Case study approach to exercise prescription: one size does not fit all

Samantha Breen

Clinical Lead Physiotherapist

Manchester Heart Centre

Aims

• Explain benefits of exercise training • Discuss prescription for NYHA I patient • Discuss prescription for NYHA III patient

– Considerations for symptomatic patient • prescription • Pacing • Dysponea management

Ergoreceptor ++ Deconditioned fatigue

Lactic acid

Excess CO2

Breathless Accessory muscle use

Straining heart Dizziness, pain, arrhythmias

CNS -Spinothalamic tract

Without inspiratory muscle fatigue

Heart supplies blood in

proportion to metabolic

needs

Fatiguing inspiratory muscles

send signal to the brain

Brain sends signal to

narrow blood vessels

supplying the legs

Leg blood vessels

constrict and blood flow decreases

Blood is diverted

towards the inspiratory muscles

Leg fatigue is accelerated

With inspiratory muscle fatigue

June 2012

Metaboreflex

Dampen down ergoreceptor and metaboreflex

“…A universal agreement on ex prescription in CHF does not exist; thus, an individualized approach is recommended, with careful clinical evaluation, including behavioural characteristics, personal goals, and preferences…”

Spectrum of HF. NYHA I-IV Meet Alan

• Male age 38

• LVEF 45%

• NYHA 1

• ETT

∙ 92% HRmax

∙ 10 METs

• Goal – return to the gym and would like to return to previous power lifting

Meet Jean • Female age 79

• LVEF 25%

• NYHA III

• FCA – 6 min walk

∙ 420 meters / 2 rest stops

∙ 3 METs

∙ CR-10 RPE 5 (legs 7)

• Goal – ADL and walking

FITT Principle FREQUENCY 2 – 3 x week 2 rehab classes / 1 home circuit INTENSITY dependent upon assessment/ risk

stratification 40-70 %HRR RPE 12-14 (6-20) or 3-5 (CR10) TIME 20-30 mins conditioning phase plus warm up & cool down TYPE Aerobic, CV endurance training Large muscle groups

AHA/ACSM Strength Training FITT

F Min 2 x per week I Upper body 30 – 40% 1 Rep max Lower body 50 – 60% 1 Rep max

RPE < 15 (“Volitional Fatigue”) T 1 set min (2 to 4 sets optimal) of 10 – 15 reps

T 8 to 10 different muscle groups

ACSM, 2010

Safe and effective exercise session

1 hour

Warm-up 15 min

Main component Total work CV or MSE 20-30min

Cool-down 10 min

Target intensity HR 40-70% HRR RPE 12-14 (CR-10 3-5) METS 40-70% VO2 40-70%

ACPICR, 2009

Resistance

Programme Training objectives Intensity Reps Training vol

Step I Pre-training Learn and practise 30% 1-RM. 5–10 2–3 x/wk correct implementation, RPE , 12 1-3 circuit improve intermuscular co-ordination

Step II Resistance/ local aerobic endurance 30–40% 1-RM. 12–25 2-3 x / wk endurance intermuscular co-ord RPE 12–13 1 circuit

Step III Strength increase muscle mass 40–60% 1-RM. 8-15 2-3 x/wk Muscle build-up 15 RPE 1 circuit intramuscular co-ord

ESC (2011) Minimum recommendations of implementation of Resistance Training in CHF

Modified according to Bjarnason-Wehrens et al.15

Strength training

Jogging

Treadmill exercise: walking

BP 110/70

BP 150/80

BP 155/80

BP 120/80

RPP 245

RPP 257

RPP 170

Acknowledgement Professor Patrick Doherty

TASK METS METS (min) (max) Walking 2 mph 2 3 Dressing 2 3 Bathing 2 3 Bed Making 2 6 Walking 3 mph 3 3.5 Shower 3 4 Housework gen 3 4 Cleaning Windows 3 4 Walking Upstairs 4 7 Washing Car 6 7 Cycling 5 mph 2 3 Fishing (boat) 2 4 Billiards 2 3 Cricket 3 7.5 Ballroom Dancing 4 5 Golf (carrying clubs) 4 5 Swimming (slow) 4 5 Badminton 4 9 Swimming (Crawl) 9 10

METS

70% max METS (10) = 7 METS

Adapted from Ainsworth et al. 2011 Compendium of Physical Activities: a second update of codes and MET values. Med Sci Sports Exerc. 2011 Aug;43(8):1575-81

Pelliccia et al (2005) Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. European Heart Journal 26 (14), 1422–1445

Safe and effective exercise session

18 mins

Warm-up 5 min

Main component Total work CV or MSE 10 min

Cool-down 3 min

Target intensity HR 40-70% HRR RPE 12-14 (CR-10 3-5) METS /VO2 40-70% VO2 40-70%

Programme Training objectives Intensity Reps Training vol

Step I Pre-training Learn and practise 30% 1-RM. 5–10 2–3 x/wk correct implementation, RPE , 12 1-3 circuit improve intermuscular co-ordination

Step II Resistance/ local aerobic endurance 30–40% 1-RM. 12–25 2-3 x / wk endurance intermuscular co-ord RPE 12–13 1 circuit

Step III Strength increase muscle mass 40–60% 1-RM. 8-15 2-3 x/wk Muscle build-up 15 RPE 1 circuit intramuscular co-ord

ESC (2011) Minimum recommendations of implementation of Resistance Training in CHF

Modified according to Bjarnason-Wehrens et al.15

TASK METS METS (min) (max) Walking 2 mph 2 3 Dressing 2 3 Bathing 2 3 Bed Making 2 6 Walking 3 mph 3 3.5 Shower 3 4 Housework gen 3 4 Cleaning Windows 3 4 Walking Upstairs 4 7 Washing Car 6 7 Cycling 5 mph 2 3 Fishing (boat) 2 4 Billiards 2 3 Cricket 3 7.5 Ballroom Dancing 4 5 Golf (carrying clubs) 4 5 Swimming (slow) 4 5 Badminton 4 9 Swimming (Crawl) 9 10

METS

6MWT 3 METST

Importance of being accurate with prescription for low functioning and high risk patients…

If you increase speed of walking from 3KPH (2.4 METS) to 4 KPH (2.9 METs)

• Mr A max capacity is 10 METS

= increase from 24% – 29% of max capacity

• If max capacity is 4 METs

= increase from 60% to 73% of max capacity

Progression

• Introducing steady (continuous) state • Increasing ratio’s of:

Work: rest, CV : MSE, standing : seated

• Increase, Range, Reps, Rate, resistance (4R’s) • Once 15 mins achieved intensity may be

increased • Increase through step I, II and III of resistance

training

Over activity / rest cycle

Deterioration in function

Alter prescription for ‘good’ and ‘bad’ days

Dyspnoea Management

Breathless at rest - Seek respiratory physio advice - Tidal breathing / Pursed lip breathing - Inspiratory/expiratory ratio 1:2 (rectangle model) - Posture - Use of fan

Breathing control during activity/exercise - Pace breathing with activity - Diaphragmatic breathing during active recovery - Recovery positions - Avoid breath hold / valsalva manoeuvre

Other ex considerations Safety: starting position, balance, Posture, core muscle strength

Target key muscle groups for strength

Importance of accuracy of prescription

feet moving for venous return / avoid abrupt posture shifts

limit arm ex - accessory muscle fatigue / over-head arm work

swimming – immersion increases LV volume/load Caution seated ex (limit venous return)

Inspiratory Muscle Training (IMT) ‘the dumbell for your diaphragm’

IMT improves ex tolerance (19%) and QUOL (16%)

• start at 30% of max inspiratory mouth pressure (PImax) and readjust intensity every 7–10 days up to a maximum of 60%.

• 20–30 min/day 3–5 x week for > 8 weeks.

Laoutaris et al, 2004; Ribiero et al, 2009

14/05/12

High intensity interval training

• Alternate short bouts (10–30 s) of moderate–high intensity (50–100% peak exercise capacity) exercise, with a longer recovery (80–60 s) phase, performed at low or no workload.

• VO2 peak improved by 46% high intensity interval training, compared to 14% for moderate intensity continuous training with no reported adverse events and even small improvements in left ventricular end-diastolic volumes and stroke volume.

Meyer K et al 1997; Wisloff U et al, 2007.

Alan’s prescription summary • Aerobic

• Up to 70% V02 max RPE 12-14

• up to 45–60 min duration

• Resistance training • 40-60% 1-RM 8-15 reps

• RPE 15

• Can return to most sports for which he has the functional capacity…

Jean’s Prescription summary • Aerobic endurance Frequency increase to daily, several times a day Intensity reduce to lower ends of intensity target range HR 40-70%HRR METS / VO2 40-70% RPE 12-14 (CR-10 3-5) Time reduce

• Resistance – 30% 1 RM 5-10 reps

– small muscle groups in short bouts.

• Posture, pacing and energy conservation • Dyspnoea management strategies

In summary:

• NYHA I – IV patients should all engage in regular physical activity / exercise

• Individualised prescription – adapt FITT for aerobic and resistance work

• NYHA III / IV considerations

• Adapt prescription for ‘good’ & ‘bad’ days

• Energy conservation

• Breathing techniques

Thank you for listening

Samantha.breen@cmft.nhs.uk

14/05/12

References • Pina et al (2003) AHA Scientific statement. Heart Failure and Exercise. Circulation 107:

1210-1225

• Pelliccia et al (2005) Recommendations for competitive sports participation in athletes with cardiovascular disease: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology. European Heart Journal 26 (14), 1422–1445

• NICE Clinical Guideline No 108 (2010). Chronic Heart Failure

• Selig et al ( 2010) Exercise & Sports Science Australia Position Statement on exercise

• training and chronic heart failure. Journal of Science and Medicine in Sport 13 (2010) 288–294

• Piepoli et al (2011) Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. European Journal of Heart Failure 13, 347–357

• SIGN Guideline 95 ( 2007) Management of Chronic Heart Failure

References continued • Ribeiro JP, Chiappa GR, Neder JA, Frankenstein L. Respiratory muscle function and

exercise intolerance in heart failure. Curr Heart Fail Rep 2009;6:95–101.

• Laoutaris I, Dritsas A, Brown MD, Manginas A, Alivizatos PA, Cokkinos DV. Inspiratory muscle training using an incremental endurance test alleviates dyspnea and improves functional status in patients with chronic heart failure. Eur J Cardiovasc Prev Rehabil 2004;11:489–496.

• Wisloff U, Stoylen A, Loennechen JP, et al. Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation 2007;115:3086–94.

• Meyer K, Samek L, Schwaibold M, et al. Interval training in patients with severe chronic heart failure: analysis and recommendations for exercise procedures. Med Sci Sports Exerc 1997;29:306–12.

• ACPICR (2009) Standards for physical activity and exercise fot the cardiac population

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