Motivations and Deisions for Special Populations to Exercise - Research Paper Example

MOTIVATIONS AND DECISIONS FOR SPECIAL POPULATIONS TO EXERCISE (CONGESTIVE HEART FAILURE PROBLEM BACKGROUND Congestive heart failure (CHF) currently afflicts over 4.7 million Americans, and every year 550,000 individuals develop CHF with an incidence rate of 10 per 1,000 after age 65 (American Heart Association, 2002). Congestive heart failure accounts for about 7% or 523 billion of the total cost of heart disease annually (American Heart Association, 2002). Congestive heart failure (CHF) causes the heart’s muscle tissue to weaken and lose the ability to contract with enough force to keep the circulatory system working properly. This impairment results in a decrease in blood flow to the skeletal muscles making activities of daily living more difficult. In addition, there is a decrease in kidney filtration resulting in fluid retention and shortness of breath. If CHF is not optimally treated, a sharp decline in health can occur followed by sudden death. Global treatment of the disease including a proper medication regimen, muitidisciplinary patient education, and regular exercise have been shown to increase functional capacity and quality of life, while decreasing hospital admissions for CHF. A primary treatment of CHF is through a proper medication regimen. Angiotensin-converting enzyme (ACE) inhibitors is used to treat high blood pressure, the main contributor to heart failure (Meyer, 2001). Previously, CHF patients were instructed to rest and avoid exercise in order to postpone disease progression and to promote diuresis induced by bed rest (Sullivan & Hawthorne, 1996). However, exercise, although not prescribed for heart failure patients until the late 1980s, has produced positive physiological changes. Regular exercise increases the blood flow to the working muscle, reduces ventilation for each given workload, and improves skeletal muscle overall function (biochemical and histological aspects), causing the neurohormonal activity to normalize (catecholemines) (Parnell, Hoist, & Kaye, 2002). These benefits, incurred from exercise, improved quality of life scores among CHF patients (Oka et al, 2000; Weber et al, 2000). Exercise training is also responsible for producing significant increases in systemic arterial compliance in just eight weeks, an important contribution to cardiac afterload (arterial resistance encountered by blood as it leaves the left ventricle of the heart) (Parnell, Hoist, & Kaye, 2002). Furthermore, exercise may reduce the risk of death for CHF patients, just as it does for patients who have coronary artery disease (McKelvie, Teo, & McCartney, 1995). In addition, programs which include a component of aerobic exercise training contribute to improved skeletal muscle functioning, cardiac ejection fraction (EF), ambulatory distance walked, and activities of daily living among patients with CHF (Arahata et al, 2000). Simultaneously, it has been continuously reported that patients with heart failure are often readmitted to the hospital because they lack the knowledge about managing the disease and show little adherence to exercise and physical activity (Blyth, et al., 1997). This problem prompts the development and implementation of multidisciplinary education approach for CHF and other special population advocating the effectiveness and the necessity of exercise as a part of treatment regimen. This paper aims to discuss and analyze the benefits of physical activity and exercise for CHF population as well as motivational techniques and strategies targeting resisting special population improving their exercise adherence. 2. IMPACT OF EXERCISE FOR CHF POPULATION A. CARDIOVASCULAR EXERCISE PRESCRIPTION The cardiovascular exercise prescription for patients with CHF historically has been modeled from fitness training, rehabilitation studies, or another steady state protocol designed for the apparently healthy individual (Meyer, 2001). However, more recent research recommendations have advocated the interval method (exercise followed by a short rest before resuming exercise) for this population. A target heart rate of 40-60% of peak VO2 (volume of oxygen consumption) with an exercise duration of 3-5 minutes followed by rest, then exercise has proven more effective in stimulating peripheral muscle tone. Progression is recommended in the order: duration, then frequency, followed by intensity (Meyer, 2001). Long warm-ups are important to facilitate vasodilation (vessel diameter increase) before the demands of exertion of aerobic and anaerobic exercise. The cardiovascular interval training method is also effective because it resembles the patients activities of daily living such as climbing stairs, crossing a room, and walking to the mailbox. Along with exercise, it is important that patients be taught the signs of decompensation such as chest pain, worsening shortness of breath, water weight gain, edema, and dizziness (Clark & Sherman, 1998). These described exercise prescription guidelines are recommended for patients who have been clinically stable for at least three to four weeks. Clinical stability is defined as no change in symptoms, weight, and drug regimen over this period (Dubach, Sixt, Myers, 2001). Caution is also appropriate when systolic blood pressure is below 80 mmHg and heart rate is less than 50 or more than 100 beats per minute at rest (Dubach, Sixt, Myers, 2001). B. RESISTANCE TRAINING PRESCRIPTION The rationale of chronic exercise training is to induce muscular stress, causing the body to structurally or functionally adapt to the physical stress. Hence the next time the muscular stress is presented, the muscle is better equipped to handle the load. Historically, resistance training (weight training) has been avoided in the CHF population due to fear of symptom exacerbation (worsening) (Meyer, 2001). However, because muscle atrophy is a characteristic of CHF, resistance training has been effective in strengthening skeletal muscle, especially for small muscle groups with low repetitions (Meyer, 2001). Circuit training is often a method prescribed for CHF patients to improve body composition, strength, endurance, and even augment cardiovascular fitness (King, 2001). Circuit training consists of performing exercises at resistance stations with a 30-second rest before moving to the next machine. Eight to 12 repetitions per set performed on major muscle groups such as the arms, shoulders, chest, abdomen, back. hips, and legs will produce the desired training effect of increased muscle strength during activities of daily living. A lighter weight such as 60% of 1-RM (one repetition maximum) is sufficient to develop muscular strength safely without excess fatigue (King, 2001). The benefits of regular exercise for this population were demonstrated in a long-term exercise study (Delagardelle, et al.. 1999) conducted to determine the effect of a six-month exercise-training program on strength and endurance among 14 advanced heart failure patients. After an introduction period, the program was split into four cycles in which endurance and strength were assessed, reevaluated and progressively increased (Delagardelle, et al.. 1999). Participant compliance was 89% after 80 outpatient hospital sessions (Delagardelle, et al.. 1999). The NYHA class improved from a mean of 2.7 to 1.5 (P=.0001) and VO2 (volume of oxygen consumption) improved from 16.7 to 1S.4 mL x kg (-1) x min (-1) (P=.02) (Delagardelle, et al.. 1999). There was an 18% increase in muscular endurance of knee flexors (P = 0.008) and a 25% increase in knee extensors (P = 0.007) (Delagardelle, et al.. 1999). Although the sample size in this study was small, it showed that progressively adapted global strength training in association with traditional endurance training is feasible for selected patients with CHF. Often, researchers attempt to determine the best predictor of outcomes on CHF patients. There are many tests utilized in this population and finding one that is useful for developing a plan of care is often difficult considering the multitude of variables present in CHF patients. For example, one large study (Huelsmann et al, 2002) consisting of 226 CHF patients examined peak oxygen consumption, percentage of predicted oxygen consumption, ventilation, and workload with a one-year follow-up to measure the superiority of one of these parameters on survival. The end-points for the study were death and cardiac transplantation (Huelsmann et al, 2002). Interestingly, the researchers found that only ventilation and workload (on the bicycle) correlated to one-year mortality. Thus, they concluded that workload constituted a more powerful predictor on one-year survival compared with more traditional markers such as peak oxygen consumption and percentage of predicted oxygen consumption (Huelsmann et al, 2002). C. EXERCISE AND QUALITY OF LIFE Patients with dilated cardiomyopathy (enlarged and weakened heart), the signature of systolic heart failure, have experienced significant impairments in physical and social functioning, mental health, vitality, and general health (Steptoe, et al., 2000). Furthermore, major depression among patients with CHF has been correlated with increased mortality and hospital readmission rates and is independently associated with a poor prognosis (Jiang et al, 2001). Research conducted at the School of Nursing at the University of California (Dracup, et al, 1992) on 134 patients with symptoms of heart failure verified these quality of life characteristics. They found that the six-minute walk test. New York Heart Association class, and self-reported functional status were all significantly correlated with psychosocial adjustment. Self-reported functional status, depression, and hostility accounted for 43% of the variance in total psychosocial adjustment to illness in the patients (Dracup, et al, 1992). Thus, the ability to function physically can be directly correlated to patient perceived quality of life, as measured by walking tests and subjective questionnaires (Havranek et al, 1999). Exercise may be a key factor in improving quality of life in patients with CHF. From the critical perspective, the majority of the research demonstrates that quality of life improvements can be realized with increases exercise tolerance. A three-month study conducted by the Department of Physical Medicine and Rehabilitation at the University of Vienna, Austria (Quittan, et al 1999), investigated the correlation between actual and perceived physical functioning in heart failure patients. In a randomized control setting, 25 patients participated in a three-month exercise program, which included pre- and post- testing of exercise capacity and the SF-36 Health Survey (Quittan, et al 1999). The training group exercised aerobically three hours per week while the control group continued their activities of daily living (Quittan, et al 1999). Results illustrated a significant improvement in perception of quality of life for the training group in the domains of vitality (p=.0001), physical role fulfillment (p=.001), physical functioning (p=.02), and social functioning (p=.0002). Although only a weak correlation was found between physical performance and QOL domains, exercise was effective in increasing oxygen uptake and exercise time in the training group (p Read More