Agree a plan

Don't be tempted to impose your own plan at this stage - they may agree with you just to end the conversation.

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1
Summarise

“Can I summarise what I think you have said?”

Summarise the main points of the conversation without adding any new information.

This may sound something like: ‘so some of the benefits of physical activity for someone like you with X include A and B and C. The most important reasons for you personally would be P and W’.

Using a summary can be a good way to demonstrate and express empathy, that you can see the world from their perspective. Empathy contributes to outcomes in a range of settings.

2
Decide

‘So, what do you think you will do?’

If they decide that they are NOT ready
Thank them for taking the time to talk with you about physical activity and offer an opportunity to review the conversation. Reassure them that help is available when they feel ready to change.

If they decide to become more active, THEN move on to planning
Continue to keep the focus on them generating their own ideas for change, rather than telling and instructing. People are much more likely to make successful changes if they develop their own plans.

If they’ve recently had a heart attack, angina, a coronary angioplasty or heart surgery, it’s important that they start slowly, and gradually build up to this level of activity over time

The individual has heard about the benefits of physical activity for someone like them and has had chance to consider the benefits they would most like to experience. They have heard their ideas spoken back to them, which can help to reinforce them. Now it’s decision time.

Asking an open question ‘what do you think you will do?’ rather than a closed question ‘so, are you going to exercise?’ helps remind them that they – not you – are the decision maker.

If they are not ready to change now this can be challenging for you, but they might have good reasons to keep things the same for now. Encouraging further reflection can be an important part of the process of helping people to make successful changes over time. Offer an opportunity to follow up on this conversation to review their thoughts about making changes.

3
Build activity

Can they think of any easy and/or enjoyable ways of fitting in opportunities to move more during their daily routine?

Useful questions to ask include:

  • How do you think you might get started?
  • What kind of help might you need?
  • How often do you see yourself doing that?
  • What changes do you think you would notice?
  • What might get in the way of your plan?
  • How could you find a way round that?
  • Some people find it helpful to have a chat in the future. Is that something you would find helpful?
  • Can I tell you a little about our exercise referral scheme?
  • Can I tell you a little about our healthy walks programme?

You may need to give some information here – about starting slow and building up, starting with moderate, stopping if they notice any particular symptoms, etc.

Reflect back and expand on relevant points from your earlier discussion.

Build activity into everyday life

Home

Gardening

Gardening

 

There is a wide range of gardening activities, some are light and easier to do, others are more strenuous and may be more challenging.

  • Start with lighter tasks such as deadheading flowers and light pruning
 rather than anything that involves bending, digging, pushing and heavy lifting.
  • It is fine to feel that you are exerting yourself but you should be able to continue conversation.
  • As your fitness improves you will be able to progress to more challenging activities.
  • If you have a Pacemaker or Implantable Cardioverter Device (ICD) 
you may need to wait six weeks after
your procedure to allow the leads to settle before certain arm activities.

Climbing the stairs

Housework – doing the hoovering

Travel

Bicycle

Walk

Public transport

Work

Walking up stairs

Go for a walk during lunch break

Walking meeting

Play

Class Exercises

Class exercises

Group exercise is exercise led by an instructor.
This covers activities such as Zumba, Yoga, Pilates, Aerobics, Step classes, Spinning, Tai Chi and other group based activities.
 Classes are sociable and fun and offer variety and can help motivate to exercise regularly.

  • It’s important to choose wisely when selecting an exercise class. Aim for classes that offer low-to-moderate intensity.
  • As always start low and build up slowly
  • Avoid high intensity classes

Throwing ball in park

Swimming or Aqua Class

Swimming

Swimming is a great way to improving health and fitness and are a fun way to keep active. It is particularly good if you have joint and muscle problems or peripheral vascular disease.

Swimming is great for cardiovascular health, weight loss and muscle tone and strength

  • Pick a stroke that is familiar.
  • Start at a comfortable pace and gradually increase the number of lengths.
  • Patients with an ICD or pacemaker should wait until the wound is healed. Breaststroke is better than front crawl or backstroke as reduces the risk of damage to the devise.
  • Patients with ICDs should swim with someone else or at a life guarded pool.

Golf

Golf

Golf is an enjoyable and social way to improve and maintain fitness and keep active outdoors.

  • Its best to walk between holes to get maximum benefit, but don’t feel pressurized into rushing. When you first start back you may need to use a golf buggy.
  • Use a golf card or buddy to avoid having to lift heavy clubs when starting back.
  • Patients with ICDs or pacemakers should wait 6 weeks to avoid causing damage to leads.

Golf

Golf is an enjoyable and social way to improve and maintain fitness and keep active outdoors.

  • Its best to walk between holes to get maximum benefit, but don’t feel pressurized into rushing. When you first start back you may need to use a golf buggy.
  • Use a golf card or buddy to avoid having to lift heavy clubs when starting back.
  • Patients with ICDs or pacemakers should wait 6 weeks to avoid causing damage to leads.
4
Agree a plan

Different options suit different people and can be effective when used alone or with each other.

Explore the options below and print out the relevant PDF for your patient or print the workbook in Information for Patients.

1

Motivational support

Use this document for people who are keen to review and develop their motivation for behavioural change

2

Action planning

Action planning is good for those who hope to set structured goals to create a roadmap for behaviour change

Individuals are more likely to change their behaviour if they are following a set of goals they have committed to.

For action planning theory visit:

Gollwitzer P, Social RK-J of P and, 1989 undefined. Effects of deliberative and implemental mind-sets on illusion of control. psycnet.apa.orghttp://psycnet.apa.org/fulltext/1989-25917-001.html

Gollwitzer PM, Oettingen G. The emergence and implementation of health goals. Psychol Health 1998;13:687–715. doi:10.1080/08870449808407424

For a comprehensive overview of action planning visit:

Woodcock B. Action Planning. Univ. Kent. 2018.https://www.kent.ac.uk/careers/sk/skillsactionplanning.htm

3

Step counting

Use this for those keen to use self-monitoring devices such as pedometers, wrist worn accelerometers or even smartphones to monitor their daily step counts.

References

Kang M, Marshall SJ, Barreira T V, et al. Effect of pedometer-based physical activity interventions: a meta-analysis. Res Q Exerc Sport 2009;80:648–55. doi:10.1080/02701367.2009.10599604
Ogilvie D, Foster CE, Rothnie H, et al. Interventions to promote walking: systematic review. BMJ 2007;334:1204. doi:10.1136/bmj.39198.722720.BE
Jee H. Review of researches on smartphone applications for physical activity promotion in healthy adults. J Exerc Rehabil 2017;13:3–11. doi:10.12965/jer.1732928.464

4

Make a diary

Creating a personalised monthly schedule helps work out where and when someone can start to fit opportunities to become more active into their own life.

Did you know?

What to do if you get chest pain

What to do if you get chest pain

If you have symptoms that do not match the ones we have described but you think that you are having a heart attack, call 999 immediately.

  1. Stop what you are doing.
  2. Sit down and rest.
  3. Use your GTN spray or tablets. Take the GTN
as your doctor or nurse has told you. The pain should go away within five minutes. If it doesn’t, take your GTN again.
  4. If the pain has not gone away within five minutes of taking the second dose of GTN, call 999 immediately.
  5. Chew an adult aspirin tablet (300mg) if there 
is one available, unless you’re allergic to aspirin or have been told not to take it. If you don’t have an aspirin next to you, or if you don’t know if you’re allergic to aspirin, just stay resting until the ambulance arrives.

Aerobic Training

Aerobic Training

Warm up

  • A low intensity graduated warm up is essential to create sufficient blood flow to ensure the key organs are optimally prepared (metabolically, thermally, neurologically) for the controlled stresses of an effective exercise session.

 

The aim is to:

  • Prevent cardiopulmonary distress due to acute rises in catecholamines
  • Increase the ischaemic threshold
  • Prevent any unnecessary fatigue or postural instability
  • Prevent muscle and joint injuries
  • Aid performance of activities within the conditioning phase
  • Allow time to assess exercise technique

 

A warm up should:

  • Last upto 15 minutes
  • Mobilise joints and warm up all large muscle groups that will be engaged in the exercise training session.
  • Include pulse-raising activities, which are appropriate in content to the activities being performed in the conditioning phase.
  • Include static stretching interspersed with pulse raising moves to maintain HR.
  • Perform a re-warm after preparatory stretching before commencing the conditioning component.
  • Allow for alternative intensities of aerobic work.
  • Increase exercise effort gradually, so that by the end of the warm up the RPE – BORG <11 (RPE scale)

 

Conditioning phase

 

  • The recommended dose of weekly CV exercise can be achieved by varying the frequency, intensity and duration which are suitable for the individual
  • Frequency
In order to improve functional capacity, exercise should be undertaken at least 2-3 times per week
  • Intensity
Moderate intensity aerobic exercise, designed to suit a range of fitness levels, is recommended for most individuals undergoing exercise training
  • Individuals should be working at:
    • 11 – 14 (BORG RPE scale)

 

Duration of exercise

 

  • The duration and frequency are interchangeable
  • For a structured exercise session a minimum duration of 20 minutes is recommended for the conditioning phase, which can be progressed to 60 minutes

 

Cool Down

 

  • The risk of hypotension, ischaemia and arrhythmias within the first 30 minutes after stopping an exercise session is well documented
  • A graded cool down has been found to reduce the incidence of these complications.
  • Cool down exercise should be the reverse of the warm up in most respects with the aim to gradually return the cardiorespiratory system to near resting levels within 10 to 15 minutes

Reference:

http://acpicr.com, ACPICR Standards 2015; Association of Chartered Physiotherapists in Cardiac Rehabilitation

Strength Training

Resistance training

Resistance Training (also called strength or weight training) is a type of exercise where you lift an external load or use your bodyweight as resistance to improve the strength, size, or endurance of your skeletal muscles.

We would recommend seeking advice from a exercise professional who can advice and work with you to design a personalised training programme.

  • Establish the correct choice of exercises and weight to be lifted for each individual muscle group you plan to train. A cardiac exercise professional will help to do this.

 

  • Aim to participate at least twice a week. It is recommended to wait 48 hours between each resistance training session.

 

  • Warm up prior to a session by performing the movement 10 times without any weight/resistance.

 

  • Aim for 1 set of 10 -15 repetitions (reps) for each muscle group. If at least 10 reps one after the other cannot be performed then the weight is too heavy.
  • The fatigue in muscles should increase gradually as you increase the number of reps performed. By the last repetition the muscle group being exercised should feel tired to the point of being unable to continue.
  • You can begin resistance training is the first few weeks after having a heart attack or angioplasty with stents.
  • Performed as either
    • An independent session
    • Part of the active recovery component or cool down of an aerobic circuit
      • When undertaken after the CV component, a partial cool down is necessary prior to resistance work
    • Resistance work should be followed by a final cool down
  • Moderate (>30% 1 repetition maximum (RM)) to high (70% 1RM) resistance training programmes performed twice a week for 3 – 6 months have shown improvements in muscular strength and endurance of 25-100% 84.
  • Frequency
    • Train each major muscle group at least twice a week and no more than 4 times per week (no more than every other day)
  • Intensity
    • Initiating strength training and in keeping with the AHA guidelines 84, these intensities are recommended.
      • Upper body 30 – 40% 1RM
      • Lower body 50 – 60% 1RM
    • Working the selected muscle group to fatigue within 10 – 15 reps
    • Choosing a weight which elicits a Borg RPE 14 – 16
    • Training can be progressed up to 50 – 80% 1RM for both upper and lower body once patients demonstrate good technique and have had no adverse responses or symptoms.
  • Time Sets:
    • A set comprises of the recommended repetitions
    • Each set of repetitions for a given muscle group should not be repeated within the circuit
    • 2 – 4 sets will improve strength and power 55.
  • Repetitions:
    • Perform 10 – 15 repetitions to improve strength 55
    • A circuit should include 8 – 10 different key muscle groups 55,58,88
  • 
Should be performed:
    • In a rhythmical manner, though a full range of motion (ROM) that is 
controlled at a moderate to slow speed (i.e. 3 seconds concentric and 3 seconds of eccentric contraction)
    • By alternating between lower and upper body to allow muscles to rest between exercises
    • Considering muscle balance
    • With a good technique:
      • Good posture
      • Avoiding excessive gripping of weights
      • Avoiding breath hold (Valsalva)
    • It is recommended to wait 48 hours between resistance training sessions 55

 

Reference:

http://acpicr.com, ACPICR Standards 2015; Association of Chartered Physiotherapists in Cardiac Rehabilitation

Flexibility Exercises

Flexibility exercises
• Best performed 2 – 3 times a week when the muscles are warm for example following aerobic exercise
• Hold stretch for 30 seconds to point of tightness or slight discomfort
• Ensure that venous return is maintained whilst stretching
• Repeat stretch 2 – 4 times, accumulating 60 seconds per stretch
• Static, ballistic and proprioceptive neuromuscular facilitation (PNF) stretches are effective.

Key message:
• Structured exercise should:
• Include a warm up, condition component and a cool down
• Achieve a training effect via the FITT principle
• Be performed at a moderate intensity
• Be individualized
• Incorporate resistance work
• The overall volume of activity is more important than the duration or intensity to achieve improvement in CV fitness and health benefits.
• Reducing the risk of adverse events when exercising
• CR exercise is designed to reduce the incidence of adverse events (Standards 2, 5, 6 and 7). This is achieved by:
• Graduated warm up of 15 minutes
• Moderate intensity exercise/physical activity
• Keeping the feet moving during active recovery (prevent blood pooling and BP drop)
• Avoiding breath holding/ Valsalva manoeuvre
• Avoiding floor work during the conditioning phase

Reference
http://acpicr.com, ACPICR Standards 2015; Association of Chartered Physiotherapists in Cardiac Rehabilitation