Gentle activity gets patients moving

Starting out easy

Catherine Certo, ScD, PT, has worked with cardiovascular patients for 30 years. Along the way, she helped write the guidelines for cardiorehab and says clinicians need to change the way they think about CHF patients.

"Even patients who are severely compromised can show an exercise level," says the physical therapy professor at the University of Hartford in Connecticut. Last month in Seattle, she presented strategies for helping CHF patients at the APTA Combined Sections Meeting.

Whether these patients will get supervised sessions with a physical therapist or not, she can suggest exercises you can pass on to your patients to do at home. But first, she gives some signs that tell you a patient will need to be extra careful about activity and may require more supervision from you or a physical therapist:

- low angina threshold;
- resting tachycardia;
- excessive shortness of breath;
- slow recovery from activity;
- fall in systolic blood pressure more than 20 mm Hg;
- excessive fatigue lasting more than one or two hours;
- increased arrhythmia during activity;
- lack of heart rate response or extreme response to activity;
- lower extremity pain/claudication.

The key is to start slowly, making exercise a gentle — not intense — activity.

First, find their maximum heart rate by starting with the number 220 and subtracting the patient’s age. Preliminary routines should shoot for achieving a heartbeat of 20% to 40% of this maximum value. Later on, they may be able to work up to higher percentages of the maximum heart rate, but for now, 20% to 40% is the goal.

Debilitated patients will hit this mark with simple activity like straight-leg raises from a comfortable position. They should try to do it five times, making movement slow and rhythmical. Gradually, they work up to 10. Certo notes that it’s best to alternate legs reciprocally. (The first leg is raised and lowered, then the other one. When both sides have had a turn, that’s one repetition.)

"It seems to help when you give the muscles a chance to rest between repetitions on each side," she says.

Adding light weights

As patients improve, and it gets easier to do 10 alternating repetitions, the patient may go on to do the same motion with light resistance. Certo says the commercially available weighted ankle straps are useful, but should not be heavier than one or two pounds. Elastic resistance bands also are available.

If patients are walking, they can be improving the strength and range of motion in their ankles as well. Slow, simple side steps back and forth, and steps forward and back, can make patients more stable on their feet. The idea is not to make it an aerobic exercise here, but to cover short distances that can gradually lengthen as the patient improves.

Patients who are starting out probably should stick to exercising once a day. Gradually, they can work up to five times a day. Certo says it is important for CHF patients to give themselves time for exercise and rest. It’s a good idea to alternate the activities the patient is doing each day, so the muscles are not overworked and have a chance to recover. For this reason, patients should do the leg raises on one day and the stepping the next, especially when they are just starting to exercise.

When the lower extremities are improving, patients can try working their arms and upper body as well. Alternating straight arm raises are useful, first without weights, and then later with them when their conditioning improves. But only do three reps in the beginning.

Certo says it’s important to remind your patients not to bear down with the Valsalva reflex, or to hold their breath. That can worsen their CHF symptoms. Also, remind them the intention is not to work to exhaustion. Train your patients to look out for the warning signs that say it’s time to rest. These signals include:

- moderate dizziness or feeling faint;
- angina;
- nausea;
- marked dyspnea;
- unusual/severe fatigue/feelings of doom;
- mental confusion/doesn’t feel well but doesn’t know why;
- staggering or persistent unsteadiness;
- cyanosis;
- heart rate over percentage of maximum (or 80% to 90% maximum for advanced exercisers);
- development of pulmonary rales.

Certo says staying active is good for patients’ spirits, too. "If they can perform some activities, they’ll be delighted that they don’t have to spend the rest of their life sitting in a chair." An exercise program often can give them hope that they will be able to do more for themselves.

She adds that a flexible routine, like this one, helps in many ways. Because patients with CHF may feel good one day and terrible the next, it is good to have a routine that can be adjusted or gives plenty of time for rest. This also is true when patients suffer setbacks in controlling their condition.

They may have been doing well, then need more diuresis or had to go to the hospital to treat a comorbidity. Then they find their conditioning has suffered.

Certo says when that happens, patients can begin the exercise pattern again by starting out slowly with low repetitions. They can work themselves back up again by adding repetitions, stepping across longer distances, or walking at the same rate for longer periods. Remember that the intensity of the exercise should not increase, only the duration or number of reps.

Also, it may be helpful to teach patients a way to gauge and express how intensely they are working by using the Borg Scale of Perceived Exertion or another method that can assess the impact of their routine.

Program tips

- It’s generally good to exercise in the morning, when the body is best rested. But any early medications should be taken 30 minutes before beginning to exercise.

- If patients eat before exercising, they should wait 45 minutes before they begin activity. Blood can’t aid digestion and deliver more oxygen to the body at the same time. "It’s like double-dipping," she says.

- Watch the weather. Hot, humid, or windy days make it hard for the patient to breathe. When it’s cold, patients should wear a scarf in front of their mouth to warm the air they breathe. If they take in cold air, their blood vessels can respond by constricting.

- Monitor daily weight and pulse.

- Take time to rest after activities like showering, which can take a lot of energy on their own. "Heart patients have to work twice as hard to do something simple," she notes. The threshold can change, but it comes gradually.