Exercise Exercise

Exercise training may be undertaken in a variety of settings and formats. The setup of an exercise program will depend upon staffing and available resources. Regardless of location , the service model should be flexible so that patients are able to take advantage of the program whether they are working, are elderly or live a long way from health care services.[#national-heart-foundation-of-australia.-multidisciplinary-care...-2010]

Group exercise programs may be disease specific or have a more generic format (e.g., chronic disease programs).

Location

Programs are often conducted in hospital or community health centre gymnasiums, but if unavailable, other venues such as community halls or local gymnasiums can be considered. The environment should be safe (e.g., in terms of space and floor surface) and preferably air-conditioned. Patient access to the venue should be assessed (e.g., to ensure logistical access into the building/room, as well as availability of lifts, parking access and public transport).

Frequency and duration of exercise session

For group programs, it is recommended that patients attend twice a week for approximately 1 hour. If patient frailty and co-morbid disease precludes attending this frequently or if resources are limited, a weekly session combined with individual home-based exercise is an option.

All individuals should be encouraged to exercise on most days of the week so a home exercise program is an essential adjunct to any centre-based rehabilitation program.

Duration of program

Programs may be time-limited or ongoing in the case of patients wait-listed for cardiac transplantation.  Cardiac rehabilitation exercise groups are usually for 4-12 weeks whereas patients with HF usually require at least 8-12 weeks  as  longer duration may elicit greater physiological effects and slow down decline post program.[#chen-ym-li-zb-zhu-m-et-al.-2012,#collins-e-langbein-we-dilan-koetje-j-et-al.-2004,#willenheimer-r-rydberg-e-cline-c-et-al.-2001]

Entry and exit of a group exercise program

All patients should attend an individual assessment prior to attending any group program.  Rolling format allow patients to enter at any week according to availability with patients beginning and ending at different times.  A 'stop-start' format has set commencement dates.

  • The ‘rolling program’ offers more flexibility for patients who, for example, need to return to work early, and reduces the waiting time for participation in the program.
  • The ‘stop-start’ format offers a fixed time limit and strong social interconnection, but limits new membership until the next cycle of sessions commences.

Communication with all health care providers is essential to optimise patient outcomes. Sample letters/templates are available in the Resources section.

Group exercise staffing & ratios

All exercise programs should be run by an exercise specialist such as a physiotherapist or exercise physiologist. Additional support staff may include nurses, allied health professionals or lay people. It is crucial that all staff members are trained in cardiopulmonary resuscitation (CPR) and are familiar with local emergency procedures.

There is no standard ratio of staff to patients. Staffing will depend on the access to medical services, disease severity and numbers in the group. Usually, patients with HF need a staff-to-patient ratio of 1:5. A greater ratio will be required for larger numbers of patients, higher-risk participants or for programs with moderate-intensity exercises. Frail and high-risk patients may require a 1:1 ratio.

Patient education is a vital component of any centre-based rehabilitation program and is usually provided by members of the multidisciplinary team either to a group of patients or individually.

Group education scheduled after an exercise session allows time to monitor patients prior to them going home. However, education can be delivered before or after the group exercise sessions, and can be scheduled so that patients from different groups can attend a mutual education component.

For further information see the education topics section of this website.

A home-based exercise program may comprise:

  • One-on-one supervised exercise at home for a defined period of time
  • Supervised exercise for 1-2 sessions followed by telephone support once the patient is safe and independent to carry out the exercises
  • Telerehabilitation, in which exercise is conducted in the individual's home; however, the exercise specialist and participants are linked via telemedicine
  • A combination of the above, such as independent home exercise in combination with group education sessions. For those in rural or remote centres, education sessions can be attended at a local health facility, via video link to a group education session being delivered at larger metropolitan centres
  • Clinic appointments may be useful for reassessment, redefining of goals and modification of the intervention

For delivery in-home, staff should have a good understanding of cardiac disease and its management and should at all times carry a mobile phone. Specific information such as the Physical activity and heart failure booklet provide an excellent guide for patients.

Maintenance exercise is a fundamental component of all exercise rehabilitation programs and should be considered early in the rehabilitation period. Physical activity should be ongoing unless clinical deterioration necessitates a temporary reduction in activity[#national-heart-foundation-of-australia.-multidisciplinary-care...-2010] and patients should be encouraged to exercise 3-5 times per week to maintain physical improvements.

For patients with HF, deconditioning occurs in as little as 3 weeks following cessation of exercise training, and benefits of a structured rehabilitation program are often lost within 6 months.[#willenheimer-r-rydberg-e-cline-c-et-al.-2001,#hansen-d-dendale-p-raskin-a-et-al.-2010,#prescott-e-hjardem-hansen-r-dela-f-et-al.-2009]

Regular reassessment is recommended for some patients to optimise adherence.[#willenheimer-r-rydberg-e-cline-c-et-al.-2001,#hansen-d-dendale-p-raskin-a-et-al.-2010,#prescott-e-hjardem-hansen-r-dela-f-et-al.-2009]

Maintenance exercise may include:

  • Supervised exercise sessions for a defined period of time at the hospital, community centre or local gym
  • Referral to a community exercise program such as Heartmoves or Lungs In Action
  • Alternative exercise options such as local walking groups or Tai Chi
  • Individualised exercise programs at home or a local gym

Equipment requirements vary according to the type of program and available resources. Both centre-based and home-based programs can be successfully conducted with minimal or no equipment.

The  Equipment checklist provides a list of suggested equipment to run a program.