Exercise Essentials for the Client with Cardiovascular Disease. Eric Lemkin, M.S., CPT, CSCS, CES

Transcription

1 Exercise Essentials for the Client with Cardiovascular Disease Eric Lemkin, M.S., CPT, CSCS, CES

2 Cardiovascular Disease Statistics Cardiovascular diseases claim more lives each year than all forms of cancer and Chronic Lower Respiratory Disease combined. American Heart Association

3 Risk Factors for CVD non-modifiable Age Heredity Race Gender

4 Risk Factors for CVD - modifiable

5 Physical Activity and CVD Risk Benefits of Regular Exercise on Cardiovascular Risk Factors Increase in exercise tolerance Reduction in body weight Reduction in blood pressure Reduction in bad (LDL and total) cholesterol Increase in good (HDL) cholesterol Increase in insulin sensitivity

6 Quality of Life Patients with newly diagnosed heart disease who participate in an exercise program report an earlier return to work and improvements in other measures of quality of life, such as more self-confidence, lower stress, and less anxiety. Heart attack patients who participated in a formal exercise program, the death rate is reduced by 20% to 25%. This is strong evidence in support of physical activity for patients with heart disease.

7 Different forms of CVD Hypertension Coronary Artery Disease (CAD) Congestive Heart Failure Peripheral Artery Disease (PAD) Congenital Heart Disease Arrythmias Myocardial Infarction (MI) Stroke

8 Hypertension high blood pressure 2 Different Types Essential or Primary Hypertension Secondary Hypertension

9 Primary Hypertension Cause is unknown 95% of all Hypertension is essential Usually no symptoms Some individuals may experience dizziness, tiredness, headaches, or nose bleeds

10 Secondary Hypertension Most common cause of secondary hypertension is an abnormality in the arteries supplying blood to the kidneys. Airway obstruction during sleep Diseases and tumors of the adrenal gland Hormone abnormalities Thyroid disease Excessive salt or alcohol in the diet.

11 Monitoring Clients with Hypertension Check blood pressure before, during, and after exercise. Resting systolic blood pressure of 200 or higher, or diastolic of 110 or higher are absolute contraindications to exercise!!!! Arm is level with the heart. Appropriate size cuff.

12 Medications Used to Treat Hypertension Beta Blockers Diuretics Calcium Channel Blockers ACE Inhibitors Vasodilators

13 Beta Blockers Beta blockers - block the effects of the hormone epinephrine Heartbeats more slowly and with less force, thereby reducing blood pressure. Beta blockers also help blood vessels open up to improve blood flow.

14 Exercise Considerations for Beta-Blockers Exercise heart rate will be lower than individuals of same age, gender, physical capacity, bodyweight, who do not have CVD. Use a heart rate range determined by clinical stress test or recommended by physician. Use Rating of Perceived Exertion to measure exercise intensity.

15 Exercise Intensity Rating of Perceived Exertion (RPE) For many types of CVD, client may be on medication or medications that affect heart rate at rest and during exercise. Calculating a target heart rate for these individuals will not be accurate. RPE is a more effective method to measure exercise intensity. RPE should be between for clients with CVD. Clients with severe forms of CVD can start at lower RPEs of 8 11.

16 Rating of Perceived Exertion (RPE)

17 Diuretics Diuretics help rid your body of salt (sodium) and water. Most work by making your kidneys release more sodium into your urine. The sodium then takes water with it from your blood. Decreases the amount of fluid flowing through your blood vessels, which reduces pressure on your vessel walls.

18 Exercise Considerations for Diuretics Dehydration can occur much faster. Make sure client is hydrating before, during, and after exercise. Avoid exercise in hot, humid environments. Avoid exercise in cold, dry environments.

19 Calcium Channel Blockers Calcium channel blockers prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure. Some channel blockers have the added benefit of slowing your heart rate, which can further reduce blood pressure, relieve chest pain (angina) and control an irregular heartbeat.

20 Exercise Considerations for Calcium Channel Blockers May reduce heart rate during exercise. Best to use clinically determined heart rate. RPE is often a better indicator of exercise intensity rather than heart rate.

21 ACE Inhibitors Angiotensin-converting enzyme (ACE) inhibitors help relax blood vessels. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance in your body that narrows your blood vessels and releases hormones that can raise your blood pressure. This narrowing can cause high blood pressure and force your heart to work harder.

22 Vasodilators Vasodilators are medications that open (dilate) blood vessels. Affect the muscles in the walls of your arteries and veins, preventing the muscles from tightening and the walls from narrowing. As a result, blood flows more easily through your vessels. Your heart doesn't have to pump as hard, reducing your blood pressure.

23 Vasodilators and Exercise Vasodilators may cause tachycardia. Monitor heart rate frequently and stop exercise if heart rate increases suddenly and rapidly. Vasodilation may lead to rapid drops in blood pressure. Be alert for signs and symptoms dizziness, light-headedness,

24 Coronary Artery Disease (CAD) CAD is caused by plaque buildup in the walls of the arteries that supply blood to the heart (called coronary arteries) and other parts of the body. Plaque is made up of deposits of cholesterol and other substances in the artery. Plaque buildup causes the inside of the arteries to narrow over time, which could partially or totally block the blood flow. This process is called atherosclerosis.

25 Drugs Used to Treat CAD Beta-Blockers ACE Inhibitors Aspirin help to thin the blood. Statins help to lower cholesterol and reduce plaque build up. Nitroglycerin tablets, sprays, and patches cause temporary dilation of coronary arteries to reduce the heart s demand for blood.

26 Statins Reduce the production of cholesterol by the liver Can slow the formation of plaque in the arteries

27 NitroGlycerin Relaxes and widens blood vessels. Used to prevent chest pain (angina) in people with coronary artery disease. Side effects headaches, nausea, dizziness, lightheadedness.

28 Congestive Heart Failure Pumping power of the heart is weaker than normal. Cannot pump enough oxygen and nutrients to meet the body's needs. The atria and ventricles may respond by stretching. Kidneys may respond by causing the body to retain fluid (water) and salt. Fluid builds up in the arms, legs, ankles, feet, lungs, or other organs, the body becomes congested, and congestive heart failure is the term used to describe the condition.

29 Congestive Heart Failure

30 Drugs Used to Treat CHF Beta Blockers Diuretics ACE Inhibitors Anti-Coagulants

31 Blood Thinners Anti-Coagulants Clots in your arteries, veins, and heart can cause heart attacks, strokes, and blockages. 2 main types of blood thinners Anticoagulants such as heparin or warfarin (also called Coumadin) slow down your body's process of making clots. Antiplatelet drugs, such as aspirin, prevent blood cells called platelets from clumping together to form a clot.

32 Exercise and Congestive Heart Failure Prolonged warm-up and cool-down. Low intensity aerobic exercise walking, recumbent cycling, stationary bike, treadmill, walking in the pool. Client may need to take frequent breaks.

33 Precautions for Congestive Heart Failure Avoid exercising outdoors when it is colder than 40 F or warmer than 80 F or on high smog days. Do not hold your breath when doing any type of physical activity. Breath in your nose and out through your mouth. Exercise or do your selected activity at the time of day when you feel most energetic. For most heart failure patients, this is usually in the morning. May feel tired the next day after exercising. CHF patients may want to start with exercising on non-consecutive days.

34 Peripheral Artery Disease PAD Peripheral artery disease (PAD) is a narrowing of the peripheral arteries to the legs, stomach, arms, and head - most commonly in the arteries of the legs. The most common symptoms of PAD involving the lower extremities are cramping, pain or tiredness in the leg or hip muscles while walking or climbing stairs. Typically, this pain goes away with rest and returns when you walk again.

35 PAD and Exercise Have your client warm up. Stretch calf and thigh muscles in each leg for 10 to 15 seconds. Start walking. Walk at a fast enough pace for about 5 minutes, even though it may cause some mild pain. Stop and rest. After 5 minutes of mild or moderate pain, stop and rest until the pain goes away. Repeat the walk-and-stop routine several times.

36 Drugs Used to Treat PAD Beta-Blockers Diuretics Anti-Coagulants ACE Inhibitors Statins Anti-Platelet Agents

37 Anti-Platelet Agents When there is a wound, platelets clump together at the site to form a clot that stop the bleeding. Anti-Platelet agents prevent the clots from forming. Common Anti-Platelets Aspirin, Clopidogrel(Plavix), Prasugrel (Effient), Ticagrelor (Brilinta).

38 Congenital Heart Disease A congenital heart defect is a problem with the structure of the heart. It is present at birth. Congenital heart defects are the most common type of birth defect. The defects can involve the walls of the heart, the valves of the heart, and the arteries and veins near the heart. Few or no signs and symptoms. Often not diagnosed until children are older.

39 Drugs Used to Treat CHD Beta Blockers ACE Inhibitors Diuretics Anti-Coagulants Anti-Platelets

40 Arrhythmias Abnormal rhythm Electrical system. The electrical impulses may happen too fast, too slowly, or erratically - causing the heart to beat too fast, too slowly, or erratically. There are two basic kinds of arrhythmias. Bradycardia - too slow - less than 60 beats per minute. Tachycardia - too fast - more than 100 beats per minute.

41 Cardiac Conduction System

42 Ventricular Arrythmias Premature ventricular contractions (PVCs) Ventricular Tachycardia a sustained pattern of premature ventricular contractions, which can be life-threatening. Ventricular Fibrillation a fast, disorganized beating of the ventricles which quickly leads to sudden death.

43 Drugs Used to Treat Arrythmias Beta-Blockers Calcium Channel Blockers Anti-Coagulants Anti-Platelets

44 Exercise and Arrythmias ACSM guidelines 30 to 45 minutes of aerobic exercise, 3 to 5 times per week. Can start with as little as 5 to 10 minute bouts. Have client wear a heart rate monitor irregular heart beat makes it difficult to accurately check pulse by palpitation. Be alert for any symptoms.

45 Myocardial Infarction MI or heart attack Myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to a part of the heart, causing damage to the heart muscle. Chest pain or discomfort which may travel into the shoulder, arm, back, neck, or jaw. Shortness of breath, nausea, feeling faint, a cold sweat, or feeling tired.

46 Exercise Prescription for MI MI causes damage to the myocardium. This will affect the heart s ability to pump. Client who has suffered an MI will have lower aerobic capacity than individuals with other forms of cardiovascular disease. Exercise must be very low intensity to start and progress very gradually.

47 Basics of Cardiovascular Capacity Cardiac Output is the amount of blood pumped per unit of time Cardiac Output is dependent upon: HR (heart rate) x SV (stroke volume) Heart rate is measured in beats/min. Stroke volume is measured in milliliters/beat.

48 Cardiac Output and Functional Capacity

49 Medications effect on Cardiac Output Beta-blockers will cause a decrease in heart rate, thus decreasing cardiac output. Calcium channel blockers will decrease stroke volume, causing a drop in cardiac output. Diuretics will cause lower blood volume, leading to lower stroke volume, thus decreasing cardiac output.

50 Guidelines for Discontinuing Exercise - ACSM Absolute Indications Onset of moderate-to-severe angina (chest pain) Drop in systolic blood pressure (SBP) below standing resting pressure or drop in SBP with increasing workload accompanied by signs or symptoms Signs of poor circulation or blood flow, including pallor (pale appearance to the skin), cyanosis (bluish discoloration), or cold and clammy skin

51 What about Resistance Training and CVD? Resistance training is safe as long as there is proper supervision and guidelines are followed % of 1 RM for repetitions. 1 2 sets per exercise Dynamic warm-up and mobility work. Proper breathing technique. Monitor client closely for any symptoms (shortness of breath, chest pain, dizziness, nausea, cramping, etc )

52 Sample Circuit for CVD Leg Press Seated Leg Curl Chest Press Seated Row Overhead Press Back Extension Triceps Pushdown Biceps Curl

53 Things to avoid during Resistance Training Valsalva Maneuver Heavy loads in general, use light loads < 75% of 1 RM and higher repetitions 10 to 15. Rapid changes in body position.

54 Importance of Balance Training Many individuals with cardiovascular disease are older and may have balance issues. Stroke victims frequently have damage to areas of the brain that affect balance. Trainers often focus on improving aerobic fitness, strength, flexibility, and muscular endurance but neglect balance.

55 Goals of Balance Training Increase independence Decrease fall risk Improve ability to complete ADLs cooking, cleaning, gardening, bathing, yardwork, etc Improve quality of life

56 Precautions for Balance Training Clients with severe balance issues need close supervision at all times. Avoid treadmills and elliptical trainers in favor of recumbent bikes, rowers, and machines where client is seated or laying down. Avoid or limit changes abrupt changes in body position.

57 Systems that control balance Visual system older individuals often have poor eyesight. Vestibular system inner ear canals have fluid that help to control balance when the head is tilted forward, backward, or sideways. Proprioceptive system muscle and joint receptors. Golgi tendon organs (GTOs) detect changes in muscle tension. Muscle spindle fibers detect changes in muscle length. Information from these receptors is relayed to central nervous system to adjust balance and provide stability.

58 Balance training programming Balance training requires use of the nervous system to a great degree. Nervous system training causes rapid fatigue. Training balance should be done in short sessions (5 to 10) minutes. Can be used as a break or transition between aerobic training and/or strength training.

59 Balance Training Progression Always start in seated position progress to standing. Start with feet parallel, progress to feet staggered, then to single leg balance exercises. (if appropriate for client) Start on stable surfaces progress to unstable modalities. (balance pads, BOSU balls, agility discs, etc Start with full sensory awareness eyes open, hearing enabled, head in neutral position. Progress to limiting one or more senses one eye closed, both eyes closed, ear plugs in, head tilted forward, backward, or to the side.

60 Balance Training Exercises Seated Airplane

61 Seated Single Leg Raise

62 Standing One-Leg Raise

63 Balance Exercises Heel-Toe Walks Walking with cup or paper plate on the head Walking with head tilted to one side Walking backwards Walking with one eye closed Level changes walking up or down from a step or box

64 Psychological Considerations Empathy Mentoring Stress Management Progressive Muscle Relaxation Yoga Tai Chi Guided Imagery Meditation

65 Summary Every client and condition is different. Learn as much as you can about the condition. Make sure you get Physician Consent Form. Make sure client takes their medications before exercise. Assess client s HR, BP, and RPE frequently. Monitor client closely for any signs or symptoms. Start very slowly and gradually increase exercise time, intensity, and frequency. Always error on the side of safety.