Clinical Application
Initiating an exercise program in patients with chronic illnesses requires the primary care provider to:
- Examine the patient profile.
- Gather patient history including cardiovascular history.
- Perform a complete physical examination.
- Consider risk factors and functional status of the patient prior to implementation of an exercise modality.
- Refer to a specialist prior to initiating an exercise program if the patient has uncontrolled hypertension, uncontrolled heart failure, ventricular irritability, unstable angina, unstable diabetes mellitus, or morbid obesity.
- Determine exercise modality:
- Heart failure: Aerobic and resistance training
- Coronary heart disease: Aerobic and resistance training
- Frailty: Resistance and balance training
- Osteoporosis: Resistance, aerobic, and balance training
- Obesity: Aerobic and resistance training
- Lung disease: Resistance training
Aerobic Exercise
- For improving and maintaining the condition of the cardiovascular system, decreasing obesity, and decreasing blood pressure
- Involves dynamic exercise of the large muscle groups
- Always warm-up prior to any aerobic exercise.
- The intensity target can be determined by two methods:
- The "talking pace" - the intensity sufficient to feel one is working hard while being able to talk without feeling dyspneic.
- Calculating your target heart rate and keeping your heart rate between 60 and 80% of your maximum heart rate. (This method is not ideal for patients on a nonselective beta blocker).
220 – age = maximum heart rate
maximum heart rate x 0.6 = low end of your target heart rate
maximum heart rate x 0.8 = upper end of your target heart rate
- Progression of aerobic training should be gradual. Increase your training by 10% per week.
- Frequency: 3 to 7 days per week
- Examples:
- Treadmill
- Dance
- Hiking
- Stair climbing
- Bicycling
- Swimming
- Elliptical
Balance Training
- Improves gait stability and balance and decreases fear of falling
- Frequency: 2 to 7 days per week
- Examples:
- Yoga
- Pilates
- Tai Chi
- Proprioceptive exercises
- Standing and moving with eyes closed
- One-leg balances
- Toe walking
- Forward-backward leg swings with knee flexed
Strength/Resistance Training
- Improves and maintains muscle fitness, increases bone density, mobility, and agility, and decreases obesity
- Warm up prior to any strength/resistance training.
- Start with light weights that can be lifted comfortably through a full range of motion using good posture and mechanics then progress to the next heavier weight that can be lifted comfortably.
- Perform a single set of 8 to 10 different exercise sets (chest press, shoulder press, triceps extension, biceps curl, pull-down, abdominal crunch, quadriceps extension, leg curls, leg press or calf raise) with 8 to 15 repetitions.
- Frequency: 2 days per week
Process of Care
Initiation of Treatment
The provider will conduct a baseline health assessment and identify key health problems for each patient. The provider will record weight and body mass index (BMI), along with usual pattern of exercise. Having identified a client in need of exercise therapy, the provider will:
- Outline preferred modes of exercise based on the patient's health problems
- Counsel the patient on an interval introduction of exercise
- Prescribe length and intensity parameters based on the patient’s current state of health
- Instruct the patient to keep a log of exercise
Continuation of Treatment
The provider will conduct health assessments and compare findings with baseline. On an ongoing basis the provider will:
- Monitor weight and BMI
- Monitor improvement in exercise tolerance
- Monitor improvement in health status
Follow-up Visits
At intervals deemed appropriate for the individual patient the provider will:
- Evaluate compliance with exercise regimen
- Evaluate patient's subjective responses to exercise and review exercise log
- Evaluate weight and BMI and compare with expectations, discuss with patient
- Recommend modifications in exercise regimen as indicated
- Offer alternatives or solutions to obstacles the patient encounters
Intervention
- Three 30-minute counseling visits, with a detailed agenda that focuses on initiation, recording progress, modifications, monitoring fatigue, and symptoms of overexertion
- One interval 15 minute visit to follow progress and evaluate program.
Visit 1 (30 minutes)
The provider will conduct a baseline health assessment and identify key health problems for each patient. The provider will record weight and BMI, along with usual pattern of exercise and patient resources for exercise modalities (access to gym or pool, machines at home, etc.). The provider and patient then choose the most appropriate exercise method. The Health-Related Quality-of-Life Measure Tool and Six Minute Walk Test are completed. The provider instructs the patient on the recommended mode of exercise and how to advance in intervals to goal. Specific daily plans and goals are set. The patient is instructed to keep a log of exercise, including barriers, feelings, and concerns. Return in 4 weeks.
Visit 2 (15 minutes)
The provider will review the patient's exercise log and discuss compliance with regimen. The provider offers alternatives or solutions to obstacles the patient encounters. The provider asks for patient input in the prescribed regimen and makes adjustments as appropriate. Return in 2 months for follow up.
Visit 3 (30 minutes)
The provider will conduct a health assessment and compare findings with baseline. The provider will compare weight and BMI with baseline. The provider will review the patient's exercise log. The provider will discuss compliance to exercise regimen, document progression, and be attentive to patient's concerns and experience. The provider will make recommendations based upon assessment and evaluation and provide motivation and encouragement. Return in 2 to 3 months for 6-month evaluation.
Visit 4 (30 minutes)
The provider will conduct a health assessment and compare findings with baseline. The provider will compare weight and BMI with baseline. The provider will review exercise log, discuss compliance to exercise regimen, document progression, and be attentive to patient's concerns and experience. The Health-Related Quality-of-Life Measure Tool and Six Minute Walk Test are completed. The provider will make recommendations based upon assessment and evaluation and provide motivation and encouragement. Follow up as needed.
