Safety in Exercise Training for Patients

Safety with Exercise Training and Testing: Patients and Clients

• Objectives include understanding concerns during exercise, identifying at-risk individuals, determining when to stop exercise, and ensuring patient safety.

• Exercise Testing is synonymous with Exercise Training. Aerobic exercise training should replace "exercise testing" in thought processes.

• Apply safety principles from exercise testing (aerobic training) to exercise training sessions, especially during initial sessions in outpatient settings.

Know Your Patient's Medical History

• Absolute Contraindications:

  • Acute myocardial infarction within 2 days
  • Ongoing unstable angina
  • Uncontrolled cardiac arrhythmias with hemodynamic compromise
  • Active endocarditis
  • Symptomatic severe aortic stenosis
  • Decompensated heart failure
  • Acute pulmonary embolism, or deep vein thrombosis
  • Acute myocarditis or pericarditis
  • Acute aortic dissection
  • Physical disability preventing safe testing

• Relative Contraindications:

  • Known obstructive left main coronary artery stenosis
  • Moderate to severe aortic stenosis with uncertain relationship to symptoms
  • Tachyarrhythmias with uncontrolled ventricular rates
  • Acquired (advanced or complete) heart block
  • Recent stroke or TIA
  • Mental impairment with limited ability to cooperate
  • Resting hypertension (systolic >200 mmHg or diastolic >110mmHg)
  • Uncorrected medical conditions like anemia, electrolyte imbalance, and hyperthyroidism

Key Principles

• Check with the patient's physician for clearance before exercise-based testing

• Patients with complex conditions may require special consideration by the clinician

• Direct access to patients/clients can increase the burden for physical therapists.

  • Therapists need to identify patients who need physician referral

• A physical contact with the medical system could occur with a physical therapist if a patient is not a regular patient of a physician.

• Understand that risk stratification is important

Risk in Athletes

• Cardiovascular (CVD) causes of sudden death in young athletes are a concern
• Physicians need to evaluate patients with major signs or symptoms of CVD for referral to rule out risk

Pretest Likelihood of Ischemic Heart Disease

• Likelihood of Ischemic Heart Disease varies with age, sex, and symptom types.
• Likelihood scales are also dependent on symptom types.

Habitual frequency of vigorous physical activity

• Relative risk of acute myocardial infarction (AMI) is higher in sedentary individuals with intermittent vigorous exercise compared with active individuals.
• A consistent moderate level of vigorous activity may reduce AMI risk.

Key Principles (Monitoring Procedures)

• Monitor cardiovascular system (blood pressure, heart rate, EKG, oxygen saturation, rate of perceived exertion) before, during, and after exercise interventions
• Monitor patient cognition and subjective symptoms during exercise interventions
• Observe for dizziness, lightheadedness, shortness of breath, and loss of limb coordination.

Best Practices for Monitoring During a Symptom-Limited Maximal Exercise Test

• Monitor heart rate, electrocardiogram, blood pressure, signs/symptoms, and rate of perceived exertion before, during and after exercise testing.

Angina, Claudication, and Dyspnea Scales

• These scales are used to measure subjective symptoms or discomfort during exercise. They are graded from 0 (no symptoms) to 4 (severe symptoms).

Rate of Perceived Exertion

• Borg CR10 Scale is utilized to reflect a subjective exertion assessment during exercise.

The Future of Aerobic Exercise Testing

• Aerobic exercise testing may be a vital sign in future clinical practice
• The assessment is prognostic, diagnostic, and interventional in multiple scenarios.
  • Detects issues not apparent in resting status.

Key Exercise Testing Variables

• Exercise HR: Insight into cardiac function.
• Exercise BP: Insight into cardiac response to exercise and left ventricle function.
• Electrocardiography(ECG): Insight into potential rhythm and waveform abnormalities.

Pulse Oximetry, Subjective Symptoms, and METS

• Pulse oximetry assesses arterial oxygen saturation. Should be ≥95% during rest and exercise.
• Subjective symptoms (exertional dyspnea, angina)
• METs: Reflect cardiorespiratory fitness during exercise.

When Should You Stop Exercising?

• Absolute Indications: Sudden changes indicating possible cardiac issues, pain, or adverse symptoms.
  • ST elevation (>1mm) in leads without preexisting Q waves
  • Systolic blood pressure drop more than 10mm Hg
• Relative Indications: Signs requiring closer monitoring and potentially stopping exercise.
  • Increasing chest pains, irregular (ECG) rhythms, or other issues
  • Exaggerated blood pressure response

Warm-Ups and Cool-Downs

• Crucial for cardiovascular system, allowing for a gradual increase/decrease in heart and blood pressure and heart rate, plus ensuring venous return.

Professionalism

• Know your practice limits
• Monitor vital signs carefully
• Watch patients closely
• Ask questions