Clinical Exercise Physiology for Cancer, Cardiovascular, and Pulmonary Rehabilitation

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Chapter 32

• Clinical Exercise Physiology for Cancer,
  Cardiovascular, and Pulmonary Rehabilitation

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Clinical Exercise Physiologist in the Clinical
Setting

• Outcomes of disease
• Handicap
• Disability
• Functional limitations
• Impairment
• Disease
• Vital link between sports medicine and exercise
  physiology

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Training and Certification Programs for Exercise
Physiologists

• ACSM certifications
• Clinical track
• Program director (PD)
• Exercise specialist (ES)
• Health/Fitness track
• Health/fitness director (HFD)
• Health/fitness instructor (HFI)
• Exercise leader (EL)

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Clinical Applications of Exercise Physiology to
Oncology

• Cancer statistics
• Second leading cause of death in USA
• Lung cancer causes most deaths
• Men get prostate cancer most frequently, followed
  by lung, colon, then bladder
• Women get breast cancer most frequently, followed
  by lung, colorectal, and uterine

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Clinical Applications of Exercise Physiology to
Oncology

• Cancer exercise
• Strong inverse relationship between activity
  all cancer
• Cancer rehabilitation through exercise
  prescription
• Several shorter length moderate to low intensity
  sessions
• Helps patients regain strength following therapy
• Helps patient psychologically

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Clinical Applications of Exercise Physiology to
Oncology

• Nutrition and cancer
• 1/3 of cancer deaths are related to diet
• Food factors influencing cancer risk
• Type
• Preparation
• Portion size
• Overall energy balance

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Clinical Application of Exercise Physiology to
Cardiovascular Diseases

• Overview and scope of cardiovascular diseases
• Many forms of the disease
• Degenerative heart disease
• Coronary artery disease
• Arteriosclerosis
• Coronary heart disease

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Blood Pressure-Classification and Risk
Stratification

• Mild hypertension
• 140 159 mmHg systolic
• 90 99 mmHg diastolic
• Moderate hypertension
• 160 179 mmHg systolic
• 100 109 mmHg diastolic

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Exercise Training and Hypertension

• Chronic resistance training effects on blood
  pressure
• Reductions in blood pressure of 6-10 mmHg
• Reductions most apparent in those with mild
  hypertension
• Effects are transient- need to continue training

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Diseases of the Myocardium

• Angina pectoris
• Chest pain indicating inadequate oxygen supply
• Myocardial infarction
• Congestive heart failure
• Heart fails to pump required volume of blood
• Aneurysm
• Abnormally dilated wall of a blood vessel
• Creates a weak spot

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Diseases of the Myocardium

• Heart valve disease
• Stenosis narrowing or constriction
• Insufficiency fails to close properly resulting
  in regurgitation
• Prolapse enlarged valve leaflets bulge back
  into left ventricle

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Diseases of the Myocardium

• Inflammation conditions
• Endocarditis
• Pericarditis
• Congenital malformations
• Septal defects
• Shunts between aorta pulmonary artery
• Cardiac nervous system diseases
• Dysrhythmias
• Bradycardia, tachycardia, or PVCs

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Cardiac Disease Assessment

• Purpose of health screening and risk
  stratification-identifies persons
• With medical contraindications
• Needing in-depth medical evaluation
• With clinically significant disease who need
  medical supervision when exercising
• Patient history

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Cardiac Disease Assessment

• Physical examination
• Heart auscultation
• Laboratory tests
• Noninvasive physiologic tests
• Echocardiography
• Graded exercise stress test
• Ultrafast CT scan
• Electronic beam detects calcium in coronary
  arteries

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Cardiac Disease Assessment

• Invasive physiologic tests
• Radionucleotide studies
• Thallium imaging
• Nuclear ventriculography
• Pharmacologic stress testing
• Cardiac catheterization
• Coronary angiography

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Cardiac Rehabilitation

• Inpatient programs
• Medical surveillance
• Identification of significant impairments
• Patient return to daily activities
• Optimize recovery through preparation of family
  and patient

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Cardiac Rehabilitation

• Outpatient programs
• Monitoring patient to detect changes in clinical
  status
• Return to premorbid activities
• Assisting patient implement at-home, unsupervised
  exercise program
• Providing family support and education

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Exercise Stress Testing

• Reasons for stress testing
• Diagnosis heart disease
• Assess exercise-related chest symptoms
• Screen for entry into preventive and cardiac
  rehabilitative exercise programs
• Uncovers abnormal blood pressure responses
• Monitors effectiveness of therapeutic
  interventions
• Quantifies and evaluates functional aerobic
  capacity

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Exercise Stress Testing

• Guidelines for determining who requires stress
  testing have been established by the ACSM AMA
• Informed consent
• Tells patient risks benefits
• Establishes confidentiality, voluntary nature of
  tests and allows for asking questions

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Exercise Stress Testing

• Stress testing absolute contraindications
• Resting ECG suggesting acute cardiac disease
• Recent complicated MI
• Unstable angina pectoris
• Uncontrolled arrhythmias
• Third degree AV block without pacemaker
• Acute CHF
• Severe aortic stenosis
• Active or suspected myocarditis or pericarditis
• Recent systemic or pulmonary embolism
• Acute infections
• Acute emotional distress

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Exercise Stress Testing

• Stress testing relative contraindications
• Resting diastolic BP gt 115 or systolic gt 200
• Moderate valvular disease
• Electrolyte abnormalities
• Frequent ventricular ectopy
• Ventricular aneurysm
• Uncontrolled metabolic disorders
• Chronic infectious diseases
• Neuromuscular or musculoskeletal disorders
• Pregnancy
• Anxiety

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Exercise Stress Testing

• GXT termination
• Signs or symptoms of heart disease
• Abnormal BP response
• Physical distress of subject
• Nausea, dizziness etc.
• Equipment failure
• ECG indicated arrhythmias
• Patient requests termination

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Exercise Stress Test

• Stress test outcomes
• True positive
• Test shows CHD they do have CHD
• True negative
• Test shows they do not have CHD they dont
• False positive
• Test shows CHD they do not have CHD
• False negative
• Test shows they do not have CHD they do

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Exercise Stress Test

• Exercise-induced indicators of CHD
• Angina pectoris
• Electrocardiographic abnormalities
• ST segment elevation or depression
• Significant Q waves
• Prolonged PR interval

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Exercise Stress Test

• Exercise-induced indicators of CHD
• Cardiac rhythm abnormalities
• PVCs
• Flutter or fibrillation
• Bradycardia
• AV blocks
• Bundle branch blocks

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Exercise Stress Test

• Exercise-induced indicators of CHD
• Hypertensive exercise response
• Hypotensive exercise response
• Heart rate response

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Stress Test Protocols

• Bruce and Balke treadmill tests
• Bicycle ergometer tests
• Arm-crank ergometer tests
• Stress testing safety
• Pre-screening is critical
• Follow guidelines to determine who may be tested
  without a physicians presence

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Prescribing Exercise

• Improvements in CHD patients
• Cardiac workload
• Physiologic adaptations
• The program
• Supervision level
• Determined by health status risks
• Resistance exercise provides benefits

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Prescribing Exercise

• Cardiac medications and exercise response
• Medications alter heart rate response
• Physician supervision / permission for exercise
  prescription is recommended

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Pulmonary Diseases

• Restrictive lung function
• Pneumonia
• Pulmonary edema
• Chronic obstructive pulmonary disease (COPD)
• Chronic bronchitis
• Emphysema
• Cystic fibrosis

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Pulmonary Diseases

• Pulmonary assessments
• X-ray
• Computed tomography

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Pulmonary Diseases

• Pulmonary rehabilitation and exercise
  prescription
• Improve health status
• Improve respiratory symptoms
• Recognizing early signs that require medical
  attention
• Decreasing frequency and severity of respiratory
  problems

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Pulmonary Rehabilitation and Exercise Prescription

• Benefits
• Maximizing arterial O2 saturation and CO2
  elimination
• Enhancing daily functional capacity
• Modifying body composition
• Optimizing nutritional status

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Exercise and Asthma

• Sensitivity to thermal gradients and fluid loss
• Environmental impact
• Cool, dry air dehydrates bronchial tissues
• Warm, moist air inhibits bronchospasms
• Pollutants irritate bronchial tissues
• Irritations may trigger EIA

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Exercise and Asthma

• Benefits of warm-up and medication
• Refractory period
• 15 30 minutes of light to moderate warm-up
  induces a refractory period, where bronchospasms
  are not likely to be induced by exercise
• Medications
• Relax smooth muscles of airways
• Blunt inflammatory response
• Suppress asthmatic symptoms

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Health/Fitness Promotion at the Work Site

• Behavior changes/health outcomes
• Healthier behaviors
• Reduced risk factors for CHD
• Reduced health care costs
• Increased employee productivity

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Health/Fitness Promotion at the Work Site

• Decreased employee absenteeism
• Employer cost benefits
• Monetary benefits from improved employee
  productivity decreased absenteeism
• Improved work environment from psychological
  emotional benefits
• Employees feel better physically psychologically