Post-Surgery Exercise Progression

Post-Surgery Exercise Progression

• After 4 weeks post-surgery, increase intensity to moderate levels, increasing time to 15-30 minutes, one or two times a day
• After 6 weeks or more post-surgery, work towards >30 minutes at moderate or better intensities, or slowly raise workload for High-Intensity Interval Training (HIIT)

Resistance Training

• Use elastic bands, hand weights, free weights, or multistation machines, progressing to more intense exercises as the patient recovers
• Select a weight that allows for 12-15 reps, increasing weight and intensity to achieve 8-10 reps
• Progression is rational, using equipment in order of resistance

Progression for CABG (Coronary Artery Bypass Grafting) and PCI (Percutaneous Coronary Intervention) Patients

• 1-4 weeks post-surgery: CABG patients use little to no resistance, focusing on ROM exercises and strengthening exercises that don't strain the incision site
• 1-4 weeks post-surgery: PCI patients can start with light weights, progressing to moderate levels after 4 weeks
• After 4 weeks post-surgery: CABG patients can increase weight and moderate levels, while PCI patients progress to multiple muscle group exercises

Exercise Examples

• Early phase discharge exercises (2-4 weeks): seated leg extension, seated or standing leg curls, standing calf raise
• Mid-phase exercises (4-6 weeks): lat pull-down, dumbbell bent-over row, dumbbell bench press
• Late-phase exercises (6 weeks+): dumbbell shoulder press, front raise, tricep kickback

Special Considerations

• Incisional discomfort in chest, arm, and leg of surgical patient; restrict upper extremity exercises until soreness resolves
• Avoid HIIT in those with arrhythmia, angina, or abnormal blood pressure responses with exercise

Strength Testing

• Isometric and isotonic testing, using protocols like peak force and torque, repetition maximum protocol, and 3-10RM
• Clinical measures include maximal strength, blood pressure, heart rate, and signs and symptoms
• Special considerations for CABG: healing at incision site, no Valsalva

ROM Testing

• Trunk flexion, shoulder flexion, extension, and abduction testing using sit and reach and goniometer
• Clinical measures include posterior leg and lower back flexibility, shoulder flexibility
• Special considerations: orthopaedic limitations that may affect testing

Exercise Prescription

• Inpatient program: ROM and ambulation, education, and supervised exercise (2-5 days for CABG, 1-2 days for PTCA-stent)
• Outpatient programs: supervised, unsupervised, and at-home exercises, individualized according to patient needs and goals

Aerobic Exercise Prescription

• Mode: walking, cycling, rowing, stair stepper, swimming, cross-trainer
• Frequency: 4-7 days/week, with HIIT 3 days/week
• Intensity: asymptomatic - 40-85% HRmax, symptomatic - below ischemic or angina threshold
• Duration: 30 minutes, continuous or intermittent (3 x 10 minutes) depending on tolerance

Pacemakers and Internal Defibrillators

• Single chamber pacemaker: typically has one lead to and from the right atrium or the right ventricle, used when the SA node sends signals too slowly, but the conduction pathway is intact.
• Dual chamber pacemaker: has two leads, placed in the right atrium and right ventricle, used when the conduction pathway to the lower chamber is partly or completely blocked.

Exercise and Pacemakers

• Significant increase in cardiac output (Q) during maximal exercise compared to rest, with Q increasing by 200-400% and heart rate (HR) increasing by 200-300%.
• Physiological pacing: maintenance of the normal sequence and timing of contractions of both the atrium and ventricles, with AV synchrony producing higher Q without increasing myocardial O2 uptake.
• Dual chamber pacemakers: send impulses to the ventricle following appropriate AV timing when there is a complete block, improving efficiency and increasing Q.

Exercise Testing and Prescription

• Exercise testing is necessary for clients with pacemakers to provide appropriate rate responses and adjust pacemaker settings to optimize responses.
• Testing can be with or without real-time ECG monitoring, and informs settings to improve exercise capacity and reduce symptoms.
• Informal testing involves walking at a self-determined pace, followed by a brisk pace for 3 minutes each, and is more appropriate for inactive clients.
• Formal exercise testing is more appropriate for active clients likely to reach the programmed maximum sensor rate.

Exercise Prescription for Clients with Pacemakers

• The sensor-driven HR increase rate follows pacemaker algorithms, with key parameters including slope of the HR increase/decline and sensor sensitivity.
• Reduce exercise intensity to avoid sudden drops in HR, and notify the doctor/cardiologist if this occurs.
• Aerobic training: follow CHF guidelines, with intensities ranging between 40-75% VO2peak, and stable CHF clients training 3-5 days/week.
• Resistance training: aim for RPE 12-15, with 12-25 reps and work to rest ratio 1:2, and avoid upper body RT for a couple of months following pacemaker implementation.

Implantable Cardioverter Defibrillators

• Exercise guidelines need to be set by the cardiologist, and prescription should be age, health, and functional capacity-specific.
• Commence exercise under supervision with HR monitoring, and avoid unintended shocks by employing 20-30 beats below ICD activation limits.

Gas Exchange

• CO2 is released from the blood more easily than from bicarbonate
• Systemic gas exchange: loading of CO2 and unloading of O2 at the systemic capillaries

CO2 Loading

• CO2 diffuses into the blood
• Carbonic anhydrase in RBC catalyzes the reaction: CO2 + H2O → H2CO3 → HCO3- + H+
• Chloride shift: HCO3- exchanges for Cl- to maintain balance
• H+ binds to hemoglobin, reducing its affinity for O2

Oxygen Unloading

• H+ binding to hemoglobin reduces its affinity for O2, releasing oxygen
• Venous reserve: oxygen remaining in the blood after passing through the capillary beds

Alveolar Gas Exchange

• Reactions that occur in the lungs are the reverse of systemic gas exchange
• CO2 unloading:
  • Hb loads O2, decreasing its affinity for H+
  • H+ dissociates from Hb, binding with HCO3-
  • CO2 + H2O → H2CO3 → HCO3- + H+
• Reverse chloride shift: HCO3- diffuses back into RBC in exchange for Cl-, generating free CO2 to be exhaled

Gas Transport

• Oxygen transport:
  • 98.5% bound to hemoglobin
  • 1.5% dissolved in plasma
• Carbon dioxide transport:
  • 90% carbonic acid/bicarbonate + H+
  • 5% bound to amino group
  • 5% dissolved in plasma
• Relative amounts of CO2 exchanged between blood and alveolar:
  • 70% from carbonic acid
  • 23% from carbamino compounds
  • 7% from dissolved gas

Respiration

• Inspiration: diaphragm and ribs expand, increasing lung volume, and air flows in
• Expiration: diaphragm and ribs relax, decreasing lung volume, and air flows out
• Resistance to airflow:
  • Determined by diameter of bronchioles, pulmonary compliance, and surface tension of alveoli
  • Factors affecting resistance: bronchodilation, bronchoconstriction, degenerative lung diseases
• Alveolar ventilation rate (AVR): product of air that ventilates alveoli and respiratory rate

Control of Respiration

• Input to the respiratory centers: from various levels of the nervous system
• Hyperventilation: rapid breathing expels CO2, reducing blood CO2 levels, and pH increases, constricting cerebral arteries and reducing cerebral perfusion
• Sensory receptors:
  • Central chemoreceptors: respond to pH changes in cerebrospinal fluid
  • Peripheral chemoreceptors: respond to O2, CO2, and pH levels in blood
  • Stretch receptors: respond to bronchial and bronchiolar smooth muscle stretch
  • Irritant receptors: respond to irritants, triggering protective reflexes

Prevalence of Pulmonary Conditions in Australia

• In 2022, there were 467 deaths in Australia related to asthma, with 299 females and 168 males.
• Approximately 2.8 million (11%) Australians have asthma, with a higher prevalence among females (12.2% compared to 9.4%).
• Asthma prevalence is higher among people living in disadvantaged areas (13.2% compared to 10.2%) and those living with a disability (17.0% compared to 8.0%).
• 16% of First Nations people have asthma, down from 18% in 2012-13.
• Adults with asthma are more likely to be smokers (1 in 7 daily smokers, 1 in 3 ex-smokers) compared to those without asthma.

COPD

• In 2022, 2.5% of Australians had COPD, with a similar prevalence between males and females (2.4% and 2.6%).
• 7.0% of people aged 65 years and over have COPD.
• Current daily smokers are more likely to have COPD than ex-smokers or those who have never smoked (8.1% compared to 4.4% and 1.6%).
• 86.6% of people with COPD have two or more chronic conditions, and 1 in 10 adults with severe or very severe bodily pain have COPD.

Diagnostic Procedures

Spirometry

• Measures pulmonary volumes and rate of expired airflow.
• Useful for diagnosing lung diseases and monitoring improvement or deterioration.
• Tests include:
  • Vital capacity (VC): maximal volume of air that can be expired after maximal inspiration.
  • Forced expiratory volume in 1sec (FEV1): volume of air expired during 1 second during maximal expiration.
  • FEV1/FVC ratio: ≥80% is normal for healthy individuals.

Arterial Blood Gases

• Determine pH levels, bicarbonate (HCO3-), and partial pressures of O2 and CO2 in arterial blood.
• Contribute to diagnosis and determine need for oxygen therapy.

Compensatory Processes

• Primary respiratory acidosis: compensatory process = metabolic alkalosis.
• Primary respiratory alkalosis: compensatory process = metabolic acidosis.
• Primary metabolic acidosis: compensatory process = respiratory alkalosis.
• Primary metabolic alkalosis: compensatory process = respiratory acidosis.

Imaging

• Chest roentgenogram (X-ray) is used to differentiate between emphysema and chronic bronchitis.
• Emphysema is characterized by large lung volumes, hyperinflation, flattened diaphragm, and vascular weakening.
• Computed tomography (CT) scan has greater sensitivity than X-ray.

Bronchoscopy

• Involves insertion of a bronchoscope through the nose or mouth into the lungs to identify pathologies, remove foreign objects, or obtain a sample.
• Typically performed after a CT or chest X-ray.

Bronchial Provocation Test

• Assists in asthma diagnosis to assess sensitivity of the airways.
• Involves inhalation of methacholine followed by spirometry assessments.

Sweat Chloride

• Used for diagnosis of cystic fibrosis (considered gold standard).
• Higher chlorine concentrations in clients with cystic fibrosis due to mutation in two copies of the CFTR gene.

Nutritional Considerations

COPD

• Malnutrition or nutritional depletion may be an issue for up to 25% COPD clients.
• Increased prevalence with severity of disease, and malnutrition is a predictor of mortality.
• Causes of malnutrition are not well known, but may include reduced energy intake and increased caloric demand (higher BMR), affecting diaphragm contractile force.

Pathophysiology of COPD

• COPD is characterized by airflow limitation and clinical manifestations resulting from structural abnormalities at the small airways (obstructive bronchiolitis) and pulmonary parenchyma (emphysema)
• Chronic bronchitis is a key component of COPD, defined as a productive cough on most days for at least 3 consecutive months in each of 2 successive years, related to mucus hypersecretion
• Emphysema is a pathological or anatomical diagnosis due to abnormal permanent enlargement of the respiratory bronchioles and alveoli, accompanied by destruction of lung parenchyma without fibrosis

COPD Exacerbations

• Clients with COPD may experience periods of exacerbation and worsening symptoms, often requiring hospitalization
• Exacerbations can lead to reduced quality of life (QaL), increased pulmonary function decline, prolonged recovery times, and increased mortality

COPD vs Asthma

• COPD is characterized by chronic airway inflammation and hyper-responsiveness of the tracheobronchial tree, without significant reversibility or symptom-free periods
• Asthma, on the other hand, is characterized by chronic airway inflammation and hyper-responsiveness, but with exacerbations interspersed with symptom-free periods
• Asthma and COPD overlap syndrome is diagnosed when patients experience recurrent airflow obstruction with a combination of asthma and COPD features

Factors Influencing COPD Progression

• Genetic factors, age (>45 years), gender (more common in women), and race (2.3 times higher in Indigenous people)
• Lung growth and development, exposure to particles, socioeconomic status, asthma, and airway hyper-reactivity, chronic bronchitis, and infections

Pathology, Pathogenesis, and Pathophysiology of COPD

• Pathology: chronic inflammation, structural changes
• Pathogenesis: oxidative stress, protease-antiprotease imbalance, inflammatory cells, inflammatory mediators, and peribronchiolar and interstitial fibrosis
• Pathophysiology: airflow limitation and gas trapping, gas exchange abnormalities, mucus hypersecretion, and pulmonary hypertension

Inflammation and COPD

• Inflammation is present in all areas of the lungs as a protective response to inhaled toxins (smoking)
• Inflammation contributes to tissue destruction, impairment of defense mechanisms, and disruption to repair mechanisms
• Smoking and associated inflammation create an environment of oxidative stress in the lung

Inflammatory Markers and COPD

• Increased numbers of neutrophils, macrophages, and T lymphocytes, which typically reflect the degree of airflow obstruction
• Release of cytokines and mediators, such as leukotriene B4, chemotactic factors, pro-inflammatory cytokines, and growth factors

Protease and Anti-Protease Imbalance

• Protease: enzymes that break down proteins and peptides
• Imbalance between proteases and anti-proteases, which can be induced by cigarette smoke and inflammation, leading to tissue destruction

Oxidative Stress

• Sources of oxidants include cigarette smoke and reactive oxygen and nitrogen species released from inflammatory cells
• Oxidative stress can lead to inactivation of antiproteases, stimulation of mucous production, and amplification of inflammation

Pathophysiology of COPD (continued)

• Tobacco is the primary risk factor for developing COPD, with secondary effects on skeletal muscle
• Sites affected by COPD include bronchi, bronchioles, pulmonary parenchyma, and vasculature
• Airflow obstruction and hyperinflation are key features of COPD

Exercise Testing and Prescription for COPD

• COPD signs and symptoms: dyspnea, cough, sputum production, wheezing, chest tightness, and occasional fever.

Diagnosis and History

• Diagnosis based on history, physical examination, and laboratory results (CT scan and x-ray)
• GOLD recommendations include comprehensive medical history, absence of signs, and spirometry
• Initial diagnosis established through spirometry, with post-bronchodilator forced expiratory volume in one second (FEV1) and forced vital capacity ratio of less than 0.7 confirming the presence of persistent airflow obstruction

Exercise Testing

• Important for clients with COPD, even mild-to-moderate, as symptoms often do not present until increased demand is placed on the respiratory system
• Mild COPD (GOLD grade 1) shows small airway dysfunction at rest and abnormal respiratory mechanical and gas exchange responses to exercise
• More severe disease leads to further reduction in FC and simple ADLs may impose a challenge to the respiratory system
• Clients with COPD often have coexisting CAD

Exercise Prescription

• Mode: Muscular strength and endurance, flexibility, balance, and ventilatory muscle training
• Muscular strength and endurance: isokinetic, isotonic, or both; peak force development or maximum voluntary contraction
• Flexibility: stretching, balance, tai chi, and modified yoga
• Ventilatory muscle training: recommended for COPD patients to increase ventilatory muscle strength and endurance; goals include improving exercise capacity, alleviating dyspnea, and improving health-related quality of life

Ventilatory Muscle Training

• Recommended for COPD patients to increase ventilatory muscle strength and endurance
• Techniques: voluntary isocapnic hyperpnea, inspiratory resistive loading, and inspiratory threshold loading
• Guidelines for inspiratory muscle training: frequency of 4-5 days/week, intensity of ≥30% maximal inspiratory pressure, and duration of 15-30 minutes per day

Benefits of Training for COPD Clients

• Improved exercise capacity, alleviated dyspnea, and improved health-related quality of life

Asthma Prevalence

• Around 2.7 million Australians had asthma in 2017-18
• Prevalence of asthma increased from 9.9% in 2007-08 to 11% in 2020-21
• Asthma prevalence is similar for boys and girls aged 0-14 (9.3% and 7.7%, respectively)
• Higher prevalence of asthma in females over the age of 15, except for those aged 25-34
• First Nations people were 1.6 times (18%) more likely to report having asthma than non-Indigenous Australians (11%)

Asthma Phenotypes

• Allergic asthma: easily recognized, often commences in childhood, associated with allergic disease, and responds well to inhaled corticosteroid (ICS) treatment
• Non-allergic asthma: cellular profile of sputum may be neutrophilic, eosinophilic, or contain few inflammatory cells, and demonstrates a lesser short-term response to ICS
• Adult-onset (late-onset) asthma: particularly affects women, presents for the first time in adulthood, and mostly non-allergic
• Asthma with persistent airflow limitation: some patients develop airflow limitation that is persistent or incompletely reversible
• Asthma with obesity: some obese patients have prominent respiratory symptoms and little eosinophilic airway inflammation

Environmental Factors

• Allergens (indoor and outdoor), infections, smoking, diet, and certain medications can contribute to asthma development
• Host factors, including genetics, obesity, and gender, also play a role in asthma development

Airway Inflammation

• Airway inflammation is a primary contributing factor to asthma
• Inflammation can be episodic and variable, but is persistent in asthma
• CD4 lymphocyte promotes inflammation through immunoglobulin E, eosinophils, basophils, and mast cells
• Inflammation leads to oedema, structural changes, hypertrophy, and hyperplasia of the airway wall

Pathogenesis of Allergic Asthmatic Inflammation

• Allergens are presented to naive T cells, leading to the activation of the respiratory epithelium and the release of inflammatory mediators
• T cells differentiate into T-helper 2 (Th2) cells, which induce IgE antibody production and lead to bronchoconstriction and inflammation

Bronchial Hyperresponsiveness

• Bronchial hyperresponsiveness is characterized by exaggerated bronchoconstriction from one or more stimuli
• It is a hallmark feature of asthma and correlates with the degree of acute inflammation

Asthma Diagnosis

• Diagnosis of asthma is based on identifying a characteristic pattern of respiratory symptoms and variable expiratory airflow limitation
• Symptoms may be due to acute or chronic conditions other than asthma
• FEV1/FVC is reduced compared to the lower limit of normal in adults and children

Diagnosis Continued

• Variation in FEV1 or PEF is assessed to confirm asthma diagnosis
• Reversibility testing is used to assess responsiveness to bronchodilators
• An increase or decrease in FEV1 of >12% and >200 mL from baseline, or a change in PEF of at least 20%, is consistent with asthma

Effects on the Skeletal System

• Evidence of bone disease, with increased risk in >10 years old
• Early intervention (diet and exercise) can minimize the risk of osteoporosis

Effects on Mental Health

• >25% of adults with asthma experience symptoms of depression and anxiety
• Yearly screenings for depression and anxiety are recommended during routine clinical visits

Effects on Sinuses

• Development of pansinusitis and nasal polyposis is common in asthma
• Results in difficulty breathing through the nose and can create bacterial colonization, contributing to lung disease

Effects on Sweat Glands

• Chloride transport abnormality in all epithelial cells
• Sweat test is used for asthma diagnosis
• Greater than 60 mEq.dL-1 is diagnostic for asthma

Exercise Testing and Prescription for Asthma and Cystic Fibrosis

Asthma

• Exercise testing is not generally required unless exercise tolerance is reduced disproportionately to symptoms or air-flow limitations
• Symptom-limited incremental test is completed, including assessments of oxyhemoglobin saturation and ECG, with optional respiratory gas analysis and anaerobic threshold
• Contraindications to consider: acute bronchospasm, chest discomfort, increased shortness of breath, and severe deconditioning or co-morbidities

Exercise-Induced Bronchospasm (EIB)

• Pathophysiology related to consequences of heating and humidifying large volumes of air during exercise
• Symptoms: dyspnoea, cough, tightness in the chest, wheezing, and sputum production
• Diagnosis requires bronchoprovocation challenge with pre and post spirometry testing, exercise test to symptom-limited maximum
• Two most important determinants of EIB: sustained high-level ventilation during exercise and water content
• Pre-exercise warm-up important to reduce risk of EIB (15 min duration < 60% VO2max for trained individuals, lower intensities for untrained/clinical populations)

Exercise Prescription for Asthma

• Variety of exercise prescriptions to reflect the vast range of symptoms, severity, and limitations to airflow
• Mode and intensity should reflect training status, interests, and goals
• Avoidance of triggers resulting in bronchoconstriction, adequate warm-up, and use of bronchodilators prior to exercise
• ACSM recommendations: avoidance of triggers, adequate warm-up, and use of bronchodilators prior to exercise

Cystic Fibrosis (CF)

Exercise Testing in CF

• Testing is important for monitoring and management of clinical status, pre-transplant assessment, counseling, and education
• Testing should include a standardized GXT to maximum using treadmill or cycle ergometer, monitoring data pre, during, and post GXT
• Utilize ECG and pulse oximetry

Exercise Prescription for CF

• Aerobic exercise: mode, frequency, intensity, duration, and progression vary based on age group (young children, children, teens, and adults)
• Resistance training: body weight activities, frequency, intensity, and progression vary based on age group
• Flexibility: normal movement activities, daily, 10-30 s for each stretch, pain-free
• Daily physical activity recommendations vary based on age group

Benefits of Exercise Training in CF

• Benefits of aerobic exercise training: improvements in FEV1, FVC, FEV, FEF25-75, and peak expiratory flow
• Benefits of muscular strength and endurance: increased muscular strength, vertical jump, flexibility, and balance
• Benefits for body composition, nutrition, and mental health: improved body mass, nutritional supplementation, and reduced rates of depression and anxiety

Note: The numbers in the original text (e.g., 11, 12, 13) are not included in the study notes as they seem to be page numbers or slide numbers and do not add any important information to the content.