Exercise Exercise Prescriptions:Prescriptions:

Cardiac Rehab andCardiac Rehab andFrail AdultsFrail AdultsBrian K. Unwin, M.D.Brian K. Unwin, M.D.

Colonel, Medical Corps, USAColonel, Medical Corps, USA

Uniformed Services Uniformed Services UniversityUniversity

Am Heart J 2006; 152:835-841

Cardiac RehabCardiac Rehab

Only 15-25% of eligible patientsparticipate!

Am Heart J. Nov. 2006. 152(5):835-41

DiagnosDiagnosisis

Fxnl.Fxnl.

CapacitCapacityy

QOQOLL

MorbidiMorbidityty

MortalMortalityity

AMIAMI ++++++ ++++++

++++ ++++++

CABG CABG ++++++ ++++++

++++ ++++

Stable Stable anginaangina

++++++ ++++++

++ ++

PCIPCI ++++++ ++++ ++ ??

CHFCHF ++++++ ++++ ++ ++

Cardiac Cardiac

TransplaTransplantnt

++++++ ++++ ?? ??

Valve Valve Repl.Repl.

++++++ ++++ ?? ??

The Evidence

Fewer events, reduced

all cause mortality

20-34%

Core components of Core components of Cardiac RehabCardiac Rehab

Patient assessmentPatient assessment Nutritional counselingNutritional counseling Lipid managementLipid management Hypertension managementHypertension management Smoking cessationSmoking cessation Diabetes managementDiabetes management Psychosocial managementPsychosocial management General education (meds, procedures, General education (meds, procedures,

condition)condition) Physical activity counselingPhysical activity counseling Exercise trainingExercise training

Effects of ExerciseEffects of Exercise

Heart 2007; 93: 862-864

NICE GuidanceNICE Guidance

LifestyleLifestyle Regular activityRegular activity Stop SmokingStop Smoking Mediterranean DietMediterranean Diet 7 gm of Omega-3 fatty acids/week7 gm of Omega-3 fatty acids/week Healthy weightHealthy weight 14 “units” of alcohol per week14 “units” of alcohol per week No beta-caroteneNo beta-carotene No evidence for antioxidants and folic No evidence for antioxidants and folic

acidacid

NICE GuidanceNICE Guidance

Cardiac RehabCardiac Rehab Exercise offeredExercise offered Includes: exercise, education, stress Includes: exercise, education, stress

managementmanagement Involves partners/carersInvolves partners/carers Can be home based (Edinburgh Heart Can be home based (Edinburgh Heart

Manual)Manual) Advice for return to activitiesAdvice for return to activities Sexual activity okaySexual activity okay Consider wider social and health needs Consider wider social and health needs

NICE GuidelinesNICE Guidelines

Drug TreatmentDrug Treatment ACEACE AspirinAspirin Beta-blockerBeta-blocker StatinStatin Clopidogrel x12 months (after non-ST MI), at Clopidogrel x12 months (after non-ST MI), at

least 1 month after ST elevation MI.least 1 month after ST elevation MI. Aldosterone with CHF and LV dysfunctionAldosterone with CHF and LV dysfunction Consider moderate intensity coumadin (INR 2-3)Consider moderate intensity coumadin (INR 2-3)

Cardiological assessmentCardiological assessment

General RecommendationsGeneral RecommendationsIschemic Heart DiseaseIschemic Heart Disease

When stable, regular physical activityWhen stable, regular physical activity Contra-indicationsContra-indications

Recent MIRecent MI Unstable anginaUnstable angina Exercise induced arrhythmiaExercise induced arrhythmia

IntensityIntensity Below anginal thesholdBelow anginal theshold ““Talk-test”Talk-test”

Duration and Frequency = 30 min most Duration and Frequency = 30 min most daysdays

Heart, Lung and Circulation 2007; 16: S83-S87

General RecommendationsGeneral RecommendationsHeart FailureHeart Failure

All (almost) CHF patients should be All (almost) CHF patients should be consideredconsidered

Elderly not excludedElderly not excluded Intensity initially = “talk test”Intensity initially = “talk test” Duration and Frequency = 30 min most daysDuration and Frequency = 30 min most days

Risk StratificationRisk Stratification

American American Association of Association of Cardiovascular Cardiovascular Rehabilitation Rehabilitation (AACVPR) (AACVPR) (Card Clin (Card Clin 2001; 19: 415-431)2001; 19: 415-431) Lowest RiskLowest Risk Moderate RiskModerate Risk High RiskHigh Risk

American Heart American Heart Association Association (Circulation (Circulation 2001; 104:1694-1740)2001; 104:1694-1740) Class AClass A Class BClass B Class CClass C Class DClass D

AHA Guidelines include activity guidelines and supervision requirements

See handout…

Returning to workReturning to work

Many factorsMany factors Non-exercise variables are importantNon-exercise variables are important Gradual exposure to outdoor exercise Gradual exposure to outdoor exercise

programprogram See ACSM Guide Appendix ESee ACSM Guide Appendix E

Notes on total dose and Notes on total dose and volume for cardiac volume for cardiac

patientspatients For stable cardiac patients progress to For stable cardiac patients progress to expenditure of 1000kcal/week over 3-6 expenditure of 1000kcal/week over 3-6 monthsmonths

Higher level than this is associated with Higher level than this is associated with atherosclerotic regression (1500-atherosclerotic regression (1500-2200kcal/week) (15-20 miles per week)2200kcal/week) (15-20 miles per week)

Typical cardiac program is <300kcal per Typical cardiac program is <300kcal per session and <200 on non-program dayssession and <200 on non-program days

19-43% of patients in rehab programs 19-43% of patients in rehab programs reach these levelsreach these levels

Traditional exercise rx falls short of this Traditional exercise rx falls short of this goal!goal!

ACSM Guide to Exercise Rx 7th Edition

Exercise considerations Exercise considerations for the angina patientfor the angina patient

Goal: increase anginal and ischemic thresholdGoal: increase anginal and ischemic threshold Prolonged warm-up & cool down (gradual rise)Prolonged warm-up & cool down (gradual rise) Target HR below ischmic level (± 10 bpm)Target HR below ischmic level (± 10 bpm) Caution with exertion in the coldCaution with exertion in the cold Upper body exercise may precipitate Upper body exercise may precipitate

symptoms due to higher pressor responsesymptoms due to higher pressor response NTGNTG Monitor blood pressures before and after Monitor blood pressures before and after

exercise (or NTG use) exercise (or NTG use) Alternative exercise: frequent, short, Alternative exercise: frequent, short,

intermittent sessionsintermittent sessions

Exercise considerations Exercise considerations for the CHF patientfor the CHF patient

Must be on stable medical therapyMust be on stable medical therapy Monitor hypokalemia and hemodynamic Monitor hypokalemia and hemodynamic

responseresponse Malignant dysrhythmiaMalignant dysrhythmia THR 40-70% VO2max 3-7days per week, THR 40-70% VO2max 3-7days per week,

20-40 minutes per session20-40 minutes per session Long warm-up and cool downLong warm-up and cool down Interval exercise trainingInterval exercise training RPE may be usedRPE may be used

Exercise considerations Exercise considerations for the pacemaker/ICD for the pacemaker/ICD

patientpatient Fixed vs. adjustable rateFixed vs. adjustable rate Monitor systolic pressuresMonitor systolic pressures Extended warm-up and cool downExtended warm-up and cool down ICD: ECG monitoring/pulse to titrate ICD: ECG monitoring/pulse to titrate

intensityintensity Rate modulated pacemakers intensity:Rate modulated pacemakers intensity:

MHRR method of KarvonenMHRR method of Karvonen Fixed percentage of MHRFixed percentage of MHR RPERPE METsMETs

Exercise considerations Exercise considerations for the cardiac for the cardiac

transplant patienttransplant patient 1-3 year survival rates of 86% and 80%1-3 year survival rates of 86% and 80% Train wreck physically and metabolicallyTrain wreck physically and metabolically Rx from data from testing, graded protocolsRx from data from testing, graded protocols Long warm up & cool downLong warm up & cool down Denervated heart = no angina, low EKG Denervated heart = no angina, low EKG

sensitivity for ischemia, delayed sensitivity for ischemia, delayed cardioacceleratory (and deceleratory) responsecardioacceleratory (and deceleratory) response

Stress echo or radionuclide testingStress echo or radionuclide testing Intensity:Intensity:

50-75% of VO2peak50-75% of VO2peak RPE of 11-15 on the 6-20 scaleRPE of 11-15 on the 6-20 scale DyspneaDyspnea

Exercise considerations Exercise considerations for the CABG and PTCI for the CABG and PTCI

patientpatientCABGCABG ROM and mobility ROM and mobility

exercisesexercises Light hand weightsLight hand weights Stretching and flexibilityStretching and flexibility Avoid resistance training Avoid resistance training

until sternum healed (3 until sternum healed (3 months)months)

Initial aerobic training Initial aerobic training (resting HR +30bpm)(resting HR +30bpm)

Valve patients: longer Valve patients: longer recovery, slower rate, recovery, slower rate, more limitationsmore limitations

PTCIPTCI Aerobic and Aerobic and

resistance after resistance after access site healedaccess site healed

May progress rapidly May progress rapidly if no myocardial if no myocardial damagedamage

Exercise and Exercise and Frail EldersFrail Elders

Why push our frail Why push our frail elders?elders?

People live longer with chronic diseases.People live longer with chronic diseases. 10% of nondisabled adults 75 years+ lose 10% of nondisabled adults 75 years+ lose

independence in 1 or more ADL’s each independence in 1 or more ADL’s each year. year.

Exercise and physical activity can Exercise and physical activity can improve health, functional capacity, QOL, improve health, functional capacity, QOL, and independence.and independence.

Exactly What is Frailty?Exactly What is Frailty? Aging, high burden of chronic disease, Aging, high burden of chronic disease,

malnutrition and extreme lack of activity.malnutrition and extreme lack of activity. Muscle weakness and low muscle mass Muscle weakness and low muscle mass

(sarcopenia), low bone density, (sarcopenia), low bone density, cardiovascular deconditioning, poor cardiovascular deconditioning, poor balance and gait.balance and gait.

Inactivity with low energy intake, weight Inactivity with low energy intake, weight loss or low BMI.loss or low BMI.

Lunney et al. JAMA; 289:2387-92, 2003

Frailty in Relation to Other Frailty in Relation to Other End of Life StatesEnd of Life States

Physiology of FrailtyPhysiology of Frailty

Sarcopenia = decreased quality of Sarcopenia = decreased quality of musclemuscle

Strength decline: diminished walking Strength decline: diminished walking speed and balance difficulties as a speed and balance difficulties as a resultresult

Grip strength: inversely related to Grip strength: inversely related to IADL deficitsIADL deficits

Spinal mobility: affects many Spinal mobility: affects many functional tasksfunctional tasks

Exercise (Activity) Prescription for Older Adults

Fitness and Functional Status

Function

Strength

Poor

Normal

Low High

HealthyAdults

FrailAdults

NearFrail

THRESHOLD

Established Populations for Epidemiologic Studies of the Elderly (EPESE) . J Gerontology, 1994;49(3):M109-15

AM J Med. 2007. 120(9):748-753

Chronic Malnutrition

Sarcopenia

Decreasedmetabolic rate

and activity

Decreasedappetite

AgingDecreased tastePoor dentitionDementia and depressionChronic illnessMultiple hospitalizations

AgingWeight lossChronic inflammationIllness

Chronic illnessHospitalizationMedicationsStressful life eventsFalls

OsteopeniaDecreased strengthImmobilityDependencyImpaired balance and falls

FrailtyCycle

Overall: 2,762 subjects with comorbidity Overall: 2,762 subjects with comorbidity and/or disability and/or frailtyand/or disability and/or frailty

Associations with Associations with co-morbidity and disabilityco-morbidity and disability

If identified as Frail:

27% reported ADLdisability

46% had co-morbiddisease

22% had ADL disabilityand com-morbid illness

27% had neither disabilityor co-morbidity

Lancet. 2007. 369: 1328-29

Pathways to FrailtyPathways to Frailty

Prevention

Palliation

Genetic Factors, atherosclerosis,

chronic inflammation

Low level of exercise,malnutrition

Clinical Disease Primary Frailty

DisabilitySecondary Frailty

Frailty Predicted:Frailty Predicted:

Predictor of death within 3 yrs (6x Predictor of death within 3 yrs (6x mortality)mortality)

3x mortality at 7years3x mortality at 7years Increased falls, decreased mobility, Increased falls, decreased mobility,

injury and ADL disabilityinjury and ADL disability Hospitalization/institutionalization riskHospitalization/institutionalization risk Pre-frail had 2x the risk of progression Pre-frail had 2x the risk of progression

to being frailto being frail DependencyDependency

Fried. J Gerontol. 2001. 56A(3): M146-156

How to Quantify Frailty:How to Quantify Frailty: From the Cardiovascular Health StudyFrom the Cardiovascular Health Study, three or , three or

more of the following:more of the following: ShrinkingShrinking

>10 pounds (or 5%) of body weight in prior year>10 pounds (or 5%) of body weight in prior year WeaknessWeakness

Lowest 20% adjusted for gender and BMILowest 20% adjusted for gender and BMI Self report of exhaustionSelf report of exhaustion

Correlates with VO2 max and cardiovascular diseaseCorrelates with VO2 max and cardiovascular disease SlownessSlowness

Slowest 20% based on time to walk 15 feet, gender and Slowest 20% based on time to walk 15 feet, gender and standing height adjustedstanding height adjusted

Low physical activity levelLow physical activity level Weighted score of kcals expended per week, lowest 20% Weighted score of kcals expended per week, lowest 20%

adjusted to genderadjusted to gender

Fried, Tangen, et al. Frailty in Older Fried, Tangen, et al. Frailty in Older Adults: Evidence for a Phenotype. J of Adults: Evidence for a Phenotype. J of

Gerontology. 2001: 56A(3): M146-M156.Gerontology. 2001: 56A(3): M146-M156.

Quantifying Frailty:Quantifying Frailty:

FrailtyFrailty 3 or more criteria met3 or more criteria met

Pre-frailtyPre-frailty 1-2 criteria met1-2 criteria met

Criteria #1: Weight lossCriteria #1: Weight loss

Weight lossWeight loss Patients asked if they experienced 10 Patients asked if they experienced 10

pounds of unintentional weight loss in pounds of unintentional weight loss in last one yearlast one year

Criteria #2: ExhaustionCriteria #2: Exhaustion

Self-report of exhaustionSelf-report of exhaustion Two statements providedTwo statements provided

““I felt that everything I did was an effort”I felt that everything I did was an effort” ““I could not get going.”I could not get going.”

““How often in the last week did you feel How often in the last week did you feel this way?”this way?” 1= some or a little of the time (1-2 days)1= some or a little of the time (1-2 days) 2= a moderate amount of time (3-4 days)2= a moderate amount of time (3-4 days) 3= most of the time3= most of the time

Criteria #3: Walk timeCriteria #3: Walk time

HeightHeight TimeTime

MenMen

≤ ≤ 173 cm 173 cm (68”)(68”)

≥ ≥ 7 seconds7 seconds

> 173 cm > 173 cm (68”)(68”)

≥ ≥ 6 seconds 6 seconds

FemaleFemale

≤ ≤ 159 cm 159 cm (62”)(62”)

≥ ≥ 7 seconds7 seconds

> 159 (62”)> 159 (62”) ≥ ≥ 6 seconds6 seconds

Time to walk 15 feet:

6.5 secs

Criteria #4: Grip Criteria #4: Grip strengthstrength

BMIBMI Strength Strength (Kg)(Kg)

≤ ≤ 2424 ≤ ≤ 2929

24.1-2824.1-28 ≤≤3030

>28>28 ≤ ≤ 3232

MEN:

BMIBMI Strength Strength (Kg)(Kg)

≤ ≤ 2323 ≤ ≤ 1717

23.1-2623.1-26 ≤ ≤ 17.317.3

26.1-2926.1-29 ≤ ≤ 1818

>29>29 ≤ ≤ 2121

WOMEN:

<30 Kg

<18 Kg

Criteria #5: Low activityCriteria #5: Low activity

Leisure-time physical activityLeisure-time physical activity Males < 383 kcal/weekMales < 383 kcal/week Females < 270 kcal/weekFemales < 270 kcal/week

Perspective: 159# person walking at 5kph

burns 280kcal/HOUR

Frailty: An operational Frailty: An operational definitiondefinition

The aged person with unintended weight The aged person with unintended weight lossloss

WeaknessWeakness Self-report of exhaustionSelf-report of exhaustion SlownessSlowness Low activityLow activity

WASTING SYNDROME

Evidence for ExerciseEvidence for Exercise Regular physical activity reduces Regular physical activity reduces

age-related loss of muscle mass. age-related loss of muscle mass. Resistance training increases muscle Resistance training increases muscle

mass, counteracts sarcopenia, and mass, counteracts sarcopenia, and improves function.improves function.

Chronic disease and syndromes Chronic disease and syndromes respond favorably to exercise.respond favorably to exercise.

Small improvements in physiological Small improvements in physiological capacity = substantial effect on capacity = substantial effect on functional performance. functional performance.

StudiesStudies Cochrane Collaboration: falls reductionCochrane Collaboration: falls reduction Fiatarone et al: increased muscle Fiatarone et al: increased muscle

strength = increased daily functionstrength = increased daily function FICSIT Trials: balance exercises lowered FICSIT Trials: balance exercises lowered

fallsfalls FAST trial: diminished pain and FAST trial: diminished pain and

disability in OA patientsdisability in OA patients NEJM Oct 2002: 45% reduction in NEJM Oct 2002: 45% reduction in

disabilitydisability Health ABC Study: exercise = better Health ABC Study: exercise = better

functionfunction

Exercise Goals for the Frail Exercise Goals for the Frail ElderElder

Improve ADL and IADL functionImprove ADL and IADL function Improve QOL Improve QOL Enhance: flexibility, balance/postural Enhance: flexibility, balance/postural

stability, endurance, coordination, stability, endurance, coordination, movement speed, strength, and bone movement speed, strength, and bone health health

Prevent/decrease the burden of Prevent/decrease the burden of disease disease

Improve patient educationImprove patient education

Exercise HistoryExercise History

What is the patient’s lifelong pattern What is the patient’s lifelong pattern of activities and interests?of activities and interests? Patient’s investment in planPatient’s investment in plan

What has been the patient’s activity What has been the patient’s activity level in the past 2-3 months?level in the past 2-3 months? Determines current baselineDetermines current baseline

What are the patient’s concerns and What are the patient’s concerns and perceived barriers regarding perceived barriers regarding exercise?exercise? Opportunity for educationOpportunity for education

Evaluating FunctionEvaluating Function

Physical Performance Test (PPT)Physical Performance Test (PPT) Timed Get Up and Go (TUG)Timed Get Up and Go (TUG) Vulnerable Elders Survey (VES-13)Vulnerable Elders Survey (VES-13) Functional Status Questionnaire Functional Status Questionnaire

(FSQ)(FSQ) EPESE study: Physical performance EPESE study: Physical performance

measuresmeasures Others: LLFDI, PF-10 and LHSOthers: LLFDI, PF-10 and LHS

Contraindications for Contraindications for ExerciseExercise

Frailty or extreme age is Frailty or extreme age is notnot!! Caution: acute illness; unstable CP; Caution: acute illness; unstable CP;

uncontrolled DM, HTN, asthma, CHF; uncontrolled DM, HTN, asthma, CHF; musculoskeletal pain, weight loss and musculoskeletal pain, weight loss and fallingfalling

Not during treatment: hernias, cataracts, Not during treatment: hernias, cataracts, retinal bleeding or joint injuriesretinal bleeding or joint injuries

Stop!: enlarging AAA, end stage CHF, Stop!: enlarging AAA, end stage CHF, malignant ventricular arrhythmias, malignant ventricular arrhythmias, severe ASsevere AS

Risks of exercise for the Risks of exercise for the frail elderfrail elder

Main risk = musculoskeletal injuryMain risk = musculoskeletal injury Higher: vigorous exercise, higher Higher: vigorous exercise, higher

volume, obesityvolume, obesity Lower: higher fitness, supervision, Lower: higher fitness, supervision,

protective gear and well designed protective gear and well designed exercise environmentexercise environment

Risk of exercise related MI and Risk of exercise related MI and sudden death: greatest in least sudden death: greatest in least active eldersactive elders

Disease Specific Exercise Disease Specific Exercise Rx’sRx’s

OA: aquatic; flexibility training; isometric exercisesOA: aquatic; flexibility training; isometric exercises Osteoporosis: weight bearing; improve balanceOsteoporosis: weight bearing; improve balance Obesity: rotation to minimize orthopedic injuryObesity: rotation to minimize orthopedic injury HTN: aerobic activity, large muscle groupsHTN: aerobic activity, large muscle groups COPD: walking; PRT of shoulder girdle, inspiratory COPD: walking; PRT of shoulder girdle, inspiratory

and UE muscles. Bronchodilators reduce dyspneaand UE muscles. Bronchodilators reduce dyspnea CHF: aerobic and resistance training; improves VO2 CHF: aerobic and resistance training; improves VO2

max, dyspnea, work capacity and LV function; max, dyspnea, work capacity and LV function; muscle strength and muscle endurance muscle strength and muscle endurance

• Mode:

Aerobic+Strength +Balance+Flexibility• Duration• Frequency• Intensity: • Touch > No Touch > Eyes Closed for balance• 5-6/10 self-perceived exertion• Timely Follow Up• Therapy (Preventive and/or Therapeutic)

The “MD FITT” Prescription(for the older adult)

TOOL TIME!

REHAB TOOLS!REHAB TOOLS!

The Kansas City Cardiomyopathy The Kansas City Cardiomyopathy QuestionnaireQuestionnaire

The Patient Knowledge QuestionnaireThe Patient Knowledge Questionnaire Medical Outcomes Study: 36-Item Medical Outcomes Study: 36-Item

Short Form Survey InstrumentShort Form Survey Instrument 6 Minute Walking Test6 Minute Walking Test ACSM’s Guidelines for Exercise ACSM’s Guidelines for Exercise

Testing and Prescritpion (7Testing and Prescritpion (7thth Edition) Edition)

Vulnerable Elder SurveyVulnerable Elder SurveyVES-13VES-13

Saliba et al. JAGS ; 49: 1691-99, 2001

Timed Up and GoTimed Up and Go“TUG”“TUG”

Patient sits in a straight-backed high-Patient sits in a straight-backed high-seat chairseat chair

Instructions for patient:Instructions for patient: Get up (without using the armrests)Get up (without using the armrests) Stand still momentarilyStand still momentarily Walk forward (10 ft or 3 m)Walk forward (10 ft or 3 m) Turn around and walk back to chairTurn around and walk back to chair Turn and be seatedTurn and be seated >15 seconds higher risk for fall>15 seconds higher risk for fall

PPTPPT

Reuben DB, Siu AL. JAGS; 38(10): 1105-12, 1990

Exercise (Activity) Prescription for Older Adults

http://www.nia.nih.gov/NR/rdonlyres/8E3B798C-237E-469B-A508-94CA4E537D4C/0/NIA_Exercise_Guide407.pdf

Useful web sitesUseful web sites

Exercise: A Guide from the NIA Exercise: A Guide from the NIA http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide

ACSM Fit Society Page ACSM Fit Society Page http://www.acsm.org

CDC Physical Activity for Everyone CDC Physical Activity for Everyone http://www.cdc.gov/nccdphp/dnpa/phttp://www.cdc.gov/nccdphp/dnpa/physical/index.htmhysical/index.htm