Exercise: The new vital sign

Physical Activity as a Vital Sign

Becoming more physically active may be the most beneficial thing you can do to improve your health.  The least fit get the most benefit from starting an exercise program and building more physical activity into  their lives. This information is adapted from the Preventative Cardiovascular Nurses Association (www.PCNA.Net) and meant to provide guidance, tools and confidence needed to get started with a safe and effective exercise program.

Steps you can take to become more physically active:

Make exercise a vital sign.

Discuss with your healthcare provider your exercise status  at your next  office visit

  • Do you exercise?
  • If so, what type?, how long?, how hard?, and how often?

Many health systems have added this question to their electronic medical record to ensure a place to conveniently record.  Documenting physical activity at every visit allows you to track your progress over time.If  your answer is no you don’t exercise, do you understand the benefits of exercise?

You can help prevent heart attack and stroke by:

  • lowering blood pressure, or chance of getting high blood pressure
  • improving cholesterol
  • lowering  blood sugar and my chance for getting diabetes
  • burning calories to maintain or lose weight
  • reduce stress, depression or anxiety
  • improving my heart and lung function

Exercise can improve your:

  • ability to play sports
  • muscle strength
  • flexibility and range of motion of joints
  • balance
  • energy level
  • sleep

Exercise can lower your  risk for:

  • some kinds of cancers (colon, breast and lung)
  • osteoporosis (thinning of bones)

Remember:
The best exercise is the one you will do!
• Start slowly and increase activity over time.
• You may feel sore and more tired when you first start.
• Something is better than nothing.

Be encouraged to move more throughout the day even if you don’t feel ready to start an exercise program.
“Move More, Sit Less!” suggestions to for increasing daily activity.

  • Park farther away from any store or place you go—or get off the bus or out of the taxi a few blocks
  • before you get to where you are going.
  • Avoid the drive-through. Park your car and walk into the grocery store, drugstore, bank, or restaurant.
  • When you are stopped in traffic or at a stop light, tighten, then relax your stomach, arm or leg muscles.
  • Lift your grocery or shopping bags like weights.
  • Take the stairs! Climb up a flight or two whenever you can.
  • Walk around or march in place while you talk to someone on your mobile phone.
  • Clean your house, wash your car, or rake leaves. Maybe start gardening!
  • Try doing some exercises when doing chores where you don’t normally move. Examples include
  • small squats when ironing or folding clothes and calf raises while brushing your teeth.
  • Do some quick exercises during the break of your favorite TV show. Try some push ups,
  • sit ups, or do some light weight training.
  • Instead of watching TV or a movie—go window shopping, walking at a zoo or visit a museum.

Getting Started

If you  are considering starting an exercise program, are you healthy enough to exercise independently? If you have no cardiovascular symptoms and are low risk, get an exercise prescription from your health care practitioner and advice on starting an exercise program.

If you have heart disease or other health concerns, talk with your nurse or doctor before starting an exercise program. They may take a health history, perform a physical exam or request a monitored stress test. This information will be used to make sure exercise is safe for you and to develop an exercise prescription.

Exercise Prescription

There are four parts to an exercise prescription. These four things are sometimes known as F.I.T.T.
F: Frequency (Number of Times Per Week You Exercise)

  •  Try to exercise or be physically active on most, and ideally all, days of the week.
  •  If every day is not possible, work to get in at least 3 days a week. Try to spread out the days you are active (every other day is better than three days in a row).
  • Remember—something is better than nothing.

I: Intensity (How Hard You Exercise)
You may need to work with your nurse or doctor to figure out the best way to measure your exercise
intensity. A few ways are:

  •  Target Heart Rate (THR, or pulse)
  • The “Talk Test”
  •  Rated Perceived Exertion (RPE)

More about these 3 ways to measure the intensity of the exercise you do:
You can  count your heart rate (or pulse) and give you a target heart rate to reach during exercise. Your pulse is the number of times your heart beats in one minute. Pulse rates vary from person to person. Your pulse is lower when you are sitting still and gets faster when you exercise. Knowing how to take your pulse can help you evaluate your exercise program.


Remember some medications or conditions can limit how high your heart rate can go. Be sure to  discuss this  with your healthcare provider.  If taking your pulse is difficult, there are other ways to figure out if you are working as hard as you need to.

  • The “Talk Test” is simple. If you can talk while exercising, the intensity of your activity is considered tobe safe and appropriate for improving your health. If you are exercising so hard that you cannot easily talk to the person next to you, this means you are exercising pretty hard. Ask your healthcare provider  if this is safe for you.
  • You can also measure how hard you are working using the Rated Perceived Exertion (RPE) Scale

T Time: (How long you do the exercise) 

How long you should exercise—usually measured in minutes per day. While a minimum of 30 minutes of endurance exercise daily is recommended for most adults, it may take some time to increase to that level if you haven’t been exercising for a while. You may be advised to start with 5 minutes a day and add a few minutes each day as time goes on.
T Type: (What kind of exercise you do)
Walking, jogging, bicycling and swimming are examples of exercise that use large muscles and cause your body to use more oxygen than it would while resting. These types of activities are called endurance and they help the heart.

Strength exercises help to increase strength and muscle tone. They may also help with balanceand fall prevention. Examples of strength exercises are pushups, sit ups, and using weight lifting machines or free weights.

Flexibility exercises stretch and lengthen your muscles to help prevent soreness and injury Start slow and add a little more over time.

Tricks of the Trade

1. Some is better than none, so start slowly.

Don’t expect results overnight, but do take small steps each day. You might not notice any big changes— especially in your  weight—for a few weeks or even months. It is still good for your heart health!

2 .  Get a partner or join a class

Be active with a friend or a group to make it more fun! You are less likely to cancel an exercise date with a friend than one with yourself!

3.  Change your routine around

  • You will be less likely to get bored or injured if you change your activities.
  • Walk one day; bike the next.
  • Mix in fun sports like golf or tennis to stay active and keep exercise fun.
  • Learn to dance or garden.
  • Even chores like mowing the lawn and cleaning your house can keep you moving.

4.  Make exercise fun

  • Plan your walking route to see new sights—change up the neighborhoods you walk through.
  • Take awalk through the zoo or park.
  • Listen to music oran audiobook to help pass the time.
  • Exercise on a treadmill or stationary bike while reading or watching TV.

5.  Write it down

  • Keep an activity journal or diary.
  • Write down what you did, how long you did it, and how you felt. This helps to track your progress. Keeping a journal can also be a good way to set future goals.
  • Write down where you want to be next week, month or year.

6.  Try something new

It may be that jogging is not for you. Try a swimming program instead or sign up for a yoga class or tennis lesson. Find things you enjoy.

7.  Make exercise a habit

  • Choose a regular time for exercise each day.
  • Sign a contract with yourself to exercise.
  • Put exercise “appointments” on your calendarand keep them!
  • Change into workout clothes before you leave work.

8.  Make exercise a priority

  • You have to believe that exercise is important enough to make it happen.
  • Pay attention to your mood, how your body feels, and your stress levelAFTER you are active.
  • Think about your reasons for becoming active.

9.  Come up with solutions to reasons you may not want to be active

  • If you don’t like to sweat—set up a fan or split it up into three 10-minute walks.
  • If you feel too tired, try to be active earlier in the day.
  • Write down your solutions.

10.  Every little bit counts

  • Take a walk on your lunch break or a longer path back to your desk.
  • Walk your dog twice a day.
  • Take the stairs instead of the elevator.
  • Split your activity up into two 15-minute sessions

These are the 4 kinds of exercise that you can pick from:

  •  Endurance
  •  Strength
  •  Balance
  •  Flexibility

Endurance: activities that increase your breathing and heart rate (pulse)

Endurance activities  keep you healthy and more fit, help you do the things you need to do every day  improve the health of your heart and lungs delay or prevent diseases such as diabetes, colon and breast cancers, and heart disease.
Examples of endurance activities:

  •  fast walking
  •  dancing
  •  biking
  •  playing tennis
  • yard work
  •  jogging
  •  climbing stairs or hills
  •  swimming
  •  playing basketball

Strength:activities that increase your muscle strength Strength exercises help you stay independent in your daily activities like                                 climbing stairs and carrying things. Strength exercises include lifting weights and using a resistance band.

Balance: activities that make you more stable. These help improve your balance and prevent falls. Balance exercises include standing on one foot,heel-to-toe walk, and tai chi.
Flexibility: activities that keep your body flexible. These give you more freedom of movement for everyday activity. Flexibility exercises include shoulder and upper arm stretches, calf stretches, and yoga.

 

You have many choices

When you travel…

• Stay at a hotel that has an exercise room.
• Ask locals or the front desk of the hotel where you can walk or run safely.
• Walk to dinner instead of taking a taxi.
• Do your sightseeing on a bike or on foot.
Do some stretching, yoga or use a strength band in your room.

When the weather isn’t the best…

• Walk at the mall.
• Find stairs at your work or apartment building.
• Use a video or TV exercise program.
• Dance to your favorite music.
When you can’t afford a fitness center…
• Use household items for weights such as milk cartons or canned foods.
• Use your own body weight: squats, push-ups or sit ups.
• Join a walking group with friends.
• Find fun activities through a local community center.
When you feel tired…

• Try yoga, light weights or stretching—this will still help your balance,
strength and flexibility.
• Exercise early in the day.
• Start walking—you may start to have more energy with each step.

When it doesn’t seem fun...

• Do an activity while watching TV or a movie, reading a book or a magazine, listening to music, a book or podcasts.
• Consider it “play time” like kids do: play with the dog, play with grandkids.
• Try a new class or activity.
• Find a friend to be active with you.
• Help out a neighbor or friend with moving or housework.

 Get  Assistance if needed

If you need more support in starting an exercise program, consider a referral to a health and fitness professional. Your health systems cardiac rehabilitation or physical therapy programs may be good resources. Become familiar with other local resources. Senior centers and the YMCA may offer chair or water based exercise programs for your patients that have orthopedic or balance problems.
The tool, “It’s Never Too Late!” is a resource for older patients as well as those with health concerns.

http://pcna.net/index.php?option=com_dtracker&filename=images/pdf/HeartHealthyToolbox/ExercisePhysicalActivity_ItsNeverTooLate.pdf

Report your results!

At your  follow up  report any exercise-induced symptoms such as shortness of breath, chest pain, excessive fatigue or orthopedic concerns. Discuss your progress with exercise and to update their exercise prescription as needed. This is a good time to problem solve any barriers to exercise and help problem solve ways to stick with the plan.

About PCNA

The Preventive Cardiovascular Nurses Association (PCNA) is the leading nursing organization dedicated to preventing cardiovascular disease through assessing risk, facilitating lifestyle changes, and guiding individuals to achieve treatment goals. The current state of health care demands that nurses and advanced practice nurses play a leading role in identifying and implementing cardiovascular risk reduction strategies. PCNA is committed to the continued education and support of nurses so they may successfully rise to this challenge. We do this by educating and supporting nurses through the development of professional and patient education, leadership, and advocacy.

THE MISSION OF THE PREVENTIVE CARDIOVASCULAR NURSES ASSOCIATION

  • To increase public and political awareness of the critical role nurses play in comprehensive cardiovascular risk reduction.
  • To promote individual and community education in cardiovascular risk reduction and disease management across the lifespan.
  • To provide opportunities for education and professional development for nurses.
  • To advocate for professional certification and development for nurses specializing in cardiovascular disease prevention and management.
  • To disseminate information on innovative, fiscally responsible models of cardiovascular care delivery.
  • To foster productive liaisons with professional organizations sharing similar goals.
  • To support the utilization and dissemination of research and support evidence-based practice in cardiovascular risk reduction and disease management.

http://pcna.net/clinical-tools/tools-for-healthcare-providers/heart-healthy-toolbox?goback=%


Visit the American College of Sports Medicine’s Exercise is Medicine Web Site
for more resources and tips regarding helping your patients become and stay active!
ExerciseIsMedicine.org
Professional Resources: Assessment and Exercise Prescription

Based on 2008 U.S. Department of Health and Human Services Physical Activity Guidelines for Americans.

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Exercise is Medicine for your Diabetes

If you have type 2 diabetes, regular physical activity is essential for controlling your blood glucose and managing your weight. Exercise also improves how well your body responds to insulin, which may reduce the need for medication because your muscle and fat will do a better job of taking glucose out of the blood.

Furthermore, exercise may help protect you against heart disease, which often accompanies type 2
diabetes, by reducing body fat, blood pressure and improving your cholesterol levels. It will help you better understand your diet and exercise if you closely monitor your blood glucose levels to  understand how you respond to different types of activities.

If the benefits of exercise could be put into a pill would you take it?

If so why would you take it? Most likely because you know that pill is extremely helpful.  It would make your muscles stronger, including your heart muscle thus decreasing risk of death from heart disease. It would lower your bad cholesterol, triglycerides, blood pressure and blood sugar, and increase the good cholesterol. It would improve your memory. It would slow osteoporosis. It would make you less likely to have falls. It would improve your mood and lessen symptoms of depression.

Exercise is Medicine!

Exercise does all this and more, however it is extremely difficult to get people to follow exercise advice or adhere to an exercise program? Why? Because taking a pill is so much easier, and maybe because the cost of medicine is covered by insurance. So many take such care to take medications, vitamins, eat healthier, but still find it difficult to adhere to medical advice to exercise. It could be do to the information out there seems conflicting, or too complicated.

Exercise the Diabetes Drug

You take your diabetes medications every day correct? Most people also have concerns about the side effects and the cost of their medication. Yet exercise is one of the best medications out their with minimal side effects. Just like most diabetes drugs it has to be taken regularly to get the benefits, and there is a specific dosage.

Frequency of use: 6-7 days per week.

  • This regulates the body, you need  a certain amount of energy to do this from your body and its energy sources (food and insulin). The more regular you exercise the less wild blood sugar swings.

Intensity:

  •  To a level that feels fairly light to somewhat hard, but not hard. Bring your heart rate up above your resting heart rate, break a light sweat, breath a little harder – yet be able to carry on a conversation

Time or Duration:

  • 30 minutes or more per day. It can be broken up or done all at once.

Type:

  • Aerobic – meaning continuous movement that requires oxygen – walking, biking, hiking, spinning, swimming, rowing, elliptical, recumbent equipment, steppers, tia chi, yoga, karate, pilates, belly dancing, dance classes, circuit training, cross country skiing, snow shoeing, kayaking, rollerblading, ice skating….you get the idea.
  • Resistance training – it doesn’t have to be heavy body building weight training, but working with your body as resistance, dumbbells, resistive bands, weight machines, free weights all help to maintain and build muscle. Try doing some sort of resistive training 2-3 days per week.

Side effects:

While there are many benefits to exercise for people with diabetes, it should be noted that there are several potential risks as well, including a worsening of eye complications in people with conditions such as proliferative retinopathy when doing specific exercises (such as weight lifting- with heavy weights that create a large amount of strain), hypoglycemia (low blood glucose), and hyperglycemia (high blood glucose).

Building the Routine

Most people take there medications at a certain time every day, brush their teeth at a certain time, go to appointments because they are scheduled at a certain time. Exercise needs to be scheduled and worked into the daily routine. What works for you? First thing in the morning? Most studies show people who exercise first thing in the morning are more likely to stick with the routine for the long haul. Can you develop a routine –  a walk after dinner, hitting the gym on the drive home from work, fifteen minutes at lunch and fifteen after work? Keeping a log helps, and be accountable to someone with the log, make sure you bring it to your doctors appointments and discuss.

Can you stick with if for the long-term?

It takes six months of exercise to establish a habit.

In medicine we talk about the stages of change

Where are you in the stages of change when it comes to exercise?

http://exerciseismedicine.org/documents/EIMPSA_03.pdf   

Heart Rates: Why are they important to know?

 There are many things that can affect the heart rate and are important to consider if you are a heart patient. Heart rate vary as the body’s need to absorb oxygen and excrete carbon dioxide changes, such as during, exercise or physical activity, sleep or illness. The normal human heart rate is between 60-80 beats per minute at rest.

 

Slow Heart rates

Exercise implications of a low heart rate can indicate a problem when the heart rate does not increase sufficiently with exertion, creating increased fatigue, shortness of breath, exercise intolerance, or EKG changes.  It is important  for heart patients to observe how the heart rate responds to exercise. Does it increase and by how much? 

Medications known as beta blockers frequently lower resting heart rates to upper 40-60 range. That isn’t always considered a problem. If there are no symptoms of compromise such as shortness of breath, chest discomfort, fainting, overwhelming fatigue or cognitive changes and the treatment is tolerated, there is not usually concern. When the rates start to get into the low 40’s there is  more concern. When you sleep the heart rate usually drops another 10 beats per minute, and heart rates in the 30’s are not able to adequately get enough circulating oxygen in the bloodstream to nourish the organs. You might not notice it thus might be found in sleep studies, or if on remote monitoring with holter monitor studies.

If you are on beta blockers the the heart rates are quiet a bit lower than traditional heart rate posters. Many people  on beta blockers have a very blunted heart rate response to activity. On beta blockers your heart rate ranges are usually set 10-20 points lower than the traditional age predicted heart rate ranges or are often prescribed at 50 -70% of age predicted values (see chart below). This doesn’t mean you don’t get the benefits from exercise. The benefits are not directly linked to the heart rates. Exercise conditions the muscles to be efficient at utilizing the oxygenated blood and  thus takes demand off the heart to work harder to provide the blood flow to the working muscle. So the heart doesn’t have to pump as fast.  Think of the muscles as a secondary pump that extracts the oxygen and pushes the blood back to the lungs for re oxygenation.

Commonly prescribed Beta Blockers are usedd to treat the following conditions

  • HTN  is Hyperension
  • Angina =Chest Discomfort
  • Arrhy=arrhythmia or irregular heart rhythm
  • MI = Myocardial Infarction meaning heart attack
  • CHF = Congestive Heart Failure – Shortness of breath and fluid retention in abdomen, legs, weakness of the heart, low ejection fraction

  • Acebutolol -Sectral
  • Atenolol – Tenormin
  • Betaxolol – Kerlone
  • Bisoprolol – Zebeta, also sold as Ziac
  • Carteolol -Cartrol
  • Carvedilol -Coreg
  • Labetalol – Normodyne, also sold as Trandate
  • Metoprolol – Lopressor, also sold as Toprol
  • Nadolol – Corgard
  • Penbutolol – Levatol
  • Propranolol – Inderal, Inderal LA
  • Timolol – Blocadren

This is a question for you and your healthcare professional. What should my target heart rate range be at given my being on beta blockers? It is up to you to determine how you will measure and track your rates. Here are some methods and tools to monitor. 

 The Beltless Heart Rate Monitor

 

To monitor the heart rate you should  measure the rate for 60 second to determine the rate. It is also useful to note if it is regular. Fitness plays a role here. The more fit you are the lower the resting heart rate. If the heart is efficient and the muscle are strong there is less demand for the heart to go faster to meet the supply and demand of the muscles. Most symptoms of this are shortness of breath, fatigue, exercise intolerance. Then exercise is progressed more on tolerance than by the goal of getting the heart rate elevated to a higher percentage but a rate between 50 and 85% of age predicted target heart rate range.

Exercise  elevates the heart rate. How high is too high?

Most frequently the Karvonen target heart rate is method to determine the age adjusted threshold which is 220  – minus age = Maximal Heart Rate range at which one should not try to achieve when exercising a heart that has had  cardiovascular health issues. A percentage between these ranges is often prescribed by your healthcare practitioner. It is a range!!!! Not an I have to hit the top of this to benefit my heart range. The goal is to be somewhere in that range, we all have good days and bad especially when struggling with heart issues.

If you are in the low end of the range that is just as good as the upper end when it comes to exercise, and there are times when the upper range is too high and it is better to be in the lower range. Again there is an art versus  science of target heart rate ranges the best advise is  be active at a level for which you are  free of symptoms, yet the effort feels fairly light to somewhat hard and does not feel physically hard to perform for several minutes.

Some heart patients  may find a fast resting heart rate if medications are off, or if complications are developing such as the heart rhythm abnormalities or changes.  If the rate is faster than normal and in the recommended exercise levels when resting do not exercise instead contact your healthcare provider ASAP. 

Wall motion, blood pressure, heart rhythm, exercise intolerance, pacemaker or ICD programming must be discussed to really understand the extent of your target heart rates for exercise. Because of such complexity, initially starting to increase activity on a regular basis that elevates the heart rates some and remaining free of symptoms, being able to talk while exercising is an important assessment tool of how well one is tolerating exercise. Make sure to include this discussion at your cardiology or primary care appointment. Discuss safe heart rate ranges for activity, and how your medications and heart condition will influence it. What are your medical concerns?  Heart patients are not instructed to exercise at age predicted maximum heart rate ranges.

Below  is a standard chart your healthcare staff  uses to prescribes a ranges for safe activity. For heart patients there may be ranges where there are ischemic changes meaning there is a change in the EKG noted while in  Cardiac Rehabilitation or with stress testing. Theoretically one could monitor their own  for issues through use of the new Ipod apps for heart rhythm monitoring, or small handheld electronic devices like those shown above. Most exercise is initially prescribed light following a heart issue and gradually increased to meet daily living needs including work, physical, and activity/exercise needs.

Age

Maximum HR

50 percent

75 percent

85 percent

20

200

100

150

170

25

195

98

146

166

30

190

95

142

161

35

185

93

138

157

40

180

90

135

153

45

175

88

131

149

50

170

85

127

144

55

165

83

123

140

60

160

80

120

136

65

155

78

116

132

70

150

75

113

127

75

145

72

108

123

80

140

70

104

119

85

135

68

101

115

If you have cardiovascular issues such as  angina, poor heart wall motion due to the injury to the heart  from a heart attack or cardiomopathy, inadequate blood pressure responses, EKG electrical changes, then the target heart rate ranges are established by your physician to a safe level. This target heart rate range is your individual level based on your medications, your heart issues, and your fitness goals.

Most rehabilitation of the heart is done in lighter zones initially, then progresses gradually too higher heart rates to meet daily living needs including work, physical, and activity/exercise needs. Many are able to do high levels of physical exertion when trained including returning to jogging, cross country skiing, or strenuous job requirements. Rehabilitation programs are beginning to work select patients to higher target heart rate ranges with interval training. Sometimes the art of exercise prescription outweighs the science of it when balancing a complex medical history of cardiovascular disease.