Health and Fitness Intervention for a Cardiac Patient - Essay Example

Coronary heart disease is the UK's biggest killer, with one in every four men and one in every six women dying from the disease. In the UK, approximately 300,000 people have a heart attack each year (NHS.UK, 2008). Approximately 1.5 million people each year suffer an acute myocardial infarction. Myocardial infarction (MI) is the death of myocardial (heart) tissue secondary to prolonged ischemia. It is the result of thrombus formation with complete occlusion or severe stenosis of greater than 75% of a coronary artery (Sullivan & Schmitz, 1994). Treatment in the early 1900's advocated complete bed rest for people with cardiac diseases. However, during recent decades, it has been found out that complete bed rest for people with cardiac disease results to a higher mortality rate. In addition, current researches have proven that exercise is a vital part in the rehabilitation program of a cardiac patient. Though there are some patients who develop adverse effects as a result of exercise, the results of the research done by Janosi, Hoffman and Hankoczy "suggest that individualized exercise training sessions are neither proarhrythmic or antiarrhythmic after myocardial infarction" (1987). Therefore, it is the aim of this paper to be able to design a comprehensive cardiac rehabilitation program through an appropriate exercise training based on the needs and physical limitations of the patient. This paper will also explain the rationale and provide succinct justifications for the exercises prescribed to the patient. Similar to a case study, this paper will be based on a particular patient. Below is the patient's profile: Mrs. Abby Corwald is a 56 year old patient referred for a 6-week health and exercise program. Abby complains of being unable to perform sustained activities for a prolonged period of time (approximately 45 minutes to an hour) such as walking or cleaning the house. Abby also complaints of being easily fatigued and of "feeling a bit sluggish". Past medical history shows Abby had a mild heart attack 5 weeks ago and was rushed to the nearby hospital. She complained of having squeezing chest pain and difficulty in breathing and was immediately rushed to the hospital. She was given prompt medical treatment and was sent home after an overnight observation. Abby is married, living with her husband and three kids aged 13, 15 and 17 at a 2-storey apartment in the city. She is a stay-home mum and runs an online clothing business. She is overweight, with a weight of 75 kilos for her 170cm frame (BMI=26). Other co-morbidities include hypercholesterolemia and diabetes mellitus (blood sugar controlled with medications). Abby has a strong family history on her maternal side of diabetes mellitus, with her grandmother death's due to complications of the said disease. Since turning 50, she has maintained a sedentary lifestyle and spent most of her time surfing the Internet due to the nature of her business. However, she used to be active in dance lessons (foxtrot) 2x a week in her 30's and 40's and was a swimmer in her collage days. Her diet consists mainly of starchy and fried foods, with take-outs from fast food restaurants at least once a week. She has been smoking since the age of 25, consuming at least 3-5 sticks per day and is a social drinker. When asked of her expectations after the 6-week program, she said she wants to be able to walk for prolonged periods of time and be able to take "foxtrot the dance floor again". The rehabilitation program following MI is the classic model for cardiac rehabilitation. It can be divided into four phases: 1. acute in-hospital phase beginning in the cardiac care unit (CCU); 2. the convalescent phase continuing the program at home until a strong scar has formed on the damaged myocardium; 3. the training phase using aerobic conditioning to increase the patient's physical work capacity; and 4. the maintenance phase, where the gains achieved by training are sustained by regular exercise (Braddom, 2000). Abby can be classified in phase 3 or the training phase since her heart attack episode was only considered mild and was cleared by her physician for exercise. It is imperative to develop an individualized exercise prescription for aerobic and resistance training that is based on evaluation findings (eg, thorough medical history, physical and laboratory exams, exercise stress test), risk stratification, comorbidities (eg, hypertension, diabetes mellitus, musculoskeletal conditions), and patient and program goals (Ballady et.al, 2007). The determinants of a cardiac exercise, as with any exercise program, are frequency, intensity, time and type. Frequency varies, dependent on the health and age of the individual with the optimal frequency of training generally at three to four times a week (Kisner & Colby, 2002). Sullivan & Schmitz suggests "three to five evenly spaced workouts per week is recommended for individuals with functional capacities above 5 METs (1 metabolic equivalent (MET) = 3.5 mL of oxygen per kilogram of body weight per minute), exercising at moderate intensities and for moderate duration" (1994). However, as the frequency of exercise increases, the risk for musculoskeletal complications such as muscle strain or overfatigue also increases. Determination of the appropriate intensity of exercise to use is based on the overload principle and the specificity principle (Kisner & Colby, 2002). According to the overload principle, the exercise load must be above the training stimulus threshold for adaptation to occur. Simply put, the intensity at which the patient must be trained should be above the activity he/she usually does. However, this does not mean that one must be overworked in order for training effects to be seen. Proper pacing and progression should be given, most especially to cardiac patients. Since Abby is a post MI patient, some areas of her heart may not be able to perform optimally and as a result, may not be able to compensate effectively against the physiologic changes during exercise. The "gold-standard" method of exercise prescription is based on the target heart rate being "a percentage of either maximal exercise capacity or maximal heart rate achieved during an exercise test" (Medscape). Several methods can be used to calculate the exercise target heart rate using the American Heart Association (AHA) method or Karvonen's method. The AHA method uses a target heart rate of 75 to 85% of the maximum heart rate based on the stress test whereas the Karvonen's method uses a heart rate range as maximum heart rate (based on the stress test) minus resting heart rate then 40% to 60% of the heart rate range is added to the resting heart rate. The oxygen consumption method (VO2 max) is the best measure of exercise intensity (Kisner & Colby, 2002). An appropriate intensity is at 67% to 80% of VO2 max for cardiac patients (DeLisa & Gans, 1998). Consequently, and with few exceptions, most exercise training studies in cardiac patients have patients exercise at least thrice weekly at heart rates corresponding to 70% to 85% of maximum HR, although lower intensities produce a training response (Thompson, 2005). According to the Exercise Guidelines by the American Heart Association, "a heart rate limit of 130 beats per minute and a MET level of 5 is used for subjects over 40" (Fletcher et.al, 2001). Borg's Perceived Rate of Exertion simply termed as Borg scale, is a practical way of evaluating the patient's response to the intensity of the exercise. The Borg scale correlates linearly with heart rate, ventilation O2 consumption and lactate levels. Exercise rated 11 (fairly light) to 13 (somewhat hard) generally corresponds to the upper limit of prescribed training heart rates during the early stages of outpatient cardiac rehabilitation (Franklin, Bonzheim, Gordon & Timmis, 1998). The principle of specificity states that training a person for a particular task should involve exercises that simulate actions similar to the said task. For example, building Abby's upper arm strength using free weights won't guarantee that she will be better at swimming. However, applying the specificity principle, using therapeutic elastic bands as resistance and having Abby perform the specific strokes against the Therabands will improve her upper arm strength at that particular angle and function. Time of day is also another important factor in exercise prescription. Early morning or late afternoon to evening are the coolest times of the day so this may be the best option for a patient who is intolerant to heat. Ideal room temperature ranges from 65oF to 68oF, but the client's comfort level may vary with different humidity levels (Salge, 2001). Patient's convenience should also be noted as too early or too late a time can decrease a patient's compliance. As for the type of exercise, cardiac patients benefit in both aerobic and strength training programs. The cardiovascular system is best conditioned during aerobic exercise as this stimulates circulation and redistribution of blood to the active muscles, which includes the heart and peripheral active muscles. Exercise for cardiovascular conditioning should be isotonic, rhythmic and aerobic; should use large muscle masses; and should not involve a large isometric component (DeLisa, 1998). Progressive resistance training maintains or improves muscle mass, strength, and endurance. For resistance exercise training, the magnitude of the stress is usually referenced to the individual's measured or estimated maximal strength or the "1-repetition maximum (RM)," the maximal weight that the subject can lift for 1 exercise (Thompson, 2005). To determine the weight intensity: Low: 40 percent of 1-RM; Moderate: 41 to 60 percent of 1-RM; and High: greater than 60 percent of 1-RM (McDermott & Mernitz, 2006) Resistance training can be a precaution for cardiac patients since this may elevate a patient's blood pressure. However, intra-arterial blood pressure measurements in cardiac patients have demonstrated that that during low-intensity resistance training [40-60% maximum voluntary contraction (MVC)] with 15-20 repetitions, only modest elevations in blood pressure are revealed, similar to those seen during moderate endurance training (BJARNASON-WEHRENS, MAYER-BERGER, MEISTER, BAUM, HAMBRECHT & GIELEN, 2004). For Abby, each exercise session will follow a pattern: a warm-up period of 10-15 minutes, aerobic exercise, strength training and lastly, a cool-down. Patient education is very important as this will help the patient know which exercises are best for her needs and goals and will also help in her lifestyle modification (eg, healthier diet, avoiding smoking & alcohol). The long-term goal set for Abby will be "The patient will be able to perform cardiovascular activities such as dancing the foxtrot and swimming for at least 30 minutes with ease and symptom-free at the end of the 6-week period". Short-term goals are: (1) to be able to walk at normal pace for 1 hour with ease after 4 sessions; (2) to increase cardiovascular endurance; (3) to increases in muscle strength and (4) to increase muscle and joint flexibility. Week 1 will be a transition phase for the patient, from leading a sedentary lifestyle to creating an active lifestyle. This is a crucial time for the patient as the results of this builds the foundation of the patient's expectations and compliance. The lower limits of the ranges given as guideline for aerobic and strength training will be used. For aerobic exercise, the limit in heart rate will using 40% of the difference in maximum heart rate and resting heart rate and for the resistance training, the limit will be using 40% of 1 RM. By doing this, the patient's cardiovascular and muscular systems will be subjected to overload at therapeutic levels gradually. By week 2, the patient will have a "feel" of the exercise program. For progression, I will increase the duration of the aerobic exercise from 20 mins to 30 mins. For strength training, progression will be increase the number of repetitions from10 to 15 reps but still maintain 2 sets. To incorporate balance training, strength training for the upper extremity will be done in the sitting position, with back unsupported. By week 3, I will increase the duration for the aerobic exercise to 45 mins, or as tolerated by the patient. The load for the strength training will be increased to 50-60% of 1 RM, again, depending on patient's tolerance. The remaining 3 weeks will be more functional in terms of the exercises to be performed by Abby. In order to be able to gain lower extremity muscle strength for dancing, I will be incorporating therapeutic elastic bands to provide resistance while she performs basic foxtrot leg moves. For her aerobic workout, I will be shifting her from treadmill to a group dance lesson especially for women her age. By week 5, I will introduce her to an indoor aquatherapy in the fitness gym, since she used to be swimmer. This will provide an excellent cardiovascular exercise. WEEK 1 WEEK 2 WEEK 3 Warm-up Passive Stretching of major UE/LE muscle groups x 30 secs hold x 2 reps PNF Stretching (Contact-Relax) PNF Stretching (Contact-Relax) Aerobic exercises 20 mins Treadmill 30 mins Treadmill 45 mins Treadmill with some incline Strength training UE: 5 lbs dumbbell x 10 reps x 2 sets (sitting pos'n with back support) to major UE mms LE: Squats & lunges x 6 secs hold x 10 reps x 1 set UE: 5 lbs dumbbell x 15 reps x 2 sets (sitting pos'n without back support) to major UE mms LE: Squats & lunges x 6 secs hold x 10 reps x 1 set Glutes & hip extensors (using machine) x 10 reps x 2 sets UE: 8 lbs dumbbell x 15 reps x 2 sets (sitting pos'n on top of a balance ball) to major UE mms LE: Leg press x 10 reps x 2 sets Glutes & hip extensors (using machine) x 10 reps x 2 sets Cool Down Walking around center at normal pace for 5 mins Self-stretching Calisthenics Calisthenics Home Exercise Program Self-stretching Brisk walking in the late afternoon (10 mins) Self-stretching Brisk walking in the late afternoon (10 mins) Balance ball exercises (with supervision by husband or son Light jog in the afternoon (10 mins) WEEK 4 WEEK 5 WEEK 6 Warm-up PNF Stretching (Contact-Relax) PNF Stretching (Contact-Relax) PNF Stretching (Contact-Relax) Aerobic exercises Indoor dance lesson Swimming x 20 mins Swimming x 30 mins Strength training Functional leg exercises (foxtrot moves) using theraband (moderate resistance) x 10 reps x 2 sets Functional leg exercises (foxtrot moves) using theraband (moderate resistance) x 15 reps x 2 sets Functional leg exercises (foxtrot moves) using theraband (maximum resistance) x 15 reps x 2 sets Cool Down Calisthenics Calisthenics Calisthenics Home Exercise Program Balance ball exercises (with supervision by husband or son) Light jog in the afternoon (10 mins) Balance ball exercises (with supervision by husband or son) Light jog in the afternoon (10 mins) Balance ball exercises (with supervision by husband or son) Light jog in the afternoon (10 mins) The benefits of cardiovascular training for cardiac patients cannot be stressed enough. Although there are some risks involved in training a cardiac patient, the benefits such as reductions in total cholesterol level, body fat, systolic BP, and increases in peak aerobic capacity and decreased in mortality rate secondary to CAD (Milani & Lavie, 1998) outweigh the risks. Through this exercise program, the patient, Abby, will be able to attain better health and a better quality of life. She will be able to return to her dancing lessons , and with proper lifestyle modifications, can significantly reduce her chances of having another MI. As recommendation, Abby should continue her exercise program, both in the fitness center and at home. Further progression should be done under supervision of her physician to safely attain optimal return to health. Reference BALADY GJ, WILLIAMS MA, ADES PA, BITTNER V, COMOSS P, FOODY JM, FRANKLIN B, SANDERSON B, & SOUTHARD D. (2007). 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