked to confirm their limiting symptom. Record total distance walked heart rate and perceived exertion for each level completed, peak heart rate and reason for test termination. If subjects have fully recovered after 10 minutes then no further action is required. If they report continuing breathlessness or angina then a further rest period should follow during which they may receive sublingual nitrates, have an ECG or be seen by a doctor as appropriate.   Box 1.Shuttle Walking Test Source:  (2005)     Cardiac rehabilitation (.) today targets people with ischaemic heart disease, congestive heart failure and people with a high risk of developing ischaemic heart disease. The short-term goals of cardiac rehabilitation are to stabilize heart disease, to limit the physical and mental effects of heart disease, to improve the functioning of the people with heart disease and to improve their quality of life. The long-term goals are to reduce patients’ long-term risk of heart disease, to stop the progression of heart disease and to reduce morbidity and mortality. According to current evidence, these goals can best be realized through comprehensive cardiac rehabilitation programmes based on exercise training, patient education, lifestyle intervention, risk factor management and clinical assessment, psychosocial support and optimizing the pharmaceutical treatment of symptoms. Pharmaceutical treatment comprises an important part of overall rehabilitation (2003).  Efforts to prevent heart disease can be divided into primary, secondary and tertiary prevention. Primary prevention means preventing disease from arising at all. Secondary prevention means identifying patients at high risk of developing ischaemic heart disease and identifying symptoms and disease at early stages to reduce the course of disease and contribute to improving the prognosis. Tertiary prevention means preventing remission of disease and preventing chronic conditions, including reduced functioning as a result of disease (2003). In summary, the finding of this particular study suggest that physicians and allied health professionals can prescribe brisk walking on a flat surface to their cardiac patients with confidence that this intensity will achieve cardiorespiratory and health benefits. Furthermore, these results serve to discount the lingering notion that cardiac patients need to participate in vigorous exercise such as jogging or running in order to benefit from an exercise training program.  Phase II cardiac rehabilitation programs are associated with improvements in exercise tolerance, coronary risk factors, and psychosocial well-being. Nevertheless, previous reports have generally evaluated the global effectiveness of these programs (i.e., on all subjects, collectively), which may serve to camouflage or attenuate the impact of these interventions on specific patient subsets. In one particular study, the researchers investigated the effectiveness of a contemporary, exercise-based cardiac rehabilitation program that included a cardiovascular risk-reduction intervention, using a computerized database on 117 patients (average age, 66.5 years; 68% men; 96% white) who completed pre-phase II and post-phase II evaluations (2002). As pointed out by, ( 2004) cardiac rehabilitation begin with a patient assessment that helps us develop an individualized, goal-directed treatment plan with short-term and long-term objectives for reducing cardiovascular risk and improving quality of life. Ideally, patients should be referred to cardiac rehabilitation within 1 month of a coronary event, but they can begin the program (12 to 36 sessions, depending on individual need) for up to 1 year after an event. Therefore, there are short term and long term goals that will benefit the patient in a short term basis and long term basis depending on the program that was intended for the patient and the extent of the disease.  also added, physicians have an obligation to strongly recommend cardiac rehabilitation and reinforce that message in follow-up visits. More patients would comply with the recommendation if the message — that cardiac rehabilitation increases survival and improves quality of life — were strongly emphasized (2004).                                 Credit:ivythesis.typepad.com

Exercise

Critically review the case for exercise testing and prescription in cardiac patient rehabilitation. Exercise prescription as defined by Dr...